Every finding on record at Hiawatha Care Center

Based on clinical record review, staff interview, and facility policy review, the facility failed to develop and implement a comprehensive care plan for four of five residents reviewed for unnecessary medications (Resident #6, #9, #10, #27). Findings include: 1. The Minimum Data Set (MDS) for Resident #6 dated 2/9/26 recorded the resident reported no days of little interest in doing things or of feeling down or depressed over the 14 day lookback period. The MDS documented the resident exhibited no behavioral symptoms during the seven day lookback period. The MDS documented diagnoses that included depression. The MDS documented the resident received an antidepressant during the lookback period. The Care Plan for Resident #6 revealed a Focus Area of Antidepressant Medication related to depression, dated 2/18/26. The Care Plan directed staff to monitor for adverse side effects of the medication. The Care Plan failed to reflect the targeted behaviors which indicated signs of depression personalized to Resident #6. 2. The MDS for Resident #9 dated 3/1/26 recorded the resident reported no days of little interest in doing things or of feeling down or depressed over the 14 day lookback period. The MDS documented the resident exhibited no behavioral symptoms during the seven day lookback period. The MDS documented diagnoses that included non Alzheimer's dementia, anxiety, depression and bipolar disorder. The MDS documented the resident received an antipsychotic and an antidepressant during the lookback period.The Care Plan for Resident #9 revealed a Focus Area of Antidepressant Medication related to depression, dated 3/9/26. The Care Plan directed staff to monitor for adverse side effects of the medication. The Care Plan failed to reflect the targeted behaviors which indicated signs of depression personalized to Resident #9. The Care Plan further revealed a Focus Area for Antipsychotic medication related to Bipolar disorder, dated 3/9/26. The Care Plan directed staff to monitor for adverse side effects of the medication. The Care Plan failed to reflect the target behaviors which indicated signs of psychosis personalized to the resident. 3. The MDS for Resident #10 dated 1/4/26 recorded the resident reported no days of little interest in doing things or of feeling down or depressed over the 14 day lookback period. The MDS documented the resident exhibited no behavioral symptoms during the seven day lookback period. The MDS documented diagnoses that included non Alzheimer's dementia and anxiety disorder. The MDS documented the resident received an antipsychotic and an antidepressant during the lookback period.The Care Plan for Resident #10 revealed a Focus Area of Behavior which stated may forget requires assistance with transfers, possibly be non-compliant. At risk for injury. Becomes impatient some and sometimes refuses showers, initiated on 5/28/25 and revised 10/9/25. The Care Plan further revealed a Focus Area for Antidepressant Medication related to depression, dated 5/27/25. The Care Plan directed staff to monitor for adverse side effects of the medication, and failed to reflect the targeted behaviors which indicated signs of depression personalized to Resident #10.The Care Plan for Resident #10 also revealed a Focus Area for antipsychotic medication related to dementia with mood disorder, dated 5/27/25. It directed staff to administer medications as ordered and for the pharmacist to perform Drug Regimen reviews. The Care Plan failed to reflect the targeted behaviors which indicated signs of psychosis personalized to Resident #10.4. The MDS for Resident #27 dated 3/1/26 recorded the resident reported no days of little interest in doing things or of feeling down or depressed over the 14 day lookback period. The MDS documented the resident exhibited no behavioral symptoms during the seven day lookback period. The MDS documented diagnoses that included Alzheimer's Disease. The MDS documented the resident received antipsychotic, antianxiety, and antidepressant medications during the lookback period.The Care Plan for Resident #27 revealed a Focus Area for Behavior which stated on occasion refuses to come to dining room. Requires assistance with transfers, non-complaint, taking falls. History of being combative with cares as assisted, initiated 12/8/25 and revised on 3/4/26. The Care Plan further revealed a Focus Area of Antipsychotic Medication related to dementia, dated 12/11/25. It directed staff to administer medication as ordered and to monitor for adverse side effects. The Care Plan failed to reflect the targeted behaviors which indicated signs of psychosis personalized to Resident #27.The Care Plan for Resident #27 also revealed a Focus Area of Antianxiety Medication related to anxious/restlessness, dated 12/11/25. It directed staff to administer medication as ordered and monitor for adverse side effects. The Care Plan failed to reflect the targeted behaviors which indicated signs of anxiety personalized to Resident #27. The Care Plan further revealed a Focus Area of Antidepressant Medication dated 12/11/25. It directed staff to administer medication as ordered and monitor for adverse side effects. The Care Plan failed to reflect the target behaviors which indicated signs of depression personalized to the resident. On 4/2/26 at 12:29 pm, the Director of Nursing (DON) stated the facility does not have a broad documentation of target behaviors. She state the nurses monitor those things each shift but there is not specific routine. She added this would be addressed.On 4/2/26 at 12:30 pm, The MDS Coordinator stated some of the facility residents do have target behaviors on their care plans. She expanded by stating she would go through and update the needed care plans. The undated facility policy titled Care Plan, Comprehensive Person-Centered included the following documentation: A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy further revealed, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .Care plan interventions are chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, at least quarterly in conjunction with the required quarterly MDS assessment.

Based on clinical record review, dietary tray card review, policy review, and staff interview, the facility failed to ensure a resident did not receive a food item they were allergic to for 1 of 1 resident reviewed (Resident #60). The facility identified a census of 104 residents.Findings include:Resident #60's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 14/15 indicating intact cognition. Resident #60 was independent in eating. The MDS documented diagnoses of heart failure, end stage renal disease, chronic obstructive pulmonary disease, and respiratory failure.A Nutritional assessment dated [DATE] documented a food allergy to bananas. The Care Plan revised 2/13/26 included a Focus for Actual Nutritional Risk noting food allergies, and the intervention revised on 1/2/26 revealed Resident #60 was allergic to bananas.During an interview on 3/30/26 at 1:57 PM, Resident #60 reported she was allergic to bananas and was served a banana that had been cut in half at breakfast that morning (3/30/26). She took it off her tray and laid it on the table. They took her back to her room. She said something to the Certified Nursing Assistant (CNA). The CNA got the nurse and the nurse gave her something and then she started to feel better. She felt she was having a reaction to the banana. On 3/31/26 at 2:13 PM, during another interview with the resident, the resident explained they brought her a fruit bowl Monday morning after she was done with her breakfast. She had already touched the banana and given it to Resident #112 at the table. She felt like she had a tight band around her waist and had nausea right after breakfast. She had a banana allergy for 50 years and that is typical of how she feels.A 3/30/26 review of Resident #60's Electronic Medical Record (EHR) Clinical Resident Profile under Allergies documented a Banana allergy in red print. A 3/31/26 review of Resident #60's March 2026 Electronic Medication Administration Record (EMAR) documented Staff D, Licensed Practical Nurse (LPN) administered Ondansetron (anti-nausea medication) 4 Milligrams (MG) on 3/30/26 at 10:00 AM for nausea. Review of the Dietary Seating Chart revealed Resident #60 sat at table #16 next to Resident #112.Interview on 3/31/26 at 1:44 PM Staff D, reported she was the nurse that worked on Monday 3/30/26. A CNA came and got her and reported that Resident #60 didn't feel good. She stated the resident complained of nausea. She gave her medication and she was fine. Staff D reported she did see Resident #60 give a half banana to Resident #112 who sat at the same table Monday morning. Staff D reviewed Resident #60's diet in the Electronic Health Record (EHR) and stated she was not aware Resident #60 had a banana allergy. Observation on 3/31/26 at 1:47 PM Resident #60 Dietary Card was clearly marked with a red Food Allergy Sticker in the middle of the Dietary Tray Card documenting an allergy to bananas.During an interview on 3/31/26 at 1:49 PM conducted with Staff E, Dietary Aide (DA), with the Dietary Manager present, reported everything regarding the resident's diet is listed on the dietary card. She served the food from the steam table in the main dining room and someone else gets the drinks. Staff E reported Resident #60 gets a banana every day. Then Staff E stated the bananas were rotten yesterday, and Resident #60 got a fruit bowl. Staff E reported the resident allergies are listed on the resident's dietary card in red at the bottom of the card. She served in the [NAME] dining room Monday where Resident #60 sits at table #[redacted] and she gave her a fruit cup. Interview on 3/31/26 1:58 PM the Dietary Manager revealed the following: After listening to Staff E's interview, stated there are so many staff serving, it would be possible that another server stated there was something missing off the tray and may have grabbed a banana for the resident.Interview completed on 3/31/26 at 2:28 PM Staff F, DA reported there was a red sticker on the dietary card that listed resident allergies that they checked before serving.Interview on 3/31/26 at 2:29 PM Staff G, DA explained they had a rack that held the dietary cards. The dietary cards were color coded to alert to certain diets and there was a red allergy sticker on the diet card that listed the resident allergies. During an interview on 3/31/26 at 2:30 PM Staff H, [NAME] voiced there was a red sticker at the bottom of the dietary cards that listed resident allergies. She reviewed each card before the meal tray went out to the dining room. Interview was completed on 4/01/2026 at 9:59 AM Staff B, CNA. Staff B reported she assisted with serving in the dining room. If a resident asks for a food item, she would check their diet card and ask the kitchen if the resident could have the items. She reported she had received redirection in the process in the past 24 hours from the Dietary Manager. She explained for example if a resident wanted a banana, and her diet card stated she couldn't have a banana, then she would check with the Dietary Manager. During an interview on 4/01/26 at 10:05 AM the Assistant Director of Nursing (ADON), the ADON reported dietary used diet cards that listed the resident's diet. Staff were to check with the dietary staff before taking any food items out to the resident tables. Staff cannot access any food. All food had to be provided by the dietary department so dietary has to check the diet card before giving the food out to the staff to serve to the table. The diet card goes with the meal to the resident's table and staff leave the diet card on the table once the meal is served to the resident. Interview on 4/01/2026 at 10:06 AM Staff L, CNA explained all resident allergies were listed on the diet card. After they served the tray, they put the diet card in the middle of the resident's table. She always looked at the diet card to ensure the resident did not have a food restriction. If it is something the resident couldn't have, she went back and checked with dietary. During an interview on 4/01/26 at 1:17 PM Staff I, CNA reported if a resident requested food items, they could check the dietary card if it was filled out. Sometimes when there was a new admission, the dietary card was not filled out. They did not have access to any food, so they had to check with dietary if the resident could have the food item and get the food items from the kitchen staff. During an interview on 4/01/2026 at 1:48 PM the Director of Nursing (DON) reported if a resident requested other food items, non-dietary staff would go back up to the dietary steam table. It would be dietary's responsibility to look at the dietary card and see if the resident can have the food item before serving the food item out. If the dietary staff didn't know, then they would check with the nurse.During an interview on 4/01/2026 at 2:07 PM the Dietary Manager reported food allergies were listed on the diet card. The Diet Cards are on a rack on the steam table. The person serving the food is to look at the dietary card, then prepare the plate according to likes, dislikes and preferences. The aide next to them will set up the drinks. The cards go out on the dietary tray by the server or the aide. The person delivering the tray would look at the resident's name and diet as they serve the meal. She couldn't know if servers or aides were actually looking at the food allergies on the diet card when the meals were served, but she had talked to all staff to pay attention to the allergy portion of the dietary cards in the past 24 hours. The Food Allergies and Intolerances Policy, undated, provided by the facility directed residents with food intolerances and allergies would be offered appropriate substitutions for foods that they cannot eat. The Policy lacked direction how the facility communicated food allergies for the meal service.

Based on observation, clinical record review, and resident and staff interviews, the facility failed to prevent an accident/hazard when a resident who required assistance with transfer fell trying to reach for the call light which was placed out of reach for 1 of 2 residents sampled (Resident #17). The facility identified a census of 104 residents. The facility corrected the deficient practice through past noncompliance through the following actions: -Staff education regarding call light placement. Findings include:Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. Resident #17 required the use of a walker, wheelchair and was dependent upon staff for chair/bed to chair transfers. The MDS listed diagnoses of Non-Alzheimer's Dementia and age-related osteoporosis. The MDS further documented Resident #17 with a fall history in the past month and 2-6 months prior to admission. A Fall Risk Evaluation completed 12/14/25 documented a score of 19. The Evaluation further detailed Resident #17 had 3 of more falls in the past 3 months, had intermittent confusion, was ambulatory and incontinent, required the use of an assistive device (walker, wheelchair) and took 1-2 medications that could increase fall risk. The Fall Risk Evaluation documented a score of 10 or higher indicated a high risk of falls. The Risk for Falls Care Plan revised 12/17/25 directed to be sure the call light was within reach and to encourage the resident to call for assistance. The Care Plan lacked documentation the resident used a cordless call pendant. A Long-Term Care Facility Visit Note dated 1/06/26 by the Provider documented Resident #17 resided previously at an assisted living and came to the nursing home needing more assistance with activities of daily livings and exhibited more confusion which seemed to be her new normal.An Un-Witnessed Fall Incident Report dated 1/15/26 at 6:43 AM documented Resident #17 was found on the floor by the head of the bed gripping her left arm. The Resident reported arm pain of 9/10. The Incident Report detailed Resident #17 stated she couldn't call for help because she could not find her call light. She was reaching for it when she fell to the floor. Resident #17 stated her arm was hurting really bad in the upper bicep. The Incident Report further detailed Resident #17 was ambulatory with assistance. The Un-Witnessed Fall Incident Report lacked documentation on where the resident fell from. An Incident Progress Note dated 1/15/26 at 7:06 AM documented by Staff A, Licensed Practical Nurse (LPN) documented Resident #17 was found in the room on the floor at the head of the bed gripping her left arm. Resident #17 reported she hit her arm on the side bed rail and was experiencing pain 9/10 (on a 1-10 scale). Resident #17 stated she was unable to find her call light and was searching for it to call for help when she fell. During an interview on 3/31/26 at 9:42 AM Resident #17 stated a Certified Nursing Assistant (CNA) had attached her call light above her bed where she couldn't reach it. She ended up having to get up on her own and fell. She hurt her left arm which she still had pain in, but she could use it. She needed assist of one aide to transfer and walk. Observation on 4/01/26 at 9:41 AM revealed Staff B, CNA removed Resident #17's wheelchair pedals to the side of the wheelchair (WC), locked the WC in place, placed a gait belt around the resident's waist and assisted the resident to stand up to the walker. Staff B assisted Resident #17 to walk approximately 8 feet into the bathroom. Resident #17 observed with a slow gait and difficulty lifting and swinging her right foot through as she walked. During an interview on 4/01/26 at 11:55 the Director of Nursing (DON) reported regarding an investigation, Resident #17's call light was not in reach. The resident's family had asked the facility to get the resident up around 5 AM as she was an early riser at the assisted living. They revised Resident #17's care plan to not leave unattended in the wheelchair after she fell on 1/15/26. The DON further explained Resident #17's call light had been clipped to the wall back by the head of the bed out of the resident's reach. Staff B had been written up for not leaving the call light in reach of the resident.An Employee Disciplinary Report dated 1/15/26 documented a Verbal Warning due to failure to follow instructions or company rule specifically citing improper call light placement for Resident #17. Staff B signed the write up along with the Administrator and DON. On 4/01/26 at 12:01 PM, Staff A reported she was orientating with Staff C, Registered Nurse (RN) when Resident #17 fell. She recalled Resident #17 was on the floor gripping her left arm in pain and she was so scared for her. Resident #17 kept stating, my arm! My arm! She had hit her arm hard. Staff A reported Resident #17's call light was not in reach, but she couldn't recall exactly where it was as it had been a while since the fall. Staff A reported she didn't know if the resident fell from the wheelchair or the bed. On 4/01/26 at 12:16 PM Staff C, reported Resident #17 fell trying to reach for her call light. It was clipped to the upper part of the call light cord by the wall. When queried if the resident fell from the bed or the wheelchair, Staff C reported she had not been in the room and didn't see Resident #17 until the resident in the wheelchair out in the dining room for breakfast to assess her arm. Staff A had performed vital signs and range of motion. She never assessed Resident #17 until she was in the dining room for breakfast. During an interview on 4/01/26 at 1:24 PM with Staff B, Staff B explained she couldn't recall if Resident #17 had been up in the wheelchair prior to the fall, but her call light was not in reach. She has a special paddle type call light that should be placed in reach right by her hand whether she was in the wheelchair or bed. On 4/01/26 at 1:28 PM, Staff J, CNA reported call lights had to be placed in easy reach for the resident. On 4/01/26 at 1:30 PM Staff K, RN reported call lights should be pinned to the resident or if a paddle right next to the resident. Call light have to be placed so residents have easy, accessible access to the call light for help. During an interview on 4/01/26 at 1:51 PM the DON reported they had a Quality Assurance and Performance Meeting everyday where they went over falls. Obviously knowing that Resident #17 could not reach her call light prompted more investigation. The DON verbalized Resident #17's fall could have been prevented.The Call Light System Policy, undated, provided by the facility stated residents would be provided with a means to call staff for assistance through a communication system that directly calls a staff member. The Policy Procedure directed each resident would be provided with a means to call staff directly for assistance from his/her bed, chair, toilet or bathing facilities.

Based on observation, staff interviews, clinical record review, employee file review and facility policy review the facility failed to transfer one out of three residents reviewed according to their Care Plan resulting in one resident obtaining a laceration to her left leg that required sutures and a blood transfusion (Resident#1). The facility reported a census of 98 residents. Finding include:The Minimum Data Set (MDS) assessment for Resident#1 dated 9/2/25, listed diagnoses of Atrial Fibrillation (irregular heart beat), heart failure, and osteoporosis The Brief Interview for Mental Status (BIMS) score 4 out of 15 (severely cognitively impaired). The MDS reflected Resident#1 dependent on staff for chair to chair transfers. The Care Plan for Resident#1 dated 8/29/25, reflected interventions of Physical Therapy (PT), Speech Therapy (ST), and Occupational Therapy (OT) evaluation and treat, follow their recommendations Dated 8/29/25 and directed staff to transfers with assist of 1 staff with gait belt and a walker, date initiated 9/4/2025. The Medication Administration Record (MAR) dated 10/2015 directed the staff to administer Eliquis (blood thinning mediation) 2.5 milligrams (mg) two times a day for the pacemaker. The Progress Note dated 10/20/25 at 4:30 PM read a Certified Nurse Aid (CNA) called Staff D, Registered Nurse (RN) to the lounge area in the wing. Staff D found the Resident#1 in her wheelchair (w/c) with staff controlling the bleeding to her left lateral leg. The note reflected that Staff D applied a pressure dressing and wrapped it to control bleeding. Per Staff A, she was transferring Resident#1 and her left lateral leg caught the lever of the wheelchair causing the laceration. The Emergency Department (ED) Provider Note dated 10/20/25, identified staff transferred the resident into a wheelchair and accidentally cut the front aspect of her leg with significant bleeding per Emergency Medical Services (EMS). The ED note reflected a large left leg laceration with significant acute blood loss anemia requiring prolonged repair while in the ED (1.5 hours total), with patient required figure-of-eight sutures to tie off 2 different arteriolar bleeds (occurs when an artery is damaged, causing blood to flow rapidly and forcefully from the wound), multiple horizontal mattresses given that wound is under tension (stitch crosses under the wound horizontally), and wound approximated with otherwise standard simple suture. Bleeding completely resolved and was observed for over 2 hours with no development of a hematoma or any significant venous bleeding from the wound edges. No indication for anticoagulation reversal at this time. Hold Eliquis for at least 1 week. Admit to hospital, start 1 unit packed red blood cells (PRBC). Hemoglobin (Hgb) 5.9, baseline 9.1-10.6 grams per deciliter (g/dL) (a protein found in red blood cells that is responsible for transporting oxygen throughout the body). The Consult Note last updated 10/22/25, reflected Resident#1 presented to the ED on 10/20/25 with a leg laceration. The note reported staff transferred her into her w/c and accidently cut the front side of her leg with significant bleeding. The Note revealed Resident#1 required 4 figure-of-eight sutures to 2 arterial bleeders; 20 sutures total. The left anterior lateral lower leg laceration is approximated with sutures. The note included the wound painful for Resident#1 and included a photograph of the laceration post sutures. The wound approximately measured 7 centimeters (cm) long with another 2 cm curved around the top of the wound. On 10/27/25 at 2:51 PM Staff D reported as she passed medication on the wing when Staff A alerted her they needed help with a resident for a cut in the lounge. Staff D said she took her supplies, went to the lounge and when she saw the blood on the floor she knew she needed to send the resident to the hospital. She revealed Resident#1 took AC medication. Staff D reported Staff A told her, she just transferred Resident#1 from the recliner to the w/c and her upper left leg got a laceration. On 10/27/25 at 3:25 PM Resident #1 was in her room and sitting in her w/c. The w/c pedals were in place and able to move back freely. A pink bag sat in the seat of the w/c. The left w/c foot pedal metal above the release lever felt and looked sharp. On 10/28/25 at 2:01 pm Staff A reported on 10/20/25 around 4 PM Resident#1 needed to use the toilet. She said she placed the gait belt (G.B.) on Resident#1 and completed a stand pivot transfer (SPT) to the w/c that she placed right next to Resident#1. Staff A stated as she sat her in the chair Resident#1 said ouch. Staff A reported she saw Resident#1 left leg sat bent back at the knee under the w/c. Staff A revealed after she moved Resident#1's left leg she saw her knee high sock turned red from blood. Staff A reported she called for help, the Human Resource (HR) Director got to her first and applied pressure to the wound and Staff D got there next. Staff A reported the w/c pedal on the right side went back 180 degrees while the left foot pedal only went back 90 degrees. Staff A said a pink bag that held the phone hung on the left side of the w/c and prevented the foot rest from going back 180 degrees. On 10/28/25 at 12:52 PM the HR reported as she worked in her office on 10/20/25 she heard Staff A say Oh **** blood. HR said she immediately went to help. She said she saw a large puddle of blood on the floor. She told Staff A to get her a glove and she would apply pressure. She said the nurse lifted her pant leg, started to pull down her long sock and she saw a cut a few inches long and curved. HR said the nurse covered and applied pressure when she saw the blood poured out of the lower part of the cut. She said the nurse dressed the wound and she elevated her leg and she watched it as the nurse called people. On 10/28/25 at 3:40 PM Staff B, CNA reported she took the w/c pedals completely off when she transfers residents. She said she looked at the white board in their rooms to know how to transfer a resident. On 10/29/25 at 9:30 AM Staff C, Licensed Practical Nurse (LPN) reported when she transfers anyone she removes the w/c pedals so she doesn't trip on them, and sometimes flipping them back doesn't get them out of the way enough. On 10/29/25 at 10:48 AM Staff A reported she failed to use the walker with Resident#1 transfer that resulted in her leg laceration. On 10/29/25 at 11:12 AM, Physical Therapy Assistant (PTA) reported he expected the staff to use the walker for STP from the recliner to the w/c for Resident#1. He reported her discharge recommendation directed staff to transfer her with the assistance of 1 staff, G.B. and walker. On 10/29/25 at 11:30 AM Staff B, reported when she helped transfer Resident#1 she used the G.B. and the walker. On 10/29/25 between 12:15 and 12:30 PM the Director of Nursing, (DON) reported she identified a concern that Staff A failed to use the walker when she transferred R#1 and she received a laceration to her left leg. The DON reported Resident #1's pink bag hung on the left side of the w/c and stopped the w/c pedal from going all the way back. She said the w/c pedal that stuck out felt sharp and she thought that's what cut Resident #1s leg. The DON reported Staff A told her Resident #1 needed the bathroom. She put the gait belt on her and moved her to the w/c when she got the laceration. The DON reported she expected the staff to follow the white board in their rooms and the Care Plan. On 10/29/25 at 2:30 PM the PTA, reported he expected the staff to use the G.B and the walker with Resident#1 transfers for both the resident and staff safety. The facility provided a document titled Skills Fair dated 10/20/23 that reflected Staff A completed transfer training. The facility provided the Skills Fair Transfer training list that included one staff assist with gait belt and walker. The training included reminders to do all transfers slowly and follow the transfer direction on the white board in the residents room.

Based on observation, record review, and staff interview, the facility failed to ensure hair restraints were applied properly during a meal service. The facility reported a census of 101 residents. Findings include: An observation of the noon meal service in the [NAME] Dining Room on 3/11/25 revealed the following: a. At 12:01 PM, both Staff B, Dietary Aide and Staff C, Dining Assistant did not have hair properly tucked into their hair nets. Staff B had approximately 1.5 inches of hair exposed from the hair restraint. Staff C had approximately 3 inches exposed from the hair restraint. b. At 12:29 PM, Staff B, Dietary Aide left the Dining Room remained with 1.5 inches of hair exposed from the hair restraint. c. At 12:33 PM Staff C remains with 3 inches of hair exposed from the hair restraint. In an interview on 3/12/25 12:00 PM, Dietary Director reported she would expect her staff to check each other to make sure hair is properly tucked into the hair restraint before going out to serve food. A review of the undated Facility Policy titled: Dietary Infection Control had documentation of the following: all staff are required to style their hair so it does not touch their collar. Hair restraints are required and should cover all hair.

Based on observation, record review, resident and staff interviews, the facility failed to maintain a safe, palatable temperature of foods served at the noon meal on 3/11/25. The facility reported a census of 101 residents. Findings include: 1. An observation of the noon meal service in the [NAME] Dining Room on 3/11/25 revealed the following: a. At 11:45 AM Staff D, cook measured the temperature of the pork loin at 201.5 degrees Fahrenheit and the turkey burgers at 155 degrees Fahrenheit. b. At 12:40 PM, the Dietary Director measured the temperature of the pork loin at 180 Fahrenheit and turkey burgers at 115 degrees Fahrenheit. c. At 12:48 PM, the surveyor took temperatures and tasted the following: Pork loin at 125 degrees Fahrenheit and tasted lukewarm. Turkey burgers at 111.3 degrees Fahrenheit and tasted somewhat cool. In an interview on 3/12/25 12:36 PM, the Dietary Director reported she would expect the temperature of the meat to be held at a temperature of at least 135 degrees after the meal service. A review of the undated Facility Policy titled: Food Temperatures had documentation of the following: All hot food items must be served 135 degrees Fahrenheit.

Based on observation, record review, and staff interview, the facility failed to utilize the proper infection control techniques during an observation of a medication pass for 1 of 10 residents observed (Resident #57). The facility reported a census of 101 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #57 as cognitively impaired with a BIMS (Brief Interview for Mental Status) of 08 and had the following diagnoses: Heart Failure, Non-Alzheimer's Dementia, and Cancer. The MDS also identified #57 required substantial/maximal assist with showers, dressing, and putting on and taking off footwear. A review of the physician orders and the March 2025 Medication Administration Record had documentation of the order for Potassium Chloride ER (Extended Release) 40 meQ (milliequivalents) twice daily. In an observation of medication pass on 3/11/25 at 9:00 AM, Staff A, RN removed 4 capsules of Potassium Chloride ER 10 meQ from the blister-packs and placed into a medication cup. Staff A then proceeded to pick up each capsule with her bare hands and empty out the contents into a medication cup. Staff A mixed the powder with pudding and spoon-fed to Resident #57. In an interview on 3/12/25 at 3:30 PM, Staff A RN reported when emptying out the contents of a capsule, she would need to sanitize her hands and don gloves. She admitted she forgot to don gloves prior to opening up the capsules before she administered them to Resident #57. In an interview on 3/13/25 at 9:46 AM, the Director of Nursing reported before a nurse would empty out the contents of a capsule into a med cup, she would expect the nurse to use hand sanitizer, put on gloves before emptying the contents of capsules into a med cup before giving to a resident. A review of the undated Facility Policy titled: Medication Administration had documentation of the following: Staff follows established facility Infection Control procedures with medications as applicable, (ie: handwashing, antiseptic technique, gloves, isolation precautions, etc).

Based on observation, clinical record review, policy review, and resident and staff interviews, the facility failed to ensure staff treated residents with dignity and allowed them to make their own choices and decisions for 3 of 11 residents reviewed for resident rights (Residents #4, #10, and #11). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 12/30/24, listed diagnoses for Resident #4 which included fracture of the right pubis (the side of the hip bone), Alzheimer's disease, and anxiety. The MDS stated the resident required partial to moderate assistance for chair transfers and did not walk due to a medical condition or safety concerns. The MDS listed his Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition. Care Plan entries, dated 12/30/24, stated the resident had a diagnosis of Alzheimer's and self-transferred. The Care Plan directed staff to explain the need for assistance with transfers to prevent injuries and to place the resident at the nursing station if (self-transfers) continued. On 1/6/25 at 12:19 p.m., Resident #4 sat in his wheelchair near the nursing station and began to stand up. Staff A Licensed Practical Nurse (LPN) stated What are you doing? in a loud, harsh voice. The resident stated he intended to stand up after which Staff A stated No you're not, you broke your leg. The resident attempted to stand again and Staff A told him that he fell and broke his hip and now you are paying the price. Staff A stated this in a loud voice and multiple other residents and staff were in the area within earshot. 2. The MDS assessment tool, dated 11/23/24, listed diagnoses for Resident #10 which included cancer, pain in the right hip, and heart failure. The MDS stated the resident was dependent on staff for chair transfers and listed a BIMS score of 14 out of 15, indicating intact cognition. Care Plan entries, revised 1/6/25, stated the resident was adjusting to the facility and required assistance with transfers. The entries directed staff to offer 1:1 support when anxious and allow her to express her feelings. On 1/7/25 at 11:33 a.m., Resident #10 stated night shift staff told her she was not allowed to get up. She stated last night around 1:30 a.m., she asked to get up and staff told her she had to wait. She stated she woke up again at 3:30 a.m. and at that time staff agreed to get her up. She stated she mentioned this to the CNAs (Certified Nursing Assistants). 3. The MDS assessment tool, dated 1/2/24, listed diagnoses for Resident #11 which included adult failure to thrive, depression, and insomnia. The MDS stated the resident required supervision assistance with transfers and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 1/2/25, stated the resident was new to the facility and would demonstrate satisfaction with her placement and cares. On 1/7/25 at 3:53 p.m., Resident #11 stated Staff E CNA told her she could not sleep with her dentures in and did not return them to her for the night as the resident preferred. She stated another time, Staff E told her she had to go to bed even though she told her she was not tired. The undated facility policy Dignity stated each resident shall be cared for in a manner which promoted and enhanced his sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy stated individual needs and preferences of residents were identified through the assessment process and residents were supported in exercising their rights. An Employee Disciplinary Report, dated 1/2/25, stated Resident #10 complained that Staff E didn't have a lot of patience and told Resident #10 that if she could stand, she needed to do this. Resident #11 stated that Staff E told her she had to go to bed even though she didn't want to and would not allow her to sleep in her dentures after she stated she wanted to. On 1/7/25 at 10:35 a.m., Staff A stated with regard to the comment she made to Resident #4 that she did not mean it strongly and it came out wrong. On 1/7/25 at 10:52 a.m., Staff B CNA stated Resident #10 informed her on 1/3/25 that she wanted to get up early and the night shift told her it was too early for her to get up. Staff B stated the resident told her staff treated her like a dog. Staff B stated she reported this to Staff D Licensed Practical Nurse (LPN). On 1/7/25 at 11:08 a.m. Staff C CNA stated this morning Resident #10 told her she asked the night shift to get up and they told her she didn't need to get up. Staff C stated it was the resident's choice and she wanted to get up and was not allowed to do so. Staff C stated she did not report this to anyone yet. On 1/7/25 at 11:17 a.m., via phone, Staff D stated no one reported to her any allegations of mistreatment by the night shift staff. On 1/7/25 at 12:53 p.m., the Administrator stated he was not aware of any complaints Resident #10 had with the exception of what they had documented with Staff E. He stated he would provide documentation of this. On 1/7/25 at 2:28 p.m. the Director of Nursing (DON) stated staff reported to her that Resident #10 stated Staff E's approach to her bothered her. She stated she spoke to Staff E regarding the fact that this is their home and residents were never an inconvenience. She stated she would want CNAs to report it if the night shift would not get residents up or if residents stated they were treated like a dog. She stated if this happened it would be addressed and they would complete an investigation. She stated the only complaints she was aware of were the complaints with Staff E and she was not aware of allegations the night shift would not get Resident #10 up. She stated residents could get up in their chairs when they wanted. When asked about the comment made by Staff A to Resident #4 regarding him paying the price, the DON stated this was terrible and she would want it stated in a different manner. She stated staff could offer to take him to the restroom (when he tried to get up). On 1/8/25 at 11:30 a.m., the Administrator stated staff should treat residents with the utmost respect and dignity and they were allowed to get up when they wanted or sleep in. He stated he would want to know about allegations that residents reported being treated like a dog and not being allowed to get up during the night when they wanted. He stated if this was reported to him, the facility would carry out an investigation. He stated if it was determined to be anything which rose to the level of an allegation of abuse, they would suspend the staff member and report it. He stated he was not aware that Resident #10 made these allegations.

Based on observation, policy review, and staff interview the facility failed to keep bare hands off the drinking surface of glasses, and failed to bring food to the correct temperature and hold it at the correct temperature to prevent food-borne illness. The facility reported a census of 105 residents. Findings include: During an observation of the noon meal service on 5/6/24 from 11:52 AM to 12:42 PM Staff A, Dietary Aide served 12 glasses to 12 residents with bare fingers touching the drinking rim surface of the glasses. In an observation of the noon meal preparation and service on 5/7/24 from 11:43 AM to 1:14 PM the following was identified: 1. The following items were not heated to the appropriate temperature of 165 Fahrenheit (F) or cooled to the appropriate temperature of 41 F before serving: a. Pureed ham- 161.3 F b. Pureed mixed vegetables- 155.7 F c. Chicken noodle soup- 132.0 F d. Tartar sauce- 58.9 F 2. The following items were not held at the appropriate temperature of 135 F or higher, or held at the appropriate temperature of 41 F or lower throughout meal service: a. Ham- 132.6 F b. Ground ham- 133.3 F c. Pureed ham- 130.3 F d. Pureed mixed vegetables- 124.0 F e. Lettuce Salad- 50.8 F f. Tartar sauce- 61.0 F During an interview on 5/8/24 at 2:21 PM Staff B, Dietary Supervisor explained she expected staff to keep thumbs off the edge of plates, keep hands off the top of glasses, and use handles of silverware. Staff are to handle glasses by the bottom. She noted the facility has skills fairs yearly on how to serve correctly. She further expected food temperatures to be checked prior to meal service and to be up to the correct temperature. She explained the facility investigates any complaints of food not being hot enough. She noted she expected staff to follow facility policies and they will begin working on a Plan of Correction immediately. The facility policy titled Employee Sanitary Practices, undated, instructed staff to pick up silverware and cups by their handles, and to pick up glasses by their base. It further instructed staff to follow all federal, state, and local requirements. The facility policy titled Food Temperatures, undated, instructed staff: 1) All hot food items must be served at a temperature of at least 135 degrees F. 2) All cold items must be served at a temperature of at least 41 degrees F. 3) Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking.

Based on clinical record review, policy review, and staff interview the facility failed to notify the ombudsman when a resident was transferred out of the facility for 3 of 4 residents observed (Residents #11, #15, and #65). The facility reported a census of 105 residents. Findings include: 1. The Minimum Data Set (MDS) report dated 4/18/24 for Resident #11 documented a Brief Interview for Mental Status (BIMS) score of 8/15, indicating moderate cognitive impairment. The MDS documented diagnoses including: diabetes mellitus type 2 with diabetic neuropathy (nerve damage), cerebrovascular accident (stroke), and seizure disorder. Clinical record review on 5/6/24 revealed no ombudsman notification was sent upon resident transfer to the hospital on 4/27/24. 2. The MDS report dated 4/11/24 for Resident #15 documented a BIMS score of 15/15, indicating no cognitive impairment. The MDS documented diagnoses including: cancer, anemia (lack of blood), and respiratory failure. Clinical record review on 5/6/24 revealed no ombudsman notifications were sent upon resident transfers to the hospital on 8/3/23 and 4/3/24. 3. The MDS report dated 2/22/24 for Resident #65 documented a BIMS score of 8/15, indicating moderate cognitive impairment. The MDS documented diagnoses including: traumatic brain dysfunction, heart failure, and paraplegia (inability to voluntarily move lower parts of the body). Clinical record review on 5/6/24 revealed no ombudsman notifications were sent upon resident transfer to the hospital on 1/3/24 and 1/24/24. During an interview on 5/07/24 at 1:25 PM the Office Manager noted the Notice of Transfer form is sent to the ombudsman only if they resident discharges to the hospital. If they are transferred out and transferred back in they just mark that in the Electronic Health Record; they do not notify the ombudsman. During an interview on 5/8/24 at 2:03 PM the Administrator noted the lack of notification to the ombudsman was his fault. He remarked he was not sending an ombudsman notification for transfers, only for discharges. He reported he will be changing this. The facility lacked a policy on Long Term Care Ombudsman notification.

Based on observations, staff interviews, record reviews, and review of the facility's policy, the facility's failed to ensure: a. Staff performed proper hand hygiene in between glove changes during resident care for two of two residents (Resident #28 and #94); b. Staff wore the required Personal Protective Equipment (PPE) when providing care to a COVID-19 positive resident for one of one residents (Resident #255); and c. The development and implementation of an adequate water management program to prevent exposure and potential infection by Legionella for 106 facility residents, who were over the age of 65, or other residents, remained in the facility over 24 hours. Findings Include: 1. Review of Resident #28's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, blindness, sacral pressure ulcer, right heel pressure ulcer, and muscle weakness. Review of Resident #28's Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/15/22, located in the EMR under the MDS Tab, revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognitively intact. Continued review of the MDS revealed Resident #28 had one unstageable and three-stage three pressure ulcers present upon admission. Review of Resident #28's Physician's Orders dated 01/2023, located in the EMR under the Orders Tab, revealed an order for daily wound care to resident's sacral and right heel pressure ulcers. During an observation on 01/25/23 at 10:30 AM, Licensed Practical Nurse (LPN) 5 provided wound care to Resident #28's sacral wound; during wound care, LPN 5 changed her gloves fifteen times without performing hand hygiene (i.e., washing hands with soap and water or using alcohol-based hand sanitizer). Also, Resident #28 had two loose bowel movements during wound care. LPN 5 did not perform hand hygiene after cleaning the resident, changing her gloves, and continuing wound care. During an interview on 01/25/23 at 11:52 AM, LPN 5 stated, I did not use sanitizer during the dressing change. I left my sanitizer at the Nursing Station. Normally, I would sanitize my hands at every glove change. During an interview on 01/25/23 at 3:18 PM, the Infection Preventionist (IP) stated, The Wound Care Nurse should use standard precautions. The nurse told me that she had left her sanitizer at the Nursing Station. I would expect the nurse to wash her hands before the dressing change, and after removing the soiled dressing, the nurse should remove gloves, sanitize her hands, and don (apply) a new set of gloves. If the resident had a bowel movement during the dressing change, I would expect the nurse to wash her hands with soap and water. During an interview on 01/26/23 at 1:00 PM, the Director of Nursing (DON) stated it was her expectation LPN 5 would have used hand sanitizer after every glove change and washed her hands after providing peri-care. 2. Review of Resident #94's undated Admission Record, located in her EMR under the Profile Tab revealed she was admitted to the facility on [DATE] with diagnoses which included anorexia nervosa, dysphasia, and gastrostomy status. Review of Resident #94's Quarterly MDS with an ARD of 12/02/22 and located in her EMR under the MDS tab, revealed a BIMS score of eight out of 15 indicating she moderately cognitively impaired. Review of Resident #94's Physician's Orders, dated 01/2023 located in her EMR under the Orders Tab directed Nursing Staff to cleanse skin area surrounding G-Tube insertion site with soap and water and rinse well (or wound wash). Pat dry. Apply Vitamin A&D Ointment. Cover w/split 4 x 4 gauze, secure with paper tape one time a day for Skin Care. Review of Resident #94's Treatment Administration Record (TAR), dated 01/2023 located in her EMR under the Orders Tab directed Nursing Staff to cleanse skin area surrounding G-Tube insertion site with soap and water and rinse well (or wound wash). Pat dry. Apply Vitamin A&D Ointment. Cover w/split 4 x 4 gauze, secure with paper tape one time a day for Skin Care. Registered Nurse (RN 4's) initials entered for 01/23/23 which indicated the nurse completed the treatment. Review of Resident #94's Comprehensive Care Plan, dated 10/03/22, and located in the resident's EMR under the Care Plan Tab documented - Potential for impaired skin integrity due to presence of g-tube. Perform skin treatment to g-tube site per physician's orders. Provide preventative skin treatments per Physician's Orders. During an observation on 01/23/23 at 2:47 PM of RN 4 performing wound care to Resident #94's gastric tube insertion site. RN 4 cleaned Resident #94's insertion site and doffed (removed) dirty gloves and donned (apply) clean gloves; however, RN 4 did not perform hand hygiene in between glove changes. During an interview on 01/25/23 at 3:37 AM, the Infection Preventionist (IP) confirmed it was her expectation that the facility staff would have performed hand hygiene either washing their hands or use of hand sanitizer, between donning and doffing of gloves during wound care. During an interview on 01/26/23 at 10:15 AM, RN 4 stated she should have performed hand hygiene in between doffing and donning gloves when she removed the dirty dressing and cleaned Resident #94's gastric tube. During an interview on 01/26/23 at 1:00 PM, the Director of Nursing (DON) stated during the observation of wound care provided by RN 4 to Resident #94's gastric tube insertion site, RN 4 did not perform hand hygiene and should have performed hand hygiene when she doffed her dirty gloves and prior to donning clean gloves. Review of the facility's undated policy titled, Handwashing documented - Use an alcohol-based hand rub or, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before handling clean or soiled dressings. b. After handling used dressings or contaminated equipment. c. After removing gloves. 3. Review of Resident #255's undated Admission Record located in his EMR under the Profile Tab revealed he was admitted to the facility on [DATE] with multiple diagnoses to include chronic obstructive pulmonary disease (COPD), Alzheimer's Disease, pneumonia, and cardiac murmur. Review of Resident #255's Progress Note, dated 01/23/22, located on his EMR under the Progress Notes Tab documented the resident remains in isolation due to being Covid Positive. Review of Resident #255's Physician's Orders, dated 01/2023, located in the resident's EMR under the Orders Tab revealed - Budesonide [belongs to class of medications called Corticosteroids-decreases the swelling and irrigation in the airways and had potential for serious side effects including difficulty breathing, swelling of the face, throat, tongue, lips eyes hands feet ankles and lower legs, chest pain, vomiting,] Inhalation Suspension 0.5 mg /2 ml give 2 ml orally two times a day. Continued review of the order revealed no order for Transmission Based Precaution (TBP). Review of Resident #255's Medication Administration Record (MAR), dated 01/2023, located in the resident's EMR under the Orders Tab revealed - Budesonide Inhalation suspension 0.5 mg /2 ml .2 ml inhale orally two times a day. Continued review revealed RN2 had initialed the MAR for the date of 01/23/23 for his morning dose which indicated she administered the medication. Further review revealed no order for TBPs. Review of Resident #255's Comprehensive Care Plan, dated 01/17/23, located in the resident's EMR under the Care Plan Tab documented the resident had tested positive for COVID-19. Maintain isolation precautions. During a Medication Administration observation on 01/24/23 at 9:22 AM (with the DON supervising the medication preparation and beside Resident #255's door entry for medication administration), RN2 entered Resident #255's room wearing regular glasses (no side shields, no goggles or face shield), no gown, a procedure mask (no N95 mask), and gloves. RN 2 administered Resident #255's inhalation (aerosol treatment) to the resident, by depositing medication into the reservoir on his oxygen mask tubing, attached to his nebulizer machine and placed his oxygen mask on his face. RN 2 stated she wore regular glasses and a procedure mask into Resident #255's room. During a brief interview on 01/26/23 12:16 PM, the IP stated the facility required a procedure mask for entry into COVID positive rooms unless the resident was receiving aerosol treatments and a N95 mask was required to be worn by the staff. During an interview on 01/26/23 at 12:57 PM, the DON stated it was her expectation the Nursing Staff would have worn an N95 mask, goggles, gloves, and no gown while providing care for Resident #255 (COVID positive) with aerosol (nebulizer) treatment. Review of facility-provided undated policy titled COVID-19 Response Plan documented - To provide an outline for staff when working with residents that are suspected or confirmed to have COVID-19 and are participating in aerosol-generating procedures should wear the following appropriate PPE including: a. N95 or higher-level respirator mask. b. Gloves. c. Gown (if needed). d. Face Shield/Goggles. 4. Review of website for ASHRAE titled Risk Management for Legionellosis dated 10/15 indicated - The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors: a. Health-care facility with patient stays over 24 hours. b. Facilities designated for housing occupants over age 65. c. The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for Legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system. Review of the Centers for Disease Control and Prevention (CDC) website titled Legionella.Prevention and Control, dated 03/25/21 indicated - The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Seven Key Elements of a Legionella water management program are: a. Establish a water management program team. b. Describe the building water systems using text and flow diagrams. c. Identify areas where Legionella could grow and spread. d. Decide where control measures should be applied and how to monitor them. e. Establish ways to intervene when control limits are not met. f. Make sure the program is running as designed (verification) and is effective (validation). g. Document and communicate all the activities. The principles of effective water management include: a. Maintaining water temperatures outside the ideal range for Legionella growth. b. Preventing water stagnation. c. Ensuring adequate disinfection. d. Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. e. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. Review of a document provided by the facility titled Water Management Policy undated indicated the following: a. Purpose: Developing a Water Management Program to Reduce Microbial Growth and Prevent the Spread of Legionella. b. Policy: Facility will maintain a Water Management Team that meets annually to develop systems consistent with ASHRAE and CDC guidelines. Each facility will have a program specific to the building and water system. Water Management Team will actively identify and manage hazardous conditions that could lead to spread of Legionella. During an interview on 01/24/23 at 8:37 AM, the Administrator confirmed the facility has not started a process for water management, which would address water pathogens such as Legionnaires.

Based on observation, staff interview, record review, review of the facility's policy and review of the Food and Drug Administration (FDA) Food Code, the facility failed to monitor the dish machine's chemical and temperature levels to ensure the dish machine was providing the correct amount of chemicals needed to sanitize dishware. These failures had the potential to increase the risk of food borne illnesses and affect 105 residents living at the facility who received food from dietary services. Findings Include: During an observation on 01/23/23 at 9:28 AM in the kitchen, the Dietary Manager (DM) tested the temperature and sanitation levels of the dishwasher (low-temp model). The dishwasher temperature read 130 degrees Fahrenheit. The chemical levels were at 200 parts per million (ppm) concentration. At 9:28 AM, the DM stated the staff was supposed to check the temperature and sanitation levels of the dishwasher three times a day (i.e., after every meal), but in most cases, they try to check every day. Review of a facility document titled, Sanitizer and Temperature Recording Chart, dated 11/2022 through 01/2023 revealed there were 30 missing entries on this document which would register the sanitation and temperature in degrees Fahrenheit of the dishwasher. During an interview on 01/26/23 at 12:08 PM, the DM stated that the potential issue that can arise from not properly testing temperatures and checking the sanitation levels is dirty dishes. She stated, Ideally we take temperatures and check the sanitization levels after every meal service, but if we do it every day that is good. At least monthly, we know that is getting taken care of through [name of vendor]. They do a monthly routine maintenance on the dishwasher and make sure the dishes are being properly cleaned and the tubing is cleaned. During a subsequent interview on 01/26/23 at 1:45 PM, the DM acknowledged the missing entries in the temperature and sanitation logs and stated, It happens; we get busy. I don't know what more I can say, we get busy. During an interview on 01/26/23 at 1:46 PM, the Dietary Aide stated that the staff should check the temperature and sanitization of the dishwasher daily to ensure it is functioning properly. Staff then document the results on the temperature and sanitation logs. The DA further stated, We document the temperature and sanitation levels every shift and if we can't, we make time. Review of the FDA Food Code 2022 revealed, Adequate cleaning and sanitization of dishes and utensils using a ware-washing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize. If the exposure time during any of the cycles is not met, the surface of the items may not reach the time-temperature parameter required for sanitization. Contact time is also important in ware-washing machines that use a chemical sanitizer since the sanitizer must contact the items long enough for sanitization to occur. In addition, a chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Review of the facility's policy titled, Dish Machine Temperature Log, indicated Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The Food Service Director will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. The Food Service Director will spot check the log to assure temperatures are appropriate, and staff is monitoring dish machine temperatures. Dishwashing staff will be trained to report any problem with the dish machine to the Food Service Director.

Based on record reviews, staff interviews, and facility policy review, the facility failed to conduct behavior tracking and monitor the side effects of antidepressant medications for five of five sampled residents reviewed for unnecessary medications (Residents #20, #69, #74, #204 and #205). These failures place the residents at risk for not obtaining the intended therapeutic goal of the antidepressant medication and the potential for serious adverse effects from the antidepressant medications. Findings Include: 1. Review of Resident #20's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile Tab, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of Resident #20's Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/08/23, located in the EMR under the MDS tab, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognitively intact. The resident received antidepressant medication for seven of seven days during the lookback review period. Review of Resident #20's Comprehensive Care Plan, updated 01/08/23, located in the EMR under the Care Plan Tab, documented - Monitor for changes with mood/behavior and inform the physician. Review of Resident #20's Physician's Orders, dated 01/2023, located in the EMR under the Orders Tab, revealed the resident received citalopram (an antidepressant) 40 milligrams (mg) daily. Further review failed to reveal orders for behavior tracking and to monitor the side effects of antidepressant medications. Review of Resident #20's Medication Administration Records (MARs) and Treatment Administration Records (TAR), dated 11/2022 through 01/2023, located in the EMR under the Orders Tab, failed to reveal orders for behavior tracking or medication side effects monitoring for antidepressant medications. 2. Review of Resident #69's undated Admission Record located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, single episode. Review of Resident #69's Quarterly MDS with an ARD of 12/05/22, located in the resident's EMR under the MDS Tab indicated the resident's BIMS score was six out of 15 which indicated the resident was severely cognitively impaired. The MDS also indicated the resident had no depressive symptoms and the resident took an antidepressant for seven of seven days of the MDS lookback period. Review of a document provided by the facility titled Care Plan, dated 06/11/21 indicated Resident #69 had issues with mood and behavior which were related to his diagnosis of dementia. The intervention was to monitor for changes in depression. Review of Resident #69's Clinical Physician Orders, located in the resident's EMR under the Orders Tab dated 05/02/22, indicated the medical provider ordered Lexapro (an antidepressant) 10 mg to be administered by mouth daily for the resident's diagnosis of depression. Review of Resident #69's MAR located in the resident's EMR under the Orders Tab for the months of 10/2022 through 01/2023 failed to indicate the resident's depression was being monitored. Review of Resident #69's Progress Notes, located in the resident's EMR under the Progress Notes Tab failed to address monitoring for depressive behaviors. 3. Review of Resident #74's undated Admission Record located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included unspecified mood disorder. Review of Resident #74's Annual MDS with an ARD of 11/13/22, located in the resident's EMR under the MDS Tab indicated the resident had a BIMS score of three out of 15 which revealed the resident was severely cognitively impaired. The resident had minimal depression. The MDS also revealed the resident took an antidepressant for seven of seven days of the assessment lookback period. Review of a document provided by the facility titled Care Plan, dated 11/16/21 indicated Resident #74 was on an antidepressant. The interventions were to monitor for changes in depression. Review of Resident #74's Clinical Physician Orders located in the resident's EMR under the Orders Tab dated 04/11/22 indicated the medical provider ordered bupropion (an antidepressant) 50 mg to be administered by mouth two times a day related to the resident's diagnosis of major depressive disorder. Review of Resident #74's Clinical Physician Orders located in the resident's EMR under the Orders Tab dated 06/13/22 indicated the medical provider ordered mirtazapine (an antidepressant) 3.75 mg to be administered by mouth two times a day related to the resident's diagnosis of major depressive disorder. Review of Resident #74's MAR located in the resident's EMR under the Orders Tab for the months of 10/2022 through 01/2023 failed to indicate the resident's depression was being monitored. Review of Resident #74's Progress Notes, located in the resident's EMR under the Progress Notes tab failed to address monitoring for depressive behaviors. 4. Review of Resident #204's undated Admission Record located in the EMR under the Profile Tab, revealed Resident #204 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder and major depressive disorder. Review of Resident #204's EMR revealed the Admission MDS Assessment was not available for review. The facility was in the process of completing the Admission MDS Assessment. Review of Resident #204's BIMS assessment dated [DATE], located in the EMR under the Assessment Tab, revealed the resident with a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of Resident #204's Comprehensive Care Plan, dated 01/18/23, located in the EMR under the Care Plan Tab, documented - Monitor for changes with mood/behavior and inform the physician. Review of Resident #204's Physician's Orders, dated 01/2023, located in the EMR under the Orders Tab revealed the resident received mirtazapine (an antidepressant)15 mg daily and fluoxetine HCL (an antidepressant) 20 mg daily. Further review failed to reveal orders for behavior tracking and to monitor the side effects of antidepressant medications. Review of Resident #204's MAR's and TAR's, dated 01/2023, located in the EMR under the Orders Tab, failed to reveal orders for behavior tracking or medication side effect monitoring for antidepressant medications. 5. Review of Resident #205's undated Admission Record, located in the EMR under the Profile Tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of Resident #205's MDS with an ARD of 01/19/23, located in the EMR, under the MDS Tab, revealed the resident with a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of Resident #205's Comprehensive Care Plan located in the EMR under the Care Plan Tab, documented, Monitor for changes with mood/behavior and inform the physician. Review of Resident #205's Physician's Orders, dated 01/19/23, located in the EMR under the Orders Tab, revealed the resident received mirtazapine (an antidepressant) 15 mg daily and sertraline HCL (an antidepressant)100 mg daily. Further review failed to reveal orders for behavior tracking and to monitor the side effects of antidepressant medications. Review of Resident #205's MAR's and TAR's dated 01/19/23, located in the EMR under the Orders Tab, failed to reveal orders for behavior tracking or medication side effects monitoring for antidepressant medications. During an interview on 01/25/23 at 9:38 AM, the MDS Coordinator stated, I am unable to provide you with a policy and procedure; we do not monitor for behaviors or side effects of antidepressant medications like we do with more serious medications. During an interview on 01/25/23 at 11:39 AM, Licensed Practical Nurse (LPN) 1 stated if a resident was on an antidepressant the Clinical Staff only monitored for depressive symptoms for a certain amount of time after the medication had been started. LPN1 also stated the use of antipsychotics were the medications only monitored by the Clinical Staff. During an interview on 01/26/23 at 11:17 AM, Registered Nurse (RN) 1 stated the staff did not conduct behavior tracking or monitor the side effects of antidepressant medications, document resident behaviors, or side effect monitoring for antidepressants. During an interview on 01/26/23 at 12:38 PM, the Director of Nursing (DON) confirmed that staff do not conduct behavior tracking or monitor residents for the side effects of antidepressant medications. During an interview on 01/26/23 at 12:38 PM, the DON stated going forward the facility would be monitoring residents on an antidepressant, for signs of depression. During an interview on 01/26/23 at 2:29 PM, the MDS Coordinator, who was also the Quality Assurance (QA) Nurse, confirmed the facility was not monitoring residents who were on an antidepressant. Review of a facility document titled, Summary of Unnecessary and Psychotropic Medications, dated 08/11/21, documented - Monitoring of Psychotropic Medications: When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences. After initiating or increasing the dose of a psychotropic medication, the behavioral symptoms must be reevaluated periodically (at least during quarterly care plan review, if not more often) to determine the potential for reducing or discontinuing the dose based on therapeutic goals and any adverse effects or functional impairment.

Based on observation, resident and staff interviews, record review, and review of the facility's policy, the facility failed to ensure one of one residents sampled with an indwelling urinary catheter, had the catheter tubing secured by a leg strap to prevent dislodgement (Resident #254). The facility's deficient practice increased Resident #254's risk of urethral injury. Findings include: Review of Resident #254's undated Admission Record located in the resident's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral and nicotine dependence. Review of Resident # 254's Physician's Orders, dated 01/2023 located in the resident's EMR under the Orders Tab revealed no order for an indwelling catheter tubing leg strap. Review of Resident #254's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 01/2023 located in the resident's EMR under the Orders Tab revealed no order for an indwelling catheter tubing leg strap. Review of Resident #254's Baseline and Comprehensive Care Plan located in the resident's EMR under the Care Plan tab revealed no intervention for catheter care including indwelling catheter tubing leg strap. During an observation on 01/25/23 at 12:05 PM, Resident #254 with an indwelling catheter with a drainage bag on the bedframe in a dignity bag. Resident #254 stated she did not have a device on her upper leg to secure her indwelling catheter tubing. Resident #254 showed the surveyor she did not have a leg strap to her upper leg to secure her indwelling catheter tubing. During a brief interview on 01/25/23 at 4:12 PM, Licensed Practical Nurse (LPN) 1 stated the facility utilized a soft material leg strap to ensure indwelling catheters tubing stayed in place. During a brief interview on 01/26/23 at 8:36 AM, Certified Nursing Assistant (CNA) 1 (was in the room with Resident #254) stated Resident #254 did not have a leg strap to secure her urinary catheter tubing and should have one on to stabilize her tubing. During an interview on 01/26/23 at 9:51 AM, Registered Nurse (RN) 4 confirmed the facility utilized leg straps to stabilize a resident's indwelling catheter's tubing. RN 4 stated stabilization of the resident's indwelling catheter tubing with leg straps was important. RN 4 also stated securing the indwelling catheter was provided to prevent the tubing from being pulled out of the resident's body and injuring the resident's urethra. During an interview on 01/26/23 at 1:07 PM, The Director of Nursing (DON) stated Resident #254 did not have a leg strap to secure her indwelling catheter tubing and should have. The DON stated she would ensure the information was included on the resident's MAR going forward to ensure the nursing staff checked if the resident had her leg strap. The DON also stated leg straps were important to ensure Resident #254's indwelling catheter was not accidentally pulled out and caused the resident injury. Review of facility-provided undated policy titled Catheter Care, Urinary, directed on the following: a. Educate and train on catheter care and prevent catheter-associated urinary tract infections. b. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site(Catheter tubing should be strapped to the resident's inner thigh).

Based on observation, resident and staff interviews, record review, and facility's policy review, the facility failed to ensure two of twenty-seven sampled residents had a Physician's Order and was screened/assessed for the self-administration of medications prior to self-administration of medications (Resident #203 and #255). The facility's deficient practice increased the residents risk for adverse medication reactions. Findings Include: 1. Review of Resident #203's undated Admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile Tab revealed the resident admitted to the facility on [DATE] with diagnoses which included morbid obesity, diabetes mellitus, peripheral vascular disease, major depressive disorder, and chronic pain. Review of Resident #203's Minimum Data Set (MDS) assessment dated [DATE], located in the EMR under the MDS Tab, revealed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #203 cognitively intact. Review of the resident's revised Care Plan dated 01/06/23, located in the EMR under the Care Plan tab, documented Resident #203 did not have a Care Plan related to the self-administration of medication. During an observation and an interview on 01/25/23 at 8:34 AM, Resident #203 had a full medication cup of pills sitting on the overbed table. At 8:45 AM, the medication cup was empty. When asked, the resident said, I took the pills. Review of Resident #203's Physician's Orders, dated 01/2023, located in the EMR under the Orders Tab, revealed the resident did not have a Physician Order to self-administer medications. Review of Resident #203's EMR under the Assessments Tab and Miscellaneous Tab revealed the resident did not have a documented assessment to self-administer medications. During an interview on 01/25/23 at 10:25 AM, Licensed Practical Nurse (LPN) 2 stated, I left the medications at the bedside this morning. I thought there was a Care Plan to do so. I talked to the MDS Coordinator, who confirmed Resident #203 did not have a Care Plan to self-administer medications, and the medication should not have been left them at her bedside. During a follow-up interview on 01/26/23 at 9:09 AM, Resident #203 stated that LPN2 left the medications at her bedside yesterday because she (LPN2) was going to be behind in her schedule. During an interview on 01/26/23 at 12:53 PM, the Director of Nursing (DON) stated, that should not have happened. The nurse thought it was Care Planned. I already talked to the nurse. We do not have self-administration of medications here. 2. Review of Resident #255's undated Admission Record located in the resident's EMR under the Profile Tab revealed he was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), Alzheimer's, pneumonia, and cardiac murmur. Review of the resident's Physician's Orders dated 01/2023 located in the resident's EMR under the Orders Tab revealed - Budesonide (belongs to class of medications called Corticosteroids-decreases the swelling and irrigation in the airways and had potential for serious side effects including difficulty breathing, swelling of the face, throat, tongue, lips eyes hands feet ankles and lower legs, chest pain, vomiting). Inhalation Suspension 0.5 mg (milligrams)/2 ml (milliliters) give 2 ml orally two times a day. Continued review of the order revealed Resident #255 did not have an order to self-administer his medication. Review of Resident #255's Medication Administration Record (MAR) dated 01/2023, located in the resident's EMR under the Orders Tab documented - Budesonide Inhalation suspension 0.5 mg /2 ml, inhale 2 ml orally two times a day. Noted Registered Nurse (RN) 2's initials entered on 01/23/23 for his morning dose (indicating she administered his medication) and the resident did not have an order to self-administer his medication. Review of Resident #255's Comprehensive Care Plan located in the resident's EMR under the Care Plan Tab revealed no intervention for self-administration of medication. During a medication administration observation on 01/24/23 at 9:22 AM, the Director of Nursing (DON) supervised the medication preparation beside Resident #255's door entry for medication administration. RN2 administered the inhalation medication by depositing it into the reservoir of his oxygen mask tubing, attached to his nebulizer machine and placed his oxygen mask on his face. RN2 exited the resident's room and did not remain with him for the completion of his medication administration. During an observation on 01/24/23 at 9:44 AM, RN2 entered Resident #255's room and stated she was returning to remove his nebulizer treatment. The resident noted sitting on his chair with his oxygen mask off. During a brief interview on 01/25/23 at 11:19 AM, (with the DON present) RN2 stated she was not assigned to provide care for any residents who performed self-administration of their medications. RN2 confirmed the residents who self-administered medications included an order on their MAR. The DON stated the facility did not have any residents who performed self-administration of medications. The DON stated for a facility resident to perform medication self-administration, the facility performed a medication self-administration assessment to ensure the facility's resident was safe to administer their own medication and had a Physician's Order to self-administer medications. The DON also stated an intervention on their Care Plan would be developed to reflect self-administration of medications. During an interview on 01/25/23 at 2:15 PM, RN2 confirmed all medication administration should be monitored by the Nursing Staff until consumed by the residents, including inhalation medications. RN2 stated she was unsure what complications could occur with steroid nebulizer treatments. RN2 confirmed Nursing Staff should remain with residents until the nebulizer treatments completed. RN2 confirmed she did not remain with Resident #255 for completion of his nebulizer administration and should have remained with him until the completion of his nebulizer treatment. RN2 also stated she did not remain with Resident #255 because his wife was at his bedside, and he had done treatments at home. RN2 confirmed the facility did not ensure the resident's wife was educated regarding complications of nebulizer treatments. RN2 confirmed the standard of practice was for nurses to remain with residents until the administration of their medications were complete. During an interview on 01/26/23 at 12:57 PM, the DON stated it was her expectation for the facility Nursing Staff administering inhalation medication was to initiate nebulizer treatment in the room and check on the resident periodically. The DON stated she did not expect the Nursing Staff to remain with the residents for completion of their nebulizer/inhalation medication administration. The DON confirmed nebulizer treatments were usually steroid medications and Resident #255 was administered a steroid by inhalation. The DON also stated the Professional Standard of Practice was for Nursing to remain with residents, until their medication was consumed. Review of facility-provided policy titled Self-Administration of Medication, revealed - Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Assess each resident's cognitive and physical abilities to determine whether self-administrating medications is safe and clinically appropriate for the resident. Review of facility-provided policy titled Nebulizer Administration documented - Providing guidelines for safe nebulizer administration to review the Physician's Order for nebulizer administration.

Based on record review, staff interviews and facility policy review, the facility failed to report an allegation of abuse to the State Survey Agency and failed to report an injury of unknown origin for three residents of 49 sampled residents reviewed for abuse (Resident #13, #31 and #153). These failures had the potential to contribute to continued potential abuse in the facility for these three residents. Findings include: 1. Review of Resident #13's undated Admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included cognitive social or emotional deficit following a nontraumatic subarachnoid hemorrhage. Review of Resident #13's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/20/22, located in the resident's EMR under MDS Tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated the resident was moderately cognitively impaired. The MDS also revealed the resident had no physical or verbal behavioral symptoms directed to others. Review of a document provided by the facility titled Care Plan, failed to address Resident #13 had difficulties, such as verbally/physically encounters with his roommate or with other residents. Review of Resident #13's Behavior Progress Note, located in the resident's EMR under the Progress Notes dated 12/15/22 indicated the resident was verbally aggressive with his roommate (Resident #31). Licensed Practical Nurse (LPN 3) indicated in the resident's Progress Notes that Resident #13 accused Resident #31 of committing inappropriate sexual acts while in the bathroom. LPN 3 noted this was not a truthful statement. LPN 3 indicated in the resident's Progress Notes Resident #31 was so afraid of Resident #13 that Resident #31 refused to sleep in his bed. It was noted in the Progress Note Resident #31 had to leave the room and the Power of Attorney, Physician, and Social Services were notified about the incident. During an interview on 01/24/23 at 2:31 PM, LPN 3 stated she notified Social Services (SS) of the incident for follow up. LPN 3 stated the staff removed Resident #31 from his room. LPN 3 stated she did not report this resident to resident incident since this was an on-going issue between the two residents. LPN 3 stated if there was an allegation of potential verbal/physical abuse she would report it to the Director of Nursing (DON). 2. Review of Resident #31's Admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia. Review of Resident #31's Quarterly MDS with an ARD of 12/04/22, located in the resident's EMR under MDS Tab indicated the resident had a BIMS score of four out of 15 which revealed the resident was severely cognitively impaired. The MDS also revealed the resident had no physical or verbal behavioral symptoms directed to others. Review of a document provided by the facility titled Care Plan, failed to address that Resident #31 had difficulties with his roommate or with other residents. Review of Resident #31's Social Service Progress Note dated 12/16/22, located in the resident's EMR under the Progress Notes Tab indicated the SS documented she went to see the resident since staff communicated to her Resident #31 was scared of his roommate (Resident #13). SS noted Resident #31 did not remember the incident and asked him if he wanted to change rooms. Resident #31 refused a room change. Review of Resident #31's Progress Note, dated 12/17/22, located in the resident's EMR under the Progress Notes Tab indicated Resident #31 found sitting on the side of his bed while his roommate Resident #13 was speaking loudly to him. Resident #31 reported to LPN 5 that Resident #13 threatened to beat him up and he was scared. Resident #31 reported that Resident #13 was racist. LPN 5 indicated staff would check on him throughout the night and Resident #31 rested and watched TV. During an interview on 01/24/23, LPN 5 stated Resident #13 was hallucinating and believed he was pulled over by the police. LPN 5 confirmed she did not report the resident-to-resident incident to the DON as an allegation of potential verbal abuse. During an interview on 01/25/23 at 9:38 AM, SS stated both Resident #13 and Resident #31 would forget the previous day's incident. SS confirmed LPN 5 notified her, and we took the resident-to-resident to Quality Assurance (QA) and the two residents were separated and we continue to monitor them. SS stated the decision to call the State Survey Agency (SSA) was up to the Administrator. During an interview on 01/26/23 at 10:34 AM, the Administrator stated he did not report the resident-to-resident which involved Resident #31 and Resident #13 to the SSA since it did not rise to the level of potential abuse. The Administrator stated this was an on-going issue between the two residents and both were offered a room change. 3. Review of a document provided by the facility (referred to as Hospital Records) titled H&P and dated 10/15/22 indicated Resident #153 sustained a fall while at a Memory Care Unit. The H&P revealed the resident sustained a lumbar transverse process fracture. Review of Resident #153's undated Admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and a fracture of the lumbar vertebrae. Review of Resident #153's Clinical Summary Progress Notes, located in the resident's EMR under the Progress Notes Tab dated 10/20/22 indicated the resident was admitted to the facility for Skilled Services related to a lumbar fracture. The Clinical Notes revealed the resident was able to follow direction and no complaints of pain. The Clinical Notes indicated the resident was able to ambulate with assistance of one, with the use of a gait belt and a front wheeled walker (FWW) with a wheelchair following. Review of Resident #153's MDS with an ARD of 10/25/22 located in the resident's EMR under the MDS Tab indicated the resident had a BIMS score of seven out of 15 which revealed the resident was severely cognitively impaired. The MDS also indicated the resident required extensive assistance of one person for bed mobility and extensive assistance of two persons for transfers. The MDS further revealed the resident sustained a fall and a fracture prior to her admission. Review of Resident #153's Clinical Summary Progress Notes located in the resident's EMR under the Progress Notes tab dated 11/04/22, revealed the resident continued with skilled therapy due to a lumbar vertebrae fracture. The Progress Notes revealed the resident was unable to indicate pain location. The Progress Note indicated in Skilled Therapy the resident complained of left hip pain in the past. The nurse documented the resident had no current pain during this assessment. Review of Resident #153's Clinical Summary Progress Notes, located in the resident's EMR under the Progress Note tab dated 11/07/22, indicated the resident's left lower extremity was weaker than the right side. The resident expressed no non-verbal expressions of pain. On 11/08/22, LPN2 indicated the resident had expressions of non-verbal pain and had uneven hip alignment. LPN2 notified the Nurse Practitioner (NP) and obtained a portable x-ray to the resident's left hip. Review of a document provided by the facility titled X-Ray Left Minimum Two Views, dated 11/08/22 indicated Resident #153 had a comminuted, angulated, foreshortened intertrochanteric fracture of the left hip. During an interview on 01/24/23 at 2:23 PM, LPN2 confirmed she was the nurse who identified misalignment of Resident #153's hips. LPN2 stated the medical provider was notified an X-Ray obtained. LPN2 stated she either reported the incident to the on-coming nurse or to the Director of Nursing (DON). During an interview on 01/26/23 at 10:11 AM, the Administrator stated he did not report Resident #153's hip fracture to the SSA as an injury of unknown origin. The Administrator stated there was no incident and stated the facility determined the left hip fracture was a result of the resident's fall prior to her admission. When asked if the hospital records reflected his analysis of a prior left hip fracture, the Administrator stated the hospital records did not. Review of the facility's undated policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy, indicated the following: a. All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion or chemical restraint not required to treat the resident's medical symptoms. b. Verbally aggressive behavior such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating. c. Examples of injuries that could indicate abuse include, but are not limited to - Injuries that are non-accidental or unexplained, fractures, sprains or dislocations. d. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. e. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made. f. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than twenty-four (24) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation.

Based on record review, staff interviews and policy review, the facility failed to complete a thorough investigation for three residents of four residents reviewed for potential abuse/neglect (Resident #13, #35 and #153). There was no evidence the facility investigated an allegation of potential verbal abuse between Resident #13 and Resident #31. There was no evidence the facility interviewed other current residents or staff regarding the allegation of an injury of unknown origin for Resident #153. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect. Findings Include: 1. Review of Resident #13's undated Admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile Tab indicated the resident was admitted to the facility on [DATE]. Review of Resident #13's EMR indicated the resident was involved in a potential verbal abuse incident with Resident #31. 2. Review of Resident #31's Admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE]. Review of Resident #31's EMR indicated the resident was involved in a potential verbal abuse incident with Resident #13. Resident #31 voiced he was scared. A request was made for the facility's investigation which involved Resident #13 and Resident #31. The facility failed to provide documentation to support an investigation occurred, by the end of the survey. 3. Review of Resident #153's undated Admission Record, located in the resident's EMR under the Profile Tab indicated the resident was admitted to the facility on [DATE]. Review of Resident #153's EMR indicated the resident was found with misaligned hips on 11/08/22 and the facility ordered an x-ray. The results of the x-ray determined the resident had a fracture of her left hip and was sent to the local hospital for evaluation and treatment. A request was made for the facility's investigation. The facility did not provide documentation to support an investigation occurred after the discovery of Resident #153's injury of unknown origin, by the end of the survey. During an interview 01/23/23 at 4:42 PM, the Administrator stated he has not had any abuse allegations in the past six years. The Administrator stated if a resident had a concern, the facility would deal with it immediately. During an interview on 01/26/23 at 10:11 AM, the Administrator stated the facility did investigate Resident #153's left hip fracture and the facility determined the resident sustained the left hip fracture when she had a fall prior to her admission to the facility. As for the resident-to-resident potential verbal abuse, the Administrator stated Resident #13 and Resident #31 both sundown as part of their dementia and at no part did it rise to abuse. Review of the facility provided undated policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy, indicated should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the following will occur: a. The Administrator or his/her designee will designate a member of management to investigate the alleged incident. b. The Administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. c. Review documentation in the Resident Record (including review of assessment if resident injury). d. Assess the resident for injury if the allegation involves physical or sexual abuse. e. Provide proper notifications to primary care provider, responsible party, etc. f. Attempt to obtain Witness Statements (oral and/or written) from all known witnesses.

Based on clinical record review, staff interviews, and facility policy review the facility failed to notify the resident's responsible party/representative of changes in condition in a timely manner for 2 of 9 residents reviewed (Residents #9, and #10.)The facility identified a census of 101 current residents. Findings Include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #9 identified with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident with a Brief Interview for Mental Status (BIMS) as unable to be completed due to cognitive impairment According to the MDS the resident required the assistance of one staff with bed mobility, transfers, and personal hygiene. The Care Plan initiated 4/21/20 indicated the resident with the potential to fall and required staff assistance to transfer. Review of untitled form numbered #257 and dated 4/25/20 at 5:10 a.m., a witnessed fall revealed Resident #9 fell backwards into the wall and revealed no notification done to the family or physician. Review of the Progress Note dated 4/25/20 at 5:26 a.m., revealed Resident #9 fell backwards into the wall while holding onto the wheelchair and hit her head. The Progress Note failed to show family or physician notification completed. During an interview with the Director of Nursing (DON) on 6/15/21 at 3:40 p.m., the DON stated she expected families to be notified at the time a resident falls. During an interview with Staff A, Licensed Practical Nurse (LPN), on 6/16/21 at 9:40 a.m. stated that Staff B, Registered Nurse (RN) failed to notify Resident #9's family of the fall that had occurred on 4/25/20 at 5:26 a.m. Staff A notified the family member of the fall when she called and requested transfer out to hospital. During an interview with Staff B, RN, on 6/16/21 at 9:59 a.m. stated she did not notify the physician or the family related to the fall on 4/25/21. Staff B stated she received disciplinary action for failing to notify the family of the fall. Record review of the facility titled form - Employee Disciplinary Report dated 5/4/20 revealed Staff B, RN received a written warning due to failing to notify the physician and family of a resident's fall on 4/25/20 and failed to follow the facility protocols. Record review of Policy and Procedures related to falls revealed the physician and responsible party will be notified of the fall in a timely manner. 2. According to the MDS assessment dated [DATE], Resident #10 identified with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident had a BIMS of 12 out of 15 which indicated moderate cognitive impairment. The MDS revealed the resident required extensive assistance with bed mobility and transfers. The Care Plan initiated 12/8/20 indicated the resident with impaired skin integrity and potential for impaired skin integrity related to limited mobility, incontinence, and Diabetes. Review of the Progress Notes dated 12/26/20 at 5:31 p.m. revealed Resident #10's left lower extremity presented with top layer of skin gone and tender pink skin exposed. A&D ointment applied and nonstick bandage wrapped with gauze. Physician notified. Progress Note lacked documentation of notification to Resident #10's family. Review of the Treatment Administration Record dated 12/1/20-12/31/20 revealed to change the dressing to the left lower extremity shin. Cleanse area with soap and water, apply A&D ointment, non-stick bandage and wrap with dressing one time a day due to skin shearing. Treatment was ordered to start on 12/27/20. Review of the Progress Note dated 1/2/21 at 1:31 p.m. Resident #10 with a new order for dressing change and resident made aware, with no documentation of family notification. Resident #10 not identified as his own decision maker. During an interview with Staff D, LPN, on 6/17/21 at 9:46 a.m., Staff D acknowledged no notification of the family completed on 12/26/21 regarding Resident #10's change of skin condition. During an interview with the DON on 6/17/21 at 10:12 a.m., the DON identified Resident #10's family member as the Power of Attorney (POA) and acknowledged the resident representative should have been called with the order changes. Review of Admission Record form revealed Resident #10's resident representative is the responsible party and POA for healthcare. During an interview with Staff C, RN, on 6/17/21 at 10:15 a.m., Staff C acknowledged Resident #10's family not notified regarding the new order for the dressing change. Record review of the undated facility policy form revealed the Care Center will notify the resident's representative of changes in condition and physician orders. The Care Center will notify a resident's representative in a timely manner when there is any of the following situations such when a new form of treatment is commenced.

Based on facility menu review, observation, document review, and staff interviews, the facility staff failed to ensure all residents on puree textured diets, received the proper portion size based on the planned menu for 8 of 8 residents on a pureed diet in the West dining room. The facility identified a census of 99 residents. Findings include: The facility's Week 3 Menu, signed by the Consultant Dietitian, identified 1 serving of creamy chicken carbonara on 3/3/20 for pureed diet. Review of the facility therapeutic and mechanically altered diet list revealed 9 residents on a pureed diet. One resident listed okay to have regular texture food as resident request/desires. During an observation on 3/3/20 at 10:32 a.m., Staff Q, Cook pureed 10 servings of the chicken carbonara casserole using the volume technique per the Mechanically Altered Diets Policy. Staff Q measured the volume of the casserole as 8 cups, requiring a # 8 and #12 scoop to make a serving for residents on a pureed diet. During an observation on 3/3/20 at 11:59 a.m. during serving of the noon meal, Staff L, Cook served the pureed chicken carbonara casserole using only a #8 scoop. Staff L failed to serve 8 pureed diets the #12 scoop also. Staff L used a #8 and a #12 scoop for the pureed bread instead of the casserole and at the end of meal service she ran out of the pureed bread. One resident did not receive a portion of pureed bread. A post it note hanging from the steam table stated to use a #8 and a #12 scoop for the casserole. During an interview on 3/3/20 at 12:40 p.m., the Assistant Certified Dietary Manager (ACDM) states Staff L, Cook used the scoops needed for the casserole on the bread and served less than required for the pureed casserole. The ACDM explained the pureed process when using different size scoops can be difficult.

Based on observations, record review and staff interviews, the facility failed to maintain Infection Control practices during 1 out of 3 wound care observations (Resident # 92), 2 out of 6 observations of residents with catheters (Residents #5 and #8), and during 3 out of 3 dining room observations of meal service. The facility reported a census of 99 residents. Findings included: 1. The Admission Record for Resident # 5 dated 12/2/19, listed [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment for Resident # 5 dated 12/4/19, identified the resident with short and long term memory problems and severe difficulty with daily decision making skills. The MDS reflected Resident # 5 as dependent on staff for toileting and required extensive assist of 1 staff for dressing and personal hygiene. The MDS documented the resident with a urinary catheter. The Care Plan for Resident # 5 dated 6/27/18, directed staff to repot signs and symptoms of urinary tract infection [MEDICAL CONDITION]. During an observation on 3/2/20 at 10:31 a.m., Resident #5's catheter bag hung on the side of the bed in dignity bag on the floor. During an observation on 3/4/20 at 10:26 a.m., Resident #5 in bed with the catheter bag in a dignity bag on the side of the bed, the bed in a lower position resulting in the dignity bag on the floor. During an observation on 3/4/20 at 1:11 p.m., Staff P, Certified Nurses Aid (CNA) set the graduated cylinder that held 375 cubic centimeters (cc) of urine on the floor in the bathroom with no barrier under the cylinder. The Progress Note for Resident #5 dated 11/27/2019 at 2:56 p.m., read admitted following hospitalization [MEDICAL CONDITION]. The Progress Note dated 12/17/2019 at 11:45 a.m., read admitted back from the hospital a the [DIAGNOSES REDACTED]. During an interview on 3/5/20 at 8:45 a.m., Staff G, Assistant Director of Nursing (ADON)/Infection Control Monitor reported a graduated cylinder with urine in it should not be set on the floor with out a barrier. Staff G also stated the expectation is the catheter bag and dignity bags are up off of the floor. 2. Resident #92's Minimum Data Set (MDS) assessment dated [DATE] showed the resident with severe impairment with cognitive skills, required extensive staff assistance of two with transfers, toileting and personal hygiene. The assessment identified the resident with [DIAGNOSES REDACTED]. During an observation of toileting with Resident #92 on 3/4/20, Staff K, Certified Nursing Assistant (CNA) used gloved hands to wipe the residents buttocks with a disposable washcloth after the resident had smearing of bowel movement in her adult incontinent brief to buttocks. Staff K, CNA then applied barrier cream wiping the area multiple times with the same gloved hand. Staff K, CNA failed to change gloves or wash hands in between wiping the buttocks and applying a barrier cream. During an interview on 3/4/20 at 3:38 p.m., Staff O, CNA states she would change her gloves and sanitize hands between cleaning bowel movement and applying cream to a resident's buttocks. During an interview on 3/4/20 at 3:41 p.m., Staff N, Registered Nurse (RN) stated expected CNA's to change gloves after cleaning up a soiled resident and then applying a barrier cream. During an interview on 3/5/20 at 11:18 a.m. the Director of Nursing (DON) stated aware of the glove issue and expected CNA's to change gloves prior to putting on a topical cream. The facility provided a policy dated 3/5/20 which directs staff to administer topical creams in an appropriate manner. The policy directed staff to apply gloves, cleanse and dry affected area. Remove gloves, perform hand hygiene, apply clean gloves and apply topical cream as directed. 3. During random observations of Resident #8, the following noted in regards to the resident's catheter drainage bag: a. On 3/2/20 at 2:14 p.m., Resident #8 resting in bed with her catheter drainage bag directly on the floor under the bed. b. On 3/2/20 at 3:30 p.m., Resident #8 resting in bed and the catheter drainage bag directly on the floor, under the bed. c. On 3/2/20 at 4:45 p.m., Resident #8 resting in bed and the catheter drainage bag directly on the floor, under the bed. d. On 3/3/20 at 11:11 a.m., Resident #8 resting in her recliner and the catheter drainage bag in a trash can beside the chair. During an interview on March 4, 2020 at 11:50 a.m., the Director of Nursing (DON) expected a resident's catheter drainage bag to be in a dignity bag and expected the drainage bag to not be directly on the floor. The DON also stated placing the catheter drainage bag in a trash can considered not a good practice. 4. During observations of 3 meal services the following noted: a. On 3/2/20 at 12:03 p.m., during the noon meal, Staff D, Certified Nurse Aide (CNA) took a tray from the serving line and served a resident at the table. When taking beverages off the tray, fingers touched the drinking rim of the glass. Staff D observed touching the drinking rim of the glass for 2 residents. b. On 3/2/20 during the noon meal, Staff E, CNA observed taking a tray from the serving line to a resident table. When taking the beverages off of the tray, her fingers touched the drinking rim of the glass for 1 resident. c. On 3/2/20 during the noon meal, Staff F, CNA observed taking a tray from the serving line to a resident table. When taking beverages off the tray, her fingers touched the drinking rim of the glass. Staff E observed touching the drinking rim of the glass while serving 2 residents. d. On 3/3/20 at 8:20 a.m., the Dietary Manager (DM) observed taking a tray from the serving line to a resident table. When taking the beverages off the tray, her fingers touched the drinking rim of the glass. The DM observed touching the drinking rim of the glass for 2 residents. e. On 3/3/20 during the breakfast meal, Staff G, the Assistant Director of Nursing (ADON) observed taking a tray from the serving line to a resident table. When taking the beverages off the tray her fingers touched the drinking rim of the glass. Staff G observed touching the drinking rim of the glass for 2 residents. f. On 3/3/20 during the breakfast meal, Staff H, Dietary Aide observed taking a tray from the serving line to a resident table. When taking the beverages off the tray, her fingers touched the drinking rim of the glass. Staff H observed touching the drinking rim of the glass for 1 resident. g. On 3/3/20 at 12:00 p.m., Staff I, Dietary Aide observed taking a tray from the serving line to a resident table. When taking the beverages off the tray, her finger touched the drinking rim of the glass. Staff I observed touching the drinking rim of the glass for 3 residents. h. On 3/320 during the noon meal, Staff H, Dietary Aide observed taking a tray from the serving line to a resident table. When taking beverages off the tray, her fingers touched the drinking rim of the glass. Staff H observed touching the drinking rim for 2 residents. i. On 3/3/20 during the noon meal, Staff J, CNA observed taking a tray from the serving line to a resident table. When taking the beverages off the tray, her fingers touched the drinking rim of the glass. Staff J observed touching the drinking rim of the glass for 1 resident. During an interview on 3/4/20 at 1:44 p.m., the Dietary Manager stated she expected staff to not touch the drinking rim of the glass when serving beverages to the residents.

Based on record review, observation, and interview the facility failed to provide adequate supervision to prevent elopement for 1 of 10 identified at risk for elopement which resulted in an immediate jeopardy to residents health and safety. Resident #184 has a history of wandering and exited the building without staff knowledge and was found outside in the snow. The facility reported a census of 105 residents. Findings: 1. The MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #184 had [DIAGNOSES REDACTED]. Resident #184 had severe cognitive impairments. The MDS dated [DATE] revealed Resident #184 required extensive assistance of 1 staff for transfers and walking. The MDS documented Resident #184 wandered for 1-3 days during the 7-day look back period. Resident #184 had significant risk of getting to a potentially dangerous place. The Care Plan dated 2/26/19 revealed Resident #184 had hallucinations and directed the staff to allow to share prior experiences on farm, share farm photos, medicate as ordered by physician and social service staff to offer one on one support if inappropriate with mood/behaviors. The Progress Notes dated 3/1/19 4:17 p.m. revealed Resident #184 attempted to go out two different doors. The Progress Notes dated A 3/3/19 11:45 p.m. revealed Resident #184 attempted to push the door open and staff explained to the resident the door had an alarm on it and it was very cold outside. The Progress Notes dated 3/4/19 3:00 a.m. revealed Resident #184 up and down tonight, wandering in the hall and visiting with staff. The Progress Note dated 3/4/19 5:20 a.m. revealed at 5:00 a.m. Resident #184 not in his room and the staff searched the southwest hall. The staff exited the front door and found Resident #184 outside next to the second window on the right end of the building. Resident #184 had on 1 slipper sock and a hospital gown open in the back. Resident #184 had his incontinent brief around his ankles. The staff placed a jacket on Resident #148 and called for assistance. Resident #184 had 1 superficial scratch to the right elbow. According to the National Weather Service's (www.weather.gov) climatological data for Cedar Rapids, Iowa on 3/4/19, the low temperature was -9 degrees Fahrenheit with a high temperature of 7 degrees Fahrenheit. Facility documentation provided to the State Agency after the elopement stated the resident's body temperature was 96.3 degrees Fahrenheit on 3/4/19 at 5:25 a.m. During an interview on 3/12/19 at 5:01 a.m., Staff K (Licensed Practical Nurse) reported she heard the alarm sound, went to Door 3, observed the Velcro sign on the door undisturbed, looked out the window, did not see anything, silenced the alarm and went back to her work. Staff K reported 10 to 15 minutes later Staff P (Nurse Aide) asked if she knew Resident #184's location. Staff K reported they searched and found Resident #184 outside wearing a hospital gown and had a brief around his ankles. Resident #184 informed the staff he was fixing the air conditioner. Staff K stated called for assistance. The staff assisted Resident #184 indoors and completed an assessment. Staff K reported she did not receive education regarding door alarm protocol upon hire. Staff K stated she did not know she should not have silenced the alarm and should have completed a perimeter check. Staff K reported she received training after this elopement. The Assistant Director of Nursing told Staff K there was a plan to implement a training checklist so all staff receive the same training. During an interview on 3/11/19 at 07:13 p.m., Staff P (Nurse Aide) reported Resident # 184 was at the Nurse's Station when she arrived to work at 10:00 p.m. Staff K Licensed Practical Nurse (LPN) assisted Resident # 184 to bed around 4 a.m. Later, during rounds, Staff P observed Resident # 184 out of bed and banging/tearing down the toilet paper holder. Staff P continued with rounds. Staff P then heard another resident calling out for help because Resident # 184 was in their room. Staff P assisted Resident # 184 back to his room and went back to rounds. Staff P heard the door alarm sounded and it went off right away. Staff P finished completing cares and went to check Resident # 184. Staff P checked Resident #184's room and then other resident's rooms and could not find Resident #184. Staff P noticed the Velcro strip in place across the door at the end of the Resident #184's hall. Staff P asked Staff K about the location of Resident # 184. Staff K acknowledged clearing the door alarm, looking outside, and not seeing anyone. Staff P reported she went to look for Resident #184 outside. Staff P reported Resident # 184 was found outside standing in the snow. Resident #184 had on one grip sock, a t-shirt and had brief around the ankles. Staff P reported Resident # 184 stated, was working and allowed the staff to assist him/her back in the building. Staff P reported 10 to 15 minutes lapsed from the time she heard the alarm sound and when Resident # 184 was brought back in the building. Staff P stated Resident # 184's skin was cold to touch and his body temperature was low per Staff K. Staff P reported Resident #184 did not have a wander device place to alert the staff when exiting. Staff P reported Resident #184 had a normal routine of getting up at that time of the day. During an interview on 3/12/19 at 5:25 a.m., Staff L (Registered Nurse) reported she helped assist the Resident #184 indoors. Staff L stated it was so, so cold that night and the staff had to shovel Resident #184's wheelchair out of the snow. During an interview on 3/12/19 at 5:38 a.m., Staff M (Nurse Aide) reported the staff shoveled Resident #184's wheelchair out of the snow. Staff L stated it was cold out and the cold and it got in her chest. Staff M reported Resident #184 wandered on other shifts and they had him sit by the nursing station. During an interview on 3/12/19 at 6:20 a.m., Staff N (Nurse Aide) stated Resident #184 was a busy, back and forth in the hall, wandering into other resident rooms and looked out the window a lot. During an interview on 3/12/19 at 6:27 a.m., Staff O (Nurse Aide) stated Resident #184 had delusions and talked about the farm across the lake. Staff O reported when an alarm sounded staff should go outside to look around. During an interview on 3/12/19 at 8:48 a.m., Staff F (Assistant Director of Nurses) stated after the elopement she went over the door alarm protocol with Staff K. She stated she did not know if there was paperwork on hire for Staff K. Staff K reported a plan to implement a checklist for new hires that included alarms. Staff F reported this elopement was the first time she knew of Resident #184 exit seeking. During an interview on 3/12/19 at 9:37 a.m., the Administrator stated he received a phone call that Resident #184 eloped. The Administrator stated if a resident was an elopement risk, they would have a wanderguard. The Administrator reported he spoke to Staff K. The Administrator reported Staff K should have left the alarm sounding and completed a head count. The Administrator stated he did not think the resident tried to get out the doors prior to the elopement. During an interview on 3/12/19 at 9:58 a.m., the DON (Director of Nursing) stated if an alarm sounded, she would not silence it until she knew the cause and stated she would have opened the door and looked out. She stated they did not have documentation Staff K signed upon hire regarding door alarms but stated moving forward they would go over the policy with all new hires. She stated the facility implemented a wanderguard for the resident after the elopement and stated she would place a wanderguard on a resident who tried to get out the door. She stated she was not aware the resident had exit seeking behavior prior to the elopement. Care plan entries, dated 3/4/19, stated the resident had the potential for wandering and directed staff to answer door alarms per protocol and to walk outside and walk around corners, monitor and check the roam alert weekly and wanderguard daily. A 3/7/19 care plan entry stated the resident wandered out the facility and directed staff to monitor the resident's whereabouts in the building. The undated Door Alarm Policy directed staff to identify which door alarmed and to go to that door and check for a resident outside. The policy stated this might require the staff member to go outside and check for a resident in the surrounding area. The undated New Admission Risk Assessment Elopement Decision Tree policy stated if a resident had a history of [REDACTED]. The Door Alarm and Elopement In-Service Training Conducted sheets revealed the facility completed staff training on 3/8/19. The facility abated the IJ on 3/8/19 by conducting in-service training regarding the door alarm and elopement policies. Because the facility abated the IJ prior to the start of the annual health survey and facility reported incident investigation, the situation was identified an IJ past non-compliance.

Based on record review and staff and resident interviews, the facility failed to follow the Care Plan and provide adequate supervision and assistive devices to protect against hazards to Resident #2. The sample consisted of 4 residents and the facility reported a census of 104 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 had no cognitive impairment, required extensive assistance for transfer and had [DIAGNOSES REDACTED]. The Care Plan identified the resident had a fall potential related to a history of a foot fracture. On 11/18/15 the Care Plan initiated directions for staff to ambulate the resident with one person, a wheeled walker and a gait belt. The staff would have wheel chair to follow when walking to dine. The approaches directed the staff that the resident would wear a boot on the left foot when ambulating. The Progress Notes dated 11/29/15 at 7:35 a.m., identified the resident fell . Staff B, Certified Nurse Aide, CNA called the nurse, Staff A, Registered Nurse, RN and found the resident on the floor, leaning on their left side. Staff B reported the resident fell during ambulation from the bed to the restroom and as Staff B lowered the resident to the floor, the resident ' s left lower leg contacted the floor. The resident had no complaints of pain to the left leg, but did complain of pain to the left wrist. Staff A noted disfigurement and received an order to send the resident to the emergency room for an evaluation. The Progress Note at 12:45 p.m. reflected the hospital informed the facility the resident was admitted for an orthopedic consult, received a splint to the left wrist after it was set back in place and the resident was admitted with a urinary tract infection and intravenous antibiotic treatment. On 12/1/15, the resident returned to the facility with non- weight bearing status of the left upper arm, hard splint and an ace wrap to hold it in place. The resident reported pain rated at 6 out of a possible 10. An Incident Report dated 11/29/15 at 7:35 a.m., identified the resident fell in the room with Staff B present. The report reflected the left surgical boot came off during ambulation and the resident lost his/her balance. The Emergency Department notes dated 11/29/15 at 9:13 a.m., identified the resident had a deformity to the left wrist. An x-ray identified the resident had a comminuted, impacted displaced and angulated distal radial fracture (lower arm) and had osteopenia (condition of bone loss). A History and Physical report, with an encounter date of 11/29/15, documented the resident was recently admitted to the facility following a hospitalization for a left foot fracture sustained at home. The resident underwent [REDACTED]. The resident would begin antibiotic coverage for a urinary tract infection. On 1/7/16 at 2:00 p.m., the resident reported he/she broke their left arm when she/he fell . The resident reported he/she got tangled up in the walker and the boot. The fall occurred with staff present, but they (staff member) failed to apply a gait belt. The resident stated the staff normally apply a gait belt. Staff B signed the facility Gait Belt Usage policy on 1/26/15 that included direction to have the gait belt with you at all times and use the gait belt for transfers unless physical therapy determined the resident can ambulate independently. The Physical Therapy notes reflected the following: The notes signed on 11/19/15 reflected the resident stated she/he felt was going to trip over surgical boot. A longer strap attached to improve the stability/tightness and placed non-skid sock over boot to improve the compression and safety. The resident stated it felt more secure and occupational therapy and staff were educated on the new boot style. The resident ambulated 150 feet with stand by assistance. The note of 11/24/15, identified the resident ambulated with the front wheel walker 120 feet. The resident tended to be impulsive and a safety risk due to the left boot. The note of 11/27/15 reflected the resident ambulated 300 feet with front wheel walker and contact guard assistance with surgical shoe on. The resident needed some verbal cues for safe transitions and hand placement in sit-stand from wheelchair to walk. The Occupational Therapy notes reflected the following: The notes dated 11/20/15, identified the resident as a fall risk and the resident should wear a shoe or boot when up. The resident ambulated with a front wheel walker 100 feet with contact guard assistance and no wheelchair following with cues for safety with the walker placement and for increased posture. The notes dated 11/23/15 reflected the resident required assistance with the left boot for tightness with function mobility. The occupational therapist discussed possible boot discontinued with nurse and physical therapist. The physical therapist to fax request on next treatment (session). During an interview on 1/27/16 at 1:30 p.m. the DON (Director of Nursing) reported the therapy adjusted the resident's boot which did not help. The DON stated Staff B had failed to use a gait belt. On 1/28/16 at 6:00 p.m., Staff A, RN reported working on 11/29/15 when the resident fell . Staff B summoned Staff A to the resident ' s room. Staff A responded and found the resident on the floor complaining of wrist pain. Staff A notified the physician and transferred the resident to the emergency room . When Staff A arrived to the room, the resident did not have a gait belt on. Staff B told Staff A the resident was anxious and started walking ahead of her. The resident had a urinary tract infection and that may have contributed to the anxious behavior. Staff A stated the boot had slipped off and the resident had an issue with the boot staying on. On 1/26/16 at 12:00 p.m., Staff B was interviewed and stated she had a gait belt but did not use it on 11/29/15 when ambulating the resident from the bed to the bathroom. The resident had the call light on, Staff B put the boot and shoe on and the resident used the wheeled walker while Staff B held the resident's back. The resident's boot came loose and the resident tripped and fell . Staff B reported he/she thought the boot was applied correctly, though he/she had never been trained how to put it on. Normally, the resident already had the boot on when Staff B assisted him/her. Staff B called for help and Staff A, RN responded. On 1/26/16 at 2:05 p.m., Staff C, CNA was interviewed and reported working on 11/29/15. Staff C stated she assisted with getting the resident off the floor with a gait belt. When Staff C arrived to the room, the resident did not have a gait belt on. Staff C stated she had to sign a paper when she started that it was an automatic termination if caught not using a gait belt. Staff C stated the gait belt is part of the uniform and is to be used with residents needing assistance with transferring.

Based on record review and staff interviews, the facility failed to provide Resident #1 with adequate supervision to ensure against hazards from self. The sample consisted of 4 residents and the facility identified a census of 101 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment, with a reference date of 03/19/15. The MDS reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12. A score of 12 identified the resident as moderately impaired for cognitive function. The MDS identified the resident needed limited physical assistance of one staff member for ambulation and two staff members for transfers. The current Care Plan identified the resident had [DIAGNOSES REDACTED]. The Care Plan reflected the resident had a potential for falls related to a history of falls with a fracture and poor decision making. The Care Plan directed the staff to assist the resident with ambulation and the use of a walker and to provide contact guard assistance for transfers. The staff were to monitor the resident for the need of increased checks and to question the need to toilet the resident routinely. The resident needed to be reminded to have assistance when getting up. The Care Plan reflected the resident had been moved to a room closer to the nurse ' s station in September of 2013 due to the resident ' s attempts to get up and ambulate independently. The resident had subsequent falls. The Care Plan reflected a focus area for behavior due to [DIAGNOSES REDACTED]. The focus concern identified the resident transfers independently (without staff) and requires lots of reminders as the resident needed assistance. The intervention directed staff to praise the resident for calling for assistance with transfers, redirect the resident when inappropriate and offer 1 to 1 attention and provide medication as ordered by the physician. The fall risk assessment dated [DATE] reflected a score of 14 plus. The score of 14 plus represented the resident at a high risk for falls (total score of 10 or above represents high risk). Review of the Nurse's Notes dated 03/19/15 at 6:45 p.m. reflected a staff member called the nurse to the resident ' s room. The nurse observed the resident lying on the floor in the room on left side with left leg bent underneath the right leg. The resident voiced severe pain to the left hip and left leg. The nurse identified range of motion active to all other extremities. The nurse notified the physician and received orders to send the resident to the hospital. At 7:15 p.m., the ambulance transported the resident to the hospital. The Transfer sheet reflected the resident had attempted to transfer self from the wheelchair to the recliner and caught foot on the wheelchair wheel and fell on left side. The nurse documented the resident may have hit head and had left leg pain. The note reflected the resident ' s leg pain needed to be evaluated to rule out a fracture. The Nurse ' s Notes dated At 10:40 p.m., the facility received notice the resident had been admitted to the hospital due to fall, renal insufficiency and anemia. A review of the hospital emergency room (ED) notes dated 03/19/15 at 9:04 p.m. reflected the resident had fallen while transferring from the wheelchair to chair at the nursing facility. The notes identified the resident had left hip and knee pain. The note reflected the resident had an elevated blood pressure of 211/85 (pain can cause elevated blood pressure), pulse 68 (normal 60-100), respirations 16 (normal 16-20). The radiology report findings dated 03/19/15 identified the resident had a displaced left intertrochanteric femur (hip) fracture. The ED note reflected a physician had been consulted and the hip would be repaired in the morning. The Nurse ' s Notes dated 03/23/15 at 3:30 p.m. reflected the staff documented the resident had a readmission to the facility following post hospitalization with [DIAGNOSES REDACTED]. Staff A , Assistant Director of Nursing, was interviewed and stated Resident #1 has had a long stretch between falls, with the last one prior to 03/19/15 had been in January 2015 and the resident had no injuries from the January fall. Staff A stated the interventions placed after the January fall was to toilet the resident after lunch. Staff A stated after the 03/29/15 fall, the interventions started were to place a fall mat on the floor in front of the resident's bed, keep the bed in the lowest position and place the resident at the assisted dining table so the staff could monitor the resident more closely. On 04/07/15 at 11:30 a.m. Staff B, LPN (licensed practical nurse) was interviewed and stated she had been passing medications when a housekeeping staff came to her and said she had heard a resident calling out for assistance and found Resident #1 lying on the floor in his/her room. Staff B stated she went to the room and found the resident on the floor beside the recliner with his/her feet closest to the recliner and head pointed to the roommate ' s bed. Staff B stated after assessing the resident, she determined the resident may have a fractured left hip and obtained an order to send the resident to the emergency room for an evaluation. Staff B stated the Director Of Nursing (DON) agreed with her evaluation of the situation. On 04/07/15 at 12:10 p.m. Staff C, CNA (certified nursing assistant) was interviewed and stated Resident #1 had been a fall risk which meant the resident needed to be kept under closer observation by the staff. Staff C stated if the resident put the call light on and if the staff did not answer within a few minutes, the resident would get up by his/her self. Staff C stated Resident #1 did not have much patience. Staff C stated the staff were all in the dining room when Resident #1 left after eating. She stated the Resident had last been toileted around 5:15 p.m. right before the resident had been taken to the dining room which was the normal routine for the resident. Staff C stated after the resident goes to the bathroom, he/she would propel the wheelchair per self to the dining room for supper. On 04/07/15 at 1:30 p.m. Staff D, housekeeper, was interviewed and stated she had been walking in the hallway toward Resident #1's room when she heard someone yelling for help. She stated when she reached the room; she saw the resident on the floor between the recliner and wheelchair and the resident calling out for help. Staff D stated she went out, saw the nurse and told her what she had seen. On 04/07/15 at 2:35 p.m. Staff E, CNA stated she had been in the dining room when she saw Staff D come to the dining room and inform the nurse of the resident ' s fall. She stated they went to the bedroom and Resident #1 had been unable to move so the nurse called an ambulance. Staff E stated the resident did not say much but looked to be in pain. Staff E stated the nurses were doing an assessment and decided to send the resident out, so she stayed with the resident until the ambulance arrived and then went back to her duties. Staff E stated that although the resident knew he/she was supposed to wait for staff to assist, the resident propel back to the bedroom and transfer to the recliner without staff assistance. On 04/07/15 at 2:50 p.m. Staff F, CNA, was interviewed and stated he had been in the dining room assisting another resident when he heard a call on the radio that Resident #1 had fallen. He stated he went to the resident's room to help Staff E and Staff B. Staff F stated the DON came in also. Staff F stated the nurse had been assessing the resident, who had been complaining of pain. Staff F stated Resident #1 would normally put the call light on to summon assistance but would sometimes not wait and try to self- transfer/ambulate. Staff F stated the resident wanted to do things for self so she/he would propel the wheelchair to the bedroom and transfer self into the recliner. Staff F stated the resident would get clothing for the next day from the closet, put own pajamas on and transfer to the recliner and watch television for a couple of hours before bed. Staff F stated although the resident had been a stand by assistance, this had been the routine. On 04/07/15 at 3:10 p.m. Staff G, CNA, was interviewed and stated she had been in the dining room when the incident occurred. Staff G stated the resident should have been assisted for transfers but the resident would go to his/her bedroom and transfer self to the recliner after supper. Staff G stated she didn't know how often the resident transferred self without staff assistance. On 04/07/15 at 4:25 p.m. the DON was interviewed and stated CGA (contact guard assistance) means hands lightly touching the resident during transfers with the resident performing the majority of the work. The DON stated Resident #1 would leave the dining room after meals. The DON stated the staff did not always see the resident leave because the resident did not sit at an assisted table prior to the fall. The DON stated the expectation would be for the staff to follow the Care Plan and provide stand by assistance. The DON stated she would have expected if staff saw the resident leaving the dining room, then they were to follow and assist the resident as directed by the Care Plan. The DON stated the facility has a number of new staff who are trying to learn the requirements of the residents.

Based on record review and interviews, the facility failed to administer medication as ordered by the physician for one (1) of five (5) residents reviewed (Resident #8). Resident #8 received the incorrect dose of [MEDICATION NAME] (blood thinner) medication (5 milligrams) on 9/18/13, 9/20/13, 9/21/13, 9/22/13, instead of 2 milligrams as ordered by the physician. The resident's blood test ([MEDICATION NAME]/International Normalized Ratio (INR)) revealed a high critical level of INR at 10 (with a therapeutic INR range between 2.0-3.0.). The resident required Vitamin K therapy to reduce the elevated PT/INR. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 93 residents. Findings include: The hospital Discharge Summary documented Resident #8 had been transferred to the current hospital as result of a high calcium level and had symptoms upon admission of lethargy, dizziness. The resident also had a limited oral intake (15 pound weight loss in last 4 weeks). The summary identified the resident had a [MEDICAL CONDITION] (TIA) incident approximately 4 weeks prior. The hospital records documented Resident #8 had been hospitalized from [DATE] to 9/17/13 with active problems and condition updates as follow: a). Hypertension: Controlled b). [MEDICAL CONDITION] flutter: resume [MEDICATION NAME] c). Physical deconditioning: Continue PT/OT d.) Acute kidney injury: resolving e.) Supratherapeutic (above the therapeutic range) INR: Improved (The International Normalized Ratio (INR) is a blood test used to monitor the clotting tendency of the blood when on anticoagulation ([MEDICATION NAME]) therapy.) (The [MEDICATION NAME] (PT) and INR test are used in combination to test/monitor the effectiveness of [MEDICATION NAME] therapy. A hospital laboratory specimen dated 9/16/13 documented an abnormal (high) [MEDICATION NAME] of 28.5 (with a reference range from 9.3 to 11.7); and INR at 3.0 (with a reference range from 0.9 to 1.1). Resident #8 transferred from the hospital to the nursing home on 9/17/13. The physician ordered the nursing home complete [MEDICATION NAME] test Monday 9/23/13. The signed physician transfer sheet dated 9/17/13 identified Resident #8 ' s medications orders included an order for [REDACTED]. ([MEDICATION NAME] medication is commonly known as [MEDICATION NAME]. [MEDICATION NAME] is an anticoagulant medication (blood thinner).) Review of a facsimile (fax) dated 9/17/13 identified the resident's physician ordered the nursing home to complete a [MEDICATION NAME] laboratory (lab) test for his/her [MEDICATION NAME] medication within a week. The physician agreed to manage Resident #8's [MEDICATION NAME] while the resident resided at the nursing home. The resident's plan of care dated 9/27/13 identified he/she had been admitted to the nursing home after a recent hospital stay for weakness and dehydration. The resident's plan of care documented Resident #8 received an anticoagulant medication due to a history of TIA and Aflutter ([MEDICAL CONDITION] flutter). The plan of care directed staff to monitor the resident for adverse signs of bleeding due to taking the [MEDICATION NAME] medication. The plan of care directed staff to administer medications as ordered; encourage the use of soft - bristled toothbrush; monitor labs as ordered; and observe the resident for signs/symptoms of bleeding out and report concerns. The Hiawatha physician's orders [REDACTED].#8 should receive 2 mg of [MEDICATION NAME] ([MEDICATION NAME]) by mouth on Monday, Wednesday, Friday, Saturday and Sunday; and 1mg of [MEDICATION NAME] ([MEDICATION NAME]) by mouth on Tuesday - Thursday. The September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] (Wednesday), on 9/20/13 (Friday), on 9/21/13 (Saturday) and on 9/22/13 (Sunday). (The physician's orders [REDACTED].) The MAR indicated [REDACTED]'s order. Review of a medication error incident report dated 9/23/13 revealed the resident had been receiving 5 mg of [MEDICATION NAME] 5x/week verses the order from the hospital for [MEDICATION NAME] 2mg 5 times a week. The physician was notified on 9/23/13 at 2:10 p.m. of the medication error and directed the staff to hold the [MEDICATION NAME] medication and to administer 2.5 mg. The form noted Vitamin K should be administered now. (Vitamin K reverses the effect of blood thinning). The physician wanted labs done on 9/24/13. The laboratory report dated 9/23/13 revealed the resident's INR greater than 10.0 (critical) and [MEDICATION NAME] time/([MEDICATION NAME]/PT) greater than 93.9. (normal range 9.5 - 11.1) with directives to call the nursing home. The nurse's notes dated 9/23/13 at 1:30 p.m., documented the resident's PT ([MEDICATION NAME]) greater than 93, INR greater than 10. The nursing home received a physician's orders [REDACTED]. The resident received 2.5 mg of Vitamin K immediately and his/her labs would be completed the following day. Review of the laboratory report dated 9/24/13 documented a [MEDICATION NAME] Time of 35.8 and an INR of 3.7. On that date the physician ordered do not give the [MEDICATION NAME] medication (today) then [MEDICATION NAME] 1 mg. by mouth on Monday and Friday and 2 mg. [MEDICATION NAME] on all other days with a recheck on 9/30/13. The nurse's note dated 9/24/13 at 3:15 p.m. revealed the resident's lab results with his/her PT at 35.8, INR at 3.7. The notes identified the physician directed the [MEDICATION NAME] medication be held for that day (9/24/13). The notes documented 1 mg of [MEDICATION NAME] medication would be given on Monday & Fridays and 2 mg of [MEDICATION NAME] would be given all other days (Tuesday, Wednesdays, Thursdays, Saturdays and Sundays). The resident's PT/INR lab work would be completed on 9/30/13. The laboratory report of 9/30/13 documented a [MEDICATION NAME] ([MEDICATION NAME]/PT) time of 26.4 and an INR of 2.7. Interview with Resident #8's physician on 11/20/13 at 1:45 p.m. revealed she had seen the resident one time while Resident #8 was at the facility. The physician stated the resident was on [MEDICATION NAME] for [MEDICAL CONDITION] Flutter. Interview on 11/20/13 at 2:40 with the nurse of the Physician's Assistant who manages the [MEDICATION NAME] medication for Resident #8 revealed the resident started on [MEDICATION NAME] in July 2013. The nurse reported the Physician's Assistant wanted the resident's INR's between 2 -3. An interview with the pharmacist on 11/20/13 at 10:10 a.m. revealed with the system in place at the time of the medication error there was only one check completed by a pharmacist which consisted of the technician entering the medication and the pharmacist checking the order. After the medication error was brought to the attention of the pharmacy the implemented changes their process. Interview with the Director of Nursing on 11/19/13 at 3:15 p.m. revealed when the resident's abnormal PT/INR lab results came in, they noticed Resident was receiving the wrong dosage of [MEDICATION NAME]. The DON reported Resident #8 had been receiving 5 mg. of [MEDICATION NAME] 5 times per week and 1 mg. of [MEDICATION NAME] 2 times per week rather than [MEDICATION NAME] 2 mg 5 times a week and 1 mg [MEDICATION NAME] 2 times per week. The Director of Nursing indicated when the facility faxed the orders to the pharmacy and somehow the pharmacy turned the orders around. The Director of Nursing reported the nurse checking in the medication checked the medication against the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The medication matched the MAR. According to a reference article titled, National Medical Policy, by Health Net, updated January 2013; the Scientific Rational Initial section revealed the following:, " [MEDICATION NAME] is an oral compound of significant medical importance ...It decrease the tendency of the blood to clot, and is very potent in doing so. However, it is a medication that must be taken maintained within the therapeutic range to minimize adverse events associated with inadequate or excessive anticoagulation... Monitoring of the PT or INR is recommended to ensure that the dose levels remain within the therapeutic range. " According to another reference, INR by the Heart Rhythm Society, " the higher the INR, the longer it takes for blood to clot. If the INR is too high, there is a risk of uncontrolled bleeding. " The facility abated the IJ on 10/8/13 when they implemented the following: On 10/8/13, the DON directed nursing staff on the following: NURSES---We have had an instance where the pharmacy made an error in dispensing medication and it appears, we did not check medications/MARS against the (physician) orders and we did not catch it as well. MARS and MEDS MUST BE CHECKED WITH THE (physician ' s) ORDERS UPON DELIVERY Pharmacists are human and you cannot expect that they do not make mistakes. "Trust but verify" ALWAYS check new medications against the orders not the MARS. The DON reported on 11/20/13 at 11:45 a.m. along with the informational sheet she had posted for nurses, she had also educated nurses on the delivery and checking the medications against the (physician's) orders - not just the MARS. Continued interview with the Director of Nursing revealed the pharmacist as informed and a nurse's meeting held to make sure double checking of everything (the medications coming into the facility from the pharmacy) with physician's orders [REDACTED]. The facility Director of Nursing stated the medication administration records only reflects what the pharmacy does. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of physicians' orders compared to the MARs.

Based on clinical record review and staff interview, the facility failed to ensure one (1) of four (4) residents received adequate supervision during a mechanical lift transfer (Resident #1). The facility identified a census of 93 residents. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident totally dependent on 2 staff for transfers, and totally dependent on staff for dressing, eating, toilet use, personal hygiene and bathing. The MDS documented range of motion limitations on both sides of the resident's body (which included the right and left shoulders, elbows, wrists, and hands). The resident also had limitations on the left and right hips, knees, ankles and feet. The MDS documented the resident as 65 inches in height with a weight of 169 pounds. A plan of care dated 5/5/13 identified the resident required the assistance with cares. The interventions directed 2 staff to utilize a Hoyer (mechanical lift) for transfers. Review of a form titled: MAJOR INJURY DETERMINATION FORM and submitted to the Department of Inspections and Appeals revealed Resident #1 had a major injury as identified by the resident's physician on 11/3/13 at 4:30 p.m. The form completed by the facility on 11/3/13 revealed the resident slid out of the Hoyer lift sling during a Hoyer transfer on 11/3/13 at approximately 7:15 a.m. and sustained a fractured clavicle and a femoral neck fracture The form documented the top sling loops came undone and the resident slid out. The form documented corrective actions taken by the facility consisting of: Retraining of staff on the proper/correct way to utilize mechanical lifts. Review of an undated form titled: Summary of Investigation documented the straps on the lift sling were not attached correctly to the lift causing the resident to fall and get injured. The lift was functioning correctly and the sling was not damaged or in ill-repair. Review of a hospital Encounter form dated 11/3/13 documented the following in the HPI (History and physical) section of the physician's notes: The resident had been non-weight bearing for some time. This morning 2 staff were using a Hoyer lift readying the resident for the day. In speaking with a nurse from the care center the physician documented the nurse was passing medications and aides were attending to the resident behind closed doors when he/she heard a thump followed shortly afterward with calls for help. The resident was found on the floor with blood around the head. Although the nurse could not be specific she reported to the physician,"it must have come off the hook." The resident was transferred to the emergency room (ER) and received staples to his/her scalp lacerations that was described as a "pulsatile bleed." The ER evaluation also revealed a left clavicle fracture, a right femerol neck fracture, and bacteruria with leukocytosis. The hospital discharge summary dated 11/7/13 documented the resident had been admitted to the hospital for pain management. The information documented indicted the need for intravenous fluids, pain medication adjustment, Foley catheter placement for comfort, and did work with physical therapy and occupational therapy that would be continued at the care center. Review of a form titled: Quality Assurance Investigation Form Hiawatha Care Center revealed staff caring for Resident #1 consisted of Staff A, CNA and Staff B, CNA and these 2 CNA's as the staff transferring Resident #1 with the Hoyer lift. Staff C, LPN completed the form and documented he/she as outside of the resident's room and heard a thud and screams and ran into the resident's room finding Resident #1 with a pool of blood under the left side of the head. Review of SKILLS FAIR APRIL 2013 documentation revealed Staff A, CNA as attending a STATION SIGN OFF for transfers. No attendance for Staff B, CNA could be found showing attendance of the April 2013 SKILLS FAIR for transfers. Interview with the facility Director of Nursing on 11/18/13 at 9:30 a.m. revealed Staff B, as not attending the April 2013 SKILLS FAIR. The facility Director of Nursing did point out that Staff B, CNA did attend a SKILLS FAIR IN APRIL 2012 and the Therapy Sign Off Station would include Transfers as part of that sign off. Interview with the facility Administrator on 11/18/13 at 12:30 p.m. revealed all lifts in the facility are Invacare lifts and all of the lift sheets (slings) are interchangeable and are Invacare sheets. The facility Administrator found nothing wrong with the lift or lift sheet (sling) when examined. The facility Administrator indicated it as pure speculation as to what happened. He felt the left upper shoulder strap, when hooked, did not get all the way down by staff, the strap came off and this caused the resident to fall. The facility Administrator indicated both Staff A, CNA and Staff B, CNA were retrained and facility wide education completed on 11/6/13. Interview with Staff C, LPN on 11/18/13 at 10:30 a.m. revealed he/she as the nurse on duty at the time of Resident #1's fall from the Hoyer lift. Staff C, LPN indicated from what staff told her/him consisted of the upper hook coming undone and guessed it was not hooked up correctly. Interview with Staff B, CNA on 11/18/13 at 11:30 a.m. revealed he/she as one of the CNA's assigned to Resident #1 on 11/3/13 and in the room of the resident and completing a transfer with Resident #1 with the aide of Staff A, CNA with a Hoyer lift at approximately 7:15 a.m. Staff B, CNA indicated he/she as moving the resident's wheelchair into place when he/she saw the top left Hoyer pad come down with the strap down on the top left. Staff B, CNA stated Resident #1's head went down first followed by the left shoulder. Staff B, CNA indicated as seeing the resident in position and all of the Hoyer straps in place before the fall. Staff B, CNA indicated the resident could not have been brought to a sitting position if all of the straps were not hooked. Staff B, CNA stated as the resident fell he/she tried to grab the resident but everything happened so fast that he/she could not reach the resident. Staff B, CNA with interview said all of the straps as hooked to the Hoyer lift except for the top left at the time of the fall. Interview with Staff A, CNA on 11/18/13 at 1:00 p.m. revealed he/she as one of the CNA's who came to help assist in getting Resident #1 up on the morning of 11/3/13 and the day of the fall from the Hoyer lift at approximately 7:15 a.m. Staff A, CNA indicated he/she hooked the resident up with the sling to the Hoyer lift. The sling has four areas to be hooked up to the lift and he/she used the blue straps to hook the upper portions of the sling to the Hoyer and used the purple straps to hook the lower portion of the sling to the Hoyer lift. Staff A, CNA indicated he/she did the standard thing and yanked the straps into place and felt a jerk motion as if locking in place. Staff A, CNA indicated this is how he/she trained as of 6 1/2 years ago. Staff A, CNA noted as Resident #1 resided in the Hoyer sling approximately 2 feet from the bed the top left sling loop as undone. Staff A, CNA indicated he/she as immediately going to the resident but too late and the resident as already hitting the ground. Staff A, CNA indicated he/she as having no idea how the left upper strap came out of position. On 11/18/13 at 1:45 a.m. Staff A, CNA, Staff B, CNA, and Staff F, Rehab Manager completed a re-enactment of the fall from the Hoyer lift. The lift pad and the Invacare Hoyer lift, both in good repair and secure, revealed no ability to come loose from the Invacare lift swivel bar with hooks on both ends that attaches the sling supporting the resident during a lift. On 11/19/13 at 2:50 p.m. interview with Staff D, LPN revealed he/she as helping to get the paperwork started for the resident's transfer out of the facility and did not examine the lift pad or the Hoyer lift at the time of the incident. On 11/20/13 at 9:40 a.m. an interview with Staff E, CNA revealed when he/she entered the room of Resident #1 the Hoyer sat still up in the air with the sling connected except for the top left strap. Staff E, CNA indicated there as nothing irregular with the sling or lift. Staff E, CNA stated, "We always yank on our Hoyer straps to make sure they're down." Review of 1:1 Staff Education for Staff A, CNA and Staff B, CNA revealed in part the following: Area of concern: Hoyer Transfers Education on Concern: Be sure to secure cloth strap in Hoyer lift prior to activating lift device.