Every finding on record at Harmony West Des Moines

Based on clinical record review, staff, resident and provider interview and facility policy review, the facility failed to report an allegation of abuse within the required two hour time frame for one of three residents reviewed (Res #4). The facility reported a census of 98 residents.Findings include:The Minimum Data Set (MDS) Assessment of Resident #4 dated 4/20/26 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS recorded the resident experienced mood symptoms: little interest or pleasure in things over 7-11 of the last 14 days and feelings of being down, depressed or hopeless over 2-6 of the last 14 days. The MDS recorded the resident was frequently incontinent of urine and occasionally incontinent of bowel. The MDS recorded the resident had diagnoses including Parkinson's Disease and Bipolar Disorder. The Care Plan for Resident #4 identified a Focus Area of Mood State Disturbance, dated 4/20/26. The Interventions included for staff to intervene when inappropriate behavior is observed. The intervention further identified that the resident had a history of false accusations and making derogatory remarks to African American Staff.The General Progress Note dated 4/28/26 at 10:10 am, authored by Staff A, Registered Nurse (RN, former staff member) documented the resident reported spilling some water overnight to the Occupational Therapist and when staff came in to clean it, they hit his head, hit his leg and 'sucked his guts out'. Staff D, the Occupational Therapist (OT), documented in the Occupational Therapy Treatment Encounter Note, dated 4/28/26, that Resident #4 displayed increased behaviors when asked if he could put on his shorts. The note stated the resident then said, I spilled my soda last night and when they came to clean it up with that machine - they hit me in the head and legs then sucked out all my insides. The OT documented she reported this to a nurse, as well as the Assistant Director of Nursing and the Nurse Practitioner (a single report when all three were present). On 5/18/26 at 2:40 pm, Resident #4 stated he had concerns regarding an employee who entered his room at night and ripped his clothes off. He denied ever being hit or struck. He was only able to desribe the staff member as an African Woman and could not provide a name. He stated he had not seen her recently. The resident further stated he feels safe with the current staff and had no concerns at the time of the interview. On 5/18/26 at 3:28 pm, Staff A, RN stated that Staff D, OT, approached her on 4/28/26 while she was on her way to a morning management meeting and reported allegations of abuse made by Resident #4. Staff A said she went straight to the meeting after this conversation. She voiced the former Administrator, the Director of Nursing, the Advanced Registered Nurse Practitioner (ARNP), corporate employees (including the now current Administrator) and several other managers were present in the meeting. She stated she reported the allegations immediately and the other staff did not acknowledge this but continued the meeting. On 5/19/26 at 11:33 am, Staff D, OT stated she documented Resident #4's allegations in her therapy note. She stated after the resident made the allegations, she reported it to a staff nurse, as well as Staff A, and also stated the ARNP was present. She stated the machine the facility uses to clean floors is never used in resident rooms, only in hallways. When asked if when he said they sucked outside his insides if he meant with the floor cleaner machine she said she was not clear what he meant by the comment. She provided a copy of her therapy note. On 5/19/26 at 1:26 pm, the ARNP stated other staff had reported the allegation of abuse to Staff A. She stated she recalled the police were in the building for this allegation. She stated she was not present when the allegation was made but she was present when Staff A reported it in the meeting. She believed the police arrived the following day, not the day of the meeting. She could not recall the date of the meeting but felt the police were not called until the following day. The local Police Department was contacted for a copy of the police report. The report documented the call from the facility was received on 4/29/26 at 12:45 pm. The facility filed a Facility Reported Incident (FRI) to the State Agency regarding the allegations of abuse on 4/29/26 at 12:42 pm, just prior to calling the police department. The FRI documented Resident #4 reported an abuse allegation on 4/29/26 at approximately 10:45 am, just over 24 hours after the initial progress note detailing the allegations was written. On 5/19/26 at 2:53 pm, the Administrator stated she was in the building on 4/29/26 with the prior Administrator, Staff F. She stated the two of them were looking over the prior 24 hour report and Staff F asked her to review the note regarding Res #4. The Administrator stated Staff F asked her if Staff A had reported this to her. She reported she and Staff F then went to discuss this with Staff A about her note. The Administrator stated Staff A responded that she had reported it in the morning meeting the prior day but nobody discussed it. The Administrator detailed that Staff A then said that she knows she sometimes speaks quietly. The Administrator stated following the conversation about the importance of reporting allegations of abuse immediately, Staff A was suspended for an investigation and was eventually terminated. The Administrator stated the FRI was worded as the allegation being reported on 4/29/26 because that is when the resident confirmed the allegations after they found the progress note and interviewed him. On 5/19/26 at 3:38 pm Staff G, Licensed Practical Nurse (LPN) stated she worked in the afternoon on 4/27/26 and 4/28/26 . She recalled when she came into work, Staff A, RN told her about the allegation of abuse made by Resident #4. She added that Staff A told her she had reported this in the morning meeting. She could not recall if the conversation with Staff A was on the 27th or 28th. On 5/19/26 at 4:00 pm, Staff H, Maintenance Director stated he did not recall Staff A reporting an allegation of abuse in a morning meeting. He added that Staff A was very softspoken so it is possible that she did say it and he did not hear it. On 5/20/26 at 11:07 am, the Administrator stated she had visited with Staff D, OT regarding the allegations of abuse. She said Staff D told her that when she spoke to Staff A in the presence of another nurse and the ARNP, this was regarding concerns of disease progression of Resident #4 and 'use of the machine' that he reported bumped him. The Administrator clarified when she spoke to Resident #4 on 4/29/26, he initially was telling her that he felt staff needed education in regards to being bumped by the machine and he was referring to the full mechanical lift hitting him during transfers. She stated at that time, he did not feel that was abuse, it was something that the staff needed education about. Further into this conversation between the Administrator and Resident #4, she stated he then added reported concerns about a specific Certified Nurse Aide (CNA), and made allegations of abuse about her. When he made these allegations, that was when the facility immediately suspended the CNA who was accused, and reported the FRI to the State Agency. The Care Plan for Resident #4 was reviewed on 5/20/26 at 11:43 am, including resolved items. The Care Plan failed to document any history of Resident #4 every having been care planned to transfer with a full mechanical lift. An intervention dated 2/26/26 stated dependent with assist x 2 with non-mechanical lift. The non mechanical lift does not have an apparatus that can strike a resident in the head. On 5/20/26 at 11:55 am, the Administrator clarified her previous comments referred to a full mechanical lift, commonly known as a Hoyer Lift. She confirmed the boom apparatus (which raises and lowers during transfers) was what Resident #4 stated struck him in the head. Upon being shown a photograph of a different lift (photo taken in a hallway of the facility during the survey) the Administrator confirmed this device is what is referred to when a resident is care planned as using a non-mechanical lift for transfers. The facility policy titled Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation, revision date 09/2025 documented the following:Training:Upon initial employment each employee will be educated on the facilities abuse guidelines and reporting requirements. Within six months of hire each employee shall be required to complete an initial 2-hour training course approved by Iowa Department of Human Services. Each employee will take a 2-hour training every three years thereafter. Documentation of training will be tracked by Human Resources or designee. See Iowa Code S 235B.16(5)(b); Iowa Code S 235E.4. In addition, nurses' aides shall receive initial and annual resident abuse prevention training. The training will educate on: Prohibiting and preventing all forms of abuse, neglect, exploitation, mistreatment, or misappropriation of patient property.Recognizing signs of abuse, neglect, exploitation, mistreatment, or misappropriation of patient property. Ways to deal with aggressive behaviors. Ways to deal with catastrophic patient reactions. Catastrophic reaction are extraordinary reactions of patients to ordinary stimuli such as an attempt to provide care.Procedures on immediately reporting suspicions or allegations of abuse (including injuries of unknown source), neglect, exploitation, mistreatment, and misappropriation of patient property or crime against a patient. How to report knowledge related to abuse allegations without fear of reprisal. How to recognize signs of burnout, frustration and stress that may lead to abuse. Timeframe requirements for reporting suspicion of crime

Based on observation, clinical record review, staff interview, and policy review, the facility failed to attach foot pedals on the wheelchair while transporting a resident for 2 of 3 residents (#2, #7) observed for transfers. The facility reported a census of 98 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] was unable to identify a Brief Interview for Mental Status (BIMS) score because the resident was rarely/never understood. It included diagnoses of seizure disorder, legal blindness, bilateral hearing loss, and hydrocephalus (abnormal buildup of fluid in the brain). It revealed he required supervision with eating and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility. It also indicated the resident used a manual wheelchair for mobility in the 7-day look-back period.The Care Plan initiated 3/13/24 revealed the resident required assistance with ADLs and used a wheelchair for mobility. It directed staff to use foot pedals.On 5/20/26 at 8:08 AM, Staff E, Certified Nurse Aide (CNA) transported Resident #2 in his wheelchair from the nurses' station to the dining room. His right foot was positioned on the foot pedal and his left foot was dangling between the pedals with his toes dragging the floor.At 8:15 AM, Staff I, CNA moved Resident #2 in his wheelchair from his position at the table to another position at the same table. His left foot was observed dragging the floor during the transport. 2. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, paraplegia (one-sided paralysis), seizure disorder, and psychotic disorder. It revealed he required setup assistance with eating and oral hygiene, maximal assistance with bathing and bed mobility, and was dependent with all other ADLs and mobility. It also indicated the resident used a manual wheelchair for mobility in the 7-day look-back period.The Care Plan initiated 10/08/25 revealed the resident required assistance with ADLs and used a wheelchair for mobility.At 8:16 AM, Staff E transported Resident #7 in his wheelchair from his position at the dining table to another position at the same table. His wheelchair did not have a left foot pedal and the resident was able to transport himself in his wheelchair.At 10:15 AM, Staff J, Licensed Practical Nurse (LPN) stated two (2) foot pedals are required for residents' wheelchairs when transported by staff. She stated Resident #2's dangling foot should be placed on a foot pedal before transporting. She also stated his foot would stay on the pedal once positioned on it.At 10:18 AM, Staff B, CNA stated Resident #2's feet should be on foot pedals and should not be dangling during transport. At 10:29 AM, Staff E stated she didn't think about Resident #2's foot dragging the floor when she transported him. She also stated Resident #7's foot pedal should've been applied to his wheelchair before transporting him.At 10:35 AM, Staff I stated Resident #2's left foot should've been positioned on his foot pedal before transporting him to the other side of the dining table. She stated she didn't notice it dangling and dragging the floor.On 5/20/26 at 12:11 PM, the Administrator stated staff should have ensured the foot pedals were on the residents' wheelchairs during transports.On 5/20/26 at 1:05 PM, the Administrator stated the facility did not have a policy specific for applying foot pedals on a wheelchair during resident transport.

Based on observations, resident and staff interviews and record review, and policy review, the facility failed to provide adequate supervision, failed to follow policy and failed to utilize adequate assistive devices to prevent accidents or further injuries for 3 out of 4 residents reviewed (Res #2, #89 & #116). The facility reported a census of 101 residents. Findings include:1.The Minimum Data Set (MDS) dated [DATE] for Resident #116 revealed diagnoses of diabetes mellitus, stroke, heart failure and required substantial assistance for transfers and moderate assistance for toileting and personal hygiene. Walking 10 or more feet did not occur due to a medical condition or safety concerns and a manual wheelchair was normally used for mobility. The MDS identified Resident #116 had an impairment of upper or lower extremities and use of a walker was not identified for a mobility aid. The MDS did not identify Resident #116 as having negative behaviors such as rejection of care and wandering did not occur. Resident #116 had a Brief Interview for Mental Status (BIMS) score of 3 that suggested severe cognitive problems with thinking and memory without signs of delirium. The MDS did not document that the resident was on a restorative program.The Care Plan for Resident #116 identified a brain injury due to a brain bleed and directed staff to offer cues, direction, redirect as needed, explain the task to be completed as she is impulsive with movements and non-compliant with directions. The Care Plan identified a risk for falls and directed staff to assist Resident #116 to ambulate with a gait belt and a front wheeled walker (initiated date [DATE]) and transfer using a non-mechanical lift (initiated date [DATE]). Restorative care: walk to dine & ambulate in facility resolved on [DATE]. A document titled incident report revealed on [DATE] at 5:20 pm, Staff B, RN was notified by Staff A, CNA that Resident #116 had lost her balance and fell to the floor while ambulating to the bathroom. Resident #116 was screaming Please help me up!. The Nurse Practitioner was notified and Resident #116 was sent to the hospital. The Progress Notes for Resident #116 revealed:1. On [DATE], Resident #116 was examined by Nurse Practitioner (NP) and documented Resident #116 was stable sitting in her wheelchair, alert, oriented, no distress, cooperative, frail, with a weight of 100 pounds. Resident #116 musculoskeletal condition was documented as limited range of motion with muscle weakness.2. On [DATE], Staff B, Registered Nurse (RN) documented that Staff A, CNA alerted that Resident #116 had a fall and upon entering Resident #116's room, she was on the floor, near the wall, laying on her right side, screaming Please help me up! Staff A stated she was taking Resident #116 to the bathroom, using her walker, and she lost her balance, falling to her right side. Resident #116 was assisted to her bed by Staff A and Staff B. Resident #116 was continuously screaming, complaining of pain in her right arm and shoulder. The Nurse Practitioner was notified and ordered to send Resident #116 to the hospital. The daughter was aware of the hospital transfer. 3. On [DATE] at 10:03 am, the hospital update was that Resident #116 fractured the right shoulder and elbow and due to the multiple comorbidities, a conservative management of a sling instead of surgery. The trauma services were providing pain management.A document titled [NAME] Des Moines Emergency Medical Services (EMS) dated [DATE] for Resident #116 revealed:a. The primary impression listed as acute pain due to trauma and injury of shoulder from fall from chair. b. At 5:40 pm EMS arrived to find Resident #116 alert and oriented to place, time, event complaining of pain to her right shoulder. Resident#116 slid out of her wheelchair and landed on her right shoulder and had pain 10/10 on scale 0-10. c. An IV access and Fentanyl was administered.d. At 5:37 pm, Resident#116 was moved to the ambulance via stretcher.A document titled ED (Emergency Department) Provider Notes dated [DATE] for Resident #116 revealed:a. The chief complaint was right arm injury.b. History: Arrived via EMS (Ambulance) from her care facility following mechanical fall. The patient was getting out of the shower, when tried to use her wheelchair for support, causing her to fall. The patient reported hitting her head and is on anticoagulation. The patient complains of right shoulder and elbow pain. c. A physical exam of musculoskeletal revealed signs of injury present, tenderness and bruising. d. Preliminary result: Impacted right humeral (upper arm) fracture and a comminuted olecranon fracture (a severe elbow injury, breaks into multiple pieces) and elbow joint effusion (fluid buildup from trauma). e. Recommend admission to trauma for possible surgical repair. Posterior long-arm splint and slingDuring an interview on [DATE] at 1:40 pm, Resident #116's daughter stated her mother was in bed mostly as it was very hard for her to get up. The daughter stated she visited on [DATE], the resident had some memory loss but feeling normal for herself, no pain. The daughter stated she's been trying to figure out what happened and she was not ok with this. Staff B, RN told her that the CNA was following her mom with a wheelchair as she walked to the bathroom. The daughter stated she visited her mother multiple times before the fall and her mother could not walk.During an interview on [DATE] at 10:29 am, Staff B, RN stated she had been employed for two years at this facility and had provided care for Resident #116. Staff B stated Resident #116 tried to get up by herself, required the assistance of one staff, with a walker, and walked to the bathroom a long while ago. Staff B stated currently, the CNAs would change Resident #116 in bed before assisting her into the recliner. Staff B stated Staff A, CNA had provided care for Resident #116 a few times had 2 different stories of the incident on [DATE] so she questioned truthfulness. Staff B stated Staff A she was taking [NAME] to the bathroom and while she was getting things ready by opening the bathroom door, Resident #116 fell and the second report was that Staff A was following Resident #116 with the wheelchair. Staff B stated that was what she documented on the incident report. Staff B stated when she entered [NAME]'s room, she was on the floor, laying on her right side without a gait belt a few feet from the bed. Staff B stated it was about 50 feet to the bathroom and the wheelchair was by the bathroom wall, and the walker was on the floor tipped over near Resident #116 who was screaming in pain. Staff B stated Resident #116 was a few feet from the bed so they tried to stand her, but she was not able to bear weight, so they grabbed her pants and slid her on her feet, lifted and put her on the bed. Staff B stated Resident #116 was screaming, complained of shoulder pain and it appeared swollen at the shoulder. Staff B stated Staff Z, CNA responded, stayed with Resident #116 as she notified the Nurse Practitioner and called 911. Staff B stated she did not notify the administration about her concerns involving the fall. Staff B stated the DON (Director of Nursing) called her 2-3 days after the incident to ask if they used the mechanical lift to get Resident #116 off the floor, which she replied no, then had a one-on-one talk about using the mechanical lift to get residents off the floor after a fall, if they cannot get up on their own. Staff B stated no one questioned her about the incident except for asking if a mechanical lift was used to put Resident #116 into the bed. During an interview on [DATE] at 12:51 pm, Staff A, CNA stated she was hired in [DATE] and had worked both the upper and lower levels of the facility. Staff A stated she received training and felt it was good enough to know the people. Staff A stated she utilized the Therapy book for resident changes with ambulation and transfers. Staff A stated she provided care for Resident #116 a few times but was unable to recall the last time she provided her care but she usually walked to the bathroom. Staff A stated on [DATE], Resident #116 was in the recliner during walking rounds at the beginning of her shift and could not recall the other CNA reporting anything. Staff A stated she would change her while she's in the bed. Staff A stated Resident #116 was eating, activated her call light, and assisted her up from the recliner, using a gait belt and walker. Staff A stated she had the wheelchair because sometimes Resident #116 would get weak in the bathroom. Staff A stated Resident #116 might have taken 10 steps, then leaned to the right and went over, it happened so fast. Staff A stated she activated the call light and radioed for assistance. Staff A stated Staff B, RN was in the hall, responded and helped get her up with the mechanical lift into bed. Staff A stated the ambulance came and could not remember if other staff had entered the room. During an interview on [DATE] at 3:12 pm, Staff Z CNA stated last year Resident #116 could get into a recliner with assistance but did not ambulate to the bathroom as she was incontinent and CNAs changed her in bed. Staff Z stated Staff A CNA told her she could walk Resident #116 to the bathroom. Staff Z stated Resident #116 did not ambulate due to balance issues but was able to pivot transfer with assistance. Staff Z stated on [DATE] she responded to someone's screams, checked the rooms, and found Staff B, RN and Staff A, CNA placing Resident #116 in her bed without a gait belt and there was no mechanical in the room, Staff Z stated when Staff B left the room to notify the doctor and call 911, Staff A told her Resident #116 fell during assistance to the bathroom. Staff Z stated Resident #116 was crying and did not want to be alone.During an interview on [DATE] at 10:29 am, Staff BB, CNA stated she had provided care for Resident #116, who was declining but would sit in her recliner to eat. Staff BB stated she worked on [DATE], 6-2pm shift, providing care for Resident #116 and needed two CNA's, with a gait belt, to transfer her to the recliner. Staff BB stated Resident #116 was not stable, and was too weak to walk to the bathroom so staff would check and change while she was in bed. A document provided by the Administrator verified to be investigative notes for Resident #116's fall on [DATE] which revealed: 4. Staff A, CNA entered the room to respond to the call light. Resident #116 told her she needed the bathroom, Staff A told Resident #116 she needed to get a gait belt. Resident #116 said no I'm going to the bathroom, stood up to her walker and began walking to the bathroom. Staff A grabbed Resident #116's wheelchair, unsure what else to do, bring wheelchair up behind Resident #116 who lost her balance and fell onto her right side.5. Staff B, RN was told Resident #116 fell as she was getting things ready to use the bathroom. Resident #116 had a walker and no gait belt and hasn't gotten up by self in a long time.6. Staff Z, CNA responded to a scream, staff already got Resident #116 up in bed. 7. Resident #116 reported to be impulsive, doesn't always follow directions or wait for staff. 8. Resident #116 noted to be non-compliant and has been caught ambulating on her own. During an interview on [DATE] at 2:15 pm, Staff L, CNA/Restorative Aide stated she had been employed at this facility for 11 years and remembered seeing Resident #116, most of the time in bed. Staff L stated she had never provided care for [NAME] nor restorative care for her.During an interview on [DATE] at 12:29, Staff JJ, Physical Therapy (PT) stated she had worked at the facility for 16 yrs. Staff JJ stated the last time she had provided treatment for Resident #116 was [DATE] through 10/3//25 for syncope due to low blood pressure. Staff JJ stated Resident #116 was ambulatory with a front wheeled walker and stand by assistance and participation varied due to her cognition and if she wanted to participate. Staff JJ stated she did not see Resident #116 in [DATE] nor [DATE]. Staff JJ stated she then saw Resident #166 after her return from the hospital on [DATE] for a PT evaluation and one evaluation before her death on [DATE]. Staff JJ stated she provided an update form in a PT transfer binder for the staff and the ADON or MDS nursing staff would place the changes in the care plan. Staff JJ stated the facility had a restorative program but Resident #116 was not in a program due to her lack of participation. Staff JJ stated she would be made aware of changes from nursing or aides, that the resident was not doing as well, and we might look in the Point Click Care update to see if a resident had a fall or hospital visit, QAPI or daily meetings. Staff JJ stated Resident #116 did not want to do a lot of activity but would get up to the recliner. Staff JJ stated the staff should have notified her if a change of condition occurred. Staff JJ stated Resident #116 needed heavy coaxing to get up and to do any walking, it was more behavioral then medical at the time she saw Resident #116 last on [DATE]. Staff JJ stated when she saw Resident #116 on [DATE], she was very weak, unstable, reduced balance and had a fear of falling. Documents titled Physical Therapy for Resident #116 involved: 5. On [DATE], skilled interventions focused on training in turning from back to side to sitting at the edge of bed with a minimum of one person to assist and sit to stand at front wheeled walker. Resident #116 demonstrates extreme fatigue (weakness) with increased time needed to complete tasks. Toilet transfers with assistance and verbal cues for safety and turning completely before sitting. Resident #116 was able to perform peri cares with assistance to complete putting off and on of undergarment/pants. Electronically signed by Staff JJ, Physical Therapist (PT)6. On [DATE], gait (walk) training focused on adjustment of center of mass over base of support and directional changes using a front wheeled walker, CGA (contact guard assist where the therapist maintains hands-on physical contact with the patient using a gait belt to provide safety, stability, and balance) for 7 feet with slow gait and decreased step length. Assist needed for management of walker during turn as Resident #116 was unable to maneuver around a tray table with verbal cues. Resident #116 required increased length and amount of rest breaks due to complaints of fatigue. Electronically signed by Staff JJ, PT.7. On [DATE]. gait training focused on adjustment of center of mass over base of support and directional changes using a front wheeled walker and CGA for 10 feet and for 5 feet with verbal cues for directions. Resident #116 required extensive time to complete each task and extensive rest breaks between each task due to complaints of extreme fatigue. Skilled interventions focused on training in turning from back to side to sitting at the edge of bed with a minimum of one person to assist and moderate verbal cues for encouragement. Resident #116 had complaints of dizziness upon sitting (BP cuff unavailable during time). The dizziness subsided after 3 minutes of sitting. Sit to stands with minimum assistance of 1 staff with maximal verbal and visual cues for hand placement. Resident #116 was educated on the importance of drinking more fluids and eating in order to increase energy and strength. Electronically signed by Staff JJ, PT.8. On [DATE], Patient and Caregiver Training: Instructed Resident #116 and caregiver (CNA) in safe transfer techniques, use of assistive device RW (rolling walker) and proper body mechanics specifically, in order to increase functional mobility skills and increase safety and decrease need for assistance with 100% return demonstration provided during session. Electronically signed by Staff KK, PT Assistant on [DATE] and electronically co-signed by Staff JJ, PT on [DATE]. A document provided by the Administrator verified to be investigative notes for Resident #116's fall on [DATE] which revealed the following: 9. Staff A, CNA entered the room to respond to the call light. Resident #116 told her she needed the bathroom, Staff A told Resident #116 she needed to get a gait belt. Resident #116 said no I'm going to the bathroom, stood up to her walker and began walking to the bathroom. Staff A grabbed Resident #116's wheelchair, unsure what else to do, bring wheelchair up behind Resident #116 who lost her balance and fell onto her right side.10. Staff B, RN was told Resident #116 fell as she was getting things ready to use the bathroom. Resident #116 had a walker and no gait belt and hasn't gotten up by self in a long time.11. Staff Z, CNA responded to a scream, staff already got Resident #116 up in bed. 12. Resident #116 reported to be impulsive, doesn't always follow directions or wait for staff. 13. Resident #116 noted to be non-compliant and has been caught ambulating on her own. A document verified by the Administrator to be the 5 day and root cause analysis submitted to the Department of Inspections and Appeals (DIAL) on [DATE] revealed the following: j. On [DATE] at 4:30 pm the Administrator was notified by the hospital that Resident #116 was to be admitted following the fall on [DATE] due to a comminuted and impacted right humeral (upper arm) fracture and a proximal radial ulnar (elbow) fracture. k. On [DATE] at 4:20 pm Resident #116 was assisted by Staff A, CNA to the bathroom when she lost her balance and fell onto her right side. Resident #116 was sent to the emergency department for imaging (x-rays).l. An interview with Staff A, CNA stated she answered Resident #116's call light and she needed to use the bathroom. Staff A stated she told Resident #116 she needed to get a gait belt, but Resident #116 got up, stood herself to her walker and began walking to the bathroom. Staff A grabbed the wheelchair, brought it up behind Resident #116 and witnessed her lose balance and fall to her right side. Resident #116 began to scream in pain, calling out for help to get up. Staff A requested assistance from Staff B, RN and they assisted Resident #116 into bed utilizing a mechanical lift. m. Interview with Staff B, RN stated Resident #116 was not wearing a gait belt on when she entered the room, the walker and wheelchair was nearby. Staff B completed her assessment, assisted Resident #116 off the floor and contacted the on-call provider who gave the order to transfer resident to the hospital for further evaluation due to complaints of pain in right arm and shoulder. The emergency medical services were contacted and Resident #116 was sent at 5:45 pm. n. Other staff interviewed stated Resident #116 had a normal day, used her call light, did not like to wait for staff, could be impulsive per the care plan. Resident #116 was toileted at 3 pm. Resident #116 directed her cares most of the time, ate in her room, had dinner and put on her call light. Staff answered the call lights timely per reports. o. Resident #116's daughter commented, these things happen. p. The Medical Director was informed.q. Care plan followed 1. The wheelchair was locked at bedside. 2. The walker was at bedside. 3. A picture sign to call for assistance was in place. 4. Staff were providing appropriate supervision and attempted to meet her needs. 5. Her environment was quiet and calm. Resident #116 had been eating with her television per her preference. r. Based on these findings the staff adhered to the resident care plan, no evidence of staff culpability, interventions were implemented and staff responded promptly. Root cause appeared to be the resident's need for the bathroom and her impulsivity and preference for directed care. No symptoms of frequency or urinary tract infection (UTI). The lack of a gait belt at the time was not a contributing factor, as the resident was impulsive and did not wish to wait for assistance. A document titled Physical Therapy referral dated [DATE], Reason for Referral: Resident #116 was referred to therapy services due to fall from hyperglycemic (high blood sugar) episode that resulted in a right humerus (upper arm fracture) along with elbow joint effusion. Pt presents with impaired transfers and mobility at this time. Clinical Impressions: Patient referred to PT due to new onset of compromised physical exertion level during activity, decrease in functional mobility (moderate to dependent), decrease in strength in lower extremities, decreased skin integrity (large amount of bruising to right side, right arm in sling with ace wrap and splint to elbow), recent fall with Right humeral fracture (upper arm), functional limitation with ambulation (unable at this time), increased need for assistance from others, dependent with mobility, increased physical exertion during daily living tasks, reduced dynamic balance and reduced static balance. Electronically signed by Staff JJ, PT on [DATE]. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the diagnoses of weakness, unsteadiness on feet, required the assistance of one staff for supervision with ambulation and maximal assistance for hygiene and toileting. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 suggesting an intact cognition.The Care Plan for Resident #2 dated [DATE]. The Care Plan identified a risk for falls and directed staff to assist with ambulation and transfers with moderate assistance of one staff with a gait belt and front wheeled walker and as needed.The Progress note dated [DATE], the Nurse Practitioner (NP) documented a visit for Resident #2 following the fall on [DATE]. Resident #2 described the incident as a slide as she attempted to stand up with the assistance of a care giver who did not use a gait belt and despite informing the care giver she was slipping; she was reassured multiple of times that she will not fall. The NP documented Resident #2 slid down and became stuck between the toilet and the wheelchair and had to be assisted by multiple of caregivers to get back to bed. Following the incident, x-rays revealed an acute fracture of her ankle and had to be transported to the hospital where she received Fentanyl for pain management and additional x-rays. The NP documented the hospital stabilized the fracture with a soft cast and potentially transition to a boot and Resident #2 reported ongoing pain from the fracture.The Falls with Injury report dated [DATE] for Resident #2 revealed:a. The incident occurred in the resident's bathroom room.b. Staff CC, CNA tried to assist resident #2 from the toilet to wheelchair, due to weakness to her legs, she sat on the floor.c. Staff I, LPN noted resident had a gait belt on and an open area to right shin and left lateral lower leg.d. Resident #2 stated her legs gave out as Staff CC, CNA performed peri care, reported pain to right lower leg and hip. e. Resident #2 refused ER prefer mobile x-ray. Notified the Nurse Practitioner, ordered x-ray to right femur and right lower leg after a witnessed fall. f. Resident #2 was alert and ambulatory with assistive device. g. No injuries observed post incident. h. Person preparing the incident report: Staff GG, LPN Statement titled Incident [DATE] for Resident #2 revealed: a. At 11:45 am 2 cna's reported resident #2 fell during transfer from toilet to wheelchair. b. Resident #2 was found in bathroom in a wheelchair.c. CNAs stated they got her up prior to getting the nurse. d. Resident #2 was complaining of pain to her right lower extremity.e. Resident #2 had a gait belt on in wheelchair. f. Resident #2 assessed with vital signs then assisted to bed by two staff members. g. Signed by Staff I, LPN on [DATE] Form signed by Staff HH, Former DON on [DATE] at 11am revealed: a. Resident #2 sustained a Tri malleolar fracture of right ankle on [DATE] at 11:29am.b. Cause of accident as Resident #2 used bathroom with staff assist, staff assisting with peri care when resident legs became weak, lowered to the floor. c. Previous functional ability: 1 assist with gait belt and front wheeled walker. d. Checked as injury not a major injury and signed by Staff II, Doctor of Osteopathic Medicine on [DATE] at 1500. During an interview on [DATE] at 11:42 am, Resident #2 stated on [DATE] she had walked with her walker into the bathroom and when finished she activated the call light. Resident #2 stated she required the assistance of staff to provide peri care and had waited for a while until the Certified Nursing Assistant (CNA) arrived. Resident #2 stated usually when she was assisted by facility staff and she would say she's slipping, the staff would sit her back down on the toilet. Resident #2 stated she began to slip and said that to the CNA who replied with I've got you. Resident #2 stated she went down to the floor because her legs were weak from sitting so long waiting for assistance. Resident #2 stated the CNA that was assisting her was an agency staff who said she should not even be here providing care for her as she had not been trained. When inquired if she fainted, Resident #2 laughed and replied, I've never fainted in my life. Resident #2 stated the CNA had her by the arm and not a gait belt. Resident #2 stated another CNA came into the room, who also was new agency CNA, and helped to get into the wheelchair. Resident #2 stated it was hard, they had her by the arms and her right leg hurt so she was unable to stand. Resident #2 stated then the nurse came in to help.During an interview on [DATE] at 3:15 pm, Staff CC, CNA verified her work at this facility was through an agency. Staff CC stated on her first day, she was asked to come in ahead of her start time to receive a code for the Point Click Care (PCC) computer system to chart, then failed to show her how to use it. Staff CC stated she was unaware of how to look up resident information since they did not give her details and they were aware it was her first time in the facility. Staff CC stated the staff was not helpful. Staff CC verified she had worked on [DATE], working with another new agency CNA and termed the day as Hectic as staff were sick, went home and the two were on their own with 2 halls of residents. Staff CC stated the call lights were going off and the nurse yelled at her for using the radio to call for assistance. Staff CC stated she answered a bathroom call light and she did not know the resident. Staff CC stated when the leaving, staff conduct the walking round at the beginning of the shift, they didn't give details. Staff CC stated during the peri care, the resident was starting to fall. Staff CC stated she called for the other CNA who came in immediately and they tried to get the resident into her wheelchair, describing it as very hard. Staff CC stated a 2nd nurse came into the room to helped them. Staff CC stated when she left at 2pm, no one asked her what happened, no one called her and she did not go back to this center.During an interview on [DATE] at 10:41 am, Staff DD, Agency CNA verified she worked through an agency and that [DATE] was her first day to work at this facility. Staff DD stated it was complete chaos as the staff did not tell her anything, no direction and it was the first time working with the mechanical lifts that this facility utilized stating she had no idea how to run it. Staff DD stated she was assigned to work on a hall with a staff member who went home and she was unaware that she was working alone. Staff DD stated another agency CNA (Staff CC) was down the next hall and from 10am to 2pm they were on their own. Staff DD stated they assisted each other with the residents that required two assist and was in a room when Staff CC stated she needed to go across the hall as that call light had been activated for a while. Staff DD stated her resident was on the toilet and could not be left alone but Staff CC was absent for a really long time so she secured her resident and found Staff CC with her resident on the floor in front side of the toilet. Staff DD stated Staff CC asked what do I do? and it's routine if someone falls to call the nurse, used the radio for a nurse and helped to get the resident up. Staff DD stated she did not remember what happened next. Staff DD stated there were many residents, multiple two assist and both Staff CC and herself had no idea what was going on. Staff DD stated she had been trained as a CNA, worked for 8 years, and referred to that as the craziest day of her life and she would never go back as it was unsafe. Staff DD stated no one called her and she did not return to work for them.During an interview on [DATE] at 2:09 pm, Staff I, Licensed Practical Nurse (LPN) stated she was not sure how the facility on-boards agency staff, she had seen a packet but have not reviewed the content, and the staff that are leaving for the day completed a walking round. Staff I stated the agency staff can look in the computer for the Kardex but they have to navigate to the care plan. Staff I stated most of the agency staff ask to look at the therapy communication binder. Staff I stated she had good communication with the staff CNA's but there have been multiple agency CNA's and she didn't know their base line knowledge. Staff I stated she remembered a little about Resident #2's fall, it happened in the bathroom and there was an issue with the agency CNA's getting her off the floor.During an interview on [DATE] at 1:48 pm, Staff G LPN ADON stated she was unaware of any training for the agency staff as human resources (HR) and the scheduler placed them onto her unit and was not aware of who it will be until she arrives for the day. Staff G stated she was unable to remember who the agency staff were that had worked on [DATE], day shift, but when she was made aware that they were low on staffing, she notified Staff FF, Staff Scheduler and did not receive further assistance. Staff G stated the nurse on duty had responded to some activated call lights but personally no one approached her to assist. Staff G stated administration schedules staffing according to census. Staff G stated she was not aware there were new agency staff or that they were not oriented to PCC, it was a busy day. During an interview on [DATE] at 2:15 pm, Staff FF, Staff Scheduler stated the facility utilized two staff agencies, the CNAs were independent then make a post on the clipboard account so they may pick up the shifts. Staff FF stated the moment she was aware of the individual's acceptance for a shift then requests their documentation. Staff FF stated there was a packet at the nurse station they will utilize for orientation that was created in [DATE]. The agency staff will sign the four pages in the binder when they come in for their first day and leave it in the binder. Staff FF stated she would assume the staff CNA would orient and train them as it was the responsibility of the ADON's and DON to have that done. Staff FF stated Staff CC, agency CNA accepted work starting [DATE] and Staff DD, agency CNA picked up her first shift on [DATE]. Staff FF verified both agency CNAs worked on [DATE] and a staff CNA had left at 9:30 am. Staff FF stated a staff CNA was to come upstairs to work 11 am to 6 pm but was unsure if that occurred. Policy titled Fall Occurrence dated 2/2024 revealed interventions are implemented and placed on care plan based on fall risk assessment. The resident will be assessed by a licensed nurse prior to being moved after a fall. Policy Gait belts (transfer belts)When to use: Patient is weak but can bear some weight. Fall risk is present. Assisting with sit to stand or ambulation. Policy mechanical lifts (powered or hydraulic lifts)Used for patients who cannot bear weight or require full assistance. When to use: non-weight bearing patients. Total or extensive assist transfers. Staff safety concern with a manual transfer. Policy Non mechanical lifts (manual transfers) includes pivot transfers, two person lifts, and slide board transfers.When to use: patient can bear partial weight, short transfers bed to chair, patient follows commands. If a patient cannot safely bear weight, use a mechanical lift.If a patient can assist, a gait belt or non-mechanical method may be appropriate. when in doubt, get help. Safety protects both patient and caregiver.During an interview on [DATE] at 2:55 pm, the Administrator reported that he was not employed by the facility when Resident #2 had her incident. The investigations are conducted by interviewing staff and residents. The Administrator stated he would conduct interviews wi[TRUNCATED]

Based on review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), the CMS-2567's, staff interview and policy review, the facility failed to have an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility had several repeat deficiencies identified on the facility's current recertification and complaints survey. The facility identified a census of 101 residents.Findings include:Review of CASPER report revealed repeated deficient practices identified during the facility's annual surveys 3/14/23, 12/11/25 and 2/20/25. Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's recertification surveys completed 3/14/23, 12/11/23 and 2/20/25, complaint investigations 3/14/23, 6/8/23, 12/11/23 and 7/29/24, and facility-reported incident investigations 3/14/23, 6/8/23, 10/3/23, 12/11/23, 7/29/24 and 2/20/25, and the current survey and complaint investigations. The repeat deficiencies cited included: F609 cited 3/14/23,10/3/23 and during the current surveyF688 cited 2/20/25 and during the current survey. F689 cited 3/14/23, 6/8/23 and during the current survey F812 cited 6/8/23, 12/11/23, 2/20/25 and during the current survey.F865 cited 6/8/23, 2/20/25 and during the current survey.F880 cited 3/14/23, 6/8/23, 12/11/23, 7/29/24, 2/20/25 and during the current survey.In an interview on 3/4/26 at 2:15 PM, the Administrator reported the Quality Assurance (QA) Committee met monthly. The QAPI Committee had identified areas they needed to work on. The Administrator reported he had only worked at the facility since 11/2025. The facility had worked on staff scheduling and workload strategies, as well as doing audits and providing staff education. When the surveyor asked the Administrator how they were addressing repeat deficiencies cited since the past recertification survey and complaint surveys, the Administrator responded the facility had recently implemented an Infection Preventionist and a Nurse Educator role to ensure compliance and conducting audits. The facility also planned to overhaul their orientation program and do a better job before staff worked on the units. The Facility's QAPI Plan, dated 5/23/25, identified the facility is committed to standards of performance and dedicated to providing the highest quality of health care services. Regulatory outcomes are monitored and trended including licensure certification survey results, complaint survey results and focused survey results (such as infection control focus). Performance Improvement Projects (PIPs) are developed as needed and/or as determined by the QAPI Committee. Areas of opportunity identified by the QAPI Committee are corrected through the PIP process. Completion of investigations and review of the findings should demonstrate that process improvement initiatives are implemented and have been sustained.

Based on electronic health record review (EHR), staff interview, and guidance from the Resident Assessment Instrument (RAI) User Manual Version 1.20.1 October 2025, the facility failed to accurately complete Minimum Data Set (MDS) Assessment for 4 of 21 residents reviewed (Resident #3, #7, #8, and #61). The facility reported a census of 101. Findings include: 1.The Quarterly MDS completed on 12/17/25 indicted the presence of a feeding tube for Resident #3 by checking question K0520B. Review of Physician Orders for Resident #3 did not show any current or discontinued orders for tube feedings. The Care Plan for Resident #3 did not show any current or previous use of tube feedings. Review of Progress Notes did not identify the presence of a feeding tube, past or present. The RAI User's Manual (pages K-11 and K-13) outlined question K0520B should be checked only if a feeding tube was present during assessment period. 2.The Annual MDS completed on 10/31/25 was checked No to question A1500 . This indicated Resident #7 did not have a Level II Preadmission Screening and Resident Review (PASARR) mental illness and/or intellectual disability. Current diagnoses listed for Resident #7 include generalized anxiety disorder, major depressive disorder, recurrent, and schizoaffective disorder, bipolar type. During an interview on 2/26/26 at 2:05 PM, The MDS Coordinator noted the mental health diagnoses for Resident #7. However they were not aware question A1500 should be answered Yes. Review of PASRR Level I Screen Outcome, dated 1/28/26, confirmed the presence of a PASRR condition being a mental health disability. This included the diagnoses of schizoaffective disorder, major depression, and anxiety. The PASRR Outcome Explanation directs facilities to mark Yes on question A1500 on the MDS as well as selecting the specific PASRR condition with question A1510. 3.The MDS completed 12/10/25 indicated the use of continuous oxygen therapy for Resident #8. The MDS did not note the use of any further respiratory treatments. Review of Physician Orders for Resident #8 noted the following: a. Apply Continuous Positive Airway Pressure (CPAP) nightly with a start date of 10/3/25; b. Oxygen at 2 liters/minute at rest and 3 liters/minute with exertion with a start date of 11/7/25. The Treatment Administration Record for December 2025 indicated Resident #8 utilized CPAP for 2 days out of the 7-day look-back period. During an interview on 2/26/26 at 2:05 PM the MDS Coordinator acknowledged Resident #8's use of a CPAP machine. They believe it was an oversight that it was not identified on the most current MDS Assessment. The RAI User's Manual (page O-6) noted any type of CPAP respiratory support devices should be coded on question O0110G3. 4. The Annual MDS completed on 12/31/25 indicated the use of insulin for Resident #61. Question N0350 noted insulin was used 1 day and question N0415 noted the use of hypoglycemic medications. Review of Physician Orders for Resident #61 did not show current or discontinued insulin orders for December 2025. Current diagnoses for Resident #61 did not include Diabetes. The MDS completed on 12/31/25 did not list Diabetes as an active diagnosis. During an interview on 2/26/26 at 2:05 PM, the MDS Coordinator confirmed Resident #61 did not receive insulin injections and the MDS Assessment was miscoded. The RAI User's Manual (pages N-3 to N-8) note to indicate the number of days the resident received an insulin injection during the assessment period. The use of hypoglycemic medications should be checked if the medication was taken by the resident during the assessment period.

Based on observations, resident records, staff interviews and policy review, the facility failed to follow infection control policies, procedures and guidelines for contact precautions, enhanced barrier precautions, and standards of care. The facility reported a census of 101 residents. Findings include: 1.The Physician's Order, initiated on 2/23/26, directed the facility to place Resident #5 in isolation due to a Clostridioides difficile (C-diff) infection. A General Progress Note dated 2/23/26 at 6:09PM documented the following; Resident is positive for C-Diff and will start Vanco (antibiotic for treatment of C-diff), educated resident and wife as to what the diagnosis is and will be on isolation for 10 days. A sign outside the resident's door informed staff to follow contact precautions. This included the use of gown and gloves for any interaction with the resident and their environment and hand washing prior to exiting the room. A note indicated the use of hand sanitizer, which is alcohol-based, was not acceptable given the type of infection. During an observation on 2/26/26 at 9:15 AM, Staff R, Registered Nurse (RN), completed dialysis fistula site cares on Resident #5. This included the use of Staff R's stethoscope on the resident's arm to further assess the fistula. After all resident cares were completed, Staff R used an alcohol wipe to disinfect the stethoscope. In an interview on 2/26/26 at 3:50 PM, Staff S, Director of Clinical Education, acknowledged Resident #5's C-diff infection and the current isolation precautions. Due to the nature of the infection, the use of an alcohol wipe is not recommended as it will not adequately disinfect surfaces. Staff S explained bleach wipes or Super Sani-cloths should be used instead to disinfect. The facility stocks Super Sani-cloth disinfectant wipes. Staff S further noted the use of disposable equipment, like a disposable stethoscope, as an alternative infection control practice with C.diff infections. The facility document Infection Control Practice Guide, revised 9/2023, noted under Contact Precautions to utilize resident-specific non-disposable items that cannot be cleaned and disinfected between residents, e.g., blood pressure cuff, stethoscopes. If indicated, equipment should be disinfected between resident use with an EP-registered disinfectant or hypochlorite solution. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed diagnoses of heart disease, diabetes mellitus, Alzheimer's disease, dementia, a stroke and required partial to supervised assistance for cares. The MDS identified Resident #4 was taking antipsychotic, antidepressants, hypoglycemic, anticoagulant, antiplatelet and diuretics. Resident #4 was identified as receiving insulin injections 7out of 7 days. The MDS identified Resident #4's Brief Interview for Mental Status (BIMS) score of a 5 suggests an impaired cognition. During an observation on 2/23/2026 at 1:25 PM, Staff B, Registered Nurse (RN) came in his room after the noon meal and informed Resident #4 she had his insulin, laid his insulin pen in the bed, swabbed his left arm then picked up the syringe and administered the medication. Staff B failed to hand sanitize, put on gloves, and failed to perform hand hygiene before she left the room. During an interview on 2/25/2026 at 10:29 AM, Staff B RN stated she had been employed for two years at this facility. Staff B verified Resident #4's blood sugars were high and on 2/23/26 she administered insulin according to the sliding scale ordered for Resident #4. Staff B was not sure if she had hand sanitized or wore gloves but verified laying the syringe on his bed and should have used a barrier. Staff B stated she did leave the cap on it but should have used a barrier. During an interview on 3/4/26 at 1:43 pm, the Director of Nursing (DON) stated she was new to her position and at this time she could not express her expectations for the nurses. 3. During an observation on 2/25/26 at 8:01 AM, Staff U, Licensed Practical Nurse (LPN) failed to provide barrier while checking Resident #54's blood glucose. Staff U placed the glucometer on top of Resident #54's books sitting at her bedside. 4. On 2/25/26 at 10:59 AM, during observation of medication administration, Staff U, LPN, failed to put on Personal Protective (PPE) while administering Resident #6's medication via g-tube. 5. Review of Resident #9's Treatment Administration Record (TAR) for February 2026, revealed an order dated 2/19/26 to cleanse abdominal (abd) wounds with cleanser, apply Medihoney topically to wound and cover with silicone super absorbent dressing daily and as needed. On 2/26/26 at 3:00 PM, a sign outside Resident #9's room indicated Enhanced Barrier Precautions (EBP) and a bin of drawers inside Resident #9's room stocked with Personal Protective Equipment (PPE) was observed. Continued observation, Staff J, LPN and Staff X, Assistant Director of Nursing (ADON) failed to don appropriate EBP PPE for wound care/dressing change on Resident #9's lower abd wounds. 6. Review of Resident #97's TAR for February 2026, revealed an order dated 2/18/26 to cleanse right thigh with normal saline, apply Bactroban ointment, cover with silicone super absorbent dressing daily and as needed. An observation on 2/26/26 at 2:50 PM failed to indicate Resident #97's need for EBP with wound care. During observation Staff J, LPN failed to wear EBP while providing wound care treatment for Resident #97. During an interview on 2/26/26 at 3:18 PM Staff G, ADON and Staff X, ADON acknowledged the failure to don EBP for Resident #9 and Resident #97's wound treatments. On 2/26/26 at 3:52 PM, Staff S, RN Director of Clinical Education, stated expectations for all staff to wear EBP PPE during wound care and g-tube care and g-tube medication administration. Review of facility provided Enhanced Barrier Precautions Policy, revised 3/2024, stated the following: Purpose: To minimize risk of transmission of novel or targeted Multi-Drug Resistant Organisms (MDROs) during high contact resident care activities for residents requiring Enhanced Barrier Precautions (EBP).1. EBP will be used in conjunction with standard precautions for residents with any of the following:a. Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. b. Wounds and/or indwelling medical devices. (wounds generally include chronic wounds but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Not to include shorter-lasting wounds, such as skin breaks or tears. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and/or tracheostomy.) In an email dated 2/26/26 at 2:45 PM, Facility Administrator communicated he was not able to find a facility policy related to disinfecting equipment and shared medical devices and stated we follow standard of care.

Based on clinical record review and staff interview the facility failed to obtain informed consent for psychotropic medications that have black box warnings (the most serious safety warning the Food and Drug Administration (FDA) uses and requires the healthcare provider to have a comprehensive discussion with the resident/representative about the risks, benefits and alternatives for use) for 2 of 5 resident reviewed for psychotropic medications (Residents #4 & #110). The facility reported a census of 101 residents.The Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had diagnoses of Alzheimer's Disease, dementia, anxiety disorder and depression. The resident had impaired short and long-term memory and severely impaired decision-making skills. The MDS indicated the resident did not have any behaviors. The MDS documented the resident took an antidepressant medication. The MDS assessment dated [DATE] revealed Resident #110 took an antipsychotic and an antidepressant medication. The MDS indicated the resident had no behaviors. The Care Plan initiated 5/21/24 revealed the resident had behavioral problems related to sexually inappropriate behaviors in public areas, physical aggression and combativeness with cares at times. He took psychotropic medications (sertraline) related to anxiety, and trazadone for insomnia and agitation. The Care Plan directed staff to administer medications as ordered and assess for side effects and complications of the medications such as tremors, pacing, lip/tongue movement or rigidity, poor balance, urinary retention, constipation and dry mouth. The Order Summary revealed orders for Resident #110 for the following: Sertraline (psychotropic) 200 milligrams (mg) by mouth (PO) daily for depression started on 6/18/25, Trazodone (psychotropic)12.5 mg PO three times a day (TID) related to anxiety disorder and 25 mg PO at bedtime related to insomnia started on 6/20/25, Risperdal (psychotropic) 0.25 mg PO two times a day for agitation and restlessness started on 9/22/25, and Olanzapine (psychotropic) 5 mg PO TID for aggression started on 1/5/26. An Encounter Note / Progress Note dated 2/4/26 at 12:00 AM revealed risperidone, olanzapine, sertraline, and trazodone for symptom and behavior management. A Psychotropic Medication Monthly Review created on 1/30/26 lacked a consent for the psychotropic medications. The Electronic Health Record (EHR) revealed under the Assessment tab, a document titled Psychotropic Medication Evaluation. The Psychotropic Medication Evaluation assessment dated [DATE] was created / completed on 2/26/26. Section D of the Psychotropic Medication Evaluation revealed education to the resident and/or representative on the risks, benefits, and alternative options prior to starting the psychotropic medications. The record lacked a consent for the psychotropic medications the resident was prescribed. In an interview 2/26/26 at 4:40 PM, the Regional Nurse reported she had worked with the facility for a year. The facility had a few DON's (Director of Nursing) in the past year. She reported she knew there were forms about the psychotropic medications the residents were on. She found a binder with some forms but no consents found as of this date. She will continue to look to see if she can find consents for the use of psychotropic medications for Resident #110. The Regional Nurse reported they had recently added a section about the education provided to the resident /representative on a Psychotropic Medication Evaluation on-line. A follow-up interview on 3/4/26 at 11:30 AM, the Regional Nurse reported she found information about psychotropic medication education on Resident #110. The Psychotropic Medication Evaluation assessment is located under the assessment tab in the computer. Surveyor reviewed the Psychotropic Medication Evaluation for Resident #110. The Evaluation was completed on 2/26/26 (the date the surveyor requested it). A Usage for Psychotropic Medications Guidance policy revised 3/2025 revealed each resident's drug regime will be free from unnecessary psychotropic drugs. Psychotropic drugs include antipsychotics, antidepressants, antianxiety and hypnotics. Underlying causes of the resident's behavior will be assessed prior to initiation of psychotropic medications. The benefits, risks and treatment goals will be assessed and documented. The facility will obtain informed consent from residents and/or their representatives of the benefits, risks and alternatives before initiating or increasing psychotropic medications. 2. admission Minimum Data Set (MDS) for Resident #4 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. The MDS further revealed the resident had a diagnosis of depression and behavioral disturbance and received an antidepressant and antipsychotic medication during the 7 days look back period. Resident #4's clinical physician orders revealed orders for antidepressant medications and antipsychotic medication. The Electronic Health Record (EHR) for Resident #110 lacked documentation in regards to psychotropic consents. Response to an e-mail on 2/26/26 at 2:38 pm, the Administrator stated he looked for the original paper copies of the consents due to the change over to electronic system but at this time the facility did not have the signed consents for psychotropic medications requested for Residents #4 and #110.

Based on record review, resident and staff interviews, employee timecard review and policy review the facility failed to take appropriate steps to protect residents from potential abuse by not separating staff from residents when an allegation of suspected abuse was reported for 2 of 3 residents reviewed for abuse (Residents #89 & #116). The facility reported a census of 101 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 had diagnoses of arthritis and a right hand contracture. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 2 indicating severely cognition. The MDS revealed the resident had impaired range of motion (ROM) to the upper and lower extremities. The MDS also revealed the resident had dependence on staff for bed mobility and transfers. The Care Plan initiated 4/26/24 revealed the resident had arthritis and limited mobility and required assistance with activities of daily living (ADL's). The resident also had a risk for falls. The Care Plan directed staff to use a Hoyer (mechanical lift) and assistance of two staff for transfers. An Incident Report dated 2/17/26 at 1:00 PM revealed Staff G, Assistant Director of Nursing (ADON) notified by Staff I, LPN, on 2/17/26 that Resident #89 complained of right arm pain. Resident #89 was unable to give a description. The Nurse Practitioner (NP) ordered an x-ray of the right upper extremity (RUE). Resident #89 was later sent to the Emergency Department (ED) for further evaluation. The Progress Notes revealed the following: On 2/17/26 at 1:22 PM, resident with increased pain to her right arm and shoulder with movement and palpation. Resident unable to state cause. On 2/17/26 at 6:15 PM, x-ray results received. Findings show an age-indeterminate acute or subacute sub capital fracture of the right humeral neck, and diffuse osteoporosis. Information provided to the administrator. No previous records available for comparison. In an interview on 2/24/26 at 8:00 AM, Resident #64 reported a concern with how an aide handled her roommate one day last week. The certified nursing assistant (CNA) did not use the mechanical lift or any kind of device to get Resident #89 into bed. Resident #64 stated she heard the door to the room open and she heard someone wheel Resident #89 into the room. She then heard a sound like the resident was thrown into bed. Resident #89 cried out. The only time she had ever heard Resident #89 cry is when she was in pain. Resident #64 said she normally heard the staff wheel her roommate into the room, staff bring the mechanical lift into the room, and then staff get Resident #89 into bed, but that evening she did not hear the lift being brought in. She heard the CNA. She did not know the CNA's name but she was African-American, short stature, and had a stocky build. The CNA did not have a name tag on. Resident #64 reported she talked to Staff I, LPN, and let her know. She did not know the day this incident happened but it was around 8 PM when the CNA put Resident #89 in bed. The MDS assessment dated [DATE] revealed Resident #64 had a BIMS score of 15, which indicated cognition intact. In an interview on 2/25/26 at 9:40 AM, Staff G, LPN, reported she was working the floor doing wound rounds and going to meetings in-between nursing tasks/duties on 2/17/26. Later in the afternoon, she found out Resident #89 had a fracture. Staff I, LPN, had informed her about Resident #89. Staff G notified the Administrator about it. In an interview 2/25/26 at 1:48 PM, Staff K, certified medication aide (CMA), confirmed she worked on Monday (2/16) on the 2 PM to 10 PM shift and was off on 2/17/26. She only worked with Resident #89 once that day. The other staff person assigned asked her to help reposition and change her. Staff K stated she only helped get Resident #89 up but did not help to lay her down. The CNA she worked with was Staff C. Staff K again stated she had only helped Staff C with Resident #89 one time that day. In an interview on 2/25/26 at 2:13 PM, Staff L, Restorative Aide, confirmed she worked last week on 2/16/26 from 8 AM to 2 PM on the [NAME] back hall. Staff E, CNA, was assigned to the front (South) hall. Staff L stated she helped Staff E lay Resident #89 down with the mechanical lift. At that time, Resident #89 was ok, she did not complain of pain. She did not notice any bruising or anything at that time. Staff L said she left at 2 PM. Resident #89 was fine. In an interview 2/25/26 at 3:10 PM, Staff I, LPN, reported she worked upstairs on 2/17/26 but was not assigned to Resident #89. Staff I stated she was passing medications on Tuesday (2/17/26) when Resident #64 came out around 8 or 9 AM and said she was worried. Resident #64 said she thought people were not doing things safely. Then Resident #64 asked if she could tell Staff I something. Resident #64 said she was really worried and proceeded to tell her that last night (2/16) she heard the door to her room open and she heard the CNA wheel Resident #89 through the door, but she did not hear her bring the mechanical lift in like staff usually did. She then heard Resident #89 cry and heard a thud on the bed. The CNA left the room. Resident #89's (Broda) chair was by the bed. Resident #89 was oddly positioned on the bed, she was way down toward the end of the bed and had her legs over on the bed. Resident #64 thought Resident #89 was going to fall off the bed. Staff I asked Resident #64 the name of the CNA, and Resident #64 said she did not know. Staff I stated she told the Administrator about the accusation. In an interview 2/25/26 at 4:34 PM, Staff M, LPN, confirmed he worked on 2/17/26 from 6 PM to 6 AM. When he got report at shift change, Staff J, LPN, shared concerns about Resident #89's shoulder/arm. Staff J said the vendor came and got an x-ray on Resident #89. After report, he received a fax with the x-ray results showing Resident #89 had a right humeral neck fracture. He was told by multiple nurses and multiple CNA's they heard from Resident #89's roommate it may be due to an improper transfer. He spoke with the Administrator and the provider. Staff M stated he was not aware of any injury. Resident #89 did not complain of any pain or anything the night before when he worked (on 2/15/26 or 2/16/26). He did not think anything at the time, but after he got the x-ray report he wondered if something had happened. The previous night when he worked on 2/16/26, Resident #64 (Resident #89's roommate) came up to him. He was by the medication cart. Resident #64 is particular about time and getting her medications. He usually gave her medications at 7:30 PM. Resident #64 forgot to take her nutrition drink and came back to get it. At that time, Resident #64 asked him if he had done Resident #89's medications yet. Staff M said he had not. Resident #64 proceeded to tell him an aide came in the room and she kind of lifted Resident #89 into bed. Resident #89 had been crying and seemed in pain. Staff M stated he did not blow Resident #64 off. He went in the room to check on Resident #89. Resident #89 was not crying out. He noticed Resident #89 was a little askew in bed. Her feet were caddy wampus by the baseboard (on the bed) and it looked like she needed to be boosted up in bed. He did not think anything of what Resident #64 said until the next day when Staff J said they were getting an x-ray, and then the x-ray report showed a fracture. Surveyor asked Staff M what he meant by askew. When he saw Resident #89 lying in the bed askew her body was kind of at an angle on the bed, her feet were closer to the baseboard or end of the bed than usual, like she needed a boost up in bed. He thought the CNA's transferred the resident with the mechanical lift weird or something. He went out to the desk and asked the CNA's to go in and boost her up in bed. He did not recall the CNA's names that were working that night but when he asked the CNA's to do something, they were pretty good about doing things. In an interview on 2/26/26 at 8:21 AM, Staff F, CNA, reported she was assigned as Resident #89's CNA one day last week (the week of 2/16/26). She was in Resident #89's room with two other CNA's after the nurse had done wound rounds. The staff discussed that Resident #89 was in a lot of pain when they rolled her and were getting her dressed. Staff F stated she mentioned this observation to Staff G, LPN. Staff G said during wound rounds, Resident #89 was acting like she was in a lot of pain. That AM (on 2/17/26), the roommate told Staff F the night before (Monday) the aide came in to do things with Resident #89, the curtain was pulled, she heard a bunch of hassling and heard Resident #89 scream and stuff but said she did not see what happened. Resident #89 is noncommunicative and not able to tell them if something happened. Staff F reported Staff G came in and asked the roommate questions. The roommate said the aide came in the room without the mechanical lift. She did not see anything but heard something. It was reported to the Administrator. An x-ray of Resident #89's arm showed her arm was broken. Staff F stated when someone was on hospice and had a broken arm, it did not make sense to her. Staff F reported that Staff C was assigned to Resident #89 the night before (on 2/16/26). In an interview 2/26/26 at 12:35 PM Staff C, CNA, confirmed she worked on 2/16/26 on the 3-10 PM shift. She was assigned to Resident #89. Staff K was her hall partner that she worked with. Staff C stated she believed it was Staff K who helped her get Resident #89 up and put Resident #89 to bed that night. When the Surveyor questioned if she was sure it was Staff K. Staff C said 'yes. Staff C reported they use the mechanical lift to transfer Resident #89. Staff C reported she also made rounds on the resident with Staff H, CNA. Resident #89 seemed ok during rounds. In an interview on 2/26/26 at 1:18 PM, the Administrator reported he was at a conference out of town on 2/17/26 when he got a phone call from Staff I, LPN. Staff I told him she was not assigned to Resident #89 but she was working down that hall. Resident #64 told Staff I she had a concern with Resident #89 in the evening the other day and a concern with the aide and how the aide transferred Resident #89. The Administrator asked for the phone numbers of the CNA's that worked that night (2/16/26) and he contacted the CNA's. Staff C and Staff K stated they had worked with Resident #89. He talked to Staff C first and asked her what happened. Staff C said she put Resident #89 to bed around 7:30 - 8 PM. Resident #89 was mechanically lifted into bed. He asked Staff C who helped her. Staff C said Staff K helped her. Staff C told him Resident #89 says ow ow ow. Staff K took the mechanical lift out of room. Staff C then rolled the resident and changed her, then left the room. The Administrator reported he then called Staff K immediately and asked her the same questions. He asked if Staff K had assisted with Resident #89. Staff K said Resident #89 was transferred around 8 PM. Resident #89 said ow, ow, ow. Staff C was there. Staff K said she took the mechanical lift and left the room. Staff C stayed in the room and changed Resident #89. That was the end of Staff K's interaction. The Administrator reported he got a call from Staff I, LPN, at 1 PM that day that Resident #89 was still crying with pain. The Administrator asked Staff I to see if she could get an order for an x-ray from the NP. X-ray came around 2 or 3 PM, and they got the x-ray results around 6 PM. One x-ray report showed age indeterminate, and the other x-ray report showed subacute fracture. Staff M, LPN, followed up with x-ray about the reports. Staff M said the acute subacute was the correct indication. The Administrator reported he discussed the causes with the NP and ruled out abuse. In an interview on 3/2/26 at 2:55 PM, the Administrator reported when he conducted the investigation of Resident #89's incident, he spoke with the evening and overnight shift staff who last worked with the resident and asked if they noticed any changes. He would separate the staff person from the residents whenever he suspected abuse. A document titled New Report (timecard) dated 1/1/26 to 3/3/26 revealed Staff C continued to clocked in/out from the time an allegation of concern/abuse was made until the surveyor investigation and notification to the facility of the alleged abuse. Staff C worked: 2/16/26 2:05 – 10:09 PM2/17/26 2:40 – 10:00 PM2/18/26 2:00 – 10:04 PM2/19/26 2:40 – 10:00 PM2/20/26 2:40- 10:05 PM2/21/26 2:45 – 10:00 PM2/23/26 2:58 – 10:00 PM2/24/26 2:40 – 10:00 PM2/25/26 2:42 – 10:00 PM2/26/26 2:36 – 10:00 PM 2. The Minimum Data Set (MDS) dated [DATE] for Resident #116 revealed diagnoses of diabetes mellitus, stroke, heart failure and required substantial assistance for transfers and moderate assistance for toileting and personal hygiene. Walking 10 or more feet did not occur due to a medical condition or safety concerns and a manual wheelchair was normally used for mobility. The MDS identified Resident #116 had an impairment of upper or lower extremities and use of a walker was not identified for a mobility aid. The MDS did not identify Resident #116 as having negative behaviors such as rejection of care and wandering did not occur. Resident #116 had a Brief Interview for Mental Status (BIMS) score of 3 that suggested severe cognitive problems with thinking and memory without signs of delirium. The Care Plan for Resident #116 identified a brain injury due to a brain bleed and directed staff to offer cues, direction, redirect as needed, explain the task to be completed as she is impulsive with movements and non-compliant with directions. The care plan identified a risk for falls and directed staff to assist Resident #116 to ambulate with a gait belt and a front wheeled walker and transfer using a non-mechanical lift. A document titled incident report revealed on 1/21/2026 at 5:20 pm, Staff B, RN was notified by Staff A, CNA that Resident #116 had lost her balance and fell to the floor while ambulating to the bathroom. Resident #116 was screaming Please help me up!. The Nurse Practitioner was notified and Resident #116 was sent to the hospital. The Progress Notes for Resident #116 revealed:1. On 1/20/26, Resident #116 was examined by Nurse Practitioner (NP) and documented Resident #116 was stable sitting in her wheelchair, alert, oriented, no distress, cooperative, frail, with a weight of 100 pounds. Resident #116 musculoskeletal condition was documented as limited range of motion with muscle weakness.2. On 1/21/26, Staff B, Registered Nurse (RN) documented that Staff A, CNA alerted that Resident #116 had a fall and upon entering Resident #116's room, she was on the floor, near the wall, laying on her right side, screaming Please help me up! Staff A stated she was taking Resident #116 to the bathroom, using her walker, and she lost her balance, falling to her right side. Resident #116 was assisted to her bed by Staff A and Staff B. Resident #116 was continuously screaming, complaining of pain in her right arm and shoulder. The Nurse Practitioner was notified and ordered to send Resident #116 to the hospital. The daughter was aware of the hospital transfer. 3. On 1/26/26 at 10:03 am, the hospital update was that Resident #116 fractured the right shoulder and elbow and due to the multiple comorbidities, a conservative management of a sling instead of surgery. The trauma services were providing pain management with narcotics every four hours, along with ice therapy, . During an interview on 2/26/26 at 1:40 pm, Resident #116's daughter stated her mother was in bed mostly as it was very hard for her to get up. The daughter stated she visited on 1/20/26, she had some memory loss but feeling normal for herself, no pain. The daughter stated she's been trying to figure out what happened and she was not ok with this. Staff B, RN told her that the CNA was following her mom with a wheelchair as she walked to the bathroom. The daughter stated she visited her mother multiple times before the fall and her mother could not walk. During an interview on 2/25/2026 at 10:29 am, Staff B, RN stated she had been employed for two years at this facility and had provided care for Resident #116. Staff B stated Resident #116 tried to get up by herself, required the assistance of one staff, with a walker, and walked to the bathroom a long while ago. Staff B stated currently, the CNA's would change Resident #116 in bed before assisting her into the recliner. Staff B stated Staff A, CNA had provided care for Resident #116 a few times had 2 different stories of the incident on 1/21/26 so she questioned truthfulness. Staff B stated Staff A she was taking [NAME] to the bathroom and while she was getting things ready by opening the bathroom door, Resident #116 fell and the second report was that Staff A was following Resident #116 with the wheelchair. Staff B stated that was what she documented on the incident report. Staff B stated when she entered [NAME]'s room, she was on the floor, laying on her right side without a gait belt a few feet from the bed. Staff B stated it was about 50 ft to the bathroom and the wheelchair was by the bathroom wall, and the walker was on the floor tipped over near Resident #116 who was screaming in pain. Staff B stated Resident #116 was a few feet from the bed so they tried to stand her, but she was not able to bear weight, so they grabbed her pants and slid her on her feet, lifted and put her on the bed. Staff B stated Resident #116 was screaming, complained of shoulder pain it appeared swollen at the shoulder. Staff B stated Staff Z, CNA responded, stayed with Resident #116 as she notified the Nurse Practitioner and called 911. Staff B stated she did not notify the administration about her concerns involving the fall. Staff B stated the DON (Director of Nursing) called her 2-3 days after the incident to ask if they used the mechanical lift to get Resident #116 off the floor, which she replied no, then had a one-on-one talk about using the mechanical lift to get residents off the floor after a fall, if they cannot get up on their own. Staff B stated no one questioned her about the incident except for asking if a mechanical lift was used to put Resident #116 into the bed. During an interview on 2/25/26 at 3:12 pm, Staff Z CNA stated last year Resident #116 could get into a recliner with assistance but did not ambulate to the bathroom as she was incontinent and CNAs changed her in bed. Staff Z stated Staff A CNA told her she could walk Resident #116 to the bathroom. Staff Z stated Resident #116 did not ambulate due to balance issues but was able to pivot transfer with assistance. Staff Z stated on 1/21/26 she responded to someone's screams, checked the rooms, and found Staff B, RN and Staff A, CNA placing Resident #116 in her bed without a gait belt and there was no mechanical in the room, Staff Z stated when Staff B left the room notify the doctor and call 911, Staff A told her Resident #116 fell during assistance to the bathroom. Staff Z stated Resident #116 was crying and did not want to be alone. During an interview on 2/26/26 at 10:29 am, Staff BB, CNA stated she had provided care for Resident #116, who was declining but would sit in her recliner to eat. Staff BB stated she worked on 1/21/26, 6-2pm shift, providing care for Resident #116 and needed two CNA's, with a gait belt, to transfer her to the recliner. Staff BB stated Resident #116 was not stable and was too weak to walk to the bathroom so staff would check and change while she was in bed. A document provided by the Administrator verified to be investigative notes for Resident #116's fall on 1/21/26 which revealed: 1. Staff A, CNA entered the room to respond to the call light. Resident #116 told her she needed the bathroom, Staff A told Resident #116 she needed to get a gait belt. Resident #116 said no I'm going to the bathroom, stood up to her walker and began walking to the bathroom. Staff A grabbed Resident #116's wheelchair, unsure what else to do, bring wheelchair up behind Resident #116 who lost her balance and fell onto her right side.2. Staff B, RN was told Resident #116 fell as she was getting things ready to use the bathroom. Resident #116 had a walker and no gait belt and hasn't gotten up by self in a long time.3. Staff Z, CNA responded to a scream, staff already got Resident #116 up in bed. 4. Resident #116 reported to be impulsive, doesn't always follow directions or wait for staff. 5. Resident #116 noted to be non-compliant and has been caught ambulating on her own. A document titled New Report (timecard) dated 1/1/26 to 3/3/26 revealed Staff A, CNA continued to clocked in/out from the time an allegation of concern/abuse was made until the surveyor investigation and notification to the facility of the alleged abuse. Staff A worked: 1/21/26 1:57pm-10:09pm /22/26 1:59pm-10:05pm 1/23/26 9:02pm-2:24pm1/26/26 5:53pm-9:48pm 1/27/26 1:58pm-10:15pm 1/28/26 1:59pm-10:19pm 1/29/26 1:49pm-10:02pm 1/30/26 2:02pm-10:01pm 1/31/26 2:05pm-9:51pm 2/1/26 2:10pm-10:05pm2/2/26 2pm-10pm 2/3/26 2pm-10pm 2/4/26 2pm-10pm 2/5/26 2pm-10:08pm2/6/26 6am-10pm 2/8/26 6pm-10pm 2/9/26 2:05pm-10pm 2/9/26 2:05pm-10pm 2/10/26 2pm-10:08pm 2/11/26 2:10pm-10pm 2/12/26 1:47pm-10pm 2/13/26 12:23pm-10:01pm 2/14/26 2:06pm-10:01pm 2/15/26 2:04pm-10:03pm 2/18/26 2:08pm-10:01pm 2/19/26 1:51pm-10:11pm 2/20/26 6:19pm-10:10pm 2/23/26 2:00pm-10:01pm 2/24/26 2:13pm-10:00pm 2/28/26 1:58pm-10:46pm 3/1/26 2:04pm-10:09pm 3/2/26 12:41pm-missed punch The facility policy titled Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation policy revised 9/2025 revealed the facility provided care and services in an environment that is free from abuse and neglect. The facility shall immediately implement measures to prevent further potential abuse of residents while the investigation is in progress. When an allegation of abuse by an employee, the accused employee will be separated from all residents.

Based on clinical record review, observation, resident and staff interviews and policy review the facility failed to report an injury of unknown origin, and an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) within the required timeframe (within 2 hours) for one of three residents reviewed for possible abuse (Resident #89). The facility reported a census of 101 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 had diagnoses of arthritis and a right hand contracture. The MDS documented the resident had a Brief Interview for Mental Status score of 2 indicating severely impaired cognition. The MDS revealed the resident had impaired range of motion (ROM) to the upper and lower extremities. The MDS also revealed the resident had dependence on staff for bed mobility and transfers. The MDS documented the resident had no skin issues. The Care Plan initiated 4/26/24 revealed the resident had arthritis and limited mobility and required assistance with ADL's (activities of daily living). The Care Plan directed staff to use a Hoyer (mechanical lift) and assistance of two for transfers. A sling to the right upper extremity as needed for comfort was added to the care plan on 2/23/26. A Nurse Practitioner (NP) Encounter Note dated 2/17/26 revealed Resident #89 had a history of osteoporosis, tremors and impaired mobility. Resident seen for increased right shoulder pain and limited ROM in the right arm and shoulder area with movements. X-ray of the right arm ordered to rule out any underlying fractures or injuries.An X-ray Report of the right humerus on 2/17/26 revealed an acute or subacute subcapital fracture of the right humeral neck and diffuse osteoporosis. An x-ray of the right shoulder on 2/17/26 revealed age-indeterminate subcapital fracture of the right humeral neck and diffuse osteoporosis. The Order Summary revealed an order on 2/18/26 to send the resident to the Emergency Department (ED) for evaluation of a humeral neck fracture. An ED Provider Note dated 2/17/26 at 8:53 PM revealed the resident had a right humerus fracture of unknown cause. Resident is bed bound and uses a mechanical lift to transfer. Staff at the facility not aware of any injury to the resident and no witnessed falls. Resident had pain in her right shoulder. Resident cannot recall the incident. Resident on hospice. Nursing home does not want any additional workup performed but is just requesting a sling and to discharge her back to the facility. She was diagnosed with a closed nondisplaced fracture of the right proximal humerus. Resident discharged from the ED on 2/17/26 at 11:38 PM (with EMS).Medication Administration Record (MAR) dated 2/1/26 to 2/28/26 documented an order for Morphine Sulfate 5 milligrams (mgs) every 4 hours as needed for pain. The MAR did not document use of this medication until 2/17/26 at 7:06AM. Additional 5mg doses were given as follows; 2/17/26 at 8:00PM, on 2/18/26 at 5:55AM and 10:07AM, on 2/19/26 at 4:26AM and 6:17PM, on 2/20/26 at 2:23AM and 10:32AM, and 3:34PM, on 2/21/26 at 8:51AM, and at 3:23PM, on 2/22/26 at 4:23AM, at 9:30AM, at 3:19PM, and at 8:59PM, and on 2/23/26 at 12:20PMThe Progress Notes revealed the following: a. On 2/17/26 at 1:22 PM, resident with increased pain to her right arm and shoulder with movement and palpation. Resident unable to state cause. Morphine given twice this shift. New order to obtain portable 2-view x-ray to right shoulder, humerus, and forearm due to pain and decreased ROM. b. On 2/17/26 at 6:15 PM, x-ray results received. Findings show an age-indeterminate acute or subacute subcapital of the right humeral neck, and diffuse osteoporosis. Information provided to administrator. Resident calls out ow with any movement of unaffected arm.c. On 2/17/26 at 7:00 PM, on-call provider notified of x-ray results. Provider is concerned about possible severity of fracture especially with level of resident's debility and contractures and need for mechanical lift. Provider stated to send resident to the ED for further evaluation and an immobilization device. Provider informed resident on hospice.d. On 2/17/26 at 8:30 PM, ambulance called to transport resident. Resident's pain at 9 out of 10. ED nurse contacted and expressed ambivalence and asked why resident had a fracture without recent fall. e. On 2/18/26 at 12:12 AM, resident returned to the facility with a sling on the affected arm/shoulder. Observations revealed on 2/25/26 at 9:30 AM, a sling to Resident #89's right arm. The right upper arm (above the elbow) had a faded yellow bruise with a faded dark purple bruise to the inner area. In an interview on 2/24/26 at 8:00 AM, Resident #64 reported she had a concern with how the aide handled her roommate one day last week. The certified nursing assistant (CNA) did not use the mechanical lift or any kind of device to get Resident #89 into bed. Resident #64 stated she heard the door to the room open and she heard someone wheel Resident #89 into the room. She then heard a sound like the resident was thrown into bed. Resident #89 cried out. The only time she had ever heard Resident #89 cry is when she was in pain. Resident #64 said she normally heard the staff bring her roommate in, then staff brought the mechanical lift into the room, and staff got Resident #89 into bed, but that evening she did not hear the lift being brought in. She did not know the CNA's name but she was African-American, short and had a stocky build. The CNA did not have a name tag on. Resident #64 reported she talked to Staff I, LPN, and let her know. She did not know the day this incident happened but it was around 8 PM when the CNA put Resident #89 in bed. The MDS assessment dated [DATE] revealed Resident #64 had a Brief Interview for Mental Status score of 15, which indicated cognition intact. In an interview on 2/25/26 at 9:40 AM, Staff G, Licensed Practical Nurse (LPN), reported she was working the floor doing wound rounds and going to meetings in-between nursing tasks/duties on 2/17/26. Later in the afternoon, she found out Resident #89 had a fracture. Staff I had informed her about Resident #89. Staff G notified the Administrator about it. In an interview 2/25/26 at 3:10 PM, Staff I, LPN, reported she was passing medications on Tuesday (2/17/26) when Resident #64 came out around 8 or 9 AM and said she was worried. Resident #64 said she thought people were not doing things safely. Then Resident #64 asked if she could tell Staff I something. Resident #64 said she was really worried and proceeded to tell her that last night (2/16) she heard the door to her room open and she heard the CNA wheel Resident #89 through the door, but she did not hear her bring the mechanical lift in like staff usually did. She then heard Resident #89 cry and heard a thud on the bed. The CNA left the room. Resident #89's (Broda) chair was by the bed. Resident #89 was oddly positioned on the bed, she was way down toward the end of the bed and had her legs over on the bed. Resident #64 thought Resident #89 was going to fall off the bed. Staff I asked Resident #64 the name of the CNA, and Resident #64 said she did not know. Staff I stated she told the Administrator about the accusation. The Administrator had her write a statement. She wrote a statement and it should have the date on it. The CNA told her the resident was complaining of shoulder pain that day when they got her out of bed. Staff I stated she thought it was her left shoulder that had pain. Staff I spoke with Staff J who was assigned to Resident #89. Staff J, LPN had no idea about an incident. In an interview 2/25/26 at 4:34 PM, Staff M, LPN, confirmed he worked on 2/17/26 from 6 PM to 6 AM. When he got report at shift change, Staff J, LPN, shared concerns about Resident #89's shoulder/arm. Staff J said the vendor came and got an x-ray on Resident #89. After report, he received a fax with the x-ray results showing Resident #89 had a right humeral neck fracture. He was told by multiple nurses and multiple CNA's they heard from Resident #89's roommate it may be due to an improper transfer. He spoke with the Administrator and the provider. The provider was very concerned about the x-ray report, and thought it would be best to send Resident #89 to the ED for an evaluation and to get an immobilizer. He spoke with hospice and the family. He did not share any details with the family other than that there was a concern about a fracture. Staff M reported Resident #89 was completely immobile and had contractures. She required assistance of two staff and a mechanical lift for transfers. Staff M stated Resident #89 did not complain of any pain or anything the night before when he worked (on 2/15/26 or 2/16/26). Staff M stated it's hard to place a wrist cuff on Resident #89's arm to get a blood pressure due to her contractures. Resident #89 was in a Broda chair or in bed when he saw her and she was not crying out or tearful, however she complained of pain when she was transferred. He did not hear staff in the resident's room or when she was transferred. He didn't think anything at the time but after he got the x-ray report he wondered if something had happened. The previous night when he worked on 2/16/26, Resident #64 (Resident #89's roommate) came up to him. He was by the medication cart. Resident #64 is particular about time and getting her medications. He usually gave her medications at 7:30 PM. Resident #64 forgot to take her nutrition drink and came back to get it. At that time, Resident #64 asked him if he had done Resident #89's medications yet. Staff M said he had not. Resident #64 proceeded to tell him an aide came in the room, and she kind of lifted Resident #89 into bed. Resident #89 had been crying and seemed in pain. Staff M stated he did not blow Resident #64 off. He went in the room to check on Resident #89. Resident #89 was not crying out. He noticed Resident #89 was a little askew in bed. Her feet were caddy wampus by the baseboard (on the bed) and it looked like she needed to be boosted up in bed. He did not think anything of what Resident #64 said until the next day when Staff J said they were getting an x-ray, and then the x-ray report showed a fracture. Surveyor asked Staff M what he meant by askew. When he saw Resident #89 lying in the bed askew her body was kind of at an angle on the bed, her feet were closer to the baseboard or end of the bed than usual, like she needed a boost up in bed. He thought the CNA's transferred the resident with the mechanical lift weird or something. He went out to the desk and asked the CNA's to go in and boost her up in bed. He did not recall the CNA's names that were working that night but when he asked the CNA's to do something, they were pretty good about doing things. In an interview on 2/26/26 at 8:21 AM, Staff F, CNA, reported she was assigned as Resident #89's CNA one day last week (the week of 2/16/26). She was in Resident #89's room with two other CNA's after the nurse had done wound rounds. The staff discussed that Resident #89 was in a lot of pain when they rolled her and were getting her dressed. Staff F stated she mentioned this observation to Staff G. Staff G said during wound rounds, Resident #89 was acting like she was in a lot of pain. That AM (on 2/17/26), the roommate told Staff F the night before (Monday) the aide came in to do things with Resident #89, the curtain was pulled, she heard a bunch of hassling and heard Resident #89 scream and stuff but said she did not see what happened. Resident #89 is noncommunicative and not able to tell them if something happened. Staff G came in and asked the roommate questions. The roommate said the aide came in the room without the mechanical lift. She did not see anything but heard something. It was reported to the Administrator. An x-ray of Resident #89's arm showed her arm was broken. In an interview on 2/26/26 at 1:18 PM, the Administrator reported he was at a conference out of town on 2/17/26 when he got a phone call from Staff I, LPN. Staff I told him she was not assigned to Resident #89 but she was working down that hall. Resident #64 told Staff I she had a concern with Resident #89 in the evening the other day and a concern with the aide and how the aide transferred Resident #89. He then contacted the Social Worker and HR and asked them to get a statement from Resident #64 on what took place. The Administrator also asked for the phone numbers of the CNA's that worked that night (2/16/26). He contacted the CNA's. Staff C and Staff K stated they had worked with Resident #89. He talked to Staff C first and asked her what happened. Staff C said she put Resident #89 to bed around 7:30 - 8 PM. Resident #89 was mechanically lifted into bed. He asked Staff C who helped her. Staff C said Staff K helped her. Staff C reported nothing odd took place. Staff C told him Resident #89 says ow ow ow. Staff C then rolled the resident and changed her, then left the room. The Administrator reported he then called Staff K. Staff K said Resident #89 was transferred around 8 PM. Resident #89 said ow, ow, ow. Staff C was there. Staff K said she took the mechanical lift and left the room. Staff C stayed in the room and changed Resident #89. That was the end of Staff K's interaction. The Administrator reported he got a call from Staff I at 1 PM that Resident #89 was still crying with pain. The Administrator asked Staff I to see if she could get an order for an x-ray from the NP. X-ray came around 2 or 3 PM, and they got the x-ray results around 6 PM. The facility got one x-ray report that showed age indeterminate, and the other x-ray report showed subacute fracture. Resident #89 had diffuse osteoporosis. She is on hospice, has brittle bones, has contractures and tremors. The Administrator stated he focused on the facts of what took place and he felt he could rule out abuse. The Administrator confirmed he did not report Resident #89's fracture or injury of unknown origin to DIAL because it was a spontaneous fracture and spontaneous fractures are not reportable to the State. In an interview on 3/2/26 at 2:55 PM, the Administrator reported he would report to DIAL if he suspected abuse. A Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation policy revised 9/2025 revealed the facility provided care and services in an environment that is free from abuse and neglect. An injury of unknown source is when the source of the injury was not observed by any other person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury. The Administrator is responsible for reporting any alleged or suspected abuse regardless of the source of the concern. The staff are required to notify the charge nurse and Abuse Prevention Coordinator immediately for any suspicion of abuse, neglect and injuries of unknown origin. Injuries of unknown origin and allegations of abuse need to be reported to the Iowa Department of Inspections, Appeals and Licensing Reports immediately and not later than two (2) hours after the allegation is made if there is bodily injury.

Based on resident record review, staff interview, and Resident Assessment Instrument (RAI) manual review, the facility failed to submit a significant change in status for 1 of 2 residents reviewed for a significant change of condition. The facility reported a census of 102 residents.The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the diagnoses of weakness, unsteadiness on feet, required the assistance of one staff for supervision with ambulation and maximal assistance for hygiene and toileting. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 suggesting an intact cognition. The Quarterly MDS dated [DATE] for Resident #2 was totally dependent on staff for transfers and toileting with no ambulation. The Progress note dated 9/18/25, the Nurse Practitioner (NP) documented a visit for Resident #2 following the fall on 9/11/15. Resident #2 described the incident as slide/fall incident, x-rays revealed an acute fracture of her ankle and had to be transported to the hospital where she received fentanyl for pain management and additional x-rays. The NP documented the hospital stabilized the fracture with a soft cast and potentially transition to a boot and Resident #2 reported ongoing pain from the fracture. During an interview on 3/3/26 at 3pm, Staff EE, MDS Coordinator stated she completed the resident's assessment for the MDS submissions. Staff EE stated Resident #2 did qualify and there should have been a significant change MDS submitted due to her change of condition after her fall in September 2025. Resident Assessment Instrument (RAI) 3.0 User's Manual requires the facility to submit a significant change within 14 days of a major decline in a resident's health status.

Based on electronic health record review (EHR), observations, resident interview and staff interview, the facility failed to offer and apply a hand splint for 1 of 2 residents reviewed for positioning (Resident #7). The facility reported a census of 101. Findings include: 1.The Quarterly Minimum Data Set (MDS) Assessment, completed 1/30/26, revealed Resident #7 with a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Diagnoses included the following; hemiplegia (paralysis of one side of the body) and stroke. The MDS noted the need for splint assistance under the restorative nursing programs section. The Care Plan, with a Target Date of 5/25/26, listed the use of a right-hand splint as an intervention for Activities of Daily Living. The intervention directed staff as follows; right resting hand splint; assist with application every am until bedtime as tolerated.The Physician Order, initiated 8/3/23, direct staff to assist Resident #7 with putting on a right resting hand splint in the morning and taking off at night. The Treatment Administration Record (TAR) documented staff applied right hand splint every morning and removed it every night from 2/1/26 to 2/26/26. There was no documentation on the TAR that the resident refused for the splint to be placed. During an observation on 2/23/26 at 12:30 PM, Resident #7 was not wearing a right hand splint. The resident acknowledged not wearing one. During an observation on 2/25/26 at 10:25 AM and then again at 4:30 PM, Resident #7 was not wearing a right hand splint. A blue splint, with the resident's name, was seen sitting on top of a bedside dresser during the morning observation. During the afternoon observation, the splint was seen in the same location untouched. During an observation on 2/26/26 at 9:45 AM, Resident #7 did not wear a hand splint. The blue splint remained in the same position on top of the bedside dresser untouched. In an interview on 2/25/26 at 4:30 PM, Resident #7 noted staff did not offer or put the splint on in the morning. Resident #7 did not feel they could put on or take off the splint independently since they are unable to move the right arm. Resident #7 then lifted up their right hand, with their left arm, to indicate which hand the splint goes to. In an interview on 2/26/26 at 4:45 PM, the Assistant Director of Nursing (ADON), acknowledged Resident #8 had orders for a splint. Nursing staff should offer to put it on daily and document accordingly.

Based on observations, clinical record review, resident and staff interviews the facility failed to have an action plan in place to ensure new agency staff receive a timely orientation and were able to demonstrate competency in skills and equipment use before the expectation to work independently. The facility reported a census of 101 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the diagnoses of weakness, unsteadiness on feet, required the assistance of one staff for supervision with ambulation and maximal assistance for hygiene and toileting. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 suggesting an intact cognition. The Care Plan for Resident #2 dated 7/24/25. The Care Plan identified a risk for falls and directed staff to assist with ambulation and transfers with moderate assistance of one staff with a gait belt and front wheeled walker and as needed. The Progress note dated 9/18/25, the Nurse Practitioner (NP) documented a visit for Resident #2 following the fall on 9/11/15. Resident #2 described the incident as a slide as she attempted to stand up with the assistance of a care giver who did not use a gait belt and despite informing the care giver she was slipping; she was reassured multiple of times that she will not fall. The NP documented Resident #2 slid down and became stuck between the toilet and the wheelchair and had to be assisted by multiple of caregivers to get back to bed. Following the incident, x-rays revealed an acute fracture of her ankle and had to be transported to the hospital where she received fentanyl for pain management and additional x-rays. The NP documented the hospital stabilized the fracture with a soft cast and potentially transition to a boot and Resident #2 reported ongoing pain from the fracture. During an interview on 3/3/26 at 11:42 am, Resident #2 stated on 9/11/25 she had walked with her walker into the bathroom and when finished she activated the call light. Resident #2 stated she required the assistance of staff to provide peri care and had waited for a while until the Certified Nursing Assistant (CNA) arrived. Resident #2 stated usually when she was assisted by facility staff and she would say she's slipping, the staff would sit her back down on the toilet. Resident #2 stated she began to slip and said that to the CNA who replied with I've got you. Resident #2 stated she went down to the floor because her legs were weak from sitting so long waiting for assistance. Resident #2 stated the CNA that was assisting her was an agency staff who said she should not even be here providing care for her as she had not been trained. When inquired if she fainted, Resident #2 laughed and replied, I've never fainted in my life. Resident #2 stated the CNA had her by the arm and not a gait belt. Resident #2 stated another CNA came into the room, who also was new agency CNA, and helped to get into the wheelchair. Resident #2 stated it was hard, they had her by the arms and her right leg hurt so she was unable to stand. Resident #2 stated then the nurse came in to help. During an interview on 3/3/26 at 3:15 pm, Staff CC, CNA verified her work at this facility was through an agency. Staff CC stated on her first day, she was asked to come in ahead of her start time to receive a code for the Point Click Care (PCC) computer system to chart, then failed to show her how to use it. Staff CC stated she was unaware of how to look up resident information since they did not give her details and they were aware it was her first time in the facility. Staff CC stated the staff was not helpful. Staff CC verified she had worked on 9/11/25, working with another new agency CNA and termed the day as hectic as staff were sick, went home and the two were on their own with 2 halls of residents. Staff CC stated the call lights were going off and the nurse yelled at her for using the radio to call for assistance. Staff CC stated she answered a bathroom call light and she did not know the resident. Staff CC stated when the leaving staff conduct the walking round at the beginning of the shift, they didn't give details. Staff CC stated during the peri care, the resident was starting to fall. Staff CC stated she called for the other CNA who came in immediately and they tried to get the resident into her wheelchair, describing it as very hard. Staff CC stated a 2nd nurse came into the room to helped them. Staff CC stated when she left at 2pm, no one asked her what happened, no one called her and she did not go back to this center. During an interview on 3/3/26 at 10:41 am, Staff DD, Agency CNA verified she worked through an agency and that 9/11/25 was her first day to work at this facility. Staff DD stated it was complete chaos as the staff did not tell her anything, no direction and it was the first time working with the mechanical lifts that this facility utilized stating she had no idea how to run it. Staff DD stated she was assigned to work on a hall with a staff member who went home and she was unaware that she was working alone. Staff DD stated another agency CNA (Staff CC) was down the next hall and from 10am to 2pm they were on their own. Staff DD stated they assisted each other with the residents that required two assist and was in a room when Staff CC stated she needed to go across the hall as that call light had been activated for a while. Staff DD stated her resident was on the toilet and could not be left alone but Staff CC was absent for a really long time so she secured her resident and found Staff CC with her resident on the floor in front side of the toilet. Staff DD stated Staff CC asked what do I do? and it's routine if someone falls to call the nurse, used the radio for a nurse and helped to get the resident up. Staff DD stated she did not remember what happened next. Staff DD stated there were many residents, multiple two assist and both Staff CC and herself had no idea what was going on. Staff DD stated she had been trained as a CNA, worked for 8 years, and referred to that as the craziest day of her life and she would never go back as it was unsafe. Staff DD stated no one called her and she did not return to work for them. According to 9/11/25 clock-in and clock-out documentation the following occurred; with these times one CNA according to previous interviews was providing assistance to two halls from 10:19AM to 10:58AMStaff CC, CNA worked from 6:02AM to 2:37PM (breaktime 10:19AM - 10:49AM)Staff DD, CNA worked from 6:30AM to 2:27PM (breaktime 10:25AM - 10:58AM)Staff LL, CNA worked from 11:16AM to 5:12PM (breaktime 2:44PM - 3:14PM)During an interview on 3/3/26 at 2:09 pm, Staff I, Licensed Practical Nurse (LPN) stated she was not sure how the facility on-boards agency staff, she had seen a packet but have not reviewed the content, and the staff that are leaving for the day completed a walking round. Staff I stated the agency staff can look in the computer for the Kardex but they have to navigate to the care plan. Staff I stated most of the agency staff ask to look at the therapy communication binder. Staff I stated she had good communication with the staff CNA's but there have been multiple agency CNA's and she didn't know their base line knowledge. Staff I stated she remembered a little about Resident #2's fall, it happened in the bathroom and there was an issue with the agency CNA's getting her off the floor. During an interview on 3/3/26 at 3pm, Staff EE, MDS Coordinator stated she completes the resident assessment for the MDS submission and helps on the unit at times. Staff EE stated she was unaware of any training for the agency staffing and hopes the nurse would make sure they can get into the Point Click Care (PCC) and the electronic medication administration (EMAR) record. During an interview on 3/4/26 at 1:48 pm, Staff G LPN ADON stated she was unaware of any training for the agency staff as human resources (HR) and scheduler placed them onto her unit and was not aware of who it will be until she arrives for the day. Staff G stated she was unable to remember who the agency staff were that had worked on 9/11/25, day shift, but when she was made aware that they were low on staffing, she notified Staff FF, Staff Scheduler and did not receive further assistance. Staff G stated the nurse on duty had responded to some activated call lights but personally no one approached her to assist. Staff G stated administration schedules staffing according to census. Staff G stated she was not aware there were new agency staff or that they were not oriented to PCC, it was a busy day. During an interview on 3/4/26 at 2:15 pm, Staff FF, Staff Scheduler stated the facility utilized two staff agencies, the CNAs were independent then make a post on the clipboard account so they may pick up the shifts. Staff FF stated the moment she was aware of the individual's acceptance for a shift then requests their documentation. Staff FF stated there was a packet at the nurse station they will utilize for orientation that was created in June 2025. The agency staff will sign the four pages in the binder when they come in for their first day and leave it in the binder. Staff FF stated she would assume the staff CNA would orient and train them as it was the responsibility of the ADON's and DON to have that done. Staff FF stated Staff CC, agency CNA accepted work starting 8/24/25 and Staff DD, agency CNA picked up her first shift on 9/11/25. Staff FF verified both agency CNAs worked on 9/11/25 and a staff CNA had left at 9:30 am. Staff FF stated a staff CNA was to come upstairs to work 11 am to 6 pm but was unsure if that occurred. The Facility Assessment with effective date 8/2/2024 documented that the facility did utilize contracted staffing for the nursing department. The facility assessment did not address specific orientation for agency staff, but did include the following for nursing assistant orientation; Clinical orientation for nursing assistants is conducted after General Orientation. Clinical orientation is coordinated by the Director of Nursing/designee and facilitated through use of a preceptor model. Topics include but are not limited to dignity, choices, privacy, abuse, customer service, role/responsibilities of interdisciplinary team members, shift routines, quality assurance and performance improvement, clinical practice guides, documentation , change in condition, emergency management, activities of dialing living, transfers, weight/vital signs, meal service and infection control.During an interview on 3/4/26 at 1:43 pm, the Director of Nursing (DON) stated she was new to her position and at this time she could not express her expectations for the nurses. The DON was not aware of any training or orientation process for onboarding agency staff.

Based on observation, clinical record review, staff interview, and facility policy review, the facility failed to assure a medication error rate of less than 5%. Medication administration was observed for a total of five residents, with three errors being observed for 2 of 5 residents (Resident #6 and #106). A total of 42 ordered medications were reviewed with three errors, an error rate of 7.14%. The facility reported a census of 102 residents. Findings include:1. On 2/25/26 at 10:59 AM, the observation of the medication pass began. Staff U, Registered Nurse (RN) prepared a total of 6 medications for Resident #6. Among the medications observed, Staff U prepared Esomeprazole (also known as Nexium, proton pump inhibitor (PPI), stomach acid reducer). Staff U administered the medications to the resident at 11:17 am. The Medication Administration Record (MAR) for February 2026 for Resident #6 failed to indicate an order for Esomeprazole and included an order for Zegerid (combination of Omeprozole (PPI) and antacid). 2. On 2/25/26 Wednesday) at 8:20 AM, the observation of the medication pass began. Staff U, RN prepared a total of 7 medications for Resident #106. Among the medications observed, Staff U prepared 65 units of Tresiba (long acting insulin) and Tums chewable tablets. While administering medications to Resident #106, Staff U, RN stated she needed to review Resident #106's Lyumjev (short acting insulin) due to blood glucose reading of 98. The MAR for February 2026 for Resident #106 indicated the following orders:a. Lyumjev Insulin, inject 5 units subcutaneously one time in the morning every Mon, Wed, Fri for Diabetes Mellitus.b. Calcium Carbonate (Tums) chewable 500 MG tablet, give 2 tablets by mouth at bedtime for low Calcium.On 2/25/26 at 1:15 PM Review of Resident #106's nursing progress notes failed to indicate follow up documentation related to resident's AM blood glucose level and if Lyumjev insulin had been administered or held. On 2/26/26 at 9:25 AM, a review of the medication administration observation was provided with Staff S, RN, Director of Clinical Education, who stated these errors would be reviewed and follow up would be provided. 2/26/26 at 11:15 AM, Staff S, RN, Director of Clinical Education confirmed Lyumjev insulin had not been administered to Resident #106 as ordered and acknowledged the Tums that had been administered in the morning should have been administered at bedtime per Physician's order. Staff S, stated she would expect the Physician to be notified of concerns related to blood glucose levels for recommendations and to notify of any missed medication doses.In an email dated 2/26/26 at 2:45 PM, Facility administrator communicated he was not able to find a facility policy related to medication administration and stated we follow standard of care.

Based on observation, record review, staff interviews, and policy review, the facility failed to administer insulin and provide Velphoro (a phosphate binder that controls high serum phosphorus in patients with chronic kidney disease) per Physician's order for 1 of 5 residents (Resident #106) reviewed for medications, resulting in a significant medication error. The facility reported a census of 101 residents.Findings include:Review of Resident #106's Quarterly Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Resident #106's diagnoses include end stage kidney disease, diabetes mellitus, coronary artery disease, heart failure and receiving dialysis. Review of Resident #106's Care Plan, provided a focus, initiated 1/1/24, of Resident's end stage kidney disease requiring dialysis on Mondays, Wednesdays and Fridays. A focus initiated 5/11/23, Resident's diagnosis of Diabetes Mellitus with interventions to provide diabetes medications as ordered by Physician.On 2/25/26 Wednesday) at 8:20 AM, the observation of the medication pass began. Staff U, RN prepared a total of 7 medications for Resident #106. While administering medications to Resident #106, Staff U, RN stated she needed to review Resident #106's Lyumjev (short acting insulin) due to blood glucose reading of 98.Review of Medication Administration Record (MAR) for February 2026 revealed orders for Resident #106 to receive Velphoro 500mg tablets, 2 tablets by mouth with meals and to send noon dose with Resident #106 dialysis days and Lymjev insulin, 5 units subcutaneously every morning on Mondays, Wednesdays, and Fridays. On Wednesday 2/25/26, MAR indicated Resident #106 had not received a noon dose of Velphoro due to being out of the facility. On 2/25/26 at 1:15 PM Review of Resident #106's nursing progress notes failed to indicate follow up documentation related to resident's AM blood glucose level and if Lyumjev insulin had been administered or held. Review of Velphoro Pharmaceutical Prescribing Information revealed Velphoro is a phosphate binder indicated for the control of serum phosphate levels (phosphate blood levels). The recommended starting dose for adults is one 500mg tablet three times daily with meals and to adjust dose by one 500mg tablet per day as needed until an acceptable serum phosphorus level is reached, with regular monitoring afterwards (lab work). On 2/26/26 at 11:15 AM, Staff S, RN, Director of Clinical Education confirmed Lyumjev insulin had not been administered to Resident #106 as ordered and the Velphoro noon dose had not been sent with Resident #106 to dialysis as ordered. Staff S, stated she would expect the Physician to be notified of concerns related to blood glucose levels for recommendations and to notify of any missed doses.In an email dated 2/26/26 at 2:45 PM, Facility administrator communicated he was not able to find a facility policy related to medication errors and Physician notification and stated we follow standard of care.

Based on electronic health record review (EHR), observations, and staff interview, the facility offered inappropriate candy to residents on altered textured diets for 2 of 2 residents observed (Resident #14 & #58). The facility reported a census of 101. Findings include: During an observation on 2/25/26 at 4:20 PM, Staff P, maintenance, asked Resident #14 if they wanted another Snickers. The resident indicated yes and Staff P gave them a fun-sized Snickers candy bar. Staff P then offered the same to Resident #58 who accepted. Review of Physician Orders noted Resident #14 and Resident #58 are both on a mechanical soft diets. This diet consists of moist, tender, ground, or finely chopped foods that need minimal chewing for residents with swallowing or chewing difficulties. The Minimum Data Set (MDS) Assessment, completed on 12/22/25, revealed Resident #14 with a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Diagnoses include dysphagia (difficulty swallowing), dementia, and stroke. The MDS Assessment, completed on 2/6/26, revealed Resident #58 with a BIMS score of 4 indicating severe cognitive impairment. Diagnoses include dementia and dysphagia. In an interview on 2/26/26 at 8:45 AM, Staff P acknowledged providing the Snickers candy bars to Resident #14 and Resident #58. They were not aware the residents were on specialized diets. Staff P noted they had seen other staff members give these residents candy before, including Snickers. In an interview on 2/26/26 at 1:00 PM, the Dietary Manager explained a list of acceptable snack items for residents on specialized diets, like a mechanical soft or puree, are kept on each nursing station for staff reference. In an email response dated 3/3/26 at 10:00 AM, the Registered Dietitian (RD) stated Snickers candy bars would not be allowed on a mechanical soft diet. These would be too sticky and the nuts would be difficult to chew. The Simplified Diet Manual, Thirteenth edition, noted foods allowed on a Level 5 Minced and Moist diet, which resembles a mechanical soft diet, should require minimal chewing (with no biting) and can be easily mashed with little pressure from a fork. [NAME] which has nuts and/or is chewy and sticky should be avoided.

Based on observations, staff interview, and policy review, the facility failed to apply appropriate food handling practices when assisting residents to eat for 2 of 4 residents during breakfast. The facilty reported a census of 101. Findings include:During a continuous breakfast observation on 2/26/26 at 8:10 am, the following occured: a. Staff Q, Certified Nursing Assistant, reached over the table to assist a resident pick-up food from the plate. A fork & the Staff's bare hand were used to place toast in the resident's hand; b. Staff Q folded over a piece of toast and gave it to another resident using their bare hands. In both cases no hand hygiene was performed prior to handing the toast to residents. A box of gloves was visualized in the Dining Room next to the table where Staff Q was assisting residents. In an interview on 2/26/26 at 5:30 PM, the Corporate Regional Nurse acknowledged staff should not be handling resident food with their bare hands. The policy Food Handling, revised 10/2023, outlined the following: 1.Employees perform hand hygiene prior to handling food and maintain safe food handling practices; 2.Ready-to-eat food must not be touched with bare hands; 3.Disposable gloves, tongs, or other dispensing devices must be used properly in accordance with safe food handling practices

Based on review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), staff interview, and review of the facility Quality Assurance Performance Improvement (QAPI) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. This resulted in the facility receiving an Infection Prevention & Control deficiency for the fifth consecutive recertification survey. The facility reported a census of 95 residents. Findings Include: The CASPER Report for the facility identified the facility had received a deficiency for Infection Prevention & Control in August of 2019, December of 2021, March of 2023 and December of 2023 recertification surveys. At the conclusion of the recertification survey on 2/20/25, the facility was found to again be in non compliance for Infection Prevention & Control. The Facility's QAPI Plan, dated 6/23/24, identified a monitoring process which included multiple sources of data. The QAPI Plan failed to identify a process to address previously identified quality deficiencies. On 2/20/25 at 1:53 pm, the Administrator stated the facility had provided a lot of staff education regarding enhanced barrier precautions, performing staff audits on peri care, and providing one on one education on an as needed basis to staff members on infection control issues.

Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual and facility policy review, the facility failed to fully develop, personalize and implement Comprehensive Person Centered Care Plans for 5 residents (Res #22, #86, #7, #25, #87) The facility reported a census of 95. Findings include: 1. The Quarterly Minimum Data Set (MDS) Assessment of Resident #22, dated 1/7/25, documented diagnoses that included traumatic brain injury, anxiety disorder and depression. The MDS documented the resident received antipsychotic and antidepressant medications during the 7 day look back period of the MDS Assessment. The Comprehensive Care Plan of Resident #22, review date 1/2/25, recorded the use of multiple psychotropic medications for depression, anxiety and dementia. The interventions included attempting non-pharmacological interventions prior to the use of psychotropic medications. The Care Plan failed to specify any personalization of what non-pharmacological interventions should be used for the resident. The Care Plan listed as an intervention to monitor behaviors per facility protocol. However, it failed to detail what target behaviors of anxiety or depression the resident was being treated for or to monitor for. The Care Plan additionally failed to document the potential side effects of each medication and the need to monitor for the side effects. 2. The Quarterly MDS Assessment of Resident #86, dated 11/6/24, documented diagnoses that included non-Alzheimer's dementia, depression, psychotic disorder and post traumatic stress disorder (PTSD). The MDS documented the resident received antipsychotic and antidepressant medications during the 7 day look back period of the MDS Assessment. The Comprehensive Care Plan of Resident #86, review date 1/15/25, recorded the use of multiple psychotropic medications for PTSD, depression, agitation, psychosis and insomnia. The interventions included to attempt non-pharmacological interventions prior to the use of psychotropic medications. The Care Plan failed to specify any personalization of what non-pharmacological interventions should be used for the resident. The Care Plan directed to monitor for any changes in cognition, mood and behavior. The Care Plan failed to detail what target behaviors the resident was being treated for or to monitor for. The 2024 RAI, Pages N-5 and N-6, High-Risk Drug Classes: Use and Indication, documented the following: As part of all medication management, it is important for the interdisciplinary team to consider non-pharmacological approaches. Educating the nursing home staff and providers about non-pharmacological approaches in addition to and/or in conjunction with the use of medication may minimize the need for medications or reduce the dose and duration of those medications. Target symptoms and goals for use of these medications should be established for each resident. Progress toward meeting the goals should be evaluated routinely. Possible adverse effects of these medications should be well understood by nursing staff. Educate nursing home staff to be observant for these adverse effects. Implement systematic monitoring of each resident taking any of these medications to identify adverse consequences early. On 2/19/25 at 3:54 pm, the MDS Coordinator stated the admitting nurse completes the admission assessment and includes baseline information for the Care Plan. She stated on the next business day, she will complete a record review and reconcile the Care Plan. She said further revisions to the Care Plans are done via record reviews. She elaborated that if either at an interdisciplinary team meeting or meetings with the contracted behavioral health therapy services, target behaviors are identified, she will then care plan those behaviors. She said if the target behaviors are not identified by the therapy services, then nothing is needed to be updated on the Care Plans. On 2/19/25 4:18 pm, the Director of Nursing (DON) stated her expectation is for the Care Plans to include the need to monitor resident specific behaviors and the side effects pertinent to the medications they are prescribed. She stated one resident might be on a medication due to self isolating, while another is on the same medication due to episodes of crying. She said the Care Plans should be differentiated for each resident. 47079 3. On 2/17/25 at 12:07 PM, Resident #7 stated he took medication for depression. The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), Non-Alzheimer's Dementia, Bipolar Disorder, depression, anxiety disorder, insomnia, and Post-Traumatic Stress Disorder (PTSD). It also revealed the resident experienced little interest or pleasure in doing things, felt down, depressed or hopeless in the last 2-6 days, and received antipsychotic (AP) and antidepressant (AD) medications during the last 7 days. The EHR included a physician's order for an antipsychotic medication dated 7/31/24, Aripiprazole oral tablet 20 milligrams (mg); Give 20 mg by mouth one (1) time a day for Bipolar Disorder and an antidepressant medication dated 12/19/23, Sertraline Hydrochloride (HCL) 200 mg by mouth one time per day for depression. It also included a physician's order dated 12/22/23 to monitor for side effects related to the use of psychotropic medications every shift but did not identify the resident's target behaviors that required psychotropic medication use. The Progress Notes indicated target behaviors were not observed. The Behavior Monitoring & Interventions document included the following behaviors staff were to document if observed: a) Physical behaviors directed at others b) Grabbing others c) Hitting others d) Kicking others e) Pushing others f) Physically aggressive towards others g) Scratching others h) Verbal behaviors directed at others i) Accusing of others j) Cursing at others k) Express frustration/anger at others l) Screaming at others m Threatening others n) Socially inappropriate behaviors o) Disruptive sounds p) Disrobing in public q) Entering other resident's room/personal space r) Public sexual acts s) Repetitive motions t) Rummaging u) Spitting v) Throwing/smearing food w) Throwing/smearing body waste x) Other behaviors not directed at others y) Agitated z) anxious/restless The Care Plan revised 8/18/23 included the resident's antipsychotic medication use but did not include the resident's specific associated target behaviors for staff to monitor. It also did not include non-pharmacological interventions for staff to attempt if the behaviors were observed. On 2/18/25 at 1:41 PM, Staff E, Registered Nurse (RN) stated Resident #7's depression behaviors were self-isolating in his room and increased lethargy and his antipsychotic medication target behaviors were agitation, fidgeting, verbal aggression. She also stated target behaviors should be identified in his care plan. When queried at 1:53 PM, Staff A, RN, was not able to verbalize the resident's target behaviors but stated they should be in the resident's Care Plan. On 2/20/25 at 12:25 PM, the Director of Nursing (DON) stated Care Plans should be resident specific with target behaviors. 50500 4. The Annual MDS, dated [DATE], revealed Resident #25 with a BIMS of 0, indicating severe cognitive impairment. Diagnoses on the MDS include depression, frequent incontinence (bladder and bowel), and Non-Alzheimer's Dementia. No behavior, physical or verbal, documented during the MDS 7-day look back observation period. The Medication Administration Record (MAR) for Resident #25, for the month of February, documented orders for Aripiprazole, an antipsychotic. This is to be provided daily for aggression. The MAR did not direct staff to document monitoring of psychotropic targeted behaviors specifically related to Resident #25. The Care Plan, dated 2/7/25, for Resident #25 listed additional diagnoses of anxiety, mood disturbance, and psychotic disturbance. The Care Plan noted the use of a psychotropic mediation but lacked interventions of monitoring psychotropic targeted behaviors as well interventions for acute expressions of behaviors personalized to Resident #25. 5. The Significant Change MDS, dated [DATE], reveals Resident #87 with a BIMS of 12, indicating impaired cognition. Diagnoses on the MDS include anemia, depression, frequent pain, need for assistance with personal cares, and occasional incontinence (bladder and bowel). The MDS noted Resident #87 dependent on staff for toileting hygiene. The Care Plan, dated 1/23/25, revealed Resident #87 required assistance with activities of daily living. Interventions include a staff assistance of 2 for bed mobility, initiated on 10/16/24, as resident difficult to turn for cares and repositioning. During an interview on 2/18/25 at 1:30 PM, Staff M, CNA, voiced Resident #87 is a staff assist of 1 in bed when completing cares. During an interview on 2/18/25 at 2:14 PM, Staff N, CNA, reported providing cares on Resident #87 alone, without assistance, during their last scheduled shift on 2/9/25. The facility policy Care Plan, revision date 7/2023 documented the following: Point 4: After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident.

Based on observations, staff interview, and policy review, the facility failed to provide appropriate side dish serving sizes for 5 of 5 puree diets and failed to obtain final cooking temperatures for resident meal items. The facility reported a census of 95. Findings include: 1. During an observation on 2/19/25 at 10:45 AM, Staff G, cook, prepared 6 puree pea servings for 5 residents on a puree diet. For meal service, Staff G determined 2 scoops of a #12 scoop size should be used for an appropriate portion. Staff G laid a #12 scoop on top of the covered puree peas which were on the steam table service line. No note or communication to other kitchen staff members regarding the addition scoop for the puree peas observed prior to Staff G leaving the kitchen prior to lunch service. During a continuous lunch service observation on 2/19/25 at 11:30 AM, Staff H, Cook, prepared and portioned out the hot food for resident trays. Staff H seen using a #12 scoop size and providing only 1 scoop of puree peas for all of the puree diets. 2. During the continuous lunch service observation on 2/19/25, an unknown kitchen staff member seen preparing a frozen individual serving of macaroni and cheese. Once the item had finished cooking, the staff member plated the macaroni and cheese and provided it to the trayline staff for the resident's tray. The same known kitchen staff observed preparing instant potatoes for the lunch line. Once the potatoes were finished cooking, Staff H started to serve them for resident trays. At no time did the kitchen staff obtain a temperature of the individual macaroni and cheese or the instant potatoes prior to plating the items for resident trays. During an interview on 2/19/25 at 1:00 PM, the Certified Dietary Manager(CDM) acknowledged the lack of temperature for the macaroni and cheese as well as the instant potatoes. The CDM would expect kitchen staff to obtain final food temperatures prior to plating, reaching a temperature of 165 degrees Fahrenheit. During an interview on 2/19/25 at 1:00 PM, Staff H voiced a lack of communication between them and Staff G regarding the appropriate serving size of the puree peas. The policy Pureed Food Preparation dated 2020, states puree foods should be served with the appropriate scoop number to provide an equal number of portions. All of the puree food must be used in order to deliver the correct nutrient density of each resident. The policy Monitoring Food Temperatures for Meal Service, dated 2020, outlines food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures.

Based on resident interview, staff interviews and record review the facility failed to ensure resident participation option in quarterly interdisciplinary team meetings for care planning for 1 of 3 residents reviewed regarding care plan meetings (R# 9) The facility reported a census of 95. Findings include: The Annual Minimum Data Set (MDS) assessment for Resident #9 dated 12/20/24 included diagnoses, anemia, arthritis and vision deficits. The MDS listed the Resident's BIMS score of 15 out of 15 indicating intact cognition The Care plan, initiated goal on 6/26/23 relayed will activity participate in independent leisure activities of choice daily and group activities as desired, documented resident enjoys activities included current events, reading group music and parties, residents primary diagnosis of blindness. In an interview on 2/17/25 at 11:07 AM the resident did not recall attending any recent care conference meetings or meetings to discuss concerns or changes. Resident#9 reported he had gone to resident council meetings but no recent care discussion. A Progress Note dated 10/29/24 relayed resident participated in a team meeting, had concerns about new insurance and relayed feelings. In an interview on 2/19/25 at 1:37 PM with the facility Staff D, Social Worker confirmed the team meeting on 10/29/24 was the last care conference resident #9 had participated in. Staff D relayed a performance improvement plan is in the works to change procedures to ensure resident invitations. In an interview on 2/19/25 at 1:53 PM with RN, Staff C relayed had updated the required MDS assessments and the care plan however a formal meeting was not done with Resident #9 when the last annual updates were completed in December 2024. In an interview on 2/4/25 at 3:12 PM with the Administrator acknowledged process will improve to ensure residents have options to participate their plan of care.

Based on observations, clinical record review, resident, family, and staff interviews, resident council notes, and policy review the facility failed to ensure sufficient and competent staff available to provide care to all residents as evidenced by residents with pressure ulcers and not being repositioned, lack of adequate staffing supervision of a resident observed near a hazard and a resident who tipped his motorized wheelchair when outdoor at the facility, and failure to administer treatments and medications timely. The facility staff also failed to ensure call lights within reach of residents and failed to ensure staff responded and answered residents' call lights within 15 minutes to meet residents' needs in a timely manner for 2 or 2 nursing units observed. The facility also failed to ensure adequate staff on duty to allow visitors entry into the facility for timely visitation with residents. The facility reported a census of 86 residents. This failure resulted in an immediate jeopardy situation. The State Agency informed the facility of the IJ on 6/5/23 at 12:15 PM. The IJ began on 4/6/23 when the Resident Council first expressed a concern with shortages of staff. The facility staff failed to remove the immediacy prior to the survey exit resulting in the initial scope and severity of L remaining at the survey exit. Findings include: 1. Observations revealed call light response greater than 15 minutes or call light out of reach for the following: a. On 5/15/23 at 1:20 PM, three call lights on in the 200 hall on the main level of the facility. At 1:25 PM, the same call lights remained on. Staff B, Licensed Practical Nurse (LPN), stood by the medication cart and prepared medications. At 1:38 PM, call lights off in the 200 hall. The call light had been on a total of 18 minutes before staff answered the call light. b. On 5/15/23 at 1:46 PM, room [ROOM NUMBER] had call light on. At 2:00 PM, the Admissions Director entered room [ROOM NUMBER]. The resident told the Admissions Director to leave his call light on as he waited for staff because he needed assistance to the bathroom. At 2:08 PM, Staff R, certified nursing assistant (CNA), entered room [ROOM NUMBER] and turned the call light off. Call light was on a total of 22 minutes. c. On 5/16/23 at 6:05 AM, Resident # 33 lying in bed with pillow propped up on the headboard and her head and neck bent forward. The resident complained of being very uncomfortable and unable to operate her bed. The resident reported she was not able to reach her call light or bed control. The resident stated she didn't know where her call light was. The resident's call light laid on the floor under the bed out of reach of the resident. d. On 5/17/23 at 10:52 AM room [ROOM NUMBER] had call light on. At 10:53 AM, Staff L, CNA, entered room [ROOM NUMBER] and turned the call light off. Staff L told the resident he would let the nurse know he needed something. At 11:15 AM, after continuous observation of the resident's room and hallway, no nurse had responded to the resident's room. e. On 5/19/23 at 7:20 PM, room [ROOM NUMBER] and room [ROOM NUMBER] had call light on. At 7:41 PM, the call lights remained on for room [ROOM NUMBER] and 217, as well as room [ROOM NUMBER] and and a red (bathroom) light flashed outside room [ROOM NUMBER]. At 8:00 PM room [ROOM NUMBER] call light remained on. Call lights for room [ROOM NUMBER] and 217 on a total of 40 minutes. The call light remained on in room [ROOM NUMBER] and continued past 19 minutes. f. On 5/19/23 at 7:21 PM, Resident #28 sat in a wheelchair by the nurse's station yelling help me, help me please. At 7:37 PM, the resident continued to holler hurry, hurry, restroom. At 7:38 PM, Staff J, Registered Nurse walked by the nurse's station and asked Resident #28 what she was doing. Resident #28 responded bathroom. Staff J told the resident the bathroom at the nurse's station was not a resident bathroom. Resident #28 responded how do I get to a bathroom? Staff J walked into the bathroom but did not respond to the resident. At 7:49 PM, Resident #28 propelled her wheelchair down the hall calling out help me, help me please. At 7:51 PM, Staff K, certified nursing assistant, walked by Resident #28 and told the resident she planned to assist the resident to bed soon. g. On 5/19/23 at 7:33 PM, call light on for room [ROOM NUMBER]. Resident # 34 reported she had her call light on for the past 30 minutes but no staff had assisted her. The resident reported she had a clock on the wall in her room to know the time she turned her call light on. At 7:43 PM the resident's call light remained on. At 7:48 PM, room [ROOM NUMBER]'s call light off. room [ROOM NUMBER]'s call light on a total of 45 minutes. Review of Resident #34's Minimum Data Set (MDS) dated [DATE] revealed the resident had a BIMS of 15, indicating cognition intact. The resident required extensive assistance of two staff for toileting and transfers. Resident #34's care plan updated 6/27/22 revealed the resident had an ADL (Activities of Daily Living) self-care deficit and at risk for falls due to the need for assistance with transfers and ADL's related to left-sided hemiplegia and weakness. The care plan directives for staff included to reinforce the need for her to call for assistance. During an interview 5/22/23 at 2:00 PM, the Director of Nursing (DON) reported she expected staff answered resident call lights within 15 minutes or as soon as possible. The facility's Call Light Policy revised 4/2023 revealed the facility staff shall answer call lights in a timely manner. Call lights placed within reach of residents who are able to use a call light at all times but there is no reason to place the call light within the reach of a resident who is physically and cognitively unable to use the call light. 2. The Resident Council meeting notes dated 4/6/23 at 2:00 PM revealed residents voiced concerns the facility did not have enough staff. The resident council meeting notes dated 5/4/23 at 2:05 PM revealed the facility had a shortage of staff especially on the 2-10 PM shift. The notes revealed the residents voiced continued reports of not enough nursing and CNA (Certified Nurse Aide) staff. At the time of the meeting only one nurse worked the upper level of the facility. Residents reported call light response continued to be a problem, meaning it took greater than 15 minute before staff responsed, and some staff turned call lights off. In addition, some residents had not received their medications on time. 3. During confidential resident interviews 5/15/23 to 5/19/23, five of ten residents reported it took staff 20 minutes to 2 hours before staff answered their call light and provided assistance. The residents reported call light response depended on how many staff worked and what was going on. One resident reported he had to gauge the time of day when staff got him up in the chair because he required two staff for transfers, but when the facility only had one aide on duty he was left in the chair all night. 4. On 5/24/23 at 10:55 AM, a family member expressed concerns about visitors having to wait for staff to let them into the facility in order to visit their loved one. The family member reported when no staff at the desk to buzz visitors in, he pushed a button on the wall in the alcove. The buzzer rang at the nurse's station but if no staff by the desk, then visitors waited 20 minutes or longer for staff to let visitors in. The family member stated concerns the facility didn't have enough staff working to meet the needs of his loved one. 5. During confidential staff interview, Staff J, Registered Nurse (RN), reported residents' medications and treatments administered late or not administered because the facility was short staffed and staff lacked the time to administer the medications and/or treatments when scheduled and in a timely manner. Staff J reported lots of residents required two staff for assistance and cares. Staff J reported several residents had developed pressure ulcers because residents not getting repositioned like they should. Observations and clinical record review of residents sampled revealed 2 of 3 residents developed facility acquired pressure ulcers. The facility failed to ensure residents received the minimum standard of nursing care by providing routine repositioning to prevent pressure ulcers for Resident #3 and Resident #16. 6. During anonymous staff interviews, two staff members reported hesitancy to speak to the surveyor unless away from the Administrative offices for fear of being seen and retaliation. Four staff reported the Administrator and DON told staff whenever State (surveyors) asked the staff questions they needed to respond everything was fine. If they wanted a paycheck they better not say anything bad. Staff reported the CNA's schedule changed and hours were cut back after the new company took over. The facility was short-staffed and used alot of agency to fill hours, even though the facility's employed CNA's wanted and could work the hours. Staff were told options for schedule (8 hour shifts) and they could take it or leave it. However a CNA related to the DON got a special schedule created for her, and whenever this CNA worked, there was only one CNA on the hall assigned after 9 PM when that CNA's shift ended, and if residents not put in bed by 9 PM they were left up until another staff person came in after 10 PM. Staff reported being yelled at or treated rudely by the Administrator. Staff members reported names listed on daily assignment lists but staff not aware they were scheduled to work. The daily assignment sheets looked like they had adequate staff but in reality staff not scheduled to work. One staff reported lack of dietary staffing, and only had a cook and dietary aide who worked in the kitchen; suppose to have four staff in the kitchen during their shift. One staff member reported only 1 CNA scheduled on the [NAME] Hall on Garden level but suppose to have two staff. One CNA can't do everything needed for the residents on [NAME] hall; it's a heavy load. A lot of residents required two staff for assistance and transfers. Unable to provide showers and baths, answer call lights, and care for all of those residents without adequate number of staff working. The facility assessment dated ,d+[DATE] revealed a facility assessment utilized to determine the resources necessary to care for the resident population served during day to day operations as well as during emergenct situations. The facility assessment included the number of residents, the care required by the population in consideration of the types of diseases, conditions, physical and cognitive abilities, and overall acuity of the residents. The facility assessment also revealed staff competency necessary to provide the level and types of cares needed for the population. The facility assessment contained data from 10/2021 to 10/2022 about resident population and diagnoses. The resident matrix provided by the facility on 5/15/23 revealed: 9 residents had pressure ulcers, 12 residents on hospice care, 1 resident required enteral tube feedings, 4 residents on dialysis, 11 residents had a catheter, and 2 residents had intravenous (IV) therapy. A list of residents and the resident's transfer status as of 5/15/23, provided by the Director of Nursing on 5/16/23 to the surveyor, included the level of staff assistance required for transfers: 28 residents required assistance of one staff 3 residents required assistance of two staff 18 residents required use of a full mechanical lift 9 residents required a sit to stand lift. A list of residents with skin concerns provided by the facility upon entrance revealed 13 residents had pressure ulcers and/or skin conditions. The Resident Census and Condition of Residents report (CMS form 672) dated 6/5/23 revealed the following activities of daily living (ADL's) and the number of current residents who required one to two staff for activities of daily livings (ADL's): Transfers: 70 Bathing: 72 Dressing: 73 Toileting: 72 Eating: 28 The 672 also revealed the following ADL's and the number of current residents dependent for ADL's: Transfers: 2 Bathing: 14 Dressing: 2 Toileting: 1 Eating: 2 During an interview on 6/8/23 at 2:15 PM, the Administrator reported she completed the facility assessment and updated the assessment once a year. The Administrator reported facility assessment updated depending upon the resident demographics, census, vendors and providers, and emergency preparedness. She compiled data and information for the facility assessment placed the information in a binder, and submitted a copy of facility assessment to the corporate office. When the surveyor asked the Administrator if she reviewed the information or how she utilized the information if the facility assessment, the Administrator asked the surveyors how often she should look at the facility assessment. The Administrator reported she used a formula to determine staffing needs for each shift. The Administrator reported the following staff numbers for each each. The staffing levels on Garden (downstairs) level included: On the 6 AM-2 PM and 2 PM-10 PM shifts, a minimum of: 6 certified nursing assistants (CNA) 1 certified medication aide (CMA) 2 nurses On the 10 PM-6 AM shift: 4 CNA's 2 nurses The staffing levels on the Main (upstairs) level included: On the 6 AM-2 PM and 2 PM-10 PM shifts, a minimum of: 2 CNA's 1 nurse On the 10 PM-6 AM shift: 2 CNA's 1 nurse The Administrator reported they tried to fill staffing needs with facility staff and agency staff. During an interview on 5/22/23 at 2:00 PM, the DON reported staffing dependent on resident census. The ideal staffing numbers for each unit and shift included: On the Garden (downstairs) level 6-2 PM shift: 5-6 CNA's 1 CMA 2 nurses 2-10 PM shift: 5 CNA's 1 CMA 2 nurses 10 PM - 6 AM shift 3 CNA 1 nurse On the Main (upstairs) level: 6 AM - 2 PM shift 2 CNA's 1 Nurse 2 PM- 10 PM shifts: 1 CNA 1 Nurse 10 PM - 6 AM shift 1 CNA 1 nurse The DON reported the staff nurses and scheduler tried to cover staffing needs when they had call ins. 7. Staff Q, Registered Nurse (RN) administered medications into the balloon port (the balloon is filled with normal saline and is used as an anchor inside the stomach to hold the G-J tube in place) of Resident #1's G-J tube (Gastrostomy-Jejunostomy tube - a tube placed into the stomach with three external ports) instead of the correct port that is used to put medication into the body, causing the balloon to pop inside the resident. The resident had to transfer to the local hospital due to pain and a gastric outlet obstruction. The incompetent care of a resident's gastrojejunostomy tube and lack of staff training led to a burst balloon on the tube, infliction of pain, the need for surgical intervention, and hospitalization . 8. The MDS assessment dated [DATE] revealed Resident # 11 had diagnoses of stroke, diabetes, hemiplegia (paralysis on one side of the body), and sarcopenia (a gradual loss of muscle mass, strength and function). The MDS revealed the resident had a brief interview for mental status (BIMS) score of 15, indicating cognition intact. The MDS documented the resident used an electric wheelchair and independent with locomotion and movement on and off the unit. The care plan initiated on 12/5/22 revealed the resident had an ADL self-care deficit related to physical limitations after a CVA (cerebrovascular accident) (stroke) with hemiplegia and weakness. The care plan revealed the resident was independent in a power wheelchair and desired to participate in outdoor weather activities. The progress notes revealed the following: a. On 5/8/23 at 2:54 PM, the DON was summoned outside. Resident #11 found lying on his back in a supine position. The resident stated he got too close to the sidewalk and drove his electric wheelchair partway up on the curb of the sidewalk, tipped the wheelchair over, and landed headfirst. The resident stated he hit his head and complained of head pain. 911 called. An ambulance arrived and placed a c-collar (around the resident's neck). Resident transported to the hospital for further evaluation. 5/24/23 at 9:55 AM, the DON reported Resident # 11 went outside in motorized wheelchair and while he passed by another resident on the sidewalk, the two wheels got caught between the sidewalk and curb and he tipped over in the wheelchair. An ambulance was called and the resident went to the hospital to be examined. The facilty lacked adequate nursing supervision of the residents to prevent accidents and access to potential environmental hazards. 37074 9. On 5/28/23 at 9:48 AM an anonymous voicemail was received that stated today was not a good day at the facility. The residents did not receive breakfast, they are short staffed and management does not care. The call back number was not accepting calls or voicemails. On 5/30/23 at 7:00 PM Staff DD, CNA, stated there were a lot of staffing concerns at the facility and sometimes they only had one CNA on the lower level. Staff DD voiced that was not enough staff when there were residents who required two staff to assist them, answer call lights, give baths, etc. On 6/1/23 at 12:58 PM Staff CC, Certified Medication Aide (CMA), stated there were staffing issues. She added resident tasks got completed based on what and how many staff were scheduled in addition to the amount of cares the residents required. They could have one aide on each hall; that's 12 residents that needed help getting up plus call lights going off. When asked if they had plenty of staff to help she indicated they did and they had access to other staff members but they were not utilizing them. If staff showed up to work but their names were not on the schedule management would send them home; even though they needed the help. If that staff member stayed to help they would not get paid because they were not on the schedule. On 6/2/23 at 9:41 AM Staff F, Licensed Practical Nurse (LPN) stated that day Resident #39 passed away she was the only nurse on the lower level halls. She added she had two CMAs and like 6 CNAs on the floor. But that it still was a lot for one nurse to do: assessments, treatments, medications, etc. She added she was so busy running to both sides of the lower level halls to provided treatments, it was too much for just one nurse. The other nurse that was supposed to work called it that day. During a following up interview on 6/7/23 at 10:08 AM Staff F stated on 5/29/23 she called Staff GG, Registered Nurse Unit Manager, to come in and help. She was on-call that week and she told her she would not come in help her. She called Staff GG twice and she told the DON that as well. She was not blaming the facility for what she did not do but they set her up by being understaffed the day he passed away. There were like 65 people downstairs and it was just her and a CMA, plus the aides. She had three other residents transitioning, it was just too much for one nurse. The dynamic was not good there. On 6/6/23 at 1:10 PM Resident #31 stated it could take about an hour for her call light to get answered. When asked how she knew that, the looked at the clock that was on the wall to the left of her TV. She added her call light did not get answered when there was not enough staff working and it happened on all three shifts. She reiterated there were just not enough staff. On 6/6/23 at 1:47 PM Staff FF, CNA, stated on the 2:00 PM-10:00 PM shift they could use more staff on the floor to get their work done. If they had more staff things would be better; it would really help with taking care of the residents and the call lights would not be on for a long time because they would not be understaffed. 41537 10. The MDS dated [DATE] for Resident #32 documented a BIMS score of 7 indicating severe cognitive impairment. The MDS documented the need for setup help with supervision for walking, toilet use, and dressing. The MDS also listed diagnosis of hypertension, difficulty in walking, and repeated falls. During an interview on 5/18/23 at 11:38 AM Resident #32 stated she was getting tired of helping herself and it hurt so bad. She then revealed she did not know where the call light was and further explained it wasn't working right so she gave it up since no one responded. She then stated they wanted her to [NAME] and just get it over with. Observation revealed the call light laid on a blanket approximately 6 feet away from the resident's chair. During an interview on 5/24/23 at 1:06 AM with the DON revealed she would expect call lights to be in reach for dependent residents in bed. During an interview on 5/24/23 at 1:22 PM the Administrator revealed she would expect dependent residents to have their call lights when they are in their room unattended if they can use them effectively.

Based on observations, resident interviews, family interviews, staff interviews, clinical record review, facility assessment review, previous 2567 review, and employee file review, the facility's administration failed to effectively and efficiently maintain administrative responsibilities to ensure provision of ethical, high-quality health care services. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety affecting all residents. The facility reported a census of 86 residents. Findings include: The State Agency informed the facility of the IJ on 6/8/23 at 3:00 PM and provided the IJ template. The IJ began on 5/28/23 when the staff first reported issues with management not caring about their reported concerns. The survey team exited the facility prior to the IJ immediacy being removed. The initial scope and severity of L remained at the time of the survey exit. Findings include: Observation on 6/1/23 at 9:45 AM revealed a yellow sign on the doors leading to the Administrative offices that stated: NOTICE: please keep this door closed at all times. On 6/2/23 at 8:15 AM the signed remained on the door by the receptionist's desk. On 6/6/23 at 3:14 PM both doors leading to the Administrative offices were locked with the expectation one was to speak with the receptionist on what they needed then she could assist with the task. Observation on 6/7/23 at 7:30 AM revealed the administrative offices by the receptionist's desk was open upon surveyor entrance to the building. After it was noted the surveyor was in the building the receptionist went to the administrative offices, came back out and closed the door. Review of the Administrator employee file revealed her hire date was 11/21/2020. Review of the facility's survey results binder revealed the following repeated deficiencies since the Administrator's hire date of 11/21/2020: - F550 during complaint surveys ending on 10/5/21, 3/9/22, 7/28/22, 11/4/22 and current survey - F580 during complaint surveys ending on 12/10/20, 5/6/21, 7/28/22, and current survey - F684 during the recertification surveys ending on 12/30/21, 3/14/23, and during complaint surveys ending on 5/6/21, 3/9/22, 7/28/22, 11/4/22 and current survey. This deficiency had an Immediate Jeopardy (IJ) scope and severity with harm associated with it for the surveys ending on 3/14/23 and current survey - F686 during complaint surveys ending on 5/6/21, 3/9/22 and current survey. This deficiency had a harm level associated with it for the current survey. - F689 during the recertification surveys ending on 12/30/21, 3/14/23 and complaint surveys ending on 12/10/20, 5/6/21, 3/9/22, 7/28/22, 11/4/22, and current survey. This deficiency had an IJ scope and severity with harm associated with it for the survey ending on 7/28/22 and harm level associated with it for the current survey. - F725 during the recertification surveys ending on 12/30/21, 3/14/23 and complaint surveys ending on 3/9/22, 7/28/22 and current survey. This deficiency had an IJ scope and severity with harm associated with it for the current survey. - F880 during the recertification surveys ending 12/30/21, 3/14/23 and complaint survey ending on 11/23/21 and current survey. Review of the state agency's public website https://dia-hfd.iowa.gov/ contained the following certification actions during the following surveys: - ending on 11/23/21 complaint survey resulted in denial of payment was imposed and civil money penalty was imposed - ending on 12/30/21 recertification and intake survey resulted in civil money penalty imposed - ending on 7/28/22 intake survey fining and citation was issued - ending 10/10/22 intake survey resulted in denial of payment imposed - ending 3/14/23 recertification survey results in civil money imposed, directed plan of correction imposed, and fining and citation was issued Review of the state agency's public website https://dia-hfd.iowa.gov/ listed the following fines were paid by the facility: - 02/11/22 $500.00 - 08/12/22 $9,750.00 - 08/12/22 $19,500.00 Review of the Administrator's Employee File revealed a Performance Appraisal with an appraisal date of 01/2021-12/2021 with the goal to decrease the number of citations during annual and complaints for 2022. Areas for improvement: decrease turnover rate and stabilize nursing department to improve regulatory outcomes. Her file contained the Administrator's job description that was signed and dated by the Administrator on 11/2/2020 with the following essential job functions: - Resident Rights - Knows and respects patient's right - Ensures patient concerns/complaints are responded to with tact and urgency - Administrator Provision of Services Responsibilities - Directs the location staff to provide high quality in daily care which meets/exceeds all internal/external standards - Listens to family questions and concerns, assists with resolving issues, and explains related company actions and decisions - Completes rounds to assess resident climate and to address complaints or other issues; refers these issues to appropriate department head or other personnel - Drives Quality Assurance program process in the center, and ensures the implementation of follow-up corrective action - Intervenes as appropriate in potentially threatening situations and follows-up with staff after crisis has been resolved - Oversees preparation for licensure certification surveys - Administrator Human Resource Management Responsibilities - Organizes the functions of the nursing home through appropriate departmentalization and the delegations of duties. - Establishes formal means of accountability - Promotes and maintains pro-active, positive employee relations programs - Maintains frequent, daily, informal interaction and provides positive feedback to staff while they are working; maintains an open-door policy in dealing with staff - Communicates clearly and responsively on issues arising in the facility to decision makers who are outside of the facility and follows-up to minimize impact of the issues On 5/19/23 8:30 PM Staff J, RN, reported she had worked at the facility for 3 weeks and it was the worst place she had ever worked. Staff J stated the facility was so short staffed and when she tried to contact the DON regarding concerns for staffing she was told to utilize the other nurse on site to help her but only one other nurse worked on that day (the prior weekend). Staff J stated it was unsafe and had concern for her nursing license. Lots of residents needed two staff assistance. Residents not getting medications or medications administered late. Staff document treatments done on residents but treatments not done because they didn ' t have time to do them. Several residents had pressure ulcers because residents not getting repositioned like they should. Staff J then reported she ' d rather talk to the surveyor more when not at the facility because the DON had arrived at facility and didn ' t want the DON to see her talking with surveyor. On 5/22/23 at 11:05 AM, Staff J reported Staff F, LPN, told staff on 5/22/23 to do whatever state wanted them to do and after state left, staff could do what they wanted. Staff J reported staffing terrible at the facility, treatments not getting done and medications administered late because only 1 nurse and 1 CMA worked on a shift. On 5/30/23 at 7:00 PM Staff DD, CNA, stated the Administrator was not nice to staff and did not understand how she could be the abuse officer when she treated and talked to staff abusively. When trying to discuss staffing concerns, the Administrator would say she was not talking about it and it's a done deal. On 6/7/23 at 10:08 AM Staff F, Licensed Practical Nurse (LPN), stated the dynamic was not good at the facility. The Administrator stood up for the Director of Nursing (DON) so she would not look into things that needed attention. Staff F voiced the Administrator needed to be more involved with things. On 6/8/23 at 2:18 PM the Administrator was asked why the sign was on the door to the administrative door and she indicated it was closed because those in the offices talked about many things and the foot traffic was high. The Administrator commented out of respect for the residents, they kept them closed to ensure the information being discussed was private and that residents and family could still go back there. When asked why the doors were locked, the Administrator responded defensively stating it had always been that way along with the sign. The survey team discussed with the Administrator during previous visits the door never had a sign and the doors were never locked. The sign and locked doors did not reflect the open door component of her job description. It was suggested the individuals within the offices could close their office door if they needed to have private conversations. Leaving the door locked with the sign to keep the door closed was not inviting for residents and family members to come to them with concerns, issues, etc. 34817 On 6/5/23 at 12:20 PM, the Department of Inspections and Appeals (DIA) office attempted to call the Administrator as the DIA Bureau Chief (BC), surveyor, and Program Coordinator on the same conference phone call. The DIA BC spoke with a facility staff member and call transferred to the Administrator. The call went to the Administrator's voicemail box. At 12:25 PM the DIA BC repeatedly attempted to contact the Administrator by phone as the surveyor and PC on the same phone call. The phone call was transferred by facility staff to the Administrator's voicemail. At 12:34 PM, the BC attempted to contact the Administrator again. While the surveyor was on the phone with the BC and PC, the surveyor walked to the Administrator's office and advised the Administrator the DIA BC tried to reach her but the phone calls kept going to her voicemail. The surveyor placed the call from the BC on speaker and gave the phone to the Administrator. At that time, the BC provided information to the Administrator about concerns related to an Immediate Jeopardy. On 6/5/23 at 1:45 PM, an attendant sat at the front entryway desk next to the door that led to the Administrative offices. The door was locked and had a sign NOTICE this door to remain closed at all times. A second door to the Administrative offices just down the hall from the door by the attendant was locked. The Administrator, DON, Human Resources, and MDS staff not accessible. The attendant had to call Administrative staff if the surveyor needed something from an Administrative team member. During 6/5/23 AM and the prior survey weeks, the doors leading to the hallway to the Administrative offices were unlocked. During anonymous staff interviews starting on 5/31/23 to 6/7/23, two staff members (Staff DD and Staff OO) reported hesitancy to speak to the surveyor unless away from the Administrative offices for fear of being seen and retaliation. Four staff (Staff OO, MM, NN, DD) reported the Administrator and DON told staff whenever State (surveyors) asked the staff questions they needed to respond everything was fine. If they wanted a paycheck they better not say anything bad. Staff reported the CNA's schedule changed and hours were cut back after the new company took over. The facility was short-staffed and used a lot of agency to fill hours, even though the facility's employed CNA's wanted and could work the hours. Staff were told options for schedule (8 hour shifts) and they could take it or leave it. Staff reported being yelled at or treated rudely by the Administrator Staff members reported names listed on daily assignment lists but staff not aware they were scheduled to work. The daily assignment sheets looked like they had adequate staff but in reality staff not scheduled to work. One staff reported lack of dietary staffing, and only had a cook and dietary aide who worked in the kitchen during her shift, but suppose to have four staff on shift. In an interview on 6/8/23 at 8:28 a.m., Staff PP reported fear of retaliation. Staff PP reported the Administrator was falsifying plan of correction audits by going back to April 2023 and back dating and filling in information related to quality assurance efforts and that the Administrator was directing other staff to do the same. Staff PP stated the management team verified several family members confirmed difficulties obtaining entrance into the facility related to a locked front door and no staff were available to answer the door; lengthy call light response times; 6 additional residents identified with pressure sores; for staff education related to the IJ removal plans, if staff did not respond, a blanket email with the information went out without verifying the staff competency; and original concern statements submitted by a CNA regarding the care of a resident was shredded. Staff PP reported concerns the administration was covering up quality of care concerns rather than putting in a good faith effort to address and fix the immediacy of the concerns from surveys.

Based on record review, staff interviews, and facility policy review the facility failed to assess and provide immediate interventions for Resident #39 who on [DATE] at 10:00 AM experienced a significant change in physical status and informed staff he didn't feel right and felt like he was dying. The resident presented with puss coming out of the urinary catheter insertion site, skin pale, statements of cold, sweating profusely, urine cloudy, and dull gray color, and blood sugar reading of 536 mg/dL. The staff failed to contact hospice or the primary care physician (PCP) for treatment orders and the resident passed away at approximately 2:30 PM. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety. The facility also failed to initiate hospice orders after a new skin area was discovered by the hospice staff members. The facility reported a census of 86 residents, with 12 residents on hospice. Findings included: The State Agency informed the facility of the IJ on [DATE] at 1:00 PM and provided the IJ template. The IJ began on [DATE]. The facility staff did not remove the immediacy prior to the exit of the on-site survey. The initial scope and severify of K remained at the time of exit. Findings include: The significant change Minimum Data Set (MDS) assessment, dated [DATE], for Resident #39 identified a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested he had severe cognitive impairment. The MDS revealed he required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS documented he required hospice services while a resident in the facility. The MDS documented the following diagnoses for Resident #39: sepsis, heart failure, diabetes mellitus, and depression. The Care Plan focus area dated [DATE] identified Resident #39 received hospice services due to end-stage cardiac disease, severe deconditioning, and malnutrition. The Care Plan indicated the hospice team will integrate services and collaborate cares. The Care Plan also indicated he had diabetes mellitus. The Hospice Comprehensive Assessment and Plan of Care Update Report dated [DATE] documented he started to receive hospice services on [DATE]. Review of the resident's Electronic Health Record (EHR) revealed his blood sugar was checked on [DATE] at 10:22 AM by Staff CC, Certified Medication Assistant (CMA). His blood sugar was 536 milligram per deciliter (mg/dL). Review of Resident #39's [DATE] Medication Administration Record (MAR) revealed Staff CC administered his as needed (PRN) order of oxycodone 5 milligram (mg) 1 tablet on [DATE] at 10:58 AM. Resident #39's hospice binder cover and hard chart cover had the following sticky noted taped to both covers: #39 is a patient under hospice care. Please call us for any of the following: change in condition. The sticky note listed the phone number along with the attending physician's name. a.) Review of Resident #39's Progress Notes revealed the following note was documented by Staff F Licensed Practical Nurse (LPN) on [DATE] at 3:42 PM: called to the room, resident lying in bed, starring at the ceiling. He looked at the nurse when his name was called. Vitals obtained: blood pressure ,d+[DATE], respirations 14, oxygen saturation 92% on room air, and temperature was 96.4 degrees Fahrenheit. Staff F noted the urine in his drainage bag to be creamy green in color. She did not note any shortness of breath or respiratory distress. Staff F gave an as needed (PRN) oxycodone (pain management) at 11:30 AM. She went back in to the room at 2:30 PM, by the request of the Certified Nursing Assistant (CNA), resident was dead, no apical pulse, no breathing. Hospice was made aware. His Progress Notes lacked documentation of notification of his hospice provider when he started to have a significant change in condition. Review of Resident #39's Hospice Notes, provided by the hospice company, revealed a Visit Note Report dated [DATE] with the visit type listed as hospice death at home. The report documented the nurse was in the facility on [DATE] at 4:16 PM until [DATE] at 4:35 PM. Resident #39's hospice notes did not contain mention of the on-call hospice nurse or physician being notified of his emergent change in condition. On [DATE] at 7:00 PM Staff DD Certified Nursing Assistant (CNA) stated on [DATE] at 10:00 AM Resident #39 told her that he did not feel right and felt like he was dying. She noted his skin to be pale, he was cold to the touch, sweating profusely, and saw that his urine was cloudy and a dull gray color. She reported to this to Staff F but she was very nonchalant, told her the resident was on hospice. She notified Staff CC of her concerns and she checked his blood sugar; it was 536 mg/dL. Staff F went in later to check on the resident and took his vital signs. The nurse told Staff DD there wasn't anything she could do about it other than call hospice. Staff DD was unsure if the nurse actually called hospice or not but does not think she did until the resident passed away around 2:30 PM. Staff DD indicated she, herself, frequently checked on him throughout her shift; every 30 minutes between her resident cares until she left at 2:00 PM. After her shift, he passed away about ,d+[DATE] minutes after she left her shift. She added only the nurses can contact hospice staff members. Staff DD added it bothered her when she found out the resident passed away. She thinks he died alone without family or hospice staff with him. She indicated she knows hospice would've came in if they were called but doesn't think hospice was called. She cried and didn't sleep very well because she kept thinking about the resident. During a follow-up interview on [DATE] at 3:45 PM Staff DD reported she started her shift at 6:00 AM and did rounds on all of the residents on the hall she was assigned to. When she did rounds at 8:00 AM, Resident #39 was in bed and still sleeping. At 10:00 AM when she checked on the resident, he was awake but his color didn't look good so she asked him how he was doing. She added he was really pale. She asked the resident how he was feeling. The resident said he didn't feel well, didn't know what was wrong but thought he was dying. She let the nurse know right away after she spoke with Staff CC. She told her about the resident about 5 minutes after her encounter with the resident at 10:00 AM. She informed Staff F of what the resident said. The nurse said resident was on hospice. About ,d+[DATE] minutes later she heard Staff CC telling Staff F the symptoms the resident was having. Around lunchtime, 12:00 - 12:30 PM, when resident continued to complain of not feeling well, Staff F told Staff DD that she could check Resident #39's vital signs, but there was nothing she could do. On [DATE] at 12:38 PM Staff CC stated on the day Resident #39 passed away she got report from the CNA that he was losing color, cold to the touch, sweating and clammy. Staff CC stated when she took care of him when he was upstairs, he had done this before and they would send him out to the hospital. When these concerns were reported to her, she checked his vitals and took his blood sugar which was like 536mg/dL. She reported her findings to the nurse on duty that day and Staff F told her he was on hospice and they would have to go through hospice to send him out. She was unsure if Staff F called hospice. Staff CC reported Resident #39 had a second episode where he lost his color, was clammy so she went back in there and he looked dead. She got Staff F, and she told Staff CC that she went in there his eyes rolled and had not expired at that time. Staff CC verified Resident #39 had a PRN order to have his blood sugar checked but had no insulin orders. When she saw his urine that day it was cloudy and a greenish color. He did ask for something for pain, so she gave that to him. When asked how he was prior to these episodes, she stated he did not eat much, but seemed like he was fine. When asked if the felt the nurse did everything she could have for him that day, she felt like she could have done more. She believed the call to hospice should have been done sooner. She believed Staff F had a lot on her plate that day; she was the only nurse with two CMAs downstairs that day. On [DATE] at 1:14 PM Staff BB LPN was asked what she would do if a hospice resident became pale, cold to the touch, sweating profusely, had a blood sugar of 536 mg/dL and his catheter bag had cloudy, dull gray urine, she stated she would freak out then call hospice doctor. She would see what they needed to do for the resident. She would also notify hospice as well to see what they wanted to do. On [DATE] at 1:16 PM Staff E when asked stated she would call hospice and notify the physician right away if a hospice resident was pale, cool to the touch, sweating profusely, had a blood sugar of 536 mg/dL and had cloudy, dull gray colored urine. On [DATE] at 8:23 AM the Administrator with the hospice provider indicated she was on-call the day Resident #39 passed away. She indicated the only the time facility staff notified her was when he had passed away. She added their hospice staff always tell staff and the resident to call them even if it is nothing. She stated they tell them this with every hospice visit. When asked if the facility should have called them when he had an emergent change in condition, she said they should have so they could figure out the family's or resident's goal based on their symptoms. Hospice would call the physician to get orders for the best way to provide comfort for this resident. If the facility was unable to get ahold of the hospice nurse they could call the hospice physician for guidance as well. They encourage the facility staff to call the hospice nurse first then the physician. She indicated they have an on-call system that notifies the nurse on call of a facility making a call. If that on-call person does not return the call within 15 minutes, it will automatically call her. On [DATE] at 9:41 AM Staff F indicated she primarily worked downstairs. She indicated on the day Resident #39 passed away they had a nurse call in so she was the only nurse downstairs with two CMAs. She added that is a lot of work for one nurse. She recalled staff wanted her to go in and check on Resident #39, he looked fine to her. She described his urine as a creamy thick spinach color. She told the CNA his body was shutting down and she had called hospice to get them at the facility immediately. She knew he was transitioning so she gave the PRN of oxycodone because he was also grimacing when he was touched or turned in bed. She believed he did not look any different that day. Staff then came to her and reported he had expired so she went in there, she did a sternal rub on him and he took a few breaths then passed away. When asked what CNAs were reporting concerns to her she stated there were like six on the floor that day and could not remember who it was. She did acknowledge that staff notified her of Resident #39 being pale, sweaty, and cool to the touch that day but when she went in there he was normal. His normal color was pale. When asked how much time had lapsed when she was notified by staff of their concerns until she went in the room; she stated not much time had went by. She was in the middle of a medication pass so she finished that then went in to his room. She added no one saw her going in to Resident #39's room only coming out. When asked if she contacted hospice that day, she stated she called them twice. She indicated she called about 10:30 AM and the on-call person told her she was busy and could not make it to the facility. When she did arrive at the facility it was about 1:30 PM-2:00 PM right after he passed away. Staff F stated she let the hospice staff take over when she got there. Staff F added when she first called them she was told to keep him comfortable since he was on hospice there was nothing to do. During a follow-up interview with Staff F on [DATE] at 10:08 AM she indicated she could not remember what time she initially went in to his room. She added she was so busy with three other residents transitioning that that time. She indicated she went right to his room after she was done with her medication pass. When asked if she was administering morning to noon medications at that time, she stated she thought it may have been about 11:00 AM but did not look at the clock. She indicated she immediately took his vitals to see where he was at then called hospice. She told her everything and the hospice staff member advised her to keep him comfortable. Staff F stated about 1:00 PM she called hospice again, she indicated the hospice person advised her not to call the physician because he would not do anything. Staff F stated she was unsure when his blood sugar was taken and was not sure why the staff member did that. On [DATE] at 8:33 AM the Director of Nursing (DON) was asked if a hospice resident experienced a change in condition should their hospice provider be notified, she stated the nurse usually notifies hospice. When asked if this hospice resident had a change in urine characteristics and a high blood sugar, should hospice be notified she stated that is dependent on if they are close to end of life. It's a case by case decision. She acknowledged hospice should have been notified of Resident #39's change in condition, but it was her understanding that they were notified. In a follow-up interview on [DATE] at 2:52 PM she indicated she asked who Staff F spoke to and what she did once she was informed of Resident #39's elevated blood sugar. Staff F indicated she reached out to hospice in the morning and got the answering service, they told her they would get back to her. She called back again but did not take down the names of the person's she spoke to. The DON told her she should always take down the name of who you talk with. The DON then called the hospice provider to see when Staff F contacted them about Resident #39 on that day. The hospice provider indicated the facility only notified them of his passing. Staff F was then questioned if she notified the family or physician of the elevated blood sugar and she did not. She indicated the resident was on comfort measures. The DON explained to her the family has the right to change treatment or come off hospice. Staff F said that the resident was on hospice, she felt her job was to keep him comfortable and that is what she did. She provided holistic cares, pain management, repositioning, etc. She did acknowledge she called again when he passed away. When asked what the DON would have done in the situation, she stated she would have called the doctor and call the family to see what they would have wanted done. When the DON was informed the family was not notified, they did not have the option to be with him. She indicated she knew that and she would have notified them. On [DATE] at 2:25 PM the Hospice Physician/Medical Director indicated he was not notified of Resident #39's change in condition the day he passed away. He added he was only made aware of his passing. The facility should have notified him of his condition and blood sugar so they could act accordingly. On [DATE] at 2:18 PM the Administrator stated she would have expected Staff F to reach out hospice. If she was unable to do that then she should have called the physician or on-call nurse. The facility's Care Path Symptoms of Acute Mental Status Change flowsheet contained the following guidance for staff with the symptoms Resident #39 had experienced on [DATE]: New Mental Status Change Noted, staff were then directed to take vitals which included a blood sugar. If the blood sugar was over 300mg/dL the flowsheet instructed staff to notify the physician, then monitor response. The facility's Change in Condition policy with a revision date of ,d+[DATE], purpose was to provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notification. CMS requires a facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue to change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). According to the American Medical Directors Association (AMDA) Clinical Practice Guidelines-Acute Changes in Condition in the Long-Term Care Setting, immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset or a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed. b) The Progress Note dated [DATE] at 12:30 PM documented hospice came to visit Resident #39 and changed his Foley catheter. The hospice Registered Nurse (RN) reported a small sore on the right side of his penis, with a small amount of blood noted on the surface. The hospice nurse was going to report this to their doctor. A Visit Note Report completed by the hospice nurse staff on [DATE] contained the following narrative: This nurse arrived to the resident's room for a routine nurse visit. This nurse changed the Foley catheter per orders. While cleansing his penis a 1-centimeter (cm) abrasion was noted on the right side of his penis. Resident denied pain to the area. This nurse spoke with Staff BB Agency Licensed Practical Nurse (LPN) regarding the wound and new orders to be faxed to the facility. This nurse will follow up with facility staff to confirm. The Hospice documentation for Resident #39 included the following hospice physician order written on [DATE] at 9:53 AM with a start date of [DATE]: cleanse penis foreskin abrasion with soap and water, then pat dry. Apply triple antibiotic ointment two times daily (BID) and leave open to air. Hospice skilled nurse to provide wound care on hospice visit days and facility to provide wound care on non-hospice days. Hospice nurse to educate facility staff on signs and symptoms of infection. Facility staff to call hospice nurse with any signs and symptoms of infection. Review of Resident #39's [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the hospice physician order that was written on [DATE] at 9:53 AM with a start date of [DATE] was not on the MAR or TAR to be completed as ordered by hospice. On [DATE] at 1:14 PM Staff B acknowledged the hospice nurse found a sore on Resident #39's penis. She added the nurse told her he was taking care of it and put some treatment on it. On [DATE] at 2:52 PM the Director of Nursing (DON) indicated when hospice writes a new order the hospice staff and their Advanced Registered Nurse Practitioner (ARNP) would sit together and put in new orders together. When she was made aware that the order for the abrasion on his penis was not initiated after it was written by hospice, she said ok. The facility's Following Physician Orders/Transcription of Orders policy with a revision date of ,d+[DATE] indicated physician's orders will be received by a licensed nurse, therapist, or dietician. Orders may be received through written communication in the resident's chart, verbally or per telephone, via fax, or electronically entered in their charting system. If the order is for a medication or treatment, it should be entered in the MAR/TAR accordingly. Active orders should be followed and carried out as written/transcribed.

Based on record review, staff and family interviews, hospice documents, hospice agreement, and facility policy review the facility failed to notify 1 of 3 resident's hospice provider when he had an emergent change in condition (Resident #39). On [DATE] at 10:00 AM, the resident indicated the resident did not feel good and stated he felt like he was dying. The staff member noticed he was pale in color, cold to the touch, profusely sweating, and dull gray urine present. The Certified Medication Aide (CMA) checked his blood sugar and it was 536 mg/dL and gave him a pain medication for discomfort. The hospice provider on-call personnel that day indicated she was not notified of Resident #39's emergent change in condition. The only time she was notified was when he passed away later that afternoon. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety. The facility reported a census of 86 residents with 12 residents receiving hospice services. The facility was notified of the IJ on [DATE] at 1:00 PM. The IJ began on [DATE]. The facility staff did not remove the immediacy prior to the survey exit. The initial scope and severity of K remained at the time of the survey exit. Findings include: The significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 identified a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS revealed he required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS documented he required hospice services while a resident in the facility. The MDS documented the following diagnoses for Resident #39: sepsis, heart failure, diabetes mellitus, and depression. The care plan focus area dated [DATE] identified Resident #39 received hospice services due to end-stage cardiac disease, severe deconditioning, and malnutrition. The care plan indicated the hospice team will integrate services and collaborate cares. Review of Resident #39's Iowa Physician Orders for Scope of Treatment (IPOST) indicated he wanted a Do No Attempt Resuscitation (DNR) and only wanted comfort measures. Use medications by any route, positioning, wound care and other measures to relieve pain and suffering. Resident prefered no transfer to the hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in current location. This form was signed by his physician and Power of Attorney (POA). The Hospice Comprehensive Assessment and Plan of Care Update Report dated [DATE] documented he started to receive hospice services on [DATE]. Review of the resident's Electronic Health Record (EHR) revealed his blood sugar was checked on [DATE] at 10:22 AM by Staff CC, Certified Medication Assistant (CMA). His blood sugar was 536 milligram per deciliter (mg/dL). Review of Resident #39's [DATE] Medication Administration Record (MAR) revealed Staff CC administered the resident's as needed (PRN) order of oxycodone (narcotic pain medication) 5 milligram (mg) 1 tablet on [DATE] at 10:58 AM. Review of Resident #39's progress notes revealed the following note was documented by Staff F Licensed Practical Nurse (LPN) on [DATE] at 3:42 PM: called to the room, resident lying in bed, starring at the ceiling. He looked at the nurse when his name was called. Vitals obtained: blood pressure ,d+[DATE], respirations 14, oxygen saturation 92% on room air, and temperature was 96.4 degrees Fahrenheit. She noted the urine in his drainage bag to be creamy green in color. She did not note any shortness of breath or respiratory distress. Gave his PRN oxycodone at 11:30 AM. She went back in to the room at 2:30 PM by the request of the Certified Nursing Assistant (CNA), resident was dead, no apical pulse, no breathing. Hospice was made aware. His progress notes lacked documentation of notification of his hospice provider when he started to have a significant change in condition. Review of Resident #39's hospice notes provided by the hospice company revealed a Visit Note Report dated [DATE] with the visit type listed as hospice death at home. The report documented the nurse was in the facility on [DATE] at 4:16 PM until [DATE] at 4:35 PM. His hospice notes did not contain mention of the on-call hospice nurse or physician being notified of his emergent change in condition earlier in the day. Resident #39's hospice binder cover and hard chart cover had the following sticky noted taped to both covers: #39 is a patient under hospice care. Please call us for any of the following: change in condition. The sticky note listed the phone number along with the attending physician's name. On [DATE] at 7:00 PM Staff DD, CNA, stated on [DATE] at 10:00 AM Resident #39 told her that he did not feel right and felt like he was dying. She noted his skin to be pale, he was cold to the touch, sweating profusely, and saw that his urine was cloudy and a dull gray color. She noticed his catheter site had a split with puss coming out. She reported to this to Staff F, Licensed Practical Nurse (LPN), but she was very nonchalant, told her the resident was on hospice. She notified Staff CC, CMA, of her concerns and she checked his blood sugar; it was 536 mg/dL. Staff F, LPN, went in later to check on the resident and took his vital signs. The nurse told Staff DD, CNA, there wasn't anything she could do about it other than call hospice. Staff DD, CNA, was unsure if the nurse actually called hospice or not but does not think Staff F did until the resident passed away around 2:30 PM. Staff DD, CNA, indicated she frequently checked on him throughout her shift; every 30 minutes between her resident cares until she left at 2:00 PM. After Staff DD's shift she was told the resident passed away about ,d+[DATE] minutes after she left her shift. Staff DD, CNA, added it bothered her when she found out the resident passed away. Staff DD stated she thought the resident died alone without family or hospice staff with him. Staff DD, CNA, indicated she knew hospice staff would've came in if they were called but didn't think hospice was called. Staff DD, CNA, cried and didn't sleep very well because she kept thinking about the resident. On [DATE] at 12:38 PM Staff CC, CMA, stated on the day Resident #39 passed away she got report from the CNA that he was losing color, cold to the touch, sweating and clammy. Staff CC, CMA, stated when she took care of him when he was upstairs, he had done this before and they would sent him out to the hospital. When this was reported to her she checked his vitals and took his blood sugar which was like 536mg/dL. She reported her findings to the nurse on duty that day and Staff F, LPN, told her he was on hospice and they would have to go through hospice to send him out. She was unsure if Staff F, LPN, called hospice. Staff CC, CMA, reported Resident #39 had a second episode where he lost his color, was clammy so she went back in there and he looked dead. Staff F, LPN, reported to Staff CC, CMA, that she went in there his eyes rolled and had not expired at that time. Staff CC, CMA, verified Resident #39 had a PRN order to have his blood sugar checked but had no insulin orders. When she saw his urine that day it was cloudy and a greenish color but did not see his catheter site. He did ask for something for pain, so she gave that to him. When asked how he was prior to these episodes, she stated he did not eat much, but seemed like he was fine. When asked if the felt the nurse did everything she could have for him that day, she felt like she could have done more. She believed the call to hospice should have been done sooner. She believed Staff F, LPN, had a lot on her plate that; Staff F was the only nurse with two CMAs downstairs that day. On [DATE] at 1:14 PM Staff BB, LPN, was asked what she would do if a hospice resident became pale, cold to the touch, sweating profusely, had a blood sugar of 536 mg/dL and his catheter bag had cloudy, dull gray urine, she stated she would freak out then call hospice doctor. She would see what they needed to do for the resident. She would also notify hospice as well to see what they wanted to do. On [DATE] at 1:16 PM Staff E, LPN, stated she would call hospice and notify the physician right away if a hospice resident was pale, cool to the touch, sweating profusely, had a blood sugar of 536 mg/dL and had cloud, dull gray colored urine. On [DATE] at 8:23 AM the Administrator with the hospice provider indicated she was on-call the day Resident #39 passed away. She indicated the only the time facility staff notified her was when he had passed away. She added their hospice staff always tell staff and the resident to call them even if it is nothing. She stated they tell them this with every hospice visit. When asked if the facility should have called them when he had an emergent change in condition, she said they should have so they could figure out the family's or resident's goal based on their symptoms. Hospice would call the physician to get orders for the best way to provide comfort for this resident. If the facility was unable to get ahold of the hospice nurse they could call the hospice physician for guidance as well. They encourage the facility staff to call the hospice nurse first then the physician. She indicated they have an on-call system that notifies the nurse on call of a facility making a call. If that on-call person does not return the call within 15 minutes, it will automatically call her. On [DATE] at 9:41 AM Staff F, LPN, indicated she primarily worked downstairs. She indicated on the day Resident #39 passed away they had a nurse call in so she was the only nurse downstairs with two CMAs downstairs. She added that is a lot of work for one nurse. She recalled staff wanted her to go in and check on Resident #39. She described his urine as a creamy thick spinach color. She did not look at his catheter site. She told the CNA his body was shutting down and she had called hospice to get them at the facility immediately. She knew he was transitioning so she gave the PRN of oxycodone because he was also grimacing when he was touched or turned in bed. She believed he did not look any different that day. Staff then came to her and reported he was expired so she went in there, she did a sternal rub on him and he took a few breaths then passed away. When asked what CNAs were reporting concerns to her she stated there were like six on the floor that day and could not remember who it was. She did acknowledge that staff notified her of Resident #39 being pale, sweaty, and cool to the touch that day but when she went in there he was normal. His normal color was pale. When asked how much time had lapsed when she was notified by staff of their concerns until she went in the room; she stated not much time had went by. She was in the middle of a medication pass so she finished that then went in. She added no one saw her going in to Resident #39's room only coming out. When asked if she contacted hospice that day, she stated she called them twice. She indicated she called about 10:30 AM and the on-call person told her she was busy and could not make it to the facility. When she did arrive at the facility it was about 1:30 PM-2:00 PM right after he passed away. Staff F stated she let the hospice staff take over when she got there. Staff F added when she first called them she was told to keep him comfortable since he was on hospice there was nothing to do. During a follow-up interview with Staff F on [DATE] at 10:08 AM she indicated she could not remember what time she initially went in to his room. She added she was so busy with three other residents transitioning that that time. She indicated she went right to his room after she was done with her medication pass. When asked if she was administering morning to noon medications at that time, she stated she thought it may have been about 11:00 AM but did not look at the clock. She indicated she immediately took his vitals to see where he was at then called hospice. She told her everything and the hospice staff member advised her to keep him comfortable. Staff F stated about 1:00 PM she called hospice again, she indicated the hospice person advised her not to call the physician because he would not do anything. Staff F stated she was unsure when his blood sugar was taken and was not sure why the staff member did that. On [DATE] at 8:33 AM the Director of Nursing (DON) was asked if a hospice resident experienced a change in condition should their hospice provider be notified, she stated the nurse usually notifies hospice. When asked if this hospice resident had a change in urine characteristics and a high blood sugar she stated that is dependent on if they are close to end of life. It's a case by case decision. She acknowledged hospice should have been notified of Resident #39's change in condition, but it was her understanding that they were notified. In a follow-up interview on [DATE] at 2:52 PM she indicated she asked who Staff F spoke to and what she did once she was informed of Resident #39's elevated blood sugar. Staff F indicated she reached out to hospice in the morning and got the answering service, they told her they would get back to her. She called back again but did not take down the names of the person's she spoke to. The DON told her she should always take down the name of who you talk with. The DON then called the hospice provider to see when Staff F contacted them about Resident #39 on that day. The hospice provider indicated the facility only notified them of his passing. Staff F was then questioned if she notified the family or physician of the elevated blood sugar and she did not. She indicated the resident was on comfort measures. The DON explained to her the family has the right to change treatment or come off hospice. Staff F said that the resident was on hospice, she felt her job was to keep him comfortable and that is what she did. She provided holistic cares, pain management, repositioning, etc. She did acknowledge she called again when he passed away. When asked what the DON would have done in the situation, she stated she would have called the doctor and call the family to see what they would have wanted done. When the DON was informed the family was not notified, they did not have the option to be with him. She indicated she knew that and she would have notified them. On [DATE] at 2:25 PM the hospice physician/Medical Director indicated he was not notified of Resident #39's change in condition the day he passed away. He added he was only made aware of his passing. The facility should have notified him of his condition and blood sugar so they could act accordingly. On [DATE] at 9:56 AM Resident #39's Durable Power of Attorney (DPOA) indicated the hospice staff notified her of his passing. She did not receive a call from the facility that day to notify her of any changes. She was really surprised he went that fast, he was doing well once on hospice. On [DATE] at 2:18 PM the Administrator stated she would have expected Staff F to reach out hospice. If she was unable to do that then she should have called the physician or on-call nurse. The facility provided the following hospice agreement between the facility and hospice provider. This agreement dated [DATE] is between the hospice provide and nursing facility: 1) Duties and Obligations of Facility: Facility will provide the services necessary to meet the Hospice Patient's personal care and nursing needs in coordination with the Hospice representative and will ensure the level of care provided is appropriately based on the Hospice Patient's needs. Facility will have available and will provide as needed and upon written authorization from Hospice, the following accommodations and support services for Hospice Patients: - Nursing Services. Twenty-Four hour nursing care (including the services of a RN on duty every shift, 24 hours/day), sufficient to meet total nursing needs. Each Hospice Patient must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. 2) Designation of an Interdisciplinary Group Member. Facility will designate a member of the Facility's Interdisciplinary Group (IDG Member) who is responsible to work with Hospice staff to coordinate care provide to the Hospice Patient. The IDG Member must have a clinical background, function within their state scope of practice act, and have the ability to assess the Hospice Patient of have access to another person who has the skills and capabilities to assess the Hospice Patient. The IDG member is responsible for the following: - Collaborating with Hospice representatives and coordinating facility staff participation in the care planning process for those Hospice Patients receiving Hospice Services. This includes establishing how communication will be documented between Hospice and Facility to ensure the needs of the patient are addressed and met 24 hours per day. - Communicating with Hospice representatives and other healthcare providers participating in the provision of care for patient's terminal illness, related conditions, and other conditions to ensure quality of care for the patient and family. - Ensuring that Facility communicates with the Hospice medical director, the patient's attending physician and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. - Obtaining the following information from the Hospice: a) The most recent Hospice Plan of Care for each Hospice Patient d) Names and contact information for the Hospice personnel involved in the care of each Hospice Patient e) Instructions on how to access Hospice's 24 hour on call system f) Hospice medication information specific to each Hospice Patient g) Hospice physician and attending physician orders for each Hospice Patient 3) Notification to Hospice. Facility will immediately notify Hospice if: - A significant change in a Hospice Patient's physical, mental, social, or emotional status occurs - Clinical complications that suggest a need to alter the Plan of Care - A need to transfer a Hospice Patient from the Facility for any condition

Based on clinical record review, resident, family, physician, and staff interviews, and policy review, the facility failed to ensure residents provided with routine repositioning to prevent pressure ulcers (Resident #3, #16) and failed to evaluate and provide appropriate sized equipment and initiate hospice orders for 1 resident (Resident #39) out of 4 residents reviewed for pressure ulcers. This resulted in harm to the residents due to residents developing facility acquired pressure ulcers. The facility staff identified 8 residents with pressure wounds at the time of the survey. The facility reported a census of 86 residents. Findings include: MDS Definitions of Pressure Ulcers Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident totally dependent upon 2 person physical assistance for bed mobility and transfer. The MDS documented diagnoses that included sarcopenia (age related progressive loss of muscle mass and strength), diabetes mellitus, dementia, and morbid obesity. The MDS dated [DATE] documented a height of 62 inches and a weight of 386 pounds. The Comprehensive Care Plan for Resident #3 revealed a focus area of impairment to skin integrity with multiple wounds including a Stage 3 pressure ulcer to sacrum. Interventions included off load heels as ordered and turn and reposition routinely and as needed. The Progress Note dated 1/29/2023 at 6:33 pm documented Resident #3 had excoriated buttocks and stated buttucks painful when touched. The Progress Note dated 1/31/23 at 2:57 pm documented staff placed a call to the facility Advanced Registered Nurse Practitioner (ARNP) regarding buttocks excoriation. The Wound Evaluation and Management Summary dated 2/2/23 documented the resident as having a Stage III pressure wound to the sacrum. The documentation reflected this wound at Site #31 for wound evaluation. Prior to this visit, the wound physician had been treating the resident for 30 prior wounds. The Summary documented the wound as etiology of Pressure, Stage 3 and size of 2.0 centimeter (cm) x 0.5 cm x unmeasurable depth, 100% slough covered. The evaluation recorded diabetes and dementia as relevant conditions that contributed to wound healing. Recommendations made during the visit included off-loading the wound site and to reposition per facility protocol. The Wound Evaluation and Management Summary dated 3/30/23 documented the Site #31 as Stage 3 Pressure, size of 2.0 cm x 0.5 cm x 0.1 cm, 100% granulation tissue, noted as healing. Recommendations remained as off-loading and repositioning. On the 3/30/23 visit, additional wounds of numbers 41-47 were all documented as new wounds. The Summary documented Site 41 as etiology of Pressure, unstageable Deep Tissue Injury of the right heel. Sites 42-47 were documented as unstageable deep tissue injury to the fingers of both hands, all documented as pressure in etiology. The Wound Evaluation and Management Summary dated 5/5/23 documented Site #31 as Stage 3 Pressure, size of 1.5 cm x 0.5 cm x 0.2 cm (increasing in depth), 100% granulation tissue, noted as healing. Recommendations remained as off-loading and repositioning. On the 5/5/23 visit, additional wounds of numbers 48-55 were all documented. The Summary documented Site 48 as non pressure, moisture associated skin damage to the right buttocks. Site 49 was documented as a Stage 4, etiology of pressure to the right, dorsal, lateral hand. Site 50 was documented as a venous wound of the left shin. Site 51 was documented as an unstageable deep tissue injury, etiology of pressure, to the left first finger. Site 52 was documented an unstageable deep tissue injury, etiology of pressure, to the left fifth finger. Site 53 was documented an unstageable deep tissue injury, etiology of pressure, to the right fifth finger. Site 54 was documented an unstageable deep tissue injury, etiology of pressure, to the right fourth finger. Site 55 was documented an unstageable deep tissue injury, etiology of pressure, to the right third finger. On 5/15/23 at 9:56 am, a family member of Resident #3 stated every time she was in the facility to visit, Resident #3 was flat on her back. She stated she had never seen the resident turned to her side. She stated she wondered if due to the resident's obesity the facility was not capable of turning her but stated it's not good for the resident to be on her back all of the time. Observeation on 5/15/23 at 11:05 am revealed Resident #3 laid on her back with a low air loss mattress in place on her bed. Observation revealed a treatment dressing in place on the resident's right hand and her left hand had multiple dark scabs on her knuckles. Observation on 5/16/23 at 7:55 am revealed Resident #3 again laid on her back in bed. On 5/16/23 at 10:28 am Staff A, Hospice Case Manager Registered Nurse (RN) and Staff B, Licenses Practical Nurse (LPN), with assistance from Staff C, Certified Medication Aide (CMA) performed wound care on the wounds to Resident #3's sacrum and right buttoks. Following wound care, the staff provided significant repositioning assistance and changed the resident's gown. The staff left the resident positioned on her back following cares. On 5/16/23 at 10:59 am, Staff B, LPN, stated the resident stayed primarily on her back at all times but tilted with pillows. Staff B stated that was due to the resident having pain and due to her bariatric size. Continuous observation occurred on 5/16/23 from 12:30 pm to 1:57 pm. The observation revealed no staff members entered Resident #3's room since wound care completed at 10:59 am. At 12:40 PM, Staff D, Certified Nurse Aide (CNA) dropped a lunch tray off in Resident #3's room and exited the door a moment later. At 12:52 pm, Staff D returned to assist Resident #3 to eat. At 1:06 pm, Staff D exited the room carrying the food tray and placed it in the kitchen cart. At 1:20 PM, Staff D stated that Resident #3 always stayed in bed. Staff D stated the resident required total assistance of 2 staff members to provide all cares except eating which required 1 staff person only. Staff D stated it took 2 people to reposition the resident and if the resident were to get out of bed, that would take 2 staff members using a hoyer lift (mechanical full body lift). At 1:57 PM, no staff members had cared for Resident #1 except for providing lunch; more than 3 hours had passed since the completion of wound cares. Continuous observation occurred on 5/21/23 from 11:41am to 3:40 pm. Observation revealed at 11:41 am Resident #3 laid on her back with her heels floated. At 12:46 pm, Staff E, LPN stated she was unaware of what treatments were ordered for Resident #3 but she would look after she completed medication pass. Staff E stated her work hours were 6:00 am to 6:00 pm. At 1:10 pm, Staff D, CNA, entered the resident's room with a lunch tray. At 1:15 pm, Staff D sat on a bench in the resident's room using her personal cell phone with Resident #3's lunch tray sitting untouched next to her. At 1:35 pm, Resident #3 remained in the same position as at the beginning of the observation At 2:15 pm, Staff E, LPN and Staff F, LPN, Nursing Supervisor, stated they would provide wound care treatments. Staff F responded she expected Resident #3 to be assisted to reposition at least every 2 hours. Staff F stated due to incontinence, the resident would likely need assistance more often than every 2 hours. At 2:20 pm, Staff E stated she was not familiar with the orders for Resident #3 and she was having difficulty getting the computer to work in the room. At 2:25 pm, Staff E administered morphine to Resident #3 prior to beginning wound care. At 2:35 pm wound care was started. This was 2 hours and 54 minutes after the start of continuous observation. Multiple wounds were cleansed and dressed. At 3:20 pm an additional dose of morphine was given to Resident #3 for comfort during the remaining wound care. Wound care was stopped to allow the resident to rest while the morphine had time to take effect. Wound care resumed at 3:30 pm. Two additional staff members, Staff G, CNA and Staff H, CNA entered the room to assist with repositioning. Complete repositioning occurred along with bedding and gown change with continuous observation ending at 3:40 pm. On 5/22/23 at 10:02 the Director of Nursing (DON) stated she expected that any resident who was unable to turn themselves should be repositioned a minimum of every two hours. On 5/23/23 at 11:23 am, the Wound Care Physician stated she had most recently cared for Resident #3 the previous week. She stated the resident did not tolerate lying on her side for very long. She stated the biggest factors in wound healing are off loading the pressure and the use of the low air loss mattress. She further stated the resident had significant moisture associated skin damage. She said the pressure wound to her sacrum has had minimal change or improvement and the most important factor for it to heal was off loading pressure. She stated she felt it was unlikely to ever heal fully but it would be beneficial for the resident to lie on her side. She stated she was not in the building for long enough to know if staff were repositioning the resident every two hours but it was her recommendation that it be done. The policy titled Skin Care Treatment Regimen, Revision dated 7/28/22 documented: Residents who are not able to turn and reposition themselves will be turned and repositioned every two hours unless specified in the Physician Order Summary. Review of the Physician Order Summary has no additional orders for repositioning for Resident #3. 34817 2. The admission MDS assessment dated [DATE] revealed Resident #16 admitted to the facility on [DATE] and had diagnoses of diabetes, urinary tract infection, and coronary artery disease. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS revealed the resident had a risk for pressure ulcer development but had no skin problems or pressure sores. The significant change MDS dated [DATE] revealed the resident required extensive assistance of two for bed mobility, transfers, and toileting. The MDS documented the resident had a risk for pressure ulcer but had no skin problems or pressure sores. The MDS indicated the resident on hospice. The care plan initiated 3/7/23 revealed the resident had a risk for skin breakdown due to a history of dehydration, incontinence, diabetes, and immobility. The care plan documented the resident had a non-pressure wound on his right plantar lateral foot and a Stage 1 pressure sore on his right great toe. The care plan also revealed the resident required assistance with ADL's (activities of daily living) including bed mobility and transfers due to limited mobility and physical inactivity. The care plan directives for staff initiated on 3/7/23 included administer treatments as ordered and monitor for effectiveness, apply bilateral heel protectors as indicated, float heels at all times when in bed, provide a pressure relieving/reducing device on the bed and in the chair, and turn and reposition the resident routinely and as needed. The order summary report revealed the following: . a. Medex boots to heels for protection at all times while in bed started on 3/6/23 b. Body audit every Tuesday for skin observation started on 3/7/23 c. Right plantar foot wound: apply skin prep daily (started on 3/30/23); apply betadine and leave area open to air (started on 4/22/23); cleanse and apply gauze soaked in dakins quarter strength to the wound bed and cover with border gauze every day (started on 5/12/23). d. Left plantar foot wound: apply betadine and leave open to air daily started on 4/22/23 e. Right foot first (great) toe: Apply skin prep daily started on 5/6/23. The nursing admission assessment dated [DATE] revealed the resident had a small pinpoint area on his coccyx. The admission assessment revealed the resident scored 16 on the Braden Scale, indicating he had a high risk for pressure ulcer development however the top right side of the document revealed the category listed as low risk and a score of 7. The admission assessment revealed the following responses marked: the resident responded to verbal commands, but could not always communicate discomfort or the need to be turned, the resident had some sensory impairment which limited his ability to feel pain or discomfort in 1 or 2 extremities, he had exposure to moisture at least once a day, had a slightly limited ability to change and control body position, and had a potential problem with friction and shear. The progress notes revealed the following: a.On 3/21/23 at 7:01 PM, the resident's wife notified Staff W, agency Registered Nurse (RN) the resident had a wound on the bottom of his right foot. Staff W observed a necrotic wound. The wound measured 0.8 centimeter (cm) x 0.6 cm. No drainage noted. The bottom of the left foot had a 0.2 cm x 0.2 cm wound. No drainage noted. Hospice contacted. Hospice staff stated a hospice nurse would come and assess the resident. b. On 3/22/23 at 3:45 PM, the nurse practitioner (NP) documented the resident had a pressure ulcer on the anterior part of his right foot. The resident had pain rated at 4 out of 10, and was educated to elevate his leg. The NP documented the resident had a pressure ulcer present on both feet. The right lower extremity pressure ulcer measured 2.2 cm x 2 cm, and the left lower extremity wound measures 0.7 cm x 0.5 cm. The NP ordered a wound care physician (Dr) consult. c. On 3/30/23 at 3:50 PM, resident seen by the wound care Dr. A non-pressure wound on the right plantar lateral foot measured 2 cm (L)(length) x 1.8 cm (W)(width). No new orders received. d. On 4/7/23 at 7:28 AM, resident seen by the wound Dr on 4/6/23. A non-pressure wound of the right plantar lateral foot measured 2 cm (L) x 1.8 cm (W). No new orders received. e. A late entry progress note dated effective 4/13/23 at 2:12 PM, but created on 4/14/23 at 2:13 PM by Staff X, unit manager, revealed the resident seen by the wound Dr on 4/14/26. The resident's plantar lateral foot measured 2 cm (L) x 1.8 cm (W) and had a scab. New orders received and resident educated at the bedside. f. Another late entry progress note created by Staff X on 4/21/23 at 4:02 PM but effective on 4/20/23 at 4:00 PM revealed the resident seen by the wound Dr. A non-pressure wound of the right plantar lateral foot scab measured 2 cm (L) x 1.8 cm (W). A non-pressure wound on the left plantar lateral foot measured 0.3 cm (L) x 0.3 cm (W). The periwound (tissue surrounding the wound) had purpura (purple spots). New orders received. g. A late entry progress note created on 4/21/23 at 4:06 PM by Staff X but effective 4/20/23 at 10:05 AM revealed an end of bed extender lengthened by maintenance per request of the wound Dr due to the resident had a new foot wound. h, On 4/27/23 at 5:22 PM, wound Dr saw the resident. A non-pressure wound of the right plantar lateral foot measured 2 cm (L) x 1.8 cm (W). The left plantar foot wound had resolved. i. On 5/4/23 at 12:45 PM, a dark area noted to the right lateral foot. No redness or warmth surrounded the wound site. Resident compliant with wearing heel protectors. j. On 5/5/23 at 11:02 AM, wound Dr saw the resident. The resident's right plantar lateral foot wound measured 2 cm (L) x 1.8 cm (W) and had 100% thick adherent black necrotic tissue. The resident also had a wound on the right first toe that measured 0.3cm (L) x 1.1 cm (W). No drainage noted. Skin prep applied daily. k. On 5/11/23 at 3:23 PM, wound Dr saw the resident. The right plantar lateral foot non-pressure wound measured 2 cm (L) x 1.8 cm (W) and had 100% thick adherent black necrotic tissue. The right first toe wound measured 0.1cm (L) x 0.8 cm (W) x 0.1 (D). l. On 5/18/23 at 3:06 PM, wound Dr saw the resident. A non-pressure wound of the right plantar lateral foot measured 2 cm (L) x 1.5cm (W) and had 100% thick adherent black necrotic tissue. The right first toe wound measured 0.1cm (L) x 0.8 cm (W). The specialty physician wound evaluation and management summary revealed the following on the right plantar lateral foot: a. On 3/30/23 a non-pressure ulcer measured 2 cm x 1.8 cm. The physician recommended to offload the wound, reposition per facility protocol, and apply skin prep daily. b. On 4/6/23 the wound measured 2 cm x 1.8 cm. The physician recommended to offload the wound, reposition per facility protocol, and apply skin prep daily. c. On 4/13/23 the wound measured 2 cm x 1.8 cm. The physician recommended to continue to offload the wound, reposition per facility protocol, and apply skin prep daily. d. On 4/20/23, the wound measured 2 cm x 1.8 cm. The physician recommended removal of the bed foot board as the resident had a bed extender but his foot still pushed against the board. e. On 4/27/23, the wound measured 2 cm x 1.8 cm. The wound depth not measurable due to presence of nonviable tissue and necrosis. The physician recommended removal of the bed foot board as the resident had a bed extender but his foot still pushed against the board, reposition per facility, and continue skin prep daily. f. On 5/5/23 and 5/11/23, the wound measured 2 cm x 1.8 cm. The physician recommended removal of the bed foot board as the resident had a bed extender but his foot still pushed against the board, reposition per facility, and continue skin prep daily. The skin alteration record dated 5/11/23 revealed the resident had an eschar wound on the right plantar foot measuring 2 cm x 1.8 cm. A pressure ulcer healing chart used to monitor trends in PUSH scores over time revealed a record only for the right first toe. The document revealed on 5/5/23, a PUSH total score of 3 indicating the wound the size of 0.7 cm x 1.0 cm. On 5/11/23, a PUSH score of 1 indicating the wound less than 0.3 cm. A pick-up/exchange ticket dated 5/18/23 revealed a 36 inch ultracare low air loss mattress picked up on 5/18/23. Observations revealed the following: a. On 5/16/23 at 8:10 AM, resident lying in bed with feet on the mattress. b. On 5/16/23 at 9:15 AM, resident continued to lying in bed on his back and feet on the mattress. No pillow observed under the resident's legs. c. On 5/16/23 10:15 AM, resident continued to [NAME] in bed on his back. On 5/16/23 11:10 AM, resident continued to [NAME] in bed on his back. On 5/16/23 at 12:20 PM, Staff L, CNA, and Staff M, CNA, transferred the resident from the bed to the broda chair. Staff L and Staff M placed the foot platform (attached to the broda chair) in the down position. The top of the broda chair was in a semi-reclining position and the resident's feet extended over the end of the platform, The broda chair wasn't long enough for the height of the resident. Staff L placed a pillow under the resident's legs but the resident's feet and ankles were lying on the metal ridge of the foot platform on the broda chair. On 5/16/23 at 2:46 PM, resident now lying in bed. On 5/17/23 at 10:50 AM resident lying in bed with eyes closed. Bilateral feet lying on the mattress, no pillow under the resident's legs. A bed extender was observed on the end of the bed. On 5/17/23 at 12:29 PM, the DON removed the dressing on the resident's right lateral plantar food. The right lateral plantar foot had a nickel-sized scabbed, necrotic area. At 12:40 PM, Staff E, LPN, donned gloves, cleansed the right lateral plantar foot wound, changed gloves and sanitized hands, then applied a dakin's soaked gauze to the wound bed, and a border dressing to the area. Staff E removed her gloves, sanitized hands donned gloves and applied skin prep to the right great toe. During an interview 5/17/23 at 1:00 PM, Resident #16 reported he got a different bed a couple of days ago (on Monday 5/15/23, the day the surveyor entered the facility). The resident reported he was 6 foot 3 inches tall and the bed he had wasn't long enough. Staff had to put pillows in front of the end of the bed because his feet pressed up against the bedboard. The resident stated sometimes staff put a pillow under his legs to float his heels but sometimes it hurt his knees and unable to tolerate pillow at all times. The resident reported the Broda chair provided by hospice but his feet hung over the footboard because he was too tall. The resident reported staff placed a pillow under his legs whenever he sat in the chair. During an interview 5/17/23 at 4:00 PM, the DON reported documentation on wounds and pressure ulcers in the progress notes, but she also had a skin book with documentation of current wounds. The DON stated a referral made to the wound Dr anytime a resident had a significant wound. The NP came to the facility every Wednesday and evaluated the resident's wound progress. The DON stated the wound Dr's wound documentation located in the resident's paper chart. During an interview 5/18/23 at 3:15 PM, Staff Z, CNA, reported she had worked at the facility [AGE] years. Staff Z reported hospice staff came to the facility to see Resident #16 four times a week. Staff Z was unsure of the days when hospice visited. Staff Z reported Resident #16 required assistance with positioning in bed. During an interview 5/19/23 at 8:30 PM, Staff J, Registered Nurse (RN), reported lots of residents required two staff for assistance and cares. Staff J reported several residents had developed pressure ulcers because the residents had not been repositioned like they should due to the lack of staffing. During an interview 5/22/23 at 9:00 AM, Staff Q, RN, reported interventions such as positioning the resident put into place for prevention of pressure ulcer if a resident had a risk for pressure ulcer development. Staff Q reported the resident's skin risk level depended on if more specific interventions put into place. During an interview 5/22/23 at 3:00 PM, Staff V, medical records assistant reported a box located at the nurse's station for nurses to put items to go to medical records. Staff V stated the box utilized by staff to place discharged resident records, and staff supposed to file documents in the hard (paper) chart for residents who remained at the facility. Staff V acknowledged she also had a file with some records for residents who remained in the facility. The surveyor looked at Resident #16's file with documents in medical records with Staff V. The medical records file contained a pick-up exchange ticket dated 5/18/23 for a low air loss mattress, and a delivery ticket dated 3/29/23 for a broda chair and a seat lift chair. Staff V stated she believed the resident just needed the mattress because the facility had their own beds and bariatric beds. Staff V reported a certain vendor delivered equipment for residents on hospice. During an interview 5/22/23 at 3:35 PM, Staff AA, LPN, reported she let maintenance know if a resident needed a bed extender added to the bed. During an interview 5/22/23 at 3:45 PM, the DON reported Resident #16 didn't qualify for a bigger bed per hospice. The facility had their own bariatric sized bed and provided the resident a larger bed. The DON was unsure of the date when a bariatric bed provided to the resident but stated the vendor picked up the air loss mattress on date listed on the pick-up ticket. During an interview on 5/22/23 at 3:50 PM, the vendor reported the air loss mattress delivered on 3/20/23 and picked up on 5/18/23. During an interview 5/23/23 at 10:30 AM, the NP reported she had been a NP for 2 1/2 years and contracted to work as the NP with the facility for the past 10 months. The NP reported she was unable to speak on the minimum interventions put in place for a resident if a resident had a risk for a pressure ulcer. It depended on the resident. When asked if a resident not repositioned or whenever orders or treatments not done if there would be a decline with a wound, the NP responded she had no knowledge what staff were doing and couldn't speak to the surveyor's question. The NP reported most of the time if a resident alert and oriented she asked the resident if they had any skin issues. Otherwise it depended on the resident whether she performed a head to toe skin assessment when a resident admitted to the facility and during follow up visits. The NP stated no policy or protocol used when a pressure area developed to promote wound healing as they didn't have one. The NP confirmed she was notified of a wound on Resident #16's foot and saw the resident on 3/22/22. The NP stated the wound type was a lower extremity ulcer caused by pressure on his bilateral feet. She directed staff to talk to the wound Dr about wound care. The NP was unable to say if the wound was preventable because each resident was different on the things they liked to do or didn't do. A number of factors played a role in a patient getting a wound. The NP was unable to be more specific on what factors would play a role in development of Resident #16's wound. The NP reported she didn't do anything with a Broda chair so she wouldn't know proper positioning in a Broda chair or what staff do for positioning the resident in the Broda chair. During an interview on 5/23/23 at 10:47 AM, the Maintenance Director revealed the facility had a process in place for work orders to be submitted if something needed fixed or replaced. He stated staff submitted a Maintenance Request Slip. He kept the requests in a notebook after the maintenance request completed. The maintenance director stated he received maintenance request slips for Resident #16 on 3/31/23 when he fixed the wall plate for his TV and extended his bed at that time about two feet. He then revealed on 5/15/23 he replaced Resident #16's bed with a bariatric bed. During an interview 5/23/23 at 11:30 AM, the wound Dr reported if a resident had a risk for pressure ulcer, the minimum interventions expected put into place included the need to offload the area, do frequent position changes, and offload the heels if a resident stayed in bed. An air loss mattress used if a resident had a pressure injury. The resident's wound had a potential for decline if area not offloaded, especially if the resident not able to move on their own The wound Dr explained the importance of offloading the area in order to prevent development of a pressure area. The wound Dr reported Resident #16 had a nonpressure trauma injury wound on his right foot upon admission. The wound Dr stated she had no opinion on if the wound was preventable or not. If the resident had pressure for extended period of time without offloading the area then the area had an increased risk for development of a wound. During an interview 5/24/23 at 9:55 AM, the Director of Nursing (DON) reported if a resident not wearing foam boots she expected a resident's heels floated by placement of a pillow under the resident's legs so the resident's feet did not touch the bed. The DON reported the importance for staff to get pressure off the resident's heels to prevent a pressure injury. During an interview 5/30/23 at 12:50 PM, Staff E, LPN, reported skin assessments completed weekly and marked on the MAR when completed. During an interview 5/30/23 at 1:00 PM, Staff Y, LPN, reported skin assessments performed by the wound Dr, DON, and/or unit manager every Thursday. A skin sheet filled out if a resident had a skin area of concern. Skin assessment documented by the wound Dr and on a skin sheet by the DON/unit manager. An order obtained for an air loss mattress or scoop mattress, and position the resident every 2 hours whenever a resident had a risk for pressure ulcer. During an interview 6/1/23 at 12:20 PM, Staff X, RN, Unit Manager reported she worked as the unit manager for 6 months but left the facility 2 months ago. Staff X reported the admission assessment completed by the nurse on the floor or the admission nurse. Staff X acknowledged she wrote a progress note when she requested maintenance to remove or extend the end of the bed further on Resident #16. The wound Dr came on Thursdays, but she wrote the note on Friday 4/21/23. She noticed the resident's foot wound injury likely from resting on the end of the bed. She noticed a pressure area on the Thursday (4/13) prior to the week before the note she wrote on 4/21/23. The resident had two toe injuries upon admission that th [TRUNCATED]

Based on clinical record review, observations, family and staff interviews, and facility policy review, the facility failed to evaluate and document an assessment and ensure a resident able to utilize a motorized wheelchair while indoors and outdoors safely for 1 of 1 residents reviewed with a motorized wheelchair (Resident #11). The facility staff also failed to follow the facility's fall pathway and properly intervene after a resident had a fall and moved the resident despite the resident complained of pain for 1 of 3 residents reviewed for a fall (Resident #40). The facility also failed to ensure portable oxygen safely stored for 1 of 3 residents reviewed for oxygen use (Resident #16), and failed to appropriately supervise and redirect a cognitively impaired resident from accessing a fire panel with a fire extinguisher inside (Resident #15), and failed to ensure medications carts locked for 1 of 4 medication carts reviewed. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 11 had diagnoses of stroke, diabetes, hemiplegia (paralysis on one side of the body), and sarcopenia (a gradual loss of muscle mass, strength and function). The MDS revealed the resident had a brief interview for mental status (BIMS) score of 15, indicating cognition intact. The MDS documented the resident used an electric wheelchair and independent with locomotion and movement on and off the unit. The Care Plan initiated on 12/5/22 revealed the resident had an ADL (activities of daily living) self-care deficit related to physical limitations after a CVA (cerebrovascular accident) (stroke) with hemiplegia and weakness. The Care Plan revealed the resident was independent in a power wheelchair and desired to participate in outdoor weather activities. The electronic health record and paper chart lacked an assessment performed or completed on the resident's capability to use a motorized wheelchair indoors and outdoors safely. The Progress Notes revealed the following: a. On 5/8/23 at 2:54 PM, the Director of Nursing (DON) was summoned outside. Resident #11 found lying on his back in a supine position. The resident stated he got too close to the sidewalk and drove his electric wheelchair partway up on the curb of the sidewalk, tipped the wheelchair over, and landed headfirst. The resident stated he hit his head and complained of head pain. 911 was called. An ambulance arrived and placed a c-collar (around the resident's neck). Resident transported to the hospital for further evaluation. b. On 5/8/23 at 11:19 PM, resident arrived at facility via ambulance at about 11:00 PM. The resident had new diagnoses of acute non-intractable headache and a contusion on his left elbow. The resident rated his pain at a 3 out of 10, and had pain medication administered. c. On 5/9/23 at 2:50 PM the Nurse Practitioner (NP) documented she saw the resident after he had a fall. Resident reported he used his wheelchair outside, got too close to the sidewalk, and tipped his wheelchair. The resident reported he landed on his head. Resident sent to the emergency department and evaluated. The resident reported the left side of his face and head hurt. Pain rated at 5 out of 10. The NP documented had acute left sided headache and jaw pain. The treatment plan included hydrocodone (pain medication) 5-325 milligrams (mg) orally every 4 hours as needed for pain. A Fall Risk Evaluation dated 5/8/23 at 2:35 PM revealed the resident had a low risk for falls. A Post Incident Follow Up dated 5/8/23 at 2:35 PM revealed the resident had a fall incident. The document revealed vital signs and a head to toe assessment completed and a new injury found, but unable to assess the resident's neck due to pain. The resident rated his pain at 10 out of 10. Review of Occupational Therapy Evaluation and Notes 7/15/22- 1/23/23 and Physical Therapy Evaluation and Notes 12/2022 lacked a motorized wheelchair assessment and evaluation for Resident #11 to safely operate a motorized wheelchair indoors and outdoors. A Physical Therapy evaluation dated 5/11/23 revealed Resident #11 referred to therapy for a wheelchair driving assessment due to recent fall outside when his wheelchair tipped over off of the curb. The resident was independent with motorized wheelchair previously. The resident's diagnoses included repeated falls, muscle wasting and atrophy, and sarcopenia. Therapy recommended the resident be modified independent with the electric wheelchair while indoors and outdoors. During an interview on 5/24/23 at 9:55 AM, the DON reported Resident # 11 went outside in motorized wheelchair and while he passed by another resident on the sidewalk, the two wheels got caught between the sidewalk and curb and he tipped over in the wheelchair. An ambulance was called and the resident went to the hospital to be examined. The resident was medically cleared and sent back to the facility. The DON stated a therapy evaluation requested upon resident's return from the hospital to determine if the resident safe to use a motorized wheelchair before he could use the electric wheelchair again. The DON reported she was unsure when the resident had an evaluation for use of motorized wheelchair before this incident. During an interview on 5/30/23 at 9:25 AM, Staff U, Physical Therapy, reported therapy unable to access therapy notes and records after transition to new company because they no longer had access to the records. Staff U stated the surveyor needed to check with medical records for therapy notes and evaluations prior to transition to new company. Staff U reported Resident #11's last and most recent therapy evaluation completed 5/10/23. On 5/30/23 at 10:00 AM, Staff V, medical records assistant, stated she was unable to obtain or provide records prior to switch in company. She would need to fill out a form and submit it to corporate to get the information requested by surveyor. 2. The MDS assessment dated [DATE] revealed Resident #40 had diagnoses of a muscle disorder and weakness, diabetes, and a fracture. The MDS recorded the resident had a BIMS of 6, which indicated severely impaired cognition. The MDS revealed the resident had no behaviors, and required limited assistance of one staff for bed mobility, supervision for transfers, ambulation in the room and corridor, and extensive assistance of one for toileting. The MDS documented the resident had a fall without injury but had no special treatment or therapies. The resident took opiod and diuretic medications during the 7 day look-back period. The Care Plan initiated 6/20/21 revealed Resident #40 had limited mobility related to chronic back pain and a history of a L2 (second lumbar) (lower back) fracture. The Care Plan also revealed the resident had a risk for unavoidable falls due to a history of falls, weakness, dementia, chronic pain, and restlessness. The staff directives included the following: Reinforce the need to call for assistance. Anticipate resident needs due to noncompliant with call light and dementia (added 6/20/21). Encourage resident to stay in common areas when awake for increased observation (added 6/29/21). Provide a room close to the nurse's station (added 6/29/21). Scoop mattress on the bed to help identify bed boundaries (added 7/29/21); mattress checked and changed after a fall 8/11/22. Keep non-slip and well-fitting footwear on the resident (added 11/10/21). Provide and keep walker nearby (added 7/18/22). Keep bed in low position (added 12/20/22, cancelled on 1/26/23). Send to ED (Emergency Department) for evaluation (added 5/30/23). A Fall Risk Evaluation dated 5/4/23 and 5/29/23 revealed the resident had a high risk for falls. The Progress Notes revealed the following: a. On 5/4/23 at 2:54 PM, a Change of Condition Note revealed the resident found on the floor in front of his bed, and resident stated he wanted to get off the floor. ROM (range of motion) within normal limits. Resident denied hitting his head, and had no skin alterations or bruises. Staff assisted resident off the floor. b. On 5/15/23 at 2:59 PM, resident wandering the hallways without a walker. Resident educated to ask for assistance when ambulated. c. On 5/29/23 at 8:27 PM, Staff II, agency LPN, documented she was called into the resident's room by the Certified Medication Assistant (CMA). Resident found on floor lying on his right side. The resident stated he was walking and lost his balance. Resident complained of increased pain with ROM and unable to bear weight on his right leg. Blood pressure and heart rate elevated. NP notified and order received to transfer the resident to the ED for further evaluation. d. An Incident Note documented on 5/31/23 at 12:34 PM revealed Staff II charted: upon assessment resident had shortening on the right side and increased pain with movement. Resident stated area felt better when lying still. Scheduled dose of pain medication given. d. On 5/31/23 at 7:23 PM, resident readmitted to the facility. Incident Reports revealed the following: a. On 1/21/23 at 1:10 PM, resident found lying on his right side on the floor in the dining room. The resident said the chair moved when he sat down and he fell . Resident assessed for injuries and had a hematoma (bruise) on the right side of his head. Two staff assisted the resident onto his feet. Physician and family notified. b. On 1/23/23 at 3:43 PM, resident found on floor by the bed with walker in front of him. Resident tried to transfer from a lowered bed into a chair. Two staff used a gait belt and assisted the resident up. c. On 2/16/23 at 11:59 PM, resident on floor and had back against the bed. The bed was at ground level. Vital signs obtained. Resident complained of some back pain when lifted back into bed. d. On 2/27/23 at 5:32 PM, resident found on the floor and had increased pain to his right hip. Right foot abducted (moved away from the body) and right leg shorter than the left leg. Resident sent to the hospital. e. On 5/29/23 at 8:03 PM, resident lying on the floor on his right side. Resident stated he was walking and lost his balance. The resident had increased pain with ROM and unable to bear weight onto his right leg. NP notified. Resident sent to the ED for further evaluation. A Facility Investigation File provided to the surveyor on 6/6/23 revealed a self reported incident to the State Department of Inspections and Appeals (DIA) due to an accident with major injury that occurred on 5/29/23 at 8:02 PM. A CMA reported she heard a noise while standing at her medication cart. She found the resident lying on his right side in his room next to the privacy curtain. The resident had gripper socks on. No debris or moisture on the floor. Nurse notified of fall and assessment performed. Rated pain at 8 (on 1-10 scale). Resident incontinent of urine. NP notified due to resident pain and decreased ROM. Order received to transport to the ED for further evaluation. Last seen and last checked on when walked back from dinner at 6:30 PM. The Facility Investigatin File lacked witness statements from staff. A History and Physical dated 5/29/23 at 10:42 PM revealed staff found the resident on the ground and complained of right hip pain. Right foot externally rotated. Oxycodone (narcotic pain medication) received prior to EMS (Emergency Medical Services) arrival. Resident unable to ambulate per usual. History of dementia, recurrent falls, and L2 compression fracture. Resident stated he got up without his usual 1-2 person assistance and got tangled up in stuff and fell forward. Per staff, resident found on the floor. Staff helped him up, however the resident unable to put weight on his right foot. Sent to the ED. Staff reported resident falls more often after his last hospitalization . diagnosed with an L2 compression fracture at that time (in April). On examination, resident unable to move his right leg, and his left leg shorter than the right and turned outward. A pelvic CT (cat scan) revealed a nondisplaced fracture involving the posterior greater trochanter of the right hip. Ortho surgery consulted. During an interview on 6/7/23 at 9:25 AM, Staff D, CNA, stated Resident #40 confused and tried to get up and walk on his own but forgot to take the walker with him. Staff always had to remind the resident to ask for assistance and to take his walker with him. Staff used a hoyer for transfers since the resident came back from the hospital because the resident fell and had a hip fracture. Staff D stated she was not working on the day the resident fell and fractured his hip. During an interview on 6/7/23 at 9:50 AM, Resident #40 recalled he fell last week and went to the hospital. The hospital kept him overnight and gave him something for pain but he was unable to have surgery on his broken hip. The resident reported on the day of his fall incident he got out of bed, lost his balance, fell , and landed on his right side. The resident unable to recall if he had turned his call light on or not prior to the fall. During an interview on 6/7/23 at 7:10 PM, Staff II, agency LPN, reported she had worked at the facility as agency off and on since 1/2023. Staff II reported Resident #40 had dementia, poor safety awareness, self transferred alot, and noncompliant with using his walker. The resident also had alot of anxiety. Prior to the resident's fall (on 5/29/23) he required assistance of one staff for cares and ambulated with a walker. On the night the resident fell , as she passed bedtime medications for other residents, a CMA on the [NAME] hall yelled a resident on the floor. She went into the resident's room, checked the resident's vital signs, assessed the resident and performed range ROM while the resident laid on the floor, The resident couldn't tell her what hurt. After she assessed the him, two CNA's stood the resident up. The resident said Ow and pointed to his right hip. The staff then pivot transferred him into bed. A CNA stood on each side of the resident and Staff II stood in front of him. She didn't have staff walk him but rather pivoted and transferred him into bed. The staff who assisted during this time were an agency CNA and a facility CNA but Staff II unable to recall their names. As the resident laid in bed, she assessed the resident more. He continued to complain of pain with movement but had no pain while at rest. She called the on-call NP, and transferred the resident to the hospital. Staff II reported adequate staffing on the evening of 5/29/23. She observed a call light clipped to the resident but no call light on when he fell . During an interview on 6/7/23 at 2:30 PM, Staff JJ, CMA, reported she had worked at the facility since 9/2022. Staff JJ reported Resident #40 liked to wander and didn't stay in one place very long. He was constantly on the go and didn't ask for assistance. Resident #40 got up on his own and staff had to remind him to use his walker. Staff JJ reported she didn't think the resident had the mentality to ask for help. The resident recently fell and fractured his hip but still tried to stand up on his own. Staff JJ reported prior to the resident's fall he required assistance of one staff for ambulation and cares. On the day the resident fell and fractured his hip, she stood by the medication cart just outside the resident's room and prepared medications. She had just given Resident #40's roommate medication, walked out of the room, prepared Resident #40's medication, and heard the resident holler out. She turned around and saw the resident on the floor. Resident #40 was lying in bed when she had just gave his roommate medications. She found the resident lying on his right side on the floor by the privacy curtain. The resident told her he wanted to get up. She called for the nurse. The resident yelled Ow when staff started to move him. Staff JJ reported an agency nurse and agency CNA assisted the resident up but didn't know their names. Staff JJ reported the facility had so many staff coming and going, she couldn't keep up on who was who. The nurse entered the room first, then two CNA's came into the room. The nurse obtained the resident's vital signs, then sat him up on the floor. The resident started to yell out in pain. The nurse asked where his pain was, but the resident didn't tell her where he had pain. The nurse and two CNA's proceeded to stand the resident up and placed him into bed. The resident was unable to stand. The nurse tried to do ROM on the resident's legs, but the resident screamed in pain. The resident was sent to the hospital. Staff JJ reported whenever a resident had a fall, a nurse needed to assess the resident and ask the resident if he/she had any pain. If a resident had any pain then needed to leave the resident on the floor and call the ambulance. She isn't a nurse but that's what she had been instructed to do. Staff JJ reported she didn't want any part of moving him off the floor when the resident was in so much pain. Staff JJ reported she looked at the resident's kardex to know the cares needed and the interventions in place for the resident. Staff JJ reported interventions for Resident #40 included to ensure the resident had shoes and/or socks on his feet, make sure call light in reach, and remind the resident to use his walker and ask for assistance. Staff JJ recalled Resident #40 had socks on but not non-slip socks. During an interview on 6/7/23 at 8:00 PM, Staff LL, agency CNA, reported Resident #40 had dementia, always on the move and tried to stand up but had poor balance. Staff told him all day long to sit down and kept him by the nurse's station so staff could keep an eye on him. She worked the evening when the resident fell last week but didn't know he had fallen until she saw the ambulance at the facility. During an interview on 6/8/23 at 8:20 PM, Staff K, CNA, reported Resident #40 always tried to stand up or grab the bar in the hallway and stand up. On 5/29/23 evening, she assisted another resident but heard staff say this resident fell on to the ground when he tried to stand up by himself. She didn't help him off the floor. She just saw him when he had left the facility. During an interview on 6/8/23 at 8:40 AM, Staff H, CNA, reported staff tried to keep eyes on Resident #40 during the shift even though not assigned to him. The resident tried to get up on own and in a wheelchair most of the time. He required assistance of one staff and used a walker prior to a fall with fractured hip. Since the resident had prior falls, she placed walker out of reach so he didn't try to get up by himself. On the day of his fall with fracture, she heard someone say Resident #40 lying on the floor. The nurse asked who could help. Staff H reported she was helping another resident at the time but after she assisted that resident she went to see if she could help Resident #40. The nurse did an assessment Staff H reported she recalled she placed a hoyer sling under the resident and moved him back to bed. The nurse asked the resident what part of his body hurt. The resident complained of pain in his leg as the nurse touched him. When the surveyor questioned mode of transfer after resident fell on [DATE] evening, Staff H then stated she couldn't remember if she helped stand the resident up or if they used a hoyer. During an interview on 6/8/23 at 10:29 AM, Staff LL, CNA, reported Resident #40 pleasantly confused, used a walker during ambulation but now used a hoyer lift when transferred due to he had a fall and fractured his hip. Staff had to remind the resident to use his walker. She was on break when the resident fell . During an interview on 6/8/23 at 2:50 PM, the DON reported whenever a resident had a fall, she expected the staff nurse conduct a head to toe assessment, get statements from people who witnessed the fall, and complete a pain and fall assessment. The DON stated she expected staff to call the physician if a resident had pain after a fall and not move the resident. The DON stated the resident's care plan reviewed and interventions added after a fall. Resident #40 is a busy body, and walked up and down the hallways but sometimes forgot to use his walker. Staff reminded him to get his walker. On the day of incident when the resident fell , staff told her the resident had just ate dinner, went to his room, and resting in bed. A CMA prepared medications in the hallway and heard the resident holler out. The CMA found the resident on the floor by the curtain. A nurse assessed the resident but said he didn't complain of pain while lying on the floor. When the nurse palpated areas of his body, then able to tell location of his pain. The floor was clean and dry, and he had gripper socks on. Unable to recall if the resident had incontinence. The resident was unable to bear weight, and had hip tenderness when the nurse palpated the area. Resident transported to the hospital. A therapy referral was made after he returned from the hospital. The DON reported she had only talked with the CMA and Nurse but unable to reach the CNA's involved after the resident had fallen. The DON reported the interventions in place for fall prevention included the resident kept in a common area and kept busy, his bed kept in low position, scoop mattress on the bed, and staff checked on him frequently. A document dated 2011 titled Phase 1: Assess- initial plan of care revealed a plan of care developed if a resident at risk for falls or had a history of falls, and individualized interventions initiated. Fall reduction and injury prevention strategies that could be implemented upon admission may include: Orientation to surroundings and use of call light. Call light and and personal care items placed within reach. Provision of environmental modification such as a low bed and cushioned floor mats next to the bed. Use of appropriate footwear. Review of ordered medications for potential fall risk side effects. Referral to physical and occupational therapy. An Interact Care Pathway for Falls dated 2014 revealed a fall is an unintentional change in position and coming to rest on the ground or onto the next lower surface. The care pathway directive included to perform an initial nursing evaluation for injury but do not move the resident off the floor until a complete exam performed. Contact the physician if a fracture or bone deformity suspected or had new or worsening cognition. 3. Observations revealed the following: a. On 5/16/23 at 8:35 AM, a portable oxygen (O2) tank sat upright on the floor in room [ROOM NUMBER]. The oxygen had a seal over the top which indicated an unused tank. b. On 5/16/23 at 12:20 PM, the portable O2 bottle remained in an upright position by the wall in the resident's room, not secured in a holder or rack. c. On 5/19/23 at 7:20 PM a portable O2 tank sat upright on the floor in the 200 hall across from room [ROOM NUMBER], and not secured in a holder or rack. The facility's Oxygen Storage policy revised 7/28/22 revealed oxygen stored safely and properly. Oxygen tanks needed restrained or secured at all times. During an interview on 5/16/23 at 8:35 AM, a family member reported Resident #16 used oxygen as needed. During an interview on 5/23/23 at 10:51 AM the facility's Maintenance Director revealed dollies used to transport oxygen canisters stored in the lower level and main level oxygen rooms. The Maintenance Director stated staff should use the [NAME] for transportation and storage of oxygen tanks. The Maintenance Director revealed the facility had plenty of dollies for oxygen canisters and the dollies available for staff to use. During an interview on 5/24/23 at 9:55 AM, the DON reported O2 tanks stored in a roller cart or on the back of the wheelchair in a holder. The DON agreed O2 should not be left unsecured in an upright position on the floor, rather it needed placed in a cart or a holder. 4. The MDS assessment dated [DATE] revealed Resident #15 had diagnoses of hydrocephalus, seizure disorder, and legally blind. The MDS documented the resident had impaired short-term and long-term memory and severely impaired decision making skills. The Care Plan initiated on 6/24/21 revealed the resident had cognitive loss related to hydrocephalus, TBI (traumatic brain injury), and at risk for behavior symptoms related to blindness, hearing deficit, and a potential to place non-edible things in his mouth and injest them. The staff directives included frequent supervision of the resident, not to leave the resident unattended in his wheelchair in his room, and lay the resident down in bed after each meal as the resident allowed and tolerated. On 5/19/23 at 8:45 PM, Resident # 15 sat in a wheelchair facing the wall across from the nurse's station. The resident had the door that stored a fire extinguisher open. The resident reached inside the cabinet and attempted to grab the fire extinguisher. During an interview on 5/23/23 at 10:49 AM, the facility's Maintenance Director revealed he had worked at the facility five years and had never had a resident pull a fire extinguisher from the wall. During an interview on 5/24/23 at 9:55 AM, the DON reported staff needed to redirect a resident if a resident had their hand in the fire extinguisher box/panel or attempted to remove the fire extinguisher. 41537 5. During an observation on 5/21/23 at 7:34 PM of the facility's long term care floor a medication cart was unlocked. No staff present in the hallway, two residents approximately 10 feet away were observed sitting in their wheelchairs. At 7:36 PM a staff member exited a residents room and went to the medication cart. During an observation on 5/21/23 at 7:40 PM of the facility's skilled unit floor a medication cart was observed unlocked. At 7:44 PM a staff member exited a residents room and went to the medication cart. The Director of Nursing (DON) provided a list of residents via e-mail correspondence on 5/23/23 at 2:10 PM who are cognitively impaired and independently mobile equaling 22 of the 86 residents in the facility. During an interview on 5/24/23 at 12:59 PM the DON revealed she would expect medication carts to be locked at all times when not in use. During an interview on 5/24/23 at 1:20 PM the Administrator revealed she would expect medication carts to be locked at all times when not in use.

Based on record review, staff interviews, and policy review the facility failed to administer medications through the correct port on a G-J tube (Gastrostomy-Jejunostomy tube - a tube placed into the stomach with three external ports) for 1 of 1 residents reviewed with a G-J tube (Resident #1). The failure led to the resident's transfer to the hospital due to a Gastric Outlet Obstruction when Staff Q, Registered Nurse (RN) administered medication into the balloon port of G-J tube (the balloon is filled with normal saline and is used as an anchor inside the stomach to hold the G-J tube in place) instead of the correct port that is used to put medication into the body causing the balloon to pop inside the resident. The facility reported a census of 86 residents, with 1 resident receiving enteral feeding tube services at the time of the survey. Findings include: Record review of Resident #1's Minimum Data Set (MDS) log on the facility's Electronic Health Record (EHR) revealed the facility did not complete MDS's for Resident #1 during her stay at the facility. Record review of Resident #1 Admission Record dated 5/22/2023 documented an admitted [DATE] and a discharge date of [DATE]. The Progress Note dated 4/21/2023 at 11:45 AM documented the following admission note: Resident #1 arrived by gurney from hospital. The Progress Note dated 4/21/2023 at 6:42 PM documented the following change of condition note: Resident #1 was sent to the local emergency room (ER) for displacement of her G-tube by ambulance. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #1 documented one (1) medication given during her stay at the facility; Acetaminophen (Tylenol) 325 milligrams (mg), give three (3) tablets via G-Tube every eight (8) hours, may also give orally for pain with a start date of 4/21/23. Record review of Resident #1 Transfer Form assessment documented she was admitted to the facility on [DATE] for skilled care and was being transferred on 4/21/23 for G-tube displacement. The form also documented she had an enternal feeding tube. Record review of a document titled, Chief Complaint and History of Present Illness, dated 4/21/23 at 8:29 PM documented the following: Daughter reports Resident #1 recently moved long term care facilities. Today one of the nurses put crushed up Tylenol with water down the wrong tube, which caused her G-J tube's balloon to pop. The daughter informed that getting the G-J tube placement was very challenging and had to be done at a larger hospital after multiple other attempts. Resident #1 has not been able to receive her normal medications today and she denies any acute symptoms at this time. Record review of a document titled, Internal Medicine Health and Physical dated 4/21/23 at 10:10 PM for Resident #1 documented the following: At the Skilled Nursing Facility (SNF) Resident #1 was accidentally given a medication via the wrong tube causing mechanical malfunction of the tube. Since this time she has had some intermittent abdominal pain. She has not been able to take any of her medications today. Record review of a document titled, One-On-One In-service Record, dated 4/21/23 for Staff Q, Registered Nurse (RN) documented education he was shown the three different types of ports on residents G-J tube and was educated on the difference between ports. Record review of a document titled, Incident Report - Patient Involved, signed on 4/24/23 by Staff Q, the Director of Nursing (DON) and the Administrator documented the following: Description of incident: Staff Q administered medication through Resident #1 G-tube by pushing medication through the balloon port resulting in the malfunction of the G-tube. Record review of a document titled, Investigation Summary, with a date of investigation of 4/25/23 for Resident #1 documented the following: Summary of Alleged Incident: Malfunction G-J tube in resident with gastric outlet obstruction. The Nurse administered medication per tube with malfunction resulting in a burst of the balloon. Resident sent for evaluation and potential replacement, resulting in surgical intervention. Action Taken During Investigation: a. Train nurse involved immediately b. Train all licensed nurses with continuing education c. Quality Assurance of incident Conclusion: Resident remains hospitalized for other health concerns unrelated Record review of a document titled, Quality Assurance and Performance Improvement Committee Meeting dated 4/25/23 documented a new trend was identified for G-J tube malfunction and follow up is needed with staff education as the new mechanism requires nurse education plan. Record review of a document titled, Attendance, dated 4/25/23 revealed the facility provided reeducation on J-G tubes for nursing staff. Record review of a document titled Self Report, of the facilities report to Iowa Department of Inspections and Appeals (DIA) with a submission date of 4/25/23 documented the following Incident Summary: a. Chief complaint per hospital: Malfunction G-J tube for Resident #1 with gastric outlet obstruction. Nurse administration of medication per G-J tube, tube malfunctioned resulting in burst of balloon. Resident sent out for evaluation, resulting in surgery to replace the G-J tube and surgical intervention with intravenous radiology. Corrective Action: a. Sent to ER for evaluation b. Education provided to nurse Record review of Resident #1 Care Plan on 5/22/23 instructed she had a G-tube. The Care Plan lacked instruction on the type of tube she had, a G-J tube. During an interview on 5/23/23 at 7:05 PM Staff Q, Registered Nurse (RN) revealed he worked for an agency staffing company an recalled Resident #1 had a G-J tube that was a specialty tube and placed prior to her admission to the facility on [DATE]. He revealed the G-J tube had 3 ports on it, he instructed one of the ports was for draining bile. He recalled he checked placement of the tube by insertion of a little air into the port and he used a stethoscope to listen for a swooshing sound/bowel sounds prior to administration of medication. He then informed he gave Tylenol through another port and the resident had tube displacement. He informed Resident #1 had some pain and that is why he gave her something for pain. He revealed he suspected the tube was displaced and called the doctor because he didn't have an x-ray machine. Resident #1 had pain and the tube had some problems and was difficult to assess. He revealed the doctor said due to the complex nature of the resident and that she has had multiple tubes to send her to the local hospital. He then revealed he didn't flush the port after he gave the medication and later found out the tube was displaced. He then informed he was not used to the type of tube Resident #1 had as it was a special tube. He revealed whenever he was unsure of how to do something or not familiar with a process or procedure he checked the policy and looked up information on what to do by using a policy from a previous company. During an interview on 5/24/23 at 1:00 PM the Director of Nursing (DON) revealed she was notified while Staff Q was talking with the Physician on the phone of the concern with Resident #1 G-J tube. She reported she went and spoke with Resident #1's family to find out what hospital they would like to go to. She revealed she educated Staff Q to make sure to check placement prior to administering medication and also revealed the facility had not had any tubes like that for the past two years. She informed Staff Q typically worked 3 nights a week and no education was provided to Staff Q regarding G-J tubes prior to the incident occurring. She then informed all agency nurses and facility staff nurses got training on enternal feeding tubes prior to working their first shift. During an interview on 5/24/23 at 1:20 PM with the Administrator revealed she would expect education to be requested or provided as necessary to nurses regarding feeding tubes. Record review of the facilities policy titled, Medication Pass, last reviewed on 3/28/23 lacked instruction to staff on how to administer medications to a G-J tube.

Based on clinical record review, resident representatives and staff interviews, the facility failed to provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being. Clinical record review revealed the nursing staff did not perform a thorough assessment and follow-up assessments for 2 of 2 residents reviewed (Resident #87 and #150). Which resulted in an immediate jeopardy to residents' health and safety. The State Agency informed the facility of the Immediate Jeopardy (IJ) on March 8, 2023 at 10:15 A.M. and provided the IJ template. Facility staff removed the Immediate Jeopardy on March 9, 2022 through the following actions: Education to licensed nursing staff was initiated immediately 3/8/23 to include change in condition nursing procedure and assessment/intervention care paths. Current licensed nurses in the building have been educated and Licensed nurses will be educated prior to their next scheduled shift regarding change in condition nursing procedure and assessment/intervention care paths. Residents with changes in condition will be assessed and interventions documented. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #87 had diagnoses including congestive heart failure, muscle weakness, diabetic neuropathy, and obesity. Resident #87 required assistance of 2 persons for bed mobility, transfers, and toilet use and the assistance of 1 person for dressing and walking in the room. Resident #87 had a Brief Interview for Mental Status (BIMS) score of 8 suggesting moderate mental impairment. The Care Plan dated 12/24/22 instructed staff to assist Resident #87 with activities of daily living (ADL) care, to provide assistance with toilet use, report changes, and instruct nursing to notify the physician if a decline in ADL ability and if abnormalities were noted during daily cares. During an interview on 03/07/23 at 9:25 AM a family representative stated she was in the facility on 2/13/23 at 9 AM and Resident #87 complained of her butt being on fire, the nurse was notified, and stated finding a sore on her rectum, and Resident #87 told the nurse she was in pain, a 7 out of 10 pain. The family representative stated she was with the resident until about 1 PM and the nurse had not returned with a cream or anything for the pain. The family representative stated the hospital called on 2/27/23, Resident #87 was to have an emergent surgery and stated Resident #87 had 2 surgeries then passed away on 3/6/23. During an interview on 3/07/23 at 2:52 PM, Staff Z, Licensed Practical Nurse (LPN) stated she took care of Resident #87 on 2/10/23 and she did not complain of pain in the rectum. During an interview on 3/07/23 at 2:35 PM, Staff Y, Registered Nurse (RN) stated she found an anal fissure in Resident #87 on 2/13/23 and reported to the ARNP, who was at the facility. Staff Y stated I asked if she was going to look at it and she said she ordered Calmoseptine ointment but she did not look at it. It was a tear, not alarming at that time. Staff Y stated she had put a barrier cream on Resident #87's rectum and passed it on in report. During an interview on 3/07/23 at 8:34 PM Staff AA, LPN, stated she had reported to the Director of Nursing (DON) on 2/25/23 that Resident #87 had pain and the DON called the doctor. Staff AA stated I think she might have been constipated, I gave her Tylenol. Staff AA stated she was confident that the DON was going to put the order in the computer and chart on this. Staff AA stated, The DON was going to give her the constipation medication because I didn't have the order yet and it was the end of my shift. During an interview on 3/07/23 at 3:10 PM, Staff N, LPN stated she had worked 2/27/23 and remembered Resident #87, stated she had bowel coming out her vaginal area, and some stuck in her rectum, her blood pressure was 80/30, she reported nausea and her butt was on fire. Staff N stated she called the on-call doctor who would notify the physician, she waited an hour then called the office back. Staff N stated she thought Resident #87 had a bowel obstruction and held the blood pressure medication but did not remember giving a pain medication. Staff N stated, She was screaming and you could hear her down the hall, she was saying her butt is on fire. Staff N stated, It took an hour and a half before I got the order to send her to the ER. A Progress Note dated 2/5/23 at 12:18 PM provided a nutritional assessment which revealed Resident #87's appetite had decreased, and had a wound to buttocks and thigh. A Progress Note dated 2/13/22 at 2 PM Resident #87 reported pain in buttocks, a 7 out of 10 on the pain scale. Nurse found an anal fissure measuring 0.5 x 0.3 cm, excoriation, and notified the physician. Progress Notes lacked nursing assessments on 2/14 and on 2/15/23 Resident #87 was found to be COVID positive. Progress Notes lacked follow up assessments on 2/16, 17, 18, 19, 20, 23 & 24, 2023. A Progress Note on 2/25/23 at 10:30 AM revealed Resident #87 had bright red drainage from the rectum, complained of pain 8 out of 10 pain scale and the night nurse reported constipation. The note revealed there was no physician order for a preventative or as needed medication for constipation. At 11 AM the Director of Nursing (DON) was notified, she called the physician and received an order for Docusate Sodium (DSS) to be given twice a day and Milk of Magnesia (MOM) to be given as needed (PRN) for constipation. Progress Notes lacked nursing assessments for the evening of 2/25/23 and on 2/26/23. A Progress Note for Resident #87 on 2/27/23 at 7:45 AM revealed loose stool was coming from the vaginal area and a large, hard bowel movement stuck in the anus. Resident #87 was yelling My butt is on fire and a message was left for the physician. At 9:45 AM the physician returned the call and gave an order to transport Resident #87 to the emergency room . At 10:30 AM the nurse documented the call for an ambulance. A document titled Point of Care Toileting for Resident #87 revealed no bowel movements (BM) on 2/16 through 2/21/23, one BM on the evening of 2/22/23 and no BM ' s on 2/23 or 2/24/23. Physician Orders for Resident #87 revealed orders for DSS and MOM, initiated on 2/25/23, and Trazodone 50 mg to be given at bedtime for insomnia. The orders revealed that nothing was ordered for pain. The Medication Administration Record (MAR) dated February 2023 for Resident #87 revealed the DSS was given on 2/25/23 and the MOM was not given. Pain was documented on 2/23/23 as a 5 out of 10 on the pain scale, on 2/26/23 pain was documented as a 10 out of 10, on 2/27/23 pain was a 4 out of 10. Trazodone was not given. Review of a document titled (facility name) Clinical and Order Alerts Listing Report dated 2/22/23 - 2/27-23. The document revealed on 2/22/23 at 13:42 PM that Resident #87 had no bowel movement (BM) for 3 days. Document titled Preliminary Report (hospital name) Inpatient dated 2/27/23 revealed Resident #87 was admitted on [DATE] with Septic shock (widespread infection causing organ failure and low blood pressure), and Fournier's gangrene (a rare, life-threatening bacterial infection of the area between the genitals and rectum) and a rectovaginal fistula (opening between rectum and vagina) with extensive debridement (removal of dead tissue) of the perirectal (area around the rectum) from necrotizing (death of cells) soft tissue infection, right gluteal necrotic tissue, excision (removal of tissue using a scalpel) of anus, excision of portion of necrotic end of rectum, removal of a portion of the vagina. On 2/28/23 Resident #87 underwent surgery for a colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). On 3/2/23 Resident #87 had a re-debridement of the perineal wound of the right groin and placement of a wound VAC (vacuum-assisted closure). Resident #87 was intubated (tube inserted into the airway and connected to a machine that delivers oxygen) and sedated. During an interview on 3/08/23 at 2:37 PM, the DON stated the nurse who cared for Resident #87 asked her to call the physician. The DON stated, I did not assess her. The DON stated she was unaware that Resident #87 had pain. The DON stated there was a Main [NAME] Alert Charting Book that was updated on 2/21/23, which instructed the nurse to perform head to toe assessments on Resident #87, chart if she experienced pain, shortness of breath, or had a change of condition. The DON stated, the nurses could not say they didn't know about the charting alert sheets, they (nurses) are writing all over them. 2. Minimum Data Set (MDS) dated [DATE] for Resident #150 revealed diagnoses of high blood pressure, A-fibrillation (abnormal rhythm of the heart), diabetes, and end-stage renal (kidney) disease, required the assistance of 1 person for bed mobility, walking, dressing, and toilet use. Resident #150 had a Brief Interview for Mental Status (BIMS) of 13 which suggested an intact cognition. The Care Plan directed staff to monitor Resident #150's labs and to notify the physician of results, obtain vital signs and report changes to the physician, and report signs and symptoms of a urinary trach infection (UTI) such as flank pain, complaints of burning and pain, fever, hematuria (blood in urine), blood in stool, and a change in mental status. Review of a document titled Internal Medicine Resident History and Physical dated 3/3/23 identified Resident #150 presented to the emergency room with abdominal pain, and reported they vomited once a day for the past week. Blood pressure of 92/42, heart rate of 96, temperature of 97, and diagnosis of septic shock (wide spread infection causing organ failure and dangerously low blood pressure) possible urinary as there were many bacteria in the urine test. Progress Notes dated 2/26/23 after return from the hospital for blood in stool and with a blood pressure of 98/59, an order was obtained to make an appointment for the gastro-intestional physician. The appointment was not made. Progress Notes revealed no nursing assessment on 2/27, 2/28, and during the afternoon shift on 3/1/23. Progress Notes on 3/2/23 revealed the Advanced Practice Registered Nurse (APRN) assessed resident #150, findings included diarrhea for 3 days and a blood pressure of 87/58. An order was given to test the resident for Clostridium difficile (inflammation of the colon caused by bacteria). Progress Notes on 3/2/23 revealed no follow-up nurse assessment. Progress Notes on 3/3/23 5:49 AM, Resident #150 was unable to hold self up in a wheelchair to go to dialysis, the physician was notified, and an order was received to send Resident #150 to the emergency room for possible Sepsis. On 03/08/23 at 02:37 PM, the Director of Nursing (DON) stated Each hallway has an Alert Charting book and the nurses should be documenting in that each shift so the next shift is aware of who to assess, it is not an official document so it is destroyed. Interview on 3/8/23 at 3:45 PM Staff N, Licensed Practical Nurse (LPN) stated she had worked in January and February and she used the Alert Charting book as a reference we don't use it for reporting, we give a verbal report. The DON provided a document titled Main [NAME] Alert Charting updated 2/13/23, Resident #150 was to receive a head to toe assessment and directed nursing staff to chart pain, shortness of breath, and change of condition for both morning and afternoon shifts until further notice.

Based on family interviews, staff interviews, record review, and policy review, the facility failed to provide appropriate pain control and failed to notify the physician of pain not relieved for 1 out of 1 residents reviewed. (Resident #79). Which resulted in immediate jeopardy to residents' health and safety. Resident #79 began exhibiting pain in her arm on 2/7/23 that was controlled with scheduled pain medications; the pain became extreme and uncontrolled on 2/10/23. The State Agency informed the facility of the Immediate Jeopardy (IJ) on February 22, 2023 at 10:15 A.M. and provided the IJ template. Facility staff removed the Immediate Jeopardy on February 22, 2022 through the following actions: Education for staff was initiated immediately 2/22/23 to include pain assessment, steps taken to manage residents pain, reassessment, and MD notification when applicable. Current Licensed nurses in the building have been educated and Licensed nurses will be educated prior to working next shift regarding pain assessment, intervention, re-assessment, and when to notify MD. Residents will continue to be evaluated for pain daily with pain medications, provided as ordered, re-assessed if no improvement MD will be notified for new interventions. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #79 had diagnoses including: Atrial Fibrillation (abnormal rhythm of the heart), dementia, muscle weakness, and identified a base level for pain as a 4 on the pain scale of 0 to 10 (10 being the worst pain the resident has ever felt). Resident #79 had a Brief Interview for Mental Status (BIMS) score of 7 which suggested a severe mental impairment and required the limited assistance of 1 person for personal hygiene, toilet use, bed mobility, and transfers. Care Plan dated 11/10/22 for Resident #79 directed nursing staff to administer pain medication as the physician order directs, reposition frequently, and to implement non-pharmacological interventions to assist with pain management. During an interview on 2/15/23 at 4:01 PM, the Power of Attorney (POA) for Resident #79 stated her mother was independently living in the senior living center until the fall of 2022 when she fell , then went to the nursing home for Skilled care and fell again within 2 days of arrival. They didn't have a walker for her and that is why she fell . The POA stated Resident #79 fell again on January 21, 2023 and again a week later. The POA stated the primary physician tested Resident #79's INR (International Normalized Ratio, which tells how long it takes for your blood to clot), it was 2, and 3 days later her INR was 8 (normal therapeutic range 2.0 to 3.0). The POA stated, The doctor said there is no way they are giving the medication right so they stopped the Warfarin. The POA stated on 2/10/23 at 2 AM, her mother's roommate called, mom was screaming in pain, and no one was helping her. The POA stated she arrived at 6:30 AM and her mom was still crying in pain and begging for help. The POA stated her mother said, My arm, my arm, Oh my god my arm hurts. I could not touch her arm, she hurt so bad. The POA stated she called the physician on her own phone and took the phone to the nurse and he refused it, He said he did not have time to give her the Tylenol. The POA stated She was screaming Help me and you could hear it up the hall. The POA stated the physician hung up and called the nurses station at 7:30 AM and at 9:30 am no pain medication was given. The POA stated she went home at 11 AM I was feeling sick, and the Ombudsman volunteer stayed with her mother. The POA stated she received a call at 2 PM, the Ombudsman volunteer stated my mother was still in pain and she reported she called the physician. The POA stated at 6 PM the roommate called again, I could hear mom screaming in pain. The POA stated she called the on call physician who advised the family to call 911. The POA stated My sister went to the facility and our mother was gone and the staff would not tell us where she was. The POA stated the hospital called, stated mother was to be moved to another hospital downtown for Emergency Surgery, she had no pulse in the arm and her hand was turning black and they hope to not have to amputate her hand/arm. During an interview 2/21/23 at 12:56 PM, Staff CC, Ombudsman Representative, stated she was in the facility on 2/11/23 from noon to 3:45 PM and the nurse did not enter Resident #79's room. Staff CC stated she spoke to the daughter to make her aware that her mother was begging for pain control. Staff CC stated the daughter called the doctor, then the doctor called Staff CC to verify that Resident #79 was in pain and had asked Staff CC to give the phone to the nurse. Staff CC stated she heard the nurse tell the doctor to call the pharmacy, as the resident was allergic to the medicine that was requested. Staff CC stated the nurse told her it was all taken care of now and Staff CC stated she was under the impression that the nurse was going to give Resident #79 more pain medication. Staff CC stated, I called the daughter back and told her it was taken care of. During an interview on 2/21/23 at 11:15 AM Resident #53 stated she was Resident #79's roommate who was crying in the night because of pain in her arm, it was bad so I called her daughter. Resident #53 stated that staff came in and out of their room and the CNA's (certified nursing assistants), they held her hand but the nurse did not give her anything for the pain. Resident #53 stated she had called the daughter again after Staff CC left, as her roommate was crying out in pain again. Resident #53 stated the family called 911 and sent Resident #79 to the hospital. During an interview 2/20/23 2:39 PM Staff EE, Certified Nursing Assistant (CNA), stated he worked on the night shift on 2/10/23 with Resident #79 who cried and was in pain. Staff EE stated I was telling the nurse she was crying and in pain. Staff EE stated, I think they responded by giving her pain medication at the time it was scheduled, that's all they did. Staff EE stated, She cries all night and I tried to comfort her. General Progress Notes revealed on 2/10/23 at 15:10 Resident #79's INR was 2.7, the nurse called the physician's nurse, and there was no call back with an order. On 2/11/23 Resident #79's daughter was here at 7 am, the morning medications were given to the resident who was in pain, Tylenol 500 mg was given without pain relief, and the daughter sought stronger pain medication. On 2/11/23 at 2:46 AM the nurse requested the daughter to clarify with the physician about the allergy issue for the Tramadol and with the pharmacy, since Resident #79 has a documented allergy to Tramadol. On 2/11/23 at 8:05 PM the Emergency Medical Services (EMS) arrived at the facility, welfare check for Resident #79 and the nurse sent the resident to the emergency room (ER) for an evaluation and treatment. During an interview on 2/20/23 at 2:53 PM Staff BB, Registered Nurse, RN stated he worked at the nursing home on 2/11/23, Resident #79's daughter was there and talked to him about her pain. Staff BB stated, All she had was Tylenol scheduled and a Lidocaine patch on her back. Staff BB stated, I told her if it is not effective to talk to the doctor so the family called the doctor. Staff BB stated he didn't get an order from the doctor, and had talked to the daughter about her allergies. Staff BB stated, She gave me the phone, I didn't get the order. Staff BB stated the pain was ongoing, and it was not a new pain, so he did not call the facility doctor. Staff BB stated the daughter went home and a State lady was at the facility (ombudsman volunteer). Staff BB stated, She was present when we discussed at noon that the resident was in pain and she called the daughter. Staff BB stated the physician called, I told him to talk to the pharmacy about the allergy. Follow-up interview on 2/21/23 at 11:57 AM Staff BB, RN stated Resident #79 complained of right arm pain and he gave her Tylenol at 1 or 2 PM. Staff BB stated, The state lady had left and told me she had called a doctor and I did not know the doctor's name but informed the doctor that the resident had an allergy and could not take that medication, she would have to call the pharmacy. Staff BB stated, I did not communicate with the family about the resident going to the hospital, I don't remember doing that. Staff BB stated he had left at 6 PM and did not see the ambulance (EMS). During an interview on 2/22/23 at 12:49 PM, Staff DD physician, stated she received a call from Resident #79's family in the morning of 2/11/23 to inform her about Resident #79 having new severe pain in her arm that started around 3 AM. Staff DD stated she sent an order for Tramadol to the pharmacy, but the facility refused to give it due to allergy. Staff DD stated, On our chart, it said syncope and the daughter said she was just taking it wrong at home. Staff DD stated she received several calls from family, the ombudsman representative, and the pharmacy, and had conversations with the daughter for hospital care. Staff DD stated, You could hear her mom screaming out in pain in every phone call. Staff DD stated she had spoken with the facility nurse twice and spoke to the pharmacist. Staff DD stated the pharmacist was in agreement with giving her the Tramadol as it was not a true allergy and was going to release the order so the facility could give it mid to late afternoon. Staff DD stated, I assumed since I spoke with the pharmacy, it was taken care of until I got a call around 7 pm from the other on call doctor who said he received several pages from (resident 79's) family stating she was still in pain, the pain was not being treated, and I recommended to him that the resident be taken to the hospital for treatment. Staff DD stated, The facility never paged me about the patient to report her pain, I never received a request from the facility. Interview on 2/21/23 at 11:42 AM, Staff R, LPN (Licensed Practical Nurse) stated she worked on 2/11/23, a Saturday, and was helping Staff BB with Resident #79, who was in pain. Staff R stated, The family wanted Tramadol but the resident was allergic to it. Staff R stated Resident #79 went to the hospital for an elevated INR on 2/7/23 and had the pain in her legs and right arm since that day, so I thought it was a behavior. Staff R stated the EMS (Emergency Medical Services) came and assessed her, and said the family requested for Resident #79 to go to the hospital. Staff R stated, I did not fill out a bed hold for her and I did not assess her, she was not my patient. The Medication Administration Record (MAR) February 2023 for Resident #79 Acetaminophen 500 mg 2 tabs three times a day. Pain assessment documented on 2/10/23 at 7 AM as a 9 out of 10, at 1 PM as a 9 out of 10, at 7 PM as a 4 out of 10 and on 2/11/23 at 7 AM pain documented as a 0 out of 10 and at 1 PM as a 0 out of 10. Physician orders for pain control for Resident #79 ordered 1/30/23 Acetaminophen Extra Strength 500 mg Give 2 tablets 3 times a day ordered 12/5/22 Aspercream Lidocaine External cream 4% apply to back 1 time a day ordered 1/30/23 Diclofenac Sodium External gel 1% topical Apply to right upper arm 4 to 16 grams every 6 hours PRN (as needed) ordered 2/6/23 Lidocaine External cream 4% (Lidocaine) apply to legs and back every 6 hours as needed for pain. During an interview on 3/14/23 at 1:37 PM, DON stated the nurses who receive the order, places the order on the MAR but if I remember correctly the family declined the Ibuprofen. The DON stated, If a family declines a medication, the nurse will note it in the nurses notes and advise the doctor. The DON stated Resident #79 returned from the hospital on 2/7/23 with an order for Tramadol and the nurse would have alerted the physician because of the allergy. The DON stated she did not understand why that was not documented in the nurses notes. Facility policy dated 11/21 Pain management Guideline process steps required for interventions to prevent and or manage both acute and chronic pain. Pain is evaluated on admission. Pain is evaluated daily for each patient. Pain is evaluated whenever there is a change of condition. Pain scores of 4-7 twice in a 7 day period or those who have a single score of 8, 9, or 10, report to the practitioner for consideration of treatment adjustment. Alert Charting Log dated 2/2014 purpose is to provide a guideline for monitoring documentation that may be needed following a change in condition. The Alert Tracking Log is a tracking and communication system to alert licensed nurses to changes in a patient's condition that warrants continued observation. Patient's are entered into the Alert Log when identified as requiring continued follow-up. Change of Condition policy dated 11/2016 is to provide guidance in the identification in clinical changes that may constitute a change of condition and require intervention and notifications. The Centers for Medicare & Medicaid Services (CMS) requires A facility must immediately inform the resident; consult with the resident's physician and notify resident representatives when there is a significant change in resident's physical, mental or psychological status (a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). During an interview on 2/22/23 at 5:10 PM, the Director of Nursing (DON) stated Pain is subjective and someone can have a pain of an 8 and no facial expressions and others be crying. The DON stated she expected the staff to be mindful of this. I attempt to get the same Agency staff and they are educated on these expectations also.

Based on observations, clinical record review, facility record review, staff and police interviews, the facility failed to provide adequate supervision and proper use of assistance devices to mitigate a resident's risk for elopement and to prevent hazards for 1 of 3 residents reviewed (Resident #1), which resulted in an immediate jeopardy to resident's health and safety. On 7/2/22 sometime after 8:30 PM Resident #1 exited the building. The staff stated the resident did not have a wander guard device on and they did not know the resident had left the building. The resident was found by the police at 11:03 PM five miles from the facility on Interstate 235 heading east. A passerby called in a concern due to the resident was walking alongside the shoulder of the interstate wearing a blue jersey late at night. The speed limit along that part of the interstate is 60 miles per hour. It was 70 degrees with 63 percent humidity and no precipitation at the time police found him. He appeared unharmed but showed very little awareness of the situation. He stated he was trying to go to his previous group home. The resident has a BIMS of 3/15 indicating he has severe cognitive impairment. He did not have a history of wandering prior to this elopement but earlier in the evening the staff reported he had been up walking the halls and had asked about going home. They added he typically stayed in his room and this was unusual for him. The facility reported a census of 99 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool dated 6/26/22 documented Resident #1 had diagnosis that included pneumonia, hypertension, [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), abnormality of gait, lack of coordination and disorientation. The MDS revealed the resident scored 3 out of 15 on his Brief Interview of Mental Status (BIMS) test, which indicated the resident demonstrated severe cognitive impairment. The MDS also documented he required maximal assist of one staff for dressing and eating; and minimal assist of one staff for bed mobility, transfers, walking, toileting and hygiene. The MDS documented he had no alarms. The Care Plan focus dated 6/24/22 documented the resident had a self-care deficit related to physical limitations, [CONDITION(S)] and weakness. The care plan documented he required assist to bathe/shower as needed; assist with daily hygiene, grooming, dressing, oral care and eating as needed; assist with toileting routinely as needed; and transfer with assist of one staff with gait belt and front wheeled walker. The Care Plan focus dated 6/27/22 documented the resident was at risk for behaviors related to a history of [CONDITION(S)]. The care plan directed staff to observe for mental status/behavior changes when new medication started or with changes in dosage. It documented a psyche referral as needed and to use consistent approaches when giving care. The Care Plan focus dated 6/27/22 documented he had a cognitive loss potentially related to disorientation and/or [CONDITION(S)]. The Care Plan focus dated 6/23/22 documented the resident shows potential for discharge and a wish to be discharged . The facility policy Behavior Management Guidelines dated 3/2022 documented the purpose of the policy is to describe the process steps in managing patient behavioral symptoms including risk evaluation and the development of behavioral interventions. The policy documented the definition of wandering as random or repetitive locomotion and the definition of elopement as egress from safe zone without authorization or necessary supervision to assure safety. The policy documented intrinsic factors that may increase the risk of behaviors include diagnoses of mood and behavior disorders. Extrinsic factors that may increase the risk of behaviors include change in environment, and stimulatory effects of the environment. The policy documented behavior risk is evaluated and documented upon admission and with new and escalating behaviors. The Face Sheet for Resident #1 documented he resided in room 226-W. The Progress Notes for Resident #1 documented the following: On 6/24/22 at 11:43 AM the patient arrived at 1:30 PM on 6/23/22. Past medical history of [CONDITION(S)], hypertension, [CONDITION(S)], and [CONDITION(S)]. Some confusion noted while talking to the patient. On 6/25/22 at 12:30 PM recreation/activity evaluation not completed as patient voiced not wanting to do all the questions as not going to be here long. On 7/1/22 at 9:06 AM spoke with health coordinator at group home. He will be dropping off clothing for the resident for his skilled stay. On 7/2/22 at 11:38 PM call received from group home that resident found by police department walking alone on the side of the interstate. It is unclear when the resident left the facility. Police department to bring the resident back to the facility at this time. On call nurse, provider and family notified. Per the provider if the resident is not agitated, resident can stay at the facility with full set of vitals obtained and resident needs to be placed on wander guard. On 7/3/22 at 3:12 PM resident is now on one on one due to exit seeing. Aide to follow schedule at this time. Will continue to monitor. On 7/5/22 at 11:28 AM nurse spoke with health coordinator of group home about discharge back there. Resident will be discharging 7/6/22. On 7/6/22 at 5:37 AM late entry for 7/3/22. Resident returned to facility via the police department. Nurse assessed resident and stable upon arrival. Observed resident wearing blue jeans and a blue jersey prior to leaving facility. When resident returned clothing intact. Assessed skin and intact with no injuries. Resident calm and pleasant upon arrival. Escorted back to room with one on one supervision. The Police Report dated 7/2/22 at 11:03 PM documented the resident was picked up on interstate 235 along the 2800 block and the resident was headed east bound. A passerby called in the concern due to the resident was walking alongside the shoulder of the interstate and was wearing a blue jersey late at night. Upon the police officer (PO) arrival they located an elderly male exiting the interstate on the east bound ramp onto 22nd street. He appeared unharmed but showed very little awareness of the situation. He was able to identify himself as Resident #1 but could only indicate he was trying to go to a group home. The PO contacted the Group Home and they indicated the resident used to live there but should currently be under the care of the nursing facility. The PO contacted the nursing facility and the staff were unaware the resident was not in their facility. The PO transported him back to the facility. The resident had walked approximately 5 miles from his nursing facility. The facility investigation documented Staff B reported he was asking about going home earlier that night. The investigation documented Staff Z reported when she did rounds at change of shift they did not go into the resident room and actually lay eyes on him. On 7/6/22 at 4:35 PM the Administrator stated she got a call around 11:30 PM on 7/2/22 from the facility indicating a police officer had picked Resident #1 up along a highway. The officer contacted the previous placed he lived and then they forwarded it to the facility. The police returned him at 11:47 PM. He was not taken to the hospital for evaluation because he was not in any distress and he did not have any injuries. He was assessed for wander guard but the facility decided to do one on one. He remained one on one until he was discharged today back to the group home. She stated he made no attempt to meander the halls or come up front before this incident. She stated when the resident was new they looked in their chart at the hospital to make sure there are no behaviors and he did not have any signs that he was a flight risk. She stated no door alarms sounded that night and if the front door is opened by someone then it is not going to alarm. She stated someone potentially put in the door code for him or he could have gotten out when a resident was coming in. She also stated the staff release the door from the nurse station when they hear the doorbell ring. There was a door bell on both sides of the door with a camera that shows when someone was coming in but no camera to show when someone is leaving. She stated there was a resident that goes in and out and knows the door code. She stated they changed the door code after this incident just in case more residents knew the code. She stated they also educated the staff to not release the door from the inside unless they go to the door and visibly see who was leaving. She stated Resident #1 looked like a visitor or a family member when he is in street clothes. She added that he was a very fast walker. On 7/7/22 at 10:13 AM Staff V stated he was the charge nurse working the evening Resident #1 got out of the facility. He stated it was not a typical eve for the resident. He stated the resident usually stays in his room but that eve he was up walking the halls on the main level. He stated he last saw the resident at 8:29 PM on 7/2/22 when he gave him evening meds. He stated he went about his normal job duties and did not intervene with the resident. He stated he got a call shortly after 11pm stating the police found the resident and would be bringing him back. He stated him or the other staff did not hear any alarms that night and did not know how he got out. He stated he did not have wander guard on that night and was up independent with no devices. He stated the front door is secure and staff have to put in a door code to leave or enter. He stated there are two residents care planned to come and go and know the door code. He stated there is a display monitor at each nurse station showing who comes in when they push the doorbell but not when they are leaving. He stated the staff have to pay attention to who is going out. He stated he assessed the resident when he returned to the facility and he was not injured. He stated he asked the resident why he left but the resident did not have a straight answer for him. He stated the resident just told him he was walking. On 7/7/22 at 10:30 AM the Director of Nursing stated a behavioral assessment and social service assessment are done on admit to determine if the resident is a wandering and elopement risk. She stated there were no indicators he would elope. Both these assessments were done with no behaviors documented. The DON stated when behaviors such as going to doors, trying to get out and exit seeking staff would put interventions in place. She stated if they are confused and ambulating they are not necessarily an elopement risk. She stated earlier that day group home staff had brought him some clothes and with him having a BIMS of 3 and seeing his clothes she feels it may have triggered him that it was time to go back home. She stated when staff saw him up walking the halls the night of 7/2/22 she would have expected them to keep an eye on him. She stated she was not aware he was asking questions about going home earlier that evening and due to this and the wandering she would have done one on one supervision or put a wander guard on him. She stated staff are to lay eyes on all residents at change of shift. On 7/7/22 at 3:18 PM the police officer stated he responded to the call received on 7/2/22 of a concern that Resident #1 was seen walking on the side of a busy interstate. He stated when the call came in they reported he was along 2800 block of interstate 235 walking east on the shoulder of the interstate. He stated when he found the resident he had made it to the exit ramp of 22nd street. He stated the resident was not harmed but very confused. He stated once they identified the resident resided at the facility he called them. He stated the facility was not aware the resident had gotten out of the building. On 7/6/22 at 4:00 PM observed room 226-W to be the third room on the left. Observed his room to be on the main level of the building approximately 150 to 200 feet from the main entrance. Observed an exit sign down the hall. The exit is secure with an alarm pad and goes to the lower level of the facility. One push of the door sounded an intermittent alarm and the door will not open. Steady push of the door sounded a steady alarm and the door released allowing exit. Observed an aide respond to the door alarm in 34 seconds. The aide stated all doors in the building are locked and alarmed the same way including the front door. On 7/6/22 at 4:26 PM observed a resident in a wheelchair trying to get in the front door. Doorbell activated by the resident several times then heard the door open and an automated voice stated the door was now open. On 7/6/22 at 4:29 PM observed a resident in a wheelchair use the door alarm with a code and get straight into the building. When the door opened an automated voice stated the door was now open The IJ template was provided to facility on 7/7/2022 at 2:45 p.m. The IJ was removed on 7/3/2022 prior to the entrance of survey team. The IJ was removed when the facility implemented the following: On 7/2/2022 all residents at facility were all accounted for within the facility. On 7/3/2022 all exit doors were checked by the maintenance director. The door code was changed and staff members were educated not to give out door codes to visitors or residents by Admin/designee on 7/3/2022 On 7/3/2022 an Ad Hoc QA meeting was held on 7/3/2022 with interdisciplinary team and medical director and additional QAA meeting held on 7/7/2022.

Based on clinical record review and interviews the facility failed to provide treatment and care to each resident based on the comprehensive assessment in accordance with professional standards of practice and the comprehensive person centered care plan for 2 of 2 sampled (Resident #1 and #2) with [MEDICAL CONDITION] (C. diff). Resident #1 had loose stools for two weeks. The facility failed to communicate with the Nurse Practitioner that Resident #1 had loose odorous stools. The facility failed to submit a stool specimen until 10 days after the staff initially reported Resident #1's symptoms. The facility obtained three stool specimens on three different dates for evaluation. The lab rejected the samples due to inadequate prep and communicated this to the facility on the lab report with instructions to call the lab. The facility failed to properly assess, provide meaningful interventions, and failed to return a call to the lab. On 5/28/19, Resident #1 presented with an elevated temperature and confusion above baseline and transferred to the hospital where the resident passed away due to septic shock. The facility reported a census of 73 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had no cognitive impairments. The MDS dated [DATE] documented Resident #1 required extensive assistance of two staff all activities of daily living. Resident #1 had bowel and bladder incontinence. The Care Plan initiated on 6/15/19 revealed Resident #1 dependent on staff for toilet use, dressing, bathing and transfers. The Care Plan directed the staff to report gastrointestinal distress such as nausea, constipation and diarrhea. The Progress Note dated 5/18/19 at 5:13 p.m. documented a Nurse Aide informed the nurse Resident #1 had a bowel movement that smelled of [DIAGNOSES REDACTED]. The Nurse received an order to obtain a stool specimen to check for [DIAGNOSES REDACTED]. The 5/1/19 to 5/31/19 Electronic Treatment Administration Record (TAR) revealed the staff obtained stool specimens on 5/19/19 at 5:54 a.m. and 5/25/19 at 3:10 p.m. The Progress Note dated 5/20/19 at 9:52 a.m. revealed the Nurse Practitioner assessed the redness in Resident #1's abdominal folds and groin area. The Nurse Practitioner documented Resident #1 had no other concerns. The Bacteriology Routine Testing collected 5/20/19 at 7:00 a.m. revealed test canceled reason not available and please call lab. The Details for Order # 5 revealed the test cancelled on 5/20/19 at 2:56 p.m. due to Prep Inadequate. An untitled document submitted by the facility dated 5/20/19 at 2:56 p.m. revealed the lab cancelled the test for Prep Inadequate ( 5). The document revealed no documentation from facility or lab communicated the lab cancelled. The Progress Note dated 5/22/19 at 3:38 p.m. revealed the Unit Manager assessed Resident #1 for pain. Resident #1 reported constant pain at a level 8 and declined pain medications. Lab Order # 4RG noted that the facility collected the ordered stool specimen on 5/23/19 at 10:10 a.m. Details for Order # 4 noted that the lab cancelled the test on 5/23/19 at 8:18 p.m. due to Prep Inadequate. The Progress Note dated 5/23/19 at 8:16 p.m. revealed the lab called the Unit Manager and reported a new stool specimen needed as the lab unable to run the collected specimen. The lab directed to place the new specimen in an orange top stool with orange/red liquid. The Orders between 5/5/19 and 6/4/19 revealed an order dated 5/23/19 to cancel test due to specimen not in proper preservative. The Lab Order # 3RG revealed Resident #1 had a stool specimen collected on 5/24/19 at 8:25 a.m. The Details for Order # 3 noted that the lab cancelled the test on 5/28/19 at 7:28 a.m. due to No Specimen Received. The Orders between 5/5/19 and 6/4/19 revealed no specimen received and called facility on 5/28/19 at 7:19 a.m. to notify of cancel. The Progress Notes dated 5/24/19 at 9:39 a.m. revealed the Nurse Practitioner assessment for Resident #1's acute visit for evaluation of diarrhea. Resident #1 reported going up to 5 times a day and occurred with almost every meal. The Nursing staff attempted a stool sampled yesterday, but unsuccessful and a repeat needed today. The Progress Note dated 5/24/19 at 1:26 p.m. revealed the staff awaiting the proper cup for the stool sample. The Progress Note dated 5/25/19 at 3:49 a.m. revealed the staff obtained the stool specimen as ordered. The Progress Notes dated 5/26/19 at 10:54 a.m. revealed Resident #1 received [MEDICATION NAME] (anti-diarrheal medication) 2 milligrams by mouth and medication effective. The Progress Notes dated 5/27/19 at 8:37 a.m. revealed Resident #1 received [MEDICATION NAME] 2 milligrams by mouth for diarrhea. The Progress Notes dated 5/28/19 at 3:57 a.m. revealed Resident #1 presented with diarrhea and generalized pain. Resident #1 had a blood pressure of 99/76, temperature of 100.8 degrees Fahrenheit, a pulse of 173 beats per minute and respirations of 24 per minute. Resident #1 less alert compared to baseline. The staff called the physician who ordered to send Resident #1 to the emergency department for evaluation. The Internal Medicine Discharge Summary dated 5/28/19 at 8:29 a.m. documented Resident #1 had diarrhea for more than 10 days and stool specimen sent to the lab by nursing home but no results. Resident #1 received a couple doses of [MEDICATION NAME] without improvement. This morning Resident #1 had a temperature of 100.8 degrees Fahrenheit, a blood pressure of 99/76, and respirations of 24 per minute, heart rate of 73 beats per minute and oxygen saturation of 94% on room air. Resident #1 had confusion and transported to the hospital for evaluation. Resident #1 admitted to the Intensive Care Unit for septic shock, [DIAGNOSES REDACTED] result positive and nasal swab positive for rhino/[MEDICATION NAME]. Resident #1 received oral [MEDICATION NAME] and [MEDICATION NAME] with intravenous fluids. Resident #1 had multiple comorbidities and the power of attorney made a decision for comfort cares. Resident #1 passed away on 5/28/19 at 4:39 p.m. During an interview on 6/5/19 at 9:05 a.m., Staff D (Nurse Aide) recalled on Resident #1 had loose stools on 5/12/19. Resident #1 told Staff D she had loose stools for a while. Staff D reported the odor went all the way down the hall. Staff D reported the concern to Staff C (Registered Nurse) on 5/12/19 at 10:00 a.m. or 11:00 a.m. Staff C commented it smelled like [DIAGNOSES REDACTED] and she would call the doctor for an order for [REDACTED]. During an interview on 6/5/19 at 1:05 p.m., Staff B (Nurse Aide) recalled Resident #1 had foul smelling loose stools on 5/12/19. Staff B reported the nurse told him on 5/15/19 they were trying to obtain an order to collect a stool sample. Staff B described the smell as horrible and anyone that walked by the room could smell it. During an interview on 6/5/19 at 10:40 a.m., with Staff K (Nurse Aide) revealed that she and other Aids told Staff L (Licensed Practical Nurse) on 5/15/19 about Resident #1 having loose stools. On 5/18/19, she asked Staff H to call the Dr. about Resident #1 having [DIAGNOSES REDACTED] smelling diarrhea. As she stood at the Nurse's station, Staff K overheard Staff H inform the physician that Resident #1 had diarrhea for close to a week. The Aid said she obtained the sample Staff H asked her to get. During an interview on 6/5/19 at 12:35 p.m., Staff O (Nurse Aide) reported Resident #1 had foul smelling loose stools for 3 weeks before she went to ER. Staff O reported the smell was hard not to notice. Staff O reported Resident #1 had watery and dark green stools. Staff O reported she could tell Resident #1 had [DIAGNOSES REDACTED]. Staff O and Staff N reported this to the nurses. Staff O reported a week later the nurses asked her to obtain a stool specimen. The nurses kept saying they did not have the right cup. During an interview on 6/5/19 at 3:40 p.m., Staff M (Nurse Aide) reported Resident #1 had foul smelling loose stools for 3 times a day for 2 or 3 weeks before she went to the hospital. The smell lingered in the halls and at the nurse's station. Staff M reported Resident #1 had a roommate and never placed on precautions. During an interview on 6/5/19 at 1:20 p.m., Staff I (Licensed Practical Nurse) reported someone had obtained an order by the time she heard about Resident #1 having foul smelling loose stools. During an interview on 6/3/19 at 1:48 p.m., Staff C (Registered Nurse) reported the facility obtained stool specimens for Resident #1 twice and sent them to the lab. However, the lab rejected the samples as they received then in the wrong cups. Staff C reported the day shift nurses obtain the lab specimens and pass it on to the next shift if they cannot obtain them. Staff C reported the staff should notify the physician if they cannot obtain a specimen. During an interview on 6/3/19 at 2:00 p.m., Staff A (Licensed Practical Nurse) reported the lab rejected two stool specimens and she wondered why the staff didn't clarify which cup to use before sending the second specimen. Staff A had communication with the lab on 5/24/19. Staff A inquired about the results. The lab informed Staff A the facility sent the sample in the wrong cup. Staff A spent a significant amount of time on the phone with the lab inquiring about the required cups. The lab requested the facility pick the proper cup up from the lab. Staff A passed this on in report to Staff C. Staff A returned to work the following Monday and understood another sample had been collected. On 5/28/19, Staff A realized the facility did not obtain the proper cups. Staff A reported she had to write an order to obtain the correct cups. During an interview on 6/3/19 at 3:00 p.m., Staff C (Registered Nurse) reported she did not know who ordered lab supplies for the facility. Staff C recalled a series of unsuccessful attempts to obtain the correct cups. Staff C informed the Unit Manager who said she would take care of it. During an interview on 6/6/19 at 6:25 p.m., Staff J (Licensed Practical Nurse) reported the Nurse Aids called her at home on 5/18/19 and reported Resident #1 had frequent episodes of foul smelling loose stools. Staff J told the Nurse Aides to report it to the nurse. The Nurse Aides told Staff J, they were not doing anything about it. During an interview on 6/3/19 at 3:54 p.m., the Unit Manager reported she assessed Resident #1 on 5/22/19 for chronic pain. The Unit Manager could not recall if Resident #1 had bowel symptoms and an order for [REDACTED]. The Unit Manager passed the information along to the charge nurse. The Unit Manager did not check to see if the cups were available. The Unit Manager reported the lab later told them they could send the specimen in the same cups that they rejected. During an interview on 6/4/19 at 8:00 a.m. and 6/5/19 at 7:30 a.m., the Director of Nurses (DON) reported she started working at the facility on 5/15/19 and implemented 24 hour book to enhance communication. The DON reported the facility also used alert charting for Residents with acute issues. The DON reported Resident #1 had not been included on the alert charting. The DON reported she was informed Resident #1 had loose stools on 5/18/19 in morning meeting. The DON reported the sampled had been collected, but then heard the next day the lab refused it because of the wrong cup. The DON reported she assessed Resident #1 but did not document her assessments. The DON did not talk to the lab about cancelling the lab tests. During an interview on 6/4/19 at 9:30 a.m. and 10:28 a.m., the Administrator reported she found out about the lab declining the samples provided on 5/28/19 or 5/29/19. The Administrator reported the staff sent the sampled in a sterile specimen and the lab never informed the facility of a change in their protocol. The Administrator did not know why all of a sudden the lab refused to process things in the same cups they previously used. The Administrator reported she called the lab last week and they said the containers were enroute. Knowing that, the Administrator left the building; but called back and confirmed that they arrived with the Unit Manager. The Surveyor informed the Administrator the appropriate cups never arrived. The Administrator said, They should have notified me if they never got them, they knew to do that. The Administrator reported an expectation of staff to notify management if they run into an issue with the lab tests, so they can intervene. The Administrator reported she would have personally gone to the lab and picked them up in order to avoid the delays. The Administrator reported the lab told them yesterday they could send the samples in anything sterile. During an interview on 6/11/19 at 11:15 a.m., the Nurse Practitioner reported she assessed Resident #1 on 5/20/19. The Nurse Practitioner did not note any odor. The Nurse Practitioner had no knowledge Resident #1 had odorous loose stools on 5/18/19. The Nurse Practitioner learned of an issue on 5/24/19 when the lab rejected the stool specimen. This prompted the Nurse Practitioner to assess Resident #1. The Nurse Practitioner reported an expectation of the staff to notify her of their assessment findings and their difficulty with processing lab specimens. The Nurse Practitioner reported untreated [DIAGNOSES REDACTED] could be fatal. The Nurse Practitioner reported she learned Resident #2 also had diarrhea when she assessed Resident #1. Resident #1 and Resident #2 informed her they had diarrhea for a week. During an interview on 6/6/19 at 12:05 p.m., the Medical Director recalled the staff calling after hours to report a resident had loose stools. The Medical Director did not recall the staff mentioning foul smelling loose stools or suspicions of [DIAGNOSES REDACTED]. The Medical Director reported he always orders a stool specimen to rule out [DIAGNOSES REDACTED] with loose stools. The Medical Director had no knowledge the lab refused to process the stool samples. The Medical Director indicated it would have been helpful to be notified of the lab refusing to process the sample; someone could have intervened sooner. The Medical Director reported she could have wen to the emergency department to get lab results promptly. When asked, the Medical Director reported each person's immune response is different; so he supposed [DIAGNOSES REDACTED] could be fatal sometimes. The One-On-One In-service Record dated 6/4/19 noted that the Unit Manager provided education on processing lab orders. The education documented if the staff cannot obtain a lab, they need to notify the physician and document in Nurse's Notes and a place a new order for the lab if applicable. The facility failed to assess Resident #1 from onset of symptoms on 5/18/19 to 5/24/19 when the Nurse Practitioner assessed Resident #1. 2. The MDS assessment dated [DATE] documented Resident #2 had [DIAGNOSES REDACTED]. Resident #2 had no cognitive impairments. The MDS dated [DATE] revealed Resident #2 required extensive assistance of two staff for most ADLs and had frequent bowel incontinence. The Care Plan revised 6/5/19 revised revealed Resident #2 had [DIAGNOSES REDACTED] and required contact isolation. The Care Plan directed the staff to use gowns and masks when changing contaminated linens, instruct family and staff on preventive measures to contain the infection, administer medication and intravenous therapy as ordered and monitor for symptoms of weakness, dehydration, fever, nausea, vomiting and blood in her stools. The Care Plan focused on gastrointestinal distress related to diarrhea; with pending lab results and directed the staff to report and record episodes of loose stools and increase in abdominal pain. The Progress Notes dated 5/24/19 at 9:51 a.m. revealed the nursing department requested the Nurse Practitioner to assess Resident #2 for diarrhea that started a week ago. The Nurse Practitioner documented Resident #2 reported episodes of loose stools 2 to 3 times a day. The Nurse Practitioner ordered a stool sample for culture and [DIAGNOSES REDACTED], encourage fluids, hold laxatives/stool softeners until diarrhea resolves, [MEDICATION NAME] 2 mg every 6 hours for diarrhea and monitor and notify if the Nurse Practitioner if symptoms do not improve or worsen. The Progress Notes dated 5/24/19 at 1:35 p.m. revealed Nurse Practitioner informed awaiting for a proper sample cup. The Progress Notes dated 5/25/19 at 4:22 a.m., revealed Resident #2 had no bowel movement during the shift. The Progress Notes dated 5/29/19 at 6:17 p.m. revealed Resident #2 had no reports of bowel movement today. The Progress Notes dated 5/30/19 at 12:42 p.m. revealed the Nurse Practitioner visited Resident #2. Resident #2 reported she felt okay and she did not have diarrhea over the last 2 days. Resident #2 reported intermittent nausea, but ate her full breakfast. The Nurse Practitioner referred Resident #2 to a nephrologist for further evaluation. The Progress Notes dated 5/30/19 at 2:21 p.m. revealed Resident #2 had had one loose stool during the shift. The Progress Notes dated 6/4/19 at 7:37 a.m. revealed Resident #2 reported she had loose stools. The nurse asked the nurse aide to report any bowel movements. The Progress Notes dated 6/4/19 at 3:14 p.m., revealed Resident #2 had a loose stool today and the Nurse Practitioner reported Resident #2 had an order for [REDACTED]. The Progress Notes dated 6/5/19 at 8:00 a.m., revealed the staff collected the stool specimen. The Bacteriology Routine Testing dated 6/5/19 at 7:30 a.m., revealed Resident #2 tested positive for [DIAGNOSES REDACTED] and directed to maintain contact precautions. During an interview on 6/11/19 at 11:15 a.m., the Nurse Practitioner reported she assessed Resident #1 on 5/20/19. The Nurse Practitioner did not note any odor. The Nurse Practitioner had no knowledge Resident #1 had odorous loose stools on 5/18/19. The Nurse Practitioner learned of an issue on 5/24/19 when the lab rejected the stool specimen. This prompted the Nurse Practitioner to assess Resident #1. The Nurse Practitioner reported an expectation of the staff to notify her of their assessment findings and their difficulty with processing lab specimens. The Nurse Practitioner reported untreated [DIAGNOSES REDACTED] could be fatal. The Nurse Practitioner reported she learned Resident #2 also had diarrhea when she assessed Resident #1. Resident #1 and Resident #2 informed her they had diarrhea for a week. The Progress Notes dated 6/5/19 at 11:06 a.m. revealed the Nurse Practitioner visited Resident #2 and completed a note. Resident #2 had intermittent episodes of loose stools over the last 2 weeks. Resident #2 had two watery stools this morning. A stool sample for [DIAGNOSES REDACTED] in process. Resident #2 reported some mild abdominal discomfort and nausea. During an interview on 6/3/19 at 12:35 p.m., Resident #2 reported she stayed in her room most of the time. The Resident #1 reported her roommate (Resident #1) had foul smelling stools since she moved in with her 6 months ago. Resident #2 reported her roommate passed away in (MONTH) reportedly from [DIAGNOSES REDACTED]. During a subsequent interview on 6/11/19 at 8:08 a.m., Resident #2 reported the staff placed her on isolation for [DIAGNOSES REDACTED] about 6 days ago. Resident #2 reported [DIAGNOSES REDACTED] is contagious and she told the facility she got it from her roommate, Resident #1. During an interview on 6/11/19 at 7:57 a.m., Staff N (Nurse Aide) reported Resident #2 had loose stools for as long as Resident #1 had them. Staff N reported Resident #2 placed on isolation last week. Staff N said they asked a Nurse to obtain an order for [REDACTED].

Based on record review and staff interviews, the facility failed to provide adequate supervise when repositioning a resident in bed, resulting in the resident falling out of bed and hitting head on trash can which resulted in a closed head injury and lumbar fracture (Resident #6) and failed to provide adequate supervision in order to keep Resident #16 safe. The sample consisted of 20 residents reviewed and the facility reported a census of 79 residents 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of dated 11/2/17 . The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a score of 11 out of 15 for Brief Interview of Mental Status (BIMS) cognitive assessment. A score of 11 identified the resident had a moderate cognitive impairment. The MDS indicated the resident had no symptoms of [MEDICAL CONDITION], and required extensive assistance by 2 or more staff members for transfers to and from bed and chair, bathing, dressing, toileting, personal hygiene, and frequently incontinent of bowel and bladder. The Care Plan, identified the resident had a problem with activity of daily living skills. The plan directed staff to assist the resident with dressing, bathing, personal hygiene and transfers. The physician orders [REDACTED]. An Incident Report, completed by Staff A, licensed practical nurse (LPN), dated 1/1/17 at 6:30 a.m. identified the resident rolled out of bed when changed ( due to incontinency) by staff, hit face on garbage can and the staff used a mechanical lift to transfer the resident from the floor. A hospital Emergency Department physician note, dated 11/1/17 at 8:50 a.m. indicated the resident assessed after a fall, and later admitted to the hospital for a closed head injury and facial swelling after a fall from the bed. The Final Report of the images included a compression fracture at L2 (lumbar) and a chronic [MEDICAL CONDITION] Thorasic spine, T 12. The resident returned to the facility on [DATE] at 2:30 p.m., with 2 bruises on the left side of the neck that measured 10 centimeters (cm) by 3.5 cm and 7 cm by 2 cm, both purple colored. On 1/4/18 at 8:10 a.m., Staff A was interviewed and stated on the morning of 11/1/17, the resident became incontinent and as she removed the soiled bedding with the resident positioned on her side, the resident and the air mattress slid off the opposite side of the bed and the resident hit her head on the waste can as she fell to the floor. There were no other staff in the room at the time. Staff A stated she should not have provided the care unassisted. On 2/27/18 at 1:01 p.m. Staff A was interviewed and stated the resident fell off the left side of the bed in between her and the room- mate's bed. Staff A stated the area had a trash can and a recliner chair on that side of the bed. The air mattress was partially hanging over that side of the bed but still mostly on the bed with the sheet over the mattress. The bed was in the normal position and was not a low bed but she had raised the bed up for the care. The bed had no bed rails on the bed. Staff A stated after the incident, she yelled for help and another nurse and a CNA came in quickly. 2. The MDS with a reference date of 8/16/17 indicated Resident #16 had [DIAGNOSES REDACTED]. The Care Plan indicated the resident had a deficit with activity of daily living (ADL) self-care. The plan directed the staff that 2 staff needed to assist the resident with dressing, transfers and bathing. Another problem identified on 5/23/15, reflected the resident to be at risk for falling. The interventions directed the staff to change the resident's positions slowly, place commonly used articles in reach and reinforce the need to call for assistance. An Incident Report, created on 11/1/17 at 2:27 p.m. identified the resident found on the floor on 10/30/17 at 6:15 p.m. by her bed, with sheet under her and incontinent of urine, without major injury, no mental status changes, pupils equal and reactive to light, grips equal, range of motion within normal limits for the resident, resident crying, unable to determine if crying was due to pain or some other reason. The staff assisted the resident to bed. Another Incident Report, created on 10/14/17 at 1:15 p.m., revealed the staff found the resident on the bedroom floor at 10:45 a.m. on her back with feet up in air against side of the bed. No injuries identified. Staff interviews identified the following: 12/18/17 at 10:52 a.m., Staff K, licensed practical nurse (LPN), on duty at time of the fall on 10/30/17, stated she didn't know how the resident fell , it happened at the change of shifts, the resident didn't attempt to self transfer. 12/18/17 at 12:10 p.m., Staff BB, LPN, stated the resident could not move by herself, she had contractures. 12/18/17 at 12:25 p.m., Staff L, LPN, stated she never saw the resident move. 12/18/17 at 12:43 p.m., Staff M, LPN, stated the resident couldn't move on her own. 1/23/18 at 3:30 p.m., Staff G, certified nursing assistant (CNA) stated the resident didn't move on her own, she had to be fed, she didn't know how she could have fallen on her own. 12/18/17 at 5:20 p.m., the former Director of Nursing (DON) stated the resident could scoot herself in bed, and she didn't have any investigative note or file related to he 10/30/17 fall.

Based on record review, staff and physician interviews and review of policy and procedures, the facility failed to ensure that 1 of 19 residents reviewed were free from significant medication errors (Resident #17). The facility reported a census of 79 residents. Findings include: The Minimum Data Set (MDS) assessment, with a reference date of 9/4/17, indicated Resident #17 had an admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance of at least 1 staff for transfers to and from the bed and chair, bathing, dressing, toileting and personal hygiene. The physician orders [REDACTED]. 1. [MEDICATION NAME] Bisulfate ([MEDICATION NAME] - a medication used to prevent blood clot formation following coronary vessel bypass procedures) 75 milligrams (mg) administered oral daily. 2. Apixaban (Eliquis - an anticoagulant medication) 5 mg administered oral 2 times daily. The facility's Admission policy, dated 12/2009, directed staff to notify physician of resident admission and obtain or verify orders. The policy and procedures titled Medication and Treatment Administration Guidelines, dated 12/2014, directed that orders are transcribed and noted by the licensed nurse. The licensed nurse noting an order is responsible for accurate transcription and initiation of orders. The August, 2017 and September, 2017 Medication Administration Records (MAR's) revealed Resident #17 received the [MEDICATION NAME] medication daily as ordered from 8/29/17 through 9/5/17, and had not received the Eliquis medication. A Nurse's Progress Note transcribed on 9/6/17 at 6:29 a.m. by Staff A, licensed practical nurse (LPN), revealed the spouse informed the nurse the resident's leg was swollen. The nurse assessed the leg and described the leg as [MEDICAL CONDITION] (swollen), hard and warm to touch, the physician notified, and obtained an order for [REDACTED].>A Nurse's Progress note transcribed on 9/6/17 at 6:28 a.m., by Staff B, LPN (licensed practical nurse) indicated the physician ordered the resident sent to the hospital emergency room for evaluation and treatment related to deep vein thrombus ([MEDICAL CONDITION]) to the right hip and right lower extremity. A hospital discharge summary dated 9/12/17 revealed the resident admitted on [DATE], with [DIAGNOSES REDACTED]. Documentation on a facility self-reported event to the Iowa Department of Inspections and Appeals (DIA), identified Resident #17 admitted on [DATE], sent to the emergency roiagnom on [DATE] for right leg swelling with redness, admitted to the hospital for [MEDICAL CONDITION], and a hospital surgeon contacted the facility on 9/6/17 and questioned if the resident had received the [MEDICATION NAME] and Eliquis medications as ordered. On 12/11/17 at 5:22 p.m., the Director of Nursing (DON) was interviewed and stated 2 different nurses were required to enter physician orders [REDACTED]. The DON stated Staff K, licensed practical nurse (LPN), entered the orders on the resident's admission, omitted the Eliquis order, and no other nurse verified the orders were entered as prescribed. On 1/18/17 at 11:15 a.m., the resident's [MEDICATION NAME] surgeon was interviewed and stated staff should have administered both the [MEDICATION NAME] and Eliquis medications as ordered, and if administered as directed, it would have eliminated or greatly reduced the resident's risk of blood clot development that required his re-hospitalization and surgical intervention.

Based on clinical record reviewed and staff interviews, the facility failed to protect 1 of 7 residents from physical/environmental hazards (Resident # 6). Interviews and record review revealed Resident #6 requested additional supports to prevent him/her from falling out of bed. Three days after admission, Resident #6 rolled out of bed and sustained injuries to his/her right thigh which developed into [DIAGNOSES REDACTED] and hospitalization . The facility reported a census of 90 residents. Findings include: Resident #6 had a Minimum Data Set (MDS) with an assessment dated [DATE]. The MDS indicated the resident had [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) had not been completed. The resident needed extensive assistance of 2 staff with bed mobility, transfers, and extensive assistance of 1 staff with ambulation. The resident had functional limitation in range of motion of a lower extremity (leg) and unsteady balance and required staff assistance. The resident's record indicated h/she had been admitted on [DATE] at 2:08 p.m. The Progress notes dated 9/13/16 at 2:08 p.m. revealed the resident transferred and ambulated with the assistance of 1 staff. The [AGE] year old had been admitted following trauma from a fall with his/her scooter. Progress notes dated 9/13/16 at 3:23 p.m. revealed the resident needed standby assist with ambulation. Progress notes dated 9/15/16 at 6:40 a.m. revealed the resident needed assistance with transfers and repositioning as tolerated. A care plan with a focus area dated of 9/14/16 indicted the resident could transfer independently in h/her room. A focus area dated 9/13/16 identified the resident at risk for falls, with an initiated date of 9/14/16, established interventions directing staff to assist with transfer and ambulation as needed and have commonly used articles within reach. An intervention dated 9/17/16, with an initiated date of 9/19/16 indicated a wider bed had been installed. An occupational assessment completed 9/14/16 at 7:29 a.m. indicated the resident had decreased level of participation with activities of daily living (ADL's) and an increased need for assistance from others. A physical therapy evaluation completed 9/14/16 at 9:19 a.m. revealed the resident needed contact guard assist with transfers. Risk factors included physical impairments and associated functional deficits and a risk for falls, increased pain, limited out of bed activity, DVT and decreased level of mobility. Progress notes dated 9/15/16 at 1:01 p.m. revealed a comprehensive evaluation completed by a nurse practitioner identified fall precautions directing staff to assist with transfer and ambulation as needed. Notes indicated an inner left thigh wound has a wound vac intact with moderate serous/sanguineous draining, tissue beefy red with scatter black speckles and tunneling present at both ends. The right leg is edematous at 3+ and left leg at 2+. The resident rated h/her pain at 4-5 out of 10 and described the pain as a throbbing ache. Progress notes dated 9/16/16 at 7:05 a.m. documented the resident needing assist with transfers and repositioning. Progress notes dated 9/17/16 at 5:38 a.m. indicated staff found the resident on the floor next to h/her bed. The Incident Report dated 9/17/16 at 1:30 documented the resident was asleep in bed and h/she had rolled out of bed and onto the floor. The resident had no injuries or pain when assessed. The report documented the bed had been in a low position. A written statement by maintenance supervisor, reported a 42 inch mattress had been placed on the resident's bed on 9/13/16 at the time of admission (wider size than the normal size initially placed.) On 9/17/16, he was asked to place a 48 inch mattress on the resident's bed frame as a fall intervention. Progress notes dated 9/17/16 at 9:25 a.m. revealed staff attempted to give Tylenol 325 mg - 2 tablets for pain greater than 4 out of 10 or fever greater than 100.5 degrees. The resident refused this medication and requested a stronger pain medication. Progress notes dated 9/17/16 at 11:13 a.m. revealed Hydrocodone/Acetaminophen 10 milligram (mg)/325mg - 1 tablet every 6 hours as needed (prn) had been given because the resident complained of pain of 3 out 9. An Encounter note dated 9/17/16 at 2:49 p.m. documented the resident had been seen for insomnia. The report documented the resident is a new admission for skilled care at the nursing home on 9/13/16 for skilled post hospitalization for left inner thigh wound. The resident is currently on Lovenox with bridging back to Coumadin therapy for atrial fibrillation/mechanical mitral valve replacement. The resident is able to transfer with 1 assist. Notes indicated the administration of Coumadin 11 milligrams (mg) on Sunday-Monday-Wednesday and Friday and Coumadin 13 mg on Tuesday-Thursday and Saturday. Notes indicated the resident had an unsteady walk with abnormal movements. The resident surgical history indicated a right total knee replacement and rated h/her pain at 5 out of 10. Progress notes dated 9/18/16 at 2:00 a.m. revealed the resident complained of right thigh and knee pain, rating the pain at 6 on a 0 to 10 pain scale. Repositioning and distraction not effective. On 9/18/16 at 5:10 a.m. revealed the resident complained of pain to the right knee and thigh rating pain at a 6 on a 0 to 10 pain scale. The Progress notes dated 9/18/16 at 10:00 a.m. revealed Hydrocodone/Acetaminophen 10 milligram (mg)/325mg - 1 tablet every 6 hours as needed (prn) had been given for a swollen right leg. Progress notes dated 9/18/16 at 6:00 p.m. revealed the Hydrocodone/Acetaminophen 10 milligram (mg)/325mg - 1 tablet was not effective. Progress notes dated 9/18/16 at 11:30 p.m. revealed the Hydrocodone/Acetaminophen 10 milligram (mg)/325mg - 1 tablet given for a swollen right leg. Progress notes dated 9/19/16 at 3:46 a.m. revealed the resident complained of right quadricept pain. Acetaminophen 325 mg -2 tablets had been given and at 4:30 a.m. Hydrocodone/Acetaminophen 10 milligram (mg)/325mg - 1 tablet had been given. The resident requested a larger bed to prevent future falls out of bed during the night. Progress notes dated 9/19/16 at 9:20 a.m. revealed the nurse practitioner had been notified by the rehabilitation staff the resident reported increased pain to the right knee after the fall from bed on 9/17/16. The resident had landed on the right side and sustained a bruise and scratch to right abdomen and the right knee swollen with decreased range of motion. The resident is able to extend the leg but had difficulty with bending and reported inability to bear weight on the right leg. An x-ray revealed no fracture/dislocation or effusion. An order to switch to a beri bed and apply ice to the knee to decrease swelling. Progress notes dated 9/21/16 at 11:45 a.m.; a nurse practitioner follow-up documented increased swelling with new bruising to the right leg. Nursing staff reported the resident had increased edema to the right leg with extensive bruising to the right posterior thigh. An x-ray had revealed negative injury to the right knee. The right leg now had 4+ edema, tight skin and difficulty palpating distal pulses due to edema and the resident unable to bear weight due to pain. The facility sent the resident to a hospital emergency department for evaluation and treatment related to hematoma complications. A medical practitioner progress note dated 9/21/16 at 3:20 p.m., indicated a [DIAGNOSES REDACTED]. The progress note revealed the resident had been presented to the emergency room (ER) for evaluation of right leg injury. The resident had a history of [REDACTED]. The resident developed a left thigh hematoma wound which got secondary infection and eventually required hematoma evacuation and he/she discharged with picc line antibiotics to the nursing home. Unfortunately Saturday ( September 17, 2016) he/she rolled out of bed and landed on the right knee. The resident had right knee pain and a reassuring x-ray. The resident reported increasing leg swelling and muscular tenderness over the next few days. The nursing home decided to transfer him/her to the veterans (VA) emergency room today by ambulance. The examination revealed the resident had right leg 3 + (plus) edema with tenderness in the right thigh. The resident had pain on the right knee with right knee flexion. There is an old post right total knee replacement. The right CT (computed tomography) of the right thigh revealed 34.2 cm x 12.5 x 7.5 cm heterogeneous fluid collection in the anterior compartment right thigh. The addendum to the progress note dated 9/22/16 documented the resident had been seen and examined by the physician with plans to monitor the resident ' s leg for signs of [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is a serious condition that involves increased pressure in a muscle compartment which can lead to muscle or nerve(s) damage and problems with blood flow. Surgery is needed immediately and delaying can lead to permanent damage according to MedlinePlus web search at: https://medlineplus.gov/ency/article/ 4.htm) The discharge summary dated 11/17/16, indicated the resident had been admitted on [DATE] for the primary [DIAGNOSES REDACTED]. The summary revealed Resident #6 had been admitted from the nursing home on 9/13/16 to 9/21/16 and transferred to a local emergency department on 9/21/16 due to falling out of bed, injuring h/her right thigh. The resident reported h/she had requested guard rails (side rails) for the bed as h/she has RLS and will fall out of the bed; and was informed by the nursing home that it was considered a restraint and could not be done. Three (3) days later, the resident fell out of bed and injured the right thigh which developed into a [DIAGNOSES REDACTED] and was sent back to the emergency department and readmitted on [DATE]. On 9/24/16 a surgical procedure had been performed to decompress the right leg hematoma. The resident transferred to the hospital long term care facility on 10/6/16. On 11/17/16 the facility discharged the resident home. During a phone interview dated 12/14/16 at 2:30 p.m., the resident reported when h/she first came to the facility, h/she told staff h/she had a history of [REDACTED]. The facility told h/her the facility did not use side rails. The resident asked about the use of a floor mat (a pad placed on the floor next to the bed). Facility staff reported they did not use floor mats. The resident reported he/she had a normal bed and the bed had not been lowered. The resident reported h/she had fallen out of bed the morning on 9/17/16. The resident reported h/she had increased pain and then hospitalized . During an interview dated 12/19/16 at 8:05 a.m., Staff G, a licensed practical nurse (LPN) reported the resident voiced concerns about the size of h/her bed and possibly falling out of bed. The resident had asked for side rails but had been told the facility didn't use them. The resident reported h/she dreams and rolls around in bed. She reported the resident had been admitted to the hospital following the fall of 9/17/16 for a possible blood clot. During a phone interview dated 12/14/16 at 3:30 p.m., Staff F, RN reported he didn't recall having a conversation with the resident at the time of admission, of concerns of falling out of bed, the use of side rails or the use of a floor mat. During a follow-up interview dated 12/15/16 at 2:05 p.m., Staff F, RN reported the resident needed to be evaluated by physical/occupational therapy to determine the resident's ability related to transfer and ambulatory status. The resident needed 2 staff to assist with transfer and needed staff assistance with a wheel-chair for mobility. He remembers the resident needed a wider bed due to the resident's size and to be comfortable while in bed. The unit manager thought he would need a wider bed. The resident was alert and oriented without cognitive problems. During an interview dated 12/15/16 at 2:50 p.m., Staff H, RN and unit manager, reported at time of admission the resident needed 2 staff assistance with transfer and 1 staff assistance with the use of a wheel-chair. The resident had continuous oxygen via nasal cannula and had a [DEVICE] in place. During a meeting dated 12/20/16 at 4:10 p.m., the Administrator reported the resident had been sent to a local hospital emergency department for evaluation and treatment. She reported the resident hadn't been happy with living at the facility and didn't want to return.

Based on observation, record review and staff and physician interviews, the facility failed to properly assess and intervene when a resident had a medical condition that warranted a thorough assessment (Resident #4). The sample consisted of 5 residents. The facility reported a census of 81 residents. Findings include: According to a Minimum Data Set (MDS) assessment form dated 10/2/13, Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, required limited to extensive assistance of staff with activities of daily living (ADL), having been at risk for pressure ulcers and with an infection of his/her foot. The facility Progress Notes revealed the following: On 9/20/13 at 12:40 p.m. a Nurse Practitioner documented the resident as admitted to the facility post ( after) a fall at home with a left great toe fractured at the lateral base 1st proximal joint, the foot as bruised, the toe wrapped to the 2nd toe for stability and the resident wore Ortho shoes when up. On 9/30/13 at 5:56 p.m. a nurse documented the resident remained on therapy services related to a left great toe fracture and with pedal pulses present and strong. On 10/1/13 at 11:59 a.m. a nurse documented the resident remained on therapy services related to a left great toe fracture and with pedal pulses present and strong. On 10/2/13 at 7:15 p.m., a nurse documented the resident ' s great toe as taped to the 2nd toe and tolerated it well with pedal pulses present. On 10/4/13 at 8:30 a.m., the Nurse Practitioner documented the resident as admitted to the facility for a left great toe fracture with toe buddy wrapped to the 2nd toe for stability. That morning new bleeding had been noted at the site. The taping had been removed and a new wound discovered underneath the tape on the 2nd toe on the lateral side. The area was described as necrotic with a small area of yellow slough, the entire toe erythemic (redness) and tender and with a small amount of blood drainage from the necrotic area. The inner aspect of both the great toe and the 2nd toe also with a small open area. The patient (resident) had been able to bear weight on the foot using an Ortho Shoe during ambulation. The resident had been afebrile (no fever) with a known history of [MEDICAL CONDITIONS]. The [DIAGNOSES REDACTED]. The plan included Bactrim DS (antibiotic) 1 tablet by mouth twice a day for 10 days, a podiatry consult for evaluation and treatment, continued use of the Ortho Shoe for ambulation, monitor temperatures and a CBC (complete blood count) PRN (as needed). On 10/4/13 at 2:36 p.m. (late entry) a pressure area noted on the right lateral 2nd toe that measured 2.7 cm by 1.3 cm by 0.2 cm. The wound as necrotic with a small area of yellow slough with a small amount of serosanguinous and yellow drainage noted. The surrounding tissue as reddened blanchable and painful. Denuded skin areas noted on the right medial 2nd toe. The distal area with yellow [MEDICATION NAME] tissue that measured 1 cm by 0.7 cm and superficial. The proximal area measured .4 cm by .3 cm and superficial with the surrounding tissue reddened and blanchable. On 10/7/13 at 1:41 p.m. the Nurse Practitioner documented a follow up visit related to a necrotic toe with [MEDICAL CONDITION]. The left 2nd toe as less red on that day (fading from markings on toe). But the lateral side of the toe continued with necrotic tissue and no drainage noted. The resident admitted to pain to the 2nd toe. A Podiatry consult had been completed and considering possible hospitalization for IV antibiotics and a salvage attempt. The plan currently on hold as the toe had been showing slight improvement. The resident remained on Bactrim Therapy for [MEDICAL CONDITION], afebrile and admitted (voiced) to malaise (overall feeling of tiredness and fatigue), appetite just fair and occasional nausea. The resident as diagnosed with [REDACTED]. The staff had been ordered to keep two or three 4 by 4 ' s between the resident ' s toes with no constrictive dressings. On 10/9/13 at 10:45 a.m. the Nurse Practitioner documented the resident received recent treatment for [REDACTED]. The toes remained tender to the touch but with less redness to the area. The resident had a [DIAGNOSES REDACTED]. The staff had been ordered to keep two or three 4 by 4 (gauze dressing) between the resident ' s toes with no constrictive dressings. On 10/9/13 at 12:00 p.m. (late entry) A pressure area noted on the right 2nd toe that measured 2.2 cm by 1.2 cm and 0.1 cm with a wound bed that contained a dark scab with light yellow/serosanguinous drainage. The surrounding tissue had been described as reddened and blanchable. On 10/10/13 at 2:21 p.m. the Podiatrist assessed the right toe ulcer, debrided and changed the treatment order to [MEDICATION NAME] covered with gauze and no constrictive dressings to the area and the administration of intravenous Zayn antibiotic. On 10/11/13 at 11:46 a.m., a nurse documented the resident ' s dressing as clean, dry and intact. On 10/14/13 at 2:30 p.m. the Nurse Practitioner documented the resident ' s left second toe wound improved which had been acquired during tape compression for a great toe fracture. The toe had been " buddy taped " to the 2nd toe (for stabilization). The color as pink with slight redness. The lateral wound as a brownish/black scab and the 2 small wounds on the 2nd toe were nearly resolved. The blackish necrotic scab on the lateral great toe had been stable. A tissue culture and sensitivity from 10/11/13 returned with a staph organism and the resident was started on [MEDICATION NAME] DS (antibiotic) for an additional 14 days. On 10/16/13 at 3:38 p.m. a nurse documented an unstageable pressure ulcer on the lateral right 2nd toe measured 2.1 cm by 1.3 cm by 0.2 cm. The wound bed contained a dark red scab with no drainage noted. The surround tissue had been reddened and blanchable. The medical 2nd toe denuded skin measured 0.7 cm by 0.5 cm and superficial with a tan scabbed wound bed and no drainage. The right great toe had a dark red scab that measured 1.6 cm by 1.8 cm and 0.1 cm with no drainage. The Nurse Practitioner had been aware of the condition of the areas with no new orders. On 10/17/13 at 1:33 p.m. a nurse documented the resident received dressing changes to the foot and toe daily and the dressing as dry and intact. On 10/18/13 at 10:03 p.m. a nurse documented the resident with pedal pulses strong bilaterally. The Physician ' s Progress Notes identified the following: On 10/17/13 at 7:20 p.m. revealed the patient (resident) without new complaints today, wants to go home. Wounds stable, [MEDICAL CONDITION] improved, wounds have a dry stable eschar. cultures positive [MEDICAL CONDITIONS] and a light growth of pseudomonas. I think we can discontinue the [MEDICATION NAME] and continue with the Bactrim as the resident had 1 week of IV antibiotics. The patient had been scheduled to go to the doctor next week for a skin substitute grafting. The graft would remain in place 21 days post operation. According to a Clinical Laboratory report from collected 10/10/13, the resident had a moderate growth of Staphylococcus Aureus bacteria in the toe lesion on 10/11/13 at 2:26 p.m. The Clinical Laboratory report form collected on 10/10/13, the resident had a moderate growth of Staphylococcus Aureus, [MEDICAL CONDITION] resistant bacteria and a light growth of pseudomonas Aeruginosa bacteria in the toe lesion on 10/12/13 at 1:27 p.m. A Medical Practitioner Discharge Summary for dated 10/18/13 at 12:39 p.m. indicated the resident ' s right great toe as fractured at the lateral base first proximal joint and as no longer bruised. The toe had been wrapped to the 2nd toe for stability and the tape caused an erosive wound to the 2nd inner toe which required IV antibiotics and debridement. Plans for skin grafting in approximately 1 week had been in place with podiatry. The resident remained on Bactrim therapy. Additionally a blackish scab as present on the resident ' s outer great toe caused by the tape compression. The area on the 2nd inner toe measured 3 cm by 1 cm and superficial with yellow slough on that day and no drainage. The Practitioner described the toe as pink. During an interview on 11/27/13 at approximately 3:20 p.m., a podiatrist (foot doctor) indicated that in his practice he educated the patients and/or their families/friends that buddy tape placed to a fractured toe and the toe beside as replaced at least every 2-3 days and or have them return to his office just as often so he and his/her staff could have performed the procedure. The physician stated that in the case of this resident, it would have been difficult to determine if the ulcer could have been prevented due to the fact he had not actually observed the toes buddy taped together and how the actual procedure had been performed. Additionally, there are/were too many unknown circumstances to make that determination. However, he confirmed the resident had undergone a toe graft and the area had been almost healed with the resident doing well.

Based on record review and staff interview, the facility failed to administer the correct medications for Resident #12 and Resident #11 with both residents requiring emergency room care. Resident #12 experienced a prolonged hospital stay (from May 25-29, 2013) and did not return to his/her normal baseline level of functioning. The sampled consisted of 16 residents reviewed with a reported census of 95 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment tool with a reference date of 3/29/13 identified Resident #12 had a BIMS (Brief Interview for Mental Status) score of 9 out of 15. A BIMS score of 9 revealed the resident with moderate cognitive impairments. The MDS documented that the resident required extensive assist of two staff members for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene, and independent with eating with setup assist. The assessment documented the resident frequently incontinent of urine and had no swallowing disorder. The MDS further documented [DIAGNOSES REDACTED]. Review of the Care Plan dated 1/23/13 directed staff to administer medications as ordered and observe effectiveness. Review of Progress Notes dated 5/25/13 at 9:00 p.m. revealed a late entry, for 8:00 p.m., of by Staff C, RN, accidentally administered roommates medications to Resident #12. Resident's physician notified and order received to administer ipecac, however not available in the facility's emergency kit. Order obtained to send the resident to the emergency room . Review of the Incident Report dated 5/24/13 at 8:00 p.m. revealed Staff C preparing Resident #12's roommate medication. Staff C noticed that the resident's roommate name not on the outside of the door and neither resident had a name band on. Staff C documented he/she mistaken Resident #12 with the roommate. Staff C reports administering the following medications to Resident #12 by error: a) [MEDICATION NAME] 10 mg b) [MEDICATION NAME] 10 mg c) [MEDICATION NAME] 1 mg d) [MEDICATION NAME]-S 8.6/50 mg e) [MEDICATION NAME] 3 mg f) [MEDICATION NAME] 10 mg g) [MEDICATION NAME] 4 mg h) [MEDICATION NAME] 10 mg i) [MEDICATION NAME] 40 mg The resident's physician notified at 8:00 p.m. and the resident sent to the hospital at 8:30 p.m. Review of the facility investigation dated 5/29/13 revealed on 5/24/13 Staff C, Registered Nurse, inadvertently administered Resident #12's roommate medications to him/her (Resident #12). (There was no physician's order [REDACTED].) Staff C had a sick feeling to his/her stomach after giving Resident #12 the medication so she/he then asked Resident #12 what her/his name was and Resident #12 responded appropriately with name. Staff C realized at that time he/she had administered the roommate's medications to Resident #12. Staff C immediately obtained vital signs on Resident #12 and notified the resident's physician. The physician ordered to give Ipecac (to induce vomiting) to the resident, however the facility did not carry that and the physician then ordered for the resident to be sent to the emergency room . The resident returned to the facility at 3:30 a.m., the morning of 5/25/13. Staff continued to monitor the resident after return from the hospital and the resident remained sleepy, which the emergency room physician said the resident would be. Later that day of 5/24/13 after continued assessment and monitoring it was determined that the resident was not responding as anticipated. Staff contacted the resident's physician and decision made to send the resident back to the hospital for further evaluation. The resident admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE] as skilled care with rehabilitation services to reach his/her highest practicable well-being. Review of the hospital History and Physical dated 5/25/13, revealed Resident #12 seen today for accidental ingestion of non-toxic substances and altered mental status. The ingestion was reported immediately and the resident sent to the emergency room . The resident was observed for 6 hours. When the resident first arrived she/he is awake but complaining of feeling fatigued and tired. During the 6 hour observation, the resident became more sleepy, but arousable. The resident felt to be stable and returned to the facility. Throughout the day today, the resident was not arousable, not eating or drinking, The resident is diabetic, therefore the resident sent back to the emergency tonight. Assessment/Plan included the resident accidental drug ingestion of multiple sedating medications, to monitor the resident's level of consciousness, keep hydrated, and NPO (nothing to eat or drink by mouth) until more awake, place a Foley catheter (a tube entered into the urethra to the bladder) as the resident is not weight bearing at this time, do accuchecks, and turn resident every two hours. Assessment done on 5/27/13 revealed the resident having trouble closing his/her mouth when eating and drinking and required verbal instructions to do so. The family reports the resident feed self and on a regular diet and thin liquids prior. Resident demonstrated continued fatigue which affected overall intake. The resident demonstrated a mild oral dysphagia but a functional pharyngeal phase of swallowing. Resident will need one to one feeding assist at this time due to the resident's tremor. Standard swallowing precautions should be followed. Diet as recommended per speech therapy orders. The resident's family reported the resident had been moaning and crying out during the night. The family reported prior to this event, the resident had been walking by him/her(self) and had gone to a family graduation last weekend. The assessment determined the resident's family had been informed he/she may not get back to his/her baseline. Review of the hospitals Discharge records dated 5/29/13, indicated Resident #12 in the hospital for accidental ingestion of the wrong medications. A CT (computerized tomography) scan of the head done on 5/27/13 for indication: loss of consciousness, history of brain hemmorage, and impression revealed: no evidence of acute abnormality, chronic small vessel ischemic changes, ceberal atrophy. The resident discharged back to the facility on [DATE] on skilled care. Review of the Progress Notes dated 5/29/13 at 12:46 p.m., revealed Resident #12 arrived to facility with family members. Transferred with assist of two staff members to bed. Resident observed to be unable to bear weight. Resident able to return a verbal "hi", but unable to give own name. Resident unable to follow most instructions or cues, stares at a fixed point on the ceiling with mouth open. Family members at bedside and nursing will continue to monitor resident. Progress Notes at 2:41 p.m., per the Nurse Practitioner, indicated an order for [REDACTED]. Review of the Physical Therapy Evaluation dated 5/30/13, revealed unable to assess Resident #12 due to resident not responding or arouse with sternal rub. Review of the Physical Therapy Evaluation dated 5/31/13, revealed Resident #12 supine in bed and unable to arouse and resident not responsive despite PROM (passive range of motion), sternal rub, or verbal command. Resident is dependent on staff for all bed mobility and transfers, and resident would benefit from skilled therapy. Prior level of resident was one assist for bed mobility and transfers, currently dependent on staff for this. Review of Progress Notes dated 5/31/13 at 2:45 p.m. indicated Resident #12 mental status is at baseline. Continues to sleep for prolonged periods of time, which is normal for the resident, needs encouragement and assist to take medications and meals. The note identified the resident no longer ambulates as he/she once did, primarily using wheelchair for mobility. Review of the Progress Notes dated 6/7/13 at 12:22, type of note is Nutrition/Weight, indicated staff visited with family in the dining room. Family assisting resident to eat. Resident feeds self some and at other times requires both verbal and physical assist of staff to eat. Resident currently eats in the assisted dining room. When resident returned from the hospital the resident is lethargic at times and unable to always chew the food properly and placed on a mechanical soft diet for safety. Resident currently working with speech therapy. Review of the Progress Notes dated 6/11/13 at 5:31 p.m., indicated Resident #12 diet was upgraded to a regular CHO diet, and recommended by Speech Therapy to have resident eat in the main dining room. Review of the Progress Notes dated 6/19/13 and 6/18/13, revealed Resident #12 alert and oriented to self only, is able to ambulate with walker and assist of one, appetite is good. Resident requires assist of one staff member for all ALD's (activity of daily living), wheel chair for mobility and resident able to maneuver short distances independently. Interview on 6/26/13 at 9:41 a.m., Staff C states this is the first time he/she had been assigned to Resident #12. Staff C states he/she had passed medications to Resident #12 and roommate earlier in the shift;, 2:00 p.m. to 10 p.m. shift. Staff C states he/she had identified both resident's prior to administrating the hour of sleep medications by their picture on the MAR (medications administration record), asked their names, their date of birth and their allergies [REDACTED].#12 prior to giving the resident's roommate medications. Staff C stated she had a sick feeling right after giving Resident #12 the medications and asked the Resident #12 his/her name and the resident responded appropriately. Staff C stated she immediately realized he/she gave the Resident #12 his/her roommate's medication. Staff C assessed the resident and called the resident's physician, who ordered Ipecac to be administered, but the facility did not carry that and the physician ordered to send the resident to the hospital. Staff C indicated that she/he made a mistake, that he/she should have identified the resident prior to giving medications. Staff C states that he/she had been trained by the facility and his/her prior nurse schooling on the appropriate medication administration. Staff C states he/she feels very bad for what happened to Resident #12 and regrets the medication error that he/she made. 2. The MDS (Minimum Data Set) assessment tool with a reference date of 05/04/13 identified Resident #11 as having a BIMS (Brief Interview for Mental Status) score of 14 out of 15. The MDS documented that the resident required limited assist of one staff member for ambulation, setup assist for bed mobility and transfers, and limited assist for dressing, eating, toilet use, and personal hygiene. The MDS documented [DIAGNOSES REDACTED]. The MDS documented the resident admitted to the facility on [DATE]. Review of the Care Plan dated 3/12/13 directed staff to administer medications as ordered and observe effectiveness. Review of the Progress Notes dated 3/17/13 at 9:15 a.m. revealed Staff D, RN (Registered Nurse) documented assessment of Resident #11 that included a blood pressure of 134/71 and a heart rate of 74 beats per minute. Review of the next entry of the Progress Notes dated 3/17/13 at 9:50 a.m., revealed Staff D documented the Resident #11 transported to the hospital via ambulance. Review of Physician Telephone Orders dated 3/17/13 at 9:40 a.m. reviewed an order to send Resident #11 to the emergency room due to decreased blood pressure. Review of Staff D's statement and interview on 6/26/13 at 4:06 p.m., revealed he/she passing medications at 9:15 a.m. on 3/17/13. Staff D pulled medications to give to Resident #11, however, Staff D states he/she was looking at another resident's MAR (medication administration record) and cross checked the medication with that residents MAR. Staff D states he/she entered Resident 11's room, did an assessment of the resident which indicated the resident's blood pressure at that time to be 134/71. Staff D reports that he/she gave the oral medication, that belonged to another resident, to Resident #11 at that time. Staff D states Resident #11 family in room visiting with the resident. Staff D states he/she left the room at that time and moved down the hall to continue to pass medications. Staff D indicated when she/he got to the other resident's room of whom he/she had just given Resident #11 that resident's medications, Staff D then realized that she/he had made a medication administration error to Resident #11. Staff D documented that at that time Resident #11 put on their call light and reported to a CNA (certified nurse aide) that he/she did not feel well. Staff D indicated the CNA reported this and Staff D instructed the CNA to obtain a set of vital signs of Resident #11 at 9:30 a.m. Staff D reports the resident's blood pressure at this time to be 98/63 and Staff D went to the Nurses Station to call the resident's physician and received no answer and attempted to call another physician and no answer. Staff D instructed the CNA to recheck the resident's blood pressure at 9:40 a.m. and it was 92/58. Staff D states he/she then called the supervisor, reported the situation, and advised that an ambulance was needed. Staff D states he/she then called 911 for transport of Resident #11 to the hospital. Staff D reports he/she then went to the resident's room and told the resident and family of the medication error and that an ambulance is on the way to transport the resident to the hospital. Staff D states he/she gave the resident the following five medications in error: a) [MEDICATION NAME] 25 mg (milligrams) b) Pantopazide 40 mg c) [MEDICATION NAME] 1 mg d) [MEDICATION NAME] 300 mg e) Carvedilol 25 mg Staff D states he/she reported to the physician the decreased blood pressure along with the resident's symptoms of weakness and dizziness. Order received to transport resident to the ER for further evaluation and treatment. Staff D states the physician told him/her that the resident's symptoms were most likely due to the [MEDICATION NAME] medication and the resident would most likely need to receive IV (intravenous) fluids. Staff D further states he/she had been trained by the facility and with nurse schooling on the appropriate medication administration, however he/she failed to follow the facility's policy/procedure. A review of Resident #11' s medications listed on the physician order's dated 3/4/13 identified no order for [MEDICATION NAME], or [MEDICATION NAME] which had been administered on 3/17/13. The list of medications prescribe by the physician had an order for [REDACTED]. The [DIAGNOSES REDACTED]. Review of the next entry of the Progress Notes dated 3/17/13 at 12:50 p.m. revealed Staff D documented Resident #11 returned back to the facility from the hospital by family members. New orders received for the medication of [MEDICATION NAME] 1 gram to be taken orally four times a day and to continue with all orders and cares. Review of the Facility's Medication Administration dated 8/11/06, includes guidelines for staff for safe and accurate administration of medications that included: a) confirm the identity of each individual patient prior to medication administration. b) confirm the medication is the right medication c) confirm right dose of medication d) confirm right route how the medication is to be administration e) confirm right time the medication is to be administration f) right documentation of medication administration g) right of resident to refuse medication

Based on clinical record review and interviews, the facility failed to direct nursing services to ensure Resident #6 received adequate supervision against hazards and failed to implement care plan directives to meet the resident's safety needs. On [DATE], two staff assisted Resident #6 with a shower and left the resident unattended. The resident fell face forward and sustained a hematoma on his/her head and died shortly after the fall (on [DATE]). Staff interviews determined both the staff had left the resident unattended during the shower; and the clinical record identified Resident #6 required staff assistance during bathing. The facility reported a census of 77 residents. Findings include: Review of the Admitting Record for Resident #6 revealed an admission date of [DATE]. A physician's orders [REDACTED]. A history report dated [DATE] diagnosed Resident #6 with a stroke, atrial fibrillation, diabetes, depression, gout, insomnia, gastro esophageal reflux disease, chronic pain, [DIAGNOSES REDACTED] and dysphasia. The Physical Exam noted Neurological: quadriplegia. A Minimum Data Set (MDS) assessment tool, dated [DATE] assessed Resident #6 with the following: a). A cognitive score of 11 out of a possible 15. b). Feelings of being tired or having little energy. c). Required extensive assistance of two persons for transfers and toilet use. d). Resident unable to walk. e). Required the total assistance of two persons for bathing. f). Functional limitations in range of motion on both sides of his/her upper and lower extremities. g). Impaired balance, not steady, only able to stabilize with staff assistance. h). Active [DIAGNOSES REDACTED]. i). Weight: 156 pounds. j). The assessment revealed the resident's speech as clear, distinct intelligible words (and not slurred or mumbled words.) A Nurse Practitioner's progress note dated [DATE] assessed this resident with contractures of the hands and deformities including bilateral foot drop. This resident's plan of care included one problem initiated on [DATE] which addressed this resident's self-care deficit as evidenced by severely impaired mobility related to history of strokes. The plan of care instructed the staff to provide total assistance for bathing, dressing and grooming and to transfer this resident with the use of a mechanical lift with large size sling. This plan of care also identified this resident was at risk for loss of range of motion related to physical limitations, existing contractures and spasms, first initiated on [DATE]. The plan of care also identified a problem, first initiated on [DATE] which identified this resident was at risk for falls due to severe limitations on strength and mobility secondary to history of strokes, the goal instructed staff to minimize risk for injury related to falls. On [DATE] the nursing home Administrator reported an incident to the Iowa Department of Inspections and Appeals. The Administrator reported on [DATE] Resident #6 was in a shower room with two staff members. One C.N.A. (certified nursing assistant) left the resident to obtain towels. The resident's arm dropped from the shower chair and he/she leaned to the left and fell out of the shower chair. The resident fell out of the shower chair and bumped his/her head. The resident later became comatose and was transferred to the hospital where he/she died of a subdural hematoma on [DATE]. The progress notes dated [DATE] at 3:35 p.m. documented a CNA called the nurse to the shower room and the resident was observed lying on the floor on his/her back. The note documented the CNA explained the resident fell to the floor while they were getting him/her ready for a shower. The note documented the resident had been asked if he/she was in any pain and stated no. The note documented a hen ' s egg sized reddened area to his/her left forehead and his/her neurological exam (neuros) were normal with his/her BP (blood pressure ) at ,[DATE] while sitting. The resident was assisted to wheelchair with a Hoyer lift and the assistance of three (3) staff. The progress notes dated [DATE] at 5 p.m., the APRN (advanced practice registered nurse) evaluated the resident and noted no new orders. The notes identified the resident was in stable condition with notable swelling to left forehead which appeared decreased. The notes documented the resident ' s neuro checks remain wnl (within normal limits). The APRN noted the resident tries to talk but his/her speech was slurred. The APRN noted a CNA informed her this was normal for the resident. The progress note dated [DATE] at 9:15 p.m. documented the resident had been sent to the hospital via ambulance. The hospital admission record dated [DATE] documented the resident ' s spouse received a phone call from the nursing home. The spouse had been informed the resident suffered a fall, but no serious injury after being assessed by ARNP at the nursing home. The resident has a history of A-Fib and is on Coumadin. In the ER the resident was unresponsive and a CT scan of the head was performed which showed a large left sided subdural hematoma with significant rightward subfalcine shift and well as multiple additional acute and chronic findings. The [AGE] year old resident expired on [DATE] at 2:20 am. The head CT showed there ' s a large high density acute subdural hematoma measuring up to 3.8 cm (centimeters) thickness overlying the left cerebral hemisphere. There is a 2 cm left right subfalcine shift with effacement of the bodies of the lateral ventricles. When interviewed on [DATE] at 4:46 p.m. a registered nurse, Staff A stated a certified nursing assistant, Staff B had summoned her into the shower room at which time she observed this resident on the floor in the shower stall. The resident was on his/her back. The staff informed her they had left the resident unattended while they obtained supplies and in the process the resident fell . She noted the resident had a hematoma on his/her forehead. The resident told her he/she fell . She also noted the shower stall floor was wet. The resident stated that his/her hematoma on his/her forehead hurt only a little bit when touched. Review of notes from this incident written by Staff A noted one of the C.N.A.'s, Staff B stated she left the resident to get washcloths and the second C.N.A. Staff C stated she went to get something else and then the resident fell . When interviewed on [DATE] at 3:17 p.m. a certified nursing assistant (C.N.A.) Staff B stated Resident #6 required the assistance of two persons during a shower at all times to ensure he/she remained securely in the shower chair. Staff B stated this resident's spouse had called the nurse and stated they did not believe the staff were meeting this resident's needs and requested they give the resident a shower that evening. Staff B and Staff C transferred the resident into the shower chair with the use of a mechanical lift. Staff B stated she normally used a shower sling to transfer this resident and then would leave the sling under the resident, however that day, they did not use a shower sling with the mechanical lift and then place a plastic doughnut shaped cushion under the resident and then removed the sling from under the resident. Staff B then pushed the shower chair into the far end of the shower stall. Staff C turned on the water. Staff B stated Staff C left the shower stall to obtain wash cloths. Staff C then told her she could not find wash cloths so she left the shower stall to obtain wash cloths. Staff B stated when she left the shower stall, Staff C was at the entrance to the shower stall, by the curtain. Staff C was not next to this resident or within reach of the resident when Staff B left the shower stall. Staff B was just going to exit the shower room to obtain wash cloths when she heard a loud "crack". She went to the shower stall and saw the resident on the floor. Staff B stated she had been taught they could never leave a resident alone, not even for a second. She stated she was taught that in her C.N.A. class. She stated she knew this resident was at risk for falls. She also stated with this resident they had to be extra, extra precautions. Staff B stated she believed the communication between her and Staff C was lost. When she asked Staff C to come and stand by the resident while she left to look for towels, she later learned Staff C did not hear her. Staff B stated this resident could not maintain an upright position while seated. Staff B stated she found the resident lying face down on the shower stall floor and then they flipped the resident over onto his/her back. Staff B stated she informed the nurse that the incident was both her fault and the fault of Staff C due to she failed to ask the resident if he/she was tired prior to giving the resident his/her shower due she knew the resident had more difficulty sitting upright when he/she was tired and it was later in the day so the resident could have been tired. Second she felt she was at fault when she failed to ensure Staff C heard her when she asked Staff C to come and stand by the resident prior to leaving the area. Staff B stated this resident frequently "concaved" his/her stomach and leaned forward, especially when he/she was tired. In her written statement dated [DATE] Staff B documented she was by the linen closet when she heard this resident fall. When she turned around and saw the resident on the floor, Staff C was standing by the curtain at the front of the shower stall. When interviewed on [DATE] at 9:40 a.m. Staff C stated she assisted Staff B transfer Resident #6 into the shower chair with the use of a mechanical lift. They placed a foam cushion on the shower chair and then placed a towel over the cushion prior to sitting the resident on the towel/cushion/chair. She stated they then pushed the shower chair into the shower stall. Staff C left the shower stall to search for wash cloths. She told Staff B that she could not find wash cloths. She remained at the linen cupboard. When she turned around she saw the resident on the floor of the shower stall. Staff C was not in sight. She yelled out for Staff C and then turned towards the exit door where she saw Staff C standing. Staff C stated she knew prior to assisting with the shower that this resident was at risk for falls and their policy was for staff to stay with the resident at all times while in the shower. In her written statement dated [DATE] Staff C documented she did not leave the room. But was looking in the linen cart in the shower room, and when she turned around, she noticed Resident #6 lying on the floor and did not see Staff B with Resident #6. When interviewed on [DATE] at 1:15 p.m. the Director of Nursing stated she believed and would have expected the staff to remain by this resident and they should have been closer to him/her. The Facility's Policy/Procedure dated ,[DATE] for Bathing instructed the staff to gather their equipment, including towels, prior to beginning the shower and "never leave patient in tub or shower room unattended".

Based on record review, resident council minutes, resident, family, group and staff interviews, the facility failed to ensure sufficient staff were available to answer resident call lights in a timely manner and/or placed the call light within reach in order to meet resident needs (Resident #2, #3, #4, #6, #11, #12 and #13). The facility identified a census of 78 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE]; documented Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had short and long term memory deficits, severally impaired cognitive skills and required extensive assistance of staff with his/her activities of daily living (ADL). A Care Plan, documented the resident had a problem with ADL self-care deficit related to a [MEDICAL CONDITION] left sided [MEDICAL CONDITION] and required assistance with all ADL's. An observation 9/6/12 at 11:45 a.m., revealed the resident had been positioned in his/her bed however his/her call light button had been on the floor beside the bed, not in reach of the resident. During an interview at the same time, Staff G, Licensed Practical Nurse, confirmed the call light had not been within reach. An observation 9/6/12 at 2:20 p.m., revealed the resident had been positioned in his/her bed however his/her call light button had been on the floor beside the bed, not within reach of the resident. An observation 9/6/12 at approximately 2:22 p.m., revealed Staff I, Licensed Practical Nurse, had entered the resident's side of the room and exit. An observation 9/6/12 at approximately 2:23 p.m., revealed the resident remained positioned in his/her bed with the call light button on the floor beside the bed, not within reach of the resident. An interview 2:24 p.m., Staff H, Certified Nursing Assistant, confirmed the call light button had been on the floor beside the bed, not within reach of the resident. The staff member then positioned the button assessable to the resident. 2. A MDS assessment dated [DATE]; documented Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 and required extensive assistance of staff with his/her ADL'S. A Care Plan documented the resident had a problem with ADL self-care deficit as evidenced by assistance needed related to physical limitations. The interventions included the following: a. Always have 2 caregivers present with all cares. b. Assist with daily hygiene, grooming, dressing, oral care and eating as needed. During a family interview 9/6/12 at 10:20 a.m., the family confirmed staff had answered the resident's call light, shut it off and said they would return. The resident then timed how long it took the staff which had taken up to 40 and 45 minutes. The family also stated there had been times they had waited so long for staff to answer call lights that they had transferred their mother/father into bed themselves. 3. A MDS assessment dated [DATE]; documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 11 out of 15 and required extensive assistance of staff with his/her ADL's. The Care Plan documented the resident had a problem with ADL self-care deficit as evidenced by assistance required related to physical limitations. An observation 9/6/12 at 2:21 p.m., revealed the Resident had been positioned in his/her bed with his/her call light button positioned across the bedside stand, not within reach of the resident. During an interview 9/6/12 at approximately 2:26 p.m., Staff N, Registered Nurse, confirmed the call light button had not been within reach of the resident. 4. A MDS assessment dated [DATE]; documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 14 out of 15 and required extensive assistance of staff with ADL's. An observation 9/6/12 at 10:20 a.m., revealed the resident's call light had been positioned on the floor beside his/her bed and not within reach. Staff C, Certified Nursing Assistant, ambulated past the resident's room as he/she called out for help. The staff member entered the resident's room, assisted him/her and placed the call light within reach. During an interview 9/6/12 at 10:30 a.m., the resident confirmed he/she had wanted a nurse but that his/her call light had been on the floor. 5. A MDS assessment dated [DATE]; documented Resident #12 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 8 out of 15. During an interview 9/12/12 at 2:20 p.m., the resident confirmed he/she had put on his/her call light and that staff had entered his room, shut off the light and said they would return. The resident said that he/she had given them a chance to return so he/she could have gotten up. 6. A MDS assessment dated [DATE]; documented Resident #13 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 15 out of 15. During an interview 9/12/12 at 2:47 p.m., the resident confirmed that on 4 different occasions staff had entered his/her room, shut off the call light and said they would return but that it had taken them 20 to 30 minutes which had caused him/her to become incontinent of his/her bowels which had been embarrassing and caused him/her anger. The resident confirmed he/she had used the clock on the wall of his/her room to time how long it had taken staff to return. 7. Review of the facilities call light activity report dated 8/27/12, documented the call lights had been on for the following minutes. a. room [ROOM NUMBER] - 16 minutes and 12 seconds. b. room [ROOM NUMBER] - 15 minutes and 10 seconds. c. room [ROOM NUMBER] - 15 minutes and 42 seconds. Review of the facilities call light activity report dated 8/26/12, documented the call lights had been on for the following minutes. a. room [ROOM NUMBER] - 15 minutes and 13 seconds. Review of the facilities call light activity report dated 8/24/12, documented the call lights had been on for the following minutes. a. room [ROOM NUMBER] - 15 seconds and 42 minutes. Review of the facilities call light activity report dated 8/23/12 documented the call lights had been on for the following minutes. a. room [ROOM NUMBER] - 16 minutes and 41 seconds. 8. During the group interview 9/6/12 at 10:30 a.m., Resident #11 confirmed that at night staff came into his/her room, shut off the call light and leave the room. Review of the facilities Resident Council Minutes dated 7/20/12, documented the residents felt the call light problem had been improving however, the CNA'S continued to enter the resident's rooms, shut off the light and never return. During an interview 9/7/12 at 9:55 a.m., Staff A, Certified Nursing Assistant, confirmed there had been times staff had been unable to answer call lights within 15 minutes as there had not been enough staff in the facility to meet the resident's needs. During an interview 9/7/12 at approximately 10:15 a.m., Staff B, Certified Nursing Assistant, confirmed he/she felt the facility did not have enough staff to meet the resident's needs but had been unable to share any specific examples. Review of the facilities Call Light policy dated 12/2009, documented the approaches included the following: a. Answer all call lights in a prompt, calm, courteous manner. All staff, regardless of assignment, answers call lights. b. Turn off call light - the light should not have been turned off until request had been met. c. Always position the call light conveniently for use and within reach.

Based on observation, record review and staff interview, the facility failed to appropriately utilize interventions to prevent pressure ulcers. The facility reported a census of 87 residents. (Resident #3 and #4) Findings include: 1. Resident #4 had an MDS (Minimum Data Set) assessment with a reference date of 6/3/12 which identified [DIAGNOSES REDACTED]., cellulites and gout and muscle weakness. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 and required extensive assistance of a staff person with activities of daily living such as bed mobility, transfers and dressing. The MDS identified the resident at risk of developing pressure ulcers, with one or more unhealed pressure ulcer (s) at stage 1 or higher and with 1 unstageable pressure ulcers with suspected deep tissue injury in evolution. The MDS documented the resident had skin and ulcer treatments that included the following: a. Pressure reducing device for his/her chair. b. Pressure reducing device for his/her bed. c. Pressure ulcer care. d. Application of ointments/medications, other than feet. e. Application of dressing to feet, with or without topical medications. A care plan was initiated for the problem of alteration in skin integrity related to impaired mobility on 4/7/2012. The interventions directed staff to: encourage repositioning as needed; using assistive devices as needed, floating heels as able and observing skin condition with activities of daily living and report abnormalities. The care plan was initiated for a problem with a blister at the left heel related to friction on 5/30/2012. The approaches directed staff to: a. Administer treatment per physician's order [REDACTED]. b. Float heels as able. c. Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain and etc to the physician. d. Use Prevalon boot on left foot while in bed. The patient had been non compliant at times. A Telephone Order form dated 5/31/12 documented an order for [REDACTED]. Review of the HCR Manorcare Skin Alteration Record documented a left heel blister/friction ulcer with the description as follows: a. On 5/30/12 the left heel measured 4 centimeters (cm) by 5.3 cm with no depth documented, skin intact, color light, no drainage and the surrounding skin had been normal in appearance. b. On 6/4/12 the left heel had no measurements, no depth documented, skin intact, color dry, no drainage, and the surrounding skin had been normal in appearance. An observation 6/6/12 at 10:20 a.m., revealed the resident had been resting in bed, facing the door with his/her legs and feet handing off the bed with no Prevalon boots on his/her bilateral feet. An observation on 6/7/12 at 9:40 a.m., revealed Staff C, Licensed Practical Nurse and Staff D, Certified Nursing Assistant entered the resident ' s room to perform the treatment. Staff I, Direct Care Delivery nurse had also been present. The resident had been positioned in bed reading the newspaper with Ted hose on his/her bilateral lower extremities and no Prevalon boots on his/her heels. Staff C measured the left heel ulcer as 10 cm by 9 cm and then applied Marathon Skin Protect ant to the resident ' s left heel while Staff D held up the resident ' s leg. Staff C did not cleanse the ulcer prior to the application of the Marathon Skin Protectant. During the same observation, a large amount of orange/yellow stain had been noted on the Ted hose of the resident ' s right heel. Staff C was questioned if the resident had an open area on the right heel, Staff C stated that she had not known but would check. Upon removal of the Ted hose, the staff member confirmed there had been an ulcer area that measured 2 cm by 3.2 cm and described it with a red center with light brown edges and the skin intact. After reporting the ulcer area to the Nurse Practitioner, she received a new order to apply Marathon Skin Protectant. The staff member returned to the resident ' s room and applied Marathon Skin Protectant to the resident ' s right heel without cleansing the area, placed on the Prevalon boots and positioned the resident for comfort. An observation 6/7/12 at 11:20 a.m., revealed the resident positioned on a mattress that had a blue color along the bottom of the mattress with a green color along the top as noted by the side view of the mattress. Staff I, Registered Nurse confirmed the mattress as a standard mattress with no pressure relief capabilities. Review of the Progress Notes dated 6/7/12 at 1:03 p.m., documented a new pressure wound had been noted to the residents right heel that measured 3 cm by 23 cm. The surrounding skin had been pink, warm and intact. The wound edges brown, smooth and intact. The wound area had been intact with a pink center surrounded by white tissue and brown borders. A Wound Progress Note from an ARNP (Advanced Registered Nurse Practitioner) dated 6/7/12, documented a new pressure wound discovered on the right heel. The resident already has one on the left heel. Both the heels are spongy, closed blisters at this time. The note indicated the resident wore slippers only for footwear. The Ted hose were discontinued to decrease friction and had minimal [MEDICAL CONDITION] to legs. The ARNP ordered Marathon treatment to each heel and Pravolon boots while in bed. The ARNP ordered slippers for shoe wear and float heels when in bed. The preventative measures were identified as off loading. Review of the Progress Notes dated 6/7/12 at 10:54 a.m., documented a new order to discontinue Ted hose, Marathon treatment to bilateral pressure wounds on heels and to apply 3 times a day, slippers only for shoe ware, no tennis shoes and Prevalon boots bilaterally when in bed. A Marathon Liquid Skin Protectant Product Information Data Sheet documented the instructions for use had been to cleanse and dry the skin before applying Marathon Liquid Skin Protectant. The instructions directed users to make sure the skin was thoroughly dry and that all traces of moisturizers, lotions, lotion soaps or [MEDICATION NAME] were removed from the application site. 2. Resident #3 had an MDS assessment with a reference date of 6/1/2012. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance of staff with his/her activities of daily living that included bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and had a number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. A Care Plan documented the Resident had a problem with at risk for alteration in skin integrity related to impaired mobility and [MEDICAL CONDITION] in his/her bilateral lower extremities. The Progress Notes dated 5/3/12 at 10:14 p.m. (late entry), documented the Resident had a Stage 3 ulcer on his/her left buttocks that measured 2.1 cm by 2.0 with the edges well defined. The wound base had 100 percent yellow slough. A moderate amount of yellow drainage had been noted with no odor. Surrounding the wound was described as pink and blanchable. The documentation did not address the depth of the wound, signs of infection or tunneling. The Progress Notes dated 5/9/12 at 10:17 p.m. documented the Resident had a Stage 3 ulcer on his/her left buttocks that measured 2.1 by 2.0 with the edges well defined. The wound base had 100 percent covering of yellow slough. A moderate amount of yellow drainage had been noted with no odor. The surrounding area of the wound was described as pink and blanchable. The documentation did not document depth or possible tunneling. The Progress Notes dated 5/23/12 at 5:06 a.m., documented the ulcer on the Residents coccyx had been approximately 2 cm by 2 cm (centimeters) with a black center and yellow purulent drainage. The documentation did not address depth, surrounding skin, signs of infection, tunneling or pain. The Skin Alteration Record (do not use for pressure ulcer) form documented the resident had an ulcer on his/her coccyx area with the following assessments: a. On 3/7/12 the area measured 6 cm by7 cm with no depth or tunneling documented. The skin had been intake and a red/pink color. There had been no drainage and the surrounding skin had been normal in appearance/reddened. b. On 3/10/12 the area measured 6 cm by 7 cm with no depth or tunneling documented. The skin had been intact and pink in color. There had been no drainage and the surrounding skin had been normal in appearance/reddened. c. On 3/17/12 there had been no measurements, depth or tunneling documented. The skin hand been intake and pink in color. There had been no drainage and the surrounding skin had been normal in appearance. d. On 4/11/12 the area measured 7 cm by 5 cm with no depth or tunneling documented. The skin had been dark pink/red tissue. There had been no drainage and the surrounding skin had been normal in appearance. e. On 5/3/12 the area had been covered with a [MEDICATION NAME] dressing, no measurements, depth or tunneling documented. The skin had been dark pink/red tissue. There had been no drainage and the surrounding skin had been reddened. f. On 5/10/12 there had been no measurements, depth or tunneling documented. The skin had been eschar with black necrotic tissue. There had been no drainage and the surrounding skin had been normal in appearance. g. On 5/17/12 there had been no measurements, depth or tunneling documented. The skin had been intact with dark pink/red tissue. There had been no drainage and the surrounding skin had been normal in appearance. h. On 5/31/12 area with scab. A Pressure Ulcer Healing Chart dated 5/31/12 documented the area on the resident ' s coccyx had measured between 1.1 and 2.0, had light exudate with slough and had a PUSH score of 8. Review of the HCR ManorCare Skin Practice Guide dated July 2008, documented the risk factors for pressure ulcer development/impaired healing may have included but were not limited to the following; a. history of pressure ulcers. b. co-morbid conditions, e.g., diabetes, [MEDICAL CONDITION], dementia and [MEDICAL CONDITION] disease. c. medications, e.g., steroids. d. conditions which cause impaired blood flow, e.g., [MEDICAL CONDITION]. e. impaired mobility or functional abilities. f. nutritional risk factors. g. patient refusal of some aspects of care and treatment. h. incontinence. i. smoking. If a pressure ulcer had been identified, a PUSH Tool would have been initiated by a member of the wound team for each site identified. A comprehensive evaluation would have also been completed and documented in the patient's clinical record and may have included but not limited to the following: a. depth. b. appearance of surrounding skin. c. presence and location of tunneling and/or undermining. d. evidence of infection. e. pain. Patients with pressure ulcers would have had a head to toe skin evaluation, completed daily by the licensed nurse, to identify additional skin changes.

Based on review of resident records and resident council minutes and interviews with residents and Ombusdman., the facility failed to ensure sufficient staff were available to answer resident call lights in a timely manner in order to meet the needs of residents (Resident #2, #14, #15 and #16). The facility identified a census of 87 residents. Findings include: 1. On 6/5/12 at 2:45 p.m. the Long Term Care Ombudsman was interviewed and confirmed the residents had complained the facility staff had answered their call lights, turn them off, say they would return but does not return. 2. A random observation on 6/6/12 at approximately 8:45 a.m., revealed the resident in room [ROOM NUMBER], bed one, had been positioned in his/her modified wheelchair at the bedside with the call light placed on the resident ' s bedside stand positioned behind the resident and not within reach. A random observation on 6/6/12 at 8:50 a.m. revealed the resident in room [ROOM NUMBER] had been in bed with his/her call light positioned on the floor at bedside and not in the reach of the resident. A random observation 6/5/12 at 3:30 p.m., revealed Resident #2 positioned in his/her wheelchair at bedside, in front of his/her bedside stand with the call light positioned on the stand and not in reach of the resident. 3. On 6/6/12 at 3:30 p.m., Staff F, Certified Nursing Assistant was interviewed and confirmed she had not been able to answer call lights timely, especially at meal times because the facility had taken their fifth staff member and assigned that person upstairs to work. 4. A Minimum Data Set (MDS) assessment date 5/28/12, documented Resident #15 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, required extensive assistance of two staff members for bed mobility, transfers and toilet use. A Care Plan initiated on 7/26/2009 and revised on 4/12/2010 documented the Resident had a problem with a self care deficit with activities of daily living as evidenced by the patient required assistance. The interventions included the following: a. Assist with daily hygiene, grooming, dressing, oral care and eating. A Care Plan initiated on 7/27/2009 and revised on 4/12/2010 documented the Resident had a problem with urinary incontinence/constipation risk altered elimination related to occasional incontinence. The interventions included the following: a. Remind and assist as needed with toileting. On 6/6/12 at 2 p.m., Resident #15 was interviewed and stated he/she had been left in the bathroom with the call light on for 1/2 hour and that this made him/her angry as it had been stuffy with no ventilation. The Resident stated he/she had used the clock on his/her wall when he/she entered the bathroom and when he/she had been assisted out of the bathroom. 5. Resident #16 had an MDS assessment with a reference date of 5/31/12 which identified [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 13 out of 15, required extensive assistance of 2 staff members with bed mobility, transfers, toilet use and personal hygiene. A Care Plan initiated on 5/30/2012 identified the resident had a problem with self care deficit with activities of daily living related to the disease process. The interventions included the following: a. Assist with daily hygiene, grooming, dressing oral care and eating. A Care Plan initiated on 5/30/2012 identified the resident had a problem with urinary incontinence/ostomy related to impaired mobility. During an interview on 6/6/12 at 2 p.m., the Resident stated he/she had been left on a bedpan for 45 minutes one morning and that he/she had a permanent ring on bottom which caused pain and made him/her very mad. The Resident stated 3 staff members came in to her/his room but stated they needed to go get another staff member, however, no one returned. The resident confirmed he/she had used the stop watch on the telephone to time the call light. 6. Resident #14 had an MDS assessment with a reference date of 5/31/2012. The MDS identified [DIAGNOSES REDACTED]. The MDS assessment documented the Resident had a BIMS score of 14 out of 15, required extensive assistance of staff with bed mobility transfers, dressing and personal hygiene but limited assistance with toilet use. The care plan initiated on 4/24/2012 and revised on 5/3/2012, documented the resident had a problem with self care deficit with activities of daily living and required assistance with bed mobility, transfers, toileting, bathing, dressing and personal hygiene. During an interview on 6/6/12 at approximately 2 p.m., the resident stated he/she had to wait 25 minutes for staff to answer the call light and that he/she had to go to the bathroom real bad and he/she had been afraid he/she would have made a mess. The resident voiced this upset him/her because he/she could hear people talking in the hallway. The Resident stated he/she had used the clock on his/her wall to time the call light. The resident also confirmed there had been times staff would enter his/her room, shut off his/her call light and say they would return but had not come back. Review of the facilities call light activity report dated 5/26/12 documented the call lights had been on for the following minutes. a. 6:47 a.m. - room [ROOM NUMBER]/window - 20 minutes and 28 seconds. b. 8:29 a.m. - room [ROOM NUMBER]/door - 17 minutes and 45 seconds. c. 10:44 a.m. - room [ROOM NUMBER]/window - 16 minutes and 30 seconds. d. 11:22 a.m. - room [ROOM NUMBER]/window - 15 minutes and 46 seconds. e. 2:54 p.m. - room [ROOM NUMBER]/window - 16 minutes and 9 seconds. f. 2:55 p.m. - room [ROOM NUMBER]/door - 16 minutes and 1 second. g. 5:16 p.m. - room [ROOM NUMBER]/window - 15 minutes and 39 seconds. h. 5:29 p.m. - room [ROOM NUMBER]/door - 20 minutes and 48 seconds. i. 6:39 p.m. - room [ROOM NUMBER]/window - 15 minutes and 50 seconds. j. 8 p.m. - room [ROOM NUMBER]/door - 21 minutes and 18 seconds. k. 8:06 p.m. - room [ROOM NUMBER]/door - 25 minutes and 3 seconds. l. 8:49 p.m. - room [ROOM NUMBER]/bathroom - 17 minutes and 43 seconds. m. 9:23 p.m. - room [ROOM NUMBER]/window - 22 minutes and 44 seconds. n. 9:29 p.m. - room [ROOM NUMBER]/window - 23 minutes and 18 seconds. Review of the facilities call light activity report dated 5/27/12, documented the call lights had been on for the following minutes. a. 12:39 p.m. - room [ROOM NUMBER]/door - 19 minutes and 17 seconds. b. 1:05 p.m. - room [ROOM NUMBER]/door - 16 minutes and 20 seconds. c. 4:14 p.m. - room [ROOM NUMBER]/door - 45 minutes and 19 seconds. d. 4:36 p.m. - room [ROOM NUMBER]/door - 25 minutes and 29 seconds. e. 7:11 p.m. - room [ROOM NUMBER]/door - 15 minutes and 55 seconds. f. 9:14 p.m. - room [ROOM NUMBER]/door - 24 minutes and 43 seconds. g. 9:21 p.m. - room [ROOM NUMBER]/window - 16 minutes 17 seconds. Review of the facilities call light activity report dated 5/28/12, documented the call lights had been on for the following minutes. a. 6:38 a.m. - room [ROOM NUMBER]/window - 19 minutes and 58 seconds. b. 8:50 a.m. - room [ROOM NUMBER]/door - 23 minutes and 49 seconds. c. 4:25 p.m., - room [ROOM NUMBER]/bathroom - 17 minutes and 6 seconds. d. 8:06 p.m. - room [ROOM NUMBER]/door - 48 minutes and 11 seconds. e. 9:23 p.m. - room [ROOM NUMBER]/door - 23 minutes and 45 seconds. f. 9:24 p.m. - room [ROOM NUMBER]/door - 22 minutes and 24 seconds. Review of the facilities call light activity report dated 5/29/12, documented the call lights had been on for the following minutes. a. 4 p.m., - room [ROOM NUMBER]/door - 25 minutes and 58 seconds. b. 8:06 p.m. - room [ROOM NUMBER]/window - 16 minutes and 20 seconds. c. 9:57 p.m. - room [ROOM NUMBER]/door - 17 minutes and 57 seconds. Review of the facilities call light activity report dated 5/30/12, documented the call lights had been on for the following minutes. a. 8:15 p.m. - room [ROOM NUMBER]/bathroom - 16 minutes and 13 seconds. b. 8:17 p.m. - room [ROOM NUMBER]/window - 19 minutes and 58 seconds. C. 8:50 p.m. - room [ROOM NUMBER]/window - 17 minutes and 14 seconds. d. 9:23 p.m. - room [ROOM NUMBER]/door - 33 minutes and 44 seconds. Review of the facilities Resident Council Minutes dated 2/17/12, documented the residents had a nursing concern that there had not been enough staff. Review of the facilities Resident Council Minutes dated 12/16/11, documented the residents had a nursing concern with call lights. Review of the facilities Resident Council Minutes dated 7/15/11, documented the residents had a concern that nursing had been short staffed and that the residents had been told they had to wait because the facility had been short staffed. Review of the facilities Call Light policy dated 12/2009, documented the approaches included the following: a. Answer all call lights in a prompt, calm, courteous manner. All staff, regardless of assignment, answer call lights.

Based on resident record review and staff, family and resident interviews, the facility failed to provide adequate supervision to ensure against hazards from self and others (Resident #3). The facility reported a census of 97 residents and the sample consisted of 3 residents. Resident #3 entered the room of Resident #1 and Resident #2. Resident #3 crawled into bed with Resident #1 and touched the resident ' s private area. After a verbal confrontation, Resident #3 then went to the bed of Resident #2. Resident #3 did not touch Resident #2, but the incident was upsetting to Resident #2. It was unclear why the facility records and resident interviews reflected a different story than provided by Staff A. Findings include: 1. Resident #3 had an MDS (Minimum Data Set) assessment with a reference date of 3/1/2012 which identified the following Diagnoses: [REDACTED]. The MDS identified the resident with short term memory loss, moderately impaired cognitive function related to daily decision making skills, periods of inattention and disorganized thinking abilities. The care plan initiated on 2/26/12 for Resident #3 identified a potential for verbal/physical agitation/aggression toward staff by verbally threatening staff and raising fists in anger related to an unfamiliar environment, change in routine, and cognitive impairment. The care plan interventions directed staff to administer medication per physician orders, approach slowly and slightly to the side, and if strategies are not working, leave if safe to do so and re-approach later. The care plan also identified a potential problem with wandering/pacing related to cognitive impairment. The interventions directed staff to allow the resident to wander in room. Redirect as needed. Provide assistance in locating own room, and provide supervision during recreation programs. The care plan did not address a 2/27/2012 episode of wandering into other resident rooms, or attempts made to get into bed with other residents or that the facility provided continuous 1 to 1 monitoring after the incident on 2/27/12 until the resident's discharge from the facility on 3/1/12. Review of the resident record revealed the facility admitted Resident #3 into the facility on [DATE]. The resident then had a hospitalized from [DATE] to 2/26/12 due to an unknown seizure disorder. The resident returned to the facility on the evening shift of 2/26/12. The nursing note documentation dated 2/26/12 revealed the resident returned to the facility from a hospitalization at 4:36 p.m. The note indicated the resident showed confusion to place and why residing at the facility. The next nursing note entry on 2/27/12 at 1:45 a.m. by Staff A (Registered Nurse), documented " Patient has become threatening and exit seeking. Patient is harm to himself and others at this time. Prn (as needed) medication given. The Dr. notified and new orders received to send patient to hospital ER ( emergency room ) for further evaluation and possible placement in med/psych if patient is unable to be deescalated and continues to be a harm to self and others." The February MAR (Medication Administration Record) revealed no record of any as needed medications given at the time of this entry and no new medication orders received at the time of the physician notification. The nursing note documentation on 2/27/12 at 1:46 a.m. revealed the " resident began yelling at staff and became intrusive while swinging at staff with hands in their faces " . The documentation continued with " Patient is now 1 on 1 with staff " . Patient stated that this is his/her house and can go where he/she wants to. Patient went to the doorways of other rooms, but able to be redirected before went into rooms. Staff placed a piece of paper with name on it outside of door in attempts to redirect to own room and own bed. The patient laid down and resting at this time and continues to be 1 on 1. At 1:47 a.m. documentation revealed the resident exit seeking and pulling roughly on the lobby exit doors attempting to go outside. The staff redirected the resident back to room with 1 on 1 in place. At 1:48 a.m. Staff A documented she notified the physician with a change in condition report and new orders received if patient unable to be redirected to send to the hospital emergency room for evaluation and treatment. The documentation revealed the resident currently resting with 1 on 1 at the bedside. Documentation at 2:04 a.m. indicated the resident continued with 1 on 1 monitoring and remained in bed resting occasionally muttering profanities. The nurse ' s note at 3:22 a.m. by Staff A revealed Resident #3 became increasingly aggressive towards staff, attempted to get in bed with numerous peers, and stated that he/she were the resident's spouse and the resident belonged in bed with them. At this time Staff A sent the resident to the hospital emergency room for evaluation and treatment due to the resident's aggressive state. The nursing note documentation dated 2/27/12 at 5:20 a.m. revealed the resident returned to the facility with a new order for Geodon 10 mg intramuscularly as needed for aggressive behaviors. The entry also indicated the resident received the Geodon intramuscularly while at the hospital emergency room . Documentation revealed the resident resting in bed with eyes closed. There is no further documentation regarding resident behaviors but at 3:15 p.m. the resident transferred again to the hospital for a psychiatric evaluation and returned to the facility at 6:48 p.m. At 11:05 p.m. the resident received a new order for Geodon 10 mg intramuscularly as needed for increased agitation. Documentation on 2/28/12 at 6:00 a.m. revealed the resident slept through the night, exhibited no agitation or wandering during the shift. The documentation indicated the resident remained on one to one watch. The progress notes dated 2/27/2012 at 2:18 p.m. indicated the social service staff person spoke with Resident #1 regarding a male resident who entered her/his room and touched her/him inappropriately. The staff person explained the situation was currently being addressed and if the resident returned to her/his room, she/he should yell for help. The social service staff person documented the resident seemed to handle the situation well. On 3/21/2012 at 3:25 p.m., Resident#1 was interviewed by telephone (transferred on 3/16/2012 to assisted living). Resident #1 stated during the night on 2/27/2012, was awakened by another resident in bed with her. Resident #1 asked Resident #3 what he was doing. Resident #3 stated " You ' re my (spouse) " . Resident #1 informed Resident #3 that she/he was not his (spouse) and to get out! " Resident #1 stated Resident #3 had put his hand into her/his pants and touched her/his private area. Resident #1 stated Resident #3 did not hurt her/him in any way and left when she/he told him to leave. Resident#1 continued and stated Resident #3 left her/his bedside and went to the roommate (Resident #2). Resident #2 yelled out and then Resident #3 left the room. Resident #2 turned on the call light. Resident #1 stated the facility told her/him this person had been moved from the facility but stated she/he continued to see staff sitting with him/her in the dining room. Resident #1 stated she/he felt the facility should have dealt with Resident #3 immediately and removed the resident from the facility since in her/his opinion, the facility was not equipped to handle this resident. Resident #1 stated she/he felt afraid but couldn ' t verbalize what she/he was afraid. Resident#1 stated she/he felt relieved after she/he knew Resident#3 was finally gone for good. Resident #2 arrived at the facility on 2/16/2012 following knee surgery and required skilled therapy. The admission MDS assessment with a reference date of 2/23/2012 identified the resident with a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 identified the resident as cognitively intact. The MDS revealed no identified memory problems. Resident#2 was interviewed on 3/20/2012 at 1:20 p.m. by telephone. The resident ' s family was present during the call conference. The resident stated the incident occurred on Monday 2/27/2012 at approximately midnight (12:00 a.m.) Resident #2 stated she/he was sleeping when awakened by the roommate yelling " You are not my spouse so get out of here " ! The resident then approached her/his bed and asked if she/he was his spouse. Resident #2 stated she ordered Resident #3 to leave the room. Resident #2 stated Resident#3 did not hurt her/him. The family member stated the incident had been upsetting for Resident #2. Resident #2 began to cry during the interview. The family member stated the resident was discharged to home on 2/29/2012 and would receive home care and in home therapy. The family member stated she/he had informed the facility that they needed to manage residents ' better so this did not happen again. On 3/21/12 at 7:50 p.m. Staff A (Registered Nurse) was interviewed and verified she worked the night shift (10 p.m. to 6 p.m.) on 2/27/12 and cared for Resident #3. Staff A recalled that Resident #3 demonstrated more confusion and made several attempts to leave the facility. Staff A stated she and Staff E (Registered Nurse) basically followed the resident around the facility due to restlessness. Staff A stated as the shift progressed, the resident became more aggressive with the staff so she called the physician and she sent the resident to the emergency room at approximately 3:00 a.m. Staff A stated she and an agency CNA remained with the resident pretty much the whole time the resident remained at the facility. Staff A stated the next day Staff H (Director of Nursing) informed her Resident #3 entered another resident's room during the night. Staff A stated the resident stopped at several resident room doorways but never entered any resident rooms as the resident remained within her sight the entire shift. Staff A stated both Resident #1 and Resident #2 slept all night. On 3/22/12 at 11:30 a.m. Staff A was again interviewed and stated she directed Staff E and Staff C ( CNA) to closely monitor Resident #3 on a 1 to 1 basis to know Resident #3 ' s whereabouts and activities at all times. Staff A stated she instructed them both to not get too close to the resident as this seemed to increase the agitation and aggressive behaviors. Staff A stated at approximately 12:30 a.m. an agency CNA (hired by facility to work specific hour from an agency) came up from The Gardens (another facility area) to stay with Resident #3 and watch the resident. Staff A stated the resident remained in the room at this time. Staff A stated at around 12:15 a.m. she administered an as needed medication to Resident #3 by mouth due to the escalating behaviors. Staff A reported at around 2:30 a.m. the resident appeared to be resting so she directed the agency CNA to return back to The Gardens and Staff A provided 1 to 1 monitoring of Resident #3 ' s activity until transferred to the hospital at around 3:15 a.m. Staff A adamantly denied Resident #3 never entered any resident rooms during her watch. Staff A stated the resident maybe crossed the room threshold of Resident #1 and Resident #2 doorway by 3 steps but never physically entered into this room. When the surveyor questioned Staff A what it meant to her to place a resident on 1 to 1 monitoring, she replied that someone remained with the resident, watching the resident, redirecting the resident's activity and behaviors to ensure the residents safety. Staff A stated she also stated it meant remaining within 2 feet of the resident at all times. On 3/22/12 at 1:30 p.m. Staff E (Registered Nurse) verified she worked the night shift on 2/27/12 with Staff A. Staff E stated she hadn't worked much with Resident #3 but recalled the resident being very different on the night of 2/27/12. Staff E stated the resident frequently came to the nurse ' s station, became increasingly aggressive during attempts to redirect back to room, and exhibited exit seeking behaviors. Staff E stated she and Staff C attempted to keep an eye on the resident. Staff E stated she received no directives from Staff A regarding placing the resident on 1 to 1 monitoring but stated she and the CNA just attempted to keep the resident safe. Staff E stated when they taped a paper by the resident's room with his/her name on it, the resident then agreed to lay down and appeared to rest for awhile. Staff E stated sometime between 2:00 a.m. or 3:00 a.m. Staff G (Certified Nursing Assistant) informed her Resident #3 got up out of bed and entered the room of 2 female residents who stated the resident attempted to get into bed with them. Staff E stated she didn't believe the resident remained in their room long enough to attempt anything stating she believed the time in the room was less than 5 minutes. Staff E stated she recalled Staff A giving the resident some oral medication earlier in the night to help calm the resident down. Staff E denied receiving the additional help from an agency CNA on the night shift. She stated only 4 staff on duty that night: 2 nurses and 2 CNAs. Staff E stated it became increasingly difficult to monitor the resident and verified they were unable to provide 1 to 1 monitoring for the resident that night. Staff E explained 1 to 1 monitoring meant a staff member needed to be with the resident at all times no matter where they were or what they were doing. She stated a staff member assigned to provide 1 to 1 monitoring would not be assigned any other residents during their shift. An interview conducted on 3/22/12 at 10:10 a.m. with Staff B (Assistant Director of Nursing-ADON), revealed her interpretation of 1 to 1 monitoring meant a staff member remained with the resident at all times and within arms reach of the resident. The ADON explained it meant being in the room if the resident slept or being with the resident if going down the hallway; a staff member needed to remain with that resident at all times. On 3/22/12 at 10:00 a.m., the Director of Nursing (DON) stated when she did the internal investigation interviews following the incident on 2/27/12 during the night shift with Resident #3, Staff A documented in the nursing notes that she placed Resident #3 on 1 to 1 monitoring. The DON stated Staff A explained between herself, Staff E, Staff G (CNA), and Staff C (CNA), they attempted to be where they could see Resident #3 at all times. The Director of Nursing stated Staff A explained during the investigation interview that Resident#3 became more agitated and prone to hitting if the staff attempted to follow more closely. The DON stated staff reported Resident #3 did a lot of wandering in the hallways that night but staff watched the resident closely. The DON stated during the facility investigation, she was told that Staff G observed Resident #3 enter the room of Resident #1 and Resident #2 but by the time she arrived to their room, Resident #3 had already exited the room. The DON explained the facility had no specific policy or implement this type of monitoring. The DON stated the staff did not require her permission to implement 1 to 1 monitoring if needed but would hope the on call person would be notified of the situation. The DON stated the 1 to 1 monitoring meant the resident would be within sight at all times.