Every finding on record at Hubbard Care Center

Based on personnel record review, policy review and staff interview, the facility failed to prevent an employee from beginning employment prior to completion of their background check for 1 of 5 personnel records reviewed (Staff A, Certified Nurse Aide CNA). The facility reported a census of 47 residents. Findings include: Review of Staff A's personnel file listed a start date of 5/28/24. The personnel included Staff A's Single Contact License & Background Check (SING) completed on 5/28/24 at 1:57 PM. The Time Card Report for Staff A dated 5/26/24 to 6/8/24 revealed they worked at the facility on 5/28/24 from 5:55 AM to 2:31 PM. The facility policy title Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 documented the facility will conduct and Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code 58.11(3). During an interview 1/9/25 at 10:24 AM the Administrator acknowledged Staff A began working 5/28/24 prior to the completion of their background check.

Based on interviews, electronic health records, and policy review, the facility failed to document accurate information in a timely manner. Interviews and record review revealed that the facility routinely saved documentation as drafts then altered the drafts before finalizing them into the record. During the week of the survey discovered 3 progress notes finalized from drafts with alterations made after the creation date to the finalized note for 3 of 16 residents reviewed (Residents #12, #31 and #99). In addition, 1 resident had an initial fall assessment struck out with no fall assessment added for 1 of 16 residents reviewed (Resident #7). The facility reported a census of 47 residents. Findings include: 1. Resident #99's Plan of Care Nursing Note dated 1/6/25 at 11:49 PM labeled as Draft written by Staff F, Licensed Practical Nurse (LPN), printed 1/7/25 at 12:06 PM documented per speech therapy (ST) evaluation, ST swallowing protocol: Resident received a general diet, whole dense meats ground textures, regular fluids with sip tip (The Sip-Tip Drinking Aid Cup has a leak-proof lid and a mouthpiece valve that helps with lip closure, making it easier for users to drink without spilling) ensuring the sip tip is pumped prior to serving. Resident #50 required one to one (1:1) feeding to max assist. Check lung sounds and temperature after meals until 1/7/25. Resident #99's Plan of Care Nursing Note dated 1/6/25 at 11:49 PM written by Staff F printed 1/9/25 at 2:59 PM documented ST charting ST swallowing protocol: Resident #99 received a general diet, whole dense meat ground textures with small portions, regular fluids with sip tip cup for all beverages, ensuring the sip tip is pumped prior to serving. Continue positioning guidelines and swallowing strategies and cut sandwiches in halves and cut meat in the kitchen prior to serving. Resident #99 required 1:1 feeding to max assist. Check lung sounds and temperature after meals until 1/7/25. 2. Resident #31's Long-Term Nursing Evaluation template (a file that serves as a starting point for a new document. Templates contain placeholder fields you can fill in) dated 1/6/25 at 5:44 PM labeled draft written by Staff F printed 1/7/25 at 12:13 PM documented the following: Mobility/Transfer: Res Dressing/Undressing (assist needed including bilateral lower extremities BLE): Oral Cares/Personal Hygiene (do they have dentures/partial, assist needed): Grooming/Personal Hygiene (assist needed): Toileting assist (including peri care and transfer): Eating (textures/assist/adaptive equipment, swallowing difficulties): Pain: Other: Cognitive/Behaviors: Resident #31's Long-Term Nursing Evaluation dated 1/6/25 at 5:44 PM, written by Staff F printed 1/9/25 at 2:54 PM, documented the following: Mobility/Transfer: Resident #31 self-transferred in manual wheelchair throughout the facility. Resident #31 transferred independently in room with a 4-wheeled walker. Dressing/Undressing (assist needed including BLE): Independent with upper and lower body, staff assist with stockings. Oral Cares/Personal Hygiene (do they have dentures/partial, assist needed): Resident #31 is independent with oral cares. Grooming/Personal Hygiene (assist needed): Resident #31 is independent with personal hygiene cares. Toileting assist (including peri care and transfer): Resident #31 is independent with toileting. Eating (textures/assist/adaptive equipment, swallowing difficulties): Resident #31 eats independent in dining room on general diet with regular liquids. Resident #31 takes medication whole with no difficulty swallowing, coughing or choking noted. Resident #31 ate 0-25% food intake and 249 ml (milliliters) fluid intake. Pain: Resident #31 denied pain or discomfort during the shift. Other: N/A (not applicable) Cognitive/Behaviors: No behavioral changes during the shift. 3. The Plan of Care Nursing Note dated 1/7/25 at 12:12 AM printed 1/7/25 at 12:17 PM labeled draft written by Staff F documented per ST charting ST swallowing protocol: Resident #12 is on a general diet, mechanically soft textures, regular fluids. Resident required 1:1 feeding with all veggies/ fruit cut in bite size pieces. The Plan of Care Nursing Note dated 1/7/25 at 12:12 AM, printed 1/9/25 at 3:19 PM documented per ST charting ST swallowing protocol: Resident is on a general diet, mechanically soft textures, regular fluids. Resident #12 required 1:1 feeding with small portions for lunch and supper. Sandwiches should be cut in half and bite size and all veggies/fruit cut in bite size pieces. Continue to monitor positioning guidelines, set up and post meal cares. Adaptive equipment for use and vision should be modified per OT. Adaptive equipment includes a divided plate and wide mouthed mugs. Serve beverages WITH meal vs before the meal. Resident #12 has been consuming beverages prior to meals being served. 4. The struck-out Fall Nursing Note template dated 10/27/24 at 7:35 AM labeled Incorrect Documentation reflected the date and time of incident occurred on 10/27/24 at 6:10 AM. When a resident called out for help, the nurse got summoned. The nurse discovered Resident #7 on the floor. Resident #7 laid on their back rolling around trying to themselves up. The staff last seen Resident #7 at 5:00 AM when they got changed and wanted to get up for church. They laid on their back with their arms at their sides. The area was clean and dry with good lighting. Resident #7 used a standing mechanical lift for transfers. Resident #7 wore night clothing with gripper socks on. Height of bed was not all the was on ground. The bed had bilateral half side rails up. Resident #7 had a pad on the floor but not alarm and the second shift nurse set it on rounds. Resident #7 had their personal items within reach. Blood pressure 122/70 (average 120/80), temperature 97.6 (average 98.6), respiratory rate 18, and oxygen saturation 94%. Resident #7 reported back pain and had redness on their right side of their back. They could follow commands and neurological assessment (neuros) within normal limits (WNL). Resident #7 had strong hand grips and equal pupils reactive to light. Resident #7 didn't have external rotation or shortening of the hip. The staff assisted Resident #7 with 2 staff and a gait belt. They could bend their knees and helped with bent knees to push up. When asked what happened, Resident #7 stated they got up. No one witnessed the fall. Neuros initiated, and after getting up in chair, they denied pain. The Intervention directed to make sure the alarm and mat on floor bed in low position. Incident Report completed. The Communication - with Family/Physician/Resident dated 10/27/24 at 8:16 AM reflected the nurse sent a secure text to the doctor and son notified of fall by telephone. The struck-out Fall Nursing Note template dated 10/27/24 at 11:00 PM labeled Incomplete Documentation had the template incomplete except secure text to doctor and Assistant Director of Nursing (ADON). The son didn't answer his phone but returned the call at 8:30 AM and the nurse notified him at that time. Note listed [linked]. The progress notes lacked additional documentation related to Resident #7's initial assessment following their fall. The LOA and Return Nursing Note dated draft 1/4/25 at 10:26 AM labeled draft printed 1/7/25 at 12:11 PM documented Resident #7 left facility via private vehicle with their daughters for Christmas at home. Resident #7 is expected to arrive back at 6. The LOA and Return Nursing Note dated 1/4/25 at 10:26 AM labeled Late Entry printed 1/9/25 at 3:18 PM documented Resident #7 left the facility via private vehicle with their daughters for Christmas at home. Resident is expected to arrive back at 18:00. On 1/9/25 at 11:19 AM, Staff B, LPN, reported the facility had the nurses' chart in draft form. She stated they want them to chart falls, transfers to the hospital, injuries, and things like that in draft form. Then they look it over and leave them notes on what to change. They look over it and rewrite what the nurses are supposed to document in the chart. Then they made the changes they wrote and save it as permanent documentation. She stated she had a stack of notes that Staff D, acting DON (Director of Nursing), gave her. Staff D and Staff C, LPN, go over the drafts. Staff B stated that the old DON told Staff B to stop leaving documentation in draft form, that the nurses shouldn't be doing that. Staff B stated the facility wanted the agency nurses to write everything in draft. Staff D and Staff C print off the note, make changes to it and then leave it for the agency nurses to change. Staff B didn't think it was right to do this. Staff B felt they did this to look good for Department of Inspections, Appeals, and Licensing (DIAL). Staff B stated all nurses get notes on how to change their drafts, how to correct them then are expected to change the notes. When asked how long her documentation would sit in draft form, Staff B stated she worked once a week, maybe, and sometimes her documentation sat in draft form for 3 weeks. Staff B stated she had been asked to go back into charting and change eye drops. She stated you can go back into the electronic health record and add documentation. She added you could keep drafts in the electronic record and then edit them later without them showing up as a late entry. She explained incident reports could be changed/edited as well. On 1/9/25 at 12:30 PM, Staff E, Registered Nurse (RN), stated they document in draft notes any communication notes with the provider with any changes with residents, medication changes, etc. Staff E stated they have a few different templates. When asked about the drafts in the electronic records for that day, Staff E stated it had been busy, and they save in draft to try and finish later. Staff E stated the facility is trying to start with getting them done right away. Staff E stated the facility wanted any fall documentation written as a draft to look at interventions. Any time you are the nurse and you have to put in a fall note, they encourage them to come up with an intervention at that time and sometimes interventions are hard to come up with. Staff E stated they told her to keep the documentation in draft form when she first started. She stated they made a change a couple weeks ago and wanted them to finalize the documentation. Staff E stated sometimes the nurses choose to keep documentation in draft form to get input for ideas from others. Staff C and Staff D help come up with interventions for a fall. Staff C can run a report to see if drafts are open. Staff E stated she will get a note of possible ideas on what she can document in her drafts. Staff D will look over the travel nurses' notes to ensure interventions are appropriate and then offer them ideas. Travel nurses keep their documentation in drafts. When asked how travel nurses would know that they need to document in draft form, Staff E stated the travel nurses meet with Staff C and go over it in orientation. When asked how a travel nurse would know if Staff C wasn't there, Staff E stated a nurse would tell them to save a fall in draft form so if it didn't look ok Staff C or Staff D would talk to them. Staff E stated she didn't know of a time when the author's documentation got changed by someone other than the author. Staff C stated she felt confident in how to document on bruises, so she doesn't save documentation on bruises in draft form. She saves documentation regarding transfers out of the facility, falls, and skin tears in draft form. Staff E stated that admission notes can be but don't have to be saved as a draft. Staff E stated she didn't feel the guidance given for documentation altered the picture of what happened. The drafts are kept in draft form until returned to the person who wrote it. Staff E stated she felt best practice was to try and get the draft notes finalized within a couple of days. When asked how the nurses capture what happened at the time of fall for an intervention if you don't finalize the draft the same day, Staff E stated she thought the documentation would show up as a late entry. Staff E didn't know of when a progress note wouldn't show up as a late entry. Staff E stated no has asked her to go back and sign if medication was not given. She added no one asked her to go back and sign something she didn't do. On 1/9/25 at 3:36 PM, Staff F, LPN, stated that she felt neutral about documenting in draft form because nobody is perfect and it was good to see other nurses 'perspectives. Staff F stated documenting in draft form didn't change anything. Staff F stated she appreciated the feedback when it comes to certain documents. She stated the facility welcomed travel nurses to document in draft form to understand what they are documenting, protecting the residents, and following up with the procedures. Staff F stated the facility asked her to document in draft form. Staff F stated she continued to document in draft form when documenting falls, admissions, death notes, and other certain things like destruction of medication. Staff F stated she wanted to make sure she covered everything. Staff F stated she is a travel nurse and worked at the facility for about 2 years. Staff F stated she didn't work at other facilities. She worked for that facility 8 hour shifts 5 days a week. Staff F stated she tried to finalize her drafts as soon as possible. She didn't make a mental note on how quickly notes are finalized. She stated she and the other nurses just try to get the notes finalized as soon as possible. When asked about documentation she started as a draft then finished on a different shift with changes/augmentation in the documentation, Staff F stated she types what she knows at the time and saves as a draft. It's not that the information is not available at that time, it could be that she may get pulled away from the documentation. Staff F stated that she will open a lot of the long-term care documentation so she would know it was her that needed to finish the documentation and then she would go back and fill it out. When asked if there was a concern about the charting being finalized a couple days later, Staff F stated she is not able to chart some of the long-term care charting until the end of shift. Staff F stated one way to resolve that would be to not open that document, but she used the documentation as a checklist. Staff F reported being a nurse since 1996. Staff F stated that in an ideal world, she would love to sit down and focus on the nursing stuff. When asked if it was ok to not finish documentation, she stated the way to handle that is to not open the document. Staff F stated she never worked at a place before this facility where nurses could save their documentation as a draft. On 1/9/25 at 4:03 PM, Staff C stated that with any progress notes they ask that they are signed right away. When it comes to falls or bruising they do have the nurses save the notes in draft form, just in case they forget to put in the size of the bruise, or notifying the doctor of falls. Staff C stated that on more serious notes they ask the nurses to save the progress notes as drafts so they could make sure the note included all of the needed information. Staff C stated they started running reports weekly to make sure the drafts got submitted. She stated when the facility has agency nurses come in, they ask the agency nurses to save the progress notes in drafts. She stated if they have questions for the agency nurses they usually call them and ask them the question. Staff C denied having a situation where an agency nurse saved a draft and then couldn't come back in to save the note to permanent status. Staff C stated she didn't know how they would finalize a progress if written as a draft and they didn't come back. Staff C stated she wouldn't say they altered their original documentation, just making it better. When asked about documenting measurements of a bruise saved in a draft form without the measurements, Staff C responded the nurse could have gotten the measurements but then maybe forgot to document it. She stated she became a nurse in July of 2021. Staff C stated she worked in the facility only as a nurse. She stated that information can be documented as an addendum like the measurements of a bruise if they are missed in the original documentation. On 1/9/25 at 4:25 PM Staff D stated that drafts are in the electronic health records. Staff D stated the nurses saved their documentation as drafts, so someone could review it because they were used to doing that. Staff D stated in her opinion, review of drafts in a timely manner would be within the first 24 hours or if it happened the night before, the next morning. Staff D stated review of drafts, when she was the DON in the past, were done within 24 hours. She stated it depended on the situation sometimes. She stated an example would be the nurse couldn't get ahold of the family, or if they had missing information. Staff D stated this did skew the timeline when you wait to gather the information, such as contacting the family. Staff D stated it should be in the notes to document the family knows. Staff D stated in the past they had problems with families not being notified. Staff D liked to review the drafts to ensure the note had all of the information there. Staff D stated she liked to go over the drafts with the nurses, to let them know what they missed in their documentation such as intervention for falls. They added the interventions to the draft after they have the discussion with the nurse, as sometimes it is very difficult to come up with an intervention. Staff D stated that if someone had an injury, and they don't see the measurements in the draft on the wound, she would have them document the measurements in a separate note. Staff D stated documenting in draft form started with falls. She stated she would let nurses know here are all the steps you need to take and when she would go back and check, nothing was done. Staff D stated she never gone in and changed someone else's documentation as she didn't have their passwords. Staff D stated in the past few months she didn't review records unless asked to do so. When asked about the struck-out entry in Resident #7's chart, Staff D stated she remembered hearing talk about the nurse's documentation not being good. Staff D stated the nurses tried to figure out how to handle the situation. Staff D said they shouldn't have struck the documentation out. Staff D said as a previous DON, she had the nurses document in draft form and the facility did this for years. Staff D described herself as pretty fussy about documentation. Staff D stated one of her passions was coaching/teaching nurses about documentation because it is so important. Staff D stated she didn't know what they would do if agency nurses drafted documentation and did not return to the facility to finalize it. Staff D stated to her knowledge that never happened before. All of the notes she left for agency nurses for their drafts to be documented better, have been able to be documented by the agency nurse who then would finalize the draft when they returned to the facility. An undated Documentation policy listed the licensed nurses or nursing assistants had the responsibility to accurately record all pertinent information regarding resident's care and conditions - mental, physical, psycho-social and all other information, as is required according to State and Federal guidelines. The policy included a guideline to always complete documentation in a timely manner and in accordance with facility policy.

Based on clinical record review and staff interviews, the facility failed to notify a resident 48-hours in advance that their Medicare Part A coverage would end and services would no longer be covered for 1 of 3 residents reviewed (Resident #50). The facility reported a census of 47 residents. Findings include: Resident #50's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. The Skilled Nursing Facility (SNF) Beneficiary Protection Notification (BPN) form completed by the facility indicated Resident #50's skilled services started on 11/14/24 and ended on 11/19/24. The SNF Advanced Beneficiary Notice (ABN) with Resident #50's verbal signature dated 11/19/24 revealed beginning 11/20/24 they may have to pay out of pocket for physical therapy (PT), occupational therapy (OT) and daily skilled nursing care. The Notice of Medicare Non-Coverage (NOMNC) form with Resident #50's verbal signature dated 11/19/24 revealed effective 11/19/24 skilled services would end. During an interview on 1/8/25 at 9:45 AM the Social Worker acknowledged residents must receive a 48-hour notice in regards to termination of Medicare Part A coverage. During an interview on 1/8/25 at 12:40 PM, the Administrator reported the facility didn't have a policy regarding the completion of the SNF ABN and NOMNC forms, as they follow Medicare guidelines. During an interview on 1/8/25 at 3:55 PM, the Administrator explained they expected the notification of Medicare non-coverage forms be completed 48-hours in advance.

Based on clinical record review, guidance from the Resident Assessment Instrument manual and staff interview, the facility failed to accurately reflect the completion date on the Minimum Data Set assessments for three of three residents reviewed in the sample (Resident #32, Resident #33, Resident #37) for MDS accuracy. The facility reported a census of 43 residents. Findings include: Resident #32 had a quarterly MDS with an Assessment Reference Date of 8/14/2022. The completion date (item Z0500) was documented as 8/28/2022. The signature line (item Z0400C) revealed Sections G, GG, H, I, J, M, N, O and P of the MDS were dated as being completed on 9/2/2022, 5 days following the date documented as the MDS being completed. Resident #33 had a quarterly MDS with an Assessment Reference Date of 8/21/2022. The completion date (item Z0500) was documented as 9/4/2022. The signature line (item Z0400C) revealed Sections G, GG, H, I, J, M, N, O and P of the MDS were dated as being completed on 9/12/2022, 8 days following the date documented as the MDS being completed. Resident #37 had an annual MDS with an Assessment Reference Date of 10/23/2022. The completion date (item Z0500) was documented as 11/6/2022. The signature line (item Z0400C) revealed Sections G, GG, H, I, J, M, N, O and P, as well as portions of Section L of the MDS were dated as being completed on 11/14/2022, 8 days following the date documented as the MDS being completed. 1. Per review of the guidelines stated in the Resident Assessment Instrument (RAI) manual, dated October, 2019, both quarterly and annual Minimum Data Set (MDS) assessments must be completed by the Assessment Reference Date plus 14 calendar days. 2. Per review of document from Point Click Care (electronic health record software) titled How to Determine What Date was printed in Z0400 on MDS 3.0 assessment, the document revealed the facility may choose settings for the group signature page, Section Z0400. The options are: Yes: which indicates all MDS items/sections for which a user completes are grouped together on one signature line and the signature line only the most recent completion date No: which indicates all items an/or sections completed by a user are printed according to the completion date. If one user completed items/sections on more than 1 date, then there is a different signature line for each individual date. 3. Further information also revealed the information the system uses the date information as entered into the MDS (Revised date) as the Completion Date if a staff member cannot sign on the same day. If the Revised Date is not the the date the information was collected then provide the collection date that will print in Z0400. On 11/15/22 at 4:37 pm, the Assistant Director of Nursing/MDS Coordinator ADON stated all of the information was collected during the ARD period and she used the feature of Edit collection date (noted above in item 3) through the electronic health record software due to the information was gathered but was not coded on the MDS.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff utilized proper infection control technique when performing wound care for one of seven residents reviewed. (Resident #41) The facility census was 42 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #41 had [DIAGNOSES REDACTED]. During observation on 5/8/18 at 9:40 a.m., Staff A, licensed practical nurse, LPN entered the resident's room and washed hands and donned gloves. Staff A cleansed the residents right buttocks, pat dry, and applied [MEDICATION NAME] cream as ordered. Staff A completed the treatment wearing one pair of gloves and not did change gloves after cleansing the resident's right buttock and did not wash her hands. Staff A proceeded to assist the resident back to the recliner, grabbed the residents water pitcher and stated it needed filled up, touched the remote control to the television and resident's recliner without washing her hands. During interview on 5/8/18 at 9:50 a.m., Staff A stated she should not have touched the resident's water pitcher without washing her hands. Staff A stated she got the resident a new water pitcher. When asked if she should have touched the resident's television remote and recliner chair without washing her hands, Staff A said no. During interview on 5/8/18 at 9:55 a.m., the Director of Nursing stated Staff A should have washed her hands after the treatment and before touching the water pitcher. A document titled Hand Hygiene Techniques revealed staff performing direct resident contact will use proper hand hygiene to prevent the spread of infection to other staff, residents and visitors.

Based on clinical record review, staff interviews and facility abuse policy review the facility failed to ensure each resident received kind and considerate care at all times and had been free from mental abuse. A staff member posted a humiliating photograph of Resident #1 on a social media site Snapchat. Resident #1 had cognitive impairments due to dementia [DIAGNOSES REDACTED]. Record review identified Resident #1 could not advocate for him/her(self). A reasonable person would be embarrassed and degraded if his/her care provider humiliated him/her in this manner. Staff B acknowledged she had posted the photograph of Resident #1 on Snapchat. A concern had been identified for 1 of 3 residents reviewed with a facility census of 59 residents. Findings include: Review of the undated facility Abuse Prevention and Identification policy identified each resident had the right to be free from abuse; and residents must not be subject to abuse by anyone including facility staff. The policy defined mental abuse as not limited to humiliation, harassment, threats of punishment or deprivation (neglect). The Abuse policies revealed resident would be protected during an investigation of alleged abuse and will be investigated thoroughly by the Administrator with assistance from the Director of Nursing. Resident #1 had been admitted to the nursing home on 3/3/16 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 3/9/16 indicated the resident had been unable to complete a Brief Interview for Mental Status (BIMS) cognitive assessment and scored 0 out of 15. Resident #1 required extensive physical assistance of one staff with transfers, dressing, toilet use, and personal hygiene. The resident had occasional incontinent of urine and frequently incontinent of bowel. The Care Plan initiated 3/22/16, identified bowel and bladder incontinence and required padded pullups. The resident ' s care plan identified he/she had impaired vision due to [MEDICATION NAME] degeneration, impaired communication due to cognitive impairment and hearing loss. The resident had an unspecified dementia and a potential for activity decline, depression. The resident ' s hobbies included music, playing trombone, woodworking, reading, golf, painting and traveling. The admission record identified Resident #1 ' s prior occupation as a professor of mathematics. An employee ' s statement revealed on 3/16/16, at 7:30 p.m., the employee received a Snapchat from Staff B and saw a picture of an individual with his/her pants around his/her ankles. The individual in the picture had been covered with feces (Resident #1). The employee knew the person in the picture was a resident at the nursing home (Resident #1). The employee contacted the DON immediately. Snapchat is a video messaging application whereas using the user can take photos, record videos, add text and drawings. The sent photographs and videos are known as Snaps. Snapchat community guidelines directed their users to keep it legal and directed users to not take Snaps of people without their knowledge or consent. The community guidelines address invasion of privacy and urged their users to not take Snaps of people not to violate their privacy in spaces, like bathrooms. The community guidelines did not address humiliation. A copy of the undated photograph posted on Snapchat showed an elder person standing in a stooped position with their knees bent. The elder person was wearing checkered pants that were down around the person ' s ankles and a soiled brief at or near the person ' s lower calf area. The elder person had a long gray shirt on that covered their upper body down to their upper thighs. The shirt was soiled with what appeared to look like smeared stool throughout the shirt and on the persons, left hand, bilateral knees and calf area. A caption on the picture read 'Shit Galore'. On 3/31/16 at 11:30 a.m. Staff B admitted on [DATE] she used her personal cell phone and took a picture of Resident #1 while covered with bowel movement (BM). She sent the picture as a Snapchat to coworkers titled Shit Galore. Staff B described the resident in the picture had been covered with BM with his/her brief/pants were around his/her ankles. The resident's privates were covered by his/her shirt. She admitted staff could probably identify the resident even though the resident's face had not been in the photograph. Staff B reported she had not sent the Snap right away as the resident had been trying to reach around her for a hug and he/she had BM on his/her hands. Staff B reported the DON removed Resident #1 from the unit and asked her to leave the nursing home. She returned the following day to talk with the Administrator. Staff B stated the resident's family member wanted to talk with her and told her how disappointed they were with what she had done. The resident's family told her they hoped she never worked in another nursing home again. On 3/30/16 at 12:08 p.m. the Director of Nurses (DON) reported on 3/16/16 at approximately 8:20 p.m. she received a call from Staff A, certified nursing assistant CNA, reporting she received a Snapchat from Staff B, CNA, of a resident that had been incontinent (of bowel). The DON was in the facility at the time and immediately checked on Resident #1 and determined Staff B's location. The DON notified the Administrator per phone and they began their investigation. Staff B had been removed from the assigned area, and interviewed with the Administrator per phone. Staff B admitted she took the picture of Resident #1 after he/she had been incontinent of bowel and sent it to approximately four coworkers with a caption Shit Galore. Staff B indicated she no longer had the picture on her phone. On 3/30/16 at 2:40 p.m. the Administrator stated on 3/16/16 at approximately 8:30 p.m. the Director of Nursing reported she was notified she received a Snapchat from Staff B of an elderly resident with pants around his/her ankles covered with bowel movement (BM). The DON and Administrator immediately separated and interviewed Staff B. Staff B indicated knowledge of the facility abuse policy and information regarding mandatory reporter obligation to report. Staff B admitted her cell phone had been in her pocket and she took a picture of Resident #1 after he/she had been incontinent of bowel. She then sent the picture per Snapchat to approximately 5 (6) coworkers. Staff B titled the picture Shit Galore. The local sheriff's office and the local police department were notified. Staff B was suspended on 3/16/16 and terminated on 3/17/16. The Administrator indicated they just updated the abuse policy to include social media and staff received education regarding use of resident information on social media. The Administrator indicated the facility followed their policy regarding Abuse and Staff B was immediately separated, suspended and terminated. The facility investigation revealed Staff B had been asked if she understood this was dependent adult abuse and asked her why she would do this. Staff B stated it was a stupid thing to do. The disciplinary action identified Staff B had been terminated on 3/17/16 with the following infractions: The employee had verified resident abuse or neglect. The employee had posted Snapchat photo of the resident with his/her underwear around his/her ankles and obviously incontinent of feces and sent the photo to six coworkers with a captions of [***]Galore on 3/16/16 at approximately 7:30 to 8:00 p.m.

Based on clinical record review, staff interview and facility documentation of Resident Rights, the facility failed to ensure one (1) of (3) residents dignity had been preserved. Staff B failed to display respect and take into consideration Resident #1's dignity when she displayed a photograph of Resident #1 on the social media site Snapchat. Record review identified Resident #1 could not advocate for him/her(self). A reasonable person would be mortified if his/her care provider posted a private photograph during personal cares on any social media site. A concern had been identified for 1 of 3 residents reviewed with a facility census of 59 residents. Findings include: Resident #1 had been admitted to the nursing home on 3/3/16 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 3/9/16 indicated the resident had been unable to complete a Brief Interview for Mental Status (BIMS) cognitive assessment and scored 0 out of 15. Resident #1 required extensive physical assistance of one staff with transfers, dressing, toilet use, and personal hygiene. The resident had occasional incontinent of urine and frequently incontinent of bowel. The Care Plan initiated 3/22/16, identified bowel and bladder incontinence and required padded pullups. The resident ' s care plan identified he/she had impaired vision due to [MEDICATION NAME] degeneration, impaired communication due to cognitive impairment and hearing loss. The resident had an unspecified dementia and a potential for activity decline, depression. The admission record identified Resident #1 ' s prior occupation as a professor of mathematics. An employee ' s statement revealed on 3/16/16, at 7:30 p.m., the employee received a Snapchat from Staff B and saw a picture of an individual with his/her pants around his/her ankles. The individual in the picture had been covered with feces (Resident #1). The employee knew the person in the picture was a resident at the nursing home (Resident #1). The employee contacted the DON immediately. Snapchat is a video messaging application whereas using the user can take photos, record videos, add text and drawings. The sent photographs and videos are known as Snaps. Snapchat community guidelines directed their users to keep it legal and directed users to not take Snaps of people without their knowledge or consent. The community guidelines address invasion of privacy and urged their users to not take Snaps of people not to violate their privacy in spaces, like bathrooms. The community guidelines did not address humiliation. A copy of the undated photograph posted on Snapchat showed an elder person standing in a stooped position with their knees bent. The elder person was wearing checkered pants that were down around the person ' s ankles and a soiled brief at or near the person ' s lower calf area. The elder person had a long gray shirt on that covered their upper body down to their upper thighs. The shirt was soiled with what appeared to look like smeared stool throughout the shirt and on the persons, left hand, bilateral knees and calf area. A caption on the picture read 'Shit Galore'. On 3/31/16 at 11:30 a.m. Staff B admitted on [DATE] she used her personal cell phone and took a picture of Resident #1 while covered with bowel movement (BM). She sent the picture as a Snapchat to coworkers titled Shit Galore. Staff B described the resident in the picture had been covered with BM with his/her brief/pants were around his/her ankles. The resident's privates were covered by his/her shirt. She admitted staff could probably identify the resident even though the resident's face had not been in the photograph. . On 3/30/16 at 12:08 p.m. the Director of Nurses (DON) reported on 3/16/16 at approximately 8:20 p.m. she received a call from Staff A, certified nursing assistant CNA, reporting she received a Snapchat from Staff B, CNA, of a resident that had been incontinent (of bowel). Staff B admitted she took the picture of Resident #1 after he/she had been incontinent of bowel and sent it to approximately four coworkers with a caption Shit Galore. Staff B indicated she no longer had the picture on her phone. On 3/30/16 at 2:40 p.m. the Administrator stated on 3/16/16 at approximately 8:30 p.m. the Director of Nursing reported she was notified she received a Snapchat from Staff B of an elderly resident with pants around his/her ankles covered with bowel movement (BM). Staff B admitted her cell phone had been in her pocket and she took a picture of Resident #1 after he/she had been incontinent of bowel. She then sent the picture per Snapchat to approximately 5 (6) coworkers. Staff B titled the picture Shit Galore. The facility Resident Rights indicated residents would be treated with dignity. The disciplinary action identified Staff B had been terminated on 3/17/16 with the following infractions: The employee ' s conduct had been regarded as immoral, improper or inappropriate. The employee violated the resident ' s HIPPA privacy and security. The employee had failed to maintain the confidentiality of the resident information (resident rights). The employee had posted Snapchat photo of the resident with his/her underwear around his/her ankles and obviously incontinent of feces and sent the photo to six coworkers with a captions of [***]Galore on 3/16/16 at approximately 7:30 to 8:00 p.m.

Based on record review, observation and staff interviews, the facility failed to follow care plan interventions for one resident with swallowing problems (Resident #9). The sample included 14 residents. The facility reported a census of 53 residents. Findings included: According to the Minimum Data Set (MDS) Assessment Tool dated 3/29/15, Resident #9 documented the resident experienced severely impaired cognitive function. The resident required extensive assistance for transfers and ambulation, and set up assistance for eating/drinking. The resident's Care Plan listed [DIAGNOSES REDACTED]. The Care Plan revealed the resident as at risk for alteration in nutritional status and directed staff to follow the 3/25/15 Swallowing Protocol established by Staff B, Speech Pathologist. The Swallowing Protocol listed a [DIAGNOSES REDACTED]. During observation on 4/28/15 at 7:29 a.m. Staff A, Certified Medication Aide (CMA) prepared the resident's medications for administration including [MEDICATION NAME], Senna and Tylenol. She crushed the medications and mixed them with a small amount of pudding. She administered the medication in 3 bites from a spoon. After the first bite, the resident grimaced. After the second bite, the resident continued to make faces and stated, "that one made me sick." At that time, the table failed to contain beverages or water. The CMA did not offer the resident a drink or any food, and told the resident we'll be eating soon. She then walked away from the resident to the Medication Cart, approached the surveyor and stated she would have to wait to administer the resident's [MEDICATION NAME] because the resident drank from a special cup. During an interview on 4/29/15 at 9:08 a.m. Staff B, Speech Pathologist stated the Swallow Protocols written on 3/25/15 should still be in effect. When informed of staff administering crushed medications without a drink to wash them down she stated she would expect staff to offer a drink after the medications.

Based on record review and staff interviews, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 5 residents reviewed. Resident #5 was known to not reliably use the call light and was also known to attempt to self-transfer. The resident stood up and walked approximately 2 feet and fell to the floor fracturing a hip. The resident's alarm did not activate as staff previously turned the alarm off to walk the resident before supper and failed to turn the alarm back on after walking the resident. The facility identified a census of fifty-three (53) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 1/19/14 assessed Resident #5 with a brief interview for mental status (BIMS) score of "13". A BIMS score of 13 identify no cognitive impairments. The resident required extensive staff assistance with transfers, ambulation, dressing, toileting, personal hygiene and bathing. A "balance during transitions and walking" test identified the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident had functional limitations in range of motion on one side of the lower extremities. The resident utilized a walker and wheelchair for mobility. The resident was occasionally incontinent of bladder and not on a toileting program. The resident had [DIAGNOSES REDACTED]. The MDS identified that the resident did not have falls since the previous assessment. A falls care area assessment (CAA) dated 8/7/13 revealed the resident required assistance with transfers, ambulation and toileting. Alarms were in place for safety. A physician discharge summary dated 4/23/13 identified the resident with "nocturnal agitation with recurring falls due to noncompliance with ambulation limitations". The form revealed that the resident attempted to ambulate without assistance despite repeated warnings. A physical therapy notice of discharge from part A/part B therapy dated 12/9/13 revealed the resident could ambulate short distances with front wheeled walker and assistance of 2 with one person to push the wheelchair. The resident should use a wheelchair for longer distances. The resident required one staff to assist with pivot transfers with gait belt in room and bathroom; utilize front wheeled walker for wheelchair to bed transfers and grab bar in bathroom. A pain evaluation completed on 1/23/14 identified that the resident had occasional pain over the previous 5 days. The resident rated the worst pain at a "6" out of the previous 5 days with 0 being no pain and 10 as the worst pain imaginable. A fall risk evaluation dated 1/23/14 identified the resident with a score of "11". A score of 10 or above represented high risk. Interdisciplinary progress (ID) notes identified the following information: 11/19/13 at 1:30 p.m. revealed the resident was in the lobby attempting to stand up without assistance or walker. The resident stated he/she wanted to see if they could do it themselves. Staff reminded the resident to wait for staff assistance and the resident stated no he/she would do it themselves. 11/26/13 at 6 a.m., The resident sat up by self in bed and attempted to get up. Staff redirected the resident to wait until staff can assist him/her. 12/17/13 at 6:30 a.m. the resident sat on the edge of the bed with alarm sounding. Staff instructed the resident to put feet back in bed and staff would assist. 12/17/13 at 10:35 p.m., identified the resident often declines to use the call light to make needs known therefore requires bed and chair alarm. The resident will often attempt to self-transfer when in room alone. 3/8/14 at 7:40 p.m. staff observed the resident with increased propelling in wheelchair despite fatigue. The resident had increased slouching and poor posture, the resident leaned forward after excessive wheelchair maneuvering. The resident also completed all restorative exercises then exhibited excitability asking to do more. Resident wheeled throughout main lobby and hallway after therapy. Staff documented they questioned if the behaviors were related to decreased Haldol (antipsychotic) dosage. 3/21/14 at 7 p.m., the resident transferred self to recliner with alarm sounding. The unusual occurrence report dated 4/10/14 at 7:45 p.m., identified Resident #5 self-transferred out of his/her wheelchair and fell . The resident complained of right thigh pain and had difficulty bearing weight. The resident ' s alarm ' s did not sound. The facility counseled the employee regarding the alarm policy and importance of following the policy for resident safety. 4/10/14 at 7:45 p.m. and documented by Staff N (registered nurse) identified that Staff N passed medications when she heard Resident #5's roommate call for help. Staff N responded and observed the resident lying on his/her back with legs extended and slightly bent at the knee. The resident laid near the foot of the roommate's bed. The resident did not respond when asked what he/she was doing. The call light was accessible and not on. The resident was viewed multiple times between 7 p.m. and 7:30 p.m. with the last observation at 7:30 p.m. At that time, the nurse aide asked the resident if he would like to go to bed and the resident stated it was too early. The resident's alarm sensor pad did not sound when the resident fell . Assessment showed two small abrasions to the lateral right knee. The areas measured 1.5 centimeters (cm.) by 1.5 cm. and 1 cm. by 1 cm. Staff then attempted to stand the resident and it was obvious the resident had increased pain with weight bearing so staff immediately seated the resident and notified the ARNP on call of the fall and pain. At 8:45 p.m. the ambulance arrived and the resident transported to the hospital for examination. On the same date at 11:30 p.m. Staff N phoned the hospital and they informed her the resident admitted to the hospital with [REDACTED]. 4/11/14 at 10 a.m. the Director of Nursing wrote that she reviewed the 4/10/14 fall. The facility will replace the resident's alarm with an alarm that staff cannot turn off. The facility educated/counseled the staff member responsible for not checking the alarm. In addition the facility educated the nurse aide instructor on the facility alarm policy. The nurse aide instructor will educate students prior to next clinical. The resident returned to the facility on [DATE] at 3:25 p.m. following gamma nail surgical repair of the right hip fracture. The resident was treated with intravenous antibiotics following surgery for [REDACTED]. After return the resident was to be touch toe weight bearing for one month and would receive skilled therapy in an attempt to return to prior level of functioning. The resident had staples and a dry dressing to the right hip. The resident would use a Hoyer mechanical lift for transfers and wheelchair for mobility. Staff would administer Tylenol (analgesic for pain) for pain management. A history and physical note from the hospital dated 4/10/14 identified the resident with a right femur fracture. The resident had been doing well and feeling stronger and as a result of that, the resident ambulated without assistance. The resident fell sustaining a significant fracture of the right proximal femur. The resident arrived to the hospital in significant severe pain. The resident had a history of [REDACTED]. A pain evaluation completed on 4/17/14 identified the resident with frequent pain over the previous 5 days. The resident rated the worst pain at a "10" out of the previous 5 days with 0 being no pain and 10 as the worst pain imaginable. The resident stated he/she could live with it and the Tylenol helped a lot. On 4/30/14 at 11:43 a.m., the activity director stated on 4/9/14 the resident's spouse visited and after leaving, the activity director visited with the resident who informed her that when he/she could get up from the wheelchair per self then he/she could go home and the resident wanted to go home. The next morning on 4/10/14 the activity director heard an alarm and observed the resident attempting to get out of the wheelchair per self. Staff arrived and the resident sat back down. On 4/29/14 at 3:15 p.m. Staff D (nurse aide) stated she helped the resident ambulate that afternoon and when the resident stood, the alarm sounded so a nursing student turned the alarm off. They walked the resident down the hall and sat the resident back in the wheelchair and the resident went to supper. Staff D could not recall if the alarm sounded when the resident sat back down in the wheelchair. After supper, the resident wheeled self back to his/her room. At 7 p.m. Staff D stopped in the room to see if the resident needed anything and the resident did not need anything. Staff D told the resident she would come back later and that the resident should use the call light if he/she was ready. Staff D stated she kept looking for Resident #5's call light and when it came on, she went right down after she finished cares in another room. When she arrived at the room, the resident was in a wheelchair but someone told Staff D the resident fell . Staff D stated she did know the student turned the alarm off. Staff D stated she was responsible and she didn't recall if she checked the alarm for function after walking the resident. She stated she didn't even think about the alarm after they put the resident back in the wheelchair. On 4/30/14 at 4 p.m., Staff D stated prior to the fall, staff would keep a close eye on the resident due to prior attempts of the resident to stand. One of the strategies staff used to keep the resident from self transferring was to keep the resident out of his/her room. She stated the day of the fall it was not mentioned that the resident tried to stand earlier that day or that the wife told the resident that he/she needed to transfer self before he/she could go home. Staff D stated if she would have known that information, she would have encouraged the resident to go to bed earlier instead of asking the resident if everything was Ok. On 4/30/14 at 5 p.m. (after visiting with the surveyor) Staff D wrote a statement that stated when she walked the resident on 4/10/14 the resident informed her that his/her spouse stated the resident needed to walk so he/she could go home. On 4/30/14 at 2:20 p.m. Staff C (nurse aide) stated she worked the evening of the incident. She stated around 4 to 4:30 p.m. the resident sat in a recliner in the front and she placed the resident in the wheelchair around 4:45 p.m.,. and assisted the resident to the bathroom. After using the toilet, she made sure the alarm sounded when the resident sat back in the wheelchair. She went to break and returned around 5:10 p.m. During that time, Staff D and students walked the resident. Around 6:30 to 6:45 p.m. the resident sat in his/her room talking with his/her roommate. At 7:30 p.m. Staff C and a student put a resident to bed and Resident #5 sat in his/her doorway and said it was too early for bed. Staff C came out of a room and saw the resident's call light on and when she arrived, Staff N was there with the nursing students and instructor. They got the resident up from the floor. The resident stated he/she got up and to wash his/her hands. The resident stated his/her spouse said the resident needed to do things on their own. Staff C stated the resident tried to get up on their own before and staff would tell the resident not to. The alarm would sound and staff would know the resident was up. Staff C stated it was not reported that the resident tried to stand the morning of 4/10/14 and the resident's spouse's comments were not reported to them. Staff C stated if she would have known, she would have the resident stay with staff for closer observation. On 4/30/14 at 1:57 p.m. Staff N (registered nurse) stated she went in the resident's room at 7:05 p.m. to give the resident medication. The resident was very calm and talking with his/her roommate. At 7:45 p.m. Staff N was halfway down the hall when he/she heard "help". Staff N found the resident on the floor laying on his/her back with legs bent at the knee. The resident's roommate hollered help. Staff N stated prior to the fall, staff would try to keep the resident out of his/her room to allow for closer observation. The resident also had an alarm on the bathroom door. Staff N stated she heard at report that the resident's spouse said if the resident could walk better, then he/she could go home. Staff N stated the resident was good about making his/her needs known and the resident would use the call light. She stated between 7:05 p.m. to 7:45 p.m. three staff checked the resident and he declined help. She stated the alarm did not sound. When Staff N looked at the alarm it was not on, It looked like it was in the "off" position. On 4/30/14 at 12:55 p.m. Staff A (nurse aide) stated prior to the fall the resident would put his/her foot down on the floor mat when in bed to activate the call light. She stated the resident used the call light approximately 50% of the time. Staff A stated they would never leave the resident in his/her room alone. The resident wasn't to be in the room alone unless the resident was in bed or if the resident's spouse was with him. She stated the nurse would tell staff the resident couldn't be in the room by his/herself. On 4/30/14 at 10:24 a.m. Staff L (registered nurse) stated prior to the fall the resident didn't use the call light a lot. The resident would be in the wheelchair and just stop staff if he/she needed help. She stated she had seen the resident self transfer twice. The resident's spouse said if the resident could walk then he/she could go home which caused the resident to make attempts to stand. Staff preferred to have the resident out of the room so they could observe the resident. The resident would not be as likely to self-transfer if he/she was out of the room. She stated there was nothing in writing about keeping the resident out of the room, staff just knew to try and keep the resident out. On 5/5/14 at 11:15 a.m., Staff M (registered nurse) stated the resident can stand up fast. The resident uses the call light depending on his/her mood. Staff M stated prior to the fall the resident would try and get up at night and would sit on the edge of the bed. On 5/5/14 at 12:27 p.m. Staff R (nurse aide) stated prior to the fall the resident was not good about using the call light and would try and get up causing the alarms to sound. On 5/5/14 at 2:15 p.m. Staff Q (licensed practical nurse) stated she saw the resident try to get up in the past and would hear the alarm. The resident used the call light sometimes and other times, the resident would yell out. On 5/5/14 at 1:14 p.m., Staff F (certified medication aide) stated the resident would put his/her feet out of the bed and the call light would go on. The resident would try to get up. On 4/30/14 at 10:05 a.m. Staff B (nurse aide) stated the resident was not 100% reliable to use the call light. She stated prior to the fall when the resident was in the wheelchair they really had to keep an eye on him/her. She didn't like to leave the resident in his/her room unattended and most of the nurses she worked with wouldn't let staff leave the resident in his/her room unattended. They would have staff take the resident out of the room when in the wheelchair because the resident would try to stand. On 5/5/14 at 1 p.m. Staff K (registered nurse) stated that prior to the fall the resident's use of the call light varied. The resident would also stand up on his/her own. She stated they didn't want the resident in his/her room unattended. It was kind of an understanding among staff. There was nothing written, it was just 'known". A care plan dated 1/28/14 and in place when the fall occurred identified the resident with a history of falls due to [DIAGNOSES REDACTED]. The care plan directed staff to place a sensor pad alarm in the wheelchair. The care plan also contained an intervention dated 9/11/13 that directed staff to assist the resident with bedtime care and to bed soon after the supper meal and the resident should independently propel wheelchair in common area until ready for bed time care and bed. On 4/29/14 at 2:05 p.m. three staff assisted the resident with changing and per-icare. A wedge cushion was used between the resident's legs when staff turned the resident. At that time the resident stated he/she fell in the room when he/she tried to get in the wash room to wash his/her hands. The resident stated he/she tripped over his/her own feet. The resident stated he/she did not use the call light prior to the fall. On the same date at 5:45 p.m. two staff transferred the resident from bed with the mechanical lift. The alarm beeped when the resident sat in the wheelchair on the alarm pad. During the investigation, the Administrator measured the distance from the resident's wheelchair to the area where the resident fell . She stated it measured approximately 2 feet. The facilities personal alarm policy (not dated) identified the facility used personal alarms including but not limited to bed alarms, sensor pad alarms, under seat alarms, etc. The guidelines noted the alarm does not prevent a fall, in most cases the alarm will alert the staff that a resident who has been determined to be at risk for falling while ambulation or transferring independently is attempting to do so. The prompt staff response to the alarm may prevent the fall/accident from occurring. The policy identified when the resident is assisted off the alarm the alarm should sound which indicates that it is functioning. If the alarm is not functioning properly the staff person needs to investigate the situation to determine why the alarm is not functioning.

Based on observation, clinical record review, staff interview and facility policy review, the facility failed to ensure staff provided adequate supervision and assistive devices as planned to prevent falls for two of four residents reviewed with a history of falls (Resident #1 and #4). The facility identified a census of 55 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment form dated 2/7/13, Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident displayed moderately impaired cognitive status, fluctuating inattention and disorganized thinking. The MDS revealed the resident required extensive assistance of 2 staff members with bed mobility, transfers and toilet use and experienced functional limitations in range in motion to his/her bilateral lower extremities. The MDS documented the resident with no falls since admission to the facility. A Care Plan dated 2/12/13, indicated the resident had a history of [REDACTED]. The approaches included the following: a. Sensor alarm to recliner. (dated 1/25/13) b. Sensor pad alarm to wheel chair and bed. (dated 2/12/13) c. 1 mat and 1 concave mattress beside both sides of the resident's bed for safety and comfort. (dated 2/14/13) d. Hi-low bed. (dated 2/12/13) e. Call light alarm added to bed sensor alarm. (2/19/13) A Fall Risk Evaluation form dated 2/6/13, indicated the resident had a score of 19. (10 or above represented a high risk for falls). An Unusual Occurrence Report form dated 1/25/13 at 8:30 p.m., indicated the resident had been found on the floor in his/he room between the bed and recliner with no alarm on. The resident stated that he/she had been trying to go to the bathroom, lost his/her balance and went down slowly. An Unusual Occurrence Report form dated 2/10/13 at 1:35 p.m., indicated the resident had slid out of his/her wheel chair while reaching for bugs, had no injury but the alarm battery required replacement. During an interview 4/10/13 at 3:15 p.m., Staff D, Licensed Practical Nurse (LPN) confirmed the resident's alarm had not been sounding following his/her fall on 2/10/13 which resulted in the facility staff replacing the battery. An Unusual Occurrence Report form dated 2/19/13 at 8:05 a.m., indicated the resident had been resting on a concave mattress and then found on the floor next to the mattress with a 6 centimeter (cm) x 4 cm skin tear on his/her left upper arm and an abrasion to his/her left post rib cage. There had been no documentation present related to the status of the bed alarm. Review of a Interdisciplinary Progress Notes form dated 2/19/13 at 7:40 a.m., indicated the resident had been resting on a mattress next to his/her bed on the floor, awake and pulling on his/her covers. The call light had been in reach and staff were notified to assist the resident to get up shortly. There was no documentation related to the alarm status. Review of the Interdisciplinary Progress Notes form dated 2/19/13 at 8:05 a.m., indicated a certified nursing assistant (CNA) found the resident off of the concave mattress on the floor and sitting on the floor near the bathroom wall. The resident had been bleeding from a left upper arm skin tear which had been cleansed and wrapped with king. The resident also had an abrasion on his/her post rib case and complained of slight back pain. The resident had been able to move all extremities and had been oriented to person. There was no documentation related to the alarm status. During an interview 4/10/13 at 1:40 p.m., Staff A, Registered Nurse (RN) confirmed the bed alarm had not been sounding when the resident was observed on a fall mat beside the low bed and/or when he/she had been observed sitting along the wall outside the bathroom door in his/her room. The staff member also confirmed there should have been a pressure alarm on the resident's bed. During an interview 4/10/13 at 11:40 a.m., Staff B, RN confirmed the resident should have been alarmed at all times. During an interview 4/10/13 at 10:40 a.m., Staff C, CNA confirmed the resident required an alarm prior to his/her injury and was at risk for falls. 2. According to the MDS dated [DATE], Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident displayed short and long term memory deficits with severely impaired cognitive skills and required extensive assistance of 2 staff members with transfers. The MDS revealed the resident was unable to ambulate (walk) in his/her room or corridor. A Care Plan dated 7/10/12, indicated the resident had a history of [REDACTED]. The approaches included the following: a. Hi-low bed. (dated 6/26/12) b. Sensor pad alarm to the bed, wheelchair and recliner. (dated 6/26/12) c. Bed next to wall, mat on the floor by the bed. (6/28/12) d. Alarm in mat on floor by the bed. (7/6/12) e. Concave mattress on the bed. (7/10/12) A Fall Risk form dated 3/27/13, indicated the resident had a score of 14. (10 or above represented a high risk for falls). An Unusual Occurrence Report dated 10/2/12 at 10 a.m., revealed staff found the resident on the floor in the main seating area in front of the television set, positioned on his/her left side. Staff found no alarm placed in the wheelchair. The fall was unwitnessed and the resident sustained [REDACTED]. During an interview 4/10/13 at approximately 1:50 p.m., the Administrator confirmed it was not a facility practice to check the functionality of any of the resident's personal alarms on a routine basis. According to a Fall Prevention form, the facility had a fall program to identify the residents that may have been at risk for falls, to ensure that residents were safe from potential falls and to identify interventions that may prevent or reduce resident falls. The form revealed risk factors included previous falls, problems with mobility/walking and multiple medications.

Based on observation and staff interview, the facility failed to ensure resident medications were kept locked at all times. The facility identified 18 residents as cognitively impaired on the 100 and 200 hallway and 4 with a wandergaurd system. The facility census was 52 residents. Findings include: 1. Observation on 12/26/12 at 10:10 a.m., revealed the following resident medications on top of a medication cart in the 200 hallway with no staff present: a. 1- 500 milliliter bottle of MGP- Generlac solution 10/grams/15 milliliters for oral or rectal administration. Warning- Keep this and all drugs out of reach of children. b. 1- 8 ounce bottle of Senexon (Senna) liquid-laxative. Warning- Keep out of reach of children, in case of over dose, get medical help or contact a poison control center right away. Interview on 12/26/12 at 10:15 a.m., Staff A (registered nurse) stated that the medications needed to be kept locked at all times, and that they forgot to put them away.

Based on observation, clinical record review, and staff interview, the facility failed to provide safety devices (wheelchair foot pedals) to safely transport residents in wheelchairs for 4 of 12 residents, (Residents #4, #10, #11, #12) and failed to have a planned intervention (alarm) in place for a resident with a history of falls. (Resident #7). Residents propelled in wheelchairs, without their feet resting on wheelchair pedals, have been known to plant their feet on the floor during transit and be propelled out of the wheelchair onto the floor causing major injury and/or death. The facility reported a census of 54 residents. Finding include: 1. The minimum data set (MDS) assessment, with an assessment reference date of 10/16/11, indicated Resident #4 had [DIAGNOSES REDACTED]. The MDS revealed the resident required extensive staff assistance with transfers, dressing, and toileting and limited staff assistance with locomotion both on and off the unit. The assessment indicated the resident was non-ambulatory and used a wheelchair. The resident's plan of care with a goal date of 01/24/12, indicated the resident as able to self-propel his/her wheelchair. During an observation at 8:20 a.m. on 11/9/11, the resident's spouse pushed the resident, who sat in a wheelchair with no foot pedals, from the day room to the dining room for the breakfast meal. The resident's feet rested in very close proximity to the carpeted and tiled flooring in these areas. 2. The minimum data set (MDS), with an assessment reference date of 10/24/11, indicated Resident #10 had [DIAGNOSES REDACTED]. The MDS indicated the resident did not walk and required limited staff assistance with transfers, locomotion in the wheelchair, dressing, toileting, and hygiene. The resident's care plan, with a goal review date of 2/1/12, indicated the resident could self-propel his/her wheelchair, but required staff assistance at times. During an observation at 8:00 a.m. on 11/9/11, Staff A pushed the resident in his/her wheelchair with no foot pedal present, from the dayroom in front of the nurses' station into the main dining room. During the observation, the resident's right foot intermittently touched the tiled and carpeted floors. The resident wore a tennis shoe on the right foot. During an interview on 11/10/11 at 10:10 a.m., the Director of Nursing revealed that if residents were able to propel themselves in their wheelchairs, wheelchair pedals weren't attached to the wheelchairs; if staff had to propel residents, pedals would be used. 3. The Minimum Data Set (MDS) assessment, with an assessment reference date of 09/04/11, documented Resident #11 had [DIAGNOSES REDACTED]. The MDS identified the resident with severely impaired cognition. The MDS noted the resident required extensive assistance of one staff for transfers, ambulation, and locomotion on the unit. The assessment further noted the resident used both a walker and a wheelchair for mobility. The resident's care plan, with a goal date of 12/13/11, directed staff to ambulate the resident using a gait belt and walker; the plan didn't address the resident using a wheelchair for locomotion. During an observation on 11/08/11 at 12:41 p.m., Staff B (certified nursing assistant) wheeled the resident out of the dining room with his/her feet skipping across the carpeted floor; there were no foot pedals on the resident's wheelchair. Staff paid no attention to the resident's feet touching the floor. During an observation on 11/09/11 at 9:51 a.m., Staff B wheeled the resident in his/her wheelchair and his/her feet skipped across the floor out of the Chronic Confused Dementia Individual (CCDI) unit. Staff paid no attention to the resident's feet touching the floor. 4. The Minimum Data Set (MDS) assessment, with an assessment reference date of 8/21/11, documented Resident #12 had [DIAGNOSES REDACTED]. The MDS identified the resident with severely impaired cognition. The MDS noted the resident did not walk, relied totally on staff for bed mobility and transfers, and required extensive assistance of one staff for locomotion both on and off the unit. The assessment indicated the resident used a wheelchair for mobility. The care plan, with a goal dated of 11/29/11, indicated the resident seemed to enjoy propelling self in the wheelchair daily. During an observation on 11/08/11 at 12:41 p.m., Staff B (certified nursing assistant) propelled the resident in his/her wheelchair from the unit with his/her feet skipping across the carpeted floor. No foot pedals were on the wheelchair. Staff paid no attention to the resident's feet touching the floor during transit. During an observation on 11/08/11 at 12:51 p.m., Staff D (certified nursing assistant) propelled the resident, sitting in his/her wheelchair, away form the dining room table with no foot pedals, and the resident's right foot skipped across the carpeted floor. 5. The Admission Record [DIAGNOSES REDACTED]. The MDS assessment, with an assessment reference date of 09/25/11, documented the resident required limited staff assistance with transfers, dressing, locomotion on and off the unit, toilet use and personal hygiene. A discharge [DIAGNOSES REDACTED]. The resident's care plan, dated 08/16/11, documented the resident with limited ability to dress, bathe and do his/her own personal hygiene related to anxiety, Alzheimer's disease, macular degeneration and arthritis. Interventions included: a. Occupational/Physical evaluation and treatment as needed. b. Alarm review: continue sensor alarm on bed, continue alarm on bathroom door. Observations on 11/09/11 at 6:46 a.m., 7:15 a.m., 8:09 a.m., 8:42 a.m., and 9:13 a.m. revealed the resident in bed with his/her pressure alarm cord unattached from the alarm box, lying on the floor. During an interview on 11/09/11 at 9:35 a.m., Staff C (certified nursing assistant) stated that the resident needed his/her alarm to be on and functioning at all times; he/she verified the cord leading to the alarm was unattached from the alarm box.