Every finding on record at Harmony Waterloo

Based on observations, staff interviews, and record and policy reviews, the facility failed to ensure that staff securely stored all medications for 2 of 2 residents reviewed (R#2 and R#8). The facility also failed to maintain a safe environment because staff left the medication carts and treatment carts unlocked and unsupervised. The facility reported a resident population of 68. Findings include: 1. Resident R#2's Minimum Data Set (MDS) admission assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS listed diagnoses of major depressive disorder (severe depression), coronary artery disease (heart disease), high blood pressure, dementia (memory loss), stroke (brain tissue damage from blood flow blockage), sleep apnea (nighttime breathing interruptions), and chronic tension-type headaches (frequent severe headaches). The facility's Investigation reflected on 5/2/26 Staff J, Certified Medication Aide (CMA), passed out having seizure-like behavior at the nurses' station. The facility immediately called for an ambulance who took Staff J to the hospital. While at the hospital, the staff found a drug administration record sheet for a former resident, a package of fluconazole medication from a former resident, and R #2's sumatriptan 100 milligrams (mg) containing 4 tablets. The hospital called the facility and the Administrator went to investigate. R#2's May 2026 Electronic Medication Administration Record (EMAR showed an order for Sumatriptan 100 milligrams (mg), one tablet every 4 hours as needed for migraines, which staff could repeat once, up to a maximum of 2 tablets per day. A review of R#2's EMAR from April 2026 and May 2026, up to the time of the incident on 5/2/26, revealed R#2 didn't receive any doses of Sumatriptan. 2. Resident R#8's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS listed diagnoses of high blood pressure, diabetes (high blood sugar), Alzheimer's disease (progressive mental decline), and depression. On 5/2/26 at 2:45 PM, Staff member J went to the Emergency Department (ED). At the ED, the hospital staff opened her backpack and discovered one tablet of fluconazole (fungal infection medication) with a pharmacy label on the bag indicating the medication belonged to R#8. A review of R#8's Electronic Medication Administration Record (EMAR) for February 2026 revealed an order for fluconazole 150 mg to give one dose and repeat 72 hours later. The EMAR showed that staff administered both doses to R#8 as prescribed. On 6/8/26 at 9:26 AM, Staff C, Certified Medication Aide (CMA), stated that when a medication changes or finishes but medication remains in the blister pack, staff place it in a bag labeled return to pharmacy inside the locked medication room. Staff C didn't know when the pharmacy picked up the bag. On 6/8/26 at 11:53 AM, Staff H, Licensed Practical Nurse (LPN), stated that if a medication is discontinued or completed, she sends it back to the pharmacy using the bag in the locked medication room. On 6/10/26 at 12:52 PM, the Director of Nursing (DON) confirmed that the facility's protocol for discontinued medications involves placing them in a bin within the locked medication room for return to the pharmacy. She noted that although the pharmacy makes daily deliveries, she didn't know how frequently the pharmacy picked up the return bins. Furthermore, the DON acknowledged that the facility needs to improve this current process. On 6/8/26 from 3:06 PM to 3:20 PM, an observation revealed the medication cart and treatment cart left unattended in the back hallway. On 6/8/26 at 4:12 PM, Staff A, Licensed Practical Nurse (LPN), reported she hadn't used the treatment cart during her shift yet, which started at 2:00 PM, so she didn't know how long it remained unlocked. Staff A reported she sometimes has trouble remembering to lock the medication cart when she works down a certain hallway, and she acknowledged that staff left the carts unlocked and unattended. On 6/9/26 from 9:24 AM to 10:10 AM, an observation revealed the treatment cart in the back hallway unlocked while staff came and went from the area, and three residents wheeled past the cart. On 6/9/26 from 10:15 AM to 10:19 AM, an observation revealed the medication cart on the Pars hallway left unlocked and unattended. On 6/10/26 from 9:30 AM to 9:32 AM, an observation revealed the medication cart on the Pars hallway left unlocked and unattended. On 6/10/26 at 9:44 AM, the Administrator reported that when staff members working the medication and treatment carts aren't within arm's reach of the carts, they must lock them. She acknowledged that staff leaving the carts unlocked and unattended creates a problem. The facility policy titled Medication Administration-Medication Pass dated May 2023 directed staff to secure carts as required.

Based on observations, and staff interview the facility failed to keep the daily nurse staff posting current for 2 of 4 days during the survey. In addition, the facility failed to post the number of hours nursing staff worked for 4 of 4 days during the survey. The facility reported a census of 71 residents. Findings include: On 1/11/26 at 11:23 AM witnessed the facility's Nurse Staff Posting dated 1/10/26 (the day before) posting up. In addition, it lacked the number of hours staff worked. On 1/12/26 at 2:03 PM observed the facility's Nurse Staff Posting lacked the number of hours staff will work. On 1/13/26 at 12:51 PM witnessed the facility's Nurse Staff Posting lacked the number of hours staff will work. On 1/14/26 at 9:14 AM observed facility's Nurse Staff Posting dated 1/13/26 (the day before) staff posting up. In addition, it lacked the number of hours staff worked. On 1/14/26 at 10:04 PM the Administrator reported the facility's night shift nurse completed the Nurse Staff Posting. The Administrator explained it should be current every day. She acknowledged the staff didn't complete the section for nurse hours worked 1/12/26 and 1/13/26 staff posting. She added she didn't have one completed for 1/11/26 and 1/14/26.

Based on observation, policy review, staff, and resident interviews, the facility failed to serve rooms trays at or above 135 degrees Fahrenheit ( F) for 3 of 3 test trays and 4 of 12 resident interviews (Resident #54, #34, #78, and #63). The facility reported a census of 71 residents. Findings include: 1. Resident #54's Minimum Data Set (MDS) assessment for Resident #54 dated 10/13/25 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/12/26 at 9:00 AM Resident #54 reported she ate in her room and the food is not always the hottest. 2. Resident #34's MDS assessment dated [DATE] documented a BIMS of 13, indicating no cognitive impairment. On 1/12/26 at 10:36 AM Resident #34 said sometimes the food is not hot enough. 3. Resident #78's MDS assessment dated [DATE] documented a BIMS of 15, indicating no cognitive impairment. On 1/11/26 at 11:02 AM Resident #78 reported the hot food is not always hot enough. 4. Resident #63's MDS assessment dated [DATE] documented a BIMS of 11, indicating moderate cognitive impairment. On 1/12/26 at 12:07 PM Resident #63 stated the food is not good and she had cold tomato soup the other day. She added the staff will reheat it if you ask them too. On 1/13/26 the noon meal observation revealed food temperatures prior to serving on the steam table at 11:24 AM: Mashed potatoes 207 F Roast beef 195.6 FSquash 177 F. On 1/13/26 at 11:34 AM the observation of the PARS meal tray cart leaving the kitchen of the test tray food temperatures for the facilities PARS cart on 1/13/26 at 11:45 AM revealed the following temperatures below 135 F: Mashed potatoes 134.7 FSquash 126.3 F. On 1/13/26 at 11:58 AM the observation of test tray food temperatures for the facilities Front and Center cart revealed the following below 135 F: Roast beef 133.1 F Squash 127.4 F.On 1/13/26 at 12:19 PM the observation of test tray food temperatures for the facilities Back cart revealed the following below 135 F: Squash 133 F.Observation of the steam tables final temperatures after completion of meal services on 1/13/26 at 12:11 PM revealed the following: Roast beef 200 FNo mashed potatoes left to checkSquash 169.9 F.During the observation of rooms trays on 1/13/26 from 11:24 AM to 11:58 AM revealed dietary staff preheated hot plates prior to using, and left them sitting on the counter. On 1/14/26 at 12:19 PM the Administrator, Director of Nursing (DON), and Infection Preventionist reported they expected the dietary staff to heat the hot plates up as they use them and not in advance. Review of the facility's policy Monitoring Food Temperatures for Meal Service, reviewed 2020 instructed food temperatures of hot foods on room trays at the point of service are preferred to be at 120 F or greater to promote palatability for the resident.

Based on observation, staff interviews, and policy review the facility failed to use an 8 ounce (oz.) scoop to serve mashed potatoes as the menu instructed and instead used a 6 oz. scoop resulting in an unknown amount of room trays and 13 of 13 residents in the dining room receiving less mashed potatoes than the menu instructed. The facility reported a census of 71 residents. Findings include: The review of Week 4, Week at a Glance with Portion (facility menu) instructed to serve mashed potatoes with a #8 scoop and roast beef with a 3-ounce (oz.) scoop. On 1/13/26 at 12:28 PM after completion of meal service Staff D, Cook, reported she used a green scoop and thought it was a #8 scoop but instead it was a #6 scoop. She explained she used it for all residents she served mashed potatoes. She added she used a 6 oz. scoop to serve roast beef to all the residents as well and not a 3 oz. as the menu instructed. An observation on 1/13/26 at 12:29 PM of the dining room revealed 8 of 13 resident plates had no mashed potatoes left on their plates, indicating they ate them all. In an interview on 1/14/26 at 12:19 PM the Administrator, Director of Nursing (DON), and Infection Preventionist, reported they expected the staff to follow the menus.Review of Menu Planning and Requirement policy, reviewed 2020 instructed menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served.

Based on observation, staff interviews, and policy review the facility failed to have 2 of 2 cooks able to explain the puree process and procedure. The facility reported a census of 71 residents. Findings include: The review of the Week 4, Week at a Glance with Portion (facility menu) instructed to serve 3 ounces (oz.) of roast beef and 4 oz. of roasted butternut squash. On 1/13/26 at 10:59 AM observation of the puree process for 4 residents revealed Staff E, Cook, didn't measure the roast beef or squash after pureeing in the blender to ensure they provided equal portions. On 1/13/26 at 11:12 AM Staff E reported she didn't use a measuring cup after pureeing the food. She instead uses the scoop size as directed on the menu and never got trained to measure the pureed food. She asked Staff D, Cook, who oversaw the kitchen while the Certified Dietary Manager is off, to help her. Staff D explained they didn't measure the pureed food after pureeing; they use the scoop size directed on the menu. Staff D and Staff E added they didn't use a guide to instruct them on what serving size to use. On 1/13/26 at 12:20 PM after completion of meal service, Staff D informed 1 of 4 residents who received a pureed diet is not at the facility. The explained that is why they had extra puree left. Observation of the roast beef and butternut squash revealed they had about one serving remaining. In an interview on 1/14/26 at 12:19 PM the Administrator, Director of Nursing (DON), and Infection Preventionist reported Staff D and Staff E did have training on the puree process. They didn't know why did not measure the pureed food on 1/13/26 during the meal observation. Review of the facilities, Pureed Food Preparation policy reviewed 2020 instructed staff to serve with an appropriate scoop number or to divide the food equally to provide an equal number of portions and all of the pureed food must be used in order to deliver the correct nutrient density to each resident. The number of servings obtained from the pureed recipe must equal to the number of servings from which it started. For example, if ten servings of the regular recipe are to be pureed, follow the pureed recipe for ten servings. The yield of the pureed recipe must give you ten equal pureed servings. If the recipe was altered, the scoop size may also need to be altered. Due to the nature of variance in foods, it is possible that slight alterations or not using all the liquid in a recipe will be required. Therefore, the division of an equal portion of final product to the starting number of servings insures equal nutritive value in each portion.

Based on observation, clinical record review, policy review, manufactures instructions for use, and staff interviews, the facility failed to properly prime an insulin pen before administering for 1 of 2 residents observed (Resident #22). The facility reported a census of 71.Findings include:On 1/12/26 at 11:20 AM, observed Staff A, Licensed Practical Nurse (LPN), attempt to prime the insulin pen. Staff A turn the dial on the Humalog insulin pen to 2 units without the needle on and pressed the plunger of the insulin pen. After Staff A placed the needle on the pen and set the insulin pen to 10 units, she indicated being ready to administer the insulin to Resident #22. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS listed a diagnosis of diabetes mellitus. Resident #2 used insulin seven days a week in the lookback period. The Order Review History Report acknowledged by the provider on 1/8/26 listed the following physician orders:Humalog Injection solution 100 units (U) per milliliter (ML) injection 4 units subcutaneously 3 times a day for diabetes.Humalog Injection solution 100 U/ML inject 6 units per sliding scale for a blood sugar of 251-300 subcutaneously 3 times a day.On 1/12/26 at 11:20 AM observation of Staff A insulin administration. Staff A wiped insulin pen with alcohol prep, turned the pen dial to 2 units before pen needle was attached to the pen, turned the dial to 10 units. Staff A verbalized she was ready to administer insulin. On 1/12/26 at 11:21 AM Staff A said she thought she prepped the pen to get the air out of the pen. She didn't know the pen needed to have the needle in place to clear the needle of air. On 1/13/26 at 2:10 PM the Administration reported she knew of the medication error and the facility already started educating the nurses on prepping the insulin pen prior to administration.On 1/14/26 at 11:24 AM the Director of Nursing (DON) explained she expected the nurse to place the needle on the insulin pen prior to priming. The DON added she already started providing staff education. The facility's Medication Administration: Injections policy revised April 2024 instructed to prime the insulin per manufacturers guidelines. The Manufacturer's Step by Step guide to using a Humalog KwikPen directed the following to prime the insulin pen: Wipe the pen tip (rubber seal) with an alcohol swab.Remove the protective seal from the new needle.Line the needle up straight with the pen and screw the needle on. Dial a test dose of 2 Units.Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose.Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again.

Based on observation, record review, policy review, resident and staff interviews the facility failed to implement and maintain a restorative program for 2 of 2 residents reviewed (Resident #17 and # 26). The facility reported a census of 71 residents. Findings include:1. Resident #17's Minimum Data Set (MDS) assessment dated [DATE] the Staff Assessment for Mental Status listed her with severely impaired cognition. Resident #17 required maximal assistance to roll in bed. The staff didn't attempt sit to stand due to medical conditions. The MDS listed Resident #17 as dependent with bed to chair transfers. The MDS included diagnoses of encephalopathy (disease or disorder that changes brain function causing altered mental state), leukemia (cancer of the blood), high blood pressure, chronic kidney disease (gradual loss of kidney function), hyperlipidemia (high cholesterol), dementia (decline in mental ability), convulsions, anxiety, depression, irregular heartbeat, and reduced mobility. The MDS lacked documentation of a restorative program. The Occupational Therapy (OT) Discharge summary dated [DATE] listed the prognosis to maintain current level of function (CLOF) as excellent with consistent staff support. Resident #17's husband would verbalize and demonstrate understanding of safe Restorative Nursing Program techniques with no more than 1 verbal cue from OT. The Husband demonstrated proper passive range of motion (PROM) techniques. The Husband demonstrated proper PROM techniques. The Summary listed a Restorative Program to provide gentle PROM to both upper extremities 1-2 times a day to maintain comfort and joint mobility. Stop if Resident #17 showed discomfort and don't force any range. The Summary lacked direction of who would provide the Restorative Program. The Care Plan Focus initiated 8/4/25 indicated Resident #17 complained of pain described as chronic generalized discomfort. The Goal reflected Resident #17 wouldn't have an interruption of normal activities due to pain. The Care Plan lacked the OT recommended Restorative Program from 12/26/25. Resident #17 Kardex/Tasks lacked documentation of a Restorative Program. On 1/12/26 at 9:26 AM Resident #17's Representative verbalized the staff just didn't do the Restorative Program consistently. On 1/13/26 at 2:23 PM Staff B, Certified Nursing Assistant (CNA), verbalized Resident #17 didn't have a Restorative Program. If a resident had a Restorative Program, the staff chart on it in the Electronic Health Record (EHR). On 1/13/26 at 2:25 PM Staff C, CNA, explained if they needed to do exercises for a resident, they are in the EHR. On 1/13/26 at 2:48 PM the Director of Nursing (DON) and Administrator reported when therapy discharges a resident with a program, the Director of Rehab let the DON and Administrator know. The staff document the program in the EHR for a resident with a Restorative Program. The progress of residents with a restorative program is reviewed at the weekly staff meeting. The DON and Administrator reported they expected if therapy recommended a restorative program, then the program is started and ensured that it is done correctly. On 1/13/26 at 3:53 PM the DON and Administrator spoke to the Director of Rehab. The Director of Rehab described Resident #17's Restorative Program as more for the husband to do. The facility policy titled Nursing Rehabilitation/Restorative Care revised May 2025 defined the Purpose as to improve or maintain function in physical abilities, activities of daily living (ADL), and prevent further impairment. The policy directed a rehabilitation, or restorative practice should attempt to meet the criteria of the activities carried out or supervised by members of the nursing staff. The staff would determine the need for rehabilitation/restorative care through a comprehensive assessment and/or skilled evaluation. 2. Resident #26's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. Resident #26 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting, transfers, walking, and lower body dressing. The MDS included diagnoses of hypertension (high blood pressure), respiratory failure (a condition where your lungs cannot properly perform their primary job), and Parkinson's disease (a brain disorder that makes it hard to control movement, causing symptoms like shaking or tremors, stiffness, slow movements, and balance problems because the brain doesn't produce enough dopamine, a crucial chemical for smooth motion). The Care Plan Focus initiated 5/8/25 reflected restorative active ROM (AROM) to upper and lower extremities for 3 repetitions (reps) for 3 sets or attend group exercise for 15 minutes per day as tolerated. The Goal listed Resident #26 would improve or maintain walking ability of 200 feet with a front wheeled walker (FWW) with one assist as tolerated within next review. The Interventions instructed the staff the following: Follow therapy recommendations as applicable Encourage to participate in restorative programs Provide ROM exercises per resident needs. The Physical Therapy Initial Evaluation document dated 4/20/25 recommended Resident #26 walk with nursing staff 4 times a day in the halls. Encourage active exercises of upper extremities and lower extremities. The review of Resident #26's Restorative documentation on 1/13/26 related to her walking to improve/maintain walking ability of 200 feet with FWW with one assist as tolerated revealed staff documented completion 1 time out of 13 days in January 2026 and 2 times out of 31 days in December 2025. Both month lacked documentation of refusal to complete the Restorative Program. On 1/12/26 at 3:16 PM Resident #26 reported she would like to walk more. Therapy told her she should walk more and she would like to participate in a Restorative Program. On 1/13/26 at 4:30 PM the Administrator explained the staff should complete the walking restoratives for the Resident #26 and informed staff have only been documenting restoratives as needed. On 1/13/26 at 4:31 PM the Director of Nursing (DON) acknowledged the staff didn't document Resident #26's walking restoratives. They expected the staff to document the completion of her Restoratives.

Based on observations, record review, resident and staff interviews and policy review, the facility deprived a resident of care by failing to communicate in a respectful manner during bedtime care, abandoned the resident in a vulnerable state and failed to respond to the resident's requests for necessary care resulting in the resident's ongoing fear and anxiety. Resident #4 stated on 10/13/25 one of the two nursing staff was arguing with her about her preference of care. Both nursing staff knowingly left Resident #4 on her bed, soiled with urine, without a cover and no staff answered the light for approximately an hour. Resident #4 began crying and expressed fear as her phone was placed out of reach by staff and she had no way of getting assistance as staff would not come when she called out for help. When Resident #4 requested the staff to get the Director of Nursing (DON) so she could report the abuse, the DON refused to respond. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 13, 2025 on October 29, 2024 at 12:20 p.m. The facility staff removed the Immediate Jeopardy on October 30, 2025 by implementing the following actions:1. On 10/14/25 resident #4 had a skin assessment completed by DON with no findings and had a routine skin alternation sheet completed on 10/16/2025 by Staff A, Licensed Practical Nurse (LPN).2. On 10/16/25 resident #4 was assessed by Staff B, Advanced Registered Nurse Practitioner (ARNP), new orders received and followed. 3. On 10/22/25 resident #4 was assessed by Staff C, Nurse Practitioner (NP) psychiatric provider, new orders received and followed. Resident #4 will continue to receive services from Staff C weekly for 4 weeks and reassessment will be completed after that. 4. The alleged staff will no longer provide care to resident #4. 5. Interviews with alert and oriented residents on 10/14/25 regarding abuse and call light response completed. 6. Education was completed on 10/29/25 at 1:30pm with staff regarding reporting allegations of abuse and to whom, preventing abuse and neglect. The abuse policy and guidelines will be utilized for training and education of reporting requirements. Education and training will include chain of command, how to access administrative staff and on-call numbers. Staff will be instructed on preventative measures and protocols to ensure prompt responses and clear communication to prevent similar incidents. Staff unavailable to receive education will receive the education prior to clocking into their next shift. Following education random questionnaires will be completed with staff to prevent potential neglect and abuse. 7. Communication with Residents Skilled Nursing Facility (SNF) Clinic course assigned to all staff on 10/30/2025. The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 72 residents. Findings Include:The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed the diagnoses of congestive heart failure, diabetes mellitus, morbid obesity, anxiety, depression, need for assistance with personal care and was dependent on 2 or more staff for transfers, dressing, toileting and personal hygiene. The brief interview for mental status (BIMS) score for Resident #4 was 15 which suggested an intact cognition. The Care Plan for Resident #4 directed staff to provide clear, concise explanation of anything that was about to occur, talk in a low pitch, calm voice and if strategies were not working, leave (if safe to do so) and reapproach later. Allow for flexibility in activities of daily living (ADL) routine to accommodate Resident #4's mood, preferences, and customary routine. Staff were also directed to reassure Resident #4 if she was upset about her care and discuss her concerns. Resident #4 required the assistance of 2 staff for transfers, dressing and grooming. During an interview on 10/22/25 at 3:52 pm, Resident #4 stated on 10/13/25 about 7:15 pm she had pressed the call light to notify staff she was ready for her usual night time routine that was to be transferred from the recliner to bed with the mechanical lift, remove the sling, cleaned, a clean brief and changed into clean bed clothes. Resident #4 stated Staff D Certified Nursing Assistant (CNA) and Staff E, CNA responded and Staff D began to argue with Resident #4 regarding her preferences of care. Resident #4 stated she told Staff D that she did not want her to come back into her room anymore and the two staff placed her onto the bed, disconnected the mechanical lift, exited the room without changing her and shut the door. Resident #4 stated she turned her call light on with no response for over an hour. Resident #4 stated her phone, I-pad, TV controller and water was on a night stand that was pushed into the bathroom, out of her reach so she was unable to call for help and the TV was on loud so no one heard her when she shouted for help. Resident #4 stated she was thirsty, freezing cold due to air conditioner blowing over her and her brief, the mechanical lift sling that was still under her was soaked with urine and she did not have a blanket to cover herself with. Resident #4 stated she became frantic, sobbing, could not catch her breath and was stranded. Resident #4 stated, It hurt me so deep. Resident #4 stated Staff F, CNA found her and stated she wanted her phone to call the police to report the abuse. Resident #4 stated Staff F calmed her down, cleaned her up and said the Director of Nursing (DON) was in the building, working as a charge nurse on a different hall, where Staff F was working. Resident #4 stated she requested to talk to the DON to report this. The DON did not want to deal with it. Resident #4 stated she felt Staff D left her in that condition on purpose as punishment. Resident #4 stated in the morning on 10/14/25 she asked to speak with the Administrator to report the abuse. Resident #4 stated she had asked her provider for an antianxiety medication to take during the day and at night as the staff that abused her continued to work at the facility and walk past her room and she had on going fear, anger and anxiety. Resident #4 stated the office manager said she should shut her door so she won't see Staff D and Staff E walk by her room and stated her response was that she should not have to live behind a closed door. During an interview on 10/23/25 at 1:21 pm, Staff G, CNA stated she had taken care of Resident #4 before 10/13/25, that she was anxious but it had increased after 10/13/25. Staff G stated Resident #4 reported two nursing staff were not nice and left her for over an hour and had increased in her requests for Lorazepam. During an interview on 10/23/25 at 2:14 pm, Staff F, CNA stated she worked on the back hall on 10/13/25 with the DON as her charge nurse. Staff F stated she had gone to the front hall shower room at approximately 8:30 pm, directly across from Resident #4's room, to gather a gown for her back hall resident. Staff F stated the charge nurse on the front hall, Staff H, RN directed her to answer the call light that had been on for a while. Staff F stated Staff H did not usually ask for her to answer a call light, she would answer it. Staff F stated she had provided care for Resident #4 before and when she entered the room she found Resident #4 distraught, screaming, and Staff F stated she had never seen Resident #4 in that condition, her face red and her veins bulging. Staff F stated Resident #4 was laying on top of the mechanical lift sling, not covered, as she usually had a sheet over her legs and her fleece blanket so she could reach it if she was cold. Staff F stated she calmed Resident #4 so she could form words and Resident #4 stated her nursing staff left her in that condition. Staff F stated Resident #4 was wet and the air conditioner was blowing on her, which she usually would have staff turn it away from her when in bed. Staff F stated this broke her heart as she did not like to see her residents distraught and comforted her, changed her wet clothes, changed her brief, provided cream and powder. Staff F stated Resident #4's phone was on a table out of reach and Resident #4 requested to use it to call 911. Staff F stated at that time she had opened Resident #4's door, Staff D, CNA walked past and Resident #4 shouted That's her, she left me like this and was yelling bulldog, like it was a trigger for her anxiety. Staff F stated she had stayed with Resident #4 until she had calmed and asked to report the abuse. Staff F stated she was aware that Staff H heard Resident #4 as the door was open and she was standing outside the room with the DON. Staff F stated the DON asked her to shut the door as Staff F explained what happened the DON left. Staff F stated the DON had disregards to everything she told her and felt the DON should have addressed the situation.During an interview on 10/27/25 at 12:59 pm, Staff K, DON stated she was the former Director of Nursing and was terminated on 10/16/25 due to allegations of abuse. The DON stated she had worked on 10/13/25 as the DON on the day shift and as a charge nurse 2 pm to 10 pm on the back hall. The DON stated Staff D, CNA and Staff E, CNA asked the staff in the back hall to provide care for Resident #4. The DON stated Staff L, CNA and Staff F, CNA had provided care for Resident #4 and Staff H, RN had addressed it and she calmed down. The DON stated she had spoken to Staff F about 9 pm and asked if anything needed to be addressed and Staff F said no it was under control. The DON stated she did not enter Resident #4's room as she was to be provided care in pairs and the charge nurse Staff H stated Resident #4 was doing what she always does and kicked the CNA's out of her room and left it to be addressed in the morning. The DON stated she did not know the reason for the CNA's to be kicked out of the room. The DON stated she reported to the Administrator that Resident #4 treats all staff that way. The DON stated she consulted with Staff C, Nurse Practitioner for Psychology as Resident #4 was verbally aggressive to the staff. The DON stated she had not received a 'write up' before that day and was terminated. During an interview on 10/27/25 at 2:12 pm, Staff J, RN stated two weeks ago on day shift, her nursing staff reported that Resident #4 wanted to report abuse. Staff J stated Resident #4 asked to speak with the Administrator. Staff J stated Resident #4 was not difficult to provide care for and she got along with her. During an interview on 10/27/25 at 3:07 pm, Staff I, CNA stated he worked on 10/13/25 at 2 pm with Resident #4, who was in a pleasant mood and had no problems working with her. Staff I stated he had to leave the facility for a personal matter early in the shift and was off work for 10 days. Staff I stated when he returned, he seen a change in Resident #4, stressed and upset. Staff I stated he was providing care on this day and she was good as he stated being her favorite aide. During an interview on 10/27/25 at 12:10 pm, Staff E, CNA stated she was a new CNA and employed for 4 months in the facility, had not received the adult abuse training. Staff E stated the only training she had received was how to transfer a resident with a mechanical lift by another CNA, learn as you go here. Staff E stated she had worked front hall on 10/13/25, assisted Staff D, CNA to transfer Resident #4 from her recliner to bed and Staff D began to argue with Resident #4. Staff E stated Resident #4 told Staff D to get out and yanked the bed controller out of her hand. Staff E stated she was not told to get out but was aware the resident needed two staff to provide care so she also left the room. Staff E stated she reported to Staff L, CNA on the back hall that she needed help and Staff E would assist when she was through providing care for her residents. Staff E stated about 20 mins after that, she witnessed Staff F, CNA entering Resident #4's room and heard Resident #4 screaming. Staff E stated she told Staff H, RN her charge nurse on front hall who gave direction to ignore the resident. Staff E stated she reported Resident #4 screaming and it was escalating to the DON who stated she would take care of it. Staff E stated the next day, she was passing snacks in the front hall, Resident #4 stated she should be ashamed of her actions. Staff E stated that was the first altercation she had gone through, did not know what to do and the Administrator gave her direction not to enter Resident's room again. Staff C stated she was suspended for one day and it was not explained why and received assignment to work in the skilled unit, away from front and back hall. Staff C stated she did not receive further training. During an interview on 10/28/25 at 8:41 am, Staff D, CNA stated she had been employed by the facility for 13 years and had completed adult abuse training but the facility had not provided any training for 3 months. Staff D stated she had worked as a float staff on 10/13/25 and on or about 7:30 pm, she assisted Staff E, CNA to transfer Resident #4 from her recliner to her bed. Staff D stated Resident #4 gave direction to be lifted higher in the mechanical lift and Staff D stated she told Resident #4 that she knew what she was doing. Staff D stated she was aware Resident #4 had a routine and she had moved her night stand with her water, phone and other things into the bathroom but did not adjust the air conditioner. Staff D stated Resident #4 got mad because they ran her charger cords over with the mechanical lift as the room was not big enough for the recliner. Staff D explained while Resident #4 was in the air on the mechanical lift, staff have to move the recliner back and out of the way. Staff D stated Resident #4 thought she was queen bee and that was why she needed care in pairs. Staff D stated Resident #4 kicked her out, told her to just leave and Staff E can put her to bed. Staff D stated after they lowered Resident #4 onto the bed, Resident #4 took the remote from Staff E and then both staff left the room. Staff D stated Resident #4 turned the call light on, the charge nurse Staff H, RN knew about the situation so she went to another resident's room to provide care and Staff E went to the back hall to ask staff to assist her. Staff D stated it took about 15 minutes to help the other resident then she went on her 30-minute break and when she returned, Resident #4's call light was still on. Staff D stated she went to the back hall to ask Staff L, CNA if anyone had requested her to assist with Resident #4 and she had stated yes, but had not been able to assist. Staff D stated she had provided night time care for Resident #4 only one time about four months prior to that day. Staff D stated she and Staff E then talked to Staff H, RN who directed them to talk with the DON who directed them to write a statement as she was leaving the facility. Staff D stated it was about 9 pm, she walked past Resident #4's room and the door was open and Resident #4 shouted bulldog and other bad names. Staff D stated she was not provided a training from administration, directed to not go into Resident #4's room and received a one-day suspension. During an interview on10/28/25 At 9:56 am, Staff L, CNA stated she worked in the back hall on 10/13/25 for the 2-10 pm shift. Staff L stated she was providing care to a resident when Staff E, CNA entered the room and started to talk about Resident #4 in front of her resident and said Staff D was helping her adjust the chuck (the absorbent pad used for incontinent residents) and Resident #4 began screaming they were not putting her to bed the proper way. Staff L stated Staff E explained they used the mechanical lift to put Resident #4 to bed, nothing more about an hour before and they wanted her to provide the night care for Resident #4. Staff L stated she informed Staff E that it may be an hour or more wait as she was providing care to her residents. Staff L stated she was not assigned or reassigned to Resident #4. Staff L stated about 8:30 pm, Staff F, CNA went to the front hall to gather gowns from the shower room. Staff L stated Staff F returned about 9 pm mad due to Staff H, RN telling her to have fun in Resident #4's room and she had found Resident #4 screaming. Staff L stated the DON stated to pretend she was not there, shut Resident #4's door and she would deal with it the following day. Staff L stated Resident #4 was perfectly within her mind, she can explain clearly step by step what she wanted done and each time care was provided, she was nice. Staff L stated about 9:45 pm, she went to the front hall to check the schedule book and found Staff E laughing at the nurse station about Resident #4 who wanted to call 911 to have her arrested. Staff L stated the administration did not conduct any training and no one had spoken to her about the incident. On 10/28/25 at 12:55 pm, Staff H, RN stated that she was aware of the incident on the evening of 10/13/25. Staff H stated she was administering evening medications and heard yelling from Resident #4's room, Staff D, CNA left the room with Staff E, CNA, shut the door, stated Resident #4 had banned Staff D from the room, and Resident #4 grabbed the controller from Staff E's hand so she did not want to go back in the room. Staff H stated she directed the CNA's to talk to the DON on the back hall, which was protocol, and continued working. Staff H stated one CNA went back and talked to DON. Staff H stated Resident #4 put her call light on and Staff E was afraid to answer the call light. Staff H stated she did not remember how much time passed before Staff F, CNA came from the back hall as she had worked steady and rarely gets time to eat. Staff H stated Staff F entered Resident #4's room, then came out and reported Resident #4 was very upset and did not want Staff D back into her room again but did not state Resident #4 wanted to talk to anyone about abuse. Staff H stated every time Staff D walked past Resident #4's room she yelled at her and when Staff E walked past the room, Resident #4 said 'how could you do this to me'. Staff H stated she was in Resident #4's room later without complaint, exited, closed the door, and the DON was in the hall, walked to the other side of the hall and stated 'she would deal with this in the morning'. Staff H stated Staff F, CNA who provided care for Resident #4 told the DON what happened. Staff H stated there are a lot of residents with needs and it is not an easy place to work. A review of the Progress Notes for Resident #4 on 10/13/25 failed to have documentation of the incident. During a follow-up interview on 10/29/25 at 11:36 am, Staff F, CNA stated on 10/13/25 the DON was absolutely aware that Resident #4 wanted to report abuse. The DON was standing outside of Resident #4's room when she asked to speak with her. Staff F stated she told the DON that Resident #4 was going to call 911 and wanted to report the abuse to her. Staff F stated she could not believe the DON did not go in to talk with Resident #4 as this could have been prevented. Staff F stated there were no staff training that was completed since this time and she did not want this to happen to another resident.Incident Report: alleged abuse/neglect dated 10/14/25 at 9 am revealed:1. Staff J, RN filed a report for Resident #4.2. The description of a CNA who reported to the nurse that Resident #4 wanted to talk to the Administrator to report abuse that occurred last evening 10/13/25. 3. The nurse immediately informed the Administrator.4. No injuries noted.5. Predisposing physiological factor listed anxiety.6. Person notified Staff B, Advanced Registered Nurse Practitioner (ARNP) on 10/14/25 at 9:26 am. During an interview on 10/28/25 at 3:56 pm, Staff B ARNP stated she had resumed Resident #4's cares this year and she had manipulative behaviors, anxiety and depression. Staff B stated was informed on 10/15/25 Resident #4 was crying, anxious, mad and gave the order for the Lorazepam to be administered immediately before she went to her eye appointment but was not administered as the resident exited the facility for the appointment. Staff B stated she did not visit Resident #4 until 10/16/25 and she was anxious, face red, her body language was different and she reported feeling depressed since the day of the incident. Staff B stated Resident #4 intertwines anxiety and depression. Staff B stated Resident #4 was more anxious and angrier and said I can't believe that happened several times. Staff B stated she ordered Lorazepam as needed and the increased the Lexapro antidepressant medication after consulting Staff C, ARNP Neuropsychology. The Physician Orders for Resident #4 revealed:1. Lexapro 5 milligram (mg) administer 2 tablets daily dated 10/16/25 at 6 pm. 2. Lorazepam 0.5 mg administer 1 tablet every day dated 10/16/25 1 pm with end date 10/30/25. The Medication Administration Record (MAR) dated October 2025 for Resident #4 revealed:1. Lexapro 5 mg 1 tablet at bedtime for anxiety was administered 10/1/25 through 10/15/25.2. Lexapro 5 mg 2 tablets at bedtime for anxiety were administered daily after 10/16/25.3. Lorazepam 0.5 mg 1 tablet for anxiety 1 tablet, 1 time only, dated 10/14/25 not given.4. Lorazepam 0.5 mg 1 tablet every 12 hours as needed (PRN) anxiety administered daily after 10/16/25 and two times on 10/19/25. During an interview on 10/28/25 at 4:27 pm, Staff C, ARN Neuropsychology stated the Assistant Director of Nursing (ADON) reported an incident on 10/13/25 with Resident #4. Staff C stated she was unable to visit her until 10/22/25 when Resident #4 reported having had an argument with Staff D, CNA, abandoned when wet with urine, cold, no call light or phone. Staff C stated Resident #4 was angry, face red, pressured speech, loud, talking fast, taking Lorazepam due to the anxiety, stated I cannot believe this happened multiple times. Staff C stated Resident #4 did not feel she needed to close the door as she was instructed by facility staff when the CNA's that were involved in the incident worked. Staff C stated it was a resident right issue with closing her door. Staff C stated during the last visit with Resident #4 on 10/8/25, she was doing well and was titrated to a lower dose of Lexapro (5mg), her mood improved and was happy while shopping with her sister. Staff C stated the situation on 10/13/25 set her back. Staff C stated the Administrator was not available on 10/22/25 to report the ongoing anxiety but did contact her by phone and she stated the facility investigated it. The Progress Note titled Encounter, Staff C, ARNP Neuropsychiatry dated 10/8/25 for Resident #4 revealed:1. Resident #4 received a revisit for further evaluation of anxiety as she spoke of having her call light in for hours and staff being lazy.2. Resident #4 was oriented, spoke clearly with logical thought, engaged, cooperative, and good eye contact.3. Resident #4 admits to getting overwhelmed at times and now feels calm and in control again. She considered her mood to be ok. 4. Resident #4 went on a short shopping trip with her sister.5. Resident #4's needs take longer than average to meet and was satisfied with the private room.6. The ordered antidepressant Lexapro 5 mg nightly to continue for continued stability. A documented titled Employee Warning Notice revealed that the DON violated facility policy and procedure when in the facility on 10/13/25 and nursing staff requested that she speak with a resident, made aware that the resident was frustrated and verbalizing extreme dissatisfaction with service from staff, she did not follow up, address or investigate any of her concerns. As a leader within this facility, it is expected that the department heads take the initiative to handle, address, and follow up on patient concerns timely and appropriately. The DON also had past warning notices for not completing an 8-hour shift. The DON was terminated 10/16/25.A review of the Progress Note for Resident #4 on 10/18/25 Resident #4 was replaying what happened on 10/13/25 with a CNA and the nurse came in to report call lights are needing answered. The Progress Note titled Encounter, Staff C, ARNP Neuropsychiatry dated 10/22/25 for Resident #4 revealed:1. Resident #4 stated she had an encounter with a CNA on 10/13/25 during care and told that CNA to leave the room.2. Resident #4 stated the nursing assistant abandoned her during care, prior to changing her, without a blanket covering her, and without access to a phone and believes she was left for an hour and half. 3. Resident #4 discussed the incident that occurred as having caused daily anxiety in the afternoons when the staff member she had the disagreement with works. 4. Resident #4 feels some staff avoid her due to the level of work required for her versus interpersonal skills. Resident #4 did not see how her words affect relationships, feeling angry and frustrated awaiting a resolution. 5. Resident #4 was taking a dose of Lorazepam daily in the afternoon for anxiety.6. The visit diagnosis: Anxiety disorder.7. Plan to continue medication as ordered, to include Lorazepam 0.5 milligram (mg) two times a day as needed for anxiety for 14 days, no referral to a therapist and a follow up scheduled in two weeks. During an interview on 10/29/25 at 10:32 am, The Administrator stated she was notified on 10/14/25 that Resident #14 wanted to report abuse that occurred on 10/13/25. The Administrator stated she had conducted an investigation, suspended Staff D, CNA and Staff E, CNA during the investigation and reported the abuse allegation to the police and the Department of Inspection and Appeals. The Administrator stated a trauma assessment was completed for Resident #4, conducted interviews with other residents that revealed there were no further concerns of abuse or neglect. The Administrator stated the DIAL report returned No Investigation, placed the CNA's back into work status and plan to provide targeted education focused on effective communication strategies when interacting with residents who may be experiencing distress or are difficult to engage. A policy titled Patient Protection Guidelines: Abuse Prevention, Reporting, and Investigation revealed:1. To provide professional care and services in an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.2. Centers can best support the detection and prevention of abuse by implementing a process that supports immediate reporting of suspected abuse. The process should be available to patients, family members, and staff to report abuse in a manner that elicits immediate attention without fear of retribution. The Abuse Prevention Coordinator/Grievance officer should provide feedback to patients, family members and staff regarding any concerns or grievances that have been expressed.3. The center creates and maintains a proactive approach for identifying events that may constitute or contribute to abuse. When investigating whether abuse has occurred, the center identifies and considers events such as behavioral changes, bruising of patients, suspicious patient patterns, unexplained injuries, communication or social interaction changes and other trends that may signify abuse. Any allegation requires an investigation.4. Key to investigating abuse allegations is an environment that facilitates the reporting of such allegations. Once reported, the center conducts a timely, thorough, and objective investigation of the consideration of the indicators of possible abuse.5. Following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee may be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the State Department concludes its investigation and issues the written results of its investigation.6. 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.7. In response to allegations of abuse, neglect, exploitation, or mistreatment, injuries of unknown origin, or misappropriation the facility must: - Have evidence that all alleged violations are thoroughly investigated. - - Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report all allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections, Appeals and Licensing and any other required state agency if applicable (ie: law enforcement). Reports of abuse or if there is resulting bodily injury, the facility should report immediately and not later than two (2) hours. Allegations of neglect, exploitation, misappropriate of resident property, or mistreatment to be reported not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Based on observation, clinical record review, document review, policy review, resident and staff interviews, the facility failed to keep resident's free from financial exploitation (abuse) when a staff member utilized a resident's credit card to pay their personal cell phone bill for 1 of 4 resident's sampled (Resident #7). The residents gave the staff money, credit, and/or debit cards to purchase pop for them from the vending machine. The staff reported they always did this, especially for residents who couldn't get out of bed to get the pop themselves. After 1 resident discharged from the facility, the resident received a phone call from her bank regarding an overdraft charge for a cellular phone bill, the resident contacted the police who started an investigation. The investigation determined the name on the cellular phone account belong to a staff member, Staff A, Certified Nurse Aide (CNA), who worked at the facility during the time Resident #7 lived at the facility. The facility identified a census of 74 residents. Findings include: Resident #7's Clinical Census reflected she admitted to the facility on [DATE] and discharged on [DATE]. She resided in room [ROOM NUMBER]-B in the back hallway at that time. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] indicated she had adequate hearing, clear speech, the ability to understand communication and be understood. She had adequate vision without corrective lenses. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #7 did not exhibit any behaviors. The MDS listed Resident #7 as dependent upon staff for bed to chair transfers, she couldn't walk, and required full staff assistance once up in a wheelchair. Resident #7 had frequent pain, that she rated a level 4 out of 10 which required scheduled and as needed pain medication. The MDS included diagnoses of paraplegia (loss of movement and sensation in the lower part of the bod), stage four (deep wounds into the bone) pressure ulcers of the sacrum, right hip, left hip, osteomyelitis (bone infection) of the vertebra, lumbosacral (lower spine) region, diabetes mellitus, anxiety and depression. The MDS reflected Resident #7 had 3 pressure ulcers that received care. The Compliance Plan Receipt and Acknowledgement signed by Staff A on 11/5/24 reflected she acknowledged she received a personal copy of the company Code of Ethics. In addition, she read and fully understood the Code of Ethics and agreed to comply with the Code of Ethics. An Iowa Incident Report dated 12/2/24 at 3:46 PM identified the police officers responded to a call about credit card fraud. The Iowa Incident Report listed Resident #7 as the victim. Resident #7 stated her bank notified her someone used her credit card on 11/19/24 to (pay) a cellular phone bill for $417 or $418 dollars. Resident #7 did not utilize that cellular phone services. Resident #7 reported she lived at the facility from 10/14/24 to 11/27/24 and thought an employee of the facility used her card. An Investigation Summary dated 2/25/25 - 2/28/25 completed by the facility listed the Summary of Alleged Incident as a Police Officer notified the Administrator on 2/25/25 that Resident #7, contacted the police department after she left the facility about credit card fraud. The Police Officer showed the Administrator a subpoenaed cellular phone bill with Staff A's name on it as the account holder. The Critical Information Obtained During the Investigation summary noted Resident #7 gave her cash app card and her bank card to staff to get her pop from the vending machine. Resident #7 reported Staff B, Licensed Practical Nurse (LPN), reported she couldn't take her card, but other staff took her card to the vending machine to get her pop. Resident #7 reported Staff C, CNA; Staff D, CNA; Staff E, CNA; and Staff F all got her pop from the vending machine. Resident #7 identified other staff also got her pop, but she couldn't remember who else, other than both nurses and CNAs. Resident #7 believed someone stole her credit card information when the staff got her pop from the vending machine. She received a call from her bank when a charge to her card made her account negative. At that time, she contacted the police. In addition, Resident #7 reported to the Administrator a staff member helped her pay her WIFI bill on-line. That CNA didn't have a pen or paper during the incident so she didn't believe it happened then. The Administrator called Staff A on 2/26/25. Staff A reported she didn't take any residents' card to pay her phone bill. She didn't know who Resident #7 was and didn't work at the facility long. Staff A reported she never worked in the back hall. A review conducted on 3/17/25 at 1:00 PM of Staff A's Employee File revealed an Iowa Record Check Request Form S dated 5/17/24. The results section had an X marked for computerized criminal history (CCH). The Record Check Evaluation completed on 5/20/24 reflected Staff A may work at the facility. The Single Contact License & Background Check complete as of 10/30/24 listed the report required further research. The Iowa Criminal History Results dated 11/4/24 indicated the search resulted with an Iowa Criminal History Record Found. The section labeled Criminal History Record Information listed a history of third-degree theft that turned into a fourth-degree theft. The charge resulted in a non-conviction with a deferred judgement of $315 civil penalty and a 12-month probation. Staff A's Employee File contained a verbal One-to-One In-service Record review dated 11/8/24 regarding her unsatisfactory work performance including, but not limited to, her failure to complete work assignments, incompetence, or poor performance of work assignments. An Iowa Incident Report Supplemental (Police Department) dated 4/2/25 documented on 2/14/25 the officer received with the name of the cellular phone service account holder. The account paid with Resident #7's credit card returned as Staff A. A 4/28/25 review of Staff A's Iowa Time Card Report revealed the following work hours: a. 11/6/24 In at 9:38 PM; out at 6:06 AM; total hours 7.45. b. 11/7/24 In at 9:47 PM; out at 6:02 AM; total hours 7.45. c. 11/10/24 In at 9:42 PM; out at 6:09 AM; total hours 8.0. d. 11/11/24 In at 9:33 PM; out at 6:04 AM; total hours 8.0. e. 11/11/24 In at 9:42 PM; out at 6:09 AM; total hours 8.0. Review of the Daily Staffing Schedules listed Staff A as scheduled to work the back hallway where Resident #7 lived on 11/7/24 and 11/12/24. Interview on 4/28/25 at 2:18 PM Staff G, CNA, voiced the facility had a vending machine in the breakroom with pop machines in the back-hallway lounge and in rehabilitation unit. She reported Resident #14 asked the staff to get her Mountain Dew out of the pop machines. She had a small wallet, that she gave the staff. The staff went right down to the pop machine, used it and brought it right back with the pop. She used the pop machine right across from another resident's room. She assumed other staff get pop for Resident #14. Staff G reported she only worked at the facility for a few weeks, but she didn't receive direction about getting pop for residents when she started at the facility. Interview on 4/28/25 at 2:22 PM Staff H, LPN, reported if a resident wanted a pop, the resident needed to ask the activity coordinator to assist them to the vending machines to get a pop. The staff aren't to assist or take money/cards from a resident to get them pop. She reported it as always supposed to be that way. Interview on 4/18/25 at 3:00 PM Staff J, CNA, reported they used to take Resident #7's money or credit card and swipe it in the pop machine. Afterwards Staff J took her the pop and the card back to her. That happened probably six months to one year ago, then management stopped that. Staff J recalled Staff A worked at the facility, but she didn't stay long. She believed Staff A told her, this isn't enough money, then she just disappeared and didn't work at the facility any longer. On 4/28/25 at 3:18 PM the Provisional Administrator stated obviously it (incident) happened. The statements brought in by the police documented the incident. She thought it happened when Resident #7 gave her card to staff to get her pop. Resident #7 reported she gave the staff her card on the third shift, but couldn't recall the names of all the staff she gave her card. They thought Staff A may have took a picture of her card. Resident #7 didn't reside at the facility when it happened. The facility didn't have other residents who identified any misuse of their cards when they got pop. Interview on 4/28/25 at 3:36 PM Staff E, stated she primarily worked the night shift, usually assigned to the back hallway. The residents gave the staff money or a card to get them pop from the pop machine. The rehabilitation unit and the back-hallway lounge had pop machines with a vending machine containing candy/chips in the staff breakroom. Resident #7 asked the staff to get her a pop. She reported she did get Resident #7 a pop once. Management knew the residents who couldn't get out of bed gave the staff money or credit cards to get them a pop. She didn't know for sure if the facility had any stipulations that only managers could get residents a pop. Interview on 4/28/25 at 3:51 PM Staff C, reported she worked at the facility for approximately [AGE] years. Staff C stated she never got pop for any residents, then changed her response and stated she actually had residents give her cash to get them pop from the pop machine. Resident #7 asked her to get her a pop from the vending machine. Resident #7 offered to give her a credit card, but she refused to take it. Staff C instead, bought Resident #7 a pop using her own card. Staff C verbalized the facility didn't allow staff to carry cell phones when they worked the floor. Staff C explained the facility didn't want staff to take resident credit cards anymore as something happened with a resident's credit card. Interview on 4/28/25 at 4:05 PM Staff K, CNA, voiced she worked at the facility for close to nine years, primarily working the third shift (10:00 PM to 6:00 AM). When asked if residents gave the staff cash or credit cards to get them a pop, Staff K responded, ya. She got a pop for Resident #19 as he couldn't get out of bed. One time Resident #19 gave her cash and another time he gave her a card. She told Resident #19 she didn't feel comfortable with that, but she did get him pop a few times. The facility had a meeting about a month ago and where the told the staff they couldn't take residents' cards any longer. She missed the meeting but she learned that they couldn't take cards or the facility would terminate them. She worked with Staff A and it seemed like she disappeared from the floor every now and then. The staff have cell phones but they are not to have them out when they worked. Staff K said Staff A may have had a pen and paper on her because when they train they have report sheets they write the resident assistance levels on and keep it in their pockets. During an interview on 4/20/25 at 12:23 PM Staff L, LPN, voiced she primarily worked night shift on the front, center, and back hallways. In regards to the staff taking residents' credit/debit cards to purchase pop from the pop machines, Staff L reported it probably happened. She added if they did it, they did it behind her back. Any resident on the back hallway probably tried to get the staff to get them pop. Resident #7 lived in the back hallway and she always tried to give staff her credit card, cash app card, or cash to go to the gas station to get things for her. Staff L didn't know what direction the facility gave staff about taking residents' money or credit/debit cards. Interview on 4/29/25 at 12:55 PM Staff M, CNA, reported he worked at the facility for around 2 years. When asked about staff taking residents' cash or credit/debit cards to get pop, he responded it happened. The facility had a meeting because of that as residents had issues about missing money. They directed to not accept money or cards from residents. The facility had two residents in the rehabilitation unit and a few residents in the back hallway who would ask staff to go get them a pop. Some of the residents couldn't get out of bed, so it was convenient for staff to go get them a pop. The residents gave staff both cash and credit/debit cards. He added it happened for as long as he worked at the facility. During a telephone interview on 4/29/25 at 4:13 PM Staff A voiced she worked at the facility last year (2024), but not long. She worked the overnight shift (10:00 PM to 6:00 AM). She worked all the hallways (areas) at the facility. Staff A verbalized she didn't have any residents give her cash, cash app cards, or credit cards to get them pop from the vending machines. She added the facility locked that stuff up in the business office. Staff A reported they didn't have issues during her employment at the facility. On 4/30/25 at 11:10 AM observed a pop machine in the back hallway approximately 60-65 feet from Resident #7's room when she lived at the facility. The path from Resident #7's room to the pop machine went directly by the back-hallway nurses' station. The nurses' staff included access to paper, pens, pencils, and a photocopy machine. On 4/30/25 at 11:20 AM witnessed 2 cell phones sitting on the back-hallway nurses' station desk. Staff N, LPN, reported the staff kept their cell phones on the nurses' station desk and checked them off and on as long as they didn't take and use them in resident care areas. During an interview on 4/30/25 at 12:16 PM the Director of Nursing (DON) stated a CNA who no longer worked at the facility must have took a picture of the card. Resident #7's card had a charge of $400-$600. Resident #7 gave her card to the CNA to get her pop. The CNA would have had her cell phone on her. The DON explained the staff aren't supposed to have cell phones in patient care areas, but the staff still had phones in their pockets. The DON voiced she didn't want staff to have their cell phones at the nurses' station. The DON reported staff took residents' credit cards to go get them pop from the pop machines. The DON confirmed the staff shouldn't take residents' money or cards, unless the resident can accompany the staff member to the pop machine. The DON thought the employee handbook outlined this under abuse, but she hadn't read the handbook in years. She remarked you can't trust anybody. During an interview on 4/30/25 at 2:13 PM the Provisional Administrator reported in conclusion it had happened, but as an isolated incident. The facility didn't have the issue prior. They implemented all staff abuse training on their training software and they provided one to one education regarding all types of abuse, missing money, property, or credit card is a form of financial abuse. The reviewed with residents about missing items and provided them lock boxes. The staff do a weekly angel round to check with residents, which included missing items. Interview on 4/30/25 at 2:30 PM Staff B voiced she worked at the facility since February 2020 on the 2:00 PM to 10:00 PM shift in the back hallway. Residents would give staff their credit/debit cards. Then the staff would take the card, tap on the pop machine, and take the pop and card back to the resident. They used the machine in back hallway lounge. The staff did get pop for Resident #7 once in a while. Before Christmas, the facility instructed them to not to take residents' credit cards to get pop. The Patient Protection Guidelines, Abuse Prevention, Reporting and Investigation Policy revised September 2023 directed residents must not be subjected to abuse by anyone, including, but not limited to the facility staff. The Policy defined misappropriation of resident property as the deliberate wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. The policy lacked direction to the staff regarding handling of a resident's cash app, debit, or credit cards. The facility's Employee Handbook, 2023, regarding Ethics and Confidentiality directed the company had the responsibility of safeguarding the privacy of all patients so that no patient is caused unnecessary embarrassment or discomfort, or is made the object of scorn, ridicule or exploitation as a result of their stay at the facility. Examples of Confidential Information included patient records and information including financial information. The Handbook directed each patient had the right to be free from financial abuse. The Company would promote and protect the rights of each patient. The staff behavior must reflect the belief in those patient rights. The Handbook specifically prohibited the use of a personal cell phone use during worktime.

Based on record review, resident and staff interviews, the facility failed to treat residents with dignity and respect ensuring the resident 's rights were met for 2 of 3 residents reviewed (Resident #65 and #8). The facility reported a census of 80 residents. Finding include: 1.The Minimum Data Set ( MDS) for Resident #65 dated 12/19/24 revealed Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further documented she has diagnoses of congestive heart failure, hypertension, diabetes and anxiety. During an interview on 1/12/25 at 1:12 PM Resident #65 reported Staff A, Licensed Practical Nurse (LPN) is not a nice nurse she at times talks rude and degrading toward her. Resident #65 reported when her roommate (Resident #11) was in the hospital, Resident #8 came around to deliver the monthly newsletter for the facility. When Resident #8 asked where Resident #11 , Resident #65 told her she was in hospital. Resident #65 reported they both were saying they hoped Resident #11 felt better soon. Resident #65 reported they didn't feel that they did anything wrong saying that . She reported she felt bad after she was told not to talk about her roommate to other people by Staff A, LPN. During the interview with Resident #65 her roommate Resident #11 verbalized she was not upset because her roommate told the other resident she was in the hospital. She reported the residents are like family and that she didn ' t say anything concerning to get into trouble. She reported Staff A, LPN is not very nice to Resident #65 and was not treated with dignity. Review of Resident #65 ' s the progress notes dated 1/10/25 at 12:54 PM documented this resident was discussing roommate with another resident. This nurse educated them that this was not appropriate to have this type of conversation. Administrator notified. During an interview on 1/14/25 at 1:05 PM Staff A, LPN reports that she did not overhear the residents talking to each other; it was another staff member who heard it and told her about it. She could not remember what staff member it was that told her about it. She did not get any information on what was said just was told Resident #65 was talking about her roommate to Resident #8. In an interview on 1/14/25 at 1:35 PM The Director of Nursing reports they encourage residents not to talk about other residents but they are not medical professionals so they do not have to follow the Health Insurance Portability and Accountability Act (HIPPA). The conversation Resident #65 had with Resident #8, she felt there was no concern with the conversation they had. She felt there was no need to discuss concerns to Resident #65 about the conversation. 42134 2. During an interview on 1/12/25 at 11:57 AM, Resident #8 reported that she frequently visits other resident's as they are her only family. She was visiting Resident #65 recently and asked where the Resident #11 was as she noted the resident was not in the room. Resident #65 explained Resident #11 was in the hospital. Resident #8 stated she expressed concern saying I hope she feels better. Resident #65 said me too. Nothing more was said about Resident #11. A short time later Staff A came into the room and told them they couldn't be talking about other residents. She stated it made her feel upset because it was genuine concern.

Based on observations, resident and staff interviews, the facility failed to keep the shower room at a comfortable temperature to meet within regulation of 71 to 81 degrees per resident request (Resident#38 and #65). The facility reported a census of 80 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #38 dated 12/25/24 identified a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented the resident needs supervision or touching assistance with bathing and dressing (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently). The MDS further documented the resident had diagnoses of anxiety, hypertension, localized edema and chronic back pain. During an interview on 1/12/25 at 2:05 PM Resident #38 reported the temperature in the shower room is cold. The water is warm but the room itself is cold. He reported it was discussed since November at resident council but nothing gets done. In an observation on 1/13/25 at 10:00 AM Maintenance took the temperature in the shower room on the PARS end of the building and the temperature is 66.7 degrees. Maintenance reported they are having issues with the heating system and there is someone coming to look at the system. He reported it is cold in the PARS lounge , shower room and Physical therapy room. In an observation on 1/14/25 at 9:45 AM after two residents on the PARS wing were showered in the shower room, Maintenance took temperature in the shower room and it was 66.5 degrees today. He reported they are looking into the heat. He reported staff are to be using the heat lamps in the shower to warm the room in the meantime. During an interview on 1/14/25 at 10:10 AM Resident #38 reported staff do not use the heat lamp in the shower room. He reported they never do. During an interview on 1/14/25 at 10:30 AM the Administrator gave a concern form with a date received as 12/17/24 documenting the shower rooms are cold. She reported that in November there was an electrician here to fix the heat lamp in the shower room on 11/22/24 but residents still reported it was cold. She reported she did not know of the concern form filled out right away because the activities department that does resident council did not get the concerns to her right away and so it was not assigned until 12/23/24 and still is a concern. 2. The MDS for Resident #65 dated 12/19/24 revealed BIMS score of 15 indicating intact cognition. The MDS documented the resident requires substantial/maximal assistance with bathing (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) and dependent with dressing (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity). The MDS further documented she has diagnoses of congestive heart failure, hypertension, diabetes and anxiety. During an interview on 1/14/25 10:00 AM Resident #65 reported she had a shower last evening on 1/13/25 and the shower room was cold. She reported staff do not use the heat lamp in the shower. She reported they never use it.

Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) Assessment for 2 of 5 residents reviewed (Resident #36 and #65). The facility reported a census of 80 residents. Findings include: 1. The MDS for Resident #36 dated 11/16/23 revealed a diagnoses of congestive heart failure, hypertension and renal insufficiency. The MDS lacked documentation of the resident on a diuretic (medication to help increase excretions of water from the body through the kidneys). Review of the November 2024 Medication Administration Record (MAR) documented the resident received Lasix during the 7 day look back period. In an interview on 1/14/25 at 2:29 PM, the Director of Nursing (DON) reported the MDS was not correct for Resident #36 and he should have been coded for diuretic medication on the MDS and it was missed. On 1/14/25 at 3:02 PM the Administrator reported the facility does not have a policy for MDS. She reported the facility follows the RAI manual. Review of the Long-Term Care Facility RAI 3.0 Manual section N:Medications revised October 2024 directs staff to review the resident 's medical record for documentation that any of the high risk medications were received by the resident and for the indication of their use during the 7-day look back period (or since admission/entry or reentry if less than 7 days). Diuretics are on the list of high risk medications. 2. The MDS for Resident #65 dated 12/19/24 revealed a diagnoses of congestive heart failure, hypertension, diabetes and anxiety. The MDS documented the resident had received an anti-psychotic medication on a routine basis. Review of Resident #65 MAR for November 2024, December 2024, and January 2025 lacked documentation of an anti-psychotic medication given. During an interview on 1/14/25 at 2:50 PM, the DON reported the MDS was coded wrong and Resident #64 was not on an anti-psych medication.

Based on record review and staff interview the facility failed to ensure 1 of 1 residents (Resident #72) Pre-admission Screening and Resident Review (PASRR) was submitted for review when she had new diagnoses documented in her medical record. The facility reported a census of 80 residents. Findings include: The Minimum Data Set (MDS) for Resident #72 dated 10/17/24 identified a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS documented the resident had diagnoses of diabetes, hypertension, alcohol abuse and history of stroke. Review of Resident #72 ' s PASRR dated 10/09/24 documented no mental health conditions and did not require a level II to be completed. It documented the resident was on an anti-psychotic medication but no diagnosis was given for the medication. Provider Intake Notes from Neuropsychiatry documented Resident #72 had a diagnosis of anxiety and Bipolar depression in which she was on an anti-psychotic medication and started on a new antidepressant. Review of Resident #72 ' s Electronic Health Records lacked a new PASRR submission with the new diagnosis and medications. During an interview on 1/13/25 at 3:00 PM Social Services Director reported the MDS coordinator will report to her if a resident gets a new mental health diagnosis that she needs to be aware of to submit a new PASRR. She reported she was not aware of Resident #72 having the new diagnosis for Bipolar depression and she should have had a new PASRR completed. On 1/14/25 at 3:00 PM, the Administrator reported the facility does not have a PASRR policy. She reported the facility follows the federal regulations.

Based on clinical record review, facility policy and staff interview the facility failed to follow up on blood sugar levels that were out of physician defined parameters for 1 of 2 diabetic residents (Resident #9) reviewed. The facility reported a census of 80 residents. Findings include: The Medication Administration Record (MAR) for Resident #9 dated December 2024 included an order for fingerstick blood sugar 4 times a day. The order directed staff to call the Medical Doctor (MD) for levels less than 70 or greater than 300. On 12/15/24 at 9:00 PM the MAR documented a blood sugar of 364. On 12/22/24 at 4:00 PM the MAR documented a blood sugar of 375. The Progress Note written on 12/15/24 at 9:29 PM documented the resident had a blood sugar of 364. Per orders staff are to notify the MD if the blood sugar is greater than 300. The nurse attempted to reach the MD. She was unable to do so and put the fax in the fax folder. The clinical record lacked documentation for 12/22/24. The facility policy titled Diabetes Management (Hyperglycemia/Hypoglycemia) last revised 11/2023 directed staff to report the physician any abnormal blood sugar level outside of the parameters as ordered. The facility policy titled Physician Orders/Transcription of Orders last revised 7/2023 directed staff to follow and carry out active orders as written. During an interview on 1/14/25 at 1:30 PM the Director of Nursing explained she would expect the MD to be notified of blood sugars outside of the parameters. She further explained that she would expect to be notified if there were issues reaching the MD. She would expect an order to be received and a progress note to be written in the resident's clinical record regard the abnormal level, MD notification and new order received.

Based on clinical record review, staff interviews, family interviews and policy review, the facility failed to complete a full assessment to include neurological assessments and failed to notify family and the provider timely for 1 of 4 residents reviewed (Resident #1). Resident #1 fell out of her wheelchair and landed on her face. The fall was witnessed by Staff A, Registered Nurse (RN). The facility reported a census of 79 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE], documented diagnoses for Resident #1 included non-Alzheimer's dementia, unspecified dementia with other behavioral disturbances, and repeated falls. A Brief Interview for Mental Status (BIMS) score revealed that this resident was rarely/never understood. This resident was dependent on staff for transfers. Resident #1's Progress Notes documented the following: On 10/27/24 at 8:45 p.m., (completed as a late entry on 10/28/24 by Staff A) Resident #1 had been attempting to get out of her chair and bed all shift. At some point, the resident fell and hit her right forehead, leaving a 5cm bruise. Resident is now in a new room, and is lying comfortably in bed. Neuro's (neurological checks) started and all aware. On 10/27/24 at 10:30 p.m., Staff C documented unable to get vital signs (VS) due to resident cooperation at this time. Resident #1 was lying in bed holding her head and yelling out. Upon assessment, there was a 5 cm (centimeter) in diameter hematoma (bruise) noted to the right side of her forehead at the hairline. Resident was asked what happened but she just groaned and continued to cry and yell out. No falls were noted recently. Attempted neuros (neuro checks). Unable to obtain VS or neuro eval due to resident cooperation. It does not appear there was a change in LOC (Level of Consciousness). 5mg (milligrams) of Morphine sulfate solution (narcotic pain medication) administered via oral syringe. Staff A stayed with resident at bedside while this nurse contacted the Nurse Practitioner. Contacted Resident #1's daughter and she does not want to send resident out to the hospital at this time. Facility nurse on call also notified. Will continue to monitor resident frequently throughout the overnight shift. On 11/19/24 at 11:34 a.m., Staff C stated she had gone into work the night of 10/27/24 and received shift report. Staff C heard Resident #1 call out and Staff C went to check on the resident. Staff A had told Staff C that the resident had been in her room and her roommate opened a window and as it was getting cold out, Staff B had moved Resident #1 to a different room that was close to the nurses' station, the one that was next to the lounge. Staff A had not told Staff C that Resident #1 had fallen. Staff C stated Resident #1 falling should have been on report. Staff C did ask Staff A before Staff A left if Staff A had noticed that Resident #1 had a bruise on her forehead and Staff A said no. She stated Staff A did not tell her that Resident #1 had fallen and Staff C did not hear that Resident #1 had fallen until she returned to work a few days later. It was not long after Staff C got to work when she went to assess Resident #1 and she was kind of smacking her forehead and reaching out. That prompted Staff C to pull back Resident #1's hair because this resident normally doesn't hit/smack her head. That's when Staff C noticed a hematoma right along her hairline. It was like a purple goose egg. Staff C stated she got vital signs first and then called the Nurse Practitioner who wanted to send Resident #1 out for evaluation. The on call provider called the daughter with Staff C on the phone to ask the daughter if she wanted to send her mother out to the ER. The daughter at that time said no because she didn't want her mother to go back on Hospice. When dayshift came on Staff C shared all of the information with the day nurse. Resident #1 had been moved to the other end of the hall as her room was too cold for her. Staff C thought it was Staff D that she gave shift to shift report to. She told Staff D that she had done neuro checks on Resident #1 through the night. On 11/19/24 at 12:51 p.m., Staff B stated the night shift reported Resident #1 had fallen the evening before, hit her head and had a goose egg on her head. Resident #1 was being restless in bed. Staff B had staff get the resident up. Resident #1 wasn't acting right. They offered Resident #1 a banana, she loves bananas. The resident kind of glanced at the banana but really didn't track it. It was like she didn't recognize it as food. She was up in her wheelchair for like 15 minutes. She could hear your voice but really didn't follow, like turn her head toward a voice. The resident had kind of a blank stare on her face. That's why it was decided to send her out around 7:30/8:00 a.m. Staff B stated she had not done any neuros as she hadn't made it in to Resident #1's room yet. When asked if the resident's pupils were fixed, Staff B stated that a few of the staff noticed that Resident #1 kind of had a fixed stare, she wasn't tracking. Staff B along with other staff decided Resident #1 wasn't acting right and she needed to be sent out. Staff B stated she sent her out for AMS (Altered Mental Status). Staff B called the daughter and told her that Resident #1 had a huge bruise on her forehead. Staff B told her about the banana. The daughter agreed to send her mom up to the hospital. On 11/19/24 at 3:28 p.m., Staff A stated Resident #1's roommate had been keeping the room at a freezing cold temperature and Resident #1 kept trying to get out of her bed. It was getting close to the end of shift. Resident #1 was in her wheelchair (w/c) and she dropped her baby doll on the floor and tried to reach for it and fell out of the w/c. Staff A saw it happen but couldn't get to the baby doll in time to hand it back to Resident #1. This happened in the hallway. Staff E, Certified Nurse Aide (CNA), and Staff A helped this resident back into her w/c. Staff A assessed Resident #1 but didn't start the neuros. Staff C came in shortly after the fall. When report was over Staff A ran out of the facility and forgot to do neuros or document anything but Staff C had started neuros. Staff A reported to Staff C that Resident #1 had a fall. Staff A stated that when Resident #1 fell out of the w/c, her forehead wasn't anything like the goose egg and bruising. Staff A thought that during the 15 minutes when they were giving report the goose egg and bruise happened. Staff A called the daughter to tell her what happened and she didn't answer the phone. Staff A didn't leave a message. Staff A was then shown the late entry she documented on 10/28/24 the day after the fall, regarding the fall where Staff A had documented that the entry should have been put in on 10/27/24 at 8:45 p.m. The entry was read to her to include that at some point the resident fell and hit her forehead, leaving a 5 cm bruise. Staff A stated the above time of the late entry for the effective date is an error. She said it wasn't at 8:45 p.m., it was more like 9:45 p.m. On 11/19/24 at 3:56 p.m., Staff E stated she worked 2nd shift the evening of 10/27/24 with 2 other CNA's. Staff E had walked in the room because they were going to lay Resident #1's roommate down. It looked like Resident #1 was cold, so Staff E changed the resident's clothes and put her in her w/c with a blanket on her. Staff E stated it was around 4:45 p.m. to 5:00 p.m., before supper. Staff E didn't recall if Resident #1 ate supper that night. Resident #1 started down the hallway. She was propelling herself down the hall. Then Staff A asked Staff E to help Staff A put Resident #1 back into the chair. Staff E helped Staff A pick this resident off of the floor and back into her wheelchair. Staff E did not see Resident #1 fall. Staff E then went back into the resident's room to help lay Resident #1's roommate down. Staff A pushed Resident #1 down by the nurses' station. Then Staff A called for Staff E's assistance again. Staff E went down to the lounge area (across from the nurses' station) and Staff A said that Resident #1 was very antsy and Staff A was worried this resident was going to roll off the couch. Staff E stated that it was a long time in between from when Staff E helped Staff A get this resident off of the floor and into her w/c, to Staff E helping Staff A lay this resident on to the couch in the lounge. Staff E went down again when Staff A asked for help to lay this resident onto the floor as Resident #1 was getting antsy and acting like she was going to roll off of the couch. Staff A wanted to prevent this resident from falling off the couch so Staff A had grabbed blankets and the pillows and placed them on the floor. Staff E stated she thought they laid this resident on the couch around 8:45 p.m. Then around 9:30/9:45 p.m., Staff A and Staff E lifted this resident back into her wheelchair. Staff A and Staff E then brought this resident into a different room, room [ROOM NUMBER] and not her regular room which was room [ROOM NUMBER]. Staff E then transferred Resident #1 into bed. Staff E stated that Resident #1 was shivering all through the shift. Staff E stated the resident's regular room, room [ROOM NUMBER], was like 66 degrees (Fahrenheit(F)). Staff E repeated that Resident #1 was shaking and was doing the shaking thing for the rest of the shift. Staff E thought Resident #1's shaking was maybe related to dementia and maybe Resident #1 was stuck on thinking she was cold. Staff E told Staff A that she (Staff E) still thought that Resident #1 was cold. Resident #1 looked drowsy, which was a normal look that she would get. Staff A had just come to Staff E earlier and as she needed help because Resident #1 had slid out of her chair. Staff E went to lift Resident #1 up and Resident #1 was like dead weight. Staff E looked at Staff A for help and then Staff A helped. Staff E stated that resident #1 really didn't want to get off of the floor. Staff E didn't notice any bump or bruising. The only assessment Staff E saw Staff A do was take Resident #1's temperature. Staff E laid Resident #1 down (in room [ROOM NUMBER]), and Staff A was in there. Staff E saw a little bruise on the side of this resident's forehead. Staff E pointed this out to Staff A and asked Staff A how Resident #1 got a bruise. Staff A responded that she didn't know how that happened. Staff E asked Staff A to take this resident's temperature. Staff E thought Staff A said this resident's temperature was 96.5/F. Staff E did not know if Staff A did anything further as far as assessment. Staff E just assumed Staff A would do an incident report and whatever her other duties were. When asked if the time of fall could have been closer to the end of the shift like around 9:30, Staff E said no. When told that was the timeframe given by Staff A, Staff E stated this resident's fall happened before supper. Staff E stated that this resident's roommate always wants to lay down at 5/5:30 p.m., that's how Staff E can remember about what time it was. Staff E stated at around 5/5:30 was when she went into the room to assist another CNA. Staff E noticed this resident was shivering. Staff E then stopped and tended to Resident #1, getting her dressed and up out of bed and into her wheelchair, then Resident #1 propelled herself down the hall. Staff E then assisted getting the roommate in the bed and when she was finished with that, Staff A asked Staff E to come help as Resident #1 was on the floor. On 11/20/24 at 9:52 a.m., Resident #1's daughter stated she never received a call from Staff A the evening of her mother's fall. Resident #1's daughter stated she had looked back at her call log when she found out from the Administrator that the fall had happened on the second shift. The daughter stated there were absolutely no calls until Staff B called the daughter with the on call provider service around 11:00 p.m. On 11/20/24 at 2:09 p.m., Staff A stated she could not put an exact time on the fall. She stated it was maybe bed time but it was not supper time. When Staff A saw Resident #1 fall, it was in the hallway and no one would come to help but Staff F. When Resident #1 fell she was in the hall approximately 10 feet in front of the nurse's station. Resident #1 was falling asleep in her wheelchair and her baby doll fell on the floor. Resident #1 reached down to grab her baby doll and fell face first onto the floor. Staff A hollered at Staff E. Staff E and Staff A then got Resident #1 up off of the floor and into the wheelchair. Staff A checked her arms and legs and noted Resident #1 was talking. Staff A waited until she could get a hold of management so that Staff A could put this resident in a different room. Staff B came onto her shift and found the bump on Resident #1's head. Staff C started doing neuros. It was not supper time. Staff A stated she should have started neuros at the time of the fall but it was in the middle of medication (med) pass and Staff A was just everywhere. Staff A stated that Resident #1 had fallen a lot, and was acting fine, so that's why she didn't start neuro checks. Staff A didn't see the bump on Resident #1's forehead at that time. Staff A stated that policy directs that the nurse has to do an assessment and IR (incident report) and they are to inform everybody. Staff A stated she called a provider. Staff A used the company phone to call the daughter and Staff A left a message. Staff A stated she did call the daughter and she had the proof. When asked to see the proof of the call, Staff A said she could not show proof as it wasn't on the company phone. The proof was in Staff A's head. Staff A said that Staff C then called the daughter again later. When told that the provider service had no record of a call previous to the one Staff C had made, Staff A stated that it was Staff C who called the provider not Staff A. Staff A was just sitting by Staff C when Staff C made the call. On 11/20/24 at 2:43 p.m., the DON stated that she talked to Staff A and Staff A thought that maybe Staff E had confused the night of the fall with another fall that had happened earlier in the month. When asked about the shivering and chills, laying on the couch then the floor, then moving to a different room happened after both falls, the DON acknowledged it did not. All of the above only happened on the evening of 10/26/24. The Administrator stated that the on-call phone showed that on 10/27/24 Staff A called the on-call phone at 8:26 p.m. and 8:48 p.m. On 11/20/24 at 3:00 p.m., Staff G, MDS Coordinator, RN, stated she was the on-call nurse the night of 10/27/24. Staff G stated she received a call from Staff A that night as the roommate (Resident #5) was hot and Resident #1 was cold. Staff G gave permission to move Resident #1 into an empty room for the night. Staff G stated that Staff A did not tell Staff G that Resident #1 had fallen. Staff G stated that Staff A should have told her. The DON was in the room during this conversation and stated that it was an expectation that the on call nurse was to be notified of all resident falls. It was acceptable that if it was a fall with no injury that the nurse could text the on-call nurse and let her know. The DON stated that in this case there was a hematoma and the on call nurse should have been called. She stated neuros should have been started at the time of the fall. On 11/20/24 at 3:37 p.m., the DON stated there were no texts sent by Staff A about the fall to the on-call phone. On 11/20/24 at 3:40 p.m., Staff E was asked if there was any way she had confused the two recent falls that Resident #1 had in November. Staff E said there was no way she was confusing the two falls. She said she absolutely did not confuse them. She stated she knows for sure because it was the day after her son's birthday. She said there is no way the fall happened at 8:00 p.m. or 8:30 p.m. on 10/27/24. She stated the fall was between 5:30 p.m. and 6:00 p.m. She said she knows what happened and nobody is going to change her mind. A Fall Occurrence policy dated 2/24 directed staff: Purpose: It is the policy of the facility to ensure that residents are evaluated for fall risks and implement interventions to minimize risk for falls and/or risk for injury from falls Procedure: 1. A Fall Risk Assessment is completed by the nurse upon admission, readmission, and as necessary. 2. Based on assessment, interventions are implemented and placed on care plan. 3. An incident report will be completed by the nurse each time a resident has a fall. 4. Residents will be assessed by a licensed nurse prior to being moved after a fall. 5. Nurse will notify physician and resident representative. 6. Additional intervention(s) will be implemented post fall. IDT may change the intervention(s) if IDT investigation identifies a more appropriate intervention for the individual fall. 7. The resident's care plan will be updated with any new or revised intervention(s). 8. Neurological assessment will be initiated for unwitnessed falls and/or falls that are witnessed and resident hits their head (neuros completed as directed on neuro flowsheet, see below). 9. Documentation and monitoring to be completed for 72 hours post fall.

Based on observation, interviews and record reviews, the facility failed to treats residents with dignity for 4 residents (Resident #2, #6, #7, and #8). Observations revealed the 4 residents left in the dining room for extended periods after meals. The facility reported a census of 84 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS coded Resident #2 as dependent for mobility, transfers, and they didn't attempt to walk him due to a medical condition. The MDS included a diagnosis of amyotrophic lateral sclerosis (ALS). The Care Plan Focus dated 4/10/24 indicated Resident #2 required assistance with activities of daily living (ADLs). The Intervention described him as dependent for eating and needed assistance of two for transferring. In an interview on 8/6/24 at 1:45 PM Resident #2 reported the staff left in the dining room for long periods of time after meals. He explained he had waited up to three hours for the staff to assist back to his room. 2. Resident #6's MDS dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS coded Resident #6 as dependent for mobility, chair to chair transfers, and listed walking as non applicable. The MDS included a diagnosis of Parkinson's disease. The Care Plan Focus initiated 3/1/24 reflected Resident #6 required assistance with ADLs. The Interventions indicated he required partial assistance with supervision with eating. In addition, he required two assist and a mechanical standing lift to transfer. On 8/5/24 at 9:00 AM witnessed 4 residents in the dining room who required assistance with eating. Of the 4 residents, observed Resident #6 asleep in a geriatric wheelchair. In an interview on 8/6/24 at 9:05 AM Resident #6 sat in the main dining room in his wheelchair. He stated the staff usually started assisting him out of bed about 6:30 AM. They wheel him to the dining room right after they get him up. He ate breakfast around 8:00 AM and then has to wait for someone to push wheelchair back to his room. Resident #6 explained he wanted to go back to his room but he had to wait for someone to take him. He declared the wait could be a long time after the meal. In an interview on 8/6/24 at 1:30 PM Resident #6 explained that day the staff brought him right back to the room after lunch. He felt it had to do with the surveyor's presence. Sometimes they take everyone else, then he waited an hour or more alone, as he couldn't propel the wheelchair himself. Resident #6 stated, he felt alone and forgotten. He had another resident push him once because he waited so long. The other also sat in a wheelchair and pushed him in his wheelchair. 3. Resident #7's MDS dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS listed Resident #7 used a wheelchair. The MDS included a diagnosis of multiple sclerosis. The Care Plan Focus initiated 2/20/23 reflected Resident #7 demonstrated physical aggression as evidenced by running his wheelchair into staff. In an interview on 8/6/24 at 1:15 PM Resident #7 reported he could take himself back in his wheelchair but residents that couldn't had to wait a long time for help back. Resident #7 explained around 10:00 PM, he attempted pushing Resident #6 back to his room while in his wheelchair because he still sat in the dining room. The staff often said they would be back again and again. 4. Resident #8's MDS dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS coded Resident #8 needed partial to moderate assistance with transfers and walking. The MDS included diagnosis of stroke with hemiplegia (one-sided paralysis). The Care Plan Focus initiated 4/16/24 indicated Resident #8 required assistance with ADLs. The Interventions instructed Resident #8 required assistance of one person with transferring and used a wheelchair with a right side armrest. On 8/5/24 at 9:00 AM observed Resident #8 with her head on the table, asleep after breakfast. In an interview on 8/6/24 at 12:30 PM, Staff A, Certified Nursing Assistant (CNA), said the staff could get very busy. They said the residents did wait a very long time in the dining room if they can't get back to their room independently. Staff A reported a resident recently complained they waited until 8:00 PM to be brought back from supper. A facility policy titled Resident Rights, Dignity and Respect revised April 2024 directed each resident has the right to considerate and respectful care, 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 clinical record review, resident interview, staff interview and pharmacist interview, the facility failed to ensure anxiety medications administered for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 84 . Findings include: Resident #2's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS coded Resident #2 as dependent for mobility, included dependent for transfers, and they didn't attempt to walk him due to medical condition. The MDS included a diagnosis of amyotrophic lateral sclerosis (ALS), weakness, anxiety disorder and depression. The Care Plan Focus initiated 6/3/24 indicated Resident #2 utilized psychotropic medications for anxiety. The Interventions directed to administer medications as ordered. On 8/8/24 at 11:55 AM Resident #2 said he didn't receive his anxiety medication because the facility ran out. Resident #2 relayed this is not the first time the facility didn't have his medications. Resident #2's August 2024 Medication Administration Record included the following orders: a. Started 7/5/24 at 12:00 AM: Diazepam 5 milligrams (mg) by mouth one time a day for anxiety, while awake. i. Discontinued 8/6/24. b. Started 8/6/24: Diazepam 5 mg by mouth every 6 hours for anxiety. i. On 8/7/24 at 12:00 PM dose not given, coded unavailable (UV). ii. On 8/7/24 at 6:00 PM dose not given, coded UV. iii. On 8/8/24 at 12:00 AM dose not given, coded UV. iv. On 8/7/24 at 6:00 AM dose not given, coded nurses note (NN). - Hospice notified Resident #2 needed a script. v. On 8/7/24 at 12:00 PM dose not given, coded UV. On 8/8/24 at 12:05 PM Staff B, Registered Nurse (RN), explained the facility ordered the medications on demand. She reported Resident #2 received his last dose of diazepam on 8/6/24. The narcotic count sheet reflected zero diazepam left. Staff B voiced the ordering process for medication is on demand, the nursing staff need to notified the pharmacy when a medication has 3 to 4 left. They typically receive the medications the next day. Staff B couldn't find that someone ordered the diazepam medication before being depleted. On 8/8/24 at 12:56 PM Staff C, Pharmacist, said the pharmacy didn't receive a reorder for Resident #2's daily diazepam. If they did Resident #2 wouldn't have ran out of his diazepam medication. The Pharmacist added the new order to increase the daily dose didn't have a physician's signature. The pharmacy sent a request to the primary care doctor who responded, they no longer managed Resident #2's medication. The Pharmacist identified the need to contact the hospice affiliated physician which led to further delays in Resident #2 receiving his medication. On 8/8/24 at 1:00 PM the Director of Nursing (DON) explained the staff should order the controlled medications when the resident had three or four doses left. The DON added that hospice may give a new order but fail to have the physician sign the order. Then sends it to the pharmacy which delayed the residents from getting their medications. The DON believed that resulted in Resident #2 not receiving his diazepam. The DON explained she contacted Hospice that morning to inform them the pharmacy still didn't have a script. The DON acknowledged Resident #2 missed several doses of medication. They confirmed they needed to work to ensure the pharmacy received new orders from hospice appropriately and that staff order medications timely. The Physician Orders/Transcription of Orders policy dated July 2023 instructed to carry out active orders as written and transcribed.

Based on observation and resident interview the facility failed to maintain dignity for 2 of 2 residents reviewed (Residents #6 and #65). The facility failed to shave the facial hair of 1 female resident (Resident #6) and 1 male resident (Resident #65). The facility reported a census of 71 residents. Findings include: 1. On 5/19/24 at 2:41 PM and 5/20/24 at 1:26 PM observed Resident #6 (female) with multiple lengthy chin hairs. On 5/21/24 at 10:15 AM observed Resident #6's chin hairs removed. 2. On 5/19/24 at 2:55 PM witnessed Resident #65 with multiple days of facial hair growth. During an interview at that time, he explained he preferred to be clean shaven. On 5/20/24 at 5:12 PM and 5/21/24 at 10:14 AM noted Resident #65 still had multiple days of facial hair.

Based on observation, staff interview and policy review, the facility failed to provide a comfortable, clean, homelike environment. Resident #21 had difficulty managing their urinal and frequently spilled his urinal. This resulted in his room and hallway outside of his room to smell like urine. Resident #51's room had dried fecal on his floor that remained there for over 24-hours. Resident #60's had a urinal present sitting on his floor and then moved to the hearing unit. The urinal contained urine and had a visible amount of urine on the floor/heating unit beneath the urinal. In addition, the facility failed to provide a homelike enviroment during meals by removing the trays used to carry the residents' food to the table. The facility reported a census of 71 residents. Findings include: 1. On 5/19/24 at 11:28 AM, smelled the presence of strong urine odor outside of Resident #21's room. On 5/20/24 at 8:58 AM, identified the presence of strong urine odor in the hallway outside of Resident #21's room. Interview on 5/20/24 at 9:32 AM, with Resident #21 in his room, revealed the continued presence of a strong urine odor. Resident #21 stated he often spilled his urinal while attempting to use it. On 5/21/24 at 6:37 AM, noted a strong urine odor outside of Resident #21's closed room door. During an interview on 5/21/24 at 2:11 PM, observed Resident #21 sit in his wheelchair with wet pants. He reported having trouble using his urinal without spilling it. He explained therapy is looking for an alternative urinal to avoid spilling. Noted a half full urinal hung on the footboard of his bed, with a puddle of urine on the floor pooling underneath the bed, and smelled of urine. During an interview on 5/21/24 at 2:58 PM, Staff F, Administrator, acknowledged the urine smell coming from Resident #21's room. During an interview on 5/22/24 at 7:49 AM, Staff F provided interventions the facility put in place to help minimize the urine odor in Resident #21's room and stated therapy continued to find an alternative urinal for Resident #21. Interview on 5/21/24 at 8:47AM, with Staff D, Housekeeping Manager, explained they cleaned the residents' rooms daily including mopping floors. The staff notify housekeeping if any areas need cleaned prior to their routine cleaning. 2. Observation of Resident #51's room on 5/20/24 at 9:20 AM, revealed presence of dried fecal (poop) on the floor. Noted a larger spot next Resident #51's bed (closest to the door) with smaller spots that trailed across the room to the restroom. Observation of Resident #51's room on 5/21/24 at 6:22 AM, revealed Resident #51's room continued to have the same areas of fecal on the floor from his bed trailing smaller spots across the room to the restroom. Observation of Resident #51's room on 5/21/24 at 8:23 AM, revealed Resident #51's floor of his room unchanged. Observation of Resident #51's room on 5/21/24 at 9:20 AM, continued to remain unchanged. On 5/21/24 at 8:47AM, Staff D explained they cleaned the residents' rooms daily including mopping floors. The staff notify housekeeping if any areas need cleaned prior to their routine cleaning. Interview on 5/21/24 at 9:19 AM, Staff E, Housekeeping, reported the housekeepers are to clean resident's rooms daily, including sweeping, mopping, dusting, cleaning bathrooms, wiping tables, doors, and door handles. Interview on 5/21/24 at 2:58 PM, Staff F, Facility Administrator, acknowledged she saw the fecal areas on Resident #51's room floor and had housekeeping clean his floor. 49990 3. During observation of Resident #60's room on 5/21/24 at 5:34 AM revealed a hand urinal 3/4ths full of urine sitting on the floor. The floor had a visible spot of a drying yellow substance present beneath the hand urinal. During a subsequent observation of Resident #60's room on 5/21/24 at 9:21 AM witnessed the hand urinal moved to the top of a heating unit, not emptied, and had a small quantity of dried urine staining on the heating unit. The yellowed spot noted earlier remained on the floor. At the time, the surveyor took a picture. In an interview on 5/21/24 at 9:32 AM Resident #60 noted that he used the hand urinal before bed on 5/20/24. He stated he worried about the staff not emptying his urinal in a timely manner, as he struggled to use a hand urinal when it became heavy. He stated he placed the hand urinal on the floor, but did not place it on the heating unit. In an interview on 5/22/24 at 11:24 AM Staff G, Certified Nurse Aide (CNA)/Certified Medication Aide (CMA), stated she understood no one should place urinals on the floor, heating elements, or other surfaces outside of a designated place to hang them on the bed. Staff G noted they should sanitize the areas the hand urinal came into contact with after every encounter. Staff G stated that at minimum, they should empty the urinals every two hours when conducting rounds. In an interview on 5/22/24 at 12:29 PM the Director of Nursing (DON) reiterated what Staff G stated. She believed someone should empty the hand urinals at a minimum every two hours on rounds, and they should clean all surfaces the hand urinal came into contact with. She acknowledged the area didn't appear clean below the urinal. The Resident Room Daily Cleaning policy revised October 2023 directed to dust mop hard surface floors, and vacuum if carpeted. The Infection Control Manual Exposure Control plan revised March 2024 instructed to clean all surfaces that come into contact with bodily fluids. 42134 4. During an observation of the noon meal on 5/19/24, 13 residents chose to eat in the facility dining room. All 13 residents received their meals on trays, the staff failed to remove the trays and place the meals on the table. During an observation of the noon meal on 5/21/24, 14 residents chose to eat in the facility dining room. All 14 residents received their meals on trays, the staff failed to remove the trays and place the meals on the table.

Based on observation, record review, resident and staff interviews, the facility failed to obtain a physician order for the use of oxygen therapy for 1 of 19 residents reviewed (Resident #19) for oxygen therapy. The facility reported a census of 71 residents. Findings include: Resident #19's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #19 required the assistance from 1 2 persons for care. The MDS included diagnoses of asthma, chronic obstructive pulmonary disease (COPD). The MDS lacked documentation of Resident #19 receiving oxygen. On 5/19/24 at 11:44 AM, observed Resident #19 wearing oxygen with the dose set at 2 Liters (L). The Clinical Physician Orders reviewed on 5/20/24 at 9:54 AM lacked a current order for oxygen. The last order of oxygen, discontinued on 4/15/24. The Care Plan Focus reviewed on 5/21/24 at 10:41 AM, indicated Resident #19 had an altered respiratory status related to COPD, obesity hypoventilation syndrome, chronic bronchitis, and had a risk for inadequate gas exchange. The Interventions directed to provide oxygen as ordered. During an interview on 5/19/23 at 11:44 AM, Resident #19 stated the nurse started her on oxygen (O2) when she admitted to the facility and she used the C Pap (breathing machine to help breathe in air) at night. The Weights & Vitals related to oxygen saturations reviewed on 5/21/24 at 10:51 AM identified Resident #19 received oxygen on 12/26/23 and 5/17/24. The record lacked documentation of Resident #19 using oxygen between those dates. During an interview on 5/21/24 at 11:33 AM, Staff A, Licensed Practical Nurse (LPN), stated she worked at the facility for 2 years. She identified Resident #19 received oxygen therapy and the C Pap. During an interview on 5/21/24 at 11:42 AM, Staff B, Assistant Director of Nursing (ADON), stated when the Care Plan team addressed her oxygen therapy and accidentally deleted it.

Based on clinical record review, staff and resident interviews and observations the facility failed to provide adequate supervision to ensure the safety of 2 of 4 residents reviewed (Resident #12 and #4). The facility reported a census of 78. Findings include: 1. According to the discharge Minimum Data Set (MDS) dated [DATE], Resident #12 had diagnoses which included stroke, pain and [CONDITION(S)]. The MDS indicated the resident had intact memory and cognitive function and did not exhibit behaviors. The resident required extensive assistance with transfers, dressing and hygiene needs. The resident had occasional bowel and bladder incontinence. Review of the Care Plan dated 3/18/2022 with an update on 3/22/22 and 3/27/2022, directed the staff to transfer the resident with 2 staff, walker and a gaitbelt due to self care deficit as evidenced by impaired gait and mobility difficulty, reconditioning, impaired balance related to a stroke. The resident ordered to utilize a brace to their left lower leg when out of bed. Review of a Progress Note dated 3/29/2022 at 8:35 p.m. Staff B-LPN reported a Temporary Nurse Aide (T.N.A.) informed nurse that during a transfer, she was unable to get the resident completely back into her bed and had to lower her to the floor, at that time she heard a popping noise. Staff B reported upon entering the room he noticed the resident on the far side of her bed, her left leg under her and the knee full bent back and out to the side. The nurse assessed the resident, contacted the physician and summoned the local emergency management service for transport to the local emergency room . Staff B reported he received a phone call back at 10:41 p.m. that Resident #12 admitted to the hospital. During an interview with Staff A-Administrator on 8/29/2022 at 2:06 pm, the Administrator stated the resident received a fracture of her left leg on 3/29/2022 due to an aide transferring a resident alone when she was a two staff transfer, the aide transferred her alone and the resident fell . The staff member left on 3/29/2022 and did not return. Staff A stated they attempted several times to talk to the aide but she refused to return any of their calls. The facility terminated the staff's employment. Staff A stated they did a Performance Improvement Plan and re-educated all staff on proper transfers with residents. Review of facility investigation revealed interviews conducted with Staff C; the initial interview on 3/29/22 conducted after the fall indicated Staff C placed a gait belt on the resident while the resident sat on her bed, the staff assisted resident to a standing position and pivoted her towards the commode. While the staff pivoted the resident alone to the commode the resident began to slip, the aide indicated she lowered the resident to the floor and upon doing this both aide and resident heard a popping sound. The aide left the room to get the nurse. The second interview conducted on 3/30/22 per telephone, Staff C stated the resident had her walker and a gait belt on. Staff C indicated she thought another aide was coming to assist but did not come, so the aide thought she could transfer the resident alone. She indicated if she thought the resident was weak she would get another person to help otherwise she would transfer the resident alone. Staff C stated she knows the Kardex is at the nurses station, and received transfer training while on orientation. The staff indicated the resident did not have shoes on as she refused to put them on. During an interview with Staff C-Temporary Nurses Aide on 8/31/22 at 5:00 pm, the aide stated she was assigned to Resident #12 the evening of her fall with fracture (couldn't remember the date). The resident put on her call light and Staff C responded to the light, the resident requested to use the toilet. Staff C indicted she did not know the resident required 2 staff to transfer but indicated she gave the resident a shower earlier in the shift, the resident experienced weakness so she got another staff to assist with the transfer to and from the shower chair. The aide stated she asked the resident if she was comfortable with her transferring her alone to the commode, the resident indicated yes. At the time of the transfer the resident had on a gait belt and gripper sock along with her quad cane. The aide stood the resident up and the resident said she was going to fall. The aide attempted to hold the resident up but she was too heavy so she lowered her to the ground. The resident landed on the floor with her left leg bent under her and in extreme pain. The aide stated she usually reviews the residents care cards prior to working her shift but admitted she was too busy to review them prior to working. The aide admitted she should have got another person to help with the transfer but didn't indicating they were busy that night. The nurse in charge sent the aide home right after the incident for failing to transfer the resident correctly. During an interview with Resident #12 on 8/30/2022 at 9:30 a.m., the resident stated she had 2 falls shortly after her admission to the facility in March, the first fall no injury but he second fall she got a fracture of her left leg. The aide transferred me alone when she was suppose to have another person helping her. The resident stated she asked the aide prior to the transfer about another person the aide replied back I got it. The resident stated she was being transferred from commode to her wheelchair when the resident stated she told the aide she was falling and instructed the aide to lower her to floor slowly. When the resident hit the floor she and the aide both heard a popping noise and the resident yelled in pain. The aide went to summon help while the resident laid on the floor. They called the ambulance and transferred the resident to local emergency room . Resident #12 stated she had to have surgery on her broken left leg. Review of a local hospital x-ray report dated 3/29/2022, Resident # 12 had an x-ray of the left tibia and fibula. The x-ray revealed the resident has a mildly displaced comminuted spiral fracture of the distal left tibia, simple comminuted minimally displaced spiral fracture of proximal diaphysis near the neck of the left fibula, [CONDITION(S)] and [CONDITION(S)]. The resident admitted to a local hospital for surgical repair of fractures. The resident returned to the facility on [DATE] after surgical repair of fractures. 2. According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had diagnoses which included heart failure, Diabetes, anxiety, depression, [CONDITION(S)] disease, [CONDITION(S)], [CONDITION(S)] and severe [CONDITION(S)]. The resident had a Brief Interview for Mental Status score of 14 which indicated the resident could participate in the assessment and had intact cognitive ability. The resident required extensive assistance of 2 staff for bed mobility, dressing and toilet use and required extensive assistance of 2 staff for transfers. The resident utilized a mechanical lift for transfers. Review of Resident #4 Care Plan revised on 8/9/22 directed staff to utilize a Hoyer lift and 2 staff for transfers, non-skid seat cushion and cushioned arm rest in her wheelchair. Review of an Investigation Report dated 9/2/2022 revealed staff assisted the resident from her wheelchair to bed with a mechanical lift when her foot caught on the Hoyer. The resident immediately complained of pain to her right foot/ankle and an X-ray revealed a [NAME] B ankle fracture dislocation. The report indicated the resident put on her call light at 5:00 p.m., staff noted she was sliding down in wheelchair. Two staff quickly hooked her up to the mechanical lift and started to lift her up so she would not fall. The resident began to scream out, the staff did not visualize her foot being caught underneath the lift. The staff finished the transfer and the RN assessed her foot/ankle, the resident had the ability to move her foot but complained of pain. At that time the foot did not have any visible injuries. The staff notified the physician and x-rays ordered. The Administrator concluded the resident fractured her right ankle due to her sliding out of her wheelchair and staff responding quickly to transfer her with the Hoyer lift, resulting in her stretching her leg out and catching her leg between the legs of the mechanical lift. During an interview with Resident #4 on 9/6/22 at 7:15 a.m., the resident stated she fractured her ankle on 9/2/22. The staff were helping her with her wheelchair as she wanted to be in a different positon. She stated the staff hooked her Hoyer sling up to the lift and reported instead of lifting her up in the Hoyer, they put it down and her foot got caught between the Hoyer legs. The resident reported she got multiple fractures and was in a lot of pain. Observation of the resident's right foot while laying in bed revealed the right foot wrapped in an ace wrap, the visible skin dark purple in color and edematous. The resident complains of pain to the area. During an interview with the Administrator on 9/6/22 at 8:15 a.m. revealed the resident began to slip down in her wheelchair, the staff hurried to prevent her from falling from the wheelchair with the use of the Hoyer lift. The Administrator stated the staff quickly lifted her to be to prevent a fall at the time of the transferred the resident yelled out in pain. The Administrator reported the 2 staff completing the transfer did not receive discipline but prevented her from falling to the floor from the wheelchair. During an interview with Staff G-LPN on 9/14/22 at 4:20 pm, the staff stated the resident put her call light on and wanted to move from the wheelchair to the bed as she felt she was slipping out of the chair. The resident already had the sling under her so the staff hooked her up to the Hoyer lift. They lifted her up and she yelled, my foot, my foot you broke my foot. The resident appeared to be in pain. Staff G assessed the resident's right foot as the resident was complaining of pain, contacted the physician and obtained an order for an X-ray. Staff G stated she stood right in front of the resident during the transfer from chair to bed and stated she did not see the resident bump or get her foot caught. She stated she was very surprised to hear of the fracture to the resident's right foot/ankle area. During an interview with Staff K-C.N.A. on 9/14/22 at 5:00 pm, the staff stated he assisted the resident on 9/2/22 with a transfer from the wheelchair to her bed per the residents request. Staff K stated he assisted the resident to return to her bed using the Hoyer lift, he stated he did not see the resident bump or get her foot caught on the Hoyer but heard her yell out my leg is hurting. The staff stated he did not know how she got a fracture to her right foot. Review of a Witness Statement dated 9/2/22 indicated the resident put her call light on as she wanted to get back into bed. The resident stated she was sliding out of her wheelchair and going to fall as she was not sitting upright. Staff G-LPN stated they hooked the sling to the Hoyer, lifted her up at which time the resident yelled her foot was caught. Staff G stated she quickly lifted up the resident's legs and safely transferred her to bed. Review of Staff K-C.N.A.'s Witness Statement dated 9/2/22 indicated at about 5 pm Resident #4 put her call light on. Staff answered the call light, upon entering the room the resident stated she was falling out of her wheelchair and wanted to go to bed. Staff K left to get help as she is a 2 person transfer with the Hoyer. Staff G-LPN entered the room and assisted with the transfer, they hooked up the sling to the Hoyer and when they lifted her she yelled out my right foot is caught. Staff K moved the foot to the side and they placed her into bed. Review of a Progress Noted sated 9/2/22 at 5:40 p.m., the resident put on her call light to get put back in bed. The resident was not sitting upright before the transfer and almost slid out of her wheelchair. Staff K-CNA used the Hoyer control to lift the resident up quickly to prevent a fall to the floor. When he lifted her up she yelled out you caught my leg. Staff G picked up her leg and transferred her to the bed. The nurse assessed the resident's foot, the resident could move her toes, toes pink and the resident did not complain of pain. She applied bio freeze cream, placed an Ace wrap to right ankle and notified the physician. The physician ordered x-ray of affected foot. Review of a Radiology Report dated 9/3/2022 revealed the resident sustained a [NAME] B pattern-ankle fracture dislocation. The report indicated the fracture is mildly displace transverse fracture of the medial malleolus and obliquely oriented facure of the lateral malleolus.

Based on clinical record review, staff and resident interviews and observations the facility failed to ensure the safety of 1 of 5 residents reviewed (Resident #1). The facility failed to provide other interventions for Resident #1 who was at high risk for falls other than to remind the resident to use call light. The facility reported a census of 67. Findings include: According to the Minimum Data Set ((MDS) dated [DATE] Resident #6 had [DIAGNOSES REDACTED]. The resident had a BIMS score of 6 which indicated severe cognitive ability. The resident required supervision of 1 staff for transfers, ambulation and toilet use. The resident utilized a walker and wheelchair. Review of the resident's care plan [DATE] Resident #1 had a self-care deficit evidenced by weakness with a history of a stroke. The plan identified the resident needed assistance to meet his activities of daily living and directed the staff to ambulate with assistance of 1 staff, gait belt and walker. The plan indicated the resident had a risk for falls due to recent falls and impaired mobility and directed staff to reinforce the need to call for assistance. The care plan failed to contain interventions for resident's refusal to utilize call light and wait for assistance. Review of the Manor Care Investigation Report dated [DATE], the staff found Resident #1 on the floor of his bathroom briefs around his ankles and a bowel movement in the toilet. The staff noted resident without pulse, started CPR and activated EMS. The resident was pronounced dead at a local emergency room . Review of local emergency room notes revealed the resident arrived at the emergency roiagnom on [DATE] at 7:17 a.m. with a [MEDICAL CONDITION] from an unwitnessed fall. The physician documented the resident had a large laceration with large amount of blood on the face, large gash over left forehead measuring 7 centimeters. Review of a statement from Staff A-C.N.A. on [DATE] revealed the resident was up to the bathroom by self that night and required the staff assistance to clean up. The statement revealed the staff checked on him during the night because and would find him up in the bathroom by himself several times that night. Review of a progress notes revealed the following: 1. On [DATE] staff encouraged the resident to use their call lights for assist prior to transfers related to illness. 2. The Social Worker progress note dated [DATE] at 4:36 p.m. the resident had a BIMS of 6 which indicated severe cognitive ability, the resident alert but had trouble with recall. 3. Resident #1 had a fall while exiting the bathroom, lost their balance and landed on their buttocks without injuries. The staff assisted the resident into wheelchair with limited assistance of 2 staff and gibbet. 4. On ,[DATE] staff entered residents bathroom and found him on floor, bleeding from head and without vital signs. CPR started, resident expired at local emergency room . Review of a Physical Therapy evaluation and Plan of care dated [DATE], the document indicated the resident had exacerbation of illness with decrease in functional mobility, reduced ability to safely to ambulate and described the resident as a high risk for falls. The functional assessment revealed the resident required contact guard assist with transfers. During an interview with Staff B-Physical Therapy Assistance (P.T.A.) on [DATE] at 2:10 p.m. revealed Resident #1 required assistance of 1 staff, with gait belt and walker. Staff knew he was non-complaint with waiting for assistance and use of call lights. During an interview with Resident #1's roommate on [DATE] at 3:09 p.m., the roommate stated the staff were constantly reminding him to use his call light and wait for help, but he just wouldn't wait. During an interview with Staff C-C.N.A. on [DATE] at 2:05 p.m., Staff C stated she got report from the night aide the morning of [DATE], she reported Resident #1 had been up a lot during the night on ,[DATE]-[DATE]. The resident required assistance of 1 staff but he refused to use call light to get help. During an interview with A.R.N.P. on [DATE] at 10:05 a.m., resident #1 had a history of [REDACTED]. The A.R.N.P. indicated cause of death was [MEDICAL CONDITION]. During an interview with Staff D-RN Nurse Manager on [DATE] at 7:34 a.m., the manager stated the resident required assist of 1 staff and walker and he had a history of [REDACTED]. He would frequently get up without his walker. The care plan failed to identify interventions to prevent falls due to his non-compliance.

Based on observation, clinical record review, and interviews with staff and resident, the facility failed to ensure recommendations provided by a therapist were followed to maintain or prevent a decline in function for two of three residents reviewed for activity of daily living abilities (Resident #6 & #5).The facility identified a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #6 dated 12/30/17, included [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two to walk in room and corridor. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS dated [DATE], documented the resident required supervision and set up to walk in room and corridor. A Therapy Discharge Communication form dated 9/8/17, included a directive for walk to dine with assistance of one with four wheeled walker three times a day. The MDS dated [DATE], documented the resident required extensive assistance of one to walk in room and corridor. The care plan revised 1/11/18, included a problem of activity of daily living self-care deficit related to physical limitations, history of subarachnoid hemorrhage and right orbital floor fracture status [REDACTED]. Resident #6's clinical record review revealed no documentation of a walk to dine program initiated for the resident. On 1/25/18 at 12:45 p.m., Staff I, Certified Nurse Aide, CNA and Staff J, Licensed Practical Nurse, LPN provided a list of residents on any kind of ambulation program. The list did not include Resident #6. During interview on 1/25/18 at 1:57 p.m., Resident #6 stated no one had provided routine assistance with ambulation regularly for two years. The resident stated staff had provided ambulation assistance in their room but not in the hall and they felt they had a decline because of it. The resident stated they had told facility staff they wanted to walk and had been told to walk in the room. Staff H, Physical Therapy Aide verified during interview on 1/29/18 at 7:45 a.m., the directive on the residents Therapy Discharge Communication sheet had been for walk to dine with assistance of one with a four wheeled walker three times a day. At 12:43 p.m., the facility Director of Nursing (DON) stated they had a concern with residents ambulating a while ago but it had been at least 6 months since they had reviewed it. On 1/30/17 at 7:40 a.m., the resident propelled themselves to the dining room in a wheelchair. At 7:45 a.m., the facility DON stated they had counseled staff the previous evening on walking residents who were to be on the walk to dine program. 2. The MDS for Resident #5 with a reference date of 12/29/17, documented [DIAGNOSES REDACTED]. The MDS further documented the resident required extensive assistance of one for bed mobility, transfer and toilet use, and supervision with set up assistance for meals. The MDS documented the Resident used a walker and wheelchair for mobility and walk in room and corridor did not occur. A document dated 11/8/17, titled Therapy Discharge Communication included a recommendation for the Resident to walk to dine with one person physical assist and walk from bed to bathroom with one person physical assist using forward wheeled walker twice a day. The document had been signed by the physical therapist with the signature of the nurse manager signed by DON. A physical therapy treatment note dated 11/8/17 documented the resident stated he had not ambulated with staff never sees anyone. Physical therapy note dated 11/6/17 documented resident gait training with forward wheeled walker 150' with caregiver assist with cues to increase left foot clearance. When asked if he ambulates with staff he said no. PT educated he needs to ask staff 2x/day to ambulate with him. The care plan dated as initiated 8/20/17 and last revised on 9/15/17, included ADL (activities of daily living), Self-Care deficit as a focus area related to physical limitations, [MEDICAL CONDITION] right sided weakness/hemi neglect and dysphagia. A goal was established that the resident will receive assistance necessary to meet ADL needs with a target date of 3/17/18. The care plan directed staff to transfer with: refer to Kardex. A document labeled Visual/Bedside Kardex Report dated as printed on 1/29/18 directed: Ambulate in hallway twice daily as tolerated. In an interview on 1/23/18 at 2:45 p.m., the Physical Therapist (PT) stated that therapy was provided to patient under (Medicare) part A until 9/27/17 and then continued under part B until 11/8/17. Stated would expect the facility to proceed with recommendations from Physical Therapy after discharge from therapy services. In an interview on 1/23/18 at 3:45 p.m., Staff M, CNA, she reported being responsible to check and change patient throughout the shift, reposition patient with assist of 1 and gait belt ( transfer assistance device) and assist resident to the dining room in wheelchair. Denied she routinely provided other cares for resident. In an interview on 1/24/18 at 1:32 p.m.,Staff F, CNA reported the cares she provide for patient are assist out of bed in the morning, take to dining room by wheelchair, check and change, and assist to the bathroom if requested. Staff F denied providing any walks or exercises. In an interview on 1/24/18 at 3:15 p.m., Resident #5 stated he had not walked today. In an interview on 1/25/18 at 9:20 a.m., Staff K, RN stated he worked in several areas of the building and had not witnessed Resident #5 being walked with staff since he had been in current room [ROOM NUMBER]/1/17. In an interview on 1/25/18 at 11:00 a.m., DON confirmed they do not have restorative program after discharge from therapy. The DON confirmed recommendations go on CNA task Kardex. She stated she expected staff to offer to walk resident and resident is not responsible to ask CNA's to walk them. She would expect the CNA to alert the charge nurse if a resident had refused/declined to participate in therapy recommendation. DON would expect RN to document and follow up with resident that does not participate.

Based on record review, observation and staff and family interviews, the facility failed to ensure the facility provided an environment that promoted safety and well-being, and failed to ensure each resident received adequate supervision to prevent an elopement from the facility for one of six residents with an alert bracelet reviewed. (Resident #4). The facility reported a census of 66 residents. Findings include: 1. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 4/5/17. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 identified no cognitive problems. The MDS identified the resident transferred from an acute hospital setting, required limited assistance of two staff member to transfer between surfaces, ambulate in the room and within the unit with the support of 1 staff member but again required the assistance of two staff members to use the toilet. The MDS indicated the resident had an unsteady balance, able to stabilize without staff assistance while moving from seated to standing position, walking (with assistive device if used), turning around, moving on and off toilet, and transfer between bed and chair or wheelchair. The resident had functional limitation in range of motion of one lower extremity and used a walker and wheel chair for mobility. The MDS reported the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had a fall within the last month prior to admission/entry or reentry, in the last 2 - 6 months, and had a fracture related to a fall in the 6 months prior to admission or reentry. It also indicated the resident had a fall since admission/entry without evidence of injury. The CAA (MDS worksheet) dated 4/5/2017 included the following analysis of findings: Resident #4 required assistance with ADLs (Activities of Daily Living) with consideration given to the fact the resident had a hip fracture, fall, recent hospitalization , psychoactive medications, and physical limitations. The resident had a fall risk after hospitalization for a hip fracture, then dislocation and revision, arthritis of multiple joints, impaired balance, potential medication side effects, dizziness, limited range of motion of the right lower extremity, self- transferring. Resident at risk for increased dependence on ADLs, increased pain, infection, altered skin integrity and injury. The resident is able to use call light and verbalize needs. On 4/6/2017 the Care Plan added: Resident #4 had resistive/noncompliant with treatment/care, refusal to remove TED (compression) hose at night, self-removal of Wander Guard related to belief that treatment not needed/working. The Care Plan directed staff to provide education about risks of not complying with therapeutic regimen, give choice and flexibility with ADLs, and if resists care, leave and return later if safe to do so. On 3/31/2017 the Care Plan initiated: Resident #4 had an elopement risk related to cognitive impairment with the goal of not leaving center unattended. The Care Plan interventions included: Accompany to meals and scheduled activities, calmly redirect to an appropriate area, check alert bracelet placement every shift and functioning every day. The Care Plan canceled the focus on 4/21/2017. On 4/6/2017 the Care Plan identified Resident #4 had cognitive loss as evidenced by confusion. It directed staff to allow adequate time to respond, approach/speak in a calm, positive/reassuring manner, explain each activity/care procedure prior to beginning it, give two choices when presenting options, identify self, provide cues and prompting for such things as activities, personal care, or room location use patient's name when addressing, use brief and simple words and repeat communication using more than one method. The facility canceled the focus on 4/21/2017. On 4/8/2017 the Care Plan added: Patient shows potential for discharge and patient expresses wish for discharge. It directed staff to complete a discharge plan, discuss with family or representative, investigate need for home health services, and provide education for family/patient to include self-care techniques. On 3/29/2017 the Care Plan included: Resident #4 had a fall risk due to impaired balance/poor coordination, potential medication side effects, unsteady gait, recent right hip fracture and post-surgical dislocation, osteo-arthritis, cardiac disease, chronic kidney disease, diabetes with neuropathy, edema, colostomy, dizziness, impaired cognition and self-transferring. It instructed staff to administer Calcium and Vitamin D, medications according to physician orders, encourage to transfer and change positions slowly, evaluate medications if patient demonstrates changes in mental status, ADL function, appetite, and neurological status, have commonly used articles within easy reach, provide assist to transfer and ambulate as needed, reinforce need to call for assistance, reinforce wheel chair safety as needed such as locking brakes, report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status per facility guidelines post fall. On 4/4/4017 the Care Plan added: Cardiac disease related to [DIAGNOSES REDACTED] (high lipids), and hypertension. Interventions included: administer medication as ordered, assist with activities as needed, encourage to dangle at edge of bed/chair before transfers, encourage to take rest periods as needed, notify physician of heart rate of less than 50, obtain vital signs as indicated, weights as needed, and orthostatic blood pressures as ordered. On 4/4/2017 the Care Plan added: at risk for complications due to musculoskeletal problems related to dislocation of right hip after surgical intervention for fracture, primary multiple site osteo-arthritis. Goal: Fracture will heal without complications. It directed staff to administer medication as ordered, assist with bed mobility as needed, report evidence of infection, and treatment as ordered. On 3/29/2017 the Care Plan identified the resident had a potential for pain related to complaint of pain of the right hip, recent right hip fracture and post-surgical dislocation, osteo-arthritis, depression, colitis, reflux, diabetes, neuropathy, and alteration in skin integrity. It directed staff to report expression of pain, administer medication, encourage to reposition frequently to position of comfort, implement non-drug therapies as needed to assist with pain and monitor for effectiveness and notify physician if pain worsens. The Task List Report indicated Resident #4 had an Alert Bracelet, transferred and ambulated with the assist of one and a front wheeled walker initiated on 3/31/2017 and canceled on 4/14/2017. The resident used a walker and wheel chair to move about and had a fall risk. The physician's orders [REDACTED]. Weight bearing as tolerated, ordered 3/29/2017. Wander Guard on at all times, monitory for placement and functioning every shift, ordered 3/30/2017, discontinued 4/14/2017. Lovenox, (anticoagulant) 40 mg (milligrams) for DVT (Deep vein thrombosis) daily for ten days. (3/29 - 4/9/2017). Orthostatic blood pressure checks every shift times three days including pulse, making sure readings are taken at least one minute apart for dizziness, ordered 4/6 - 4/9/2017. The Medication Administration Record (MAR) revealed staff checked the resident's Wonder Guard every shift from 4/1 - 4/14/2017 when it discontinued. The 4/8/2017 MAR indicated Resident #4 had a blood pressure of 138/69 on the day shift and 114/65 on second shift. The Progress Notes included: On 3/29/2017 at 5:13 p.m., Resident #4 arrived to the facility after right hip replacement, alert and oriented times three, had periods of confusion per report and required one assist. On 3/30/2017 at 10:53, Staff A, LPN (Licensed Practical Nurse) documented Resident #4 walked to the bathroom with the walker to brush his/her teeth. The resident reached for the door handle to door leading to the hall, leaned against the wall and fell to the floor. The resident denied pain or hitting his/her head and had normal range of motion. 3/30/2017 at 12:28 p.m., Staff A documented the resident had confusion that morning and talked about leaving and going to school with three to four friends. Staff A placed a Wander Guard on the resident's right ankle. On 3/31/2017 at 1:14, Staff A documented the resident had the Wander Guard on the right ankle. At 9:28 p.m. Staff B, LPN documented the resident was alert and oriented to person with intermittent confusion. The resident spoke of going to school and it pertained to stocks and bonds. In a late entry on 4/5/2017 at 12:29 p.m., Staff C, Social Services indicated the resident recently admitted to the facility for skilled therapies, and alert and oriented to self. The resident's former spouse, present at the time, reported taking care of the resident prior to his/her hip replacement. The former spouse indicated the resident had some confusion but it appeared to worsen with anesthesia. On 4/6/2017 at 1:07 a.m., Staff D, LPN observed the resident had no Wander Guard on. The resident reported tired of the noise, removed it and threw it in the trash can. Staff D re-applied the Wander Guard (bracelet). At 7:19 a.m., Resident #4 revealed he/she used a scissors to cut off the Wander Guard and placed it in the red overnight bag. The resident used the cuticle scissors that he/she used to open the ostomy appliance. The resident allowed staff to lock the scissors up for safekeeping. On 4/6/2017 at 11:57 a.m., staff documented Resident #4 worked with Occupational Therapy and complained of feeling dizzy after ambulating several feet. The resident's blood pressure (BP) read 117/55, heart rate at 92 (normal is 60-100) while sitting, and BP 64/35 with heart rate of 62 while standing. The resident also reported a bad taste in his/her mouth and blurred vision. Staff notified the physician and received orders to check blood pressures every shift for three days and encourage fluids. On 4/6/2017 at 1:17 p.m., staff observed the resident trying to leave the facility and stated he/she had an appointment at 2:30. Staff explained the resident needed to stay at the facility so they could monitor blood pressure and dizziness. The resident denied feeling dizzy. Staff redirected the resident back to the room. On 4/7/2017 at 9:12 a.m. staff documented the resident was alert and oriented to name and situation with forgetfulness, and denied dizziness. On 4/8/2017 at 5:38 a.m., Staff D, LPN indicated the resident had a Wander Guard on the right ankle and it functioned. At 12:08, Staff A, LPN documented the resident was alert and oriented with some confusion at times, had no complaint of dizziness and denied pain and discomfort at that time. At 2:15 p.m., Staff E, RN (Registered Nurse) indicated Staff C, Social Worker came to the desk and asked for Resident #4. Staff checked the room, bathroom, therapies, and dining room and failed to locate. Staff called the family at 2:40 p.m. with no answer. Staff called the other family and got the son-in-law who gave Staff E the resident's cell phone number. Staff called the number, located the resident at the local bank and picked the resident up. Staff called the family and let them know the resident had been located. Staff assessed the resident. At 5:41 p.m. Staff C indicated they informed Resident #4's daughter that the resident went to the bank and the facility locked up the cash in a facility safe. Staff C discussed discharge planning at that time and family indicated they considered an Assisted Living facility. At 5:50 p.m. Staff C revealed he/she completed a MDS assessment and determined Resident #4 had intact cognition and no depression. Staff C indicated the Wander Guard had been placed on the resident upon admission as a precaution related to orthostatic blood pressures and falls that could contribute to confusion. On 4/8/2017 at 10:35 p.m. Staff E reported Resident #4 had pain rated at 3 on a scale of 1-10 in his/her groin area. Staff administered Tylenol. On 4/9/2017 at 5:48 a.m., Staff D reported the resident had a Wander Guard intact and functioning on the right ankle with no elopement ideation noted. On 4/10/2017 at 12:55 p.m., Staff noted the resident ambulated with a wheeled walker and did not wait for assistance even with reminders. Staff educated the resident. The resident failed to use the call light. Staff observed the Wander Guard intact to the right ankle. The resident had no attempts to leave the facility without assistance. On 4/10/2017 at 4:45 p.m. Resident left the facility with family, went out to dinner and returned at 6:15 p.m. In a Late Entry on 4/11/2017 at 9:15 a.m., Staff C revealed he/she notified the resident's family that the resident's insurance coverage would discontinue and of the intended discharge date of [DATE]/2017. On 4/13/2017 at 12:58 a.m., Staff D documented the resident had a Wander Guard on the right ankle. On 4/14/2017 at 12:34 a.m., Staff D noted the resident had a Wander Guard on the right ankle. On 4/14/2017 at 12:12 p.m. Resident #4 discharged home. The resident left walking stable without an assistive device. The Physical Therapy (PT) Evaluation and Plan of Treatment with a start dated of 3/30/2017 included the following documentation related to Resident #4: Referral Reason: Patient referred to PT due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced activity tolerance, paralysis/paresis, reduced ADL participation and increased need for assistance from others indicating the need for PT to increase independence with gait, promote safety awareness, improve dynamic balance, increase activity tolerance and lower extremity range of motion and strength and facilitate discharge planning. History/complexities: Patient with history of right hip fracture 1/18/2017 and right hip dislocation 1/29/2017, went to a nursing home and then home. fell [DATE] with dislocation and to emergency room for hip relocation. Home with hip Spica (brace). Had severe pain and back to hospital on [DATE] and 3/27/2017 had right total hip. The PT Discharge Summary dated 4/13/2017 revealed the resident required supervised ambulation with a walker due to safety/cognitive issues. The resident had inconsistent step sequence without cues when ascending/descending 5 stairs. Education provided to patient and caregiver for safety/technique with gait on levels and stairs; hip precautions. discharged home with home health, therapy evaluation and treat. Payer source changed. Recommend Assisted Living Facility, home exercise program and assistive device for safe functional mobility. Resident #4's Occupational Therapy Discharge Summary: 4/13/2017. ADLs and IADLs (Instrumental Activities of Daily Living) required supervision at discharge. Resident #4's Admission assessment form dated 3/29/2017 did not reveal the resident had exit seeking behaviors: No history of exit seeking, no history of wandering and no verbalizing desire to exit. The physician progress notes [REDACTED].#4 hypotensive (low blood pressure) on 4/6/2017. The physician discontinued the residents Lisinopril (blood pressure medication). The resident denied feeling dizzy or lightheaded. The physician Discharge Summary dated 4/12/2017 reported Resident #4's stay at the facility had been generally unremarkable, blood sugars were initially consistently running low so the Novolog (insulin) had been discontinued and the blood sugars remained stable and controlled with the Lantus (insulin). The resident also had dizziness determined to be orthostatic (blood pressure), and ordered Lisinopril held if systolic blood pressure read less than 100. The resident made good progress in therapies and had no concerns. Staff had no concerns either. The resident planned to go home for a short period of time before moving to an Assisted Living Facility in Arizona. During an interview on 7/14/2017 at 2:20 p.m., Resident #4's son-in-law reported he received a call from the facility on 4/8/2017 at approximately 2:50 p.m. asking if the resident was with family. The facility indicated they were not sure of the resident's whereabouts, and an employee had seen the resident walk out of the facility. The son- in- law stated he gave the facility the resident's cell phone number. A couple of minutes later, the son-in-law called the resident but got no answer. The son-in law stated at approximately 2:58 p.m. the facility called and informed him they got in touch with the resident at the bank and they were going to get him/her. During an interview on 7/14/2017 at 10:00 a.m., Resident #4's daughter revealed the facility had called asking if family had the resident with them. The facility said they did not know where the resident went and did not know how to contact him/her. The daughter indicated she worked the night shift and therefore slept during the day. They later called her spouse to say they had found the resident. The daughter indicated she always signed the resident out when taking the resident out of the facility. At approximately 5:30 - 6:00 p.m., the daughter called the facility. Whoever answered indicated he/she knew nothing of the incident and transferred the daughter to the Administrator and she had a conference call with the Director of Nursing (DON) and the Social Worker. They asked the daughter if the resident had ever been at another facility. The daughter informed them that the resident had been at another facility for rehabilitation after surgery. They informed the daughter that the resident went to the bank, but they never explained how the resident got there. The daughter assumed someone went with the resident to the bank. They told the daughter that the resident took money out and asked for permission to lock it up. She thanked them for locking it up. They asked if it was okay for the resident to go to the bank and she said yes. They never said the resident cut off his/her Wander Guard and they never said the resident walked without the walker (assistive device). The resident never said anything to the daughter about calling a cab. The resident thought a social security check had been deposited and he/she wanted to withdraw money. The resident told the daughter a good samaritan woman picked him/her up along the way and he/she was limping. The resident told the daughter he/she walked out of the facility through the double doors following a gentleman in a wheel chair, and nobody stopped him/her. The daughter said it scared her to think about the incident. The resident obviously knew to cut off the Wander Guard. On 6/30/2017, Staff G (Administrator) was interviewed and reported being in his/her office on 4/8/2017 at 1:30 p.m. when Resident #4 stopped and said he/she intended to go to the bank. Staff G knew the resident was going to the bank without the walker. Staff G asked the resident if he/she told the nurse and the resident said yes. The resident told Staff G he/she planned to go to the bank by Walgreens. Staff G stated the resident had gone to Walgreens in the past. The Wander Guard alarm failed to sound. Staff G, did not know Staff C, Social Worker had been looking for the resident. Staff G stated she had no knowledge of anyone looking for the resident. Staff G sat in the office with the door shut. The resident went to the bank, withdrew a couple of hundred dollars and they locked it up. The resident had a BIMS of 15 and had informed staff. The facility did not consider it an elopement. Staff G did not know who found the Wander Guard. They reviewed the video of the front door exit and saw the resident ambulated out the door without a walker and the alarm failed to sound. Staff H, Receptionist watched the resident leave. On 7/12/2017 at approximately 2:45 p.m., Staff G stated on 4/8/2017, the facility called a Code Green (missing person). They reviewed the procedure and looked at the normal trigger points. Staff G stated the resident told staff he/she called a cab and they failed to see that as a problem. They did notice the resident failed to sign out on the Leave of Absence sheet. Staff G stated the alert resident had a means of communication and they knew the resident would soon go home. At shift change report, there had been confusion. The video showed the resident went from the hall past the front desk, stop and talk to Staff H and walked out the front door wearing plaid pants and a shirt. The resident told Staff H he/she intended to go to the bank and would be right back. An hour before the resident left, Staff G went to the resident's room and the resident told Staff G he/she intended to go to the bank. Staff G told the daughter the resident went to the bank alone and she was happy he was independent and strong enough. The resident had a high BIMS score and Staff G did not see the incident as reportable. They failed to see where anything should have been done differently other than the resident should have signed out. Staff G stated the facility had no other residents who removed the Wander Guard bracelet. During an interview on 6/30/2017 at 12:10 p.m., Staff I, Director of Nursing stated she received a call at home on April 8 from Staff C, Social Worker. Staff I stated Resident #4 was supposed to be outside but went to the bank and staff went to pick the resident up. Staff I came to the facility after the resident had returned. Staff I stated Staff J, RN did an assessment. They wanted to make sure the resident was not exhausted. The resident indicated he/she went to the bank to get money out. Staff I stated she heard the resident got a ride. The resident told staff they would find the Wander Guard in the red suitcase. Staff I stated it appeared the resident used a finger nail clipper to cut it off. Staff I stated Staff K, Maintenance, pulled out the suitcase and found the Wander Guard. By the time Staff I arrived to the facility, someone had already applied a new Wander Guard. Staff I talked to everyone. Staff H reported the resident said he/she was going outside. Staff A revealed the resident mentioned wanting to cash a check. The resident should not have had a Wander Guard on with a BIMS of 15. The facility had an exit seeking book with photographs of residents with Wander Guards. At that time, Resident #4's photo and name would have been in the book. The resident discharged on [DATE] with plans to go to an Assisted Living in Arizona. Staff I stated that Staff H worked at the facility a couple of months and check Wander Guard placement every shift. The DON stated the resident did not sign out of the building on 4/8/17. The resident never mentioned wanting to go home. On 7/13/2017 at 11:35 a.m., Staff I (DON) reported Staff L, Dietician, picked up Resident #4 at the bank at 2:15 p.m., and returned with the resident at 2:30 p.m. On 6/30/2017 at approximately 8:15 a.m., Staff C, Social Services reported on 4/8/17 she looked for Resident #4 at approximately 2:00 p.m. to ask a question about discharge. Staff C asked Staff J, RN if she knew where the resident had gone. The resident had at times gone out with family. Some staff indicated the resident mentioned going to the bank. Staff C stated that Staff J called the resident's family, got the resident's cell phone number, called it and found the resident went to the bank. During an interview on 6/30/2017 at 11 a.m., Staff J, RN reported working second shift on 4/8/17, when Resident #4 went to the bank. During report, Staff C asked if they had seen Resident #4. Later, Staff C returned and indicated they failed to locate the resident. Staff J called the resident's family and obtained the resident's cell phone number. Staff J called the resident at the bank and Staff L went to get the resident. Upon return, Staff J did a head to toe assessment. The resident had no Wander Guard on and the resident reported removing it. Later, someone said they found it. Staff J never completed an Incident Report. The resident appeared alert and oriented and answered questions. When Staff J asked the resident why he/she failed to inform staff about going to the bank, the resident replied it was my business. Staff J stated the resident had previously mentioned wanting to go home. During an interview on 6/30/2017 at 12:30 p.m., Staff H, receptionist reported at 1:30 p.m. a resident wearing plaid pants came up and said it's a beautiful day and wanted to sit outside. The door alarm did not sound. When residents sit out front, staff checks on them every 15 minutes and offer them water. The resident sat on the bench at the first 15 minute check and refused water. At 2:00 p.m., Staff C came looking for Resident #4 and failed to find him/her. The facility called a Code Green. Staff G, Administrator came out of the office and helped looking for the resident. Staff G never said the resident went to the bank. Nobody knew the resident went to the bank. Staff H stayed at the desk to monitor. Staff F, dietician brought the resident back. The resident reported feeling fine and he/she just went to the bank. Staff H reported being happy to see the resident's face. Staff H reviewed the facility Exit Seeking book. If the resident had a Wander Guard on, the alarm would have sounded. Staff H would have re-directed the resident away from the door and called a staff member to take the resident away from the area. During an interview on 6/30/2017 at 9:00 a.m., Staff L, Dietician reported working in the kitchen on Saturday, 4/8/17. Staff C, Social Services asked Staff L to get Resident #4, sometime in the afternoon, around 2:00 p.m. Staff L picked the resident up at the local bank. The resident told Staff L he/she walked to the bank and had business to do. The resident had no walker when he/she got into the car with Staff L. During an interview on 7/11/2017 at 11 a.m., Staff A, LPN reported working from 6 a.m. - 2 p.m. on 4/8/17. Staff A stated between 9:00 and 10:00 am, Resident #4 came to the nurse's station and requested a phone number for a taxi cab. The resident indicated he/she had a $10 check to cash. The resident used a phone book and returned to his/her room. The resident never mentioned going to the bank again that day. That morning, Staff A checked the resident's Wander Guard and found it on and functioning. The resident made no other remarks about leaving and had no other attempts to leave. After lunch, Staff A observed Resident #4 ambulating near the back nurse's station. At the change of shift, someone asked about the resident's whereabouts. Staff A stated the staff looked in the resident's room and outside and they called a Code Green. Staff A an incident report was not completed since the resident was alert. Staff A heard the resident removed the Wander Guard. During an interview on 7/11/2017 at approximately 2:55 p.m., Staff M, RN reported working on 4/6/2017 and the resident thought he/she had a doctor's appointment. Staff M found the resident standing at the end of the hall with a walker and a coat, and reported waiting for a cab. Staff M reported the resident had the wrong day. The resident became upset and family came and calmed the resident down. Staff M stated If a resident had a Wander Guard, they are not allowed to leave the premises. During an interview on 7/12/2017 at 11:50 a.m., Staff S, RN reported the facility has a book at the receptionist desk. The book contains photographs of residents with an elopement risk and with Wander Guards. During an interview on 7/13/2017 via phone, Staff B, LPN reported working the day shift on all units. Resident #4 initially had confusion, and then became less confused and eventually cleared. Staff B heard the anesthesia caused the confusion. Staff B observed the resident ambulating with therapy. During an interview on 7/12/2017 at approximately 4:10 p.m., Staff X, OT (Occupational Therapy) revealed at discharge, Resident #4 required assistance with ADLs and IADLs. IADL, or Independent Activities of Daily Living, includes tasks such as cleaning, cooking and household management. Resident #4 had impulsive behaviors, decreased memory and decreased safety awareness. Sometimes the resident remembered hip precautions and other times, not. The resident would require supervision with community mobility such as going to a grocery store or a bank. The resident had a concern for safety due to cognitive issues and ambulated with supervision. During an interview on 7/18/2017 at approximately 10:30 a.m., Staff Y, PT (Physical Therapy) stated Resident #4 had a history of [REDACTED]. Staff Y stated the resident had dizziness for a couple of days and that resolved. Staff Y entered the resident's room one day and found the resident standing at the foot of the bed without a walker; a safety concern. The resident had inconsistent follow through. When the resident used the walker, he/she could ambulate independently. Staff Y stated due to cognitive/safety issues, Staff Y recommended supervision. The resident may not always react to safety concerns. The walker provided support and slowed the resident down. During an interview on 7/12/2017 at approximately 10:30 a.m., Staff N, CNA reported working on Resident #4's hall during the day shift on 4/8/2017. The resident never gave any indication he/she intended to leave the facility. Staff N stated never knew the resident had a Wander Guard, the nurses check it. Staff N stated had no knowledge if the resident had any other attempts at leaving unattended. Staff N stated she assumed if the resident had a Wander Guard it was due to wandering off. During an interview on 7/11/2017 at approximately 2:35 p.m., Staff P, CNA reported working second shift on 4/8/2017. Staff P never witnessed any attempt to leave, nor did the resident mention wanting to leave. Normally when residents can walk by themselves, they have a Wander Guard. On 7/11/2017 at approximately 10:05 a.m., Staff Q, CNA reported working second shift on 4/8/2017. They had just finished report and someone called a Code Green. Everyone looked for Resident #4 checking bathrooms and resident rooms. Nobody knew the resident went to the bank. On 7/13/2017 at 12:45 p.m., Staff Q indicated the resident appeared confused about 60% of the time. The resident said things like going to a meeting, committee members are waiting . During an interview on 7/13/2017 at approximately 2 p.m., Staff V, CNA reported working on second shift. Some days Resident #4 required assistance and other days the resident could do his/her own cares. The resident forgot to use the walker at times. At times the resident had a little confusion and failed to know where he/she was at. On 7/12/2017, Staff T, Receptionist reported working Monday through Friday, and one weekend a month. Staff T showed the surveyor the Exit Seeking binder with photos of residents. When residents sit outside, they check on them every fifteen minutes, especially during hot weather. Staff T did not recall Resident #4 attempting to leave. During a phone interview on 7/11/2017 at 2:20 p.m., the state climatologist reported on 4/8/2017 at 1:54 p.m. the Waterloo area had a temperature of 74 degrees, clear skies and breezy conditions. A review of the area between the facility and the local bank identified a 1 mile distance. The facility faced Ridgeway Avenue (East/ West) with 35 miles per hour speed limit. It sat next to Walgreens' pharmacy and used the same street entrance from Ridgeway. Ridgeway intersected with Kimball (North/South), a four lane road with a 35 miles per hour speed limit. The bank faced San Marnan (East/West), a four lane road with a 45 miles per hour speed limit. There were stop lights on Kimball at Park Lane, Rachel and Brookeridge. The distance bet(TRUNCATED)

Based on record review and staff and resident interviews, the facility failed to ensure Resident #2 was free from verbal and sexual abuse. The sample consisted of 4 residents and the facility reported a census of 66 residents. Findings include: 1. The Admission Record Report for Resident #2 identified an original admission date of [DATE] with a readmission on 03-17-16 and had [DIAGNOSES REDACTED]. Resident #2 had a MDS (Minimum Data Set) assessment dated [DATE]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 11 out of 15. A score of 11 identified the resident had a moderate cognitive impairment. The assessment indicated the resident as independent with bed mobility, transferring, ambulating, eating and personal hygiene. Resident #2 required staff supervision with dressing and extensive staff assistance with bathing. The Care Plan dated 06-09-2016 identified a problem with potential grief reaction related to restarting [MEDICAL CONDITION] treatment. The interventions directed the staff to do the following: Attempt to involve in activities respecting choice and preferences; Discuss feelings of sadness/hopelessness and options of appropriate channeling of these feelings; Offer choices to enhance sense of control; and validate feelings During an interview on 08-16-2016 at 3:50 p.m. Resident #2 stated there were several times in which the night shift nurse, Staff A had kissed him/her on the lips. Resident #2 stated this had happened 4 or 5 times in the last 2 or 3 weeks. Resident #2 stated he/she felt like Staff A held his/her mouth open and tried to French kiss . Resident #2 stated the first time he/she was surprised. The second and third time the resident stated he though Staff A had an agenda and the fourth time he/she pushed Staff A away. Resident #2 stated he/she would ask who would be coming on to work. Resident #2 stated he/she would feel ' dread ' when learned it was Staff A coming on duty. Resident #2 stated he/she does not have those kind of needs Resident #2 stated Staff A never touched any other part of his/her body, but he/she felt Staff A had plans, and/or an agenda and would have made further advances. Resident #2 also stated Staff A once stated, You know if I was younger I ' d be working up to marrying you when you get out . On 08-17-2016 at 1:27 p.m. Staff A (Registered Nurse) was interviewed and admitted she had kissed Resident #2, adding it was on the top of the head, maybe three times at most. Staff A stated it was a kiss comparable to kissing a baby on the top of their head and there was no sexual meaning in it what so ever. Staff A stated that he/she did not expect anything in return from the kiss. During the interview Staff A also described Resident #2 as being special. Staff A also stated she once commented to Resident #2, that when you get better and I grow up, we should get married. Staff A stated Resident #2 just laughed about the statement. During an interview on 08-17-16 at 4:08 p.m. Staff B stated she was called into Resident #2 ' s room one night. The resident stated Staff A was being very rude and short with him/her. Staff B stated all of a sudden during the conversation, Resident #2 stated, And that [***] had the nerve to grab my face and kiss me all over. Staff B stated Resident #2 became teary, then broke down and cried. Staff B stated the resident informed her it was not the first time this had happened. Staff B stated she didn ' t want to believe it, but when Resident #2 broke down (cried), she knew something had happened. Staff B stated the resident told her If she is doing this to me, what is she doing to others?

Based on observation, record review and interviews with staff, physician and a nurse practitioner and review of the facility policy/procedures, the facility failed to properly assess the resident's skin under ace wraps and or braces and intervene for Resident #4 and #7 and failed to adequately assess Resident #8's skin and identify an open area present when performing treatment of [REDACTED]. The sample consisted of 7 residents and the facility reported a census of 64 residents. Findings include: 1. Review of a Minimum Data Set (MDS) assessment dated [DATE], Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident usually understood and had the ability to understand others, with moderately impaired cognitive skills, fluctuating inattention and disorganized thinking. The MDS indicated the resident required extensive assistance of 2 staff members with bed mobility, transfers and toilet use. The MDS indicated the resident required extensive assistance of 1 staff person with ambulation, dressing eating and personal hygiene. The resident had an impairment of one lower extremity. The MDS indicated the resident had no identified skin problems. The skin and ulcer treatments identified only a pressure reducing device on the bed and chair and no other programs or treatments. The Care Plan initiated on 5/17/16 identified a focus area with the resident ' s activities of daily living self-care deficit. The Care Plan reflected the resident had this focus area related to physical limitations, weakness, recent left ankle fracture and a history of TIA ' s (mini [MEDICAL CONDITION]). The Care Plan identified a focus area with infection of lower extremity wounds on 6/6/16. The Care Plan identified a focus area for skin integrity alteration related to impaired mobility and initiated on 5/17/16). The resident had an incision at the left ankle related to a recent ORIF (open reduction internal fixation) to the left ankle (dated 5/18/16), a deep tissue infection to the left heel measuring 2.2 centimeters (cm) by (x) 2.3 cm, a ruptured blister to the left dorsal foot that measured 5.5 cm x 5.3 cm (dated 6/6/16 ) and a ruptured blister to the left medial malleolus that measured 9.5 cm x 8.5 cm. (dated 6/6/16). The approaches included the following: a. Assist with daily hygiene, grooming, dressing, oral care and eating as needed. b. Encourage and/or assist to reposition frequently. c. Off-loading boot as ordered. d. Pivot transfer with 2 assist. e. Prafo boot as ordered. f. Used wheel chair and walker for mobility. g. Administer medications per physician orders. h. Record temperature as clinically indicated. i. Report nonverbal expressions of pan such as moaning, striking out, grimacing, crying, thrashing change in breathing and etc. j. Implement non-drug therapies to assist with pain and monitor for effectiveness. k. Observe skin condition with ADL care daily, report abnormalities (initiated 5/17/16). l. Administer a treatment per physician's order. (5/18/16). m. Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain and etc. Notify the MD as needed. (6/6/16) The Care Plan identified the resident at risk for complications due to musculoskeletal problems regarding the [MEDICAL CONDITION] ankle on 5/18/16. The interventions included to report evidence of infection such as pain, redness, drainage, increased tenderness or other complications at the surgical site. A Patient Admission/Readmission Screen dated 5/17/16, indicated the Resident at risk for developing pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk forms dated 5/24/16, 5/31/16 and 6/7/17, indicated the Resident at a moderate risk for developing pressure sores. A Physician Transfer Order Report dated 5/17/16, included the following information: a. A problem list that included - a closed left ankle fracture (5/13/16 to present). b. Discharge orders that included - 1. An ace wrap to the left lower extremity. Keep clean, dry and intact. 2. Partial weight bear - 50 % weight bearing to the left lower extremity. c. Patient instructions that included - an open reduction with internal fixation of a limp. A Handoff Report form dated 5/17/16 at 2:51 p.m., documented the following: Wound: Yes - ace wrap to the left ankle with a cam boot on. According to a Progress Notes form dated 5/17/16 at 6:24 p.m., the Resident arrived at the facility for rehabilitation following an ORIF of the left ankle. A Treatment Administration Record (TAR) dated 5/1/16 through 5/31/16, indicated the resident with an order for [REDACTED]. (discontinued 6/3/16) An Office Visit form dated 5/23/16, indicated the resident with a follow up visit on a left ankle fracture. The physician exam included the lower left extremity which contained a CAM boot, no swelling present, toes warm to touch and the dressing intact and dry. An x-ray form dated 5/26/16, documented the resident had a history of [REDACTED]. The x-ray showed good maintenance of the reduction and alignment with no widening of the syndesmosis. No increased clear space. The incisions had been healing well and sutures removed. A physician progress notes [REDACTED].>A Progress Note dated 5/30/16 at 1:32 a.m., indicated the Resident complained of pain to the left leg and receive an order for [REDACTED]. A Progress Note dated 5/31/16 at 4:24 p.m., a Nurse Practitioner (NP) indicated the staff reported the Resident had been complaining of pain in his/her left ankle. A Progress Note dated 5/31/16 at 8:59 p.m., indicated the Resident remained on skilled level of care due to a left ankle repair, voiced discomfort often and pain medication administered as ordered. A Progress Note dated 6/2/16 at 9:36 p.m., NP indicated the staff reported the Resident's pain to the left ankle fracture as uncontrolled as he/she complained of quite a bit of pain. A Progress Note dated 6/3/16 at 2:11 p.m., indicated a late entry for 6/2/16 which read as follows: Noted a 4 - 6 cm length area to the left outer ankle with noted brown odiferous exudate from area, macerated unapproximated skin to edges, unable to determine etiology of affected area. A Telephone Order form dated 6/3/16 at 9:36 p.m., documented the following: If drainage continued to the left lower extremity, send to the emergency room to be evaluated (drainage as brown and odorous) one time only for signs and symptoms of infection for 1 day. A Progress Note dated 6/3/16 at 10:49 p.m., documented the following: Upon assessing wound for measurement this evening, noted a wound to the left outer ankle and left inner ankle with a scant amount of brown odorous drainage. The nurse notified the nurse practitioner of the wound assessment and received new orders for Keflex (antibiotic) 500 milligrams by mouth twice a day for 10 days. The nurse practitioner ordered Dakin ' s (solution for cleansing the wound), ABD (large thick dressing type) and then secure with Kerlix and Tuibirgrip (type of wrap). The staff were to hold (not put on resident) the CAM Boot and place the offloading boot on at all times except for dressing changes and skin checks. The nurse practitioner ordered the nurse to notify the orthopedist medical doctor. The orthopedist doctor gave an order to send the resident to the emergency room if continues to have drainage tomorrow. A Progress Note dated 6/4/16 at 1:50 a.m., indicated the Resident with no drainage or seeping through the wraps/[MEDICATION NAME] at that time. A Progress Note dated 6/4/16 at 10:39 a.m., indicated the Resident complained of a little bit of pain but unable to specify where. The note indicated the resident ' s urine as dark and odorous. The off- loading boot was on and the dressings to the ankle dry and intact. A Progress Note dated 6/4/16 at 10:32 p.m., indicated the resident with significantly less drainage and odor compared to last night. The area remained macerated with peeling skin surrounded with an area of red to dark brown/black. A Progress Note dated 6/5/16 at 5:35 a.m., indicated the resident with no drainage noted through the dressing to the left lower extremity and the resident indicated to signs of pain/discomfort. A Progress Note dated 6/5/16 at 11:04 p.m., indicated the resident with a scant amount of drainage from the site with no redness or warmth surrounding the wounds. The wounds had no redness or warmth. On a Progress Note dated 6/6/16 at 2:31 p.m., the NP included the following documentation: I (NP) spoke with an orthopedic surgeon related to the new onset of wounds to the left ankle and the he (surgeon) was upset. The physician requested the wounds be left open to air to dry out, however, the patient rubs on foot with his/her other foot. I (NP) feel the resident needs a light protective dry coverage. The physician wants the resident ' s his/her feet floated on the pillows when in bed. The resident will be wearing a prafo boot when in the wheelchair. A Task Sheet form dated May 2016, indicated the resident received a shower/bath on 5/30/16 at 7:41 p.m. A Task Sheet form dated June 2016, indicated the resident received a shower/bath on 6/2/16 at 5:33 p.m. A Skin Alteration Record dated 6/3/16, indicated the resident with an area on the left outer ankle measured 12 cm x 6 cm, (no depth, tunneling or undermining documented), a scant amount of a foul drainage and pain. A Skin Alteration Record dated 6/3/16, indicated the resident with an area on the left inner ankle with a 6 cm x 4 cm area, (no depth, tunneling or undermining documented), slough, a scant amount of foul drainage, maceration and pain. A Progress Note dated 6/6/16 at 3:58 p.m., documented the following: a. Reported by the nurse that the patient had an open area on Friday 6/3/16 (although first identified on 6/2/16) to the left lateral ankle. The area reported to NP and on-call supervisor in the evening hours. Orders were updated at that time and the orthopedic doctor was notified. Upon further assessment today on rounds with the wound team, 3 deep tissue injury (DTI) were verified. The original area reported to the left lateral malleolus measured 8.0 cm x 3.3 cm. That area had been an untraceable pressure ulcer with 100% necrotic escarp. The wound edges had been pink/macerated and non-blanchable. The second area assessed had been an unstageable DTI to the left heel that measured 2.2 cm x 2.3 cm. The wound bed had been 100% necrotic eschar with soft wound edges. No drainage present, however, an odor had been identified. The area had also been tender to the touch with no induration and the surrounding skin as soft spongy but blanchable. The final area assessed had been identified as an unstageable DTI located on the sole of the left foot that measured 6.6 cm x 2.2 cm., currently closed with dark underlying tissue. The surrounding skin soft, with no induration, tender to the touch and blanchable. Two 2 additional areas open, however, not considered DTI's per the NP. The 1st are on the left dorsal foot measured 5.5 cm x 5.3 cm described as a ruptured blister with fragile soughing wound edges with a pink wound bed and scant amount of clear drainage. The second area to the left medial malleolus measured 9.5 cm x 8.5 cm described as a ruptured blister with fragile wound edges, sloughing skin and a small amount of clear drainage. All surrounding skin had been soft but blanchable. A physician progress notes [REDACTED]. a. Discontinue the boot!!! b. Do not put anything on the wound. c. Remove the sock as soon as patient arrived. d. Do no put any dressing, ointment or gauze on the left ankle. e. Start [MEDICATION NAME] 500 milligrams every day (QD) for 14 days unless the family physician ordered otherwise. f. Physical Therapy QD for one month to work with the WBAT (weight bearing as tolerated). g. Elevate the leg calf on a pillow, no blankets over the wound, h. Return appointment 7/7/16 at 1:45 p.m. i. Only place a sock that family brought and only wear sock when he/she had been WBAT. An I-Heal form (wound clinic) dated 6/8/16, identified the following: Left foot - medial, proximal surgical injury - dated acquired 5/12/16 - 5.6 cm x 5.8 cm and 0.1 cm deep. Left foot - dorsal surgical injury - date acquired 6/6/16 - 5 cm x 4 cm and 0.1 cm deep. Left Calcaneus pressure injury - date acquired 6/6/16 - 2.1 cm x 2.5 cm and 0.1 cm deep. A physician progress notes [REDACTED]. a. Paint all wounds with [MEDICATION NAME] twice daily (BID). b. Prevalon foam boot as soon as possible. (ASAP). c. Keep heel off loaded at all times. d. Keep leg straight while in bed to avoid pressure on the ankle. Use pillows or props to keep foot upright. An imaging form collected 6/13/16 at 3:10 p.m. and resulted 6/13/16 at 4:24 p.m., indicated the impression as severe resting arterial insufficiency of the lower extremities, left more than the right per the Doppler waveforms and pressures. A History and Physical form dated 6/13/16 at 4:01 p.m. indicated the physician personally obtained the full history from the patient and the chart and personally examined the patient, fully reviewed the chart and any lab or imaging studies and formulated the medical decision making. A Full Operative Note dated 6/13/16 at 4:41 p.m., indicated a Pre-op [DIAGNOSES REDACTED]. The procedure included an excisional debridement of skin and subcutaneous tissue of the left ankle wounds. The indications/procedure included the following: the resident had a ORIF of the left ankle fractures about a month ago. The resident developed a black eschar over the lateral ankle wound and a black eschar and necrotic skin over the top of the foot and medial wound in obvious need of debridement. Over the lateral malleolus there was eschar that was about 4.5 cm x 1.5 cm wide. That was excised with a scalpel. Right underneath the necrotic skin and little subcutaneous tissue, the plate and screws from the repair of the lateral malleolus was sitting right there. There was no healthy tissue around it. The scalpel was then used to excise the skin and subcutaneous tissue from the top and medial aspect of the foot. Again right underneath the skin and a little bit of subcutaneous tissue there was tendon and one of the screws from the medial plate was exposed as well. It was obvious at this point that the wounds were not going to heal and the realistic option had been amputation. The excisional debridement included the following: Laterally the wound was 4.5 cm x 0.5 cm and about a half a centimeter deep with exposed hardware. Medially the wound was about 6 cm x 1 cm. The depth of the debridement was about 1 cm and the physician did not reach healthy tissue. Record review revealed the resident received a left mid-thigh amputation on 6/15/16. During an interview on 6/23/16 at 2:42 p.m., an Orthopedic Surgeon stated the following: a. The wounds had been preventable. b. The wounds could have developed in 1-2 days due to poor blood supply however the staff should have observed the area. c. He/she had nothing good to say about the situation and they (wounds) should not have occurred. d. The areas had been a result of poor care. During an interview 6/23/16 at 2:06 p.m., Staff H, Licensed Practical Nurse (LPN) stated he could not remember the date but around supper time the resident's friend said there had been a spot on the ace wrap that he/she had not seen before. The staff member described the spot as a dark brown/black area on the left outer ankle. The staff member removed the ace wrap and observed a 4 x 4 gauze pad had a dark brown/black, dried, odorous area about the size of a 1/2 dollar and the wound appeared gangrenous. The staff member observed the foot and ankle and noted a straight line on the left outer ankle (scar) with the surrounding skin macerated with a brown liquid oozing out of an open lower area in the region. The staff member cleansed the wound with water, tried to approximate the skin as much as possible, however, the skin could not meet and proceeded to cover the area with a 4 x 4, wrapped it with Kerlix and placed a [MEDICATION NAME] stocking over the Kerlix. The staff member confirmed he/she only measured the area visually and failed to utilize any tool and/or device. The staff member stated later that evening he/she reported the area to the night nurse so he/she could report it to the day nurse who could have had the NP look at the area. The staff member confirmed he/she forgot to document the area in the Progress Notes because it had been a hectic night so the next day he documented a late entry. Additionally, the following day he asked the resident's charge nurse if she received a new treatment for [REDACTED]. The staff member said she knew later that night she went to assist the other nurse to assess the area and take vitals. The staff member confirmed looking back he should have called the nursing supervisor and the physician. During an interview 6/24/16 at 8:51 a.m., Staff I, LPN stated he/she had been in the middle of a medication pass when Staff H informed him/her about the resident's foot. Staff I informed the NP who directed him/her to get measurements of the wound. The staff member followed through and called the orthopedic surgeon and received treatment orders. The staff member confirmed if a new skin and/or pressure area had been identified on a resident he/she would immediately call the supervisor and physician. During an interview 6/24/16 at 9:24 a.m., the NP stated she first became aware of the open area on Friday night, 6/3/16, when Staff I called her at home. The nurse described the wound and she gave the nurse treatment orders. The NP stated she called the facility on Sunday and Staff I indicated the wound as better. On Monday she assessed the area and said she had been completely shocked. The medial top of the foot looked like a popped blister and the lateral wound had been all eschar. The staff then made an appointment with the orthopedic surgeon that day and the wound clinic on 6/8/16. When the resident went to the wound clinic they sent him/her for vascular studies. The staff member confirmed she never removed the ace wrap to assess the foot because she thought the wrap had been there to stabilize the foot and the resident would not let you anywhere near the foot plus he/she had [MEDICAL CONDITION]. The staff member confirmed the resident did complain of increased pain but it did not raise her curiosity due to the broken ankle and [MEDICAL CONDITION]. The staff member confirmed she would have expected Staff H to have called and reported the open area to her once it was identified. During an interview 6/24/16 at approximately 10 a.m. Staff J, Registered Nurse (RN) confirmed she had no knowledge of the open area on the resident ' s foot when she worked the day shift on 6/3/16. During an interview 6/23/16 at 12:10 p.m., Staff B, RN stated she first became aware of the situation from Staff I on 6/3/16 during the 2nd shift when Staff I called and informed her it had just been brought to attention by Staff H, there had been an area on the resident's left ankle so they went to look at the area. The staff member confirmed Staff H found the area on 6/2/16 on the 2 p.m. to 10 p.m. shift but no one informed her until 6/3/16, after hours. The staff member confirmed she would have expected Staff H to report the area and call the physician. On Monday 6/6/16 the staff member along with the NP assessed the area. The NP changed the treatment, called the orthopedic surgeon and made an appointment. When the resident returned from the appointment the orthopedic Surgeon directed the staff to place nothing on the resident's foot. The NP had been concerned the resident would rub the foot and cause more injury so she (NP) wanted to change the treatment but the family refused. During an interview on 6/23/16 at 3:37 p.m., Staff K, RN confirmed she never removed the resident's boot or ace wraps when she had been assigned as the resident's charge nurse. Additionally, the staff member confirmed the supervisor and physician should have been called with any new skin issues. During an interview 6/28/16 at 1:15 p.m., Staff M, RN confirmed he/she never removed the resident's boot or ace wraps when she had been assigned as the resident's charge nurse. When the staff member observed the resident's left ankle the drainage had been a creamy white serosanguinous substance and very odorous and further described as a [MEDICATION NAME]/rotten egg smell. The surrounding tissue had been slough with the wound a dark pink in color and about a plum size. During an interview 6/23/16 at 4:43 p.m., Staff N, Certified Nursing Assistant (CNA) indicated the last time he/she bathed the resident it must have been a bed bath. (During the rest of the interview the staff member kept contradicting his/her statements) During an interview 6/29/16 at 7:15 p.m., Staff L, Certified Nursing Assistant (CNA) confirmed she assisted the resident with bed baths but never removed the boot or the ace wrap as that had been the nurse's responsibility. 2. According to an MDS assessment form dated 5/29/16, Resident #7 had [DIAGNOSES REDACTED]. The assessment indicated the resident with a BIMS score of 6. A score of 6 represented the resident as severely cognitively impaired. The MDS indicated the resident had fluctuating inattention, disorganized thinking and altered level of consciousness, required extensive assistance of staff with dressing and personal hygiene, as non-ambulatory and an impairment of one lower extremity. A Care Plan with a focus area dated 6/1/16, documented the resident at risk for alteration in skin integrity related to weakness, incontinence, impaired mobility, recent surgery, aspirin use, anticoagulant use, diuretic use, [MEDICAL CONDITION], hypertension, a right knee brace and ted hose. Review of instructions for knee brace use form dated 3/15 revealed the following directives: Do not over tighten. If swelling, pain, skin irritation or an usual reaction occurred discontinue the use immediately and consult your medical professional. Locate the hole in the brace. Position brace with the oval hole behind the knee centered at the bend of the knee. the condyle pads should have been next to the knee condyles. Ensure that all straps were located on the outside of the knee. An Admission form dated 12/2009, indicated the purpose had been to prepare for and admit a patient to the center in a manner that reduced anxieties/fears and obtained necessary clinical information. The procedure included the following: Notify a physician of admission and obtain or verify orders. The Suggested Documentation included the following: A baseline physical evaluation, unusual observations and/or complaints and subsequent interventions including communications with physician. A Treatment Administration Record (TAR) dated 6/1/16 through 6/30/16, indicated the resident with a right knee brace for comfort. Assess skin nightly under the brace (not dated). An observation on 6/24/16 at 10:45 a.m., revealed the resident positioned in his/her wheel chair with a right knee brace on backwards and tight as the air holes for the posterior knee where positioned on top of the knee cap causing the skin to protrude through holes causing [MEDICAL CONDITION]. During an interview at the same time, Staff B, Registered Nurse (RN) confirmed the above stated observation. Record review on 6/30/16 at 12:00 p.m., identified no physician order for [REDACTED]. Review of a Braces/Splints/Boots/Ace Wraps form updated on 6/24/16, the purpose had been to maintain functional range of motion, decrease muscle contractures and provide support and alignment for weakened limbs through use of braces and/or splints. The procedure included the following: Apply device as directed by a therapies or physician. Hand or foot should have been supported and straps secure, but not too tight. 3. According to a MDS assessment form dated 5/27/16, Resident #8 had [DIAGNOSES REDACTED]. The assessment indicated the resident with a BIMS score of 15. A score of 15 represented no cognitive impairment. The MDS identified the resident required extensive assistance of 2 staff members with bed mobility, transfers and toilet use and with application of ointments/medications other than the feet. A Care Plan, with a focus area initiated 5/20/16, identified the resident at risk for alteration in skin integrity related to impaired mobility, weakness, diuretic use, obesity, [MEDICAL CONDITION] (weakened left sided heart muscle), tricuspid/aortic/mitral heart value insufficiency, [MEDICAL CONDITION] and a left lower extremity brace. The interventions directed the staff to do the following: observe skin condition with activities of daily living care daily, report abnormalities. An observation on 6/29/16 at 10:40 a.m., indicated Staff G, LPN and Staff C, LPN completed treatments to the resident's left lower leg, right and left abdominal folds and left chest area. While cleansing and treating the left abdominal fold, Staff G supported the abdomen while Staff C cleansed the area and applied an ointment/medication. The staff member did not acknowledge and/or treat an open area just above the left abdominal fold which appeared the size of a dime with a slight white center and red around the edges. During an interview at the same time, Staff C identified no open areas in and/or around the left abdomen or abdominal fold. When asked to recheck the area, the staff members confirmed there had been a 1.0 cm x 0.5 cm superficial open area. Staff G stated the area looked like a popped blister. Note: At the time of the complaint investigation, the complaint was coded at as a J, immediate and serious jeopardy. By 6/24/16, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the G level. The facility policy/procedure for braces, splints, boots and or ace wrap was revised to reflect the need to check the skin under brace, splint boot, and ace wraps every shift. The facility provided inservices and educated the revision of the policy and the need to clarify any orders with the physician when orders say to not remove the brace, splint, boot or ace wrap and to assess the skin thoroughly. The nurses were educated to obtain orders to check the skin every shift as per facility procedure prior to their next scheduduled shift to work. The Director of Nursing will monitor orders for any patient receiving a new device to esnure there are also an order to check the skin under the device every shift for 4 weeks to ensure compliance. As of the 7/1/16 exit conference, the facility continued to need to: · Continue to provide inservices and educate the nurses of the revised policy and procedure for assessing the skin thoroughly and under braces, splint boots, ace wraps and ace wraps. · Continue to provide inservices to verify physician's orders when questioning if the ace wrap, boot, splint, braces should be removed so the skin could be assessed. · Continue to monitor if physician's orders are being verified when questioned.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to protect residents from hazards from self and the environment (Resident #4, #8). Resident #4 eloped from the facility without staff knowledge and eventually found in a business district and near a main street. Resident #8 experienced continuous falls and fractured a hip. The facility reported a total census of 70 residents and 9 residents wore Wanderguard devices (Device to lock designated doors when resident attempts elopement and alarm sounds). The sample consisted of 15 residents. Findings include: 1. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 3/26/15 which identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident scored 5 out of 15 on the BIMS (Brief Interview for Mental Status). A score of 5 identified the resident with a severe cognitive impairment. The MDS documented the resident's signs and symptoms of delirium included inattention, disorganized thinking and psychomotor retardation. The MDS reflected the resident exhibited no behaviors or wandering during the assessment period. The resident required limited assistance with bed mobility, transfers, walking and required extensive assistance with dressing, toilet use and personal hygiene. The MDS documented the resident's balance as unsteady and utilized a wheelchair. On 5/7/15 at 2:10 p.m. the Social Service Designee, Staff G, was interviewed and stated she documented on the MDS dated [DATE] which reflected the resident exhibited no behaviors or wandering at that time. Staff G stated she normally completed MDS assessments by information obtained from the progress notes and their daily Eagle Room meetings. She stated she missed the Nurse Practitioner's progress note dated 3/23/15 that noted the resident continued to try to escape the building. Staff G stated she first completed a Behavioral Symptoms Assessment on 4/27/15 with Resident #4, after he/she eloped from the building. Staff G stated she was unaware she was to complete these forms for each resident with a Wanderguard so after the resident eloped from the building Behavioral Symptoms Assessment were completed for each resident who wore a Wanderguard braclet. The Care Plan dated 3/11/15 reflected the resident preferred not to attend activities, was verbally/physically agitated and threatened to hit staff, resistive/noncompliant with treatment/cares, refused showers, refused to change clothing, attempted to transfer/walk independently, wanted to go home and was at risk for eloping from the facility. The Care Plan identified the resident would not leave the nursing home as one goal. The interventions listed to achieve the goal included: calmly redirect to an appropriate area, check for presence and function of security bracelet (Wanderguard) every shift, educated family/visitors to advise staff when leaving patient following visit, elicit family input into former routine which might explain attempts to leave unescorted and request family provide familiar objects from home such as pictures and mementoes. The facility's HCR ManorCare Wandering Patient Practice Guide dated 04/2008 reflected some indicators of potential patient elopement may include wearing a hat or coat inside. The interdisciplinary team was to identify patients with known or potential exit seeking wandering behaviors in order to plan effective prevention strategies. Mobile patients with cognitive impairments and poor decision making skills could be a potential exit seeking/unsafe wandering risk. The guide documented while alarms could help to monitor a patient's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms would not replace necessary supervision. Behavior Tracking Tool was to be initiated when exit seeking or unsafe wandering was identified. Approaches on the Care Plan should be selected and implemented based on patient's preferences and behavior patterns. Reassess patients with exit seeking behaviors regularly. The patient's individualized plan of care to be reviewed and updated as needed to match the patient's current needs. During periods of increased frequency of behaviors helpful interventions may include one-on-one supervision and supervised walking. A Psychological Evaluation dated 3/15/15 documented the resident as oriented to self only, he/she was not oriented to place, year, month, day or date. The resident ' s attention span was short and concentration poor. The resident ' s memory was impaired for recent events and poor for remote events. Immediate retention and recall was also impaired. The licensed psychologist documented long term care as appropriate due to physical and mental issues. The psychologist documented the resident as experiencing poor insight and did not know why he/she lived at the facility. A Behavioral Symptoms assessment dated [DATE] indicated the resident was at immediate threat to self and immediate intervention was required. The form documented the resident exhibited exit seeking and wandering behaviors. The Progress Notes reflected the following: On 3/2/15 the resident arrived and admitted to the facility. The resident could not give a return demonstration with using the call light. The resident sat in a wheelchair and had a unsteady gait. On 3/3/15 at 5:50 a.m. the resident redirects easily when idealation of going home. At 12:37 p.m. the resident alert to name only. At 12:59 p.m. the resident refused breakfast and lunch with no reason given. On 3/4/15 at 7:17 a.m. the documentation reflected the resident as alert and oriented to name with confusion noted. The resident out of bed through night wheeling around facility in wheelchair. Resident easily redirected and cooperative. Verbalizes desire to go home and refuses to lie in bed throughout night. Wanderguard in place on left ankle. At 8:44 a.m. resident walking the halls independently with an un-steady gait. Pt stated he/she was going to punch staff member in the face. At 10:27 a.m. the ARNP ordered a psych evaluation by a licensed psychologist. On 3/5/15 at 6:08 am (late entry 10 p.m. to 6 a.m. shift) resident tried eloping several times throughout night, required more cueing and redirection than usual due to inability to understand simple commands. At 4:09 p.m. the ARNP documented per the staff, the resident constantly wanting to leave the facility. At 7:21 pm the staff found Resident #4 in another resident ' s room. Staff began 15 minute checks and checked the placement and function of the Wanderguard device. On 3/7/15 at 10:10 a.m. the resident tried to leave the facility and easily redirected. At 4:11 p.m. the resident ambulatory tonight and speaks of going home. The resident wearing coat, hat and mittens and declined the need to remove them. On 3/23/15 at 3:14 p.m. the ARNP documented the resident as pleasantly confused and cooperative and continues to try to leave the building. On 4/23/15 at 3:44 p.m. the ARNP documented the staff stated the resident roams the facility often, speaking of wanting to leave. On 4/25/15 9:30 a.m. Late Entry: Note reflected the resident was found walking on the side walk behind a local pharmacy store and returned to the facility. Staff removed the old Wanderguard and replaced with a new Wanderguard device. On 4/27/15 at 12:36 p.m. the resident received one on one with staff the entire shift and the resident has not attempted to leave the facility. On 5/1/15 at 9:10 p.m. the supervision of 1:1 continued and the resident states got to go but was not specific as to where or how. Pt liked to sit by the front door. On 5/2/15 at 5:47 a.m. the resident left via the front door once. On 5/4/15 at 1:05 p.m. the State Climatologist reported the weather information for Waterloo on 4/25/15 at 9:00 a.m. included: the temperature was 44 degrees Fahrenheit with an east wind of 18 mph (miles per hour) creating a wind chill of 36 degrees. Skies were cloudy but no precipitation was occurring. Observation on 5/4/15 at 5:00 p.m. revealed the resident walked around the facility. The resident would stop and visit with staff. The resident would walk toward the front doors at which time staff would step between the resident and the exit doors. On 5/7/15 at 9:50 a.m. the Administrator was interviewed and stated one day prior to the elopement, the resident followed a visitor out the front door. Observation on 5/7/15 at 10:00 a.m. revealed a large desk just inside the front door. When interviewed at this time, Staff A stated the resident liked to come up to her desk by the front door and he/she would either take a piece of candy from her desk and either sit or stand and watch people go in and out of the front doors. Staff A observed several times when Resident #4 would watch the front door and exit through the doors after people either entered or exited the building. Staff A stated the resident would literally run out the door. Staff A stated the day prior the resident eloping from the facility, she informed staff on the second shift they needed to watch the resident due to his/her attempts to exit through the front door. When interviewed on 5/7/15 at 10:30 a.m. the facility's Nurse Practitioner stated she had observed the resident bolt out the front door on several occasions after someone entered or exited the building through the front door. When interviewed on 5/6/15 at 9:18 a.m. Staff B (licensed practical nurse) stated she worked the day shift on 4/25/15 and her duties included caring for Resident #4. Staff B stated she observed the resident in the dining room about 8:30 a.m. At approximately 9:00 a.m. she left the facility to go to a local restaurant. Staff B exited the front door, and got into her car in the parking lot right outside the front door. She drove through the parking lot in front of the facility and then into the parking lot of the Walgreens east of the facility. She reported she went through a local pharmacy due to road construction. Staff B stated she drove around the pharmacy and observed the resident walking south of the pharmacy. Staff B recognized the resident and proceed to turn and stop the car. Staff B stated she called the resident ' s name. The resident wore tennis shoes, pants and a sweat shirt. Staff B stated she asked the resident if he/she was getting cold and the resident stated he/she was getting a bit chilly. She asked the resident what he/she was doing and the resident replied he/she was going for a walk. When she asked the resident why he/she did not come back to the nursing home, the resident stated he/she did not know which way to go. Staff B assisted the resident into her car and drove to the facility. As they approached the front door, she could not open the door due to the resident's Wanderguard. She had the resident step back so she could open the door and then the resident entered the facility. On 5/6/15 at 12:34 p.m. Staff C, a certified nursing assistant, was interviewed and stated prior to 4/25/15, Resident #4 walked around the facility all day long. Staff C stated almost four times a day the resident would try to leave the facility. The resident stayed by the front door and when visitors would come in or leave, the resident would try to leave through the front door. The resident was constantly exit seeking and he/she knew visitors were the resident ' s way out of the facility. The visitors knew the code to enter and then exit the facility. Staff C reported normally the front doors were locked on the weekends and only unlocked from 8:00 a.m. to 4:30 p.m. Monday through Friday when Staff A was at the front door, however, for three weekends the front doors were not locked on the weekends. The day Resident #4 eloped, the front door was not alarmed so visitors entered and exited without having to put in the code. Staff C stated on 4/25/15 she last saw Resident #4 at about 7:45 a.m. in the dining room. When Staff B brought the resident back to the facility, Resident #4 stated he/she walked right out the front door. The resident informed her, he/she was freezing. On 5/7/15 at 9:40 a.m. Staff D, a licensed practical nurse, was interviewed and stated she would normally see Resident #4 at the nurse's station visiting with staff, in the dining room or walking the halls around the building. Prior to 4/25/15 she had heard the resident had tried to elope from the facility. Staff D stated the weekend of 4/25/15, the front doors were not locked and later the facility fixed the doors. Normally visitors had to push the doorbell and staff had to go up front to let visitors in. On 4/25/15 anyone could just go in and out of the facility. If a resident wore a Wanderguard device, then as the resident approached the front door, the door would lock, however if someone was going in or out of the front door, then the resident with a wander guard could exit the building and an alarm would sound. The Wanderguard and the door alarm were the same alarm, so staff could not tell what set the alarm off. Visitors were also given the code so they could turn the alarm off. Staff D saw Resident #4 on 4/25/15 in the dining room for breakfast. Staff D stated when she heard the front door alarm and then it is silenced she assumes it was taken care of so she did not go to the door. Staff D stated normally they have visitors on the weekend, even at breakfast time. Staff D stated there is another resident who would make attempts to leave the facility. Staff D stated the other resident is constantly pushing on the exit doors and sounding the alarm. When interviewed on 5/7/15 at 12:40 p.m. Staff E, Care Plan/MDS coordinator, was interviewed and stated she completed the resident's Care Plan on 3/5/15. She stated she did not update the resident's Care Plan until after the elopement from the facility on 4/25/15. When interviewed on 5/7/15 at 7:35 a.m. Staff F, a night shift registered nurse, stated prior to eloping from the facility, Resident #4 was up and awake 99% of the time during the night. Resident #4 would say he/she wanted to go home. When interviewed on 5/7/15 at 2:00 p.m. a certified nursing assistant, Staff H stated prior to 4/25/15 Resident #4 was constantly pacing. The resident wandered throughout the building. Staff H stated she witnessed Resident #4 follow a visitor out the front door and staff intervened. Staff H stated the morning of 4/25/15 she had seen the resident pacing the facility. The resident liked to go to the area by the front door. Observation on 5/20/15 at 3:30 p.m. revealed door alarms sounding. Staff A followed a visitor out to their car. Staff A then returned to the facility and denied knowing why the alarm sounded. Staff then reset/silenced the alarm. Note: At the time of the complaint investigation, the complaint was coded at a K, immediate and serious jeopardy. By 4/28/15, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to G. The Administrator had in-serviced the staff to monitor the front door and to not give the door code to the resident's families. The facility informed the family members of the planned procedure not to release the code. After the abatement, the facility planned to have a staff person present at the front nurse's station 24 hours a day to monitor the alarm panels for all exit doors until a door alarm system could be upgraded and completed in order to meet sound requirements (5/12/15). The facility planned to add annunciators through the facility strategically so all staff will be able to hear the door alarms when sounding. Note: At the time of the complaint investigation, the complaint was coded at a K, immediate and serious jeopardy. By 4/28/15, the facility had implemented measures that addressed the immediacy by having an in-service to monitor the front door and not to give the door code to the resident ' s families. The facility also informed the family members of planned procedure of not releasing the door code. On 5/12/15, the facility assigned a staff person to be present at the front nurse ' s station 24 hours a day to monitor the alarm panel for all exit doors until the door alarm system could be upgraded and completed in order to meet sound requirements. The facility completed corrective actions to address the jeopardy on 5/12/15 and the grid placement was lowered to G due to the second example in the deficiency being a fracture. As of the 6/3/15 exit conference, the facility need to: · Continue to in-service staff to check the alarms and not to give the code to family members. · Continue to have a person assigned to the front nurse's station to monitor the door panels until the new system is in place to meet sound requirements. · Continue to monitor the staff to ensure resident's with Wanderguard devices are provided supervision in order to prevent an elopement. 2. Resident #8 had a MDS assessment with a reference date of 4/16/15 which identified indicated Resident #8's active [DIAGNOSES REDACTED]. The MDS reflected the resident scored 10 out of 15 on the BIMS (Brief Interview for Mental Status). A score of 10 represented the resident had a moderate cognitive impairment. The MDS indicated the resident exhibited verbal behavioral symptoms directed towards others one to three days in the seven day assessment period. The resident required extensive assistance with bed mobility, transfers, walking, dressing, toilet use and personal hygiene. The MDS documented the resident's balance as unsteady and only able to stabilize with staff assistance. The resident utilized a walker and a wheelchair. The MDS identified the resident had a recent and remote history of falls and had fallen since admission to the facility. The admission physician orders [REDACTED]. The admission orders [REDACTED]. The Plan of Care dated 4/9/15 identified the resident at risk for falls due to non-compliance with asking for assistance, mobility impairment, impaired balance/poor coordination, medication side effects, history of falls, end-stage COPD, osteoarthritis and right hip fracture. The interventions initiated on 4/9/15 directed the staff to administer medications as ordered, bed in low position, provide assist to transfer and ambulate as needed, reinforce need to call for assistance, reinforce wheelchair safety as needed such as locking brakes and pillows for positioning. The Falls risk assessment dated [DATE] identified contributing factors included the resident's difficulty maintaining standing position, impaired balance, medications, decline in functional status, narcotic usage, impulsivity or poor safety awareness, cognitive impairment, infection, low levels of physical activity, pain and fatigue. An Incident Report dated 4/9/15 reflected on 4/9/15 at 11:15 p.m. the staff witnessed the resident fall backwards onto the floor in the bathroom, after an unsuccessful self-transfer. A Nurse's Progress Note dated 4/10/15 at 3:34 a.m. by Staff CC noted at 11:15 p.m. Staff DD summoned her to the resident's bathroom. The nurse found the resident sitting on the floor near the toilet. The resident stated he/she was trying to go back to bed and fell on his/her bottom. Staff DD stated she observed the resident fall. A Falls document dated 4/9/15 reflected the resident had difficulty maintaining standing position, impaired balance during transfers, her medications included antianxiety, antidepressant and narcotic analgesics. The report indicated the resident had a decline in functional status, impulsivity or poor safety awareness, cognitive impairment, anxiety disorder, depression, infection, low levels of physical activity, pain and fatigue, weakness. The resident refused to answer any questions. A Progress Note created by Staff M, Director Care Delivery (Unit Manager) on 4/10/15 at 3:25 p.m. reflected on 4/9/15 at 11:15 p.m. the resident fell while attempting to get self- up off the toilet. Staff had responded to the resident's call light, assisted the resident to the toilet and the resident fell after being left alone in the bathroom and attempted to transfer him/herself back to bed. A statement by the nurse on duty at the time of the fall dated 4/9/15 created by nurse, Staff CC documented the resident got self out of bed, transferred to bathroom, attempted to take self-back to bed, stumbled and fell . Resident had toileted self. Staff assisted the resident up and back to bed. A statement by the nurse aide on duty at the time of the fall dated 4/9/15, created by Staff DD,documented the resident transferred him/herself to the restroom. Staff DD documented she stood in the hallway when she witnessed the resident transferring him/herself back to his/her room when the resident began to stumble backwards and fell to the floor. Staff M (registered nurse) documented the new intervention after this fall directed the staff to offer toileting more often. This new intervention did not identify the resident's need for closer supervision to prevent the resident from exiting his/her bed independently, closer supervision in the bathroom, the resident's stumbling and required assistance transferring off the toilet and returning to bed. A Progress Note dated 4/12/15 at 4:53 p.m. documented the resident as non-compliant with the use of the call light. Staff educated resident about the importance of call light use. A Progress Note dated 4/13/15 at 5:02 a.m. documented the resident as non-compliant with transfers and call light use. The staff educated the resident on the importance of using the call light for assistance and risk of falls. A Progress Note dated 4/29/15 at 7:54 p.m. reflected the resident got upset with the nurse and demanded the nurse assist him/her immediately or else the resident would urinate all over him/herself and bed. A Progress Note dated 5/3/15 at 4:23 a.m. indicated the resident informed a nursing assistant, he/she fell on [DATE] and hurt his/her left wrist. The resident informed the nurse, he/she went to the bathroom and fell to the floor. The resident reported he/she used his/her left arm to break his/her fall. An Incident Report dated 5/3/15 reflected the resident reported on 5/1/15 sometime between 6:00 p.m. and 10:00 p.m. he/she got up to walk to the bathroom and fell . The resident reported he/she used his/her left arm to break his/her fall. Staff wrote Check Bladder Patterning on the Incident Report. Staff DD documented on 5/2/15, she assisted the resident out of the bathroom when the resident reported he/she could not move his/her left wrist. The resident reported he/she fell the night before. The resident requested pain medication. The nursing assistant reported the situation to the nurse. Staff DD documented the resident's wrist appeared a little bruised. A statement by the resident on 5/4/15 reflected the resident fell when coming out of the bathroom. The resident reported he/she did not use the call light. The resident reported he/she lost his/her balance and fell . The Bladder Diary dated 5/4/15 included directions. These directions instructed the staff to complete one 18 hour section for a period of 3 successive days. The Bladder Diary contained sections for staff to complete for fluid intake, trips to the bathroom, if incontinent how much, did the resident feel a strong urge to go, and what was the resident doing at the time, such as lifting, sneezing or laughing. The staff documented for one 24-hour period. The staff documented the resident was incontinent twice in the 24-hour period and the staff did not assist the resident to the bathroom. The staff failed to document the resident's intake, how much the resident was incontinent, did the resident have an urge to go to the bathroom and what was the resident doing at the time of the incontinence. A Progress Note dated 5/3/15 at 7:33 p.m. the resident reported pain to the wrist due to the fall. A Progress Note dated 5/4/15 at 2:12 p.m. indicated in the morning, the nurse noted the resident's left hand and wrist bruised, deep purple, and a significant amount of edema. The nurse assessed a slight decrease in range of motion to the area. The nurse documented they were attempting to see if the injury was linked to the fall. Review of the resident's Care Plan revealed the facility failed to implement new approaches to address the resident's need for closer supervision due to the resident continued to transfer him/herself to and from the bathroom. On 5/4/15 at 1:00 p.m. the ARNP documented the staff reported the resident fell while taking self to bathroom and had a bruised left hand. The resident refused to talk to the nurse practitioner. Then shortly after the assessment, the resident transferred him/herself from the wheelchair to the bed and staff found the resident on the floor with a laceration to the right side of the head. The ARNP documented the [DIAGNOSES REDACTED]. The ARNP documented this was a difficult case due to the resident was not a good candidate to sit at the nurse's station due to advanced COPD (chronic obstructive pulmonary disease) and weakness. The resident did not comprehend his/her limitations or how to use the call light. They could put the resident on a toileting schedule and a schedule to be out of bed/lay down for naps, however he/she still would transfer him/herself. An Incident Report dated 5/4/15 at 12:00 noon reflected the staff found the resident on the floor with a cut to the right brow. The resident stated he/she slid out of his/her wheelchair attempting to get into bed. An Action Plan dated 5/5/15 reflected the x-rays completed on 5/5/15 identified a fractured left wrist and a fractured right hip. Review of the Progress Notes included the following entries: On 5/4/15 at 2:12 p.m. reflected at 12:05 p.m. the staff found the resident lying on the floor with a 3 cm (centimeter) by 1 cm cut to the left eye brow. Around 1:30 p.m. the resident expressed increase pain and voiced discomfort to the right hip. On 5/4/15 at 9:13 p.m. the resident voiced complaints of pain in wrist and hip to a family member and requested Morphine (narcotic analgesic). The nurse called to set up an x-ray at 7:45 p.m. today. On 5/5/15 at 1:36 a.m. the resident's pulse remained elevated and the resident rated his/her pain to right leg and left hand at a 7 out of 10. The resident was unable to straighten out his/her right leg. On 5/5/15 at 5:33 a.m. attempted to advise the resident's primary care physician, however, no live answering service available. Will advise when the office opens. On 5/5/15 at 7:36 a.m. Addendum: on 5/3/15 at 3:43 a.m. resident reported to nurse that he/she thought he/she had fallen either Saturday or Sunday attempting to take him/herself to the bathroom. The resident reported he/she lost his/her balance and caught him/herself with his/her left arm. The resident got up independently and went back to bed and did not tell anyone of the fall. The resident reported his/her legs just gave out. On 5/5/15 at 7:54 a.m. Addendum regarding the fall 5/4/15 at 12:00 noon, the resident was last seen approximately one hour prior to the fall. The staff found the resident on the floor. The resident he/slid out of the wheelchair when he/she attempted to transfer self to bed. The resident had a laceration above his/her left brow. The staff assisted the resident off the floor. On 5/5/15 at 2:47 p.m. The Nurse Practitioner documented the resident had acute pain due to falls, complicated by a right hip fracture, and left wrist fracture. Fractures were non-displaced and did not need surgical intervention, plus the resident was not a surgical candidate due to end-stage COPD. On 5/5/15 at 3:53 p.m. The resident had an indwelling catheter for terminal illness with associated pain with repositioning and clothing changes. On 5/5/15 at 4:35 p.m. a new order received to keep the resident on bed rest. On 5/5/15 at 4:48 p.m. Biotech was here to do x-rays of the left hand/wrist and the right knee/hip. Results confirmed fractures of the right hip and left wrist. 5/6/15 at 7:57 p.m. the ARNP indicated the staff reported the resident now required assistance with eating due to increased weakness and activity tolerance. The Foley catheter was placed due to terminal illness. The resident reported his/her pain was under control. On 5/8/15 at 5:14 p.m. the ARNP documented the staff reported the resident was much more sleepy with the narcotic pain control medication. On 5/16/15 at 12:04 a.m. Upon entering the resident's room, the staff found the resident sideways in bed with legs dangling over the side, the body pillows were in place, the resident stated he/she had to go to the bathroom. The nurse showed the resident the catheter bag and readjusted the resident in bed. On 5/16/15 at 4:50 p.m. Staff found resident on the floor. One pillow remained on the bed. The second pillow was still under the sheet and hanging over the edge of the bed. Staff applied a scoop mattress to the resident's bed. 5/17/15 at 7:45 a.m. rolled resident on to blanket and with 4 assist lift back to bed. An Incident Report dated 5/16/15 indicated on 5/16/15 at 4:50 a.m. the staff found the resident on the floor next to his/her bed. Resident lying on his/her right side. The Kardex Report (a report used by the nursing assistants to provide care to residents according to their care plans) dated 5/14/15 identified this resident's for safety. The interventions listed for safety instructed the staff to place the resident's bed in a low position, the resident may be socially inappropriate, do not leave unattended while smoking and use pillows for positioning. When interviewed on 5/19/15 at 7:00 a.m. the Director of Nursing stated the facility did not plan an increase in the supervision of the resident after her falls. The Director of Nursing stated the staff would have passively increased their supervision due to the resident was on bed rest after one fall with a hip fracture, the resident had been independent with eating and then became dependent with eating, the resident had been independent with bed mobility and now required assistance with turning, the resident used to get up to walk to the bathroom and now utilizes a bedpan. The Director of Nursing stated on 5/18/15 she first asked the resident and the resident's family about the potential of moving the resident closer to the nurse's station to increase supervision, however the resident wished to remain in a private room. The Director of Nursing stated she did talk the resident into moving from the first bed to the bed by the window last night due to the staff could not see the resident's bed from the hallway due to the bedroom door swung open at the foot of the resident's bed and blocked the view of the resident's bed from the hallway. When interviewed on 5/19/15 at 11:50 a.m. the resident visited freely. Resident laid in bed with the head of the bed elevated. The resident reported being tired of being in bed all the time. The resident stated the physician said he/she could not get out of bed, however his/her bottom and back were sore lying in bed all the time. The resident stated he/she fell a couple of days ago. The resident stated he/she wanted to get out of bed to wash his/her hands. The resident stated he/she sat on the side of the bed and went to stand up when all of a sudden he/she slipped down and fell to the floor. The resident stated the bottom sheet slid under him/her. Observation at this time revealed the resident's mattress blue, a form of plastic and slippery. The resident stated he/she had fallen several times. The resident stated one time he/she went to the bathroom by him/herself and when he/she went to come out of the bathroom, he/she slipped and fe

Based on clinical record review, staff and resident interviews the facility failed provide the necessary care and services to attain and/or maintain each resident's highest practicable physical and psychosocial well-being when they failed to treat one post-surgical resident's pain in a timely manner (Resident #15). The facility reported a census of 70 residents. 1. The Admission Record Report indicated Resident #15 admitted to the facility on [DATE]. The report indicated the resident's medical [DIAGNOSES REDACTED]. A Health History Form dated 4/19/15 indicated a physician saw the [AGE] year-old patient in the clinic due to low back and left knee pain. A Summary of hospitalization dated 5/17/15 indicated the resident admitted to the hospital on [DATE]. The report documented status [REDACTED]. The medication instruction list indicated the resident received two [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) tablets that morning at 9:22 a.m. The list indicated next dose due at 1:20 p.m. The Discharge instructions indicated the resident would receive a prescription for pain medication at discharge, the resident could take the medication every four hours and the resident may want to take the pain medication every four hours around the clock for the first few days after discharge. The instructions also indicated to notify the surgeon with signs and symptoms of infection which may include increased redness to the incision and increased pain. The instructions also indicated it would be important to ice and elevate the knee for 30 minutes 3-4 times a day for a total of at least two hours a day. The Admission Physician order [REDACTED]. The record identified Resident #15's vitals were obtained at 1 p.m. and listed the resident's blood pressure, temperature, pulse, and respirations. The Progress Notes included: The very first progress note, dated 5/17/15 at 2:45 p.m. indicated the resident's friend came to the nurse's station to request assistance to help the resident go outside. Staff assisted the resident into a wheelchair and outside the building, staff instructed the friend to push the doorbell for assistance back inside the building. The second entry, dated 5/17/15 at 2:50 p.m. indicated the resident voiced frustration about his/her pain medication not being given on time. Attempted to explain procedure of new admissions with narcotic medication on the first day of admission. The resident called the nurse incompetent. The third entry, dated 5/17/15 at 4:03 p.m. noted resident admitted to the facility from an out of town hospital. The resident had a left total knee replacement performed on 5/14/15. Resident alert and oriented and able to make his/her own decisions. Denied pain on admission. Resident admitted for therapy after the left knee replacement. The initial Care Plan dated 5/17/15 identified the resident at risk for falls due to unsteady gait related to left total knee. The interventions/tasks instructed the staff to administer medication per physician's orders [REDACTED]. The Interventions/Tasks instructed the staff to report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. The Interventions also instructed the staff to administer pain medication per physician's orders [REDACTED]. The Care Plan also identified the resident's risk for adverse effects related to the use of antianxiety/anxiolytic medication. The interventions instructed the staff to evaluate effectiveness of the medications and to notify the physician of decline in care ability or mood/behavior related to a dose change. The Patient Admission/Readmission Screen dated 5/17/15 at 4:10 p.m. indicated no behaviors present and resident reported presence of pain. The assessment also indicated the resident had a condition likely to cause pain. A Pain Evaluation form dated 5/17/15 at 4:42 p.m. indicated pain in the left knee. The resident rated the present pain at a 2 and rated the most severe pain at a 7. The resident reported exercise caused pain. The Pain Evaluation form instructed the nurse to identify the last dose of medication and the amount given to the patient prior to admission and when the next dose was to be given. A Pain Level Summary dated 5/17/15 indicated the resident's pain at 6:14 p.m. rated a 9. Review of the Progress Notes revealed the following entries: On 5/17/15 at 4:30 p.m. indicated the resident continued to be upset about not getting pain pills four hours after last medication at the hospital prior to he/she came to the facility. No body language indicating pain other than patient was angry. Nurse left the room to allow the resident to calm down. A Progress Note dated 5/17/15 at 6:14 p.m. indicated the pharmacy called with an authorization code to remove 4 [MEDICATION NAME] tablets from the Narcotic Emergency kit and reported the rest of the resident's medications would be delivered in about 2 1/2 hours. The nurse informed the resident. The resident continued to voice frustration with staff and policies and incompetence of the facility. On 5/17/15 at 7:00 p.m. resident at the front door pushing dining room (chair) into staff stating he/she could see that staff were not going to help him/her with a walker. The nurse asked the resident to sit in the chair so she could go and get a walker for the resident. The nurse went and obtained a walker. The resident took the walker and proceeded to the front door. The nurse informed the resident, the front door was locked and needed a code to open the door. The resident swung the walker at the nurse and called the nurse incompetent. The nurse left the area to call the supervisor on call. When interviewed on 6/2/15 at 10:30 a.m. a nursing assistant, Staff FF stated on 5/17/15 she assisted the resident out of a private vehicle when the resident arrived. She assisted the resident to stand with the use of a gait belt. The resident stood and pivoted from the car to the wheelchair. She assisted the resident to his/her room and took the resident personal supplies. Staff FF stated the resident was very respectful to her. When interviewed on 6/1/15 at 2:50 p.m. a registered nurse, Staff BB reported the resident arrived/admitted to the facility a little before noon. The resident arrived in a private vehicle accompanied by a friend. The resident arrived with physician orders [REDACTED]. The resident denied any pain at the time of admission while he/she was sitting still. The resident informed the nurse he/she received pain medication at the hospital prior to his/her transfer. The nurse informed the resident they had pain medication for him/her and instructed the resident to let them know when he/she had pain. The nurse reported she put the resident's orders in the computer and when they were printed off, she faxed the orders to the out of town pharmacy. The nurse reported after the second shift nurse came on duty, the resident reported pain. At that time she called the pharmacy for a code to obtain the resident's narcotic pain medication. The nurse stated she probably should have called the pharmacy for the narcotic code when the resident admitted to the facility. Staff BB reported the resident was very cooperative and very pleasant during her shift. When interviewed an agency staff member, Staff HH stated she was at the front nurse's station and saw the resident come out of his/her bedroom, pushing a large heavy chair to walk with. The resident stated he/she wanted to leave the facility. The resident stated they had no reason to lock him/her in the facility. The resident stated he/she was going to get out of the facility. She heard the staff inform the resident the front door was locked. She also heard the staff tell the resident he/she could not get out. The resident kept saying they could not keep him/her. The resident hit the window in the front door with the walker. The resident did not want to stay in the facility, the resident wanted to leave. A statement by nurse, Staff BB indicated the resident arrived to the facility around noon with no complaints of pain on admission. The nurse faxed the medications scripts to the pharmacy around 1:00 p.m. or 1:30 p.m. She then called the pharmacy around 4:00 p.m. and it took three phone calls to obtain the authorization code to obtain the narcotic pain medication. Staff BB documented she did not call the pharmacy when she faxed the scripts. She indicated she forgot she should have called them. Staff BB documented she did not think to call the resident's physician. A statement by the Director of Nursing dated 5/21/15 indicated the nurse failed to call the pharmacy when she faxed the scripts. The resident began to complain of pain at 2:50 p.m. the nurses failed to call the resident's physician to request another pain medication. The nurse's failure to call the pharmacy delayed the process of timely medication administration. The resident received [MEDICATION NAME] at 9:50 p.m. at the hospital and then received the next [MEDICATION NAME] at 6:14 p.m. at the facility. Both nurses received written warnings. When interviewed on 6/1/15 at 9:15 a.m. Resident #15 stated he/she admitted to ManorCare three days after having his/her left knee replaced. The resident reported he/she was in incredible pain during the trip to ManorCare. The resident received pain medication about 9:00 a.m. when he/she left the hospital. The resident's friend informed the staff at ManorCare to make sure the resident received the pain medication every three to four hours to prevent the pain from getting out of control. The resident informed his/her friend at 2:00 p.m. of his/her pain. The resident stated he/she also had three herniated disks which caused chronic back pain. The resident reported his/her back pain was aggravated due to the way he/she had to sit after the total knee replacement. When the resident expressed pain to the nurse, the nurse stated that was a problem with pain medications on admission. The nurse informed them, resident and friend, the facility was not like a hospital. The nurse stated they needed to obtain a code to obtain the narcotic pain medication. The resident stated he/she was getting agitated due to his/her pain. The resident continued to ask for pain medication. The nurse stated there was a problem with the physician's orders [REDACTED]. The resident stated his/her pain became severe. The friend left the facility to see if they could get the resident transferred to the hospital for pain control. The resident needed to use the chair in the bedroom as a walker due to the facility staff would not give him/her a walker. The resident pushed the chair from the bed to the bathroom and then back to the bed. The nurse informed him/her the first day of admission was always the worse due to anesthesia was wearing off, however the resident stated he/she did not have anesthesia, he/she had a block. The resident begged his/her friend to bring him/her pain medications from home. The resident missed two doses of his/her pain medication and the pain was getting out of control. The resident's leg was becoming swollen and the pain was unbearable. The nurse gave him/her the pain medication around 6:30 p.m. or 7:00 p.m. The resident became angry and could not tolerate the pain. The staff were not helping him/her. The resident wanted to leave the facility. The resident went to the front door. The door was locked. The resident asked the staff to let him/her out. The staff tried to restrain him/her. The staff told him/her, he/she could not leave. The resident told the staff they could not keep him/her against his/her will. The resident saw someone exit the employee entrance so he/she headed towards the employee exit. When he/she got outside, they made him/her sit in a recliner. The resident stated there were about five employees around him/her and would not let him/her up out of the chair. It drove him/her nuts. The only thing the resident wanted to do was to go home. The Administrator came and yelled at a nurse to get an AMA (against medical advice) form. The Administrator told the resident if he/she signed the AMA then he/she could go home. The resident wanted the police to tell the facility they could not hold him/her against his/her wishes. The resident got into his/her friend's car. The friend took the resident to the emergency room where the resident received an antibiotic for his/her leg. The hospital stated they would have admitted the resident, however due to the AMA they rejected his/her request to admit for rehab therapy. The resident stated he/she regretted not checking the facility out prior to admitting, however he/she assumed the facility had certain standards to meet. The resident felt bad about his/her behaviors, however the behaviors were due to his/her pain was out of control. The resident stated his/her main concerns were the facility did not assist him/her such as to the bathroom, the call light was not accessible for the resident to use, the staff did not give him/her any pain medication and the pain got out of control and the facility denied him/her his/her right to leave the facility when his/her needs were not being met. A statement by an RN (registered nurse) Supervisor, Staff O indicated on 5/17/15 at approximately 7:30 p.m. she reported to the front of the facility. She observed the resident seated at the secretary's desk by the front door. The nurse observed the resident trying to call 911. The resident stated the facility was holding him/her against his/her will. After being unable to call 911 the resident got up and started walking down the main hallway with his/her walker. She left to take a telephone call. The next time she saw the resident, he/she was seated in a recliner outside the employee entrance. They tried to get the resident to stay seated and the resident became very agitated. The Waterloo Fire and Rescue and the Waterloo Police came to the facility. The police reported the resident was not a danger to others and could not be forced to go get treatment. The Administrator arrived and informed the staff, the police and the resident that because the resident caused property damage and was abusive towards staff, the resident would not be allowed to remain at the facility. When interviewed on 6/2/15 at 9:25 a.m. an Staff V, R.N., stated on 5/17/15 she responded to the front door alarm. An agency staff member, seated at the front nurse's station reported the resident attempted to exit the facility. The resident informed her, he/she had been in the facility since 11:00 a.m. and had been asking for pain medication. The resident reported being in a lot of pain. The resident explained that ' s why he/she had been mad and wanted to leave the facility. The resident stood by the front door and she noted the small window pane broken in the front door. Staff V informed the resident if she was in pain for that long, she too would be upset as well. The resident declined her offer to call his/her physician. She followed him/her down the hall to the employee entrance. She thought he/she would not be able to exit the building so she stayed back. The resident pushed on the exit door and an alarm sounded. The door opened and the resident walked out of the facility. Once the resident exited the building things became hectic. Staff talked the resident into sitting in a recliner outside of the facility. She bent down in front of the resident and asked if she could call the physician. The resident became agitated and hit her and tried to kick her. The resident's friend yelled at the resident. Staff V stated that had been the first time she had seen the resident. Staff V informed the resident's friend the next day the resident could come back to the facility anytime. Staff V stated the resident had been upset due to his/her pain and the lack of pain management. Staff V stated the resident was not psychotic the resident was in pain. When interviewed on 5/21/15 at 9:00 a.m. the Administrator stated on 5/17/15 he received a phone call from Staff N who had received a phone call from the facility reporting the resident broke a window at the facility. The Administrator instructed Staff N to call 911. The Administrator then went to the facility. He arrived at the facility at approximately 7:45 - 8:00 p.m. at which time he found the resident, two police officers and staff outside the employee service entrance. The Administrator asked the police if the facility could press charges against the resident. The police stated no. The Administrator then asked if they could make the resident pay for the window. The Administrator stated he would not let the resident stay at the facility. The resident signed a AMA (against medical advice) form and the resident got into his/her friend's vehicle and left the facility. When interviewed on 5/21/15 at 9:15 a.m. Staff N stated she was on call on 5/17/15. Staff N stated she received a phone call about 7:00 p.m. or 7:30 p.m. from a nurse, Staff Y who reported the resident was upset about not receiving his/her pain medication. The nurse asked Staff N if she could come into the facility and sit with the resident until they received the authorization code to obtain the narcotic pain medication from the emergency kit. Staff N then called the Administrator. She then told the staff to call 911. When interviewed on 5/20/15 at 6:10 p.m. a licensed practical nurse (LPN), Staff Y stated she worked the afternoon shift, 2:00 p.m. to 10:00 p.m. on 5/17/15. The nurse reported she had been assigned to care for the resident that shift. The day shift nurse informed her the resident admitted to the facility that day due to a knee replacement. Staff Y stated she put leg rests on a wheelchair so the resident could go outside. Staff Y stated the resident appeared to have a brassy personality. Staff Y stated about 2:50 p.m. the resident voiced frustration regarding his/her pain medication at which time she explained the procedure for obtaining pain medication. Staff Y stated the day nurse was working on putting the resident's (physician) orders into the computer. Staff Y stated about 5:15 p.m. she answered the resident's call light. The resident complained of pain and the nurse told the resident she could put ice on his/her knee. Staff Y stated the resident did not come out of his/her room for the evening meal. They served the resident the evening meal in his/her bedroom. The nurse denied knowing if the resident ate the meal. She received a phone call from the pharmacy at 6:14 p.m. She then took the pill to the resident. She told the resident his/her pain medication at that time. At about 7:00 p.m. the resident stood in the his/her bedroom doorway. Staff Y reported the resident had been upset with her because she would not give him/her a walker. He did not bring a walker with him/her. She went to find at walker. When she returned the resident stood by the front door. Now he/she was mad and was swinging the walker. The resident was jamming the door with the walker. The nurse informed the resident the door was locked and she could not open it. The resident picked up the walker and shoved the walker into the window of the door. The resident continued to try to open the front exit door. She then went to call the nurse supervisor who instructed her to call the resident's physician for an (physician ' s) order to have the resident evaluated. She then called 911 at 8:00 p.m. The resident left the front door and went to the employee entrance. A staff member attempted to keep the door shut. The resident then went out the door. The resident's friend was outside and the resident sat in a recliner. The resident tried to get up out of the recliner. The resident had been angry. At that time the nurse left the area and went inside to finish passing medications to other residents. The nurse reported she did not see the resident again.

Based on observation, record review, staff and resident interviews, the facility failed to complete the Braden Scale pressure ulcer risk assessment accurately which resulted in the facility's failure to identify this resident's actual risk for pressure ulcers. The facility also failed to inspect the resident's skin daily, failed to provide bed baths and failed to take off the resident's non-skid socks every morning to inspect. The facility census was 70 residents.(Residents #9) Findings include: 1. The resident Roster/Sample Matrix dated and signed by the Director of Nursing on 5/4/15 assessed Resident #9 without pressure ulcers. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. The MDS identified the resident with a Brief Interview for Mental Status Score (BIMS) of 15 out of 15 which indicated no cognitive impairment. The MDS identified the resident resisted cares on a daily basis. The MDS identified the resident required extensive assistance of two persons for bed mobility, transfers and toilet use. The MDS documented the resident utilized a wheelchair to move about the facility and did not walk. The MDS documented the resident was frequently incontinent of bowel and bladder. The MDS documented the resident stood six feet tall and weighed 174 pounds. The MDS indicated the resident was at risk for the development of pressure sores. The MDS documented the resident did not have any pressure ulcers at the time of the assessment. The MDS indicated the resident utilized pressure relieving devices for the chair and the bed. The Care Plan dated 5/7/15 revealed the resident's focus areas included self-care deficit related to decreased mobility, functional limitations, erosive arthritis, chronic pain, [MEDICAL CONDITION], weakness [MEDICAL CONDITION]. The Care Plan identified physically assertiveness with throwing food in dining room related to cognitive impairment. The Care Plan identified resistive/noncompliant with treatment/care following fluid restriction, refusing to have fingernails cut related to belief that treatment was not needed, refusal of oxygen at times and refusal to call for assistance with transfers from bed/chair. The Care Plan identified the need for palliative care due [MEDICAL CONDITION] and the risk for alteration in skin integrity related to decreased mobility, functional limitation and incontinence. The interventions listed for the potential for skin integrity included barrier cream to peri area/buttocks as needed, encourage and assist to reposition every two hours, float heels as able (dated 9/13/13), observe skin condition with cares daily and report abnormalities (dated 9/13/13), pressure redistributing device on bed and chair, provide preventative skin care routinely and as needed, use pillows/positioning devices as needed and wrap/pad oxygen cannula. The Admission Record Report indicated the [AGE] year-old resident admitted to the facility on [DATE]. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. A Clinical Summary dated 10/29/14 identified current health issues included abnormal blood chemistry, adrenal disorder, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], diabetes, cancer and [MEDICAL CONDITION] arthritis. A Nurse Practitioner progress note dated 4/28/15 indicated the resident received three units of packed red blood cells and the resident stated he/she felt weak and tired all the time. The skin was assessed to be warm and dry. Resident #9 received medications to help promote oral intake and the resident complained of no appetite. On 5/11/15 at 10:35 a.m., the surveyor heard Resident #9 calling out for a nurse. The resident reported being in a lot of pain and having holes in her/his feet. When interviewed on 5/11/15 at 10:40 a.m. nurse, Staff I stated she could not find any skin sheets for this resident. The resident informed the nurse of his/her pain from the open wounds on his/her feet. The resident stated he/she could not sleep at night due to the pain from the wounds. The nurse removed the resident's right sock. Observation revealed black eschar surrounded by red tissue on the left ankle. The nurse reported she checked the computerized record and found no treatment for [REDACTED]. The resident cried out in pain when the nurse washed the wound with water. Observation revealed very dry flaky skin over the resident's feet and between the toes. The nurse then removed the resident's left sock. Observation revealed an open wound with yellow/white moist center. The nurse informed the resident she would have the nurse practitioner come and look at his/her feet. The Nurse Practitioner's Progress note dated 5/11/2015 16:02 included: CHIEF COMPLAINT: wounds to both ankles. HPI : New onset of wounds to medial aspect left ankle and lateral aspect of right ankle. Pt states have been going on for a month but he/she did not tell anyone about it. C/O burning pain to left ankle. EXAM : SKIN : ,Warm & (and) dry, Left ankle (inner) - 2 cm x 1.8 cm unstageable PU (pressure ulcer). 100% eschar with small area of frank blood. periwound pink and tender to the touch, Right ankle (outer) - 2.5 cm (centimeter) x 2 cm unstageable PU. 90/10% slough/granulated tissue. periwound pink. nontender. scant. DIAGNOSIS : Acute impaired skin integrity b/l (bilateral/both) ankles d/t (due to) unstageable pressure ulcer complicated by [MEDICAL CONDITION], T1DM (Type 1) and DM (diabetes) [MEDICAL CONDITION], PLAN : Cleanse. Pat dry. [MEDICATION NAME] paint. cover with [MEDICATION NAME]. change q (every)3 days/prn (as needed). prafo boots on when in bed. Keflex 500 mg BID x 14 days. He/she will be followed by wound team until resolution. When interviewed on 5/12/15 at 11:20 a.m. a certified nursing assistant, Staff C stated she was normally assigned to care for the resident on the day shift. She stated the resident was afraid of water so they were assigned to give the resident a bed bath every Wednesday and Saturday. She stated she did not give the resident his/her scheduled for last Saturday and last Wednesday and she assumed another aide gave this resident a bed bath. Staff C stated by the time she got to the resident's room in the mornings, the resident was ready to get up in his/her wheelchair for the day. Staff C reported normally the staff assisted the resident up out of bed, into a wheelchair before breakfast and the resident stayed up in the wheelchair until bedtime. Staff C stated she had noticed skin issues on the resident's legs and ankles. Staff C stated normally she did not see the resident's ankles due to the resident wore non-skid slipper socks to bed every night and in the mornings she would dress the resident and would leave the socks on the resident's feet. Staff C stated she had not given the resident his/her bed bath in a long time. Review of the Bed Bath records for this resident, indicated Staff C gave the resident a bed bath on 5/9/15 and on 5/6/15. A Nurse Practitioner's Progress Note dated 5/8/15 noted the resident sustained [REDACTED]. A Skin Alteration Record dated 5/11/15 instructed staff not to use for pressure ulcers. The entry dated 5/11/15 indicated the resident's right outer ankle had a 2.5 cm (centimeter) by 2 cm area of slough and the resident's left inner ankle, had a 2 cm by 1.8 cm area of thick, hard, black leathery eschar, necrotic tissue with reddened skin surrounding the eschar. The nurse practitioner documented the resident's pressure areas were evaluated by the wound team and treatment orders in place which included PRAFO (orthosis ankle foot orthosis). Patient is turned and repositioned every two hours. A Nurse Practitioner's Progress Note dated 5/19/15 indicated the resident's left ankle wound measured 2.5 cm by 1.4 cm unstageable pressure ulcer with 100% slough, periwound within normal limits, scant serosanguineous drainage and tender to the touch. The resident's right ankle wound measured 0.6 cm by 0.5 cm unstageable pressure ulcer with scant serosanguineous drainage. A Patient Admission/Readmission Screen dated 5/27/15 assessed the resident's left ankle pressure sore as 2 cm by 1.5 cm pressure ulcer with light pink tissue on the outer portion and s slough on the inner portion of the wound. The assessment indicated the resident's right outer ankle wound measured 1.5 cm by 1.5 cm pressure ulcer with pale pink tissue. A Pressure Ulcer assessment dated [DATE] indicated the resident's left inner ankle pressure sore measured 2.3 cm by 2.7 cm by 0.1 cm deep. The assessment indicated the resident's right outer ankle pressure ulcer measured 2.6 cm by 0.1 cm deep. The most recent MDS Care Area Assessments (CAAs) report dated 8/2/14 completed by their MDS RN (registered nurse), Staff E indicated the resident was at risk for alteration in skin integrity related to decreased mobility, functional limitations, [MEDICAL CONDITION], occasional incontinence, [MEDICAL CONDITION], obesity,[MEDICAL CONDITION]. The CAAS indicated the residents skin integrity would be monitored daily with cares. The staff would encourage and assist the resident to reposition approximately every two hours and as needed. Interventions included: pressure reducing mattress and cushion to bed and wheelchair, continue to work with therapy to increase function and mobility, and dietician to follow. Staff E documented she would proceed to care plan and review and revise as needed. Review of the CAA report for pressure sores revealed Staff E failed to complete the sections to provide input from resident regarding his/her risk for pressure ulcers and the section for the staff to describe the impact of the resident's risk for pressure ulcers and their rationale for care plan decision. Although the Braden Scale for Predicting Pressure Sore Risk indicated this resident was at a low risk for pressure sores, other assessments completed at or around this time frame revealed conflicting information regarding the resident's condition. A Braden Scale for Predicting Pressure Sore Risk dated 5/5/15 and created by Staff J indicated the resident scored 17, which indicated a low risk for pressure sore development. The assessment indicated the resident's mobility was slightly limited, made frequent though slight changes in body or extremity position independently. The assessment also indicated no apparent problems with friction and shearing due to the resident moved in bed and in chair independently and had sufficient muscle strength to lift up. The assessment indicated the resident's usual food intake pattern was adequate and the resident ate over half of most meals. The assessment indicated the resident's skin was occasionally moist, skin was occasionally moist, which required an extra linen change approximately once a day. A Nutrition assessment dated [DATE] indicated the resident sustained [REDACTED]. The MDS dated [DATE] indicated the resident required extensive assistance with bed mobility and transfers. The resident did not walk and required extensive assistance with dressing and toileting. The MDS indicated the resident was always incontinent of bowel and bladder. A Braden Scale for Predicting Pressure Sore Risk dated 5/11/15 and created by the Director of Nursing indicated the resident scored 16, which indicated a low risk for pressure sore development. The assessment indicated the resident's mobility was slightly limited, made frequent though slight changes in body or extremity position independently. The assessment indicated the resident's usual food intake pattern was adequate and the resident ate over half of most meals. A Nutrition assessment dated [DATE] indicated the resident sustained [REDACTED]. Review of the resident's computerized Weight Summary revealed the resident weighed 161.2 on 5/6/15; 173.2 on 4/10/15; 188 on 3/6/15; 196.6 on 2/6/15 and 201.2 on 1/16/15.

Based on record review and interviews, the facility failed to provide adequate supervision to protect 1 of 4 residents from hazards during mechanical lift transfer (Resident #3). Two staff transferred Resident #3 with a gait belt and the resident sustained [REDACTED]. The facility identified a census of 76 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident with a Brief Interview for Mental Status Score of 13 out 15 which indicated the resident is not cognitively impairment. The MDS identified the resident required two staff assistance with bed mobility, toilet use and transfers. The MDS assessment documented the resident utilized a wheelchair and walker to move about the facility. The Care Plan dated 12/13/14, revealed the resident will receive assistance necessary to meet his/her ADL (Activities of Daily Living). The care plan identified the resident had a decrease in mobility and directed staff to provide assistance with transfers with two staff and to use a mechanical lift. An incident report dated 12/22/14, documented the resident complained of left ankle pain and staff obtained an order for [REDACTED]. The portable x-ray report revealed the resident had a non-displaced left ankle fracture, presumably acute in nature. The local emergency room report dated 12/22/14, indicated the resident complained of left ankle pain and had swelling to their lower left leg. The resident reported to emergency room staff that as staff were transferring the resident on Saturday night, 12/20/14, from the bed to the chair the resident heard a pop and had immediate pain that persisted until 12/22/14. A witness statement by Resident #3 identified on Saturday 12/20/14 around 9:30 p.m., two certified nurse aide (CNAs) transferred him/her and his/her ankle got twisted. Resident #3 identified he/she felt a snap and told the CNAs they just broke his/her ankle. Resident #3 told the nurse what had happened. Resident #3 noted he/she went to therapy today and could not walk on it. Resident #3 reported he/she is too weak from pneumonia and sepsis. Resident #3 reported it was his/her left ankle (that got fractured). During interview on 2/12/15 at 11:50 a.m., Staff A, certified nurse aide, CNA stated on 12/19/14, she and another staff member transferred the resident from his/her bed to recliner and did not use the mechanical lift but performed a pivot transfer from the resident's bed to the recliner. Staff A stated she did not know the resident required the assistance of a mechanical lift as no one told her. Staff A admitted she should have looked on the resident's plan of care to see how the resident transferred. During interview on 1/21/15 at 10:40 a.m., Staff B, registered nurse, RN stated the resident began complaining of pain in both ankles on Saturday,12/20/14. Staff B stated the resident's ankles were assessed and Staff B directed the resident to keep them elevated and provided pain medication. Staff B stated the resident continued to complain of ankle pain on Sunday, 12/21/14 and on 12/22/14. Staff B notified the Director of Nurses and Advanced Registered Nurse Practitioner, (ARNP) on 12/22/14. An x-ray of the left ankle was ordered and completed and confirmed a fracture of the resident ' s left ankle. The resident transferred to a local emergency room for evaluation and treatment. Review of a Statement of Witness from Staff C, CNA dated 12/22/14, indicated on Friday, 12/19/14, Staff C assisted Staff A with a two person transfer with a gait belt for the resident. The two staff stood the resident up from the bed and assisted the resident into the recliner. The resident complained of a sore ankle and staff failed to tell the nurse of the complaint. Staff C identified she failed to check the task list to see how the resident transferred. The resident told staff he/she was afraid to use the mechanical lift stating it scared him/her. During interview on 1/26/15 approximately 2:00 p.m., Staff D, CNA stated on Saturday 12/20/14 and 12/21/14 they transferred the resident with 2 staff and a mechanical lift. Staff D stated the resident complained of ankle pain and Staff D observed the resident's ankles to be swollen. During interview on 1/21/15 at 1:45 p.m., Staff E, CNA stated on Sunday, 12/21/14 she transferred the resident with the use of a mechanical lift and the resident was not moving their left ankle and had complaints of left ankle pain. The resident stated the pain subsided when they were not standing on it. During interview on 1/26/15 at 2:00 p.m., Staff F, CNA stated on 12/20/14 she received report from the night shift that the resident had complaints of ankle pain. When Staff F asked the resident about the complaint, the resident stated he/he broke his/her ankle. Staff F stated the resident appeared to be in more pain on Sunday, 12/21/14, seemed more agitated and refused to get out of bed. Staff F stated the resident complained of ankle pain and the resident's ankles were swollen. During interview on 1/26/15 at 9:00 a.m., the Advanced Registered Nurse Practitioner, ARNP stated she spoke with the resident regarding the fracture of the left ankle. The resident stated when staff got him/her out of bed into the chair staff sat the resident down and the resident ' s foot twisted and the resident told the ARNP he/she heard a pop sound. The ARNP stated the resident had a large amount of edema in both ankles and had constant complaints of pain. Staff A's written warning noted on 12/19/14, she transferred a resident incorrectly and had not followed the resident's plan of care. Staff C had been suspended pending the investigation on 12/22/14.

Based on observation, record review and staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazards to self (Resident #1). The sample consisted of 7 residents and the facility reported a census of 80 residents. Resident #1 had a history of [REDACTED]. The resident fell off the toilet, hit head and received a subdural hematoma (collection of blood outside the brain) and a head laceration. The Care Plan directed staff not to leave the resident unattended in the bathroom. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 3/5/14. The MDS identified Resident #1 with [DIAGNOSES REDACTED]. The resident required extensive assistance of 2 staff with bed mobility, transfers, toilet use and did not walk about their room or the facility. The MDS reflected Resident #1 could only stabilize themselves with staff assistance for moving on and off the toilet or transfers and utilized a walker and wheelchair. Resident #1 had an intact cognitive ability with a BIMS (Brief Interview of Mental Status) score of 14. The Care Plan dated 2/27/14, identified the resident at risk for falls due to a decrease in mobility and functional limitation. The Care Plan directed the staff not to leave the resident unattended in their bathroom. Review of an Incident Report dated 4/3/14 at 8:20 a.m. reflected Resident #1 experienced a fall onto their bathroom floor. The staff found the resident on the bathroom floor with red fluid coming from the head. Resident #1 stated she/he fell off the toilet. Review of the Progress Notes dated 4/3/14 at 8:15 a.m. reflected the staff noted the resident on the floor. The resident had red drainage noted on the left side of their forehead. Review of a hospital report dated 4/3/14 at 12:40 p.m. identified the resident sustained [REDACTED]. A CT (Computerized Tomography) of the residents head revealed Resident #1 had a small subdural hematoma (collection of blood outside the brain) along the right frontal calvarium measuring approximately 4 centimeters. The resident also sustained a laceration to the right forearm and left knee. During an interview with Staff A (Certified Nursing Assistant) on 4/19/14 at 9:00 a.m., Staff A stated they went into Resident #'1 room the morning of 4/3/14 to answer the resident ' s call light. Staff A assisted the resident to the toilet. Staff A left the resident sitting on the toilet to retrieve a requested item from the resident ' s closet. Staff A walked around the corner in the resident's room and heard a crash in the resident's bathroom upon return to the bathroom they found the resident on the floor. Staff A stated they didn't know the resident should not have been left on the toilet alone as she didn't check the plan of care tracker prior to assisting the resident. Staff A stated they failed to check the care tracker kiosk prior to assisting the resident to the bathroom. During an interview with the Director of Nursing (DON) on 4/29/14 at 7:30 a.m. the DON stated they would have expected Staff A to review Resident #1's care tracker to review how the resident transferred and safety measures the facility had in place to assure Resident #1's safety. Staff A failed to check the care tracker kiosk on 4/3/14 prior to assisting the resident to the bathroom. On 4/29/14 at 8:32 a.m., Resident #1 was interviewed and stated she/he had a black out in the bathroom and had cut forehead. Observation revealed a scab present on head. The resident stated the aide was suppose to be in the bathroom with her/him but she went to the close. The resident stated she/he is going to the wound clinic for the gash on his/her knee from the fall at home.

Based on record review and staff interviews, the facility failed to ensure Resident #4 received adequate supervision and assistive devices to prevent accidents. The facility failed to revise the Care Plan to ensure staff used a gait belt when transferring the resident. Concerns were noted for one resident (# 4) who sustained a fall resulting in a fracture. The facility identified a census of 82 (eighty two) residents. Findings include: 1. Resident #4 entered the facility on 09/12/2013 following a hospitalization and [DIAGNOSES REDACTED]. Resident #4 had a Minimum Date Set (MDS) assessment with a reference date of 09/19/2013, which revealed the resident required extensive staff assistance with bed mobility, transferring, ambulation in the room and corridor and toilet use. According to the Care Plan, initiated 09/12/13, the facility staff identified a potential problem with ADL (Activities of Daily Living) self-care deficit related to decreased mobility, functional limitations, urosepsis, pneumonia, macular degeneration and [DIAGNOSES REDACTED]. Planned interventions directed staff to transfer Resident #4 with one assist and use the wheelchair and walker for mobility. Review of the Nurse ' s Notes dated 09/24/13 at 2:26 p.m., revealed the nursing assistant called the nurse to Resident #4's room and reported to the nurse that Resident #1 stood up from the toilet with the assist of one staff, and then was too weak to stand so the nursing assistant stated he/she had to lower Resident #4 to the ground. The documentation reflected Resident #4 complained of pain to the left leg, had a total knee done, it gave out on him/her and he/she could not move it. Staff completed and documented a full assessment and received a physician's order [REDACTED]. The hospital Physician history and physical report determined Resident #4 sustained a periprosthetic fracture around internal prosthetic left knee joint The facility policy titled Transfer: Bed-Chair/Wheelchair dated 01/2011, directed staff to use a gait belt, if necessary. The facility policy titled Gait Belt, dated 12/2009, directed staff to place gait belt around waist. Do not place the belt below the patient ' s waist or above his chest. On 09/25/2013 at 9:07 p.m. Staff A (Certified Nursing Assistant) was interviewed and stated she usually used two staff assistance when assisting Resident #4. Staff A stated on the day of the above incident, she did not use a gait belt due to not wanting to place the belt near/over the resident's wound/colostomy. On 10/9/2013 at 1:00 p.m. Staff C (Registered Nurse) was interviewed and stated she would have expected the staff to use a gait belt. On 10/9/2013 at 1:05 p.m. Staff D (Registered Nurse) was interviewed and stated she would have expected staff to use a gait belt whether or not the resident had a colostomy. On 10/9/2013 at 1:10 p.m., Staff E (CNA) was interviewed and state she always used a gait belt even with the colostomy. On 10/9/2013 at 1:17 p.m., Staff F (CNA) was interviewed and stated always used a gait belt. Staff F stated she had seen other staff not use the gait belt On 10/9/2013 at 4:58 p.m. Staff B (Registered Nurse) was interviewed and stated she would have expected staff to use a gait belt. According to other random staff interviews during the survey, some staff stated they would use gait belt and others said they would not, due to Resident #4's colostomy which was at waist level. On 10/10/2013 at 10:40 a.m. the Director of Nursing was interviewed and stated on (a resident ' s) admission, the nurses complete an assessment of the resident and physical therapy reviews that assessment. The Director of Nursing stated some nursing staff used a gait belt when assisting Resident #4 and some did not. The Director of Nursing stated some nursing staff used 2 staff to assist Resident #4 while other's used one staff. During the interview, the Director of Nursing agreed the facility policy with using gait belts when necessary and the Care Plan for Resident #4 could be confusing to staff.

Based on clinical record review and interviews with the resident ' s physician and staff, the facility failed to direct nursing services to ensure Resident #1 received adequate supervision against hazards and failed to implement care plan directives to meet the resident ' s safety needs. Concerns were noted for 1 of 5 (Resident #1) residents sampled for review. The facility reported a census of 77 residents. Findings include According to documentation in the medical record, Resident #1 entered the facility on 10/20/2012 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment form date 10/27/12, Resident #1 required extensive assistance with bed mobility, transferring, and walking in his/her room and the corridor. The resident had a Brief Interview for Mental Status Score of 10, which indicated he/she had moderate cognitive impairments. Documentation in the nurses' notes indicated Resident #1 sustained falls on the following dates: 10/30/12, 10/31/12, 11/01/12, 11/11/12, 11/19/12, 11/26/12 and 12/13/12. A review of progress notes dated 12/12/12, 12/10/12, 12/8/12 and 12/6/12 staff noted the resident showed confusion and received staff assistance (1 or 2 staff) during transfers. Documentation revealed facility staff placed alarms and fall mats due to Resident #1 being unable to demonstrate use of the call light. The facility identified the risk of falls in the individual care plan dated on 10/20/12 developed for Resident #1 and updated following each fall. Interventions included the following: On 11/9/12, add alarms to bed to be alerted to when resident attempts to get up on his/her own. On 11/6/12, add Velcro to mattress to attach to frame of bed. On 11/26/12, attach 2 signs in resident's room that provide visual for resident to use the call light. On 10/26/12, bed in low position. On 10/31/12, bolster sheet to bed. On 10/20/12, fall mats. On 10/26/12, have commonly used articles within easy reach. On 11/1/12, hipsters while in bed. (Hipsters are a product worn to protect the hips during a fall.) On 10/30/12, low bed. On 11/2/12, medication review. On 11/6/12, nonskid device on mattress and frame checked and replaced. On 10/26/12, provide assistance to transfer and ambulate as needed. On 10/26/12, reinforce need to call for assistance. On 10/26/12, reinforce w/c safety as needed such as locking brakes. On 11/8/12, report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status per facility guidelines post fall. On 11/12/12, therapy to evaluate for possible reacher. Documentation in the facility care guidelines "additional information", for nursing assistants, listed "hipsters while in bed, pull tab alarm in w/c"(wheelchair). The progress notes dated 12/13/12 at 5:41 a.m., a CNA (certified nurse aide) called the nurse to Resident #1's room. The progress note identified staff found Resident#1 on the floor next to his/her roommate's bed. Upon assessment, the resident revealed he/she had right hip and upper leg pain rated at 9 (out of 10), with no deformities noted. The resident could not move the right leg and the nurse received an order to transfer the resident to the hospital. The progress note revealed the resident's call light had been extended close to him/her on the floor and staff explained the importance of using the call light to Resident #1. According to documentation in the medical record, incident report dated 12/13/12, at 5:30 a.m. staff found Resident #1 on the floor with increased pain with right leg movement. The resident was unable to move his/her leg without experiencing pain. Interventions in place included sensor alarm (blinking but no increase in sound), fall mats, low bed and non-skid socks on Resident #1. The radiology results dated 12/13/12 at 8:10 a.m. documented the chest X-ray showed a minimally displaced acute (new) fracture to the left seventh rib. The right hip showed an impacted intertrochanteric fracture. During an interview on 01/03/13 at 1:31 p.m. Resident #1's primary physician indicated that if hipsters were on the care plan, whether a physician's orders [REDACTED]. Resident #1's physician confirmed that as a result of the fall on 12/13/12, Resident #1 sustained an intertrochanteric fracture as well as an acute fracture of the left seventh rib. A written witness statement by Staff B signed 12/14/12 revealed she was walking down the hall around 5 a.m. (on 12/13/12) when she heard a noise in Resident #1's room. She entered the room and found the resident on the floor next to his/her roommate's bed. The resident stated he/she wanted to get out of bed. Staff B documented she could not recall whether the bed alarm was sounding, but knew the bed alarm was between the bed and mattress. Staff B was asked by the facility staff if she knew who shut off the alarm and stated no. A written witness statement by the Staff A signed 12/14/12 identified she did not hear the resident's alarm or a muffled sound. Staff A documented she did not check to see if the resident's alarm was (turned) on. A written witness statement by Staff C, the nurse she identified the call light cord had been fully extended, but not on; and the alarm (bed alarm) was sounding. Staff C documented she did not hear the alarm sounding, but had been told by the CNA the alarm had sounded. (Both CNA identified in their written witness statements the alarm did not sound.) Staff C indicated during an interview on 01/03/13 at 12:50 p.m. indicated that when he/she responded to Resident #1's fall, he/she did not observe hipsters to be in place on Resident #1. Staff AC also stated he/she did not see that Resident #1 removed the hipsters nor was he/she aware that Resident #1 routinely or at times removed the hipsters. During an interview on 01/03/13 at 1:58 p.m. Staff B, CNA stated she had been walking past the resident's room and heard a noise. Staff B stated the alarm was not sounding and was green and she pushed it, then it turned red. Staff B stated she had awoken Resident #1 up ? hour before and the resident reported he/she did not have to use the bathroom. Staff B confirmed that hipsters were a planned intervention for Resident #1 and stated that Resident #1 did not have hipsters on at the time of the fall on 12/13/12. Staff B stated he/she knew hipsters were on the facility produced worksheet, and added that he/she had not had time to apply the hipsters that evening/night. Staff B indicated he/she did not think Resident #1 could remove the hipsters and he/she was not aware that Resident #1 had ever removed the hipsters. During an interview at 11:11 a.m. on 01/03/13, Staff A stated she did not hear an alarm going off and did not know if the other CNA had turned it off. Staff A stated "hipsters" would have been listed on the nursing assistant "worksheet" that all nursing assistants carry with them. Staff A also indicated that if the care worksheet indicated staff apply hipsters, then they should have been in place on Resident #1. During an interview with the DON (Director of Nursing) on 1/3/13 at 1:50 p.m., she expected Resident #1 to have hipsters applied as directed in the individual plan of care.

Based on observation, clinical record review, physician, family and staff interviews, the facility failed to transfer Resident #2 as directed by the plan of care. The facility failed to ensure interventions were followed to keep the resident safe. The facility reported a census of 83 residents. Resident #2 had increased leg pain and unable to bear weight on one leg. The resident was sent to the hospital on [DATE] and determined to have a distal left femur fracture (thigh bone). Based on staff interviews, the nursing staff did not transfer the resident with the planned mechanical lift. During one interview, it was determined a staff member transferred the resident alone. During the remaining interviews, the staff transferred the resident with 2 staff persons and did not use the mechanical lift. The family had requested to the staff that the lift not be used and this had not been relayed to the care plan nurse for an evaluation. On [DATE], the resident died at the hospital. Findings include: 1. The quarterly MDS (Minimum Data Set) assessment with a reference date of [DATE], reflected Resident #2 had [DIAGNOSES REDACTED]. Resident #2 had severe cognitive ability impairment. The resident required extensive assistance of 2 staff for bed mobility, transfers and toilet use and utilized a wheelchair for moving about the facility. Review of the Patient Information Worksheet (PIW) dated [DATE], revealed Resident #2 required assistance of 2 staff members and a mechanical lift for transfers. After the resident was transferred to the hospital on [DATE], the care plan was revised on [DATE] to direct staff to transfer the resident with an E-Z stand, or 2 assistance as family wished to keep the resident ' s legs stronger. The resident did not return to the facility. The IPN (Interdisciplinary Progress Notes) notes dated [DATE] at 5:00 p.m., documented a late entry for [DATE] at 7:00 p.m. The note documented the resident ' s daughter questioned the author about an increase in pain to the patient. The daughter stated patient had decrease in appetite and appeared more 'drowsy' than usual. Patient assessed at that time. Patient called out 'ow' when aides transferred with two assistance from wheelchair to bed. Patient asked if the left hip hurt and patient replied 'yes'. Then patient stated their back hurt and requested the head of bed be lowered. Patient called out while cares performed as per usual. When cares completed, patient closed eyes and rested while author and daughter discussed the increased pain and current medications. The patient started snoring while conversation continued. The medications were given as ordered. The daughter and author agreed to monitor patient ' s pain as the patient seemed comfortable. The IPN notes dated [DATE], documented a late entry for [DATE] at 8:00 p.m. The note documented the resident ' s daughter arrived before supper and requested the patient stay in bed for supper. Another daughter arrived to the facility and contacted author about the patient ' s increase in pain. This author and family talked about different potions. The family considered sending the resident to the emergency room due to increased pain. Family and this author decided to contact triage nurse at the family practice clinic. The triage nurse and this author discussed the resident assessment, vital signs, increase pain, lack of adequate pain control and possible emergency room evaluation. During this time the family decided against emergency room visit at this time and triage nurse and this author agreed as patient was asleep in bed and seemed comfortable. It was decided if the patient had increased pain again the triage nurse would be contacted. The family agreed. The IPN notes dated [DATE] at 4:10 a.m., documented vital signs charted in computer. The resident complained of pain in the legs but unable to rate the pain. The resident rested quietly but awake most of the shift. The IPN notes dated [DATE] at 1:00 p.m., documented during morning cares the resident complained of increased pain with movement of the left leg and could not bear weight as usual and stated they could not stand. The resident was transferred to the bed from the wheelchair with two staff assistance and a gait belt. The resident bore weight on the right lower extremity and not the left lower extremity. Staff noted 3 to 4 plus edema to the resident ' s left knee only. The pedal pulses present to both lower extremities and no new bruising noted. The resident yelled out in pain with range of motion. Per normal hollers out with cares, noted increased hollering with range of motion to left lower extremity. Staff called emergency personal and the resident was transferred to a local emergency room . The local hospital records dated [DATE] indicated the resident arrived in the emergency room with left knee pain and swelling and had a new inability to bear weight. The emergency room report revealed a significant amount of bruising around the resident ' s left knee with moderate sized effusion. Through evaluations and testing on [DATE], the resident had a comminuted left distal femur fracture. The emergency room note revealed the family reported the resident had an increase in pain on Saturday and Sunday, ,[DATE]-[DATE] to facility staff. On [DATE] at 10:30 a.m., the Director of Nursing (DON) was interviewed regarding the revision of the Care Plan on Sunday, [DATE]. The DON stated prior to the revision and prior to the left knee fracture the care plan and the PIW directed the staff to utilize a lift with 2 staff for transfers. The DON stated they anticipated Resident #2's return to the facility and did not know the resident passed away on the date they did the revision. On [DATE] at 9:30 a.m., Staff M was interviewed and revealed they transferred the resident with 2 staff and did not use a mechanical lift for transfers. On [DATE] at 8:00 a.m., Staff K was interviewed and stated they transferred the resident with 2 staff and a gait belt and did not use a lift. Staff K revealed the resident had more than usual weakness in his/her legs on ,[DATE] during a transfer. The resident's family member reported to Staff K the resident had complaints of pain in the left thigh area. Staff K stated they reported the pain and weakness to the nurse. Staff K stated on [DATE], the resident had an increase in pain from the previous day and did not get out of bed on the evening shift of [DATE]. On [DATE], Staff N stated they transferred the resident with 2 staff and a gait belt and did not use a lift. On [DATE] at 2:00 p.m., Staff I stated have assisted the aides in transfers. They had transferred the resident with 2 staff and a gait belt and did not use a lift. Staff I stated the resident's daughter reported the resident complained of left leg pain. Staff I indicated they did not do range of motion to the resident's left leg as the resident frequently complained of pain with transfers and repositioning. Staff I stated the resident did not get out of bed for the evening meal on [DATE] due to pain. On [DATE] at 1:30 p.m., Staff L was interviewed and stated they transferred the resident without another staff but used a gait belt. Staff L stated they transferred the resident to the wheelchair the morning of [DATE] and noted a change in the resident ' s ability to bear weight, they could not bear weight and the resident had something protruding from the left knee and complained of pain to the left knee. Staff L stated the resident should have been transferred with the assistance of 2 staff, but the family knew they transferred the resident by themself and trusted them. On [DATE] at 12:00 p.m., the DON was interviewed and stated staff failed to transfer the resident as indicated on the PIW and the Care Plan. The DON stated the staff were re-educated on the proper use of the PIW and the importance of following the recommendations. The DON stated if the staff noted a change in a resident's condition or a change in how they transfer they needed to alert the nursing staff so the PIW could be updated and reflect the residents condition. During an interview on [DATE] at 7:30 a.m., Staff J revealed on Sunday [DATE], family members reported an increase in joint pain. Staff J stated he/she looked at the resident while in the room but did not do range of motion. During an interview on [DATE], the resident's family indicated they reported an increase in the resident's pain on [DATE] and [DATE], but felt the facility minimized the pain due to an upcoming appointment with their orthopedic physician to receive an injection for a joint disorder. On [DATE], the physician reported treating the resident since August of 2010 and the resident received multiple injections into the shoulder and hips due to being a nonsurgical candidate. The resident sustained [REDACTED]. The resident had good bone and no intraoperative findings were appreciated other than generalized osteoporosis, but not bad enough to lead to spontaneous fracture of this sort and no abnormal masses or bones were appreciated. There is always the chance the fracture started as a small fracture with transfer and got worse with positioning, but with the amount of comminution, the physician did not feel this happened. Usually if that happens you have a small fracture and then it displaces and comminution happens at the time of fracture.