Every finding on record at Harvest Acres Nursing and Rehab

Based on clinical record review, facility policy review, and staff, Advanced Practice Registered Nurse Practitioner (ARNP) and resident family member interviews, the facility failed to notify the physician/extended provider of resident condition changes that required hospitalization for 2 of 6 resident records reviewed (Resident #1 and Resident #2) hospitalized in critical condition as a result of the delayed treatment when the provider was not notified of the changes in a timely manner. The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) Assessment with 5/7/26 reference date revealed Resident #1 scored 13 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated no cognitive deficits, the resident had symptoms of delirium present, always able to understand others and always able to make herself understood. The resident had diagnoses that included hypertension (high blood pressure) urinary tract infection (UTI), diabetes, seizure disorder and delirium due to known physiologic condition. The assessment revealed the resident required extensive staff assistance for transfers to and from bed or chair, dressing, toileting, bathing and personal hygiene. The resident's Nursing Care Plan included a problem labeled as (Resident's name redacted) has an ADL (Activity of Daily Living) Self Care Performance Deficit initiated 5/2/26, listed an 8/1/26 goal (Resident's name redacted will improve current level of function by next review, directed staff to provide interventions that included, but were not limited to:1. PT/OT evaluation and treatment as per MD orders and treatment plan of care, initiated 5/2/26.2. Stand pivot transfer with walker, gait belt, assist x 1 of staff, initiated 6/24/26. Nursing Progress Notes revealed the following entries: 7/2/26 at 5:11 a.m. described a U/A (urinalysis) with C & S (culture and sensitivity) physician order for confusion.7/3/26 at 1:22 a.m. Acetaminophen Oral Tablet 650 milligrams (mg) administered oral as needed for pain.7/3/26 at 2:38 a.m. U/A back with positive Leukocyte Esterase (sign of infection), faxed to primary care provider (PCP).7/4/26 at 12:06 a.m. RESIDENT CRYING THAT SHE IS IN PAIN, Oxycodone (strong opiate narcotic medication) HCl Oral Tablet 5 MG given oral as needed for severe pain.7/4/26 at 12:49 p.m. : Acetaminophen Oral Tablet Give 650 mg administered oral as needed for pain. 7/6/26 at 1:17 a.m. Resident in lobby area sitting on recliner due to calling out, resident UA on 7/2/26 leukocyte esterase small (normal result negative, indicator of infection when positive) noted has been faxed for review to PCP and currently awaiting culture results. Called On-call PCP and there was no answer, or call back yet at this time. given Tylenol per temp 98.9 temporal and flushed warm to touch.7/6/26 at 2:52 a.m. Resident was screaming, temp increasing, 99.0 temporal, unable to obtain BP, pulse irregular 89-111, resident consistently crying and calling out and trying to undress self, gave Tylenol 650mg, resident showed 0 improvement asked resident if she would like to seek treatment outside facility resident stated yes, resident asked to go to the hospital several times within 5 minutes, called EMS for transport, EMS arrived and resident continued to cry, warm and flushed skin, MAR/TAR IPOST, BED HOLD, FACESHEET provided and copy of labs. Resident is own POA listed on profile, at this time she was only oriented to self. Exercised residents' rights to seek medical attention outside facility. DON notified.7/6/26 at 5:33 a.m. At this time received call from attending Physician in ER (Emergency Room) at local hospital, stated resident will be admitted for treatment of UTI and Ileus all based on this conversation since resident cannot make decisions at this time due to confusion/disorientation and husband (Resident #2) is also exhibiting confusion and is unable to make decision for resident.7/6/26 at 11:05 p.m. ER called and spoke with this RN regarding resident. Resident is septic, primary diagnosis is bacteremia caused by Staph Aureus. The Urinalysis collected 7/2/25 at 3:36 p.m. revealed abnormal results that included:Bilirubin - Small (normal negative)Protein - 30 (normal 0)Leukocyte Esterase - Small (normal negative)Urobilinogen - 2.0 (normal 0.2 to 1.0 E.U/dL).The test refluxed for a Culture and Sensitivity test (indications of infection present). The Culture and Sensitivity report associated with the 7/2/26 Urinalysis reported on 7/7/26 revealed:40,000 colony forming units (CFU) per milliliter (ml) Enterococcus Faecalis and 10,000 to 25,000 CFU/ml Aeruginosa. Vital signs recorded at 1:55 a.m. on 7/6/26 revealed temperature 99.0 degrees Fahrenheit, oxygen saturation 95 percent on room air (normal 97 to 100 percent), pain level 10 on 0 to 10 pain scale, with 10 assigned to the worst pain possible. A hospital Discharge summary dated [DATE] described: The resident seen in the ER at 2:39 a.m. on 7/6/26 with altered mental status, yelling out in pain, vital signs temperature 102.6 degrees Fahrenheit, blood pressure 195 over 74, pulse 97 and oxygen saturation 95 percent on oxygen administered at 2 liters per minute. She is normally able to hold conversations but was unable to provide a review of systems. She was admitted to the hospital as an acute inpatient for treatment of sepsis. Blood cultures returned positive for Staph Aureus, started on Vancomycin and Zosyn (strong antibiotics administered intravenously, IV). She went into atrial fibrillation (irregular heart beat) with rapid ventricular response, developed worsening delirium, worsening lactic acidosis and uncontrolled pain, which she was able to state was coming from her back. She received additional IV fluids with some improvement in lactic acid and mentation. Continued on IV antibiotics while hospitalized , discharged to the nursing home on 7/8/26 with Hospice referral. The facility's Change in a Resident's Condition or Status policy dated as revised February, 2021 directed staff with actions that included, but were not limited to: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse reaction to medication;d. significant change in the resident's physical/emotional/mental condition;e. need to alter the resident's medical treatment significantly;f. refusal of treatment or medications two (2) or more consecutive times);g. need to transfer the resident to a hospital/treatment center;h. discharge without proper medical authority; and/[NAME]. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting);b. impacts more than one area of the resident's health status;c. requires interdisciplinary review and/or revision to the care plan; andd. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the ResidentAssessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations andgather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. During an interview on 8/5/26 at 10:33 a.m. the facility's Nurse Practitioner (ARNP) stated the physician's group that she worked with were closed for the holiday on 7/3/26, faxes sent into their office on 7/3/26 would not have been read until Monday, 7/6/26 when the office re-opened. The ARNP stated if a resident was symptomatic with abnormal laboratory results they should have called the provider on call for directives, not faxed the office. Staff should have called the provider if they had to administer Oxycodone for the resident's pain symptoms that weren't normal and should have called the provider when Resident #2 had delusional symptoms that were not normal and a change in his condition. During an interview 8/5/26 at 12:57 p.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #1 was okay for the first part of the 7/4/26 weekend, then wasn't getting better. It wasn't normal for her to remove her clothes and yell. When she asked the resident where her pain was the resident said I don't know. She was waiting for a call from the physician from the UA report that was faxed to the office on 7/3/26 and why she had not called the provider until 7/6/26. She had called the provider and left a message on 7/6/26 and didn't get a call back from the provider. The resident was able to say she wanted to go to the hospital and why she sent her to the hospital Emergency Room. Staff A stated she had to monitor Resident #2 as he said strange things, referred to Resident #1 by a different name and was agitated at times. During an interview 8/5/26 at 1:22 p.m., Staff B, Registered Nurse (RN) stated the physicians/providers don't want to be called for the day-to-day notifications, but to call if the resident is symptomatic or orders needed for condition changes. Resident #1 usually had leg pain, that was normal for her, but if she had increased pain the provider should have been notified. During an interview on 8/5/26 at 2:14 p.m. Staff C, LPN, stated the provider should be notified by phone when there were changes in resident conditions that required treatment changes/changes in orders, otherwise routine notifications were communicated via fax. If a physician/provider didn't return a call she would try to call again one to two more times, then would call the Administrator or the DON to inform them and ask what should be done. During an interview on 8/5/26 at 1:41 p.m. the Director of Nursing (DON) stated if the physician/provider did not return staff calls he expected the staff to notify him or the Administrator that the provider wasn't responding and would provide further direction and attempt to reach the provider. 2. The Minimum Data Set (MDS) Assessment with 5/14/26 reference date revealed Resident #2 admitted to the facility on [DATE], scored 14 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated no cognitive deficits or symptoms of delirium, always able to understand others and always able to make himself understood. The resident had diagnoses that included congestive heart failure, hypertension (high blood pressure), asthma, low back pain and adult failure to thrive. The resident required extensive staff assistance to transfer to and from bed and chair, toileting, dressing and personal hygiene, the resident unable to stand or ambulate. The resident had a problem labeled (Resident's name redacted) has acute pain/chronic pain initiated 5/9/26 on the Nursing Care Plan, with 9/2/26 goal Resident's name redacted) will voice a satisfactorylevel of comfort through the review date, and directed staff to administer interventions that included:Administer analgesia as ordered. Give 1/2 hour before treatments or care, initiated 5/9/26. Nursing Progress Notes included the following entries: 7/5/26 at 2:53 a.m. Heard yelling coming from resident's room, Certified Nursing Assistant (CNA) and this nurse arrived in room and resident noted standing in middle of room shirtless yelling look at all the blood, all over the walls reassurance provided, assisted resident back to bed, resident asked again do you not see the blood? continued to reassure, will reach out to PCP if labs are recommended at this time since previous episode similar to this resulted to be caused by electrolytes being off balance. 7/5/26 at 9:41 p.m. Resident very confused at this time called 3 times and asked if we called the police yet asked resident why we need the police, resident stated tell them they need to come arrest that killer [NAME] reassurance provided and resident looked straight ahead clinching jaw you son of a bitch (telling [NAME]), afebrile, PCP was faxed yesterday in regards behaviors. 7/6/26 at 11:19 p.m. resident with altered level of conciseness. does open eye to name but not verbally responsive. Respirations 21 and occasionally labored. Temp 97.9 Pulse 70 saturation 99% blood pressure 70/40 having an irregular heartbeat. Bowel sounds active. Lung sounds clear to auscultation bilaterally. Skin is pale. yesterday per report was having hallucinations and yelling out which is not typical for him. Called ARNP and received order to send to hospital emergency room for eval. Tried to call resident's family contact but number is disconnected. Call placed to dispatch (for ambulance request). A hospital Discharge summary dated [DATE] included the results of a commuted tomography (CT) scan of the abdomen radiographic report that stated the resident had cholelithiasis (gall stones in the common duct of the gallbladder) without acute cholecystitis (obstruction of the gallbladder common duct due to obstruction by gall stones). A hospital document dated 7/15/26 revealed the following notation: On 7/7/26 presented to hospital with altered mental status, hypotensive (low blood pressure) to 74/55, started on Levophed (a vasopressor medication that rapidly raises blood pressure), and acute kidney injury with evidence of acute calculus cholecystitis (gall stones that caused inflammation/obstruction/infection of the common bile duct in the gall bladder on commuted tomography (CT) scan of the abdomen. Received 2.5 liters of fluid and insulin/glucose administration for hyperkalemia (high potassium level). Received Cefepime, Vancomycin and Flagyl (strong antibiotics and antifungal medication administered intravenously, IV). The resident required an emergency image-guided radiographic percutaneous cholecystostomy on 7/7/26 (a procedure in which a tube is inserted into the bile duct of the gall bladder to drain/remove infected fluid or bile). The resident was diagnosed with acute sepsis secondary to cholecystitis and leukocytosis (high white blood cell (WBC) count) WBC count 20.2, (normal WBC count is 4.0 to 11.0). The hospital document revealed the resident remained hospitalized on [DATE]. During an interview on 7/30/26 at 4:45 p.m., a family member of both Residents #1 and #2 stated they visited the residents on 7/4/26 and 7/5/26, Resident #1 felt warm, looked flushed, didn't feel well and they had to direct the nursing staff to check her temperature and check on the resident. The family member did not think the 2 residents received the care they required by staff at the facility, and they refused to permit the hospital to return Resident #2 to the facility due to their concerns about the resident's care. During an interview on 7/30/26 at 5:17 p.m., Staff D, LPN, stated he remembered when he worked on 7/6/26, staff told him Resident #2 had been delirious since the day before, that was not normal for the resident, he called the provide r right away and received the order to transfer the resident to the hospital. Staff D stated Staff A, LPN told him they tried to contact the provider but didn't get a call back. Staff D stated if the provider didn't return his call he would call again, and if he didn't receive a return call he would notify the Administrator or the DON.

Based on record review, staff interview and facility policy review, the facility failed to complete and document care conferences after admission for two of three residents (Residents #5 and #11) and quarterly for two of three residents (Residents #3 and #5). The facility failed to document the following; the planning of care should include and assessment of the resident's current condition, needs that the resident requires, and updates which should be shared and communicated to the resident and or resident representative. A copy of the care plan should also be available to the resident, and or resident representative for review which the facility failed to do. The facility reported a census of 25 residents. Findings include:2. The modified Minimum Data Set (MDS) Assessment tool with reference date 8/20/26 revealed Resident #5 admitted to the facility on [DATE] with diagnoses that included hyponatremia (low sodium level), non-Alzheimer's dementia, traumatic brain injury (TBI), anxiety, bipolar disorder, schizophrenia and asthma, scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment, with symptoms of delirium present. The resident's clinical record revealed the resident had a Court Appointed Guardian that was her decision maker, and the first care conference documented on 11/26/25, over 3 months after the resident's admission to the facility. The resident's Court Appointed Guardian stated in an interview on 5/5/26 at 2:03 p.m. the resident had been in 3 different long-term care facilities in a little over a year and familiar with some of the procedures. The Guardian stated the facility had not had a care conference with him until November, and had made changes to her psychiatric medications that were not communicated to him within the first month that she was there, because if he had been notified he would have directed that her psychiatric medications were to be managed by her psychiatrists at the psychiatric hospital and not the facility's Nurse Practitioner or other providers not familiar with her history and care requirements. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 03 and had the following diagnoses: Heart Failure, Diabetes Mellitus and Non-Alzheimer's Dementia. The MDS also identified Resident #3 was totally dependent on staff for assistance with eating, toileting, showers, lower body dressing and putting on and removing footwear and repositioning. The MDS identified Resident #3 required substantial/maximal staff assistance with upper body dressing and oral hygiene. The MDS also identified Resident #3 displayed behaviors of delusions and physical, verbal and other behaviors of behavioral symptoms directed toward others. A review of the care conference notes revealed no documentation between 10/8/25 and 3/8/26. The notes did not include documentation of a facility self report regarding a staff member who grabbed Resident #3's arm. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 05 and had the following diagnoses: Di George's Syndrome (a genetic disorder caused by a small missing piece of chromosome 22, resulting in poor development of several body systems), Diabetes Mellitus and Schizophrenia. The MDS also identified Resident #11 required substantial/maximal staff assistance with putting on and removing footwear and required partial/moderate assistance with showers and upper body dressing. She was independent or required minimal assist with the remaining activities of daily living. A review of the Care Conference progress notes revealed only one entry dated 2/16/26. A review of a form the facility provided had the resident's name on it, admit date [DATE], however the date of the current meeting was not complete 10. The form had staff signatures of those who attended. At the bottom of the page, handwritten in resident refused to sign 10/21/25 The form did not have documentation to show what had been discussed with the resident. A review of a form the facility provided 48 Hour Care Plan Meeting with resident's name on it and date 11/4/25, signatures of staff who attended, however, no documentation of notes to show what had been discussed with the resident. In an interview on 5/12/26 at 10:29 AM, the Social Worker reported care conferences are held weekly and documented in the Multidisciplinary Care Conference and Progress Notes in the electronic medical record. When asked why Resident #3 did not have documentation of care conferences held for 5 months, she reported it could have been when she was not here on that day. She also is the Social Worker at another facility and splits her time between that facility and this one. When asked why Resident #11 did not have documentation of a care conference note within 2 weeks after her admission date, she reported this should have been completed within a week after admission and could not explain why it was not documented. In an interview on 5/13/26 at 1:36 PM, the DON reported care conferences are held weekly and would expect the first care conference to be completed at least within the first 30 days after admission. The Facility Policy titled: Comprehensive Care Plans dated as last revised March 2022, had documentation of the following: The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on record review, staff interview and facility policy review, the facility failed to notify residents' guardian/power of attorney of changes for 2 out of 4 residents reviewed (Residents #5, with medication changes) and failed to notify the physician of Resident #6's continued problem with abdominal pain and distention until 6 days later. The facility reported a census of 25 residents. Findings include:1. The modified Minimum Data Set (MDS) Assessment tool with reference date [DATE] revealed Resident #5 admitted to the facility on [DATE] with diagnoses that included hyponatremia (low sodium level), non-Alzheimer's dementia, traumatic brain injury (TBI), anxiety, bipolar disorder, schizophrenia and asthma, scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment, with symptoms of delirium present. The resident's clinical record revealed: The psychiatric hospital's discharge and transfer orders dated [DATE] that directed the resident's admission to the facility also directed continued follow-up care by psychiatrists familiar with the resident's care, with follow-up appointments scheduled. Psychoactive medication orders on the resident's [DATE] admission included: a). Benztropine (an anticholinergic medication used to treat involuntary muscle movements caused by antipsychotic medication) 1 milligrams (mg) administered oral twice daily b). Divalproex (an anticonvulsant and mood-stabilizing medication) Extended Release (ER) 1500 mg administered oral at hour of sleep (HS) c). Levocarnitine (an amino acid dietary supplement used to treat high ammonia levels) 990 mg administered oral 3 times daily. d). Levothyroxine 100 micrograms (mcg ) administered oral daily. e). Risperidone (a strong antipsychotic medication) 1 mg administered oral twice daily. f). Trazodone (an antidepressant medication with sedative properties) 75 mg administered oral at HS (not started until [DATE]). g). Paliperidone (an atypical antipsychotic, also called a second-generation antipsychotic that works by rebalancing certain chemicals in the brain, primarily acting as a serotonin and dopamine antagonist to help improve thinking, mood, and behavior) 564 mg administered by intramuscular injection (IM) every 84 days. Within 14 days of the resident's admission to the facility, the facility sought changes in the resident's psychiatric medication regimen from their medical director and the facility's psychiatric Nurse Practitioner (NP), and did not confer with the resident's psychiatrist provider of record, or the resident's Court Appointed Guardian and decision maker. The medication changes included: a). On [DATE] started Haloperidol (Haldol, a very strong antipsychotic medication) 0.5 milligrams (mg) administered oral every 6 hours as needed (PRN) for 14 days, for manic episodes and aggressive behaviors. b). On [DATE] started Buspirone (an anxiolytic medication) 10 mg administered oral twice daily for schizoaffective disorder (discontinued [DATE]). c). On [DATE] added Valporic Acid (prescription anticonvulsant and mood-stabilizing medication) 250 mg administered oral twice daily for schizoaffective, bipolar disorder .(discontinued [DATE]) d). On [DATE] added Haldol 0.5 mg administered oral 4 times daily for schizoaffective disorder, (discontinued on [DATE]) e). On [DATE] increased Haldol to 1 mg administered oral 4 times daily for schizoaffective disorder (discontinued[DATE]). f). On [DATE] decreased Risperidone to 1 mg administered oral daily for 5 days, then discontinue. g). On [DATE], started Ziprasidone (a strong antipsychotic medication) 20 mg administered oral twice daily (discontinued [DATE]) h). Added Lorazepam (a strong controlled anxiolytic medication) 0.5 mg administered oral every 6 hours PRN for 14 days for behaviors or agitation. The Notification of Resident Family, Legally Responsible Party policy, dated 3/2015, provided staff directives that included: 1. When any one of the following instances occurs, the resident, family or significant other, as appropriate, is notified. a. There is a change in the resident's physical, mental or psychosocial status; b. The resident is transferred to the hospital emergency room and/or admitted for care. c. In the event of an incident, accident or unusual occurrence d. A significant change of therapy, treatment, medications or care plan approaches e. Any time the resident leaves the building for a medical consultation, x-ray, etc. f. Refusal of medications, treatments, labs and diagnostic tests for three consecutive days or a pattern of refusal that may impact on resident condition 2. The nurse must document the name of the person notified, the date and time in the nurse's notes. Any pertinent comments made by this person should be documented. The resident's Court Appointed Guardian stated in an interview on [DATE] at 2:03 p.m. the resident had been in 3 different facilities in a little over a year, she had problems with her mental health, schizophrenia with hallucinations and sees things that aren't real. One of the greatest challenges had been her medications. They know her at the psychiatric hospital, they know what works and what doesn't. There have been problems when other doctors, usually nurse practitioners (NP's) change her medication and she usually ends up with more symptoms/aggression/behaviors and has to go back to the hospital. He is resolute that they continue to have her psychiatric medications managed by her psychiatrist for consistency. The facility didn't call him to let him know they were changing her medication, because if they had, he would have directed them that all of her psychiatric medications were to be managed by her psychiatrists at the psychiatric hospital. Staff interviews revealed: [DATE] at 6:26 a.m. Staff Q, LPN (licensed practical nurse) stated the resident's Guardian would not allow their psych NP to manage her meds, she had to go to her psychiatrist at the psychiatric hospital. [DATE] at 9:50 a.m. Staff M, LPN stated the resident's Guardian ordered that her psychiatric medications were managed by the psychiatrists at the psychiatric hospital and not the facility providers. 2.The Minimum Data Set, dated [DATE] identified Resident #6 as cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 09 and had the following diagnoses: Fractures and other multiple trauma, Coronary Artery Disease and Diabetes Mellitus. The MDS also identified Resident #6 to be dependent on staff for assistance with oral hygiene, toileting, dressing, putting on and removing footwear and personal hygiene. The Nurse's admission assessment dated [DATE] had documentation that the resident did not have any gastro-intestinal issues, last bowel movement (BM) was [DATE]. The pain assessment was not completed to indicate which facial grimace of pain Resident #6 had. The Nurse's Progress Notes had documentation of the following: a. [DATE] 7:27 PM Abdomen is firm round and distended, as report received from the hospital nurse. b. [DATE] 3:41 AM Resident is new admit, alert and oriented x3, pivot transfer, earlier on this shift, she c/o nausea and vomiting and pain, was given as needed (PRN) Zofran and pain medication and she has been sleeping most of the night. Assessments documented over the next 3 days did not include documentation of a reassessment of the round, distended abdomen or presence of bowel sounds. c. [DATE] 6:22 AM After eating fresh fruit that had been out all day, Resident #6 had stomach pain and vomited out the undigested fruit. Bowel sounds active to all quadrants. dXXX[DATE] 9:22 AM Resident vomited this morning before breakfast. (No documentation of an assessment of her abdomen or bowel sounds) e. [DATE] 12:06 PM abdomen is bloated and she had vomited small amounts of brown emesis. Kept trying to eat more while her stomach is bloated. fXXX[DATE] 5:15 PM Abdominal Evaluation/Bowels/Continence: Nausea, vomiting, diarrhea, constipation, complaint of abdominal pain and gas. PRN Gas-X given on 1st shift per report. Resident has had a daily suppository and has requested an enema (not on facility bowel protocol). g. [DATE] 5:56 PM Resident has had problems with constipation since she arrived at facility. She is receiving oxycodone for pain, which is new to the resident. She has had a suppository everyday since the 12th. Minimal results, some diarrhea, one reported medium BM. Today she started vomiting. Given Zofran, this nurse thought it was resolved, and reported it as such. Then she started vomiting again after eating supper. Emesis is dark, not coffee ground emesis, but close in color. Abdomen is distended. Bowel sounds are present in all 4 quadrants. VS: 97.2, 100/40, 79, 16, 95% RA. She continues to complain of abdominal pain. Call to Provider. Received order to transport to emergency room (ER) via ambulance for possible bowel blockage, with request for abdominal CT. h. [DATE] 6:43 PM Transported to the hospital per ambulance. i. [DATE] 12:30 PM Resident family just arrived at the facility with the news that resident had deceased early this morning. A review of the [DATE] Medication Administration Records reviewed revealed Injections received – Humalog sliding scale with meals, Novolog three times daily and Lantus once daily. Ondansetron HCl Oral Tablet 4 mg one tablet every 6 hours as needed for nausea. Doses signed out were on [DATE] at 5:57 AM and at 3:56 PM and [DATE] at 2:18 PM Bisacodyl Rectal Suppository 10 mg one suppository rectally one daily needed for constipation. Doses signed out [DATE] at 8:18 PM and [DATE] at 00:16 AM On [DATE], the Care Plan identified Resident #6 with the problem of an alteration in gastrointestinal status and directed staff to administer medications as ordered. Observe for/document side effects and effectiveness. A review of the BM records from [DATE] to 15, 2026 revealed the only BMs documented were a large one on [DATE] at 8:15 PM, constipated, large puffy like, on [DATE] at 2:36 AM large, loose diarrhea and [DATE] at 8:13 PM small and formed A review of the hospital admission history and physical notes dated [DATE] had documentation that the chief complaint: Abdominal pain, ileus versus partial small bowel obstruction (SBO) s/p NG tube placement. (small bowel obstruction status post nasogastric tube placement ) Transferred to intensive care unit ICU for shock and respiratory failure on 1/19. Cardiovascular: Shock, likely septic from suspected bowel perforation Her daughters reported not being entirely sure which medications she was being given at the rehab facility and haven't been told anything about when her last bowel movement was. Patient and daughters report she has had low appetite since the surgery, but was able to tolerate some diet. For the last two days however, she has not had much oral intake at all due to increasingly worse abdominal distention and pain accompanied by nausea and vomiting. The vomit has had coffee ground like material and dark bilious contents. Primary Cause of Death: Cardiac arrest Conditions Directly Contributing to Death: Septic shock and bowel perforation. At approximately 2:45 AM on [DATE], the patient was pronounced dead. In an interview on [DATE] at 10:14 AM, Staff Q, LPN reported he could not recall very much about the resident and was unable to recall his assessment of her abdomen while she was here. Staff Q did report if he assessed a resident's abdomen that was firm and distended, that he would listen to bowel sounds, check the bowel record, they probably need a laxative to help them go. Normally, we give milk of magnesia (MOM) on 3rd with no BM and if no results, give Dulcolax suppository. He should reassess her at least once a shift. After she has a BM, we should chart the amount, consistency, this should be on the bowel record under tasks. In an interview on [DATE] at 10:13 AM, Staff M, LPN recalled Resident #6 had complained of pain to her hip, abdomen and back. She reported her abdomen was soft for the most part, she could not recall charting that her abdomen was bloated and vomited. If someone had a firm, distended abdomen, she would check to see what kind of bowel movements she had, check per shift, check for bowel movements, bowel sounds, if she needs a laxative. If a resident did not have a BM for 3 days, give MOM (Milk of Magnesia), if MOM is ineffective, then we should give a suppository. Then we should notify the doctor. She could not recall if any of the above had been given to Resident #6. In an interview on [DATE] at 1:15 PM, Staff P, LPN reported the following: she admitted her. She didn't speak English and Staff P spoke Spanish and she translated for her. She was in pain, she had been admitted to the facility for Physical Therapy after she broke a hip. She complained about pain, her abdomen was very distended and complained of constipation. The hospital told Staff P that she had a BM there. She recalled charting her abdomen was distended. Her bowel sounds were active to all quadrants. But she did complain that she needed to have a bowel movement and she couldn't. She did not complain of nausea, no vomiting. She did want something to eat, we gave her a sandwich and gave her something to drink. At that time, she did not have orders for a laxative. I asked if she needed one right away, she said no. Staff P reported if she assessed a resident's abdomen and noticed it's firm and distended, she should document an assessment every shift. The facility had a protocol that if the resident did not have a BM for 3 days, we give MOM (Milk of Magnesia), if MOM is ineffective, give Dulcolax suppository, if that doesn't work within a day, call the doctor for an order, he may order an enema. If enema is effective, call the doctor. In an interview on [DATE] at 2:33 PM, Staff I, RN reported she found out from Resident #6's family member that she had a resected bowel which was not in the medical records sent to this facility. She had only complained of abdominal pain for Staff I only on the day she was sent out to the hospital. Staff I also reported if a nurse assessed the resident's abdomen and noticed it was firm and distended, she should listen for bowel sounds with a stethoscope. If hypoactive – the nurse would need to notify the doctor. Check the medication administration record (MAR), if no BM for 3 days, give MOM (Milk of Magnesia), if no results, give Dulcolax suppository, if that doesn't work, call the doctor. If a nurse gave a suppository, she/he would need to chart the results, size of the BM, consistency and presence of bowel sounds. She recalled Resident #6's abdomen was distended before she was sent to the hospital. If the nurses had been told she had a resected bowel, they should have sent her out to the hospital earlier than they did. In an interview on [DATE] at 1:36 PM, the DON (Director of Nursing) reported if a resident was admitted with complaints of abdominal pain and firm and distended abdomen, she would expect the nurse to get a set of vitals, listen to bowel sounds, do an overall head to toe assessment then call the doctor right away. She would expect the nurses to assess the abdomen at least every shift for the next 48 to 72 Hours. She would expect them to document bowel sounds, any non-behavioral observations to indicate pain, when the last BM was, what medications were given, vital signs. If no BM after 3 days give MOM, if no results, give Dulcolax suppository, if no results, call the doctor with an update. After the resident has a BM, would need to document that interventions were tried. Document size, consistency of the BM, any presence of blood, any straining, if complaining of pain while they're having a BM. She could not explain what happened before Resident #6 was sent to the hospital or why the physician was not notified until 6 days later. In an interview on [DATE] at 12:06 PM AM, Resident #6's primary care physician and facility Medical Director reported the following: she could not recall when the facility first notified her of Resident #6's problems with abdominal pain since admission. She was not sure if the facility had a BM protocol. She reported if the facility had notified her earlier of the resident's condition, she would have given orders to check vital signs, check labs and to have the nurses to check for bowel sounds and palpate. A review of the Facility Policy titled: Notification of Resident Family, Legally Responsible Party dated as last reviewed [DATE] had documentation of the following: When any one of the following instances occurs, the resident, family or significant other, as appropriate, is notified. a. There is a change in the resident's physical, mental or psychosocial status; b. The resident is transferred to the hospital emergency room and/or admitted for care. c. There is a need to alter the resident's room assignment or roommate. d. In the event of an incident, accident or unusual occurrence e. A restraint is recommended. f. There has been a significant change in the resident's skin integrity. g. A significant change of therapy, treatment, medications or care plan approaches h. Any time the resident leaves the building for a medical consultation, x-ray, etc. i. Refusal of medications, treatments, labs and diagnostic tests for three consecutive days or a pattern of refusal that may impact on resident condition j. The resident is discharges without medical authority k. A decision has been made to discharge the resident from the facility 2. The nurse must document the name of the person notified, the date and time in the nurse's notes. Any pertinent comments made by this person should be documented. A review of the Facility Policy titled: Notification of Changes dated as implemented [DATE] had documentation of the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include: Life-threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment.

Based on clinical record review, facility policy review, and staff and resident responsible party interviews, the facility failed to implement an effective discharge planning process for 1 of 4 records reviewed for discharge plan, (Resident #4) that focused on the resident's discharge goals, prepared the resident to effectively transition to post-discharge care, and resulted in the resident's homelessness within 7 days of discharge, and the resident's return to substance abuse and hospitalization in critical condition from a drug overdose. The facility reported a census of 25 residents. Findings include:Resident #4 was admitted to facility on 10/2/25, transferred there from a sister facility due to the resident's exit-seeking behavior, where she'd been admitted from the hospital on 9/29/25. The MDS Assessment tool with reference date 10/9/25 revealed the resident scored 12 out of 15 points possible on the BIMS cognitive assessment that indicated mild cognitive impairment, without symptoms of delirium present, and had a Level II PASRR for serious mental illness. Her diagnoses included hypertension (high blood pressure), renal insufficiency, diabetes, arthritis, anxiety, depression (other than bipolar disorder), major depressive disorder, attention-deficit hyperactivity disorder (ADHD), insomnia, chronic pain, spinal stenosis (narrowing of spinal canal inside vertebrae) of cervical region and low back pain. The assessment revealed the resident was independent for all activities of daily living, including ambulation of 150 feet on even surfaces, with exception of shower/bathe self not assessed, and transfer into shower/tub not assessed. A level II PASRR (Pre-admission Screening and Resident Review, an in-depth, person-centered evaluation triggered when there is a suspected or confirmed mental illness, intellectual disability, or related condition. It ensures individuals are placed in the most integrated, appropriate setting and receive necessary specialized services) dated 9/24/25 was a short term,180-day approval for services that ended 3/23/26 and revealed the following information: 1. Met PASRR criteria for serious mental illness for the diagnoses of schizophrenia which has led to significant symptoms that impact daily functioning and have required intensive supports in the past.2. Medical provider noted that the resident was unable to care for herself Independently due to difficulty with basic cognitive tasks and impaired judgement, noted to be confused with impairment in long and short term memory.3. A Court Appointed Guardian had been established for decision making.4. The resident had an open criminal case for charges of Assault Causing Bodily Injury and Domestic Abuse, Assault-Injury of Mental Illness with a competency evaluation scheduled for 10/08/2025.5. The resident's Guardian stated she will need to live in a supportive setting such as a nursing home or assisted living facility because the resident is unable to care for herself at home.6. Medical records note there may be an open assessment with HHS (Iowa Health and Human Services) relating to possible dependent adult abuse or self-denial of critical care.7. History of methamphetamine use with most recent use occurring just prior to 8/2/25 hospital admission. It does not appear that the resident has ever attended substance abuse treatment.8. A Modlfied Short Blessed Cognitive Test (SBT), a screening test to measure cognitive ability resulted in a score of 12. Scores of 0-4 represent cognitive functioning to be intact, scores of 5-9 indicate possible impairment and may suggest a need for evaluation of early dementing disorder, and scores of 10 or more indicate impairments that are consistent with dementia.9. The MoCA (Montreal Cognitive Assessment), a cognitive screening test designed to assist health professionals to detect mild cognitive impairment and Alzheimer's disease resulted in a score of 7. Scores of 26 and higher represent normal cognition, scores of 18-25 indicate mild cognitive impairment, scores of 10-17 indicate moderate cognitive impairment, and scores of less than 10 indicate severe cognitive impairment. The score of 7 indicates the resident would have trouble remembering, learning new things, concentrating, and making decisions that affect everyday life. The receiving facility was required to provide:1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services) Individual therapy by a licensed behavioral health professional.2. Initial substance use evaluation to determine diagnosis and develop a plan of care Referral and make access possible for participation in a support group for recovery from substance abuse (AA, NA, etc.)3. Services to assist the individual in preparing to pursue supported community living.4. Language Therapy - the resident will benefit from ongoing speech therapy to improve ability to swallow and cognitive, problem solving, and reasoning skills.5. Facilitate family involvement in the individual's care and care planning, including inviting family for regular visitation, and participation in care conferences.6. Supportive counseling from nursing facility staff.7. Due to the serious history of substance use and apparent challenges it has created the resident willbenefit from a referral for evaluation of need for substance use treatment. If it is determined the resident needs substance use treatment in an inpatient setting following nursing facility care, then plansshould be made to enter treatment in whatever manner will be most beneficial for the resident.8. Obtain archived psychiatric/behavioral health treatment records to clarify history and then make those past records available to all medical and behavioral health service providers9. Because the resident has ongoing medical and mental health conditions and requires assistance from others, the resident will need to live in a supported living setting, such as supported independent living, a group home, residential care facility, assisted living, or other supported setting where help from staff is available with consistent supervision for safety and well-being. Staff at the receiving nursing facility are encouraged to reach out for immediate collaboration with MCO case managers, and any other community providers that may be involved with the resident, to find and arrange for any services the resident is eligible to receive before discharge.10. The resident will benefit from a referral to a support group for recovery from substance use and a recovery group for people with serious mental health issues to help the resident get and stay sober and to support recovery in both mental health and substance use. Additional PASRR requirements include: The admitting nursing facility must incorporate PASRR findings as part of the individual's plan of care. Maximus must be notified of all PASRR admissions and discharges viaPath Tracker within AssessmentPro If for any reason the resident chooses to discharge prematurely or without adequate services and supports in place, we strongly encourage any concerned providers or others to take all necessary steps to keep the resident safe, including requesting court orders if needed, and to contact the lowa HHS Abuse Hotline at [PHONE NUMBER], to report the resident's high potential for dependent adult abuse and/or self-denial of critical care. The resident's Nursing Care Plan did not address any of the PASRR requirements. On 10/20/25, the resident requested to be discharged , and the resident was discharged with a friend on that date. The facility's Admission, Transfer and discharge policy, with effective date March, 2015, directed staff, in part:No resident shall be discharged without a written order from the attending physician or through other legal processes and timely notification of the legally responsible party or authorized representative.The facility may not transfer or discharge the resident unless:a. The transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility.b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.The facility must notify the resident and, if known, the family member, surrogate, or representative of the transfer and the reasons for the transfer, and record the reasons in theclinical record.The facility is required to provide sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility.There shall be a centralized coordinated discharge plan to ensure that the resident has a program of needed continuing care after discharge from the facility. The plan shall bedeveloped within 7 days of admission and shall be an integral part of the resident care plan and updated at least every 90 days and as needed in social services progress notes. The facility could not provide the documentation that supported the resident no longer had a Court Appointed Guardian. Records available in Iowa Courts Online revealed the following: The resident's Court Appointed Guardian was revoked on 10/7/25, and a motion for temporary guardianship of the resident was filed by another individual that was denied. Documentation related to the resident's pending assault charges since 10/8/25 and through 4/1/26 revealed she was not competent to stand trial, she suffered from a mental disorder and could not assist in her legal defense and ordered to comply with treatment by a psychiatrist to the point of restoration in mental condition. During an interview on 5/6/26 at 9:04 a.m., the resident's Court Appointed Guardian (that ended on 10/7/25) stated the resident was a life-long drug addict that had severely effected and impaired her mental capacity and was not capable of taking care of herself. The facility didn't notify them that the resident was discharged . The resident was discharged with a friend, without her medications, started using methamphetamine as soon as she was discharged and was kicked out of the friend's home within 1 day, then lived with another friend for 5 or 6 days until she was kicked out of there as well. Then the resident stayed with various acquaintances until she was homeless and lived in a park in a large city. The resident was currently hospitalized in ICU on a ventilator from a drug overdose and from what they've heard she was not expected to survive. The Hospital medical records revealed the resident hospitalized in critical condition in the intensive Care Unit with conditions related to a drug overdose on 4/12/26. The resident remained hospitalized as of the time of survey exit.During an interview on 5/14/26 at 2:10 p.m. the facility Administrator stated the resident was discharged within 2 hours of her request for discharge, and the facility did not have time to make or coordinate any referrals for substance abuse counselling or support groups.On 5/19/26, the facility Administrator stated their medical provider sent the resident's prescriptions to the pharmacy requested by the resident on 10/20/25 (Pharmacy A). During an interview on 5/19/26 at 12:02 p.m., pharmacy staff at Pharmacy A stated they had a profile for the resident (had her information in their database) but did not receive any prescriptions from any provider on or around 10/20/25, and had not dispensed any medication to the resident.

Based on record review, staff interview and facility policy review, the facility failed to address PASRR recommendations on the Care Plans for two of three residents reviewed with Level 2 PASRR evaluations. (Residents #4 and #5) and failed to include interventions identified in an interdisciplinary meeting after incident involving one resident entering another resident's room causing Resident #7 to fear Resident #8). The facility reported a census of 25 residents.Findings include:1. The modified Minimum Data Set (MDS) Assessment tool with reference date [DATE] revealed Resident #5 admitted to the facility on [DATE] with diagnoses that included hyponatremia (low sodium level), non-Alzheimer's dementia, traumatic brain injury (TBI), anxiety, bipolar disorder, schizophrenia and asthma, scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment, with symptoms of delirium present. The resident's Level II PASRR (Pre-admission Screening and Resident Review, an in-depth, person-centered evaluation triggered when there is a suspected or confirmed mental illness, intellectual disability, or related condition. It ensures individuals are placed in the most integrated, appropriate setting and receive necessary specialized services) dated [DATE] was a short-term,180-day approval for services that ended [DATE], and revealed the following information: 1. Met PASRR criteria for serious mental illness for the diagnoses of schizoaffective disorder, bipolar type, which led to significant symptoms that impact daily functioning and have required intensive supports in the past. 2. The resident had multiple inpatient psychiatric hospitalizations between 2019 and 2025 for treatment of schizoaffective disorder, bipolar type. 3. At the time of the assessment the resident was hospitalized on an inpatient psychiatric unit by court order, for treatment of schizoaffective disorder, bipolar type, and neurocognitive disorder (conditions that cause a decline in mental functions such as memory, attention, problem-solving, and language) related to TBI. 4. The resident had a history of behaviors that included refusal of medication and care when not doing well, yelled at others, and threw and broke things when upset. 5. The resident required placement in a locked facility for safety. The receiving facility was required to provide: 1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services) 2. Individual therapy by a licensed behavioral health professional 3. Occupational Therap 4. Physical Therapy 5. Routine and/or special Dental Services to address care of teeth or dentures and oral health 5. Socialization/leisure/recreation activities appropriate to current skills or adapted to facilitate optimal participation 6. Facilitate family involvement in the individual's care and care planning, including inviting family for regular visitation, and participation in care conferences 7. Supportive counseling from nursing facility staff. The resident's Nursing Care plan did not address the PASRR requirements until [DATE]. The facility submitted a PASRR review as required before the [DATE] expiration of the PASRR that was dated [DATE]. A conditional short-term 60-day Level II PASRR dated [DATE] included the following information: 1. A ServiceMatters (company contracted for management of PASRR care coordination) review dated [DATE] was started to see if all PASRR identified services and supports noted in the most recent completed PASRR report ([DATE]) were being care planned and delivered. The ServiceMatters review was not completed because the admitting nursing facility was not compliant and did not submit the requested information needed to complete the review. 2. A ServiceMatters review dated [DATE] was completed to see if all PASRR identified services and supports noted in the most recent completed PASRR were being care plan and delivered. The ServiceMatters review found the nursing facility was not compliant. The [DATE] PASRR directed the continuation of: 1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services) 2. Socialization/leisure/recreation activities appropriate to current skills or adapted to facilitate optimal participation 3. Supportive counseling from nursing facility staff The resident's clinical record revealed: 1. Resident sent to a hospital emergency room (ER) for a psychiatric evaluation and treatment of aggressive behaviors on [DATE]. 2. Resident sent to a hospital ER for a psychiatric evaluation and treatment of aggressive behaviors on [DATE]. 3. Resident sent to the psychiatric hospital ER for psychiatric evaluation and treatment of aggressive behaviors on [DATE]. The resident hospitalized on the inpatient psychiatric unit until [DATE] for treatment of schizoaffective disorder. 4. Resident sent to the psychiatric hospital ER for psychiatric evaluation and treatment of aggressive behaviors on [DATE]. The resident hospitalized on the inpatient psychiatric unit until [DATE] for treatment of schizoaffective disorder. 5. Resident sent to the psychiatric hospital ER for psychiatric evaluation and treatment of aggressive behaviors on [DATE]. The resident hospitalized and had not returned to the facility. 6. Resident #4 was admitted to facility on [DATE], transferred there from a sister facility due to the resident's exit-seeking behavior, where she'd been admitted from the hospital on [DATE]. The MDS Assessment tool with reference date [DATE] revealed the resident scored 12 out of 15 points possible on the BIMS cognitive assessment that indicated mild cognitive impairment, without symptoms of delirium present, and had a Level II PASRR for serious mental illness. Her diagnoses included hypertension (high blood pressure), renal insufficiency, diabetes, arthritis, anxiety, depression (other than bipolar disorder), major depressive disorder, attention-deficit hyperactivity disorder (ADHD), insomnia, chronic pain, spinal stenosis (narrowing of spinal canal inside vertebrae) of cervical region and low back pain. A level II PASRR dated [DATE] was a short-term,180-day approval for services that ended [DATE] and revealed the following information: 1. Met PASRR criteria for serious mental illness for the diagnoses of schizophrenia which has led to significant symptoms that impact daily functioning and have required intensive supports in the past. 2. Medical provider noted that the resident was unable to care for herself Independently due to difficulty with basic cognitive tasks and impaired judgement, noted to be confused with impairment in long and short term memory. 3. A Court Appointed Guardian has been established for decision making. 4. The resident's Guardian stated she will need to live in a supportive setting such as a nursing home or assisted living facility because the resident is unable to care for herself at home. 5. History of methamphetamine use with most recent use occurring just prior to [DATE] hospital Admission. It does not appear that the resident has ever attended substance abuse treatment. The receiving facility was required to provide: 1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services) Individual therapy by a licensed behavioral health professional. 2. Initial substance use evaluation to determine diagnosis and develop a plan of care Referral and make access possible for participation in a support group for recovery from substance abuse (AA, NA, etc.) 3. Services to assist the individual in preparing to pursue supported community living. 4. Language Therapy – the resident will benefit from ongoing speech therapy to improve ability to swallow and cognitive, problem solving, and reasoning skills. 5. Facilitate family involvement in the individual's care and care planning, including inviting family for regular visitation, and participation in care conferences. 6. Supportive counseling from nursing facility staff. 7. Due to the serious history of substance use and apparent challenges it has created the resident will benefit from a referral for evaluation of need for substance use treatment. If it is determined the resident needs substance use treatment in an inpatient setting following nursing facility care, then plans should be made to enter treatment in whatever manner will be most beneficial for the resident. 8. Obtain archived psychiatric/behavioral health treatment records to clarify history and then make those past records available to all medical and behavioral health service providers 9. Because the resident has ongoing medical and mental health conditions and requires assistance from others, the resident will need to live in a supported living setting, such as supported independent living, a group home, residential care facility, assisted living, or other supported setting where help from staff is available with consistent supervision for safety and well-being. Staff at the receiving nursing facility are encouraged to reach out for immediate collaboration with MCO case managers, and any other community providers that may be involved with the resident, to find and arrange for any services the resident is eligible to receive before discharge. 10. The resident will benefit from a referral to a support group for recovery from substance use and a recovery group for people with serious mental health issues to help the resident get and stay sober and to support recovery in both mental health and substance use. Additional PASRR requirements include: a. The admitting nursing facility must incorporate PASRR findings as part of the individual's plan of care. Maximus(company that manages PASRR's) must be notified of all PASRR admissions and discharges via Path Tracker within AssessmentPro. b. If for any reason the resident chooses to discharge prematurely or without adequate services and supports in place, we strongly encourage any concerned providers or others to take all necessary steps to keep the resident safe, including requesting court orders if needed, and to contact the Iowa HHS Abuse Hotline at [PHONE NUMBER], to report the resident's high potential for dependent adult abuse and/or self-denial of critical care. The resident's Nursing Care Plan did not address any of the required PASRR interventions, or indicate the resident had a Level II PASRR. The resident was discharged from the facility on [DATE] per her own request. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease), Diabetes Mellitus and Respiratory Failure. The MDS also identified Resident #7 to be totally dependent on staff for assistance with toileting, showers, putting on and removing footwear and required substantial/maximal assistance with dressing. Observations of Resident #7 could not be completed as she expired prior to the initiation of the investigation survey. The Nurse's Progress Notes revealed the following: [DATE] 12:05 PM Hospice social worker here to visit. Resident did inform the hospice staff that she had an incident with another resident coming into her room last night and expressed concerns regarding personal safety while in room and feeling anxious from the incident. Social worker discussed with this writer that resident stated, I would like to have a safety plan in place. [DATE] 10:31PM Resident #7's family member reported Resident #7 stated Resident #8 put his hand on her shoulder and put his fist near her face. However, multiple staff interviewed Resident #7 who denied Resident #8 actually touched her. A review of the Facility Incident Report revealed the following: [DATE] at 1:00 PM Resident #7 reported Resident #8 came in to her room and raised his arm, but did not touch her. The hospice nurse reported there were different versions of the story being reported by the resident's family member and the resident. Care plan updated to show previous concerns with attention seeking behavior from this resident. The Care Plan was not updated after the above incident occurred. 3. The Minimum Data Set (MDS) dated [DATE] identified Resident #8 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 06 and had the following diagnoses: Non-Traumatic Brain Dysfunction, Unspecified Dementia and Non-Alzheimer's Dementia. The MDS also identified Resident #8 required substantial/maximal staff assistance with all activities of daily living except eating, walking and repositioning. The MDS did not identify him with any indicators of possible psychosis or any behaviors directed towards others. A review of the Progress Notes revealed the following: [DATE] 9:40 PM Resident #7 reported that Resident #8 entered her room, shut the door meddled with her things then came over to her recliner. He then made a fist 2 to 3 inches from her face. He said, How about I give you five? She reports that she was screaming, she had put her light on when he came into the room. He said, They can't hear you. Resident #7 said there was no physical contact with this resident. Observations of Resident #8 revealed the following interactions: [DATE] at 9:54 AM resident arguing with another female resident who kept telling him to shut up. Staff S, RN approached this resident and asked him if he wanted a cookie. Resident #8 walked away from the female resident and stood in front of the nurse's station where Staff S gave him something to read. [DATE] at 10:10 AM resident now arguing with another female resident sitting in a recliner by the nurse's station who kept telling him to shut up then resident sat next to this resident and began arguing with her again. No staff member sitting nearby. He did not attempt to get up and hit her. [DATE] at 10:57 AM standing at the nurse's station , arguing with Staff S, RN, who tried to re-direct him to the main dining room, he started yelling No, I do not want to hold your hand! and followed her in to the dining room and he sat down in the dining room chair. In an interview on [DATE] at 9:26 AM, the MDS Coordinator reported usually the MDS Coordinator or the DON (Director of Nursing) is responsible for making changes to the resident's care plan. When asked when a resident has a level 2 PASRR evaluation, the PASRR recommendation would need to be added to the Care Plan, she reported she did not know. She thought Social Services was responsible, however, was not sure if it was part of her job yet. She works between two buildings and may not always be aware when changes may occur. When asked why the recommendations were not added for Resident #4's Care Plan, she reported she was not working at the facility at that time. When asked why recommendations were not added to Resident #5's Care Plan, she reported she had only been working here a few weeks before she was admitted . Regarding the incident that took place between Resident #7 and Resident #8 was not added to their Care Plans as she was working at the other facility as a staff nurse. In an interview on [DATE] at 1:36 PM, the DON reported usually the MDS Coordinator and the DON is responsible for updating the care plans. When there is a level 2 PASRR evaluation completed, those recommendations be added to the resident's care plan within the first 5 days. Regarding the incident that occurred between Resident #7 and Resident #8, she would have expected that to be added to the Care Plan within a few days. A review of the Facility Policy titled: Cared Plans, Comprehensive Person dated as last reviews [DATE] failed to address the need to update Care Plans where there is a change in medication or the need to address PASRR recommendations.

Based on clinical record review, policy review, and staff interviews, the facility failed to ensure their staff had basic competencies and skills sets that met the behavioral health needs for residents the facility has assessed and developed care plans for, in accordance with their Facility Assessment. The facility failed to provide the education, as specified in the Facility Assessment, to promote the staff's competency, and failed to document staff competency for behavioral health management as required. The facility reported a census of 25 residents. Findings include: The Facility's assessment dated 5/2025 revealed:The facility had an average daily census of 27 resident, with age range of 43 to [AGE] years old. Seven of the residents had Level II PASRR's (Pre-admission Screening and Resident Review, an in-depth, person-centered evaluation triggered when there is a suspected or confirmed mental illness, intellectual disability, or related condition. It ensures individuals are placed in the most integrated, appropriate setting and receive necessary specialized services), and 4 residents were identified with intellectual disabilities. The facility identified they provided assistance with behavioral symptoms for 28 residents. Their staff included 8 to 10 Certified Nursing Assistants (CNA's), 6 Certified Medication Assistants (CMA's, that are also CNA's), 2 Registered Nurses (RN's), 5 Licensed Practical Nurses (LPN's), and no mental health professionals. Psychiatrists and Psychologists were available through telehealth technology. The Assessment reported the average CNA to resident ratio was 1 to 9, and the average nurse to resident ratio was 1 to 24. The Assessment described their staffing is adequate for caring for residents with dementia, mental health conditions, or history of trauma as evidenced by: 1 part time social worker and in service training and competencies for all staff. Specialized training: All staff are trained in the care on monthly and yearly trainings. The Staff Training/Education and Competencies described in the Assessment revealed: Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. We complete an educational needs assessment and develop a curriculum and training plan based on staff need and resident characteristics. The content at a minimum includes: Effective communicationResident rights and facility responsibilitiesAbuse, neglect, and exploitationInfection controlCulture change/person-centered careDementia management and abuse preventionSpecial needs of residentsCaring for residents who are cognitively impairedIdentification of resident changes in conditionCultural competency/trauma informed careQAPI Compliance and ethicsEmergency preparednessWorkplace hazards On [DATE] at 11:12 p.m. the Administrator provided a list of 9 current residents that had Level II PASRR's. On [DATE], the Surveyors requested copies or access to copies of their Staff Competency Assessments. As of the time of survey exit, the facility had not provided the required Competency Assessments. The facility provided a copy of their 2026 Education Calendar that revealed the following planned education programs: January - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Fall Prevention, CPR - knowing code status and proper response, Disaster Preparedness, Safety. February - QAPI, Regulatory Prep, & Improvement Plan Review, Abuse and Mandatory Reporter, Code of Conduct Review: Customer Service Pledge, Disaster Preparedness: Elopement Procedure and Process, Safety. March - QAPI, Regulatory Prep, & Improvement Plan Review, Abuse and Mandatory Reporter, Dementia and Behavior Management, Resident Rights, Disaster Preparedness: Tornado/Strong Winds/Severe Thunderstorms, Safety. April - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Dietary Awareness, Diabetic, & Dental, Restorative Program, Disaster Preparedness: Workplace Violence (Active Shooter), Safety. May - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Identifying Change of Condition, Staff Burnout/Coping with StressDisaster Preparedness: Utility Failure, Safety. June - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Activity Involvement as a part of daily life, Disaster Preparedness: Extreme Weather - Heat, Safety. July - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Communication (residents, peers, supervisors, families, vendors), Compliance and Ethics, Disaster Preparedness: Hazardous Material/Waste Spill, Safety. August - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Infection Control & Bloodborne Pathogens, Caring for Residents with Mental/Psychosocial Disorders, Disaster Preparedness: Infectious Disease & Homeland Security Threats, Safety. September - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Wheelchair Cleaning Process, Antibiotic Stewardship & Activities of Daily Living, Disaster Preparedness: Shelter in Place, Safety. October - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Person Centered Care, Survey Prep, Disaster Preparedness: Fire Safety, Safety: Oxygen safety and awareness. November - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Hospice, Disaster Preparedness: Winter storm/Extreme Weather, Safety. December - QAPI, Regulatory Prep, & Improvement Plan, Abuse and Mandatory Reporter, Dementia and Behavior Management, Disaster Preparedness: Bioterrorism, Safety. On [DATE], Surveyors requested a copy of the facility's 2025 Education Calendar, a copy of staff attendees at the March, 2026 education program, the Staff Competency Assessment policy, an outline of the material presented and credentials of the March, 2026 monthly education speaker. As of the time of survey exit, the facility did not provide the 2025 Education Calendar, the staff attendance at the March, 2026 education program or a Staff Competency Assessment policy. The facility provided the outline for the presentation of Resident Rights that was provided by their Long-Term Care Ombudsman in March, 2026, and did not provide any documentation about the Dementia and Behavior Management education that was scheduled for the March, 2026 education program. The facility also provided a Documentation Training Sign-In Sheet, dated [DATE], that stated Training Topic: Documentation & Charting, and signed by 19 staff members, of unknown disciplines, for a program that started at 1:30 p.m., and without a time that the program ended. The facility provided an undated 7-page LTC Staff Training Handout: Schizophrenia and Bipolar Disorders outline with the [DATE] staff sign-in document, however there was no validation of the date the information was provided, or who provided the education if it was provided. The outline included a post-education quiz that staff would have completed, and the facility did not provide copies of the tests completed by staff members after the presentation that would have verified the delivery of the education. Staff interviews revealed: [DATE] at 6:26 a.m., Staff Q, LPN stated they had several residents with behaviors and staff had to be reactive and flexible to keep everyone safe. Management says this is how it is, younger residents with psych illnesses are in the mix and that it's normal across all long-term care. He knew/has learned from practice what usually worked and what usually doesn't, but each situation is individual. You had to try to keep all the resident's safe. They have staff meetings, sometimes they talk about resident behaviors but they could do that at every meeting and it might be more helpful. [DATE] at 9:50 a.m. Staff M, LPN stated there were several residents here with aggressive behaviors, most were younger but not all, but they are different than their older frail residents with normal dementia. They really didn't educate staff with specifics for managing resident behaviors, staff had to deal with them as they arose. The only option they really had was to send the resident to the hospital emergency room (ER) for assessment when their behaviors were aggressive and threatening. [DATE] at 1:03 p.m., Staff T, RN, stated they were getting more and more of the younger psych residents with behaviors. Staff weren't really educated to manage those complex conditions, there might be some information in the breakroom, a couple sheets of paper, if you call that education, otherwise there wasn't a plan to make sure that staff had the knowledge they needed to manage complex resident conditions and aggressive resident behaviors. [DATE] at 11:16 a.m. Staff L, CNA, stated she thought they did some education on resident conditions at staff meetings, she wasn't sure if they covered what to do about resident behaviors or psychiatric problems, she couldn't remember if they did. [DATE] at 2:21 p.m. Staff E, CNA and Staff U, CNA stated they had training when they first started, couldn't say if they have had education about behaviors or what to do with resident's that were aggressive when they had staff meetings but thought they probably did. When asked if they could remember what to do if a resident was being difficult, they said to try to approach the resident with a different staff member, otherwise they couldn't offer any other examples of education they had received. [DATE] at 2:49 p.m. Staff I, RN stated they used to have an all dementia facility, and behaviors were a little easier to manage due to the similarities between the residents. Now their population was so diverse, the residents with psychiatric problems are younger, more mobile, stronger and agile, and staff try to do the best they can with what they have. The had monthly staff meetings and they had some quizzes to fill out for education on resident conditions, and they could never have too much of that.

Based on clinical record review, policy review, and staff and resident responsible party interviews, the facility failed to incorporate care requirements into resident comprehensive care plans as directed for 2 of 5 residents reviewed with Level II PASRR's (Pre-admission Screening and Resident Review, an in-depth, person-centered evaluation triggered when there is a suspected or confirmed mental illness, intellectual disability, or related condition. It ensures individuals are placed in the most integrated, appropriate setting and receive necessary specialized services), and failed to ensure the 2 resident's attained or maintained the highest practicable mental and psychosocial well-being, evidenced by 1 of the resident's repeated inpatient psychiatric hospitalizations (Resident #5), and the other resident's inappropriate discharge that lead to homelessness and later demise (Resident #4). The facility reported a census of 25 residents. Findings include: 1. The modified Minimum Data Set (MDS) Assessment tool with reference date 8/20/26 revealed Resident #5 admitted to the facility on [DATE] with diagnoses that included hyponatremia (low sodium level), non-Alzheimer's dementia, traumatic brain injury (TBI), anxiety, bipolar disorder, schizophrenia and asthma, scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment, with symptoms of delirium present, the resident always able to make herself understood and always able to understand others, and the resident did not have behaviors in the 6 days that preceded the assessment. The assessment revealed other related conditions documented in the PASRR section, and did not indicate the resident had a serious mental illness. The assessment revealed the resident required staff supervision/touch assistance for dressing, toileting and personal hygiene, independent for ambulation of 150 feet, transfers to and from bed and toileting, and partial/moderate staff assistance for bathing. The resident's Level II PASRR dated 8/7/25 was a short-term,180-day approval for services that ended 2/3/26, and revealed the following information:1. Met PASRR criteria for serious mental illness for the diagnoses of schizoaffective disorder, bipolar type, which led to significant symptoms that impact daily functioning and have required intensive supports in the past.2. The resident had multiple inpatient psychiatric hospitalizations between 2019 and 2025 for treatment of schizoaffective disorder, bipolar type.3. At the time of the assessment the resident was hospitalized on an inpatient psychiatric unit by court order, for treatment of schizoaffective disorder, bipolar type, and neurocognitive disorder (conditions that cause a decline in mental functions such as memory, attention, problem-solving, and language) related to TBI.4. The resident had a history of behaviors that included refusal of medication and care when not doing well, yelled at others, and threw and broke things when upset.5. The resident required placement in a locked facility for safety. The receiving facility was required to provide:1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services)2. Individual therapy by a licensed behavioral health professional3. Occupational Therap 4. Physical Therapy5. Routine and/or special Dental Services to address care of teeth or dentures and oral health5. Socialization/leisure/recreation activities appropriate to current skills or adapted to facilitate optimal participation6. Facilitate family involvement in the individual's care and care planning, including inviting family for regular visitation, and participation in care conferences7. Supportive counseling from nursing facility staff The resident's clinical record revealed:1. Psychoactive medication orders on the resident's 8/14/25 admission included:a). Benztropine (an anticholinergic medication used to treat involuntary muscle movements caused by antipsychotic medication) 1 milligrams (mg) administered oral twice dailyb). Divalproex (an anticonvulsant and mood-stabilizing medication) Extended Release (ER) 1500 mg administered oral at hour of sleep (HS)c). Levocarnitine (an amino acid dietary supplement used to treat high ammonia levels) 990 mg administered oral 3 times daily.d). Levothyroxine 100 micrograms (mcg ) administered oral daily.e). Risperidone (a strong antipsychotic medication) 1 mg administered oral twice daily.f). Trazodone (an antidepressant medication with sedative properties) 75 mg administered oral at HS (not started until 8/27/25).g). Paliperidone (an atypical antipsychotic, also called a second-generation antipsychotic that works by rebalancing certain chemicals in the brain, primarily acting as a serotonin and dopamine antagonist to help improve thinking, mood, and behavior) 564 mg administered by intramuscular injection (IM) every 84 days. 2. The PASRR directives were not addressed in the resident's comprehensive person-centered care plan until 2/16/26.3. The psychiatric hospital's discharge and transfer orders dated 8/14/25 that directed the resident's admission to the facility also directed continued follow-up care by psychiatrists familiar with the resident's care, with follow-up appointments scheduled.4. Within 14 days of the resident's admission to the facility, the facility sought changes in the resident's psychiatric medication regimen from their medical director and the facility's psychiatric nurse practitioner, and did not confer with the resident's psychiatrist provider of record, or the resident's Court Appointed Guardian and decision maker. The medication changes included:a). On 8/28/25 started Haloperidol (Haldol, a very strong antipsychotic medication) 0.5 milligrams (mg) administered oral every 6 hours as needed (PRN) for 14 days, for manic episodes and aggressive behaviors.b). On 8/28/25 started Buspirone (an anxiolytic medication) 10 mg administered oral twice daily for schizoaffective disorder (discontinued 9/23/25).c). On 8/29/25 added Valporic Acid (prescription anticonvulsant and mood-stabilizing medication) 250 mg administered oral twice daily for schizoaffective, bipolar disorder .(discontinued 9/23/25)d). On 9/4/25 added Haldol 0.5 mg administered oral 4 times daily for schizoaffective disorder, (discontinued on 9/15/25)e). On 9/15/25 increased Haldol to 1 mg administered oral 4 times daily for schizoaffective disorder (discontinued10/22/25).f). On 9/15/25 decreased Risperidone to 1 mg administered oral daily for 5 days, then discontinue.g). On 9/16/25, started Ziprasidone (a strong antipsychotic medication) 20 mg administered oral twice daily (discontinued 10/22/25)h). Added Lorazepam (a strong controlled anxiolytic medication) 0.5 mg administered oral every 6 hours PRN for 14 days for behaviors or agitation. 5. Resident sent to a hospital emergency room (ER) for a psychiatric evaluation and treatment of aggressive behaviors on 9/9/25.6. Resident sent to a hospital ER for a psychiatric evaluation and treatment of aggressive behaviors on 10/7/25.7. Resident sent to the psychiatric hospital ER for psychiatric evaluation and treatment of aggressive behaviors on 10/27/25. The resident hospitalized on the inpatient psychiatric unit until 11/6/25 for treatment of schizoaffective disorder.8. Resident sent to the psychiatric hospital ER for psychiatric evaluation and treatment of aggressive behaviors on 2/20/26. The resident hospitalized on the inpatient psychiatric unit until 3/2/26 for treatment of schizoaffective disorder.9. Resident sent to the psychiatric hospital ER for psychiatric evaluation and treatment of aggressive behaviors on 3/3/26. The resident hospitalized and had not returned to the facility. Documentation on a 9/19/25 Psychiatrist Progress Note stated, in part:Was last seen 3 weeks ago at which time the plan was to continue current medications without changes that included:Benztropine 1 mg twice dailyBuspirone 10 mg twice dailyDepakote ER 1500 mg at HSValproic acid 250 mg twice dailyHaldol 0.5 mg q 6 hours PRN mania and aggressive behaviorsRisperidone 1 mg twice dailyTrazodone 75 mg at HSInvega trinza 546 mg IM every 84 days. Current facility med list:Haldol is now 1 mg scheduled 4 times dailyDecreased Risperidone to 1 mg once daily, scheduled to discontinue (DC) on 9/21/25Started Ziprasidone 20 mg twice dailyDepakote ER 1500 mg at HSValproic acid 250 mg twice dailyBenztropine 1 mg twice dailyBuspirone 10 mg twice dailyTrazodone 75 mg at HSInvega Trinza 546 mg every 84 days IM Was accompanied to this appointment by a staff member from a different facility that could not answer this provider's basic questions about her moods/condition. Plan was to discontinue Valproic acid due to high ammonia level, continue Depakote ER, electrocardiogram was needed before they could increase Ziprasidone, Haldol needed to be discontinued due to the resident already had marked Parkinsonism symptoms before adding the Haldol, continue Haldol for now, Ziprasidone, Benztropine, Buspirone, Trazodone and Invega Trinza, formally DC Risperidone. A Hospital emergency room (ER) Physician Progress Note dated 10/7/25 described: Patient is [AGE] year-old female presenting via EMS from local nursing home. Patient claims that she is not getting along with nursing home staff and has seen some abuse at the nursing home. She is unable to elaborate on the alleged abuse. Also states that she is not getting along with nursing home staff and continues to bicker with them. They called EMS to have patient brought to the emergency department for psychiatric evaluation. Patient thinks this is ridiculous and states she has no suicidal, homicidal ideations. Also denies any hallucinations. Denies any other complaints. Patient is alert and oriented and denies complaints on initial exam. States she is quite tired as she did not sleep well the past several nights. Patient is able to answer questions appropriate and denies any psychiatric complaints including suicidal or homicidal ideation. After discussing with patient and reviewing nursing report, it sounds like patient and nursing home staff have some personality conflicts that are not being handled well. Patient may not be sleeping well at night and becomes grumpy. Discharge instructions from the ER: If you note any abuse at your care home, contact the police by dialing 911 or contact the appropriate state agency as noted below. Care home staff should not be aggravating you or inappropriately chastising you. If you do encounter this behavior, you can contact the state of Iowa long-term care facility regulation department at [PHONE NUMBER]. If you feel you are in immediate danger at your care facility, dial 911. A conditional short-term 60-day Level II PASRR dated 1/25/26 included the following information:1. The resident's medical provider note dated December 2025 stated, in part: Patient is worse than last visit. She was walking about with very slow shuffle. She was not doing this so much last time I saw her. She also states she is doing worse, taking some medications that are sedating her. She does have a low-grade hand tremor. She states she is falling asleep at meals and she was much stronger before this. She is concerned about how she's feeling. Spoke with staff about her case. They said she did have some shuffling before and tremors, but not so much fatigue, and this seems to appear to be more.2. A ServiceMatters (company contracted for management of PASRR care coordination) review dated 9/20/2025 was started to see if all PASRR identified services and supports noted in the most recent completed PASRR report (8/7/25) were being care planned and delivered. The ServiceMatters review was not completed because the admitting nursing facility was not compliant and did not submit the requested information needed to complete the review.3. A ServiceMatters review dated 10/24/2025 was completed to see if all PASRR identified services and supports noted in the most recent completed PASRR were being care plan and delivered. The ServiceMatters review found the nursing facility was not compliant. The 1/25/26 PASRR directed the continuation of:1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services)2. Socialization/leisure/recreation activities appropriate to current skills or adapted to facilitate optimal participation3. Supportive counseling from nursing facility staffThe Modified MDS Assessment tool with reference date of 2/12/26 revealed the resident scored 9 out of 15 points possible on the BIMS cognitive assessment, with symptoms of delirium present, rejected care and had verbal and other behaviors that occurred from 1 to 3 days of the 7 days that preceded the assessment, required substantial/maximal staff assistance for dressing, toileting, toileting and personal hygiene, transfers to and from bed or chair, totally dependent on staff for bathing and putting shoes on, and supervision/touch assistance for ambulation of 150 feet. The assessment indicated the resident's physical condition and abilities had declined since their admission to the facility 6 months prior.The resident's Nursing Care Plan included a problem labeled as PASRR has identified that I need Specialized Services due to (Specify: MI; ID; MI and ID, or Related Conditions).Specialized Services will assist me to achieve optimal functioning and recovery. Date Initiated: 02/16/2026. The 5/21/26 goal for the problem was Ongoing psychiatric medication management by a psychiatrist, (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services) this service must be delivered by a psychiatrist in order to be compliant Any changes to my treatment plan, as a result of ongoing psychiatric services, shall be (1) incorporated into my care plan and (2) communicated to my Primary Care Provider.Interventions on the Nursing Care Plan directed staff as follows:1. Facility's psychiatric Nurse Practitioner (NP) will provide ongoing psychiatric services. Date Initiated: 02/16/20262. Specialized service: Ongoing psychiatric medication management by a psychiatrist or psychiatric nurse practitioner Start date: On (DATE), individual started seeing a psychiatric nurse practitioner for medication management. Frequency: Individual will be seen once a month Duration: services received every month for two years Facility's psychiatric NP will provide ongoing psychiatric services by [NAME] AGNP. Date Initiated: 02/16/2026.**The resident's Court Appointed Guardian did not consent to the resident's psychiatric medication managed by anyone other than the resident's psychiatrists of record, with treatment at the psychiatric hospital.**A Nursing Progress Note transcribed by Staff M, licensed practical nurse (LPN) on 10/7/25 at 2:01 p.m. stated, in part: Primary care physician gave verbal order to send to hospital for psychiatric evaluation. 911 called all paperwork sent with ambulance. Resident's guardian notified and demands that she is taken to the psychiatric VA hospital for treatment.A Provider Progress Note transcribed on 10/13/25 by the facility's psychiatric nurse practitioner stated, in part: Last month was my initial meeting with the resident, I did a few medication changes. Staff reports that moods are all over the place. I did see a note that her POA (power of attorney) would like her to see her psychiatrists from the VA psychiatric hospital. Staff says that she has an appointment there later this month. Will have her removed from my service list.The resident's Court Appointed Guardian stated in an interview on 5/5/26 at 2:03 p.m. the resident had been in 3 different facilities in a little over a year, she has problems with her mental health, schizophrenia with hallucinations and sees things that aren't real. One of the greatest challenges has been her medications. They know her at the psychiatric hospital, they know what works and what doesn't. There have been problems when other doctors, usually nurse practitioners (NP's) change her medication and she usually ends up with more symptoms/aggression/behaviors and has to go back to the hospital. He was resolute that they continue to have her psychiatric medications managed by her psychiatrist for consistency. The facility didn't call him to let him know they were changing her medication during the first month or so that she was there, he wasn't invited to a care conference when she was first at the facility or he would have told them that her psychiatric medications would be ordered by her psychiatrists and nobody else. He found out on 10/7/25 when they were going to send her to the local hospital for a psychiatric evaluation and he told the nurse they couldn't do that, she had to go to the psychiatric hospital. Prior to that he was not informed the facility's NP made changes with her psychiatric medications and he never would have agreed with that or consented to it. Staff interviews revealed:5/5/26 at 6:26 a.m. Staff Q, LPN (licensed practical nurse) stated resident #5 was easily agitated, usually easily redirected. She had schizophrenia, delusional and would have transference - would accuse him of being her husband that had cheated on her, she would be very upset about it, not always able to redirect that. Her Guardian would not allow their psych NP to manage her meds, she had to go to her psychiatrist at the psychiatric hospital. 5/5/26 at 9:50 a.m. Staff M, LPN stated Resident #5 had mood swings and behaviors that could be hot or cold and change on a dime. Her behaviors were unpredictable and often not redirectable. She made verbal threats to staff, physical as well, threw her walker over the Nurse's Station at this nurse. Her Guardian ordered that her psychiatric medications were managed by the psychiatrists at the VA psychiatric hospital and not the facility providers.5/5/26 at 1:03 p.m. Staff T, RN stated Resident #5 had aggressive behaviors, very unpredictable, she was large, loud, slammed doors and threw things and some residents were afraid of her. Sometimes her behaviors were redirectable, but often times they weren't. She was able to get her into her room and away from the other resident's one night when she was aggressive, that was the best she could do until the resident settled down. 2. Resident #4 was admitted to facility on 10/2/25, transferred there from a sister facility due to the resident's exit-seeking behavior, where she'd been admitted from the hospital on 9/29/25. The MDS Assessment tool with reference date 10/9/25 revealed the resident scored 12 out of 15 points possible on the BIMS cognitive assessment that indicated mild cognitive impairment, without symptoms of delirium present, aways able to make self understood and always able to understand others, no behaviors identified and had a Level II PASRR for serious mental illness. Her diagnoses included hypertension (high blood pressure), renal insufficiency, diabetes, arthritis, anxiety, depression (other than bipolar disorder), major depressive disorder, attention-deficit hyperactivity disorder (ADHD), insomnia, chronic pain, spinal stenosis (narrowing of spinal canal inside vertebrae) of cervical region and low back pain. The assessment revealed the resident was independent for all activities of daily living, including ambulation of 150 feet on even surfaces, with exception of shower/bathe self not assessed, and transfer into shower/tub not assessed.A level II PASRR dated 9/24/25 was a short term,180-day approval for services that ended 3/23/26 and revealed the following information:1. Met PASRR criteria for serious mental illness for the diagnoses of schizophrenia which has led to significant symptoms that impact daily functioning and have required intensive supports in the past.2. Medical provider noted that the resident was unable to care for herself Independently due to difficulty with basic cognitive tasks and impaired judgement, noted to be confused with impairment in long and short term memory.3. A Court Appointed Guardian has been established for decision making.4. The resident has an open criminal case for charges of Assault Causing Bodily Injury and Domestic Abuse, Assault-Injury of Mental Illness with a competency evaluation scheduled for 10/08/2025.5. The resident's Guardian stated she will need to live in a supportive setting such as a nursing home or assisted living facility because the resident is unable to care for herself at home.6. Medical records note there may be an open assessment with HHS (Iowa Health and Human Services) relating to possible dependent adult abuse or self-denial of critical care.7. History of methamphetamine use with most recent use occurring just prior to 8/2/25 hospital admission. It does not appear that the resident has ever attended substance abuse treatment.8. A Modlfied Short Blessed Cognitive Test (SBT), a screening test to measure cognitive ability resulted in a score of 12. Scores of 0-4 represent cognitive functioning to be intact, scores of 5-9 indicate possible impairment and may suggest a need for evaluation of early dementing disorder, and scores of 10 or more indicate impairments that are consistent with dementia.9. The MoCA (Montreal Cognitive Assessment), a cognitive screening test designed to assist health professionals to detect mild cognitive impairment and Alzheimer's disease resulted in a score of 7. Scores of 26 and higher represent normal cognition, scores of 18-25 indicate mild cognitive impairment, scores of 10-17 indicate moderate cognitive impairment, and scores of less than 10 indicate severe cognitive impairment. The score of 7 indicates the resident would have trouble remembering, learning new things, concentrating, and making decisions that affect everyday life.The receiving facility was required to provide:1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric advanced registered nurse practitioner ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services) Individual therapy by a licensed behavioral health professional.2. Initial substance use evaluation to determine diagnosis and develop a plan of care Referral and make access possible for participation in a support group for recovery from substance abuse (AA, NA, etc.)3. Services to assist the individual in preparing to pursue supported community living.4. Language Therapy - the resident will benefit from ongoing speech therapy to improve ability to swallow and cognitive, problem solving, and reasoning skills.5. Facilitate family involvement in the individual's care and care planning, including inviting family for regular visitation, and participation in care conferences.6. Supportive counseling from nursing facility staff.7. Due to the serious history of substance use and apparent challenges it has created the resident will benefit from a referral for evaluation of need for substance use treatment. If it is determined the resident needs substance use treatment in an inpatient setting following nursing facility care, then plans should be made to enter treatment in whatever manner will be most beneficial for the resident.8. Obtain archived psychiatric/behavioral health treatment records to clarify history and then make those past records available to all medical and behavioral health service providers9. Because the resident has ongoing medical and mental health conditions and requires assistance from others, the resident will need to live in a supported living setting, such as supported independent living, a group home, residential care facility, assisted living, or other supported setting where help from staff is available with consistent supervision for safety and well-being. Staff at the receiving nursing facility are encouraged to reach out for immediate collaboration with MCO case managers, and any other community providers that may be involved with the resident, to find and arrange for any services the resident is eligible to receive before discharge.10. The resident will benefit from a referral to a support group for recovery from substance use and a recovery group for people with serious mental health issues to help the resident get and stay sober and to support recovery in both mental health and substance use.Additional PASRR requirements included:The admitting nursing facility must incorporate PASRR findings as part of the individual's plan of care. Maximus must be notified of all PASRR admissions and discharges via Path Tracker within AssessmentPro.If for any reason the resident chooses to discharge prematurely or without adequate services and supports in place, we strongly encourage any concerned providers or others to take all necessary steps to keep the resident safe, including requesting court orders if needed, and to contact the lowa HHS Abuse Hotline at [PHONE NUMBER], to report the resident's high potentlal for dependent adult abuse and/or self-denial of critical care.The resident's Nursing Care Plan did not include any of the PASRR required interventions, or indication that the resident had a Level II PASRR.The resident had psychoactive medication orders that included:Administer Tetrabenazine 12.5 milligrams (mg) oral twice daily, ordered 10/3/25. The medication is classified as a Vesicular Monoamine Transporter 2 (VMAT2) inhibitors that prevents neurotransmitters like dopamine, serotonin, norepinephrine, and histamine from being stored and released in the brain, which helps reduce involuntary, hyperkinetic movements associated with long-term use of some psychoactive medications.The resident's clinical record revealed the medication was administered as ordered when the resident was at the sister facility from 9/29/25 through 10/1/25, and the medication not administered at the facility from the time of the order on 10/3/25 through 10/11/25, both doses administered on 10/12/25, 1 dose administered on 10/13/25 then the medication order discontinued on 10/13/25. Per Google search, sudden withdrawal of Tetrabenazine medication caused rapid re-emergence of involuntary, jerky movements within 12 to 18 hours, and can also trigger increased restlessness, insomnia, anxiety and mood swings.A Pogress Note transcribed by the facility's psychiatric Nurse Practitioner on 10/13/25 stated, in part:Staff told me that the Tetrabenazine was not covered by her insurance and it was going to cost 900$ a month- and asked me to discontinue this. I can try to see if she can get on Ingrezza 40mg oral daily for this. ( Ingrezza is a medication used to treat involuntary, repetitive, or sudden body movements in adults, such as tardive dyskinesia.) The clinical record revealed Ingrezza was ordered on 10/14/25, discontinued on 10/14/25 and never administered to the resident. Pre-authorization was required for the medication, and per pharmacy interview on 5/6/26 at 3:24 p.m., the facility did not complete the documentation required for prior authorization as required.During an interview on 5/5/26 at 1:03 p.m. Staff T, Registered Nurse (RN) stated when the resident was first at the facility she didn't have behaviors, they waited for her medication to be approved and delivered. She started to have behaviors that got worse after a week or so, she contacted the pharmacy and asked if it was associated to her not getting the medication and the pharmacy agreed to send an emergency supply. Interview with the facility's pharmacy (Pharmacy A) on 5/6/26 at 3:24 p.m. revealed they received a call from facility staff on 10/11/25 requesting the resident's medication, a 3 day Emergency supply of 6 tablets was dispensed at that time pending the facility's authorization and payment for the medication. The staff member stated they dispensed 28 tablets to the facility's sister facility on 9/29/25, for a cost of $425.95.The clinical record revealed the resident requested to be discharged on 10/20/25, and the resident was discharged with a friend on that date.The facility could not provide the documentation that supported the resident no longer had a Court Appointed Guardian. Records available in Iowa Courts Online revealed the following: The resident's Court Appointed Guardian was revoked on 10/7/25, and a motion for temporary guardianship of the resident was filed by another individual that was denied. Documentation related to the resident's pending assault charges since 10/8/25 and through 4/1/26 revealed she was not competent to stand trial, she suffered from a mental disorder, could not assist in her legal defense and ordered to comply with treatment by a psychiatrist to the point of restoration in mental condition. During an interview on 5/6/26 at 9:04 a.m., the resident's Court Appointed Guardian (that ended on 10/7/25) stated the resident was a life-long drug addict that had severely effected and impaired her mental capacity and was not capable of taking care of herself. The facility didn't notify them that the resident was discharged . The resident was discharged with a friend, without her medications, started using methamphetamine as soon as she was discharged and was kicked out of the friend's home within 1 day, then lived with another friend for 5 or 6 days until she was kicked out of there as well. Then the resident stayed with various acquaintances until she was homeless and lived in a park in a large city. The resident was currently hospitalized in ICU on a ventilator from a drug overdose and from what they've heard she was not expected to survive. Hospital medical records revealed the resident hospitalized in critical condition in the intensive Care Unit with conditions related to a drug overdose on 4/12/26. The resident remained hospitalized as of the time of survey exit.During an interview on 5/14/26 at 2:10 p.m. the facility Administrator stated the resident was discharged within 2 hours of her request for discharge, and the facility did not have time to make or coordinate any referrals for substance abuse counselling or support groups.On 5/19/26, the facility Administrator stated their medical provider sent the resident's prescriptions to the pharmacy requested by the resident on 10/20/25 (Pharmacy B). During an interview on 5/19/26 at 12:02 p.m., pharmacy staff at Pharmacy B stated they had a profile for the resident (had her information in their database) but did not receive any prescriptions from any provider on or around 10/20/25, and had not dispensed any medication to the resident.

Based on observation, record review and staff interview, the facility staff failed to change gloves after completing incontinence care (of stool) and before applying Triad cream to a pressure ulcer to the coccyx area for one of one residents reviewed with a pressure ulcer. (Resident #3). The facility reported a census of 25 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] identified Resident #3 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 03 and had the following diagnoses: Heart Failure, Diabetes Mellitus and Non-Alzheimer's Dementia. The MDS also identified Resident #3 was totally dependent on staff for assistance with eating, toileting, showers, lower body dressing and putting on and removing footwear and repositioning. The MDS identified Resident #3 required substantial/maximal staff assistance with upper body dressing and oral hygiene. The MDS also identified Resident #3 displayed behaviors of delusions and physical, verbal and other behaviors of behavioral symptoms directed toward others. A review of the Progress Notes revealed the following: 2/15/26 6:26 AM Resident's buttock red, open area in center upper portion of buttocks. Measurements 10 cm (centimeters) in length x4 cm in width, open area in middle of a circular 13 cm circular red area. On 3/16/26, the Care Plan identified Resident #3 with a Stage 3 pressure ulcer to the coccyx measuring 4 cm x 2 cm x 0.3 cm requiring daily treatment. The Care Plan failed to address the need to change gloves after providing incontinence care and before applying cream to the pressure ulcer. In an observation of incontinence care on 5/6/26 at 9:14 AM, Staff K, CNA and Staff L, CNA turned resident to his left side he began to strike Staff L, Staff K held his hand to keep him from hitting Staff L. Staff K then used correct technique to cleanse stool off Resident #3's rectal crease. There was an open area noted to coccyx approximately 4 cm long and 2 cm wide, difficult to see depth. Surrounding skin appeared slightly reddened. Then Staff K applied Triad cream to Resident #3's coccyx area without changing her gloves first. Afterwards both aides changed their gloves and applied a new incontinent brief on to the resident. In an interview on 5/12/26 at 9:57 AM, Staff K, CNA reported the following: after she cleans BM (bowel movement) off a resident, she would need to change gloves before she applies a cream to the resident's coccyx afterward. She admitted she forgot to change gloves when providing incontinence cares to Resident #3 and before she applied Triad cream to his coccyx area. She also verified he did have a pressure ulcer to his coccyx area. In an interview on 5/12/26 at10:06 AM, Staff L, CNA reported after she would clean off BM off a resident, she would need to change gloves before applying any cream to the resident's coccyx afterward. She did report Staff K, CNA forgot to change her gloves during incontinence cares the surveyor observed earlier. In an interview on 5/12/26 at 10:13 AM, Staff M, LPN reported after cleaning off BM off a resident, she would change her gloves before applying any ointment to the resident afterwards. She also verified Resident #3 did have a pressure ulcer to his coccyx area. In an interview on 5/13/26 at 1:36 PM, the DON (Director of Nursing) reported after cleaning BM off a resident, she would expect the aides to change their gloves before applying ointment to the resident's pressure ulcer to the coccyx area. A review of the undated Facility Policy titled: Incontinence Care had documentation of the following:Remove the soiled briefs or pad.Immediately clean the resident's skin gently with a wipe or cloth moistened with water or pH-balanced cleaner.Remove and discard your gloves.Perform hand hygiene.Put on clean gloves.Dry the resident's skin.Apply a moisture barrier protectant, as necessary.Inspect the skin for signs of breakdown; promptly report changes in skin integrity.Put on clean briefs or pad.

Based on record review, staff interviews, and the facility policy, the facility failed to complete the initial baseline care plan within 48 hours for 4 of 5 residents reviewed for baseline care plans (Resident #1, Resident #7, Resident 18, and Resident #34). The facility reported a census 27 residents. Findings include: 1.The Nursing Evaluation (Admit/Readmit/Quarterly/COC) V 15 form dated 11/4/25 at 3:12 PM for Resident #1 lacked initiation of a baseline care plan assessments for elopement/wandering, skin integrity, Activities of Daily Living (ADLs), fall, nutrition, neurological, and pain. The MDS assessment dated [DATE] revealed Resident #1 admitted to the facility on [DATE]. The MDS revealed Resident #1 scored a 5 out of 15 on the BIMS exam, which indicated that cognition severely impaired. The MDS revealed resident had delusions, independent with ADL and mobility. The MDS indicated medical diagnoses for Type II diabetes mellitus, anxiety disorder, depression, psychotic disorder (not schizophrenia), and schizophrenia. The Care Plan revealed a focus area for potential skin impairment dated 11/10/25; a focus area for alteration in neurological status related to disease process dated 11/10/25; focus area for ADL Self Care dated 11/10/25; a focus area for elopement risk/wanderer dated 11/10/25; and a focus area for verbal behavioral symptoms dated 11/17/25. 2.The Nursing Evaluation (Admit/Readmit/Quarterly/COC) V 15 form dated 11/25/25 at 12:35 PM for Resident #7 lacked initiation of a baseline care plan assessment for skin integrity, nutrition, neurological, and pain. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 admitted on [DATE]. The MDS indicated Resident #7 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition severely impaired. The MDS revealed resident used a walker and needed supervision or touching with bed/chair to chair transfers and walking 10 feet once standing. The MDS indicated medical diagnoses of unspecified fracture of right femur, subs for closed fracture with routine healing, non-Alzheimer's dementia, and delirium due to known physiological condition. The Care Plan revealed a focus area for nutrition initiated on 11/30/25, a focus area for acute pain on 12/4/25, and focus area for delirium and dementia on 12/3/25, and a focus area for potential for pressure ulcer development on 12/3/25. During an interview on 12/11/25 at 9:38 AM, Staff D, Licensed Practical Nurse (LPN), stated she completed new admission paperwork except for the baseline care plans. Staff D stated she had not been told how to do them and the MDS Coordinator or the Director of Nursing (DON) put them in. Staff D stated when she completed the admission she could like on the goals and interventions on the form, but didn't know if that information pulled over to the care plan. During an interview on 12/11/25 at 1:50 PM, DON stated the facility recently hired someone to do specifically do the care plans. The DON stated the facility completed a 48 hour care plan meeting with the family. The DON showed the admission nursing evaluations for Resident #1 and Resident #7 and she confirmed the care plans not completed. The DON stated the facility were putting in a process for the care plans. The Facility Baseline Care Plans Policy dated March 2022 revealed a. A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 3. The Minimum Data Set (MDS) for Resident #18 dated 9/10/25 documented diagnoses of hypertension, urinary tract infection within the past 30 days, anxiety and depression, and restlessness and agitation. The resident's Brief Interview for Mental Status (BIMS) score of 4/15 indicated she was severely cognitively impaired. Resident #18 required partial to moderate assistance with eating, hygiene, and dressing as well as supervision or touch assistance with bed mobility, transfers, and walking. The resident's admission date was listed as 9/4/25. During observations of Resident #18 on 12/8/25 at 10:30 AM, 10:58 AM, 11:17 AM and 12/9/25 at 9:19 AM the resident was noted to walk independently from her room to the nurses station where she would find a staff to stand with, walk with, and hold their arms for attention and support. She regularly needed 1:1 attention from staff and could be difficult to redirect as evidenced by repeat reminders not to enter other resident rooms or pick up items that did not belong to her. She wore a wanderguard on her left ankle. A document titled Nursing Evaluation, signed 9/4/25, included 17 Care Plan (CP) sections. The box for 'Care Plan given to resident/responsible party' was not checked. None of the CP sections were completed. On 12/09/25 at 1:41 PM the Administrator indicated the facility would provide a baseline CP for the resident. The document provided was titled MDS Kardex Report for Harvest Acres Nursing and Rehab with an admission date of 9/4/25. The document did not include mental health needs, behaviors, goals, medications, restorative therapy, or needs related to the resident's recent urinary tract infection. It did not include a start or end date, document who completed it, or documentation that a copy had been offered/provided to the resident's representative.Resident #18's Care Plan (CP) with an admission date of 9/4/25 was not completed as a baseline CP. There were focus areas for trauma, behaviors, and adjustment to the facility with blank 'related to' sentences entered 9/4/25 that were not completed until 9/17/25. A focus area for chronic pain was added 9/8/25. On 9/11/25 psychotropic medications were added without a person centered reason, and elopement risk and incontinence care were added. On 9/17/25 focus areas for hypertension, anti-anxiety medication, history of drug use, dementia and risk for altered mood, and Activity of Daily Living (ADL) deficits were added. On 9/18/25 a focus area for hypertension was added. 4. The Minimum Data Set (MDS) for Resident #34 dated 11/5/25 documented diagnoses of wedge compression fracture of the fourth lumbar vertebra, hypertension, anxiety and depression, and chronic pain. The resident's Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. Resident #34 used a walker and a wheelchair, and needed partial to moderate assistance with hygiene, upper body dressing, sit to stand, bed transfers, and walking 10 feet. On 12/09/25 at 1:41 PM the Administrator indicated the facility would provide a baseline Care Plan (CP) for the resident. The document provided was titled MDS Kardex Report for Harvest Acres Nursing and Rehab with an admission date of 7/23/25. The document did not include mental health needs, goals, medications, therapy or restorative therapy, diet, or code status. It did not include a start or end date, document who completed it, or documentation that a copy had been offered/provided to the resident or the resident's representative. A document titled Nursing Evaluation, with sections signed 7/23/25 and 7/24/25, included 17 Care Plan sections. The box for 'Care Plan given to resident/responsible party' was not checked. Care plan sections for admission adjustment, skin integrity, bed mobility, cardiovascular care, genito urinary care, pain, and advance directives were not completed. Resident #34's Care Plan (CP) with an admission date of 7/23/25 was not completed as a baseline CP. On 7/23/25 focus areas for falls and performance deficits were entered. No fall interventions were added until 8/6/25. The diagnoses related to the performance deficits were added 10/20/25 and included fibromyalgia, weakness, and Chronic Obstructive Pulmonary Disease (COPD). On 7/24/25 entries for psychotropic medication, behavior problems, and adjustment to the facility were added without person centered indicators or interventions included. On 8/6/25 chronic pain, incontinence care, hypertension, altered respiratory status, and impaired skin integrity were added. During an interview with the Director of Nursing (DON) on 12/9/25 at 2:08 PM she confirmed she expected baseline care plans to be completed within 48 hours. During an interview with the Administrator on 12/10/25 at 2:58 PM the Administrator indicated she was aware of the incomplete baseline care plans and had spoken with the DON. She stated the facility had just hired a new staff person to make corrections to them and they were working on a better process.

Based on record review, staff interviews, the facility policy, and the Medicare Claims Processing Manual, the facility failed to provide resident ending skilled care with the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) Advanced Beneficiary Notice for one resident (Resident #37) and Notice of Medicare Non Coverage (NOMNC) documents for 3 of 3 residents reviewed for ABN (Resident #22, Resident #36, and Resident #37). The facility reported a census of 27 residents. Findings include: 1. The SNF Beneficiary Protection Notification Review Form revealed Resident #36 started Medicare Part A services on [DATE] and his last day covered of Part A services was on [DATE]. A document titled Notice of Medicare Non-Coverage (NOMNC) for the resident was signed by their representative on [DATE]. The document footnote was Form CMS 10123-NOMNC (approved [DATE]). 2. The SNF Beneficiary Protection Notification Review Form revealed Resident #22 started Medicare Part A services on [DATE] and his last day covered of Part A services was on [DATE]. A document titled Notice of Medicare Non-Coverage (NOMNC) for the resident was signed by the resident on [DATE]. The document footnote was Form CMS 10123-NOMNC (approved [DATE]). 3. The SNF Beneficiary Protection Notification Review Form revealed Resident #37 started Medicare Part A services on [DATE] and his last day covered of Part A services was on [DATE]. The form indicated the Form CMS-10055 was not provided to the resident due to accidentally used the wrong ABN form CMS-R-131. A document titled Notice of Medicare Non-Coverage (NOMNC) for the resident was signed by the resident on [DATE]. The document footnote was Form CMS 10123-NOMNC (approved [DATE]). Form CMS-10123 has a current footnote of Form CMS 10123-NOMNC, OMB approval 0938-0953, Exp. [DATE]. During an interview on [DATE] at 12:19 PM, the Social Worker confirmed she filled out the wrong form for Resident #37. The Social Worker stated she was not aware that the CMS form 10123 had expired and recently received training and the training gave her the forms she been using. During an interview on [DATE] at 2:36 PM, the Administrator stated she didn't know the forms were changed and they had already downloaded the new forms to use. CMS manual Medicare Claims Process Manual issued [DATE], Chapter 30, 50.5 B., documented ABN's were effective as of the OMB approval or expiration date given at the bottom of each notice and routine approval was for 3 year use. Notifiers were expected to exclusively use the current version of ABN's. Manual section 260.3.2 further documented providers must use the OMB-approved NOMNC (CMS-10123). The Facility Beneficiary Notice Policy (no date indicated) revealeda. The SNF ABN is issued when Part A services end and resident is staying in facility post Medicare stay. (The NOMNC Letter needs to be issued also).

Based on observation, clinical record review, interviews, and policy review the facility failed to develop a comprehensive care plan for 2 of 5 residents reviewed (Residents #18 and #34). The resident's care plans contained focus areas, goals, and interventions that did not include person centered information. These sections were not updated when the comprehensive care plan was due at 14 days or with additional revisions. The facility reported a census of 27 residents.FIndings include: 1. The Minimum Data Set (MDS) for Resident #18 dated 9/10/25 documented diagnoses of hypertension, urinary tract infection within the past 30 days, anxiety and depression, and restlessness and agitation. The resident's Brief Interview for Mental Status (BIMS) score of 4/15 indicated she was severely cognitively impaired. Resident #18 required partial to moderate assistance with eating, hygiene, and dressing as well as supervision or touch assistance with bed mobility, transfers, and walking. The resident's admission date was listed as 9/4/25. During observations of Resident #18 on 12/8/25 at 10:30 AM, 10:58 AM, 11:17 AM and 12/9/25 at 9:19 AM the resident was noted to walk independently from her room to the nurses station where she would find a staff to stand with, walk with, and hold their arms for attention and support. She regularly needed 1:1 attention from staff and could be difficult to redirect as evidenced by repeat reminders not to enter other resident rooms or pick up items that did not belong to her. She wore a wander guard on her left ankle.Resident #18's Care Plan (CP) with an admission date of 9/4/25 included the following incomplete focus areas: [NAME] has hypertension related to (r/t)Date Initiated: 09/18/2025, Revision on: 12/09/2025 Adjustment to facility r/tDate Initiated: 12/05/2025, Created on: 09/04/2025, Revision on: 12/05/2025 Interventions did not include adjustment related triggers, behaviors [NAME] has a history of trauma related to life experience (specify trauma and triggering events)Date Initiated: 12/05/2025, Created on: 09/04/2025, Revision on: 12/09/2025 Interventions did not include triggering events [NAME] has a behavior problem r/tDate Initiated: 12/05/2025, Created on: 09/04/2025, Revision on: 12/09/2025 Interventions did not identify concerning behaviors [NAME] uses psychotropic medications r/tDate Initiated: 12/05/2025, Created on: 09/11/2025, Revision on: 12/09/2025 Intervention directed staff to observe for/record occurrence of target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Date Initiated: 09/11/2025, Created on: 09/11/2025, Revision on: 12/05/2025 The intervention was not specific to the resident. 2. The Minimum Data Set (MDS) for Resident #34 dated 11/5/25 documented diagnoses of wedge compression fracture of the fourth lumbar vertebra, hypertension, anxiety and depression, and chronic pain. The resident's Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. Resident #34 used a walker and a wheelchair, and needed partial to moderate assistance with hygiene, upper body dressing, sit to stand, bed transfers, and walking 10 feet.Resident #34's Care Plan (CP) with an admission date of 7/23/25 included the following incomplete focus areas: The resident uses psychotropic medications r/tDate Initiated: 10/29/2025, Created on: 07/24/2025, Revision on: 10/29/2025 An intervention directed staff to observe for/record occurrence of target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Date Initiated: 07/24/2025, Created on: 07/24/2025, Revision on: 10/29/2025 The intervention was not specific to the resident. The resident has a behavior problem r/tDate Initiated: 10/29/2025, Created on: 07/24/2025, Revision on: 10/29/2025 A revision 9/17/25 indicated the behavior was due to non-compliance with transfer status. That was removed with the revision on 10/29/25. Adjustment to facility r/tDate Initiated: 10/29/2025, Created on: 07/24/2025, Revision on: 10/29/2025 The resident has hypertension r/tDate Initiated: 08/06/2025, Created on: 08/06/2025 The resident has altered respiratory status Difficulty Breathing r/tDate Initiated: 08/06/2025, Created on: 08/06/2025 The resident has potential/actual impairment to skin integrity r/tDate Initiated: 08/06/2025, Created on: 08/06/2025 An intervention indicated the resident should have treatment as ordered by the medical doctor. No resident specific skin impairments or treatments were documented.Anxiety and depression were not addressed in the care planDuring an interview with the Director of Nursing (DON) on 12/9/25 at 2:08 PM she confirmed she expected care plans to be complete and person centered. She thought staff were taking good care of the residents and acknowledged it was important to have current information in the care plan.During an interview with the Administrator on 12/10/25 at 2:58 PM she stated she had spoken with the DON regarding the care plan information not being complete. She reported that the facility had just hired a new staff person to be responsible for corrections to them and they were working on a better process.A policy titled Care Plans, Comprehensive Person-Centered revised March 2022 documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. It was developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status) and no more than 21 days after admission. It included measurable objectives and time frames, described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including specialized PASRR services and the professional services for each element of care, resident's stated goals upon admission and desired outcomes, was built on resident strengths, and reflected currently recognized standards of practice.

Based on record review, staff interviews, and the facility policy, the facility failed to notify the provider for blood glucose levels over 400 mg/dl (milligrams per deciliter) for 1 of 3 residents reviewed for assessment/intervention (Resident #1). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated that cognition severely impaired. The MDS revealed diagnosis for Type II diabetes mellitus and the resident received insulin 4 out of 7 days. The Care plan revealed a focus area dated 11/17/25 for potential for hypo/hyperglycemia related to diabetes mellitus and resident had a Dexcom. The interventions dated 11/17/25 revealed accuchecks as ordered, and call MD (Medical Director) for accuchecks greater than 400 and less than 70.The Electronic Medical Record (EMR) revealed the following Physician Orders: a. dated 11/10/25- Blood Glucose Monitoring- four times a day for diabetes. Call MD if below 70 or above 400.The Blood Sugar Summary revealed the following dates/times Resident #1 blood sugar over 400 mg/dl and the facility lacked documentation the provider notified:a. 11/12/25 at 5:56 PM- 584 mg/dlb. 11/17/25 at 8:25 AM- 449 mg/dlc. 11/18/25 at 8:56 AM- 421 mg/dld. 11/18/25 at 12:37 PM- 411 mg/dle. 11/20/25 at 8:20 AM- 414 mg/dlf. 11/20/25 at 2:40 PM- 447 mg/dlThe Medication Administration Note dated 11/12/25 at 9:19 PM revealed Insulin Glargine Solution 100 UNIT/ML (units/milliliters)- Inject 8 unit subcutaneously one time a day for diabetes: refused x 3 attemptsThe Nursing Note dated 11/13/25 at 3:46 AM, revealed resident BS (blood sugar) was checked at 1800 by previous shift which was 584. Previous shift attempted to give the resident her insulin and the resident refused saying that she was trying to give her heroin. On my current shift I have attempted to recheck the patients blood sugar and give her insulin 3 times, the resident is still refusing. I contacted metro and the doctor asked if she was symptomatic which she is not, and stated to try and get another BS reading on the morning shift, and to call her if the resident becomes symptomatic. Will continue to monitor the resident for symptoms and have the morning shift attempt to check her again. resident is resting with her eyes closed in the common area.During an observation on 12/8/25 at 12:33 PM, Resident #7 ambulated in the hallway with her wheeled walker independently. During an interview on 12/11/25 at 9:38 AM, Staff D, Licensed Practical Nurse (LPN) stated it was standard to notify the provider for blood sugars under 70 or over 400 mg/dl. Staff D stated the nurse would call the provider to see how many units of insulin to give if over 400 and put in a progress note. Staff D queried if she ever contacted the provider for Resident #1 blood glucose checks and Staff D stated she didn't think she ever called for Resident #1 blood sugars. During an interview on 12/11/25 at 2:02 PM, the Director of Nursing (DON) queried on Resident #1 blood glucose over 400 mg/dl and no documentation indicated in the chart and the DON stated she knew the nurses called the provider and the DON guessed the nurses didn't chart it. The DON stated more education was needed for the nurses. The DON stated when blood glucose levels were over 450 mg/dl, the nurses needed to notify the provider. The Facility Change in a Resident's Condition or Status dated February 2021 revealed: a. The nurse will notify the resident's attending physician or physician on call when there has been a specific instruction to notify the physician of changes in the resident's condition.

Based on observation, clinical record review, interviews, and policy review the facility failed to maintain a medication administration error rate under 5% related to unprofessional standards and principles during the survey process. Of 31 medications observed 3 were not administered according to provider orders or medication inserts, and a missing medicated patch that was to be removed from a resident was not located. (Residents #1, 7,12, and 13) The facility reported a census of 27 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #1 dated 11/10/25 documented diagnoses of pneumonia, thyroid disorder, and schizophrenia. The Brief Interview for Mental Status (BIMS) documented a score of 5/15 which indicated severely impaired cognition.At 7:47 AM on 12/9/24 Resident #1 was observed seated in a recliner in the common area after eating breakfast.During a medication administration observation on 12/9/25 at 8:02 AM Staff B, Licensed Practical Nurse (LPN) administered Levothyroxine Sodium Oral Tablet 88 mcg to Resident #1 with 11 other medications. The LPN stated she knew it was late but it would be okay.The progress notes do not indicate the provider was notified of the late medication.The Medication Administration Record (MAR) indicated that as of 11/14/25 Levothyroxine Sodium Oral Tablet 88 mcg was ordered by mouth one time a day related to hypothyroidism unspecified at 6:00 AM.A document provided by the facility titled [NAME]-T tablets for oral use, revised December 2017, section Indications and Usage revealed the medication should be administered once daily, preferably on an empty stomach one half to one hour before breakfast. and at least 4 hours before or after drugs that are known to interfere with absorption. The need for dose adjustments should be evaluated when regularly administering within one hour of foods that may affect absorption.During an interview with the Director of Nursing (DON) on 12/9/25 at 2:08 PM she stated that some of the nurses have been confused with the medication administration times. They were changing from scheduled windows of administration to scheduled times. They were working on it because they knew administration times had been an issue.2. The Minimum Data Set (MDS) for Resident #7 dated 12/1/25 documented diagnoses of non-Alzheimer's dementia and delirium due to known physiological condition. MDS Section C documented a Brief Interview for Mental Status (BIMS) of 3/15 indicating severe cognitive impairment.During a medication administration observation on 12/8/25 at 3:59 PM the Director of Nursing (DON) came in to the medication room to ask Staff A, Registered Nurse (RN) if Resident #7 had an as needed (PRN) medication for anxiety. Staff A reviewed the resident's clinical record and determined he did not. The RN administered PRN melatonin and the resident's evening medications. Neither the DON nor Staff A contacted the resident's provider about the resident's increased anxiety or behaviors.The Medication Administration Record (MAR) documented that beginning 11/29/25 Resident #7 could have a PRN melatonin oral tablet, 5 mg, by mouth as needed for trouble sleeping at bedtime. On 12/8/25 it was administered at 4:01 PM by Staff A. Staff A stated that giving the melatonin before the ordered bedtime administration time was 'close enough' because the resident was 'probably tired' and needed to sleep. The resident was observed taking the medication. He did not go to bed, he went by wheelchair out of his room for dinner.A Progress Note dated 12/8/25 at 4:01 PM titled eMar Medication Administration Note documented that the melatonin oral tablet 5 mg, give 5 mg by mouth as needed for trouble sleeping at bedtime, was administered for agitation/needs sleep. The progress notes did not include follow up with the provider or a responsible party regarding behavior or a PRN medication for agitation or anxiety.During an interview with the DON on 12/9/25 at 2:08 PM the DON recognized the melatonin was given too early and that it was not prescribed for agitation or anxiety. She did not think the nurse called the provider to follow up.A policy titled Liberalized Medication Pass documented 6 rights when passing medication: right drug, right dose, right route, right resident, right time, and right documentation. The guidelines for administration included HS (night time between 7:00 PM and 10:00 PM). It also included bedtime if different than above times.3. The Minimum Data Set (MDS) for Resident #12 dated 11/5/25 documented diagnoses of diabetes mellitus, schizophrenia, and muscle weakness and other lack of coordination. MDS Section C documented a Brief Interview for Mental Status (BIMS) of 13/15 indicating intact cognition.During medication administration observation on 12/9/25 at 11:09 AM Staff B, Licensed Practical Nurse (LPN) took insulin to Resident #12's room. She primed the 3 ML insulin lispro 100 Unit/ml pen injector with 2 units. After cleaning the resident's left bicep, she injected 23 units of insulin per doctor's orders. She held the pen for a count of one one thousand, Two one thousand and removed the needle.On 12/9/25 at 11:11 AM, when asked how long she was supposed to hold the pen in, Staff B did not give a number. She stated she knew it (the insulin) all got in because otherwise it would be leaking out of the injection site. She was not able to explain what the directions required.During an interview with the DON on 12/9/25 at 2:08 PM the DON she didn't think two seconds was probably long enough and would have to look at the instructions. She agreed to provide them for follow up.On 12/10/2025 at 7:54 AM the facility provided directions for the insulin pen titled Instructions For Use, revised July 2023. The document directed the user of the insulin pen to insert the needle into the skin, push the dose knob all the way in, and continue to hold the dose knob in and slowly count to 5 before removing the needle.A policy titled Nursing Care of the Older Adult with Diabetes Mellitus revised November 2020 documented staff would attend a diabetes in-service education and demonstrate competency before caring for a resident with diabetes. For further diabetes education and guidelines, staff were directed to refer to the provider orders and instructions as well as the American Diabetes Association, Standards of Medical Care in Diabetes.4. The Minimum Data Set (MDS) for Resident #13 documented diagnoses of diabetes mellitus, non-Alzheimer's dementia with mood disturbance, and depression and psychotic disorder. The Brief Interview for Mental Status (BIMS) score of 4/15 indicated severe cognitive impairment.During a medication observation on 12/9/25 at 7:49 AM Resident #13 was seated in a chair outside of the dining room. Staff B administered her medication, house supplement, and a scopolamine patch. She moved the resident's hair away from her right ear and placed the patch behind it. She did not initially look for an old patch to remove and did not wash her hands after touching the resident's skin, hair, and the patch.The resident's MAR for December 2025 documented a scopolamine patch was put on the resident on 12/6/25 during the day shift.At 8:52 on 12/9/25, when asked if there was a patch to remove from behind Resident #13's left ear, Staff B checked. There was not a patch there. Staff B shrugged. When asked why there was not a patch to remove, Staff B stated she didn't know. She said sometimes the resident picked them off, sometimes they fell off, and sometimes they came off in the shower. When asked who checks on that, Staff B shrugged again and stated she wasn't at the facility that often and didn't know. Staff B did not check the progress notes, ask other staff, or call the provider to follow up about the missing patch. Resident #13's progress notes do not include documentation regarding loss or removal of the patch.During an interview with the Director of Nursing on 12/9/25 at 2:08 PM she stated nurses were trained in facility expectations for medication administration when they started, and nurses were not allowed on their own until they demonstrated they could be independent. She would expect the nurse to follow up regarding the missing patch.

Based on observation, clinical record review, interviews, and policy review the facility failed to administer medications in a sanitary manner during medication administration. A nurse was observed putting pills in her hand before putting them in medication cups, applying a medicated patch without washing her hands afterward, and touching personal items between medication passes without washing her hands. The facility reported a census of 27 residents.Findings include:During a medication administration observation on 12/9/25 at 7:35 AM Staff B, Licensed Practical Nurse (LPN) unlocked the medication cart to administer medication. The Electronic Health Record (EHR) showed the resident was scheduled for a controlled medication located in a second locked area of the cart. Staff B took out the resident's medication card for Trazodone, matched the card to the EHR, and popped the pill into her left hand, and placed it in the pill cup. After administering the medication she washed her hands and moved on to another resident. During a medication administration observation on 12/9/25 at 7:49 AM Staff B unlocked the medication cart to administer medication to another resident. She reviewed the EHR and determined the resident was supposed to have Eliquis. She was unable to find the resident's medication card and touched the computer mouse, 3 sections of the medication cart, 2 cabinet doors, two rows of resident medication cards, the marker to date the medication patch, a second medication cart, and the door of the medication room without washing her hands. One of the items she prepared was a medicated Scopolamine transdermal patch that was administered behind the resident's right ear. The LPN touched the resident's ear, hair, and right shoulder then looked for the old patch behind the left ear before she moved away. The exterior of the package indicated the nurse should wash her hands after applying the patch. When the nurse was asked what the Scopolamine was for, she stated it helped dry her out and prevented nausea. She thought the resident had improved. She held the package that included the directions to wash her hands, and looked at it when she opened it. When she returned to the medication room she did not wash or sanitize her hands.The next medication administration observation was 12/9/25 at 8:02 AM. A resident in the common area was asking for her medication. One of the medications was in the locked controlled substance area of the cart. The LPN took out the resident's Lorazepam, matched it to the EHR, pushed it into her left hand, and then placed it in the medication cup. After putting the rest of the resident's medication in a cup, she took it out to the resident. The resident had been taken to the shower room. Staff B knocked on the door, entered the shower room with the medication cup and drink, and administered the medication in the shower room. When she returned she picked up her bag, took out a personal water bottle, drank from it, touched her bag again to put it away and started preparing medication for the next resident. She did not wash or sanitize her hands.Staff B prepared medication for another resident before she next washed her hands. She administered 17 medications between hand washes and did not use hand sanitizer during the observation. When asked on 12/9/25 at 8:16 AM about training for nurses in the facility Staff B confirmed that she had training for infection control. She thought she had washed her hands but confirmed that sometimes she forgot.During an interview with the Director of Nursing on 12/9/25 at 2:08 PM she stated she expected nurses to wash their hands between residents when administering medication. She stated nurses were trained when they started, they went over medication administration expectations, and nurses were not allowed on their own until they demonstrated they could be independent.A policy titled Handwashing/Hand Hygiene revised October 2023 indicated the facility considered hand hygiene the primary means to prevent the spread of healthcare associated infections. All personnel were trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections and were expected to adhere to hand hygiene policies and practices. Hand hygiene was indicated immediately before touching a resident, after contact with body fluids or contaminated surfaces, after touching a resident, after touching a resident's environment, and immediately after glove removal.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse for two of twelve residents reviewed for abuse (Resident #12, Resident #19). Resident #12, was a severely cognitively impaired resident with a previous history of unsolicited sexual touching. On 10/26/24, Resident #12, was touched on the breast underneath her clothing by Resident #19. On an unknown date, Resident #19 touched Resident #12 on the buttock. On an unknown date, staff reported Resident #19 grabbed/groped Resident #12. Resident #12's family explicitly instructed the facility staff that they did not consent to Resident #12 engaging in sexual contact with another resident. This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of residents. The facility failed to protect the resident's right to be free from resident to resident physical abuse for 5 of 15 residents reviewed for abuse(Residents #11, #12, #13, #21, #77). Resident #22 hit Resident #77, grabbed and scratched Resident #12, slapped Resident #11, slapped and pinched Resident #13, and grabbed the arm of Resident #2. The IJ was determined on 11/14/24 at 1:57 PM. The IJ began on 10/26/24. The IJ immediacy was removed on 11/18/24 at 12:27 PM. The Facility Staff removed the Immediate Jeopardy on 11/18/24 through the following actions: a. Care Plan revision for Resident #12 and Resident #19. b. All staff education about abuse. c. An ad-hoc Quality Assurance Performance Improvement (QAPI) meeting completed 11/14/24. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: 1. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #12 dated 9/13/24 revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident cognitive patterns were documented as inattention which fluctuated and had behaviors described as having delusions. Review of Medical Diagnoses for Resident #12 included Wernicke's encephalopathy, dementia with psychotic disorder, dementia with mood disturbance, restlessness and agitation, and delusional disorders. Review of Resident #12's Care Plan dated 7/5/23 revealed the following: Trauma Informed Care: [Resident #12] is at risk for alterations in my psycho-social well being related to: Allegation of abuse. History of being recipient of unsolicited sexual touching. Review of Resident #12's Care Plan dated 7/7/24 revealed, [Resident #12] has a Mutual friendship with a resident of the opposite sex. Interventions per the Care Plan included the following: a. (Created 7/7/24, revised 9/10/24): Do not shame or embarrass [Resident #12] for her friendship. b. (Created 7/7/24, revised 9/10/24): If [Resident #12's] friendship escalates beyond hugging/hand holding/sitting together, please redirect in a calm manner and we will re-assess the plan with staff, family and medical advice. c. (Created 7/7/24, revised 9/10/24): Mild affection (hugging/hand holding/sitting together) is acceptable for both families. d. (Created 10/28/24): Per POA: hand holding, sitting together, resident sitting on other male resident's lap, and a gentle kiss on the lips is within her scope for approval of behavior. Please separate residents if behaviors become more sexual in nature such as touching of one another's private areas e. (Created 7/7/24, revised 9/10/24): Report interactions as needed to Charge Nurse. f. (Created 7/7/24, revised 9/10/24): This friendship is acceptable if [Resident #12] is safe and happy. Review of Progress Notes for Resident #12 revealed the following: The Nursing Note dated 7/4/24 at 6:10 PM revealed, [Name Redacted] POA (Power of Attorney) aware of this resident engaging in activities of hand holding, hugging et (and) sitting together with another male resd (resident), POA consents to above activity continuing in public settings, not behind closed doors. Review of the Care Conference note dated 9/3/24 at 3:10 PM revealed, in part, [Resident #12] is declining in mental status. She is becoming increasingly confused and aggressive with cares. [Resident #12] is no longer able to take her medications whole, as she pockets them, or becomes confused by what to do with them and puts them in cups, bowls, or anywhere that she no longer can see them .[Resident #12] is increasingly confused. She is sleeping more and spending a significant amount of time in her room. She no longer sits in the common area or with the cat. The Nursing Note dated 10/26/24 at 5:56 PM revealed, CNA (Certified Nursing Assistant) reports to this nurse that at around 1555 (3:55 PM) a male resd reached up this resd (resident) shirt et groped her lt (left) breast while she was standing next to him. These 2 resd are care planned to have a friendly relationship that involve holding hands et hugging. This nurse witnessed female resd approach male resd seated in lobby, they proceeded to hold hands before this nurse had left to attend another resd. CNA separated the 2 resd. CNA reports that resd was asking where male resd went? CNA redirected et kept them apart. When female resd asked by this nurse if the male resd had touched her breast she states No. Administrator made aware. Called x 2 numbers for POA (Power of Attorney) with no answer et (and) left message. Review of a Nursing Note dated 10/28/24 at 8:04 AM revealed, Spoke with POA [name redacted] regarding potential incident from 10/26 where male friend may have touched resident's breasts. [POA name redacted] verbalizes that hand holding, sitting together, resident sitting on other male resident's lap, and a gentle kiss on the lips is within her scope for approval of behavior. She states to please separate residents if behaviors become more sexual in nature such as touching of one another's private areas. Care plan updated. On 11/13/24 at 12:06 PM, Resident #12 observed in her room in bed. On 11/18/24 at 2:10 PM, Resident #12 observed standing up by the nurses station near the lobby area of the facility. 2. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 10/9/24 revealed Resident #19 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of diagnoses for Resident #19 included schizophrenia and dementia with anxiety. Review of Resident #19's Care Plan dated 7/4/24 and revised 7/5/24 revealed, [Resident #19] has a Mutual friendship with a resident of the opposite sex. Interventions per Resident #19's Care Plan included the following: a. (Initiated 7/5/24, Revised 9/10/24): Do not shame or embarrass [Resident #19] regarding this relationship. b. (Initiated 7/5/24, Revised 9/10/24): If [Resident #19's] friendship escalates beyond hugging/hand holding/sitting together, please redirect in a calm manner and we will reassess the plan with staff, family and medical advice. c. (Initiated 7/5/24, Revised 9/10/24): Mild affection (hugging/hand holding/sitting together) is acceptable for both families. d. (Initiated 10/28/24): POA (Power of Attorney) [Name Redacted] verbalizes that hand holding, sitting together, female resident sitting this resident's lap, and a gentle kiss on the lips is within his scope for approval of behavior. He states to please separate residents if behaviors become more sexual in nature such as touching of one another's private areas. [POA name redacted] also requests to be made aware if resident's behaviors with female friend appear to become inappropriate and not reciprocated. e. (Initiated 7/5/24, Revised 9/10/24): Report interactions as needed to Charge Nurse. f. (Initiated 7/5/24, Revised 9/10/24): This friendship is acceptable as long as [Resident #19] is safe and happy Review of Progress Notes for Resident #19 revealed: The Communication-with Family/NOK/POA dated 7/4/24 at 6:07 PM revealed, [Name Redacted] POA aware of this resident engaging in activities of holding hands, hugging et sitting together with another female resd, POA consents to above activity continuing in public settings, not behind closed doors. The Nursing Note dated 10/26/24 at 5:43 PM revealed, CNA reports to this nurse that at around 1555 (3:55 pm) this resident (resd) reached up a female resd shirt and groped her breast while she was standing next to him. These 2 resd are care planned to have a friendly relationship that involve holding hands et hugging. This nurse witnessed female resd approach male resd seated in lobby, they proceeded to hold hands before this nurse had left to attend another resd. No other resd in lobby witnessed event when asked. [Resident #19] was confronted and asked if anything happened when female resd approached him? resd states No. when asked if they were holding hands? He states yeah we were holding hands. Resd was asked if he touched female resd anywhere else? states her back side a little. Resd asked if he reached up female resd shirt? States no. Administrator made aware. POA [POA Name Redacted] made aware. The Nursing Note dated 10/28/24 at 8:12 AM revealed, Spoke with POA [Name Redacted] regarding potential incident from 10/26 where resident may have touched female friend resident's breasts. [Name Redacted] verbalizes that hand holding, sitting together, female resident sitting this resident's lap, and a gentle kiss on the lips is within his scope for approval of behavior. He states to please separate residents if behaviors become more sexual in nature such as touching of one another's private areas. [Name Redacted] also requests to be made aware if resident's behaviors with female friend appear to become inappropriate and not reciprocated. Care plan updated. The Behavior Note dated 11/1/24 at 2:22 PM revealed, Resd inappropriately touched activity director, when confronted that it is not appropriate to touch staff like that, resd becomes upset, made rude comment regarding situation to activity assistant ER ignored activity director. On 11/6/24 at 9:23 AM, Incident Reports for Resident #19 for the last six months requested via email to the facility's Administrator and Director of Nursing (DON). The Incident Report received did not address any interactions between Resident #12 and Resident #19. On 11/6/24 at 1:12 PM, Staff B, Licensed Practical Nurse (LPN) queried if had any residents who were boyfriend and girlfriend. Staff B responded they said that Resident #12 and Resident #19 were allowed to touch, kiss, and said I'm not really sure. Per Staff B, she had not seen them touch each other or speak word to each other. When queried how to know what was appropriate, Staff B responded she believed the POA said ok to do those things for both of those two. On 11/12/24 at 11:47 AM during an interview with Staff E, Registered Nurse (RN), Staff E explained Resident #12 and Resident #19 were not a couple, and were friends. Per Staff E, up until recently the residents had no notice of each other. Resident #19 started talking to Resident #12, and Resident #12 talking, not daily. Staff E explained they would hold hands, nothing had happened, and Staff E didn't think Resident #12 would let it as Resident #12 was very [NAME] and proper. Per Staff E, one day she was working second or day shift, and Resident #19 went down to Resident #12's room. Staff E responded to situation, and Resident 19 exited. When queried if ever heard of touching over or under clothes, Staff E responded no. On 11/12/24 at 2:27 PM, Staff D, Licensed Practical Nurse (LPN) explained the following about Resident #12 and Resident #19: Per Staff D, she (Staff D) was the one that brought to the DON's attention, ok with family, because kept on doing stuff holding hands, hugging. Per Staff D, had gotten approval from family that ok for friendly relationship, peck on the lips, sit with each other, hold hands, and nothing behind closed doors. Staff D explained Resident #12 would seek Resident #19 out, and Resident #19 calmed Resident #12 down. Staff D explained an aide said he saw Resident #19 reach up Resident #12's shirt. Staff D further explained the aide did not want them (residents) to be together because the aide thought Resident #12 could not make decisions for herself. The aide was identified as Staff H. When queried if Resident #12 had ever had a negative reaction, Staff D responded no. Per Staff D, she had never seen Resident #19 pursue Resident #12, and when she saw, Resident#12 went to Resident #19. On 11/13/24 at 12:22 PM, Staff H, Certified Nursing Assistant (CNA) explained the following about Resident #12 and Resident #19: Staff H explained they had seen interactions between Resident #12 and Resident #19 on two or three different times, and Resident #19 had inappropriately touched Resident #12 in some way. Per Staff H, Resident #12 stood there not doing anything, Resident #12 would bring herself to Resident #19, and needed to separate constantly and redirect to keep them away from each other. Staff H further explained they thought only one time Resident #19 grabbed Resident #12's breast, and they thought occurred the weekend of October 26/27. Per Staff H, another time Resident #19 grabbed Resident #12's butt. A third time, Staff H did not remember if Resident #19 grabbed or groped, Resident #19 did touch Resident #12 and Staff H did not remember how. Staff H provided the following details about when Resident #12's incident with breast touching: Staff H explained the grabbing of Resident #12's breast was under the clothes with full arm up When queried how Staff H knew what interactions were appropriate, Staff H explained they did not need a degree to see inappropriate anywhere. Staff H explained don't need to be grabbed/groped. Staff H explained they reported all of them (incidents) to staff at facility. When queried which staff Staff H talked to, Staff H responded the Director of Nursing (DON) one time, then talked to the floor nurses every time. Staff H further explained Resident #12 would just stand there and let Resident #19 do everything. When queried if Resident #12 said anything when it was happening, Staff H responded no. On 11/13/24 at 1:07 PM, Staff G, RN queried about any interactions between Resident #12 and Resident #19, responded yes, explained the DON said was ok, and Staff G thought inappropriate. Staff G explained Resident #12 sat on Resident #19's lap right in the middle of the day hall with all the residents there. Staff G explained she (Staff G) thought probably not good idea related to behaviors, and if approved by family, ok she supposed. Staff G explained the DON said had it approved by families could see each other. Staff G explained Resident #12 was not really with it. Per Staff G, it wasn't like sitting beside him (Resident #19) holding hands, was sitting on his (Resident #19's) lap. Staff G further explained she had told CNAs (Certified Nursing Assistants) why don't let divert these two, and got their attention somewhere else, which was easy to do. On 11/14/24 at 1:56 PM, the Administrator responded Resident #19 and Resident #12 were friends, the Administrator explained had heard holding hands came to light. The Administrator acknowledged not aware of touching of the resident's breast and butt. Per the Administrator, if unaware of touching of the resident's breast, then could not report. On 11/18/24 at 9:03 AM, Staff I, CNA queried about how Resident #12 and Resident #19 interacted. Staff I explained, part, Resident #12 was very sweet, and Staff I explained Resident #19 would take advantage of someone who's medicated. When queried what Staff I meant by take advantage, Staff I responded, like touch, explained I'm sitting beside you where would my hands go, and further explained I'm your friend can we take a walk. Staff I explained she got that feeling, and didn't think Resident #19 would do anything sexual but touching. When queried about touching between Resident #12 and Resident #19, Staff I responded holding hands walking down the hall, further explained she had seen them walk to breakfast, and Resident #19 would walk Resident #12 into the breakfast room. When queried about Resident #12's cognition, Staff I responded 50/50, and explained the resident had insomnia and was sometimes up at night. Per Staff I, Resident #12 wondered where her parents were, and would say here for memory not so good, then would flash back, and thought in [Another State Redacted] at times. On 11/18/24 at 10:39 AM, Staff J, CNA queried about Resident #12 and Resident #19. Per Staff J, Resident #19 a very independent guy and did not like getting too much in his space. Staff J described Resident #19's interactions with Resident #12 as normal, and Staff J further explained she felt like Resident #12 got confused when she (Resident #12) looked at Resident #19. Per Staff J, there were times when Resident #12 looked and asked to sit on Resident #19's lap, and Resident #19 said no. Staff J denied seeing any physical interactions between the residents, and said no, he's (Resident #19's) really with it. Per Staff J, Resident #19 had respect for Resident #12 and other residents. When queried about Resident #12's cognition, Staff J explained Resident #12 was anxious, loved to pace up and down the halls, and loved to sleep. Per Staff J, around the afternoon Resident #12 would start pacing back and forth, would get really anxious, and did not stop walking. Staff J explained Resident #12 had a hard time breathing because resident walked back and forth, which was usually a 4 hour thing or all night thing, and during the day resident slept all day. Staff J explained this was normal for the resident. On 11/19/24 at 10:43 AM, the Activities Director/Social Worker (SW) queried regarding consent process, and queried regarding Resident #12 and Resident #19. The Activities Director/SW explained she came to work one day and was told about consent (for Resident #12), the Activities Director/SW did not actually get a verbal from Resident #12's Power of Attorney (POA), and the Activities Director/SW was told POA was called and consent obtained to hold hands, talk, to sit on his lap, nothing else. The Activities Director/SW explained this was communicated via the facility's Director of Nursing (DON). When queried about a documented assessment for Resident #12 regarding consent to sexual activity, the Activity Director/SW explained she did a recent BIMS, resident scored a 6, and other than that no. When queried about consent regarding Resident #19, the Activities Director/SW explained it was all told to her (Activities Director/SW) on that same day. When queried about the facility's process for obtaining consent, the Activities Director/SW responded she was told as long as no touching of private areas it was ok, and it was residents rights. Per the Activities Director/SW, she felt had rights to hold hands, and nothing more than that. When queried if any staff had come to her with concerns, the Activities Director/SW denied, explained she even witnessed them talking to each other, and other than that nothing sexual going on. Per the Activities Director/SW, there was an allegation that transpired that the DON mentioned when in morning meeting, which was when the DON told Activities Director/SW she had gotten consent from Resident #12's POA and had talked to Resident #19 about not doing anything inappropriate. When queried what the allegation entailed, the Activities Director/SW explained was about him putting his hand in her shirt. The Activities Director/SW explained there was an incident a couple weeks ago that Resident #19 did to the Activities Director/SW which she documented and talked to Resident#19 that inappropriate. The Activities Director/SW explained Resident #19 had grabbed the Activities Director/SW's butt. On 11/19/24 at 2:43 PM when queried if there was a process of whether or not resident able to give consent on the resident level, the facility's Administrator shook her head. Per the Administrator, went by the BIMS score, and the POA and see what consent they give. The Administrator further explained a situation where maybe the POA would say resident in their own mind and could make their own decisions, and the POA may be able to make consent for the resident to make their own decisions. Review of the Facility Policy titled Abuse Policy, undated, revealed the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .Sexual abuse is defined as non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion or sexual assault. 35434 On 11/4/24 at 11:26 a.m., Resident #19 sat in a chair in the main dining room and ate lunch. The State Agency(SA) made multiple attempts throughout the survey to speak with him with no success. 3. The Minimum Data Set(MDS) assessment tool, dated 6/21/24, listed diagnoses for Resident #22 which included diabetes, arthritis, and hip fracture. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 1 out of 15, indicating severely impaired cognition. The MDS stated the resident had the following: a. physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) which occurred 1-3 days out of the 7 day review period. b. verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which occurred 4-6 days out of the 7 day review period. c. other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1-3 days out of the 7 day review period. A 6/21/24 Care Plan entry directed staff to intervene as necessary to protect the rights and safety of the other residents, divert attention, remove from the situation/location if needed, and approach/speak in a calm manner. An 8/22/24 Care Plan entry directed staff to redirect the resident when she became notably agitated and to monitor her when she was around others. An 8/26/24 Care Plan intervention directed staff to monitor the resident when she was in the hallways to ensure safe interactions with other residents. The entry directed staff to remove her from other residents and intervene when she headed toward other residents. An 8/28/24 Care Plan entry stated the physician made medication changes as an intervention to behaviors and resident to resident interactions. A 9/30/24 Care Plan entry directed staff to place the resident in an area where not within an arm's length of other residents. A Care Plan entry, revised 10/21/24, stated the resident had episodes of behaviors/potential for behaviors as evidenced by combativeness, negative verbalizations, name calling, screaming out, throwing things at staff, cursing at staff and other residents, stabbing the dining table with a fork, scratching staff, cussing at staff and other residents, flipping staff off with middle finger, yelling, as well as other aggressive behaviors. The resident had the following incidents: On 8/22/24, the resident hit another resident. On 8/26/24, the resident grabbed and scratched another resident. On 9/6/24, the resident slapped another resident. On 9/30/24, the resident slapped and pinched another resident while she called them names. On 10/20/24, the resident grabbed the arm of another resident. a. Resident #22 and Resident #77 The MDS assessment tool, dated 7/10/24, listed diagnoses for Resident #77 which included diabetes, non-Alzheimer's dementia, and chronic pain. The MDS listed his BIMS score as 0 out of 15, indicating severely impaired cognition. An 8/22/24 Resident to Resident Altercation report stated the resident approached another resident who sat in the lobby area watching TV and hit him in the head. An 8/22/24 Nursing Note stated Resident #77 sat in the TV room and Resident #22 walked over to him, began talking, and hit him on the head several times. The CNA intervened and took Resident #22 to her room to lie down. b. Resident #22 and Resident #12 The MDS assessment tool, dated 6/13/24, listed diagnosis for Resident #12 which included arthritis, Alzheimer's, and non-Alzheimer's dementia. The MDS listed the resident's BIMS score as 5 out of 15, indicating severely impaired cognition. An 8/26/24 Resident to Resident Altercation report stated the Resident #22 had a hold of another resident's bilateral(referring to both sides) arms and scratched the resident. An 8/26/24 Progress Note stated another resident grabbed and scratched Resident #12's arms. c. Resident #22 and Resident #11 The MDS assessment tool, dated 8/28/24, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, anxiety, and psychotic disorder. The MDS listed a BIMS score of 0 out of 15, indicating severely impaired cognition. A 9/6/24 Resident to Resident Altercation report stated a female resident told Resident #22 to shut up and Resident #22 slapped the female resident across the face to the left cheek. A 9/6/24 Nursing Note stated Resident #11 told another resident to shut up and the other resident slapped Resident #11. Staff separated the residents. d. Resident #22 and Resident #13 The MDS assessment tool, dated 8/21/24, listed diagnoses for Resident #13 which included non-Alzheimer's dementia, depression, and psychotic disorder. The MDS listed the resident's BIMS score as 4 out of 15, indicating severely impaired cognition. A 9/30/24 Physical Aggression Initiated report hit and pinched another resident. The other resident also hit Resident #22. A 9/30/24 Nursing Note stated the resident sat in the lobby next to another resident and started hitting and pinching her. The other resident also hit and pinched. e. Resident #22 and Resident #21 The MDS assessment tool, dated 9/13/24, listed diagnoses for Resident #21 which included diabetes, Parkinson's(a disease which causes tremors), and depression. The MDS listed the resident's BIMS score of 0 out of 15, indicating severely impaired cognition. A 10/20/24 Verbal Aggression Received report stated another resident yelled at Resident #22 and Resident #22 carried out a light grasp of the right upper arm(of the other resident). A 10/20/24 Incident Note stated a resident grabbed Resident #21's arm when Resident #21 asked her not to tap the couch. On 11/7/24 at 2:04 p.m., the Administrator stated she wanted residents treated with respect,compassion and kindness. On 11/13/24 at 8:38 a.m., Staff D Licensed Practical Nurse(LPN) stated Resident #22 was banging on the couch and Resident #21 yelled at her to stop. She stated Resident #22 reached over and took Resident #21's arm. She stated Resident #22 could be pretty rough but Resident #21 did not scream out. She stated Resident #22 will snap. She stated she assumed the facility reported the altercation. On 11/18/24 at 8:44 a.m., via phone, Staff I Certified Nursing Assistant(CNA) stated Resident #22 did act out against other residents. She stated if she thought people were in her bubble, she would point her finger at them, cuss at them, and sometimes she slapped them. She stated they kept an eye on her but there were not enough staff to monitor her and they were busy. She stated when she worked there were only 2 people on staff and this was not enough. On 11/19/24 at 11:59 a.m. via phone, the Director of Nursing(DON) of a sister facility stated with regard to a resident with a history of resident to resident physical altercations, she would not sit that person near residents where she could reach them. Staff should carry out checks and monitoring. On 11/19/24 at 1:57 p.m., the Administrator stated Resident #22 was spontaneous. She stated it could get congested(in the TV area) and they needed to come up with a better plan because the residents were too close together. She stated they needed to educate staff so they were more aware of what was best to keep everyone safe. The undated facility Abuse Policy stated the resident had the right to be free from abuse which would include physical and sexual abuse.

Based on interview, record review, and facility policy review, the facility failed to ensure all allegations of abuse including allegations of staff to resident rough treatment resulting in fear, resident to resident physical altercations, injuries of unknown origin, and inappropriate touching of a resident's breast and buttocks by another resident, were reported timely to the facility administration for ten of twelve residents reviewed for abuse (Resident #7, Resident #11, Resident #12, Resident #13, Resident #15, Resident #16, Resident #19, Resident #20, Resident #21, Resident #22). This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/14/24 at 1:57 PM. The IJ began on 9/26/24. Facility staff removed the Immediate Jeopardy on 11/18/24 at 12:28 PM by implementing the following actions: 1. All residents interviewed on 11/14/24, with no further allegations of abuse or neglect identified. 2. All staff interviewed on 11/14/24, with 4 allegations reported to State Agency and initiated investigations. Any associated staff suspended, pending investigation. 3. Facility provided all staff education on abuse, immediate separation, and reporting of any abuse immediately to the Facility Administrator. Education completed by end of the day 11/14/24 or prior to working next shift. 4. An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting conducted on 11/14/24, to review policy on abuse, immediate separation, reporting of abuse, and completing thorough investigation. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings Include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. MDS revealed Resident #20 had delusions, verbal and physical behaviors, and rejection of cares. Resident #20 had impairment of bilateral lower extremities, utilized a wheelchair for mobility, and required substantial to maximal amount of staff assistance to transfer. Diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, heart failure, depression, and psychotic disorder. The Care Plan, revised on 9/27/24 revealed Resident #20 had impaired cognitive function evidenced by short and long term memory deficits, impaired decision making, and impaired ability to understand others related to a diagnosis of dementia with mood disturbance. The Care Plan identified a risk for chronic pain and revealed Resident #20 had displaced comminuted fracture of the left humeral neck and greater tuberosity with soft tissue swelling on 9/26/24. Intervention instructed staff to apply left shoulder immobilizer as ordered and as tolerated by resident, for comfort. A Nursing Progress Note, dated 9/25/24 at 5:53 AM, revealed Resident #20 was found to have swelling and slight bruising on left shoulder spread down arm to the elbow, resident unable to move arm. Note informed that nurse reported Resident #20's condition to an on call Provider and received orders to send resident to the hospital for an evaluation. On 9/25/24 at 8:18 AM, a Nursing Note revealed that Resident #20's Hospice Provider notified the Hospital of resident and family wishes for no treatment and resident sent back to the facility. On 9/25/24 at 8:50 AM, Note informed that Resident #20 had returned to facility with pain rated 8 on a scale of 1 to 10, and charted left arm appeared purple and black around the entire upper arm. At 10:00 AM, facility received an order from Provider for portable x-ray, 2 views, of left shoulder. An x-ray report, dated 9/26/24, revealed findings of displaced comminuted fracture of the left humeral neck and greater tuberosity with soft tissue swelling. Incident Report for injury of unknown cause, completed on 9/26/24 by Director of Nursing (DON). The Report description of incident revealed Resident #20 found by Certified Nursing Assistant (CNA) with pain to left shoulder, Nurse assessed resident, observed bruising and abnormal range of motion. Incident Report identified an injury located on the front of left shoulder, unable to identify injury type, and immediate action had been to send Resident #20 to emergency room (ER). Review of the facility's submitted list of self reported incidents revealed a report had been submitted on 9/26/24 at 3:22 PM to the State Agency, which listed the incident date as 9/25/24 and incident type as accident with major injury. Review of the facility's 5 day investigation summary for self-reported incident revealed an investigation was completed for an unwitnessed incident and informed that an incident occurred on 9/25/24 at approximately 2:15 PM. On 11/19/24 at 12:30 PM, Director of Nursing for sister facility, provided assistance with State Survey, revealed the expectation for an injury of unknown origin to be automatically turned in to State Agency and investigated as potential abuse. Sister facility DON revealed that the investigation would include a root cause analysis, interviews with staff and residents, to try and figure out what happened. On 11/19/24 at 2:06 PM, Facility Administrator revealed that Resident #20's injury of unknown origin had been reported to the State Agency after notification had been received from DON that resident had a left shoulder fracture. 45338 2. Review of the MDS assessment for Resident #19 dated 10/9/24 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan for Resident #19 revised 7/13/23 revealed, [Resident #19] has a behavioral management program due to his hx (history) of aggressive behavior towards other residents. Review of Resident #19's Care Plan dated 7/4/24 and revised 7/5/24 revealed, [Resident #19] has a Mutual friendship with a resident of the opposite sex. Interventions per Resident #19's Care Plan included the following: a. (Initiated 7/5/24, Revised 9/10/24): Do not shame or embarrass [Resident #19] regarding this relationship. b. (Initiated 7/5/24, Revised 9/10/24): If [Resident #19's] friendship escalates beyond hugging/hand holding/sitting together, please redirect in a calm manner and we will reassess the plan with staff, family and medical advice. c. (Initiated 7/5/24, Revised 9/10/24): Mild affection (hugging/hand holding/sitting together) is acceptable for both families. d. (Initiated 10/28/24): POA (Power of Attorney) [Name Redacted] verbalizes that hand holding, sitting together, female resident sitting this resident's lap, and a gentle kiss on the lips is within his scope for approval of behavior. He states to please separate residents if behaviors become more sexual in nature such as touching of one another's private areas. [POA name redacted] also requests to be made aware if resident's behaviors with female friend appear to become inappropriate and not reciprocated. e. (Initiated 7/5/24, Revised 9/10/24): Report interactions as needed to Charge Nurse. f. (Initiated 7/5/24, Revised 9/10/24): This friendship is acceptable as long as [Resident #19] is safe and happy On 11/18/24 at 2:10 PM, Resident #19 observed standing up by the nursing station. a. Resident #12 and Resident #19: Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 9/13/24 revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident inattention which fluctuated and delusions. Review of Medical Diagnoses for Resident #12 included Wernicke's encephalopathy, dementia with psychotic disorder, dementia with mood disturbance, restlessness and agitation, and delusional disorders. Review of Resident #12's Care Plan dated 7/7/24 revealed, [Resident #12] has a Mutual friendship with a resident of the opposite sex. Interventions per the Care Plan included the following: a. (Created 7/7/24, revised 9/10/24): Do not shame or embarrass [Resident #12] for her friendship. b. (Created 7/7/24, revised 9/10/24): If [Resident #12's] friendship escalates beyond hugging/hand holding/sitting together, please redirect in a calm manner and we will re-assess the plan with staff, family and medical advice. c. (Created 7/7/24, revised 9/10/24): Mild affection (hugging/hand holding/sitting together) is acceptable for both families. d. (Created 10/28/24): Per POA: hand holding, sitting together, resident sitting on other male resident's lap, and a gentle kiss on the lips is within her scope for approval of behavior. Please separate residents if behaviors become more sexual in nature such as touching of one another's private areas e. (Created 7/7/24, revised 9/10/24): Report interactions as needed to Charge Nurse. f. (Created 7/7/24, revised 9/10/24): This friendship is acceptable if [Resident #12] is safe and happy. The Nursing Note for Resident #12 dated 10/26/24 at 5:56 PM revealed, CNA (Certified Nursing Assistant) reports to this nurse that at around 1555 (3:55 PM) a male resd reached up this resd (resident) shirt et groped her lt (left) breast while she was standing next to him. These 2 resd are care planned to have a friendly relationship that involve holding hands et hugging. This nurse witnessed female resd approach male resd seated in lobby, they proceeded to hold hands before this nurse had left to attend another resd. CNA separated the 2 resd. CNA reports that resd was asking where male resd went? CNA redirected et kept them apart. When female resd asked by this nurse if the male resd had touched her breast she states No. Administrator made aware. Called x2 numbers for POA (Power of Attorney) with no answer et (and) left message. The Nursing Note for Resident #19 dated 10/26/24 at 5:43 PM revealed, CNA reports to this nurse that at around 1555 (3:55 pm) this resd reached up a female resd shirt et groped her lt breast while she was standing next to him. These 2 resd are care planned to have a friendly relationship that involve holding hands et hugging. This nurse witnessed female resd approach male resd seated in lobby, they proceeded to hold hands before this nurse had left to attend another resd. No other resd in lobby witnessed event when asked. [Resident #19] was confronted and asked if anything happened when female resd approached him? resd states No. when asked if they were holding hands? He states yeah we were holding hands. Resd was asked if he touched female resd anywhere else? states her back side a little. Resd asked if he reached up female resd shirt?States no. Administrator made aware. POA [POA Name Redacted] made aware. On 11/13/24 at 12:06 PM, Resident #12 observed in her room in bed. On 11/18/24 at 2:10 PM, Resident #12 observed standing up by the nurses station near the lobby area of the facility. Review of the self report list emailed by the Administrator on 11/4/24 lacked the alleged incident between Resident #12 and Resident #19 which occurred 10/26/24. Review of an updated self report list emailed by the facility's Administrator on 11/13/24 lacked the alleged incident between Resident #12 and Resident #19 on 10/26/24. On 11/14/24 at 1:56 PM, the Administrator responded Resident #19 and Resident #12 were friends, the Administrator explained had heard holding hands came to light. The Administrator acknowledged not aware of touching of the resident's breast and butt. Per the Administrator, if unaware of touching of the resident's breast, then could not report. On 11/19/24 at 2:44 PM. the Administrator explained, in part, she had received a text message over the weekend; Staff D, Licensed Practical Nurse (LPN) did the investigation, and was told one thing versus what the CNA said. When queried more about the text message, the Administrator explained she had received a voicemail, and acknowledged she listened to the voicemail maybe a couple of days ago. When queried about the voicemail, the Administrator explained said there's an allegation of CNA saying Resident #19 put hand up Resident #12's shirt and touched breast. Per the Administrator, the voicemail was from Staff D, Licensed Practical Nurse. b. Resident #15 and Resident #19: Review of the Minimum Data Set (MDS) assessment for Resident #15 dated revealed the resident scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Review of the Care Plan for Resident #15 dated 2/22/24, revised on 3/17/24, revealed, [Resident #15] has episodes of behaviors as evidenced by: being combative grabbing slapping pulling away hitting negative verbalizations name calling refusal of medications/ cares resists cares tries to leave facility crying episodes screaming out hallucinations/ delusions. Interventions per Resident #15's Care Plan included, in part, the following: a. Observe for early warning signs of oncoming behaviors- Approach in a call manner, call by name, remove b. Minimize the potential for the residents disruptive behaviors by offering tasks which divert attention. The Incident Note for Resident #15 dated 8/18/24 at 11:46 AM revealed, in part, [Resident #15] has been pacing in w/c (wheelchair) this morning, at 1015 this nurse witnessed [Resident #15] run over male resd root in w/c, male resd seated in large recliner in lobby hit [Resident #15] across back with both arms et (and) fists. Male resd asked to go to room in order to separate the two residents. No redness or bruising noted to back, when asked if having pain states yes. DON (Director of Nursing) et administrator notified at 1022. The Incident Note for Resident #19 dated 8/18/24 at 11:15 AM revealed, At 1015 this nurse witnessed [Resident #19] seated in large recliner in lobby [NAME] female resd across back with both arms et fists, female resd in w/c pacing et ran over [Resident #19's] foot. Resd wearing sneakers. Spoke with [Resident #19], informed that this female resd is not doing it intentionally, resd states I know. Discussed with [Resident #19] that there are other ways to handle a situation. [Resident #19] asked to go to his room in order to separate the two residents. Resd in bed, reports that lt (left) foot was ran over, when assessed no bruising, swelling or redness. Resd reports he is still having pain to lt foot 5/10. The Nursing Note for Resident #15 dated 8/19/24 at 5:52 AM revealed, CNA [Name Redacted, Staff I] reports 2 red marks on resident's low back from incident on 9/18/24. Although the incident between Resident #15 and Resident #19 was documented in both resident records on 8/18/24, review of the facility's list of self reported incidents revealed an Allegation of Abuse was reported between Resident #15 and Resident #19 for an incident date 8/19/24. Observation on 11/06/24 at 9:26 AM revealed Resident #15 up and ambulatory at the facility. 35434 On 11/4/24 at 11:26 a.m., Resident #19 sat in a chair in the main dining room and ate lunch. The State Agency(SA) made multiple attempts throughout the survey to speak with him with no success. On 11/14/24 at approximately 1:00 p.m., the Administrator stated the incident with Residents #15 and #19 occurred on 9/19/24 and she reported it on 9/20/24. 3. The Minimum Data Set(MDS) assessment tool, dated 6/21/24, listed diagnoses for Resident #22 which included diabetes, arthritis, and hip fracture. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 1 out of 15, indicating severely impaired cognition. The MDS stated the resident had the following: a. physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) which occurred 1-3 days out of the 7 day review period. b. verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which occurred 4-6 days out of the 7 day review period. c. other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1-3 days out of the 7 day review period. A 6/21/24 Care Plan entry directed staff to intervene as necessary to protect the rights and safety of the other residents, divert attention, remove from the situation/location if needed, and approach/speak in a calm manner. An 8/22/24 Care Plan entry directed staff to redirect the resident when she became notably agitated and to monitor her when she was around others. An 8/26/24 Care Plan intervention directed staff to monitor the resident when she was in the hallways to ensure safe interactions with other residents. The entry directed staff to remove her from other residents and intervene when she headed toward other residents. An 8/28/24 Care Plan entry stated the physician made medication changes as an intervention to behaviors and resident to resident interactions. A 9/30/24 Care Plan entry directed staff to place the resident in an area where not within an arm's length of other residents. A Care Plan entry, revised 10/21/24, stated the resident had episodes of behaviors/potential for behaviors as evidenced by combativeness, negative verbalizations, name calling, screaming out, throwing things at staff, cursing at staff and other residents, stabbing the dining table with a fork, scratching staff, cussing at staff and other residents, flipping staff off with middle finger, yelling, as well as other aggressive behaviors. The resident had the following incidents: On 8/22/24, the resident hit another resident. On 8/26/24, the resident grabbed and scratched another resident. On 9/6/24, the resident slapped another resident. On 9/30/24, the resident slapped and pinched another resident while she called them names. On 10/20/24, the resident grabbed the arm of another resident. a Resident #22 and Resident #13 The MDS assessment tool, dated 8/21/24, listed diagnoses for Resident #13 which included non-Alzheimer's dementia, depression, and psychotic disorder. The MDS listed the resident's BIMS score as 4 out of 15, indicating severely impaired cognition. A 9/30/24 Physical Aggression Initiated report hit and pinched another resident. The other resident also hit Resident #22. A 9/30/24 Nursing Note stated the resident sat in the lobby next to another resident and started hitting and pinching her. The other resident also hit and pinched. The facility lacked documentation they reported the 9/30/24 incident to the State Agency until 10/2/24. On 11/14/24 at approximately 1:00 p.m., the Administrator stated the incident between Resident #22 and Resident #13 occurred on 9/30/24. She was informed of it on 10/1/24 and reported it on 10/2/24. b. Resident #22 and Resident #21 The MDS assessment tool, dated 9/13/24, listed diagnoses for Resident #21 which included diabetes, Parkinson's(a disease which causes symptoms such as tremors), and depression. The MDS listed the resident's BIMS score of 0 out of 15, indicating severely impaired cognition. A 10/20/24 Verbal Aggression Received report stated another resident yelled at Resident #22 and Resident #22 carried out a light grasp of the right upper arm(of the other resident). A 10/20/24 Incident Note stated a resident grabbed Resident #21's arm when Resident #21 asked her not to tap the couch. The facility lacked documentation they reported the 10/20/24 incident to the State Agency. 4a. The MDS assessment tool, dated 10/23/24, listed diagnoses for Resident #7 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS stated the resident's BIMS score was 1 out of 15, indicating severely impaired cognition. A 6/20/19 Care Plan entry stated the resident was independent with transfers. b. The MDS assessment tool, dated 8/28/24, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, anxiety, and psychotic disorder. The MDS stated the resident required partial to moderate assistance for walking and listed a BIMS score of 0 out of 15, indicating severely impaired cognition. A 2/24/24 Care Plan entry stated the resident required the assistance of 1 staff for short and long distance walking as the resident allowed. c. The MDS assessment tool, dated 9/11/24, listed diagnoses for Resident #15 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. The MDS stated the resident walked independently and listed the resident's BIMS score as 0 out of 15, indicating severely impaired cognition. A 2/22/24 Care Plan entry stated the resident walked independently. d. The MDS assessment tool, dated 9/20/24, listed diagnoses for Resident #16 which included Alzheimer's, non-Alzheimer's dementia, and depression. The MDS stated the resident walked independently and listed her BIMS score as 0 out of 15, indicating severely impaired cognition. A 7/7/21 Care Plan entry stated the resident walked independently. On 11/7/24 at 1:28 p.m., via phone, Staff E Registered Nurse(RN) stated there were a couple staff members, Staff O Certified Nursing Assistant(CNA) and Staff P CNA who were a little rough with the residents when walking down the hall. She stated they pulled them instead of walking with them and said come on. She stated they pulled them with both of their hands and do this with Residents #7, #11, #15, and #16. She stated it was unsafe and the residents were scared and shaking. She stated she reported this to the Business Office Manager. The facility lacked documentation they reported the above allegations of abuse and lacked documentation they separated residents from Staff O and Staff P during the investigation. On 11/7/24 at 2:04 p.m., the Administrator stated she wanted residents treated with respect,compassion and kindness. She stated Staff O and Staff P were both kind and no staff reported any concerns to her about them. On 11/12/24 at 12:00 p.m., via phone Staff E stated she spoke to the Administrator about staff walking with staff in an unsafe manner and stated the Administrator told her she didn't like how they pulled people but she was stuck between a rock and a hard place. On 11/12/24 at 1:06 p.m., Staff G RN stated staff pulled residents by the arms while they walked them. She stated they were not abusive but rushed and rude. On 11/19/24 at 11:59 a.m. via phone, the Director of Nursing(DON) of a sister facility stated staff should report allegations of abuse to the DON and then the Administrator and they would investigate and report. She stated the staff in question would be suspended. The facility policy Abuse Reporting and Investigation revised 11/28/16, stated the facility would thoroughly investigate all reports of suspected or alleged abuse and stated if an employee is involved in the suspected violation, they would be immediately removed from duty for he duration of the investigation. The undated facility Abuse Policy stated the facility would report incidents of suspected abuse to the SA immediately but not later than 2 hours. On 11/14/24 at approximately 1:00 p.m., the Administrator stated it was her understanding that allegations of abuse be reported within 24 hours.

Based on observation, interview, and record review the facility failed to conduct thorough investigations into allegations of abuse including injury of unknown origin, following concerns with staff rough treatment towards residents resulting in fear, following resident to resident incidents, and failed to ensure separation of alleged perpetrators following staff after becoming aware of allegations of abuse for eight of twelve residents reviewed for abuse (Resident #7, Resident #11, Resident #12, Resident #15, Resident #16, Resident #19, Resident #20, Resident #21). This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/14/24 at 1:57 PM. The IJ began on 9/26/24. Facility staff removed the Immediate Jeopardy on 11/18/24 at 12:28 PM by implementing the following actions: 1. All residents interviewed on 11/14/24, with no further allegations of abuse or neglect identified. 2. All staff interviewed on 11/14/24, with 4 allegations reported to State Agency and initiated investigation. Any associated staff suspended pending investigation. 3. Facility provided all staff education on abuse, immediate separation, and reporting of any abuse immediately to the Facility Administrator. Education completed by end of the day 11/14/24, or prior to working next shift. 4. An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting conducted on 11/14/24, to review policy on abuse, immediate separation, reporting of abuse, and completing thorough investigation. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings Include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. MDS revealed Resident #20 had delusions, verbal and physical behaviors, and rejection of cares. Resident #20 had impairment of bilateral lower extremities, utilized a wheelchair for mobility, and required substantial to maximal amount of staff assistance to transfer. Diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, heart failure, depression, and psychotic disorder. The Care Plan, revised on 9/27/24 revealed Resident #20 had impaired cognitive function evidenced by short and long term memory deficits, impaired decision making, and impaired ability to understand others related to a diagnosis of dementia with mood disturbance. The Care Plan identified a risk for chronic pain and revealed Resident #20 had displaced comminuted fracture of the left humeral neck and greater tuberosity with soft tissue swelling on 9/26/24. Intervention instructed staff to apply left shoulder immobilizer as ordered and as tolerated by resident, for comfort. A Nursing Progress Note, dated 9/25/24 at 5:53 AM, revealed Resident #20 was found to have swelling and slight bruising on left shoulder spread down arm to the elbow, resident unable to move arm. Note informed that nurse reported Resident #20's condition to an on call Provider and received orders to send resident to the hospital for an evaluation. On 9/25/24 at 8:18 AM, a Nursing Note revealed that Resident #20's Hospice Provider notified the Hospital of resident and family wishes for no treatment and resident sent back to the facility. On 9/25/24 at 8:50 AM, Note informed that Resident #20 had returned to facility with pain rated 8 on a scale of 1 to 10., and left arm charted as purple and black around the entire upper arm. At 10:00 AM, facility received an order from Provider for portable x-ray, 2 views, of left shoulder. An x-ray report, dated 9/26/24, revealed findings of displaced comminuted fracture of the left humeral neck and greater tuberosity with soft tissue swelling. Incident Report for injury of unknown cause completed on 9/26/24 by Director of Nursing (DON). The Report description of incident revealed, Resident #20 found by Certified Nursing Assistant (CNA) with pain to left shoulder, Nurse assessed resident observed bruising and abnormal range of motion. Incident Report identified an injury located on the front of left shoulder, unable to identify injury type, and immediate action had been Resident #20 sent to emergency room (ER). Review of Skin Assessments completed on Resident #20, revealed the following information documented on left shoulder bruising: 1. 9/26/24: Bruise to front of left shoulder measuring 16 centimeters (cm) by 26 cm. 2. 9/30/24: Large bruise to front of left shoulder with Resident #20's arm in sling. No measurements or wound description documented. 3. 10/03/24: Bruise to left shoulder, migrated down front of left chest and down left arm to the wrist and hand. No measurements or wound description documented. 4. 10/07/24: Large bruise starting at left shoulder and extending down the left chest/breast and left arm/hand. Bruising noted to be different colors of healing and Resident #20 continued to have sling in place. Review of the facility's submitted list of self reported incidents revealed a report had been submitted on 9/26/24 at 3:22 PM to the State Agency, which listed the incident date as 9/25/24 and incident type as accident with major injury. Review of the facility's 5 day investigation summary for self-reported incident revealed an investigation was completed for an unwitnessed incident and informed that an incident occurred on 9/25/24 at approximately 2:15 PM. The investigation summarized incident as Resident #20 being fine and without pain or bruising noted to left shoulder on 9/25/24, between 8:00 AM and 5:38 PM. Bruising then observed to left shoulder on 9/26/24 at 6:00 AM and nurse sent Resident #20 to the hospital. Upon return from the hospital a portable x-ray had been completed and results of fracture shared with Provider, who stated this injury had to come from trauma or a fall, no staff had witnessed. The 5 day investigation revealed intervention for incident would be to redirect Resident #20 as she required staff assistance and often ambulated on her own. The root cause analysis of incident informed that Resident #20 is not able to recall event and had not stressed any long term effects from the incident. Facility's 5 day summary did not identify potential for abuse and lacked abuse related investigation for injury of unknown origin. The facility provided a document to State Surveyor on 11/14/24 at 12:46 PM, titled Injury Timeline, and listed that the following events had taken place on 9/25/24 and 9/26/24: 1. On 9/25/24, no time documented, Resident #20 observed standing in doorway of another resident's room, leaning heavily on left arm/elbow against the doorframe and was assisted by 2 staff into wheelchair. 2. On 9/25/24, no time documented, Resident #20 found in bathroom by nurse, self-transferred to toilet, assisted by 2 staff to ambulate with walker back to bed. 3. On 9/26/24, no time documented, night shift Certified Nursing Assistant (CNA) found bruise to Resident #20's left shoulder and reported to nurse who sent Resident #20 to the hospital. Resident #20 returned to facility and had x-ray completed on left shoulder, results received and reported to Attending Physician, family, and Hospice Provider. 4. On 9/26/24, no time documented, facility began self report process, and obtained statements from all staff members who worked with Resident #20 on 9/25/24 and 9/26/24. A Provider Note, dated 10/23/24, revealed that Resident #20 had a fall and sustained a fracture to left humerus and left upper extremity in an immobilizer. Addendum to 10/23/24 Visit Note, documented on 11/13/24, revealed that there is no facility documentation of a fall and how arm fracture occurred is unknown. On 11/06/24 at 1:00 PM, Staff L, CNA, stated they had found bruise on Resident #20's left shoulder, on 9/26/24 around 5:00 AM, when the resident stated that her arm hurt and immediately reported this to nurse. Staff L recalled that Resident #20 had previously complained of a male CNA being rough with her, Staff L unable to provide specific dates or times for these occurrences and had not personally witnessed any rough handling of Resident #20 by any staff. Resident #20 unable to provide Staff L with a name, instead described male CNA as that big guy. On 11/12/24 at 11:15 AM, Staff E, Registered Nurse (RN) stated that around 5:00 AM on 9/26/24, Staff L had called nurse into room to report left shoulder bruise. Staff E recalled that Resident #20's left shoulder appeared huge with black and blue colored bruising. Staff E stated that this injury had not been passed along in shift report and no one had reported anything previously about bruising or falls that she was aware of. Staff E informed that if Resident #20 had fallen, there would be no way resident could get up off the floor independently. Staff E also recalled that Resident #20 had previously mentioned both a male CNA, and a female CNA being rough with her, Resident #20 unable to provide Staff E with staff names. Staff E unable to provide specific dates or times for these occurrences with Resident #20. On 11/12/24 at 1:30 PM Staff G, RN, confirmed working as charge nurse on the evening of 9/25/24 and stated they did not receive any report or have any observation of Resident #20's left shoulder being bruised or swollen. Staff G reported finding Resident #20 alone in her bathroom, sitting on the toilet and called for CNA staff to assist resident with cares. Staff G stated that Staff C (CNA) and Staff J (CNA) entered Resident #20's room to assist with toileting and Staff G left the room. Staff G stated that after leaving Resident #20's room, she did hear resident call out for help and when Staff G re-entered Resident #20's room, the resident was laying in bed while Staff C and Staff J stood next to the bed. Staff G recalled that Resident #20 complained that she was hurting all over, but refused pain medication when nurse offered. Staff G stated she did not receive any report from Staff C or Staff J that any incidents or injuries occurred. On 11/13/24 at 9:16 AM, Staff C, CNA, confirmed working with Resident #20 on the evening of 9/25/24 and informed that she had been called by Staff G (RN) into bathroom to assist after Resident #20 had self-transferred to toilet. Staff C reported that Staff J also assisted with Resident #20's toileting cares and recalled that Resident #20 had difficultly when walking with walker from the bathroom back to bed. Staff C informed that Resident #20 had complained of having pain all over and reported this to the nurse. Staff C denied any incident or injury observed or reported while assisting Resident #20 with cares. On 11/18/24 at 10:30 AM, Staff J, CNA, confirmed working with Resident #20 on the evening of 9/25/24 and revealed that Resident #20 had self transferred to bathroom so charge nurse asked Staff J and Staff C to assist her. Staff J recalled Resident #20 had been sitting on toilet when approached with tabbed brief off on the floor of the bathroom, staff assisted resident with cares and when ambulating her back to bed, Resident #20 became weak and required transfer into wheelchair, then a stand-pivot transfer into bed. Staff J stated Resident #20 had complained of her whole body hurting when CNA staff repositioned her in bed. On 11/19/24 at 12:30 PM, Director of Nursing for sister facility, provided assistance with State Survey, revealed the expectation for an injury of unknown origin to be automatically turned in to State Agency and investigated as potential abuse. Sister facility DON revealed that the investigation would include a root cause analysis, interviews with staff and residents, to try and figure out what happened. On 11/19/24 at 2:06 PM, Facility Administrator revealed that Resident #20's injury of unknown origin had been reported to the State Agency after notification had been received from DON that resident had a left shoulder fracture. 45338 2. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #12 dated 9/13/24 revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident inattention which fluctuated and delusions. Review of Resident #12's Care Plan dated 7/5/23 revealed the following: Trauma Informed Care: [Resident #12] is at risk for alterations in my psycho-social well being related to: Allegation of abuse. History of being recipient of unsolicited sexual touching. Review of Resident #12's Care Plan dated 7/7/24 revealed, [Resident #12] has a Mutual friendship with a resident of the opposite sex. Interventions per the Care Plan included the following: a. (Created 7/7/24, revised 9/10/24): Do not shame or embarrass [Resident #12] for her friendship. b. (Created 7/7/24, revised 9/10/24): If [Resident #12's] friendship escalates beyond hugging/hand holding/sitting together, please redirect in a calm manner and we will re-assess the plan with staff, family and medical advice. c. (Created 7/7/24, revised 9/10/24): Mild affection (hugging/hand holding/sitting together) is acceptable for both families. d. (Created 10/28/24): Per POA: hand holding, sitting together, resident sitting on other male resident's lap, and a gentle kiss on the lips is within her scope for approval of behavior. Please separate residents if behaviors become more sexual in nature such as touching of one another's private areas e. (Created 7/7/24, revised 9/10/24): Report interactions as needed to Charge Nurse. f. (Created 7/7/24, revised 9/10/24): This friendship is acceptable if [Resident #12] is safe and happy. The Nursing Note for Resident #12 dated 10/26/24 at 5:56 PM revealed, CNA (Certified Nursing Assistant) reports to this nurse that at around 1555 (3:55 PM) a male resd reached up this resd (resident) shirt et groped her lt (left) breast while she was standing next to him. These 2 resd are care planned to have a friendly relationship that involve holding hands et hugging. This nurse witnessed female resd approach male resd seated in lobby, they proceeded to hold hands before this nurse had left to attend another resd. CNA separated the 2 resd. CNA reports that resd was asking where male resd went? CNA redirected et kept them apart. When female resd asked by this nurse if the male resd had touched her breast she states No. Administrator made aware. Called x2 numbers for POA (Power of Attorney) with no answer et (and) left message. 3. Review of the Annual MDS assessment for Resident #19 dated 10/9/24 revealed Resident #19 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of Resident #19's Care Plan dated 7/4/24 and revised 7/5/24 revealed, [Resident #19] has a Mutual friendship with a resident of the opposite sex. Interventions per Resident #19's Care Plan included the following: a. (Initiated 7/5/24, Revised 9/10/24): Do not shame or embarrass [Resident #19] regarding this relationship. b. (Initiated 7/5/24, Revised 9/10/24): If [Resident #19's] friendship escalates beyond hugging/hand holding/sitting together, please redirect in a calm manner and we will reassess the plan with staff, family and medical advice. c. (Initiated 7/5/24, Revised 9/10/24): Mild affection (hugging/hand holding/sitting together) is acceptable for both families. d. (Initiated 10/28/24): POA (Power of Attorney) [Name Redacted] verbalizes that hand holding, sitting together, female resident sitting this resident's lap, and a gentle kiss on the lips is within his scope for approval of behavior. He states to please separate residents if behaviors become more sexual in nature such as touching of one another's private areas. [POA name redacted] also requests to be made aware if resident's behaviors with female friend appear to become inappropriate and not reciprocated. e. (Initiated 7/5/24, Revised 9/10/24): Report interactions as needed to Charge Nurse. f. (Initiated 7/5/24, Revised 9/10/24): This friendship is acceptable as long as [Resident #19] is safe and happy The Nursing Note for Resident #19 dated 10/26/24 at 5:43 PM revealed, CNA reports to this nurse that at around 1555 (3:55 pm) this resd reached up a female resd shirt et groped her lt (left) breast while she was standing next to him. These 2 resd are care planned to have a friendly relationship that involve holding hands et hugging. This nurse witnessed female resd approach male resd seated in lobby, they proceeded to hold hands before this nurse had left to attend another resd. No other resd in lobby witnessed event when asked. [Resident #19] was confronted and asked if anything happened when female resd approached him? resd states No. when asked if they were holding hands? He states yeah we were holding hands. Resd was asked if he touched female resd anywhere else? states her back side a little. Resd asked if he reached up female resd shirt?States no. Administrator made aware. POA [POA Name Redacted] made aware. On 11/12/24 at 2:27 PM, Staff D, Licensed Practical Nurse (LPN) explained the following about Resident #12 and Resident #19: Per Staff D, she (Staff D) was the one that brought to the DON's attention, ok with family, because kept on doing stuff holding hands, hugging. Per Staff D, had gotten approval from family that ok for friendly relationship, peck on the lips, sit with each other, hold hands, and nothing behind closed doors. Staff D explained Resident #12 would seek Resident #19 out, and Resident #19 calmed Resident #12 down. Staff D explained an aide said he saw Resident #19 reach up Resident #12's shirt. Staff D further explained the aide did not want them (residents) to be together because the aide thought Resident #12 could not make decisions for herself. The aide was identified as Staff H. When queried if Resident #12 had ever had a negative reaction, Staff D responded no. Per Staff D, she had never seen Resident #19 pursue Resident #12, and when she saw, Resident#12 went to Resident #19. Review of the self report list emailed by the Administrator on 11/4/24 lacked the alleged incident between Resident #12 and Resident #19 which occurred 10/26/24. On 11/6/24 at 9:23 AM, Incident Reports for Resident #12 and #19 for the last six months requested via email to the facility's Administrator and Director of Nursing (DON). The Incident Report received did not address any interactions between Resident #12 and Resident #19. Review of an updated self report list emailed by the facility's Administrator on 11/13/24 lacked the alleged incident between Resident #12 and Resident #19 on 10/26/24. On 11/19/24 at 2:44 PM. the Administrator explained, in part, she had received a text message over the weekend; Staff D did the investigation, and was told one thing versus what the CNA said. Per the Administrator, she trusted the Charge Nurse to do investigation. When queried more about the text message, the Administrator explained she had received a voicemail, and acknowledged she listened to the voicemail maybe a couple of days ago. When queried about the voicemail, the Administrator explained said there's an allegation of CNA saying Resident #19 put hand up Resident #12's shirt, and doing investigation. Per the Administrator the voicemail was from Staff D. The Administrator explained Staff D asked Resident #12 and Resident #19 what really happened, and both denied. From there, separated and made sure no more contact. The Administrator further explained the DON investigated when she got back to work, there was care plan for holding hands, hugging, not to do other stuff. The Administrator acknowledged there was no statement from Staff H, CNA until 11/19/24 or 11/18/24. It was noted Staff H reported to State Agency having witnessed multiple interactions between Resident #12 and Resident #19, and it was also documented in both Resident #12 and Resident #19's clinical record on 10/26/24 that a CNA reported Resident #19 touched Resident #12's breast. 35434 On 11/4/24 at 11:26 a.m., Resident #19 sat in a chair in the main dining room and ate lunch. The State Agency(SA) made multiple attempts throughout the survey to speak with him with no success. 4. The Admission Minimum Data Set (MDS) assessment tool, dated 6/21/24, listed diagnoses for Resident #22 which included diabetes, arthritis, and hip fracture. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 1 out of 15, indicating severely impaired cognition. The MDS stated the resident had the following: a. physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) which occurred 1-3 days out of the 7 day review period. b. verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which occurred 4-6 days out of the 7 day review period. c. other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1-3 days out of the 7 day review period. A 6/21/24 Care Plan entry directed staff to intervene as necessary to protect the rights and safety of the other residents, divert attention, remove from the situation/location if needed, and approach/speak in a calm manner. An 8/22/24 Care Plan entry directed staff to redirect the resident when she became notably agitated and to monitor her when she was around others. An 8/26/24 Care Plan intervention directed staff to monitor the resident when she was in the hallways to ensure safe interactions with other residents. The entry directed staff to remove her from other residents and intervene when she headed toward other residents. An 8/28/24 Care Plan entry stated the physician made medication changes as an intervention to behaviors and resident to resident interactions. A 9/30/24 Care Plan entry directed staff to place the resident in an area where not within an arm's length of other residents. A Care Plan entry, revised 10/21/24, stated the resident had episodes of behaviors/potential for behaviors as evidenced by combativeness, negative verbalizations, name calling, screaming out, throwing things at staff, cursing at staff and other residents, stabbing the dining table with a fork, scratching staff, cussing at staff and other residents, flipping staff off with middle finger, yelling, as well as other aggressive behaviors. The resident had the following incidents: On 8/22/24, the resident hit another resident. On 8/26/24, the resident grabbed and scratched another resident. On 9/6/24, the resident slapped another resident. On 9/30/24, the resident slapped and pinched another resident while she called them names. On 10/20/24, the resident grabbed the arm of another resident. 5. The Quarterly MDS assessment tool, dated 9/13/24, listed diagnoses for Resident #21 which included diabetes, Parkinson's (a disease which caused symptoms such as tremors), and depression. The MDS listed the resident's BIMS score of 0 out of 15, indicating severely impaired cognition. A 10/20/24 Verbal Aggression Received report stated another resident yelled at Resident #22 and Resident #22 carried out a light grasp of the right upper arm(of the other resident). A 10/20/24 Incident Note stated a resident grabbed Resident #21's arm when Resident #21 asked her not to tap the couch. The facility Self Reports log lacked documentation they reported the 10/20/24 incident. The facility also lacked documentation they conducted an investigation regarding the above incident or took steps to separate Resident #22 from other residents. On 11/13/24 at 8:38 a.m., Staff D Licensed Practical Nurse(LPN) stated Resident #22 was banging on the couch and Resident #21 yelled at her to stop. She stated Resident #22 reached over and took Resident #21's arm. She stated Resident #22 can be pretty rough but Resident #21 did not scream out. She stated Resident #22 will snap. She stated she assumed the facility reported the altercation. On 11/18/24 at 8:44 a.m., via phone, Staff I Certified Nursing Assistant(CNA) stated Resident #22 did act out against other residents. She stated if she thought people were in her bubble, she would point her finer at them, cuss at them, and sometimes she slapped them. She stated they kept an eye on her but there were not enough staff to monitor her and they were busy. She stated when she worked there were only 2 people on staff and this was not enough. On 11/19/24 at 1:59 p.m. via phone, the Director of Nursing (DON) of a sister facility stated with regard to a resident with a history of resident to resident physical altercations, she would not sit that person near residents where she could reach them. Staff should carry out checks and monitoring. On 11/19/24 at 1:57 p.m., the Administrator stated Resident #22 was spontaneous. She stated it could get congested(in the TV area) and they needed to come up with a better plan because the resident were too close together. She stated they needed to educate staff so they were more aware of what was best to keep everyone safe 6a. The MDS assessment tool, dated 10/23/24, listed diagnoses for Resident #7 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS stated the resident's BIMS score was 1 out of 15, indicating severely impaired cognition. A 6/20/19 Care Plan entry stated the resident was independent with transfers. b. The MDS assessment tool, dated 8/28/24, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, anxiety, and psychotic disorder. The MDS stated the resident required partial to moderate assistance for walking and listed a BIMS score of 0 out of 15, indicating severely impaired cognition. A 2/24/24 Care Plan entry stated the resident required the assistance of 1 staff for short and long distance walking as the resident allowed. c. The MDS assessment tool, dated 9/11/24, listed diagnoses for Resident #15 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. The MDS stated the resident walked independently and listed the resident's BIMS score as 0 out of 15, indicating severely impaired cognition. A 2/22/24 Care Plan entry stated the resident walked independently. d. The MDS assessment tool, dated 9/20/24, listed diagnoses for Resident #16 which included Alzheimer's, non-Alzheimer's dementia, and depression. The MDS stated the resident walked independently and listed her BIMS score as 0 out of 15, indicating severely impaired cognition. A 7/7/21 Care Plan entry stated the resident walked independently. On 11/7/24 at 1:28 p.m., via phone, Staff E Registered Nurse(RN) stated there were a couple staff members, Staff O Certified Nursing Assistant(CNA) and Staff P CNA who were a little rough with the residents when walking down the hall. She stated they pull them instead of walking with them and say come on. She stated they pull them with both of their hands and do this with Residents #7, #11, #15, and #16. She stated it was unsafe and the residents were scared and shaking. She stated she reported this to the Business Office Manager. The facility lacked documentation they investigated the above allegations of abuse and lacked documentation they separated residents from Staff O and Staff P during the investigation. On 1/7/24 at 2:04 p.m., the Administrator stated she wanted residents treated with respect,compassion and kindness. She stated Staff O and Staff P were both kind and no staff reported any concerns to her about them. On 11/12/24 at 12:00 p.m., via phone Staff E stated she spoke to the Administrator about staff walking with staff in an unsafe manner and stated the Administrator told her she didn't like how they pulled people but she was stuck between a rock and a hard place. On 11/12/24 at 1:06 p.m., Staff G RN stated staff pulled residents by the arms while they walked them. She stated they were not abusive but rushed and rude. On 11/19/24 at 11:59 a.m. via phone, the Director of Nursing(DON) of a sister facility stated staff should report allegations of abuse to the DON and then the Administrator and they would investigate and report. She stated the staff in question would be suspended. The facility policy Abuse Reporting and Investigation revised 11/28/16, stated the facility would thoroughly investigate all reports of suspected or alleged abuse and stated if an employee was involved in the suspected violation, they would be immediately removed from duty for the duration of the investigation.

Based on observation, interview, clinical record review, and facility policy review, the facility failed to provide adequate assessment and intervention for 3 of 4 residents reviewed for a change in condition. On [DATE] at approximately 12:30 PM, Resident #25 had difficulty transferring, which was a significant change in status, then at 2:35 PM the resident later had an unwitnessed fall, and was found face down in another resident's room, with laceration to the left forehead, Physician was sent a fax on [DATE], however, there was no response from physician until [DATE] which noted they should could continue to monitor per facility protocol. There was no follow-up from the facility between [DATE] and [DATE]. Staff acknowledged continued decline in Resident #25's condition when Resident #25 required assistance and cueing with all meals when independent prior. The Resident declined to a non-weightbearing of the left leg. The physician was notified on [DATE] of decline in transferring, at which time x-ray of a hip performed, no diagnostic tests were completed at this time for the head injury, there was no fracture of the hip. On [DATE] Resident #25 transferred to the Hospital, due to experiencing stroke-like symptoms and was diagnosed with Subdural Hematoma. Resident #25 died on [DATE]. Resident #25's death certificate revealed the immediate cause of death as complications due to accidental elderly fall, Due to or as a consequence of: subdural hematoma, and due to or as a consequence of an unsteady gait. The facility additionally failed to complete neurological assessments and post fall follow up documentation for Resident #20 following an unwitnessed fall and further failed to provide continued assessment for Resident #226 after an episode of excessive coughing caused by consuming the incorrect consistency of food during lunch meal for a resident with dysphagia. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 26 residents. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 5:12 PM. The IJ began on [DATE] . Facility staff removed immediacy of the Immediate Jeopardy on [DATE] at 3:02 PM by implementing the following actions: 1. A comprehensive head to toe assessment conducted and completed on [DATE], for all residents to identify any changes that deviated from their baseline status. 2. All staff members received training on how to identify changes in residents' conditions and the importance of reporting these changes to charge nurse. Staff training completed [DATE]. 3. All Charge Nurse staff trained on how to recognize a change in condition and the expectation to notify the attending provider via phone immediately when a change is identified. Charge Nurse training completed on [DATE]. 4. Facility conducted an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting on [DATE], to review the change of condition process, assess staff education, and develop auditing mechanisms to monitor and prevent recurrence. The scope lowered from J to G after ensuring the facility implemented education and their policy and procedure. 1. The Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #25 had severely impaired cognitive skills for daily decision making and occasional behaviors that included wandering and rejection of cares. Resident #25 had no impairment of the upper or lower extremities and did not require use of mobility devices. The Admission MDS revealed that Resident #25 was able to ambulate at least 150 feet independently, transfer independently, and eat independently after set up assistance. Resident #25 had history of a fall in the last ,d+[DATE] months prior to facility admission and utilized a wander/elopement alarm on a daily basis. Diagnoses included Alzheimer's Disease and osteoporosis. A Significant Change MDS, dated [DATE], revealed Resident #25 received Hospice Care services, while a resident at facility, and had one fall with non-major injury since admission (major injury defined in MDS as fall resulting in bone fracture, joint dislocation, closed head injury with altered level of consciousness, or subdural hematoma). The Significant Change MDS revealed that Resident #25 required use of walker and wheelchair for mobility with substantial to maximal staff assistance to ambulate at least 10 feet and dependent on staff to transfer. Resident #25 required supervision or touching assistance with eating and substantial to maximal staff assistance with hygiene and dressing tasks. Diagnoses included: Non-traumatic brain dysfunction, Alzheimer's Disease, and osteoporosis. The Care Plan, initiated [DATE], identified Resident #25 at risk for falls and injury due to wandering and decreased safety awareness. The Care Plan revealed Resident #25 had an unwitnessed fall on [DATE] with a bruise to hip, interventions included a urine dip and an evaluation to be completed by Physical/Occupational Therapy. Fall risk interventions listed in the Care Plan instructed staff to: anticipate the resident's needs, ensure resident wore appropriate footwear when ambulating, provide safe environment with floor free of spills or clutter, adequate light, call light in reach, bed in low position at night, side rails as ordered, handrails on walls, and personal items within reach. On [DATE] at 3:26 PM, Nursing Progress Note revealed a yell had been heard down East Hall at 2:35 PM, Resident #25 observed face down on the floor in another resident's room. The Progress Note informed that Resident #25 had been known to wander, was last seen in lobby area, last toileted around 1:15 PM, and wore grippy socks. Progress Note revealed that active range of motion was intact and that Resident #25 was assisted by one staff to a standing position, then walked down the hall until a staff arrived with wheelchair when Resident #25 still appeared to be unsteady. Resident #25 noted to have sustained a skin tear to left forehead, measuring 2 centimeters (cm) long by 0.5 cm wide, and required skin to be approximated (closed) using 3 steri strips (adhesive skin closures). Nursing documented Resident #25's Power of Attorney (POA) was notified of fall and that the Provider had been faxed with results of a urine dip performed and Resident #25's injuries. A facility facsimile (fax), dated [DATE], revealed an FYI notification sent to Provider which informed that Resident #25 observed prone on the floor in another resident's room and had skin tear to left forehead with steri strips in place. Fax revealed that nursing would monitor every shift for 3 days, then weekly for 3 weeks and included results of a urine dip performed related to POA's indication of past falls with Urinary Tract Infection (UTI). Provider response to fax, dated [DATE], instructed nursing to monitor per facility protocol and to obtain a Urinalysis with culture and sensitivity if indicated. On [DATE] at 10:08 AM, Nursing Progress Note revealed Resident #25 continued on post fall monitoring and had utilized a wheelchair due to an unsteady, weak gait. Progress Note informed that facility was awaiting response from Provider regarding Resident #25's urine dip. Review of Resident #25 Electronic Health Records (EHR), revealed a neurological assessment had been completed on the following dates and times: [DATE] at 2:35 PM, [DATE] at 6:35 PM, [DATE] at 10:35 PM, [DATE] at 2:54 AM, [DATE] at 6:35 AM, [DATE] at 2:25 PM, [DATE] at 10:35 PM, and [DATE] at 7:59 AM. Neurological assessments included normal findings of vital signs, orientation to person/place/time, level of consciousness, pupil size, ability to response appropriately, pain, and movement of extremities. The facility provided two additional hand written neurological assessments, both dated [DATE], and both lacked documentation of the time completed. One hand written neurological assessment informed that Certified Nursing Assistant (CNA) reported difficulty with lower extremity movement when ambulating Resident #25 to the toilet. The second hand written neurological assessment informed that Resident #25 had 3 steri strip closures to left forehead, a large purple bruise to left hip, and bruising to 2 digits on the left hand. The facility provided two pages of hand written Nursing Progress Note. Review of note dated [DATE] at 1:00 PM, revealed a fax had been received related to fall with an order to obtain Urinalysis (UA) with culture and sensitivity. Progress Note also revealed that Resident #25 was unable to stand on her own, leaning to the left when walking, utilizing a wheelchair, and had large bruises noted on left outer hip. Review of a hand written Nursing Progress Note, dated [DATE] at 6:30 PM, revealed Resident #25 ambulated with staff assist of one, was noted to favor left side, and stumble during ambulation. A Provider Visit Note, dated [DATE], revealed Resident #25 had fall on [DATE] with skin tear to head and stable neuros. Provider documented that review of systems taken with assistance from nursing staff and chart review due to Resident #25 poor cognition, with no concerns or acute issues per nursing staff. Provider listed the following under orders and requisitions: monitor unsteadiness and weakness, complete neuro checks per protocol, complete skin checks per protocol, and continue current medications and treatment. On [DATE] at 1:07 PM, a Nursing Progress Note revealed that Resident #25 had not been bearing weight on left leg after fall and a fax was sent to physician about possible x-ray. On [DATE] at 8:40 PM Provider ordered x-ray to include 2 view of pelvis and left hip for acute pain post fall and to monitor bruise until healed. On [DATE] at 1:23 PM, a portable x-ray performed on Resident #25 left hip, results were negative for fracture. Review of Resident #25's Electronic Health Records and paper clinical records, revealed no Provider notification related to change in transfer ability or notification of left hip bruising was documented between the dates of [DATE] and [DATE]. A Change in Condition Assessment completed on [DATE], revealed Resident #25 had recent fall with a decline in mobility, utilized a wheelchair, and required total staff assistance with transfers, mobility, and hygiene. Change in Condition Assessment informed that Resident #25 was unable to bear at least 50% weight on at least 1 leg and unable to sit upright without physical assistance. A Care Conference Note, dated [DATE], revealed that prior to fall, Resident #25 was often found walking around and sitting in staff offices to visit with staff and other residents. At time of Care Conference, Resident #25 required increased assistance in activities of daily living and feeding assistance post fall. Review of a facility fax, dated [DATE], revealed notification to Provider the following information: Physical Therapy (PT) to evaluate, Resident #25 not walked since fall 2 weeks ago. Fax included results of x-ray completed [DATE] of left pelvis/hip. Provider response received [DATE] with order for PT to evaluate and treat. On [DATE] at 6:04 PM, Nursing Progress Note revealed that Resident #25 continued to have a decline, sat at resident assisted feeding table but did not eat, and was noted to be lethargic. Note informed that POA was notified, no documentation of Provider notification for decline in condition. On [DATE] at 10:37 AM, Nursing Progress Note revealed that nurse spoke to on-call Provider at 8:45 AM and received order to send Resident #25 to emergency room for evaluation to rule out stroke. Resident #25 noted to continue with lethargy and decrease in level of consciousness. Resident #25 transferred from facility to hospital via ambulance at 9:40 AM. Hospital Discharge Report, dated [DATE], revealed that Resident #25 had a large subdural hematoma and likely the cause for decline in mental status and functional abilities. Diagnoses listed as Altered Mental Status and Subdural Hematoma. On [DATE] at 1:19 PM, Nursing Progress Note revealed Resident #25 returned to facility via ambulance with diagnosis of subdural hematoma. Note indicated POA requested Resident #25 be admitted to Hospice. On [DATE] at 1:26 PM, verbal orders received from Provider for referral to Hospice services and to discontinue Physical/Occupational Therapy orders. Review of Provider Visit Note, dated [DATE], informed that Resident #25 had unwitnessed fall, was admitted to the hospital, and found to have a subdural hematoma. Provider documented that Resident #25 had significant decline in her status, was weak, lethargic, and slow to respond. Visit Note revealed that Resident #25 had been admitted to Hospice. On [DATE] at 9:45 AM, Resident #25 deceased . Hospice and family present at facility. Note informed that Hospice had contacted Medical Examiner. Resident #25 Certificate of Death, revealed immediate cause of death from complications due to accidental elderly fall, due to or as a consequence of subdural hematoma, due to or as a consequence of unsteady gait and dementia. Manner of Resident #25's death listed as accident with the date and time of injury occurring on [DATE] at 2:35 PM at the facility. A description of injury informed that on [DATE] at 2:35 PM, facility heard a yell and nurse found Resident #25 laying prone, face down on the floor of another residents room, sustained a skin tear on left side of the forehead and that resident did not bear weight on her left leg. On [DATE] at 11:00 AM, Staff B, Licensed Practical Nurse (LPN) revealed that Resident #25 wandered independently throughout the facility prior to fall and that around the same the time of fall, she never walked again. Staff B recalled coming back to work after a weekend and finding that Resident #25 had steri strips on her head and a dark bruise on left hip after a fall. Staff B did not recall speaking with the Provider about Resident #25's decline in transfer ability. Staff B informed that facility protocol for completing neurological assessments was to assess resident every 4 hours, then every 8 hours for 3 days. On [DATE] at 2:40 PM, Staff D, Licensed Practical Nurse (LPN), revealed that Resident #25 had difficulty transferring and ambulating, and required use of a wheelchair, on the morning of her fall. Staff D stated that she had been called to Resident #25's bathroom, sometime shortly after lunch, by Staff N, Certified Nursing Assistant (CNA) due to resident struggling to get up from the toilet. Staff D stated that she helped CNA get Resident #25 up from toilet and recalled that Resident #25 had struggled to get up from the toilet but was able to ambulate once up. Staff D informed that she did not put Resident #25 back in wheelchair because she normally ambulated independently. Staff D stated that about 3 hours after helping to assist Resident #25 up from toilet, fall occurred. Staff D reported that another resident came out of their room and told nurse that Resident #25 fell . When Staff D approached the other resident's room, she recalled that Resident #25 had been laying face down on the floor. Staff D stated that Resident #25 had skin tear to forehead with flap of skin hanging down. Staff D recalled, Resident #25 had been able to move all extremities, was assisted to sit up on the floor, then assisted to a standing position and ambulated out of room and into the hallway. When ambulating in the hallway, Staff D said Resident #25 had been a bit wobbly so another staff got the wheelchair. Staff D stated Resident #25 sat in wheelchair the rest of the day. Staff D stated Provider had been notified of fall with skin tear to head on [DATE] via fax and explained that on weekends the Provider would be faxed unless a resident needed to be sent out. On [DATE] at 2:50 PM Staff N, CNA, stated Resident #25 was in wheelchair prior to fall due to weakness, attempted to get up from wheelchair but couldn't. Staff N recalled reporting to nurse that Resident #25 was unstable in the bathroom from toilet. Staff N stated it was unlike Resident #25 to need help getting up from the toilet, normally transferred and ambulated independently. On [DATE] at 11:58 AM, Director of Nursing (DON) confirmed that Resident #25 ambulated independently without use of assistive device and wandered with steady gait prior to fall. DON recalled Resident #25 had been declining and was sent to the hospital for stroke like symptoms. DON confirmed that a fax was sent to Provider to notify of fall with head injury and revealed an expectation that nurses call Provider for a fall with head injury. DON stated Resident #25 should have been sent to the emergency room (ER) the first day because of head injury. DON unable to provide documentation of additional communication with the Provider related to Resident #25 decline in mobility or condition change. On [DATE] at 12:30 PM, DON for sister facility, assisted facility during State Survey, revealed the expectation for post fall monitoring to include documentation at least every shift for 3 days and, in addition, nursing staff would need to complete neurological checks every 15 minutes x4, then every hour x4, then every 2 hours x4, then every 4 hours x4, then every shift for a total of 3 days. The sister facility DON revealed the expectation of nurses to call, not fax, a Provider immediately when a resident has any condition change and expected if a head injury is known for staff to call Provider and send resident to ER to evaluate. The facility policy titled, Change in a Resident's Condition or Status, dated [DATE], revealed that the nurse will notify resident's Attending Physician or physician on call when there has been a significant change in the resident's physical, emotional, or mental condition and informed that notifications will be made within 24 hours of change, except in medical emergencies. The policy defined significant change of condition as a major decline or improvement in a resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. b. Impacts more than one area of the resident's health status. c. Requires interdisciplinary review and/or revision to the Care Plan. d. Ultimately is based on the judgement of the clinical staff. 2. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. Resident #20 utilized a wheelchair for mobility and required substantial to maximal amount of staff assistance to transfer. The MDS revealed that Resident #20 had one fall without injury since the previous assessment. Diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, heart failure, and psychotic disorder. The Care Plan, revised [DATE], revealed Resident #20 at risk for injury from falls related to impaired mobility, bilateral macular degeneration, lumbar stenosis, Congestive Heart Failure, Peripheral Vascular Disease, dementia with mood disturbance, delusional disorder, and osteoarthritis of right knee. The Care Plan informed that Resident #20 had an unwitnessed fall without injury on [DATE]. Fall intervention instructed staff to keep bed at appropriate height in order for resident to stand safely. A Nursing Progress Note, dated [DATE] at 9:12 AM, revealed Resident #20 was found on the floor in room and indicated that resident had slid out of bed onto the floor. Note informed that neurological assessments would be completed per facility protocol and that notification of fall was provided to physician, family, Director of Nursing (DON), and Facility Administrator. On [DATE] at 6:47 PM, a Nursing Note informed that no injuries had been observed post fall, Resident #20 able to ambulate and transfer per baseline. On [DATE] at 10:14 AM, Nursing Note informed that neurological checks were within normal limits and Resident #20 had no complaints of pain. No additional documentation provided in Nursing Progress Notes related to fall on [DATE]. Review of Resident #20's Electronic Health Records (EHR) revealed 2 neurological assessments had been completed on [DATE], at 3:46 PM and 9:57 PM, related to unwitnessed fall on [DATE]. On [DATE] at 12:30 PM, Director of Nursing (DON) from sister facility, assisted with State Survey, revealed an expectation for post fall monitoring to include documentation at least every shift for 3 days and in addition nursing staff would need to complete neurological checks every 15 minutes x4, then every hour x4, then every 2 hours x4, then every 4 hours x4, then every shift for a total of 3 days The facility policy titled, Fall Management System, dated ,d+[DATE], revealed expectation for resident evaluation to include the following: 1. Any fall that involves an actual head injury and all un-witnessed falls will include follow-up neurological checks. Neurological checks will be documented. 2. When a resident sustains a fall, an evaluation may include investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. The investigation and appropriate interventions will be evaluated at the time of the fall and reviewed by Nursing Management or the IDT. Interventions secondary to the investigation will be documented in the Care Plan, as indicated. The facility policy titled, Neurological Evaluation, dated [DATE], revealed a Neurological evaluation may be indicated following an unwitnessed fall and instructed staff to complete evaluation every 15 minutes for an hour, then every 30 minutes for 4 hours, then every 1 hour for 2 hours, then every shift for 72 hours unless otherwise specified by physician order. Policy revealed expectation for documentation of neurological evaluations to include date and time procedure was performed, all assessment data obtain during procedure, if resident refused the procedure, and the signature and title of person recording the data. 51573 3. The Medical Diagnosis form in Resident #226's Electronic Health Record had the following diagnoses listed: dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid irritates the throat), and mild cognitive impairment (difficulty processing thoughts). Resident ' s #226 ' s diet texture was ordered pureed texture with thin liquids. The Dysphagia Facility Policy, dated [DATE], directed staff to identify the cause of the dysphagia and obtain symptom details for proper treatment. The Care Plan, initiated on [DATE], instructed staff to serve diet as ordered. On [DATE] at 11:20 a.m., Staff A, [NAME] served Resident #226 a plate of regular consistency food. One minute later, Staff A, [NAME] came back and stated that he knew he was going to screw that up and proceeded to take the food away from Resident #226 after he had consumed several bites of food. At that time the resident had began excessively coughing with a large amount of phlegm coming from mouth and nose. On [DATE] at 11:22 a.m., Resident #226 stopped coughing and drooling. On [DATE] at 11:24 a.m., Resident #226 was served the correct consistency and proceeded to cough with eating intermittently, but was able to eat some more food of the pureed consistency. On [DATE] at 11:30 a.m., the DON was interviewed on what Resident#226's diet is ordered as and she stated that it is puree texture with thin liquids and handle cups. She stated that she provided it to the kitchen herself prior to the resident's arrival. She was then queried on what would happen if Resident #226 would be provided with regular consistency food and she stated that he would most likely choke because he eats his food very fast. At this point in time, the State Agency (SA) notified the DON of the findings to allow for appropriate assessment and interventions for this resident. On [DATE] at 11:38 a.m., interview from Staff A, Cook, revealed that the dietary staff get the dietary information from the nurses. Staff A, Cook, acknowledged that he provided the resident with regular consistency food and then noticed that his count was off for plates so he and went back to fix it. Staff A, Cook, acknowledged that Resident #226 would probably choke if he ate regular consistency food. When queried about the location of the modified diet postings in the kitchen, Staff A, stated that it is posted in the kitchen and that it is also in a book. Staff A, stated that he does not utilize the books because he has struggled with them. On [DATE] at 11:48 a.m., Resident #226 was found lying in his room alone. The Resident stated that he was fine and he did not feel short of breath. At that time, the resident was noted to still have an intermittent cough. The resident denied feeling like there was anything stuck in his throat. On [DATE] at 12:14 p.m., a second interview with the DON revealed that the resident had not yet had vitals or had an assessment and the physician had not been aware of the resident receiving the wrong consistency of food. The DON stated that she had a text out to the physician but had not talked with him yet. The DON reported that she had not yet done an assessment or vitals due to behavioral issues with this resident. Observation on [DATE] at 12:47 p.m., revealed Resident #226 was observed lying in bed with a blanket covering him, and a nurse walked out of the room at that time. On [DATE] at 12:50 p.m., interview with Staff B, LPN revealed that she had assessed Resident #226 at approximately 12:30 p.m. and that vitals and lung sounds did not reveal anything out of the ordinary to her. When asked for the vitals, she stated that she had provided them to the DON for her to document.

Based on observation, interview, and record review the facility failed to ensure evaluation of a mobility device prior to resident use, failed to ensure gait belt utilized for transfer, failed to remain with a resident when a non-verbal resident suspected to have a seizure resulting in a fall, failed to ensure adequate supervision for resident with known history of falls when the resident was found multiple times post unwitnessed fall in the lobby of the facility, failed to ensure residents' feet were placed on wheelchair foot pedals when residents assisted via wheelchair, and failed to ensure residents remained free from environmental hazards when one resident ingested a [NAME] egg and another resident obtained access to a locked restroom without the knowledge of facility staff for six of ten residents reviewed for accidents (Resident #2, Resident #3, Resident #5, Resident #10, Resident #21, and Resident #22). This deficient practice resulted in the following injuries: Resident #2 sustained bruises and a head laceration on 6/22/24. Resident #22 sustained a laceration to the right orbit with surrounding bruising, pain, and multiple skin tears sustained from falls on 7/5/24, 8/22/24, and 9/3/24. Resident #5 sustained bruising to the right forehead, pain, and a shattered humerus related to a fall on 11/1/24 and was hospitalized . Findings include: 1. Review of the Annual Minimum Data Set (MDS) assessment for Resident #5 dated 9/18/24 revealed the resident scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. a. Review of Resident #5's Care Plan dated 4/2/21, revised 11/1/24, revealed the following: [Resident #5] is at risk for injury from falls r/t (related to) hx (history) of right (R) femur fx (fracture), dementia, diabetes, anemia, neurogenic bladder, muscle atrophy, hx of TIA/CVA (Transient ischemic attack/Cerebrovascular accident). Falls: 11/1/24 witnessed fall with injury. Interventions per the Care Plan included the following: a.(Initiated 2/15/24, revised 9/10/24): Gripper strips to bed. b. (Initiated 2/15/24, revised 9/10/24): Gripper strip toilet. c. (Imitated 11/1/24): Send to ER (emergency room ) for evaluation d. (Initiated 2/15/24, revised 9/10/24): Toilet rails Review of the Therapy Communication Form dated 1/26/24 revealed, in part, pt. (patient) is functional independent with 4 ww (wheeled walker) gait in hallway & common spaces after assist with stance WBAT (weight bearing as tolerated). Review of the Late Entry Nursing Note dated 10/30/24 at 11:00 AM revealed, Maintenance gave three wheel walker to resident after being notified by Maintenance manager that this is the only walker that he has available at this time. [NAME] was given to resident by Maintenance manager. Maintenance Manager had been notified of wheels loose on resident's normal four wheel walker and needing it to be fixed or replaced. Review of the Fall Incident Report dated 11/1/24 at 7:38 AM for Resident #5 revealed, Nurse made aware of witnessed fall at 0738 from house keeping down [NAME] hall way. Resd (resident) utilizing new 3ww (wheeled walker) et was turning around when she lost her footing. Resd Observed lying on rt side, head against wall, sensation et movement to extremities, able to move rt hand when asked, unable to assess AROM (active range of motion) to rt (right) arm at this time as she was lying on it. Resd x1 (times one) assisted to chair in activity room, utilized walker with rt (right) hand, gripping activity director shirt with lt (left). 3x3cm (centimeter) bruise noted to rt (right) forehead .When skin protectant sleeve on rt arm rolled back up from obtaining BP (blood pressure) resd called out in pain. Swelling noted to rt arm et resd does not move extremity when asked. Verbal order to send to ER obtained at 0755 from [Name Redacted] fax out for signature .Ambulance arrived at 0835 (8:35 AM), paramedic notes crepitus to rt arm, when requested to transport to [Location Redacted] medics refuse as hey state We're not sure if its broken so we will start with x-ray in [Location Redacted]. [Resident #5] left facility via ambulance at 0841, MAR (Medication Administration Record)/TAR (Treatment Administration Record), IPOST (Iowa Physician Orders for Scope of Treatment), face sheet et hospital transfer form sent with. Per the Incident Report dated 11/1/24, Resident #5 had a bruise to the top of the scalp and pain score of 6. The Incident Note dated 11/1/2024 at 1:58 PM revealed, [Name Redacted] ER (emergency room ) nurse from [Location Redacted] called facility, informed this nurse that [Resident #5's] humorous <sic> is shattered. [Resident #5] is to be transported to [Location Redacted], et ER has already notified POA (Power of Attorney). Review of a Radiology Report of the resident's right elbow completed on 11/1/24 at 9:45 AM, with reason for process documented as bruising around elbow and fall, revealed the following: Findings/Impression: Comminuted fracture of the distal humerus with separation of medial and lateral epicondyles. Note of 49 mm (millimeter) butterfly fragment. There is foreshortening and posterior displacement of the distal fracture fragments with respect of the proximal humerus. There is dislocation of the humeral ulnar joint. Review of Hospital Records dated with admitted [DATE], and date of discharge 11/4/24, revealed the following admitting diagnoses: fall, hematoma over R (right) frontal area, just above R eye, distal R humerus fracture, and slightly angulated/overlapping, and UTI (urinary tract infection). On 11/07/24 at 10:55 AM Staff F, Housekeeper queried regarding Resident #5. When queried if she was familiar with the resident, Staff F responded she was. When queried if she worked when the resident had fallen, Staff F explained here recently she was getting ready to mop the [NAME] hall, happened to turn, and [Resident] was losing balance when tried to turn her walker around. Staff F explained the resident's walker had gotten stuck when [Resident] was turning around and happened to lose balance. Staff F explained went to try to catch [Resident], and didn't get to her in time. Staff F queried where occurred, and responded between the activity door and [NAME] hall. Per Staff F, the resident had walker with her, and walker was 3 wheel walker the resident had recently gotten. When queried if Staff F saw resident fall, said yes. When queried what happened next, Staff F explained the resident had fell and hit head on the wall, and landed on her right side. When queried about visible injuries, Staff F responded she did not notice any visible injuries. Staff F acknowledged there were no staff around that (Staff F) saw when resident fell . Per Staff F, after the fall was a bruise on the resident's forehead. Staff F explained resident did not say anything when she fell , and did not call out or anything like that. On 11/7/24 at 11:50 AM, the Director of Nursing (DON) explained there was not a PT/OT evaluation done for Resident #5's 3 wheeled walker. The DON explained for a new piece of equipment, usually got from maintenance. The DON explained called maintenance because of resident's walker wheel. Per the DON, the resident was ordered to use 4 wheeled walker, and DON explained called to have it fixed and replaced with other 4 wheeled walker. The DON further explained facility was getting a new admission at the time, maintenance came out with a walker, was told it was the wrong walker, maintenance said it was brand new, and DON said it was wrong walker. The DON explained she went to the admission, staff had the resident sitting in a chair, maintenance gave 3 wheeled walker, and definitely should not have. The DON explained did not know if was another 4 wheeled walker or not, and didn't have access to storage. The DON explained if a witnessed fall, they would do statements and had a fall report checklist. Per the DON, statements were turned into the DON if witnessed, otherwise everything was typed into notes in [electronic health record system]. The DON statements for witnessed falls were very rare, and most if not all were unwitnessed. When queried about root cause analysis, the DON explained do follow up when go though the fall incident report. When queried where would find root cause, the DON explained it was also in the incident report, and did not know if it was printed into the incident report or not. On 11/12/24 at 11:38 AM, Staff E, Registered Nurse (RN) queried about resident's arm/injury. Staff E responded the resident had four breaks, and was just told she fell . Staff E further explained was not present when it happened, and got it in report. Per Staff E, the resident normally had a 4 wheel walker with seat, the bearings were out she guessed, and someone got the resident a 3 wheeled walker. Staff E explained a staff member (Staff I, Certified Nursing Assistant) said they were not getting resident up with the 3 wheeled walker, and another staff member said the resident had used it yesterday fine, and would get her up. Per Staff E, Staff I had already said wanted no part in that. Staff E queried what she thought about the 3 wheeled walker, and provided the following description: little kid's walker, very tiny width, handles, no seat, really narrow and didn't look maneuverable. Staff E further explained in a conversation with staff member (staff member who had previously said not getting resident up with 3 wheeled walker), Staff E told Staff I they called it, [Resident #5] broke arm. On 11/12/24 at 2:19 PM an interview completed with Staff D, Licensed Practical Nurse (LPN) who had completed the resident's incident report on 11/1/24. Staff D explained she didn't see it happen, and Staff F, Housekeeping witnessed and brought to attention. Per Staff D, resident in hall, walked independently with walker, and had new walker that Staff D not aware of at all. Resident #5 using new walker, was normally pretty steady, could have lost balance, and fell right side. Per Staff D, the resident was not in pain, was able to move, and was holding onto walker with broken arm. Staff D explained Resident #5 pretty much non-verbal, and when ask if in pain the resident doesn't say anything. Staff D further explained with upward motion and bringing geri sleeve up, the resident cried out in pain. Staff D explained she contacted medics and family, and when the medics got there didn't think the arm was broken, Staff D tugged geri sleeve again, and the resident screamed in pain. Per Staff D, medics said didn't think was broken and to start x-ray in [Location Redacted], while the other medic felt crepitus. Per Staff D, the resident did have a bump on the head. On 11/18/24 at 8:54 AM, Staff I, Certified Nursing Assistant (CNA) explained, in part, Resident #5 walked with a front wheeled 4 wheel walker, because she could not do a 3 [NAME] had never been trained on it. When queried if Resident #5 ever had a 3 wheeled walker, Staff I responded two weeks ago before fall had the bearing going out of her (Resident #5's) walker and maintenance gave her a 3 wheel walker. Per Staff I, she thought the resident got the walker on a Thursday, Staff I had worked that night 10 to 6, and Friday morning the resident had it sitting there. Staff I explained she did not get Resident #5 out of bed because Staff I did not feel comfortable. Per Staff I, that morning (Resident #5) fell . Staff I explained Resident #5 was like a cylinder and Staff I did not feel comfortable to use the 3 wheel walker. Per Staff I, the resident stayed in bed until the day shift got her up, and Staff I asked the nurse if was ok to leave Resident #5 in bed until the day shift as there were no notes for her to use it (3 wheel walker). Staff I explained just played it safe. When queried about communication would occur, Staff I explained usually in nurses notes, and during report when walked in room checked resident if something different, then would ask the nurse. Per Staff I, she passed it to day shift, and they said would check into it. Observation on 11/05/24 at 12:36 PM revealed Resident #5 in the common area with bruising present to the right side of the resident's head. Resident had green bruise to right forehead. No staff observed in line of sight of the nursing desk/common area at time of observation. There was a housekeeping staff observed in the North hall. Other staff not observed to be present. Observation on 11/13/24 at 9:59 AM revealed Resident #5 in wheelchair in the common area. On 11/13/24 at 12:13 PM, the Maintenance Supervisor interviewed about Resident #5's walker. Per the Maintenance Director, somebody said the resident's walker wheels were acting weird, the Maintenance Supervisor looked at it, and the bearings were popped out. The Maintenance Supervisor explained found other one (walker) that had brought in. The Maintenance Supervisor described the walker with the bearings popped out as a walker with 4 wheels with handles and breaks on it. The replacement walker was described as follows by the Maintenance Supervisor: Had same stance, 3 wheels, and had break cables like the resident was used to. When queried if facility had any 4 wheel walkers available, the Maintenance Supervisor responded just the ones without wheels that put tennis balls on. The Maintenance Supervisor queried not like the walker the resident had, and confirmed. Per the Maintenance Supervisor, he was not sure where the 3 wheeled walker came from, it was in facility's storage. When queried if any staff expressed concerns with using the 3 wheeled walker for the resident, the Maintenance Supervisor denied, and explained he adjusted the handles down to meet the height of the resident's old one (walker) so it was the same height. On 11/19/24 at 2:56 PM the facility's Administrator explained was not the fault of the walker, was the fault of her (Resident #5's) feet. Per the Administrator, had done education about with any change in equipment, maintenance, therapy, and the DON review. The Administrator then explained she was not sure the cause was related to the resident's footing. When queried regarding an evaluation for a resident's new piece of equipment, the Administrator explained should be evaluated by therapy. When queried if there should be an evaluation when going from 4 wheel to 3 wheel walker, the Administrator responded yes. b. Review of Resident #5's Care Plan dated 4/2/21 and revised 2/15/24 revealed, [Resident #5] requires assist with ADL's (activities of daily living) due to impaired mobility, recent hip fx (9/2023), Alzheimer with dementia, diabetes mellitus, anemia, edema, neurogenic bladder, atrophy of muscles, depression/anxiety, TIA & CVA. The Intervention revised on 9/10/24 revealed, ASSISTIVE DEVICES: w/w (wheeled walker); w/c (wheelchair) PRN (as needed) for appointment. Observation conducted 11/5/24 at 12:41 PM revealed Staff C, Certified Nursing Assistant (CNA) assisted Resident #5 down the hallway in the wheelchair, and the resident's right foot observed off of the foot pedal and skimmed across the floor while the resident was assisted. 2. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 6/21/24 revealed the resident scored 1 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident severely cognitively impaired. Per the assessment, the resident had not had any falls since admission, entry, reentry, or prior assessment, had physical behavioral symptoms 1-3 days, had verbal behavioral symptoms 4-6 days, and other behavioral symptoms 1-3 days, and wandered 1-3 days. The resident's MDS dated [DATE] revealed the resident scored 00 out of 15 on BIMS exam, which indicated severely impaired cognition. Per this assessment, Resident #22 had falls since admission, entry, reentry, or prior assessment, two with no injury and two with injury (except major). The Care Plan dated 6/17/24 revised 10/14/24 revealed, [Resident #22] is at risk for falls and has had a fall related to impaired balance, poor safety awareness, functional impairment and the use of medications that may increase falls risks. a. 6/17/24 Fall with injury b. 6/24/24 Fall without injury c. 7/2/24 Fall without injury d. 7/5/24 Fall without injury e. 9/3/24 Fall with skin tear f. 9/30/24 unwitnessed fall without injury g. 10/9/24 unwitnessed fall without injury h. 10/14/24 witnessed fall with skin tear Interventions per Resident #22's Care Plan included the following: a. (Initiated 7/2/24, revised 9/10/24): Dycem placed below and on top of cushion in wheelchair. b. (Initiated 9/30/24): Educate and encourage family visits for orientation purposes. c. (Initiated 9/30/24): Educate family about fall risks and increased weakness due to resident weight loss and refusal to eat much at meal or snack times. d. (Initiated 6/17/24, revised 6/19/24): Ensure [Resident #22] is wearing appropriate footwear when ambulating or utilizing their wheelchair. Resident prefers to wear open toe shoes. e. (Initiated 6/19/24, revised 9/10/24): Fall mat at bedside. f. (Initiated 6/17/24): Follow all facility protocol related to falls ie: initiation of neuros (if applicable), fall report/investigation, immediate interventions and long term interventions, informing of physician/family. g. (Initiated 6/17/24, revised 9/10/24): Gripper socks in place when out of bed. h. (Initiated 7/5/24, revised 9/10/24): [Resident #22] was given a different wheelchair that Dycem holds to better than previous wheelchair. i. (Initiated 10/14/24): Offer and encourage resident to rest between meals or when she appears drowsy in wheelchair. j. (Initiated 6/17/24, revised 9/10/24): PT/OT (physical therapy/occupational therapy) to eval and treat if appropriate due to fall. k. (Initiated 10/9/24): Reorient resident to her own room and belongings any time that she is found in the hallways. l. (Initiated 9/3/24, revised 9/10/24): Staff to check on resident frequently when in the area that resident is in. Review of Incident Reports and the clinical record for Resident #22 revealed the following: The Incident Report dated 6/17/24 at 9:00 AM revealed, This nurse was in another resident's room when I heard a yell, walked out the door, resident sitting on floor near North hall back door, with back against wall .R (right) leg moved without pain, L (left) leg-hip pain. Dr. notified, verbal orders to send resident to ER (emergency room ) for evaluation and treat for pain to L hip. A predisposing situation factor was improper footwear. The Immediate Action Taken section revealed, ask family about replacing shoes. Discharge instructions from the Emergency Department dated 6/18/24 at 9:47 AM revealed, L (left) hip fx (fracture)-nonsurgical, walk with walker. Review of the Physician Note dated 6/20/24 revealed, in part, the following for Resident #22: Alert and oriented to person. Dementia. Episodes of confusion and disorientation. She has been having delusions about her medications and staff .She has a history of osteoporosis and hip fractures .She was sent to the ED (Emergency Department) after a fall on 6/17/24 and was found to have a left hip fracture. Uncertain if it was new or a previous fracture. It was non-surgical. The Nursing Note dated 6/19/24 at 1:02 PM revealed, Fall Interventions: fall mat next to bed, gripper socks on at all times when out of bed, PT/OT eval and treat if appropriate. The Incident Report dated 6/24/24 at 5:05 PM revealed, Was called to room [number redacted] to find resident sitting on her hands and knees in front of the bathroom facing the bathroom in front of her w/c (wheelchair). The Immediate Action Taken section revealed, in part, was helped by 2 CNAs and gait belt to her w/c then she was transferred to the bathroom, resident was then brought to the nurses station where this writer was able to have one on one with resident, to help with redirecting of resident. The Incident Report dated 7/2/24 at 10:45 AM revealed, Resident was wheeling herself down west hallway, the 2nd door on the left she tried to open, shaking the door handle, when it didn't open resident slid herself, cushion and all to the floor. Witnessed by activity aide, resident, didn't hit head. The Immediate Action Taken section revealed, Place dycem below cushion in wheelchair and on top of cushion in wheelchair. The Incident Report dated 7/5/24 at 1:28 PM revealed, Activity director notified this nurse of resd seated on the floor at 1328 (1:28 PM). Resd previously exit seeking. Resd observed by front lobby entrance seated in front of w/c on w/c cushion dycem in place below et (and) on-top of w/c cushion. AROM (active range of motion) intact, x3 skin tears to outer rt (right) forearm from elbow down 1.7x1cm, 2x1cm, 0.8x0.5cm, areas cleansed with steri strips put in place. The Immediate Action Taken section revealed, New w/c provided that is more suitable for dycem to prevent sliding out. Review of a Fax dated 7/25/24 revealed, in part, post fall injuries x3 skin tears from elbow down to rt (right) outer forearm 1.7x1cm, 2x1 cm, 0.8x0.5cm areas cleansed et approximated c (with) steri strips. The Immediate Action Taken section revealed, New w/c provided that is more suitable for dycem to prevent sliding out. The Incident Report dated 8/22/24 at 1:43 PM revealed, This nurse was called to the reception/lobby area. Resident suffered an unwitnessed fall. [Resident #22] was lying flat on the floor with legs out. Blood noted on right side of forehead with bruising. Bleeding stopped by providing pressure to the area. Resident voices complaints of pain from hitting head on floor. The Immediate Action Taken section revealed, Resident wearing sandals at time of incident, sandals removed and resident allowed grip socks to be placed. Review of the Nursing Note for Resident #22 dated 8/22/24 at 1:43 PM revealed, in part, This nurse was called out to reception/front lobby. [Resident #22] was noted to be lying on the floor with legs outstretched near chairs/table. Blood noted to left forehead. Staff and other residents reporting she fell . Staff did not witness event. The N-Weekly Non Pressure Wound Assessment V2 Form completed 8/22/24 at 3:52 PM revealed the following: FYI (for your information) post fall skin assessment was written on the form. A wound was documented to the resident's face described as follows: rt (right) orbital 1.3x0.3cm (centimeter) laceration with surrounding bruise of 7x7cm. Review of Resident #22's Care Plan to address falls lacked documentation of the resident's fall with injury in the list of resident's falls in the focus area of Resident #22's Care Plan, and lacked any interventions added in August 2024. The Incident Report dated 9/3/24 at 3:44 PM revealed, Called 15:30 (3:30 PM) to North hallway, unwitnessed fall, when resident was with Administrator and another resident standing nearby. Resident was standing and talking when I started initial assessment. Resident denies pain of discomfort at this time Skin tear to right upper arm 5'' x1.5''. The Immediate Action Taken section documented an assessment of the resident. Review of a Fax dated 9/3/24 at 3:50 PM revealed, in part, unwitnessed fall skin tear to right arm. The Fall-Initial Note dated 9/3/24 at 3:30 PM revealed the following cause: Unwitnessed fall due to confusion. The Incident Report dated 9/30/24 at 2:35 PM revealed, This nurse heard a loud thud, entered lobby to find resident laying on her right side with her wheelchair tipped over top of her. The Immediate Action Taken section revealed, ROM (range of motion) assessed without any abnormal range of motion observed or reported. Resident assisted with x2 assist to wheelchair. Resident denies pain. Review of a Fax dated 9/30/24 at 2:35 PM revealed, unwitnessed fall from wheelchair. no injuries observed at this time. Will monitor per policy. Review of the Fall Risk Evaluation dated 9/30/24 revealed Resident #22 scored 17 on the assessment, which indicated high risk. The Incident Report dated 10/9/24 at 12:45 PM revealed, This nurse alerted by housekeeping that this R (resident) was on the floor and the drawers on other R dresser were open and (et) R arm was in one sleeve of jacket .R was helped up into her wheelchair et back to her room et laid down. R is unable to respond correctly as is her usual. The Immediate Action Taken section revealed, R (resident) helped off floor and taken to bed. Per the Incident Report, a predisposing situation factor was bare feet or inappropriate footwear. The Fall Risk Evaluation dated 10/9/24 revealed Resident #22 scored 21 on the assessment, which indicated high risk for falls. The Incident Report dated 10/13/24 at 6:02 PM revealed, Resident sitting in w/c by nurses desk, slipped to floor hitting left elbow on wall on the way down. The Immediate Action Taken section revealed, Vitals, assisted back into w/c cleansed and applied dressing to elbow. The Fall Risk Evaluation dated 10/13/24 revealed Resident #22 scored 25 on the assessment, which indicated high risk. Observation on 11/13/24 at 10:02 AM revealed Resident #22 tilted back in broda chair in the television area/nursing station in the front of the facility. On 11/13/24 at 9:09 AM, Staff C, Certified Nursing Assistant (CNA) queried if at facility when Resident #22 had fallen, and responded she was sure she was. Staff C explained now the resident did not ambulate at all, and explained the resident went downhill really fast. Staff C explained she thought a lot of the resident's falls happened on the weekends. When queried how fall risk was communicated, Staff C explained usually through the nurses on report. When queried if the resident's current wheelchair was from hospice, Staff C acknowledged it was. Staff C explained the resident was in a regular wheelchair before, and wasn't working out too well. Staff C explained the resident was leaning over and leaning too forward, and was so much comfier in chair and looked so much better in it too. On 11/13/24 at 12:55 PM, Staff G, Registered Nurse (RN) explained when she first went to the facility, resident was walking. Staff G explained not having enough staff at the facility because they were all out on break instead of watching residents Per Staff G, she had CNAs on break all the time not telling that they went on break. Per Staff G, the resident started failing and was put on hospice. When queried if she had ever worked when the resident had fallen, Staff G denied. When queried about increased monitoring for the resident, Staff G responded just the behaviors, explained the resident had tried to bite a staff member when intervened, and further explained made sure to keep an eye on her and know where was at, at least where located. On 11/18/24 at 10:36 AM, interview conducted with Staff J, CNA regarding Resident #22 and falls. When queried if she had been at facility when Resident #22 had fallen, Staff J replied always. Per Staff J, when resident first at facility would walk, would put self on the floor, and was care planned now for laying on the floor. When queried if Resident #22 was someone who could be left in the common area without staff watching her, Staff J responded no, and further explained the resident still had energy and strength to sit self up, and personally she wouldn't do so. Staff J explained now resident in a wheelchair, and have caught her trying to stand up to side of wheelchair, trying to dangle legs. Staff J explained when the resident used to have an actual wheelchair she would get up and start walking down the hallways, and now the resident had a reclining wheelchair. On 11/18/24 at 8:59 AM, Staff I, CNA acknowledged Resident #22 had fallen a couple of times, and not for Staff I. Staff I explained when resident at the front desk liked to climb out of geri chair, and eased self down or sat down. When queried what the resident tried to do, Staff I explained the resident was busy, felt needed to go shopping, traveling, and was in her own world. Staff I further explained the resident had their current chair for a month/month and a half, and could get out of it. Per Staff I, even though it tilted rolled off to the side, and explained the resident was very agile. When queried about watching persons in the lobby, Staff I explained it depended upon who it was, and explained the following pertaining to Resident #22: If people like [another resident redacted] or [Resident #22], tried to keep someone up there behind the desk, a couple times would get laundry to have them help fold towels, and keep them busy, get them out of their bubble so not so agitated. On 11/19/24 at 2:59 PM, the Administrator queried if she had been at facility when Resident #22 had fallen, and denied. The Administrator explained for the last six to eight weeks the resident had been pretty much wheelchair bound. 35434 3. On 11/6/24 at 6:06 a.m., Staff B Licensed Practical Nurse(LPN) placed Resident #6's Lisinopril(a blood pressure medication) 5 milligrams(mg) and Olanzapine(an antipsychotic) 10 mg into a medication cup and placed it on top of the medication cart. Staff B left the medication cart and entered the medication room and closed the door. The Director of Nursing(DON) was present on the other side of the nursing station but left the vicinity for approximately 1 minute. When the DON returned, Staff B was still in the medication room. The DON picked up the medications and when Staff B returned to the cart, she handed the medications back to her. Untitled facility lists documenting cognitive status and mobility, listed 13 cognitively impaired, independently mobile residents. The facility policy Storage of Medications, revised 4/2007, stated the facility would store all drugs in a safe, secure, and, orderly manner. On 11/19/24 at 1:57 p.m., the Administrator stated medications should not be left unattended. 4. The Minimum Data Set(MDS) assessment tool, dated 3/14/24, listed diagnoses for Resident #2 which included seizure disorder, anxiety disorder, and depression. The MDS stated the resident required partial to moderate assistance to transfer from chair to bed and listed his cognitive skills for daily decision making as moderately impaired. Care Plan entries, dated 5/17/13, stated the resident had the potential for uncontrolled seizures resulting in a safety hazard and falls and stated he would have no major injury related to his seizure disorder. An 8/1/19 Care Plan entry directed staff to keep a gait belt on the resident when he stood while dressing and to keep ahold of him by the gait belt so he could be assisted if he lost his balance. A 9/16/20 Care Plan entry directed staff to quickly assist the resident to lie down if he felt a seizure coming on. A 10/25/21 Care Plan entry stated the resident required the assistance of one staff member for transfers. Care Plan entries, dated 4/11/22, directed staff to not leave the resident alone during a seizure and protect from injury. The Care Plan directed staff to help the resident to the floor to prevent injury if the resident was not in bed. Care Plan entries, dated 6/24/24, stated the resident was at risk for falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment, and the use of medications that may increase fall risks related to a diagnosis of seizure disorder. The entries directed staff to encourage him to ask for assistance when transferring, check on him frequently, and offer assistance with any activities of daily living(ADLs). a. Resident #2 Falls A 5/12/24 BHCP-Falls9 Report stated a Certified Nursing Assistant(CNA) assisted the resident to transfer from the wheelchair to the bed and he lost his balance and fell to the side . The CNA was unable to stop his fall and was not using a gait belt during the transfer. The resident sustained a bruise to the left iliac crest(the upper portion of the frontal pelvic bone). A 6/22/24 6:22 p.m. Incident Note stated the resident placed his call light on during meal time and the nurse lef [TRUNCATED]

Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide the correct diet for 2 of 5 residents reviewed for nutrition(Residents #11 and #226). The facility reported a census of 26 residents. Findings include: 1. The Care Plan, dated 10/31/24, revealed that Resident #226 has nutritional problem or potential for nutritional problem and required regular diet with pureed texture, and instructed staff to serve diet as ordered. Resident #226 diet order, dated 10/31/24, revealed order for regular, puree texture diet and thin liquids. Review of Nutritional Assessment, dated 11/04/24, informed that Resident #226 is at increased risk for altered nutrition due to co-morbidities, chewing and swallowing difficulty, and modified texture. The Discharge Summary from previous nursing home, dated 10/31/24, stated that resident needed supervision with eating and that resident should be served one food at a time with a small spoon . On 11/04/24 at 11:20 a.m., Staff A, [NAME] served Resident #226 a plate of regular consistency food. One minute later, staff A, cook came back and stated that he knew he was going to screw that up and proceeded to take the food away from Resident #226 after he had consumed several bites of food. At that time the resident had began excessively coughing with large amount of phlegm coming from mouth and nose. On 11/04/24 at 11:22 a.m., Resident #226 stopped coughing and drooling. On 11/04/24 at 11:24 a.m., Resident #226 was served the correct consistency and proceeded to cough with eating intermittently, but was able to eat some more food of the pureed consistency. On 11/04/24 at 11:30 a.m., the Director of Nursing (DON) was interviewed on what Resident#226 ' s diet is ordered as and she stated that it is puree texture with thin liquids and handle cups. She stated that she provided it to the kitchen herself prior to the resident ' s arrival. She was then queried on what would happen if Resident #226 would be provided with regular consistency food and she stated that he would most likely choke because he eats his food very fast. At this point in time, the State Agency (SA) notified the DON of the findings to allow for appropriate assessment and interventions for this resident. On 11/04/24 at 11:38 a.m., interview from Staff A, Cook, revealed that the dietary staff get the dietary information from the nurses. Staff A, cook, acknowledged that he provided the resident with regular consistency food and then noticed that his count was off for plates so he and went back to fix it. Staff A, cook, acknowledged that Resident #226 would probably choke if he ate regular consistency food. When queried about the location of the modified diet postings in the kitchen, staff A, cook stated that it is posted in the kitchen and that it is also in a book. Staff A, Cook, stated that he does not utilize the books because he has struggled with them. On 11/04/24 at 11:48 a.m., Resident #226 was found lying in his room alone. The Resident stated that he was fine and he did not feel short of breath. At that time, the resident was noted to still have an intermittent cough. The resident denied feeling like there was anything stuck in his throat 2. The Minimum Data Set(MDS) assessment tool, dated 8/28/24, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, anxiety, and psychotic disorder. The MDS listed a Brief Interview for Mental Status(BIMS) score of 0 out of 15, indicating severely impaired cognition. On 11/6/24 at 11:23 a.m., Resident #11 ate [NAME] slaw which contained shredded cabbage approximately a half inch long. An Order Details report listed a 5/30/24 order for a mechanical soft ground meat diet texture. The Week 1 Wednesday Menu directed staff to serve residents on a regular diet creamy coleslaw and residents on a mechanical soft diet steamed cabbage. On 11/6/24 at 12:42 p.m., the Certified Dietary Manager(CDM) stated she served Resident #11 [NAME] slaw because she did not have extra cabbage(to boil). She stated she cut it down to a smaller size for her to eat. On 11/19/24 at 11:59 a.m. via phone, the Director of Nursing(DON) of a sister facility stated the facility should follow diet orders. The facility policy Therapeutic Diets, revised October 2017, stated diets would be determined in accordance with the resident's treatment goals and would include modifications in texture.

Based on observations, record review and staff interviews, the facility failed to implement the floatation of heels or attempt to prevent deep tissue injury to the Resident #1's left foot, which resulted in a pressure ulcer. The facility reported a census of 36 residents. Findings include; 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 04/11/12, which indicated the resident required the total assistance of 2 people for bed mobility, transfer and did not ambulate. The resident had limitation in range of motion of both upper and lower extremities and required a wheelchair for mobility. The [DIAGNOSES REDACTED]. The MDS identified the resident at risk for developing pressure ulcers. The treatments for skin per the MDS were pressure reducing devices for chair and bed. Application of nonsurgical dressings other than to feet and application of dressings to feet. The resident care plan run date of 4/18/12 indicated the approaches directed staff to: - padded foot rest to wheelchair and comfort with muscle spasms - encourage elevation of feet to decrease [MEDICAL CONDITION] For impaired skin integrity the approaches directed staff to: - Monitor for self-inflicted open areas for sign of infection - May have sheepskin elbow protectors as needed as lays on abdomen in bed and props self-up on elbows - 5/23/12 air mattress, float heels, blue boot left foot (when up), dietary to monitor - 6/09/12 bilateral moon boots with gel, when up The nursing notes of 5/21/12 at 7:00 p.m. indicated staff noted a quarter size bruise located on the resident ' s left heel. On 5/22/12 at 6:30 a.m., the staff started a skin sheet which identified the area as 3 by 4 cm (centimeter) purple in color, unstageable, and no depth. A facsimile was sent to the physician. The nursing notes indicated the physician instructed staff to observe and keep pressure off. The treatment record for 5/01/12 - 5/31/12 indicated Jobst knee highs (compression stockings) on a.m. and off in p.m., elevate feet for an hour twice a day, and on 5/22/12 observe left heel until resolved and no pressure. The nursing notes dated 5/22/12 at 3:00 p.m. indicated the facility contacted the medical supply company and notified them of the need to pad or adjust left foot rest. On 5/22/12 at 11:00 p.m. the left heel was elevated on pillow so the heel is floating and no pressure on the heel. The nursing note of 5/23/12 at 10:00 a.m. indicated staff applied an air mattress to the bed and heel protector to heel. Hammer Medical at facility this morning to adjust wheelchair The nursing note of 6/02/12 at 9:15 a.m. identified a bruise on the left heel continues with a purple center with yellow surrounding area. Pressure avoided to the heel. Jobst stockings of feet. The quarterly MDS with an assessment reference date of 10/03/12 indicated an unstageable pressure ulcer due to non-removable dressing/device. The MDS indicated the resident had a prior assessment indicating a Stage III pressure and it healed. The care plan run 10/16/12 indicated for impaired skin integrity the approaches were: - monitor for self- inflicted open areas for sign or symptoms of infections with cares - sheepskin elbow protectors as needed as resident lays on abdomen in bed and props self on elbows - Monitor for areas that resident's wheelchair may rub; notify wheelchair company for adjustments as needed. Pad areas until corrected. The approaches for pressure ulcer to left heel were: - Keep bony prominence from direct contact with one another - Keep clean and dry - Inspect skin for signs of new breakdown - Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization per protocol - assess and record the condition of the skin - diet and supplements as ordered - prevent and treat pain during dressing changes and debridement - avoid friction and shearing forces during transfer and position change - treatment as ordered by doctor - observe for signs of [MEDICAL CONDITION] and report - observe for signs [MEDICAL CONDITION] - observe and report signs of osteo[DIAGNOSES REDACTED] The Braden Scale for predicting pressure sore risk were as follows: 4/12/11 Score - 12 (mobility scored as completely immobile) 4/23/12 Score - 15 (mobility scored as slightly limited) 7/20/12 Score - 11 (mobility scored as completely immobile) 10/19/12 Score - 12 (mobility scored as completely immobile) A score of 12 or less represents high risk for skin breakdown. The physician saw the resident on 6/05/12. The physician noted the left heel had a 3 by 4 cm ecchymotic area on the base of the heel and no blanchable aspects. There were no signs of secondary [MEDICAL CONDITION]. The resident had faint pulses at the dorsalis pedis, posterior tibia and had 3 plus [MEDICAL CONDITION]. Plan: Facility floating heels and non-weight bearing status, Diotherm per physical therapy and consider wound clinic. The physician noted the facility had efforts to prevent pressure ulcer and the pressure ulcer will probably recur from minimal negligence or resident's preference in terms of position. The Jobst socks discontinued on 6/05/12. The June 2012 treatment record indicated floating heels when in bed and blue boot to left foot discontinued, and on 6/12/12 heel cushions to bilateral legs at all times initiated. On 6/19/12 off loading boots on at all times initiated and elevate legs above level of heart when sitting and pressure off heels at all times. On 6/26/12, the physician order [REDACTED]. The weekly pressure ulcer sheet indicated: On 5/29/12, the measurement of the left heel wound was 4 by 5 cm. The interventions were air mattress and heel protector. On 6/06/12 the area measured 4 by 5 cm and Jobst stockings discontinued. On 6/12/12 the area was measured at the Wound Clinic. The Wound Clinic notes of 6/12/12 indicated the wound was noted on 5/22/12 and the facility started off- loading with gel heel pads, now turning resident every 2 hours and off-loading heels. On 11/13/12 the Wound Clinic notes indicated the resident had a Stage 4 pressure ulcer on the left heel, which measured 2.3 cm length by 1 cm width and 1 cm depth. There was seorsaguineous drainage with mild odor. There is 1-25% [MEDICATION NAME], 1-25% adherent yellow slough, 76-100% pale gray, pink granulation, no black eschar (moist or dry). Due to the exposed bone, it was determined the bone to be infected. A consult by Infection Disease revealed the [DIAGNOSES REDACTED]. The plan directed the facility to keep all pressure off of the wound, continue wound vac therapy, and purchase egg crate foam to be placed around foot. The physician ordered oral Bactrim DS (antibiotic) tablet to be given twice a day and [MEDICATION NAME] (antibiotic) 500 milligrams four times a day. Observation on 11/15/12 at 9:45 a.m. during range of motion identified heel suspension boots on both feet and a wound vac to the left heel. On 11/19/12 at 8:50 a.m., Staff K (medical supply person) was interviewed and stated the resident's wheelchair initially had foam padding on the foot pedals. When the resident developed reddened areas on the feet, he came to adjust the wheelchair and added gel to the foot rests and extended so the resident's feet did not touch the foot pedals. He indicated the resident had blue padded boots on, which did not suspend or float the heels. On 6/09/12, the physician ordered blue moon boots, when up and float both feet while in bed. On 6/26/12 the physician ordered off- loading boots on at all times. On 7/25/12 the physician ordered Prafo boot for left foot to be worn at all times. On 11/15/12 at 8:40 a.m. the Director of Nursing was interviewed and stated the facility had ordered Moon Boots to off-load the resident ' s heels. The Director of Nursing stated the Moon Boots do not do anything to off load the heels. On 11/15/12 at 5:15 p.m. the Consulting Nurse was interviewed and stated the resident's wheelchair foot pedals were padded with gel so therefore it prevented pressure on the resident ' s feet. The Consulting Nurse stated the resident slept on his/her abdomen so need to float heels. The Care Plan dated 4/18/12 did not have interventions for prevention of pressure areas such as elevating heels in bed on in wheelchair. The facility did not implement a turning/position changing program until June 2012 per the turning schedule sheets. The current Care Plan (10/3/2012) did not include approaches for staff to follow with a wound vac or off- loading boots.

Based on observations, record review and staff and family interviews, the facility failed to provide adequate supervision to prevent accidents and failed to implement interventions to keep the resident safe (Resident #6.) The sample consisted of 12 residents and the facility reported a census of 32 residents. Resident #6 had a history of [REDACTED]. The fall led to a brain bleed and hospitalization . Findings include: 1. Resident #6 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 7/18/2012 which identified the resident had a BIMS (Brief Interview of Mental Status) score of 15. This score indicated no long or short term memory problems. The MDS indicated the resident used a walker for a mobility device This assessment period documented no incontinency for Resident # 6. The resident had already experienced 2 falls at the facility during this assessment period. The MDS identified the resident had [DIAGNOSES REDACTED]. The plan of care with an origination date (when problems first care planned and prior to updated changes) of 07/17/2012 placed the resident at risk for injury due to falls prior to admission to the facility. The original interventions at that time consisted of the resident using his/her walker at all times when ambulating, to ask for assistance and not withdraw from asking (the facility being aware Resident # 6 would not ask for help) and to use a bed cane to assist in getting in and out of bed. After the resident's fall on 08/05/2012, the plan of care then changed on 08/24/2012 which directed the facility staff to use assist of a staff member for all activities of daily living, placement of a pressure and tabs alarm, and a sound monitor in the resident's room. The fall Risk Assessment sheet (a score of 10 or over considered at high risk for falls) rated Resident # 6 at 10 on 05/7/2012, at 12 and on 05/30/2012 at 12 which placed the resident at high risk for falls even though the facility considered the resident to be independent and without interventions for safety. The 08/2012 MAR (Medication Administration Record) documented the use of the bed alarm and the personal safety alarm (Tabs) interventions started on 08/26/2012 after the fall which resulted in a cranial bleed and hospitalization for Resident # 6. The Plan of treatment for [REDACTED].# 6 would work with the nursing restorative (exercises completed by the nursing staff) program due to the resident still being at risk for falls even after finishing the physical therapy. A daily physical therapy note on 06/27/2012 documented Resident # 6 started out with good steps, then would start shuffling again, and could not clear his/her heels when ambulating. On 07/03/2012 the physical therapist assistant documented the resident performed fair, but safety awareness continued to be difficult. During an interview on 11/15/2012 at 8:45 A.M. Staff H (Physical Therapist) verbalized remembering Resident # 6 as a fall risk. During an interview on 11/15/2012 at 4:19 P.M., Staff I (physical therapy assistant) verbalized if Resident #6 still portrayed being a fall risk at the completion of therapy, she would recommend the resident be independent. The Occupational Therapy implemented on 06/22/2012 through 06/29/2012 to work with the resident on strength and endurance due to the resident being at risk for falls. A weekly progress note dated 06/19/2012 documented Resident # 6 needed many verbal cues with safety and the use of the 4 wheeled walker. The resident voiced considering the walker a nuisance to take to the bathroom. On 06/27/2012, the weekly therapy note documented the resident fell on [DATE] at 1:50 A.M. Resident continued to refuse to use the 4 wheeled walker correctly and safely. The therapy daily progress notes documented reports of resident falls on 06/7/2012 and the 06/28/2012 episode. Further daily notes included repeated education of locking the brakes of the 4 wheeled walker and taking the walker to the bathroom with him/her on 06/18/2012, 06/19/2012, 06/22/2012, 06/25/2012 (especially at night), and 06/26/2012. During an interview on 11/15/2012 at 7:50 A.M., Staff J (Certified Occupational Therapy Assistant) verbalized Resident #6 would not set the brakes on the 4 wheeled walker before getting up and would not take the walker to the bathroom with him/her. Most of the resident's falls occurred at night or in the early A.M. hours and usually happened when going to the bathroom. The resident refused to have any reminder notes placed in the room for reminders and did not feel he/she needed the 4 wheeled walker or assistance from staff. Staff J verbalized telling the Director of Nursing Resident # 6 should not be independent at the conclusion of the therapy. On 08/05/2012 at 2:55 A.M., a nursing note in the resident's chart documented finding the resident seated on the bed with blood all over the resident/room and a 3 centimeter laceration above the left eyebrow. Resident # 6 denied falling. The nurse in charge notified family and the local hospital. The resident remained at the facility due to refusing to go to the hospital. At 8:30 A.M. on 08/05/2012, nursing staff observed the resident sliding out of a recliner onto the floor and placed a pressure alarm under the resident. At 10:35 A.M. on 08/05/2012, a staff nurse called the physician and obtained an order to transport Resident # 6 to the local hospital emergency room where a scan confirmed the resident suffered from a brain bleed. The hospital transferred the resident to the University of Iowa hospital for admission. During an interview on 11/05/2012 at 6:29 P.M., Staff G (Registered Nurse) verbalized being the nurse on duty the night Resident # 6 fell and sustained a head injury. Staff G verbalized that around 4:00 A.M., finding the resident seated on the bed with blood all over/him/her and the room. Resident # 6 did not remember what happened. After treating the wound area above the resident's left eyebrow, Staff G notified the family and the hospital emergency department about the injury and the resident's refusal to go to the hospital. The decision was made not to bother the physician until later in the morning because the resident refused to go to the hospital. Resident # 6's family agreed to abide by the resident's wishes. The facility staff kept a close eye on the resident the rest of the night shift. After making contact with the physician later that day, the facility staff obtained orders to transport the resident to the local hospital emergency room for evaluation which resulted in the resident being sent to the University of Iowa Hospital. During an interview on 11/14/2012 at 1:45 P.M., Staff A and Staff B (both Certified Nursing Assistants) stated Resident # 6 used a 4 wheeled walker to ambulate around the facility prior to the fall on 08/05/2012. Both agreed the resident appeared to ambulate in a steady fashion without any assistance and did not like to be helped. They observed the resident did not like to use the 4 wheeled walker when going to the bathroom. Both admitted being aware the resident had falls prior to 08/05/2012 and did see the resident get tired and shaky with ambulation by afternoons. The resident had no alarms prior to the fall of 08/05/2012. Both of the nursing assistants admitted the resident complained of being dizzy from time to time. Staff assisted with morning cares for the resident during that time period. Staff A verbalized working 1 or 2 night shifts in which she observed Resident #6 would get out of bed after staff checks and go to the bathroom without the 4 wheeled walker. Staff B verbalized Resident # 6 telling him about being dizzy on an afternoon shift. Staff B told Staff C (Licensed Practical Nurse) who then checked the resident. On 11/15/2012 at 3:20 P.M. Staff C (Licensed Practical Nurse) verbalized he did not recall Resident # 6 ever complaining about being dizzy. Staff C did recall seeing Resident # 6 become shaky in the afternoons while ambulating with the 4 wheeled walker. On 11/13/2012 at 1:35 P.M., the resident's family (son) verbalized being aware of the 08/05/2012 fall and prior falls. Verbalized not being sure all falls got reported to him, but felt sure the facility contacted him about most of the falls. The son considered the resident's memory poor and the resident still wanted to be independent. Observations of the resident during the conversation with the son found the resident questioning where to go. The daughter-in-law tried to comfort the resident. Observations of Resident # 6 on 11/13/2012 through 11/15/2012 identified the resident seated in a wheel chair shuffling self around the nursing station if not in activities or with staff for cares. Resident # 6 stared around and when verbally addressed, might not respond. During toilet cares on 11/13/2012 at 2:45 P.M., the resident did hang onto the bars of the sit to stand, however did not speak and hung head with eyes closed. The resident did sit on the toilet without falling. Resident # 6 offered no resistance to staff, but did not assist in own cares.