Every finding on record at Iowa Jewish Senior Life Center

Based on observations, staff interviews, facility record review, and facility policy review, the facility failed to ensure sanitary conditions in the main kitchen and failed to properly sanitize the dining room tables in one of the two facility dining rooms used by the residents for their mealtimes. These failures posed the risk of food borne illness to the residents receiving food from the kitchen and eating in the main dining room. The facility reported a census of 40 residents. Findings include: During an interview on 3/31/26 at 12:51 p.m. with the Dietary Manager, he revealed he had been promoted to the Dietary Manager position three months ago. When asked regarding the sanitizing solution used to clean and sanitize surfaces and equipment in the kitchen and how staff test the sanitizing solution for proper chemical sanitization, he provided a small plastic container of a roll of chemical sanitizer test strips. The plastic container was without a label and he stated he was not sure where the product label was. During an observation of the kitchen on 3/31/26, after the Dietary Manager interview, another container of chemical sanitizer test strips was found by the mechanical dishwasher, the second plastic container was without a label. Continued observations revealed a third container of chemical sanitizer test strips was found by the three-compartment sink. The third plastic container had a label with the product name, colored columns indicating the corresponding Parts Per Million (ppm) for 0, 150, 200, 400, and 500 levels of Quaternary Ammonium (disinfectant/sanitizer), instructions for use, and an expiration date. The expiration date listed was Exp [DATE]. During the continued interview with the Dietary Manager on 3/31/26, he was shown the third container of chemical sanitizer test strips with the label and he agreed the expiration date was January 1, 2025 which was 15 months ago. He could not confirm the expiration dates of the other two containers of chemical sanitizer test strips without labels. Sanitizer test strips with labels were requested from the Dietary Manager. During a further interview on the afternoon of 3/31/26, after the above interview with the Dietary Manager, he was asked how they sanitize the dining room tables and he stated the dietary staff used a packaged Quix Plus product that was labeled Water Release Surface Sanitizing Towel. During an interview and continuous observation on 3/31/26 from 1:30 p.m. to 2:05 p.m. with Staff C, Dietary Aide, she revealed she had worked at the facility since October 2025 and part of her duties included sanitizing the dining room tables after the residents' mealtimes. Observation of this process revealed Staff C used a red six-quart bucket, placed a Quix Plus sanitizing towel in the red bucket and filled the bucket with three quarts of tap water. After filling the bucket with water, she then put on a pair of disposable gloves and left the kitchen to enter the main dining room. She had not squeezed the towel that had been pre-treated with sanitizing chemicals to release the sanitizing chemicals in the water. In the main dining room were seven square-top tables. At 1:35 p.m., Staff C reached into the bucket filled with water for the first time after filling the bucket with water, took the sanitizing towel in her hands and wrung the towel out once to remove the excess water from the towel and cleaned the dining room tables, chair arms and seats, salt and pepper shakers, condiment trays, and vases. Throughout the process, she placed the towel back into the water in the red bucket and wrung out the cloth to wipe another table, dining room chairs, and items in the center of each table. At 1:57 p.m., Staff C placed the towel back into the water in the red bucket and wrung out the cloth for the tenth time. Staff C was informed at this point that she had wrung out the sanitizing cloth ten times after wiping five of the dining room tables, chairs, and items in the center of those tables. Staff C agreed with that observation. Staff C then continued her process to wipe the remaining two dining room tables, dining room chairs, and the items in the center of those two tables. After she completed wiping the dining room tables she returned to the kitchen with the red bucket. During an observation and interview on 3/31/26 at 2:07 p.m. with Staff C, Dietary Aide, she was asked to review the Quix Plus Sanitizing Towel label's directions which were on the box of towels used to wipe the dining room tables in the kitchen's store room. The Quix Plus Sanitizing Towel's Directions for Use revealed Prepare a 200 ppm [parts per million] active quaternary sanitizing solution by the immersion of one sanitizing towel in one gallon of water . Squeeze 10 times to activate the cleaning and sanitizing solution which, used as directed, will sanitize. hard non-porous surfaces. She agreed that she had not squeezed the sanitizing towel ten times prior to using the cloth to sanitize the dining room tables. A test of the Quix Plus Sanitizing Towel's sanitizing solution when placed in the water of the red bucket could not be completed due to the expired chemical sanitizer test strips. In an interview on 3/31/26 at 2:12 p.m. with the Dietary Manager, he revealed he was not able to find any sanitizer test strips with labels other than the expired sanitizer test strips with the 1/1/25 expiration date. When asked how long they had been using those expired sanitizer test strips, he stated he was unsure how long they had been using the expired sanitizer test strips. The Dietary Manager stated he had placed an order for new sanitizer test strips that day which should arrive tomorrow, 4/1/26. In an interview on 4/1/26 at 10:20 a.m. with the Dietary Manager, he revealed the sanitizer test strips had been received and revealed those sanitizer test strips' label had an expiration date of 1/15/28. Observation of the sanitizer test strip's label revealed Exp [DATE]. During an observation and interview on 4/1/26 at 10:25 a.m. in the kitchen with the Dietary Manager, he filled a red six-quart bucket with one gallon of water and placed a Quix Plus sanitizing cloth in the water. The Dietary Manager placed a sanitizer test strip in the water for approximately 10 seconds and then compared the color of the test strip to the color chart on the test strip's label which indicated the solution was at 150 ppm. The Dietary Manager agreed the water was at 150 ppm and had not reached the 200 ppm sanitizing solution indicated on the Quix Plus product label. The Dietary Manager then squeezed the Quix Plus cloth ten times and tested the sanitizing solution with a sanitizer test strip which tested at 400 ppm. In an interview on 4/1/26 at 10:40 a.m. with the Executive Director, she agreed that staff were not able to ensure a sanitizing solution's ppm by using sanitizing test strips that were expired. She agreed that staff should follow the Sanitizing Towel's directions for use by squeezing the towel ten times in one gallon of water to activate the cleaning and sanitizing solution to sanitize surfaces. The Executive Director agreed that the solution used to wipe the dining room tables after yesterday's noon meal was initially not sanitizing the surfaces wiped as the cloth had not been squeezed 10 times as the directions stated. She stated the consultant dietitian had recommended using those Quix Plus sanitizing towels. She was aware that sanitizer test strips were received that day with an expiration date of 1/15/28. She was not sure how long the dietary staff had been using the expired sanitizer test strips. Review of the Quix Plus Water Release Surface Sanitizing Towel's Product Label revealed These towels are pre-treated with sanitizing chemicals for use in restaurants and other food service establishments to sanitize the following hard non-porous food contact surfaces. When activated by immersion in water, they create a sanitizing solution for use on cleaned and rinsed hard non-porous food contact surfaces. These towels must be immersed in water and squeezed 10 times to activate the special sanitizing solution that will kill and control bacteria on precleaned food contact surfaces, when used as directed. DIRECTIONS FOR USE: Prepare a 200 ppm active quaternary sanitizing solution by the immersion of one sanitizing towel in one gallon of water. Squeeze 10 times to activate the cleaning and sanitizing solution which, used as directed, will sanitize the following precleaned hard non-porous surfaces. Remove all gross food particles and soil from surfaces to be sanitized by a pre-flush, pre-soak or pre-scrape treatment. Wash surfaces thoroughly with a good detergent or compatible cleaner fallowed by a potable water rinse. Store towels/wipers in the sanitizing solution between uses. Prepare a fresh solution daily or more often if the solution becomes diluted or soiled. Dispose of used towels when discarding solution. Test solution regularly with quaternary test strips to confirm ppm activity. Review of the undated facility policy Dining Room and Table Sanitation revealed The facility is committed to maintaining a clean, sanitary, and safe dining environment for all residents, staff, and visitors. To prevent the spread of infection and foodborne illness by ensuring proper cleaning and disinfection of dining room tables and surfaces before and after each meal service. The policy's procedure documented: Use an EPA (Environmental Protection Agency)-approved food-contact surface sanitizer.Follow manufacturer's instructions for proper dilution. Allow tables to air dry. Immediately after meal service:Remove all food debris and dishware Clean tables using detergent or approved cleaner Disinfect all table surfaces, including edges and undersides if soiled Chairs, high-touch areas, and assistive dining devices must also be cleaned and disinfected. Use dedicated cloths or disposable wipes for dining surfaces

Based on observations, staff interviews, and facility policy review the facility staff failed to perform appropriate hand hygiene with preparation, and administration of medication to four of four residents observed for medication administration (Resident #4, #17, #24, and #27). The facility reported a census of 40 residents. Findings include: During a continuous observation on 4/1/26 from 7:28 a.m. to 8:25 a.m. with Staff D, Certified Medication Aide (CMA), failed to clean and sanitize her hands prior to preparing thirteen medications for Resident #4. Staff D then knocked on Resident #4's room door and gave Resident #4 her medication cup filled with twelve of those oral medications, an oral inhaler medication, and a glass of water. After Resident #4 took her medications, Staff D returned to the medication cart and documented the resident's medication administration in the facility's electronic medical record (EMR) and documented the narcotic medication given in the narcotic binder located on the medication cart. Continued observation; Staff D, CMA failed to clean and sanitize her hands prior to preparing six oral medications for Resident #17. She then knocked on Resident #17's room door and assisted the resident with taking her medications and held the resident's water mug while the resident sipped the water through the straw. After Resident #17 took her medications, Staff D returned to the medication cart and documented the resident's medication administration in the facility's electronic medical record (EMR) and documented the narcotic medication given in the narcotic binder. Further observation; Staff D, CMA failed to clean and sanitize her hands prior to preparing five oral medications for Resident #27. She then wheeled Resident #27 in a wheelchair to the medication cart and placed a blood pressure monitor on the resident's left upper arm and took the residents blood pressure (BP). Staff D then used a plastic spoon and placed each pill in the resident's mouth and assisted the resident to take a sip of water through a straw in the glass of water she provided. Staff D then documented the resident's medications and blood pressure (BP) in the facility's EMR. Continued observation; Staff D, CMA failed to clean and sanitize her hands prior to preparing six oral medications for Resident #24. She then walked into the dining room and gave Resident #24 the medication cup with the six oral medications, and assisted the resident to take the pills with a plastic spoon and a glass of water. Staff D then documented the resident's medication administration in the facility's EMR, and documented the narcotic medication given in the narcotic binder. In an interview on 4/1/26 at 8:27 a.m. with Staff D, CMA, agreed that she had failed to clean and sanitize her hands during the medication administration for Residents #4, #17, #24, and #27. In an interview on 4/1/26 at 10:05 a.m. with the Director of Nursing (DON), stated her expectation was for staff to wash their hands or use a hand sanitizer while administering medications. She stated that staff should wash their hands prior to a resident's medication administration. Observations of that morning's medication pass with Staff D, CNA/CMA were discussed with the DON which included that Staff D had not completed any hand hygiene during my observations. She stated she should have used the hand sanitizer on the medication cart between the residents. The DON was informed that there was no hand sanitizer observed on the med cart. During an interview on 4/2/26 at 8:19 a.m. with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), Observations of 4/1/26's morning medication administration with Staff D, CNA/CMA, was discussed. The ADON/IP agreed that Staff D should have used a hand sanitizer between the residents who received medications. The facility policy Administration of Medication dated 7/9/24 instructed licensed nursing personnel and/or certified medication aides to Wash hands or use hand sanitizer before and after each administration of medication.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure code status between the Iowa Physician Orders for Scope of Treatment (IPOST), the electronic health record (EHR) and the Care Plan were congruent for 1 of 1 residents reviewed for advanced directives (Resident #46). The facility reported a census of 40 residents. Findings include: Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had a Brief Interview for Mental Status (BIMS) of 6 indicating severe cognitive impairment. Review of the IPOST dated [DATE] revealed Resident #46 had an order for cardiopulmonary resuscitation (CPR) signed by the physician and the resident's responsible party. Review of the EHR for Resident #46 revealed a physician's order with revision date of [DATE] documented as follows; CPR; limited additional interventions; no artificial nutrition by tube. Review of the Care Plan for Resident #46 with a focus area of advanced directives initiated [DATE] and revised [DATE] revealed a code status of do not resuscitate (DNR). During an interview [DATE] at 1:06 PM Staff A, Registered Nurse (RN)/Quality Assurance (QA) acknowledged the Care Plan code status of DNR documented in Resident #46's Care Plan did not match the IPOST order or the electronic health record (EHR) order of CPR. Staff A revealed she would expect code status to match word for word in all areas. During an interview [DATE] at 1:13 PM Staff B, Licensed Practical Nurse (LPN) revealed she would review a resident's code status as needed in their chart, their IPOST and their EHR including their Care Plan. Review of facility policy titled, Iowa Jewish Senior Life Center, dated [DATE] revealed upon determination that a resident is in cardiopulmonary or respiratory arrest, CPR will be immediately initiated by nursing staff and 911 called for advance cardiac life support unless one of the exceptions applies: a. When the resident or surrogate has indicated that resuscitation is not desired and the attending physician has insured a written do not resuscitate (DNR) order that is maintained in the facility's clinical record. During an interview [DATE] at 11:22 AM the Director of Nursing (DON) revealed she would expect code status to match in all areas of the clinical record. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had a Brief Interview for Mental Status (BIMS) of 6 indicating severe cognitive impairment. Review of the IPOST dated [DATE] revealed Resident #46 had an order for cardiopulmonary resuscitation (CPR) signed by the physician and the resident's responsible party. Review of the EHR for Resident #46 revealed a physician's order with revision date of [DATE] documented as follows; CPR; limited additional interventions; no artificial nutrition by tube. Review of the Care Plan for Resident #46 with a focus area of advanced directives initiated [DATE] and revised [DATE] revealed a code status of do not resuscitate (DNR). During an interview [DATE] at 1:06 PM Staff A, Registered Nurse (RN)/Quality Assurance (QA) acknowledged the Care Plan code status of DNR documented in Resident #46's Care Plan did not match the IPOST order or the electronic health record (EHR) order of CPR. Staff A revealed she would expect code status to match word for word in all areas. During an interview [DATE] at 1:13 PM Staff B, Licensed Practical Nurse (LPN) revealed she would review a resident's code status as needed in their chart, their IPOST and their EHR including their Care Plan. Review of facility policy titled, Iowa Jewish Senior Life Center, dated [DATE] revealed upon determination that a resident is in cardiopulmonary or respiratory arrest, CPR will be immediately initiated by nursing staff and 911 called for advance cardiac life support unless one of the exceptions applies: a. When the resident or surrogate has indicated that resuscitation is not desired and the attending physician has insured a written do not resuscitate (DNR) order that is maintained in the facility's clinical record. During an interview [DATE] at 11:22 AM the Director of Nursing (DON) revealed she would expect code status to match in all areas of the clinical record.

Based on clinical record review, staff interview and Maximus Preadmission Screening and Resident Review (PASRR) policies and procedures, the facility failed to submit a Level II PASRR evaluation for 1 of 1 residents reviewed with a new mental health diagnosis (Resident #4). The facility reported a census of 40 residents. Findings include: A Level 1 PASRR screening completed by a local hospital prior to admission dated [DATE] revealed Resident #4 had a diagnosis of depression/depressive disorder and a Level II evaluation was not required. The Level 1 PASRR evaluation lacked additional mental health diagnoses and revealed if new information refuted the findings, a new screen must be submitted. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 revealed a diagnosis of post traumatic stress disorder (PTSD). The MDS further revealed the resident received antidepressant and antianxiety medication during the 7 day look back period. The Care Plan initiated [DATE] indicated Resident #4 had a history of trauma/life events with actual/potential for PTSD as one daughter committed suicide, one daughter was in Iraq with PTSD, and her husband died when the resident was [AGE] years old. Review of the medical diagnoses dated [DATE] for Resident #4 included a diagnosis of PTSD. A Level II PASRR screening dated [DATE] revealed Resident #4 had diagnoses of major depression and anxiety disorder. The screening lacked the diagnosis of PTSD. On [DATE] at 2:27 PM the Administrator revealed the facility did not have a PASRR policy as they followed the guidelines provided by Maximus. During an interview [DATE] at 12:29 PM the Director of Nursing (DON) acknowledged a Level II PASRR evaluation should have been submitted with Resident #4's PTSD diagnosis. The DON further revealed her focus on Level II PASRR evaluations had been on medication changes rather than diagnosis changes.

Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a significant change Minimum Data Set (MDS) assessment after a resident's hospice level of care was discontinued for 1 of 2 residents reviewed for change of condition (Resident #25). The facility reported a census of 40 residents. Findings include: The census in the Electronic Health Record (EHR) revealed on 9/24/25 Resident #25 transitioned from hospice private care to private-pay status. Review of Advance Beneficiary Notice of Non-coverage (ABN) dated 9/22/25 revealed hospice services for Resident #25 would end 9/24/25. Review of the MDS assessment dated [DATE] revealed Resident #25 was not receiving hospice services. Review of the MDS assessment dated [DATE] revealed Resident #25 was not receiving hospice services. Review of the MDS tracking schedule for Resident #25 lacked a significant change assessment following the discontinuation of hospice services. During an interview 3/31/2026 at 1:06 PM, Staff A, Registered Nurse (RN)/Quality Assurance (QA) acknowledged a significant change MDS had not been completed as expected after Resident #25 discontinued hospice level of care. Staff A revealed she would have expected a significant change would have been completed and that the facility followed the Resident Assessment Instrument (RAI) manual for completion of significant changes. The Long-Term Care Facility RAI 3.0 User's Manual, version 1.20.1 dated October 1, 2025, revealed the MDS assessment must be completed no later than 14 calendar days after the determination of a significant change in the resident's status. The manual defined hospice enrollment as a significant change. During an interview 4/1/2026 at 11:25 AM the Director of Nursing (DON) revealed she would expect a significant change MDS be completed if a resident discontinued hospice level of care. The DON revealed the facility does not have a policy for MDS significant changes as they follow the RAI manual.

Based on observation, staff interview, and policy review, the facility failed to ensure proper infection control practices to reduce the risk of contamination and food-borne illness during meal service. The facility reported a census of 40 residents. Findings include: On 3/11/25 the facility lunch menu included the following: lemon scallopini with pasta seasoned peas breadstick fresh fruit cup funfetti blondie In an observation on 3/11/25 starting at 11:45 AM during the lunch meal service, Staff J, Cook, used gloved hands to serve the meal and only changed his gloves and performed hand hygiene one time throughout the entire meal service. Staff J touched plates, utensils, refrigerators, lids, and transportation carts with gloved hands during the service. He further touched the seasoned peas on each plate he prepared with gloved hands to keep them from rolling around the plate, used his gloved hands to get parsley from a bowl to sprinkle on top of the scallopini, and touched the spaghetti with his gloved hands to remove dark overcooked pasta from the residents plates or pasta that was hanging over the edge of the plate and put it back on the residents plates. Staff J touched sandwiches being served to residents with his gloved hands, held toaster waffles in his gloved hands after toasted, retrieved a piece of lettuce from a refrigerator and carried it with his gloved hands to rinse it in the sink and placed it on a sandwich, touched a grilled cheese sandwich with his gloved hands to turn it in the frying pan and held on to breadsticks with his gloved hands when cutting them up for the residents with a knife. In an interview on 3/13/25 at 12:27 PM, the Administrator stated it was the expectation that kitchen staff not wear gloves unless used for ready-to-eat foods. She stated gloves gave the staff a false sense of security. A facility provided policy titled Food Preparation and Service, with no date noted, stated: Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Gloves can become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use.

Based on clinical record review, observation, staff interview, facility policy review, and the Center for Disease Control (CDC) guidelines, the facility failed to follow infection control practices for three of three residents on droplet precautions (Resident # 3, #30, and #32) and prevent the potential spread of infection to other residents and staff. The facility staff also failed to handle soiled linens to prevent the potential spread of infection for 1 of 2 nursing units. The facility reported a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 1/23/25 revealed Resident #3 had diagnoses of Alzheimer's Disease and diabetes. The MDS indicated the resident required supervision and touching assistance for eating. The MDS recorded the resident took an antibiotic. The Care Plan lacked information or directives for staff to follow current policy and protocol guidelines related to respiratory syncytial virus (RSV) (a respiratory infection) and droplet precautions. The Order Summary revealed Resident #3 on droplet precautions since 3/5/25. The Progress Notes revealed the following: a. On 3/5/25 at 10:59 AM, the resident tested positive for RSV on 3/5/25 and had an order for droplet isolation. b. On 3/10/25 at 3:26 PM, resident continued on droplet precautions for RSV. The resident continued to have a loose cough and nasal drainage. c. On 3/12/25 at 10:41 AM, resident continued on droplet precautions. He continued to have a loose productive cough and occasional runny nose. Lungs remained diminished after coughing. 2. The MDS assessment dated [DATE] revealed Resident #30 had diagnoses of Alzheimer's Disease and dementia. The resident required substantial to maximum assistance for eating. The Care Plan revised 3/7/25 revealed the resident had a risk for altered respiratory status and difficulty breathing related to RSV. The resident required assistance with feeding at mealtime. The Care Plan lacked staff directives regarding interventions for droplet precautions. The Order Summary lacked an order for droplet precautions. The Progress Notes revealed the following: a. On 3/5/25 at 4:39 PM, resident placed on droplet precautions because she had an occasional cough and hoarse voice. b. On 3/6/25 at 8:50 AM, resident had a cough and runny nose. Viral nasal swab obtained. c. On 3/6/25 at 10:45 PM, lab results revealed the resident tested positive for RSV. Droplet precautions continued. d. On 3/12/25 at 9:16 AM, resident continued on droplet precautions. 3. The MDS assessment dated [DATE] revealed Resident #32 had diagnoses of dementia and diabetes. The resident required set-up assistance for eating. The Care Plan revised 3/5/25 revealed the resident had a risk for ineffective airway clearance. The Care Plan directed staff to encourage participation in coughing, deep breathing, and forced expiratory techniques. The Care Plan lacked information the resident had a RSV infection and lacked interventions such as droplet precautions. The Order Summary revealed a viral nose swab for cough, runny nose, and hoarse voice completed on 3/5/25, and droplet isolation ordered on 3/5/25. The Progress Notes revealed the following: a. On 3/5/25 at 12:38 PM, nasal swab for RSV due to runny nose, loose nonproductive cough, and a hoarse voice. b. On 3/5/25 at 1:26 PM, resident placed on droplet isolation pending RSV test result. c. On 3/5/25 at 10:36 PM, resident diagnosed with RSV and on droplet precautions. d. On 3/12/25 at 9:02 AM, resident continued on droplet precautions for RSV. Resident had loose cough, occasional nasal drainage, and diminished lung sounds. Observations revealed the following: a. On 3/10/25 at 11:00 AM, a droplet precautions sign hung on the door to Resident #3, #30, and #32's room. A plastic bin with drawers had gowns inside, and a box of masks and box of gloves sat on top of the bin in the hallway. b. On 3/10/25 at 12:10 PM, Staff A, Licensed Practical Nurse (LPN), sat in front of Resident #3 in the common area and fed the resident food from a styrofoam bowl. Staff A wore a mask but no gown worn while she fed the resident. c. On 3/10/25 at 12:10 PM, Staff C, certified nursing assistant (CNA), sat next to Resident #30 and fed the resident food from a styrofoam containers. Staff C wore a mask but no gown worn while she fed the resident. Resident #32 sat in a recliner next to Resident #30. d. On 3/11/25 at 10:50 AM, Resident #3, #30, and #32 sat in recliners in the common area. e. On 3/11/25 at 11:30 AM, Staff A sat by Resident #3 and fed the resident food from a styrofoam container. Staff A wore a mask but no gown or gloves worn. Staff D, CNA, sat by Resident #30 and fed the resident food from a styrofoam container. Staff D did not wear a gown while she fed the resident. During an interview on 3/13/25 at 11:55 AM, Staff A, LPN, stated staff needed to wear a mask, gloves, and a gown before entrance to the resident's room whenever a resident was on droplet precautions. Staff A confirmed Resident #3, #30, and Resident #32 on droplet precautions. Staff A reported the residents on droplet precautions were difficult to confine to their rooms due to their diagnoses so the staff tried to keep the residents on droplet precautions separate from the other residents. In an interview 3/13/25 at 12:05 PM, the MDS Coordinator reported she was not in the facility when the residents were diagnosed with RSV. The MDS Coordinator acknowledged droplet precautions should be on the Care Plan so staff knew what was expected. A droplet precautions sign posted on the resident's room door, and gown, gloves, and mask worn during cares and whenever staff entered the room. An Infection Control policy revised 7/9/24 revealed procedures were necessary to decrease and prevent the spread of infections in both resident and staff populations. The facility assisted staff in creating an environment to contain infections and to keep negative outcomes at a minimum. Policies and procedures defined the indications for isolation and were based on CDC disease guidelines and criteria. An Isolation #34 policy revised 7/9/24 revealed residents with transmittable diseases will be isolated to the degree necessary to assure resident safety to prevent the spread of disease between residents and staff. Isolation precautions were based on the CDC guidelines. An isolation precautions sign is placed on the resident's room number and specified the protective equipment needed (such as a gown, gloves, and mask). The type of isolation precautions and the reason for isolation are documented in the nurse's notes. Droplet precautions prevented the transmission of diseases spread by respiratory droplets through coughing, sneezing, or talking. PPE for droplet precautions included a face mask. A CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings updated 9/2024 revealed respiratory droplets are generated when an infected person coughs, sneezes, or talks. The CDC recommended healthcare personnel to don personal protective equipment (gowns, gloves, mask) upon entry into the patient's room for patients who are on droplet precautions since the nature of the interaction with the patient cannot be predicted with certainty and contaminated environmental surfaces are important sources for transmission of pathogens. Isolation gowns are used to protect the healthcare worker's arms and exposed body areas and prevent contamination of clothing with body fluids and other potentially infectious material. 4. During observation on 3/12/25 at 08:00 AM, Staff B, housekeeper, walked down the 200 hall carrying bed linens under her arm and against her uniform. Staff B opened the lid on the soiled linen cart in the hallway and placed the soiled linens inside the cart, pushing the linens down with her gloved hands and closed the lid. Staff B then pushed the soiled linen cart down the hall to a soiled utility room in the 300 hall. In an interview on 3/13/25 at 12:30 PM, the Infection Preventionist reported she expected staff placed soiled linens in a bag and into the soiled linen cart. Soiled linens should not be carried against the staff's uniform. A Linens policy dated 6/15/24 revealed linens maintained in a manner to ensure infection prevention and control. Proper linen management is crucial to breaking the chain of infection. Pathogen transmission can occur through direct contact with contaminated linens. Handling of used linens should be minimized including not holding linens close to the body. Used linens shall be placed in designated bags or other containers for transport at the point of use.

Based on clinical record review, staff interviews, and policy review the facility staff failed to assess and document an injury of unknown origin and perform a skin assessment for 1 of 3 residents reviewed for skin injuries (Resident #33). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] reveals Resident #33 had diagnoses of Alzheimer's disease, dementia, and muscle weakness. The MDS recorded the resident had a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. The resident also had inattention, disorganized thinking, and wandered daily. The MDS documented the resident had no falls and no skin issues. The MDS indicated the resident had dependence on staff for toileting, bathing, and transfers, and required substantial to maximum assistance for bed mobility. The Care Plan revised 2/9/25 revealed the resident required assistance with activities of daily living (ADL's) related to dementia and confusion. The resident used a wheelchair as her primary mode of transportation. The Care Plan directed staff to use an EZ stand mechanical lift and the assistance of two staff for transfers, and provide assistance of one staff to turn and reposition her in bed. The Care Plan also revealed the resident had occasional agitation and combativeness, and had a risk for impaired skin integrity. The Care Plan revised on 2/22/25 revealed the resident had a bruise on her left arm. The Care Plan directed staff to use caution during transfers and bed mobility to prevent her from striking arms, legs, and hands against any sharp or hard surface, and perform a weekly skin sweep to include measurements and any other notable changes or observations. A Weekly Skin Sweep dated 2/18/25 revealed the resident's skin clean and intact. The Skin and Wound Evaluations revealed the following: a. On 2/21/25, a bruise on the left outer forearm measured 6.3 centimeters (cm) by 4.0 cm. Education provided on bumping the resident's arm. Family and physician notified. b. On 2/25/25, the bruise measured 7.9 cm by 4.4 cm and turning yellow in color. The POC (Plan of Care) Response history for behavior monitoring revealed the resident had behaviors of grabbing and hitting others on 2/17/25, and no behaviors documented on 2/18/25 to 2/21/25. Incident Reports revealed the following: a. On 11/17/24 at 9:36 PM, a skin tear sustained on the posterior left forearm during cares. Steri-strips applied to the area. Staff educated on the importance of making sure the resident's elbows are in prior to moving through the door (during transfers). b. On 2/22/25 at 3:13 PM, the resident had a dark purple bruise to her left arm measuring 6.31 cm by 3.98 cm. The resident was confused due to dementia and does not know how she obtained the bruise. The resident propels herself in a wheelchair throughout the building. Staff education to use extra care whenever they transferred the resident with an EZ stand mechanical lift and during bed mobility due to her fragile skin. The Progress Notes revealed: a. On 2/18/25 at 2:50 PM, Staff A performed a weekly skin observation. No skin concerns noted. b. On 2/21/25 at 3:47 PM, a new bruise on left forearm appeared black and blue. Physician notified. The Facility's Investigation File revealed: a. A Grievance Report Form filled out by Staff M, Registered Nurse (RN) revealed the resident's family were concerned and upset about the protective sleeves over the resident's arms. The family thinks staff are hiding injuries and think baby powder was applied to the bruise on her left arm. Family wants to know what staff member applied the protective sleeves. There are no orders for protective sleeves. b. Written Staff Statement by Staff E, certified nursing assistant (CNA), dated 2/24/25 revealed Staff E came to work on Thursday night around midnight. During rounds he noticed the resident had a bruise on her left forearm. At the time, the resident was not wearing sleeves on her arms. Staff E reported the bruise to the nurse immediately. Resident #33 is a check and change at night but the night the bruise was discovered, the resident was not incontinent throughout the entire night. Staff E made sure she was ok and in bed. Staff E did not have any issue of the resident resisting cares that night. c. An undated written staff statement by Staff F, Licensed Practical Nurse (LPN), revealed on the night of Wednesday 2/19/25, I did not notice any bruise on the resident's forearms when I worked. d. A typed statement dated 2/25/25 by the MDS Coordinator revealed she was unaware of the resident's bruise until family pointed it out on Friday 2/21/25. I saw no protective sleeves on her until family was asking about them on Friday 2/21/25. The resident got a little feisty when I attempted to take her blood pressure and pulse in the AM but I quickly backed away and it did not become physical. That is the only contact I had with her that day other than taking off the protective sleeves in the afternoon. Family stated I was too rough pulling one of the protective sleeves off. I immediately apologized and became gentler in removing the other sleeve. d. A written statement dated 2/25/25 by Staff A, LPN, revealed Staff A was not aware of any bruise on the resident until Saturday, 2/22/25 (when Staff A came to work). e. A text message at 10:32 AM from Staff G, RN, revealed Staff G worked the last three night shifts and didn't get the message until leaving for work last night. I really don't know anything about the resident in 108. I am not sure what happened or when. I was told it was 109, so that is who I looked at. I was told at 4:15 AM that 109 had a bruise. I checked at 4:30 AM, but did not see anything. I ran off report sheets, did AM medications, gave report, and left. That is all I did, and that is all I was told. I have no further information. Not sure what happened or when. Not sure if it's from a previous blood draw site? Might be worth checking when her last blood draw was. The DON responded back to Staff G at 12:02 PM: I just want to know if you placed the geri-sleeve on Resident #33 or not. Staff G responded to the Director of Nursing (DON) at 6:14 PM: No The DON documented a summary about the incident investigation: a. On 2/21/25 at approximately 12:00 AM, Staff E, CNA, reported a bruise on the resident's left outer forearm to Staff G, RN. When questioned, Staff G denied getting the report about the resident in room [ROOM NUMBER]. On 2/21/25, the MDS Coordinator reported concerns from the resident's spouse. He was concerned the resident had geri-sleeves in place. The resident had never had the geri-sleeves placed previously. A bruise on the left outer forearm was visualized when the geri-sleeves were pulled up. The MDS Coordinator notified the Assistant Director of Nursing (ADON). The ADON went to the resident's room immediately and assessed the resident. The resident had a BIMS of 0 and unable to recall how she got the bruise. A skin evaluation was completed. The Administrator, physician, and DON were made aware of the incident. An investigation was initiated immediately. Upon completion of the investigation, the facility was unable to substantiate that abuse had occurred but recognized areas that could be improved when reporting a bruise of unknown origin. Interventions included to continue to observe and assess bruising until healed, staff education on the abuse policy and reporting to leadership. b. A Termination Report revealed a self-report was submitted on 2/24/25 due to a suspected abuse case on the resident on 2/21/25 and an investigation was initiated. Staff M reported to the ADON that Resident #33 had a bruise of unknown cause. The bruise was originally found by a resident's spouse and he expressed a concern to Staff M. The spouse wanted to know what caused the bruise and why the area was covered. Staff previously assigned to resident was interviewed. Staff E made a statement that he saw the bruise that AM prior to the end of shift and notified Staff G. Several attempts made to call Staff G but no answer. Days later, Staff G confirmed she did not know anything about the bruise and denied applying the geri-sleeves. Geri-sleeves could only be accessed by a nurse who had a key. Several other staff who took care of residents were interviewed and all denied seeing a bruise. No order found for geri-sleeves and no charting found about a bruise on the resident. Due to the suspected abuse allegation and Staff G not being cooperative with the investigation, Staff G was terminated effective 2/24/25. Observation on 3/11/25 at 9:20 AM revealed Resident #33 sat in a wheelchair in the dining area. The resident had a long sleeve shirt on. At the time, Staff A rolled the resident's sleeve up and showed the surveyor the resident's left arm. The resident's left forearm had a darkened faded bruise. On 3/12/25 at 10:45 AM, the resident propelled herself in a wheelchair in the dining room. On 3/11/25 at 9:20 AM, the surveyor asked Resident #33 how she got the bruise on her left arm. The resident looked at the surveyor and voiced some words but did not make sense. The resident was unable to tell the surveyor what happened. In an interview on 3/11/25 at 9:25 AM, Staff A, LPN, reported she was not working on the day the resident got the bruise. She was told about the bruise on the resident's arm during shift report when she came in to work on the weekend. In an interview 3/11/25 at 2:35 PM, the MDS Coordinator reported she was in the DON's office when the resident's husband came and told her and the ADON the resident had a bruise on her arm. Nobody knew how the bruise got there. She started to question staff that were working that day, as well as texted the staff that took care of her over those few days. Staff E said he notified Staff G about the bruise. The resident didn't have geri-sleeves on and that is how he noticed the bruise. Resident #33 didn't normally wear geri-sleeves but the resident had geri-sleeves on the day the husband came to talk to the MDS Coordinator. The MDS Coordinator reported geri-sleeves are locked in the medication room and only a nurse could get them. The MDS Coordinator stated she spoke with Staff G. Staff G said Staff E told her the resident had a bruise but she wrote down the wrong room number. She checked the resident in the room number she wrote down. When Staff G checked the resident and didn't see a bruise or anything but Staff G didn't follow up after that. The MDS Coordinator reported she had not noticed the resident wearing geri-sleeves prior to the incident of finding the bruise on her arm. The MDS Coordinator reported the resident had a solid bruise the size of an orange on her left arm. She did not see any finger marks on the resident's arm. The MDS Coordinator reported she talked to Staff D, CNA, who worked the 2 PM - 10 PM shift, Staff H, CNA, had worked the day prior to staff finding the bruise, and Staff I, CNA, who worked on Friday during the day and none of the staff noticed a bruise on the resident. Staff A also reported Staff H, CNA, had given the resident a shower the day before and had not noticed any bruises at that time. The MDS Coordinator stated they narrowed it down to the night nurse knowing something about the bruise but did not do any follow-up after Staff E reported the skin concern to Staff G. The MDS Coordinator reported the resident flailed her arm and staff had to remind her to hold on tight to the EZ Stand (mechanical lift). The resident was very forgetful and had frail, thin skin. She didn't take an anticoagulant or other medications that caused bruises. In an interview 3/11/25 at 5:55 PM, Staff E, CNA, reported he worked 12 AM -6 AM on the night when he found a bruise on Resident #33's arm. He made rounds on residents. When he turned on the light, he noticed a bruise right away on Resident #33's left arm. The resident was in bed sleeping and had her left arm on her abdomen. There were no geri-sleeves on her arms. He let Staff G know right away. Staff E reported Resident #33 is a check and change and she was dry all night. The prior shift lets him know if a resident had behaviors, but there was no mention about Resident #33 having any behaviors that night. Staff sometimes reported she could be difficult. Staff E reported he had not witnessed coworkers being rough or unkind to any of the residents. He would report this immediately to the charge nurse or Administrator if he had witnessed any concerns. In an interview 3/12/25 at 1:40 PM, the DON reported she had worked at the facility since 1/2025 but had worked part-time while she transitioned from her previous job to the DON position. The DON reported the MDS Coordinator found out Resident #33 had a bruise on her arm. The ADON talked to the resident's family member on Friday, 2/21/25. The resident's husband noticed the sleeve on the resident's arm and came to the office. The MDS Coordinator and the ADON went to the resident's room, and removed a sleeve on the resident's arm and did a skin assessment. The DON was told about the bruised area on Monday, 2/24/25, when she came to work. A self-report to DIAL (the Department of Inspections, Appeals, and Licensing) was submitted on 2/24/25. The DON stated she started calling staff on Monday 2/24/25, and provided staff education to notify her when they had concerns, and made staff aware of the process. During the investigations, Staff E, CNA, was the one who found the bruise on the resident's arm on Thursday night when he worked. Staff E said he reported it to Staff G. None of the nurses or CNA's knew anything about a bruise on Thursday 2/20/24. She narrowed it down to when the bruise was discovered but didn't find any documentation about the bruise. There was no skin assessment or progress note documented, and no incident report filled out. Nobody said anything about a skin concern in report. She talked to the resident's husband. She made several attempts to contact Staff G but did not receive a call back. She finally sent a text to Staff G about the incident. Staff G denied getting a notice from Staff E, denied seeing a bruise on Resident #33, and also denied putting geri-sleeves on the resident. The DON stated the nurses are the only ones had access to the room where geri-sleeves are kept. A key is required to get into the room. Staff M worked days and filled out the grievance form. In an interview on 3/12/25 at 1:50 PM, the ADON reported Resident #33's family member came to the office and said I want you to come and look at something. The ADON saw the resident had a geri-sleeve on her left arm. The family member wanted to know why the resident had the sleeve on and wondered if the facility staff were trying to cover something up. The ADON looked under the sleeve and discovered a fairly large round purple bruise on the resident's left forearm. She did not see any finger marks on the area. The ADON stated she asked Staff M if there were any notes about a skin concern. There were no notes or skin assessment documented. Resident #33 was not able to tell them what happened. The resident had dementia. The ADON reported staff used an EZ stand mechanical lift to transfer the resident. The resident didn't like the EZ stand lift, and sometimes fought staff. Resident #33 was mobile in her wheelchair and she thought maybe the resident bumped her arm on something, but she was not sure how the resident got the bruise. The surveyor attempted to contact Staff G, RN, on 3/12/25 at 9:25 AM, 3/12/25 at 6:25 PM, and 3/13/25 at 8:35 AM. Staff G failed to respond to voice and text messages. During an interview on 3/13/25 at 11:55 AM, Staff A, LPN, reported skin assessments completed by the nurses. Skin assessments documented under the skin assessments. In an interview 3/13/25 at 12:05 PM, the MDS Coordinator reported a skin sweep performed on all of the residents weekly. A Weekly Skin Assessments policy dated 7/9/24 revealed the nurse who finds a new skin issue completed the initial skin assessment in the electronic health record, including a risk management (incident report) and notified the physician and family. The skin assessment is printed and placed in the skin book located at the nurse's station for continued monitoring and follow up. The facility's Abuse Prevention Policy and Procedure revised 7/9/24 revealed employees must report any suspicious event that may constitute abuse. Any events of unknown origin are investigated. An allegation of abuse reported to the state agency as soon as possible, but not to exceed 24 hours.

Based on clinical record review, observations, staff interviews, and policy review the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 16 residents sampled (Residents #3 and #32). The facility reported a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 1/23/25 revealed Resident #3 had diagnoses of Alzheimer's Disease and diabetes. The MDS recorded the resident took an antibiotic. The Order Summary revealed Resident #3 on droplet precautions since 3/5/25. The Progress Notes revealed the following: a. On 3/5/25 at 10:59 AM, the resident tested positive for RSV (respiratory syncytial virus) (infection of the lungs and respiratory tract) on 3/5/25 and placed on droplet isolation. b. On 3/12/25 at 10:41 AM, resident continues on droplet precautions. The Care Plan lacked information or directives for staff to follow current policy and protocol guidelines related to RSV and droplet precautions. 2. The MDS assessment dated [DATE] revealed Resident #32 had diagnoses of dementia and diabetes. The Care Plan revised 3/5/25 revealed the resident had a risk for ineffective airway clearance. The Care Plan directed staff to encourage participation in coughing, deep breathing and forced expiratory techniques. The Care Plan lacked information the resident had a RSV infection, and lacked interventions such as droplet precautions. The Order Summary revealed droplet isolation ordered on 3/5/25. The Progress Notes revealed the following: a. On 3/5/25 at 12:38 PM, an order to obtain a nasal swab for RSV due to the resident's runny nose, loose nonproductive cough, and hoarse voice. b. On 3/5/25 at 1:26 PM, resident placed on droplet isolation pending RSV test result. c. On 3/5/25 at 10:36 PM, resident diagnosed with RSV and on droplet precautions. d. On 3/12/25 at 9:02 AM, resident continues on droplet precautions for RSV. Observations revealed on 3/10/25 at 11:00 AM, a droplet precautions sign hung on the door to Resident #3 and #32's room. A plastic bin with drawers had gowns inside, and a box of masks and box of gloves sat on top of the bin in the hallway. During an interview on 3/13/25 at 11:35 AM, the Director of Nursing (DON) reported the nurses updated the residents' Care Plans. The DON reported she tried to keep an eye on the Care Plans because the nurses didn't always have time to review and update them. During an interview on 3/13/25 at 11:55 AM, Staff A, Licensed Practical Nurse, reported the MDS nurse, the DON, and the Assistant Director of Nursing (ADON) updated the residents' Care Plan. Staff A confirmed Resident #3 and Resident #32 currently on droplet precautions. Staff A reported a mask, gloves, and a gown worn when staff cared for a resident on droplet precautions. In an interview 3/13/25 at 12:05 PM, the MDS Coordinator reported she updated the Care Plans whenever there was a significant change such as a resident had an infection. She added the infection and the related interventions to the Care Plan. The MDS Coordinator acknowledged droplet precautions should be on the Care Plan so staff knew what was expected. An Isolation #34 policy revised 7/9/24 revealed residents with transmittable diseases will be isolated to the degree necessary to assure resident safety. Isolation is necessary at times to prevent the spread of disease between residents and staff. The type of precautions and reason for the isolation documented in the nurse's notes, and the care plan updated as needed. A Comprehensive Resident Plan of Care policy dated 7/9/24 revealed an interdisciplinary team developed and updated the resident's comprehensive care plan including any medical and nursing needs. The RN Assessment Coordinator collaborated on the resident's plan of care with staff.

Based on clinical record review and staff interview, the facility failed to notify the State Long Term Care (LTC) Ombudsman for 1 of 2 residents reviewed for transfer out of the facility (Resident #19). The facility reported a census of 40 residents. Findings include: Review of the Census list for Resident #19 revealed the resident's status as on hospital leave on 11/6/24 and returned to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 readmitted to the facility on this date from the hospital. The Notice of Transfer Form to LTC Ombudsman for the facility for November 2024 lacked documentation of Resident #19 being sent to the hospital on 11/6/24. In an interview on 3/12/25 at 11:25 AM, Staff K, Accounting Manager and Staff L, Admission Coordinator, reported they had been running the report to send to the LTC Ombudsman monthly off of a report generated from their electronic health records (PCC) and it appeared it had not been capturing the hospitalization s. In an interview on 3/13/25 at 11:37 AM, the Administrator stated the facility did not have a policy related to notification of the LTC Ombudsman with transfers or hospitalization s. In an interview on 3/13/25 at 12:30 PM, the Administrator stated it was the expectation that any resident being sent out of the facility be placed on the Notice of Transfer Form to the LTC Ombudsman list.

Based on clinical record review, family and staff interview and policy review, the facility failed to prevent a significant medication error for 1 of 11 residents reviewed (Resident #155). The facility reported a census of 51 residents. Findings Include: The Baseline Care Plan of Resident #155 reflected a date of 4/10/24. The Care Plan documented the resident unable to easily communicate with staff, and to be vision and hearing impaired. The Admit/Readmit Summary, dated 4/10/24 at 7:35 pm, documented the resident admitted to the facility on [DATE], was oriented to self and to place, not to time. The Summary also documented the resident to have moderately impaired vision and moderate difficulty hearing. The Health Status Note, dated 4/13/24 at 7:20 am, documented the resident to be very confused and anxious and not able to follow direction. The Health Status Note, dated 4/13/24 at 11:22 am, documented Resident #155 was in a wheelchair in the dining room when approached by a medication aide and called by a name other than her own. Per the note, the resident responded to the other name and then given 650 mg of Tylenol and 0.25 milliliters of morphine intended for the other resident. After administering the medication, per the note, the medication aide then went to Resident #155's room for medication pass and then realized her error and notified the nurse on duty. The physician, family member of the resident, and nurse manager were informed of the error and the resident monitored. The Order Note, dated 4/13/24 at 5:56 pm, documented the resident's daughter chose to send the resident to the emergency room for evaluation. On 4/15/24 at 4:26 pm, a family member of Resident #155 stated the resident had blood work done upon arrival to the facility, prior to the medication error, which showed high potassium and high creatinine levels. She stated the medical director had made some medication changes due to the abnormal laboratory values. She stated when the resident arrived at the hospital, she had a CT scan (computed tomography, a test to obtain internal images of the body) which showed no concerns and she tested negative for having a urinary tract infection. She stated the hospital did not appear concerned the mental status change was related to the morphine error. The lab work collected on 4/13/24 at 5:45 pm reflected a potassium level of 5.9 (normal values 3.5-5.1). and a Creatinine of 1.6 (normal values 0.6-1.1). The History and Physical from the hospital also noted the resident was abruptly taken off of tramadol after 4 years of chronic use and documented may need to add back tramadol and slowly taper off if necessary to avoid acute detox. Hospital notes reflected mental status change likely related to hyperkalemia (high potassium) which was present prior to morphine administration. On 4/17/24 at 12:56 pm, Staff D, Certified Medication Aide stated she had been employed at the facility since 2018. She stated when she arrived to work on 4/13/24, she was scheduled to work the floor in the memory care unit, which is not where resident #155 resided. She stated the nurse in the part of the facility where Resident #155 resided had been busy and the nurse needed assistance to complete the morning medications. She voiced once she got all of her residents up and dressed on the memory care unit, she was asked to go help in the other portion of the building. She said she always works in the memory care unit and had never met either of the residents who she got mixed up with the medication error. She stated she pulled up Electronic Health Record of Resident #157, looked at her photo, looked at Resident #155 sitting in the dining room and thought that Resident #155 was actually Resident #157. She stated she walked over to Resident #155 and asked her if she was (first name of Resident #157) and the resident replied yes. She said she told her she had pills for her and Resident #155 said ok and she took them. She stated again she had never met either resident. The Medication Error/Omission Report, dated 4/13/24, documented How this error could have been prevented Have identification on any wheelchair used by residents out of room. Ask resident name and date of birth before giving meds - 5 rights (The five rights of medication administration) The facility form Medication Error Process documented Why did this occur? Resident was not ID'd correctly. She answered to (other resident's name) and was in a wheelchair with no ID. Was not asked her name. The facility policy Administration of Medication, revision date of 6/28/23 documented the Standard of: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis.

Based on observations, clinical record review, staff interview and policy review, the facility failed to maintain infection control standards due to lack of hand hygiene when providing cares and assisting residents to dine for 2 of 23 residents (Resident #15, and Resident #24). The facility reported a census of 51 residents. Findings include: 1. On 4/15/24 at 12:18 pm, dining room observation began for the 200 and 300 hallway of the facility. On 4/15/24 at 12:26 pm, Staff A, Certified Medication Aide (CMA) sat down at a table wearing single use disposable gloves. Resident #15 was to her right and Resident #24 was to her left. Staff A provided set up assistance to Resident #24, removing covers from food and cutting up food. On 4/15/24 at 12:33 pm, Staff A stood up, keeping her gloves on, walked across the dining room to speak to a dietary staff member and then returned to the table. Using her left hand, she picked up the built up silverware for Resident #15 and began to feed him. She alternated, using her right hand to offer assistance to Resident #24. After alternating between feeding the two residents, Staff A picked up the dinner roll off of Resident #15's plate using her hands, still wearing the same gloves, breaking the dinner roll into two pieces. With her gloves remaining in place, she continued offering both food and fluids to both residents. On 4/15/24 at 12:38 pm, Resident #15 had small pieces of food falling from his mouth. Staff A reached up and removed the food from the resident's chin with her gloved hand. On 4/15/24 at 12:39 pm, Staff A reached and picked up the menu of Resident #24, read it and then placed it back on the table. On 4/15/24 at 12:40 pm, Staff A stood up, and offered a drink of fluid to Resident #24, then alternated to offering foods and fluids to Resident #15 while standing. On 4/15/24 at 12:41 pm, Staff A sat back down, and offered more bites of food to Resident #15. She then placed both of her arms on the dining table, with her right hand seen touching her shirt sleeve of her left arm. On 4/15/24 at 12:44 pm, Staff A stood up, placing her gloved hands on the arm rest of the chair to stand. She adjusted the position of Resident #15 who was leaning to one side. She then removed her gloves and threw them in the trash, performed hand hygiene and donned new gloves. On 4/15/24 at 12:45 pm, dietary staff delivered a peanut butter and jelly sandwich for Resident #15 due to him not eating very much of the planned menu. Staff A picked up the sandwich with her gloved hands and cut the sandwich into four pieces. She offered a bite to Resident #15, kept the same gloves on, and turned to offer a bite of food to Resident #24. She used both hands to pick up silverware of Resident #24 and cut some more of his food. She offered sips of fluid to Resident #24. After giving verbal cues to Resident #15 to continue eating, she picked up a portion of the sandwich and brought it to his mouth. Resident #15 then took the sandwich from her and took a couple of more bites. On 4/15/24 at 12:50 pm, Staff A was again observed touching Resident #15's sandwich with her gloved hands. On 4/15/24 at 12:50 pm, a dietary aide began to distribute Thrive ice cream (a nutritional supplement) to residents with orders for nutritional supplements. Staff A, still wearing the same gloves, picked up the ice cream to remove the cover from the top. She then picked up the sandwich again. Staff A used both hands to hold the sandwich, trying to get Resident #15 to eat. She then placed her left hand on the tablecloth before using that hand to again pick up the sandwich. On 4/15/24 at 12:53 pm, Staff A was observed changing her gloves but no hand hygiene was observed. She picked up the silverware of Resident #24 to offer him bites of food as she was standing. She then sat and placed her right hand on the arm of the chair to scoot herself closer to resident #15 to continue to offer him food. On 4/15/24 at 12:57 pm, she again alternated to feeding Resident #24. During the observation, Staff A was seen repeatedly alternating between touching the silverware and the cups of both residents, touching the table, touching the chair and touching the food of the resident, failing to maintain infection control standards. On 4/18/24 at 12:24 pm, The Director of Nursing stated if staff need to wear gloves due to assisting a resident who drools or has secretions, her expectation would be to feed just the one resident to avoid cross contamination. She also stated her expectation is for staff not to touch other surfaces or to complete hand hygiene in between. The facility policy Feeding Residents, revision date 6/28/23 directs: Gloves should be worn anytime you may come in contact with contaminated objects or when feeding a resident who spits or drools. If you are going to come in contact with the resident's food, don gloves, complete task, then remove gloves and perform hand hygiene. 40905 2. A Minimum Data Set (MDS) for Resident #24, dated 3/12/24, included diagnoses of renal insufficiency and Alzheimer's. The MDS documented the resident had an indwelling catheter, and a Brief Interview for Mental Status score of 5 out of 15, indicating severe cognitive impairment. Observation on 4/16/24 1:40 PM, with Director of Nursing (DON) in attendance, Staff E, Certified Nursing Aide (CNA) entered Resident #24's room and washed her hands, applied gown and gloves. Staff E then, with her gloved hands, picked up a floor mat, touched a cabinet door and touched a dirty garbage bag. Staff E, with the same gloves on, proceeded to place a barrier and graduated cylinder on the bed beside the resident and with the same gloved hands cleansed the tip of the catheter tube, drained urine from the bag, and cleansed tubing again with an alcohol swab. Staff E emptied and rinsed the cylinder, gathered the trash and placed in red bag, and removed gloves and gown and then washed hands. Facility policy titled Emptying Catheter Drainage Bag, dated 6/28/23, directed if you soil your gloves, or touch objects while gathering supplies to perform cares, remove gloves and perform hand hygiene and don new gloves and continue with completing cares. Interview on 4/16/24 at 3:10 PM, the DON confirmed she observed Staff E touch the floor mat, garbage bag, and other items and with the same gloves emptied the catheter. DON stated the expectation is to perform hand hygiene and put on new gloves after touching items and before performing catheter care.

Based on observation, record review and staff interview, the facility failed to meet professional standards by not observing a resident take their medications for 1of 8 residents (Resident #18) reviewed. The facility reported a census of 51 residents. Findings include: A Minimum Data Set (MDS) for Resident #18, dated 3/12/24, included diagnoses of heart failure, anxiety, and depression. The MDS documented the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. Observation on 4/15/24 at 12:05 PM, resident in room and holding medication cup with several pills in the cup. Resident stated they always leave them for me, they know I will take them as they are good for me. Review of the resident's Medication Administration Record dated 4/1/24 - 4/30/24, documented the following medications ordered and administered at noon: a. ascorbic acid (supplement) b. aspirin c. buspirone (anti-anxiety) d. cholecalciferol (supplement) e. ditiazem (high blood pressure) f. duloxetine (anti-depressant) g. ferrous gluconate (iron supplement) h. furosemide (diuretic for fluid retention) i. L-Lysine (canker sore) j. metoprolol (high blood pressure) k. Tylenol l. Zyrtec (allergies) Interview on 4/17/24 at 11:36 AM, Staff B, Licensed Practical Nurse (LPN) stated she always stays with residents until they take their medication and does not leave medications with any residents. Interview on 4/17/24 at 12:08 PM, Staff C, LPN stated she always stays with residents until they take and swallow their medication, the protocol is to stay with the resident and no residents are able to self-administer their medications. Facility policy titled Administration of Medication, dated 6/28/2023, directed staff to remain with the resident to ensure that the medication is swallowed. Interview on 4/17/24 at 2:47 PM, the Director of Nursing stated she expects staff to remain with the residents until the medication is swallowed and recently provided education to the staff regarding this.

Based on observation, record review, and staff and resident interviews the facility failed to provide 6 ounces (oz). of beef tips and mushrooms in gravy to approximately 40 of 49 residents as the menu directed during the noon meal observation on 02/08/2023. The facility reported a census of 49 residents. Findings include: Record review of a undated document titled, Week 3 Wednesday, Diet Spreadsheets instructed staff to serve, 6 oz. of beef tips and mushrooms in gravy to regular diets. Record review of a document titled, Diet Roster, dated 2/06/23 documented the facility has 50 residents to serve meals too and all but one resident received a regular diet. During an observation of meal service on 02/08/2023 from 11:45 AM to 12:25 PM, Staff C, served Week 3 Wednesday, Diet Spreadsheets noon meal to the residents, however he served all regular and mechanical soft diets 3 oz. of beef tips and mushroom's in gravy instead of 6 oz. as the menu instructed. During an interview with Staff C, Cook on 02/08/2023 at 12:23 PM, reported he used the wrong scoops and informed he only used a 3 oz. scoop of the beef tips and mushrooms in gravy to all residents except the pureed diet resident or ones that did not take it. After the meal, on 02/08/23 at 12:47 PM, Resident #41 reported she ate all her food and it was very good. She denied needing more food and stated she had the pasta with beef tips and mushroom gravy. During an interview with the Dietary Manager on 02/09/23 at 7:55 AM, he acknowledged he would expect the correct scoop size to be used.

Based on clinical record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual volume October 2019, the facility failed to assure each resident received an accurate Minimum Data Set (MDS) Assessment, reflective of the residents' status at the time of the assessment for 1 of 14 residents (Resident 41) reviewed for Accuracy of Assessment. The facility reported a census of 49. Findings include: The end of Medicare stay Minimum Data Set (MDS) dated [DATE] for Resident #41 documented the resident experienced no falls since the most recent assessment (dated 10/28/22). The Quarterly MDS dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5 which indicated significant cognitive impairment. The MDS documented the resident required extensive assistance of 1 staff member for bed mobility, transfer, walking, dressing and toileting. The MDS indicated diagnoses which included right femur fracture, anemia and high blood pressure. The Comprehensive Care Plan revealed a focus area of fall risk. The Care Plan directed staff to assist the resident to a chair in main lobby as needed, dated 11/5/22. The Incident Report dated 11/5/22 documented Resident #41 found on the floor with an injury to her face. A Progress Note authored by Staff A, Registered Nurse (RN), dated 11/5/22 at 6:48 pm, reported Resident #41 had an unwitnessed fall at approximately 4:30 pm. The note further documented the resident was found lying on an alarmed mat with her head on the floor with a hematoma (a pool of clotted blood) present on the right side of her forehead. Review of the RAI, Chapter 3, beginning of page J-31 directs for question J1800: Has the resident had any falls since the prior assessment to code 0, no, if the resident has experienced no falls and to code 1, yes, if the resident has experienced falls. Page J-32 defines an injury from a fall as: Any documented injury that occurred as a result of, or was recognized within a short period of time after the fall and attributed to the fall. An injury includes skin tears, abrasions, lacerations, superficial bruises,hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. On 2/8/23 at 11:06 am, Staff A, RN, former MDS Coordinator explained the facility is currently using a consultant company to complete MDS Assessments and care planning. She also said the process for this is to send reports to the consulting company for any information needed to be placed on the MDS. She added that if a resident has a fall, the Incident Report is completed, a Nurse Manager reviews the fall and an appropriate intervention and the information is sent to the consulting company. All orders, Incident Reports or other information is scanned to the consulting company. On 2/8/23 at 12:03 pm, Staff B, MDS Consultant, stated the procedure for reviewing falls for MDS documentation is to look through risk management (a program within the Electronic Health Record for documenting incidents such as falls, skin injuries, etc.) and Progress Notes regarding falls for the resident and to appropriately document any falls on the MDS. She voiced her expectation as all falls to be documented accurately on the MDS assessment and stated she would make a modification to correctly reflect the fall for Resident #41.

Based on staff interviews and facility record review, the facility failed to have the Infection Control Nurse complete required specialized training in infection prevention and control. The facility reported a census of 50. Findings include: During interviews on 11/16/21 at 9:57 AM, the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) worked as the facility's Infection Preventionist. The ADON reported that he didn't have his certification, he has tried to sign up for it but there is so much information required for him to get registered. The DON and ADON questioned when the Infection Preventionist certification became required. During interview on 11/16/21 at 10:00 AM the ADON stated that he would get registered for the course and get it taken. On 11/17/21 at 11:29 AM, the DON provided a copy of the ADON's Infection Preventionist certification completed on 11/17/21.

Based on clinical record review, observations and resident and staff interviews and facility policy review, facility staff failed to adhere to infection control techniques while providing perineal and catheter care for two of three residents reviewed (Residents #3 and #5). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 with Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required the assistance of two people for toilet use and personal hygiene. The resident was occasionally incontinent with less than seven episodes of incontinence for the seven day look-back period. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan problem dated 10/21/21 showed Resident #3 had bladder incontinence related to impaired mobility and weakened trusor muscles. The Care Plan problem dated 9/30/21 documented she had an activity of daily living (ADLs) self-care performance deficit related to a left femoral fracture with non-weight bearing status. The intervention dated 9/30/21 instructed the resident required the assistance of one staff with personal hygiene and oral care. The intervention revised 10/19/21 instructed she required the assistance of one staff with a gait belt and front wheeled walker (FWW) stand pivot transfer (SPT) due to no-weight bearing (NWB) to left lower extremity (LLE). The resident was continent of bowel and bladder. During interview on 11/17/21 at 8:23 AM, Resident #3 stated she had an infection in her urine a while ago. She reported that it made her really confused at that time. The infection happened after her hospital stay but can't remember too much about it as her memory isn't that good. She said that the staff help her to the portapotty now and they say she does the jitterbug to get to the bathroom. During observation on 11/17/21 at 10:21 AM, Staff A, Certified Nurses' Aide (CNA) washed her hands after entering the resident's room. With gloves on, Staff A got the garbage can ready by putting in a new garbage bag. Without hand hygiene and while wearing the same gloves, Staff A then picked up the clean wash cloths. Staff A got the wash cloths wet in the sink. After wetting the wash cloths she carried the garbage can from bathroom into the room with two towels inside hanging half in and half out of the garbage can. Staff A then placed another bag on the floor near the main room garbage can. Staff A wiped the resident's perineal (groin) area from the back side going between the legs and wiping towards the buttocks. Staff A repeated this three times, each time taking a new wash cloth. Staff A placed the used wash clothes into the bag on the floor near the main room garbage can. Staff A then removed her gloves and dried the resident while not wearing gloves with the towel from the garbage can. Without hand hygiene, Staff A removed the resident's gait belt and moved the walker across the room. Before washing her hands, Staff A gave the resident her call light and a pillow under her leg. Staff A then went into the bathroom to gather the garbage and dirty laundry. After picking them up, she took them out of the room. Staff A then went to the hallway and disposed of the bags. Staff A then sanitized her hands. The Hospital record dated 10/7/21 showed the resident was a new admission. The resident had a [CONDITION(S)] treated with [MEDICATION(S)] (an antibiotic) with the last dose given on 10/10/21. On 11/18/21 at 10:35 AM, the Director of Nursing (DON) said that she would expect the staff member to wash her hands and to not use the garbage can to hold a clean towel. The DON said that the aide shouldn't have wiped the resident with a hand towel without gloves on. The DON concluded she should have washed her hands before touching other items in the room. The facility's Clinical Standard of Practice Manual: Handwashing, dated 11/16, recorded that staff involved in direct resident contact would perform proper hand hygiene procedures to prevent the spread of infection other personnel, residents, and visitors. The Standard of Practice Explanation and Compliance Guidelines reported the following. a. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as an alcohol-based hand rub (ABHR). b. Staff would perform hand hygiene when indicated, using proper technique. b. Hand hygiene is indicated and would be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The facility's undated Hand Hygiene Table directed that hands should be cleaned with either an antimicrobial soap and water or an alcohol based hand rub for the following conditions: a. After handling contaminated objects b. Before applying and after removing personal protective equipment (PPE), including gloves. c. Before and after handling clean or soiled dressings, linens, etc. d. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. The undated Peri Care Policy instructed staff to dry thoroughly using a clean dry cloth. Then doff (remove) soiled gloves, perform hand hygiene and don (put on) clean gloves. 2. The MDS assessment dated [DATE] showed Resident #5 had a BIMS score of 12, indicating moderate cognitive and memory impairment. The resident required the assistance of two people with toilet use and the assistance of one person with personal hygiene. The resident required an indwelling catheter for urination. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan problem dated 9/14/21 documented he had several non-catheter related UTIs within the last year and follows with urology related to his neuromuscular impairment of his bladder and urinary retention. Interventions dated 9/14/21 directed staff to complete catheter cares as ordered, change catheter as ordered and that resident, family, and caregiver teaching should include good hygiene practices. Observation on 11/17/21 at 8:46 AM revealed Resident #5's catheter bag laying on the floor without a dignity bag (cloth covering). The tubing contained red urine and it was laying next to the recliner with one third of bag resting on the garbage can. Observation on 11/17/21 at 1:30 PM revealed Staff B, Certified Medication Aide (CMA), placed a underpad down on the floor and placed a graduate container on top of the pad with two alcohol wipes. Staff B removed the resident's catheter bag from his privacy bag and placed the privacy bag on the underpad. Staff B then opened the catheter and emptied dark red urine into the graduate. Before closing the catheter bag tubing, Staff B cleansed it with an alcohol wipe. After closing the tubing, Staff B placed the catheter bag into the privacy bag and then hung it on the garbage can. Staff B then emptied the graduate and washed her hands. Resident #5's History of Present Illness form dated 8/12/21 recorded treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When the treatment failed the resident presented to the hospital. The Assessment section recorded Resident #5 had a recurrent [CONDITION(S)]. The Discussion/Summary explained that the resident's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The History of Present Illness dated 10/26/21 showed that the resident's last visit he had a [CONDITION(S)] with positive culture of Proteus. The resident's symptoms included reduced mobility and confused. [CONDITION(S)] prevention measures were discussed with the resident at the appointment. Review of Resident #5's Progress Notes revealed the following information: On 11/17/21 at 10:47 PM the resident denied any concerns with his catheter. The catheter remained patent and intact with dark bloody urine (hematuria) noted, urine with a foul odor. The resident denied complaints of signs or symptoms of urinary concerns. On 11/18/21 at 5:23 AM the 10:00 PM to 6:00 AM shift, the resident had 600 milliliters (ML) of urine output. The urine had visible hematuria and a small amount of bloody drainage to the outside of his penis. The resident was cleansed and patted dry. On 11/18/21 at 3:26 PM, staff documented a new order for a urinalysis (UA) with a culture and sensitivity (C&S) if indicated, a complete blood count (CBC), and to monitor his urinary output. If less than 240 ML output, assess the catheter flow, flush as needed, then notify the PCP. On 11/20/21 at 1:26 AM explained the lab and UA was called to the PCP with no new orders at that time, continue to await the culture. On 11/22/21 at 10:25 AM showed that the nurse followed up with the resident regarding the CBC and the UA completed the previous week. The CBC showed a trending white blood cell count (WBC) trending up to 15.3 from 13 on 11/1/21, 14.4 on 10/22/21, 13.4 on 10/7/21, 12.9 on 9/17/21. The UA had no nitrated with occasional bacteria. The resident had a chronic indwelling catheter. The UA with C&S showed 10,000 to 50,000 E. Coli, likely colonized due to the indwelling catheter. The indication for the UA was the low urine output, mentation changes, and hematuria. The resident's [MEDICATION(S)] (blood thinner) was held for three days due to the hematuria. The catheter was changed due to the low urine output. Since the change of the catheter, there has been no more hematuria noted and his urinary outputs have improved. The resident's PCP agrees that the UA was likely the result of colonization regarding long-term catheter use. In the absence of fever and other symptoms, the PCP didn't want to start an anti-infective agent. A new order was received to re-check his CBC in two weeks given the leukocytosis. During interview on 11/18/21 at 10:35 AM, the DON stated a catheter bag should not be placed on the floor without a dignity bag and should not be stored on the garbage can. The DON stated if there was nowhere to hang the catheter bag, the facility had new basins staff could place the catheter bag in. The facility's Urinary Catheter Care policy dated 1/23/13 documented that catheter care is performed to prevent complications such as infection caused by the presence of an indwelling catheter.

Based on observation, policy review, record review and staff interviews the facility failed to cleanse contaminated surfaces after performing a treatment for 2 of 4 residents, ( Resident #17 and #30) and ensure staff utilized infection control techniques for 2 of 3 residents ( Resident #2 and #49). The facility also failed to annually review their infection prevention and control program. The facility reported a census of 52 residents. Findings include: 1. During observation for Resident #17 with a [DIAGNOSES REDACTED].#17 with her inhaler. After giving the inhaler Staff G dropped the inhaler on the floor in the residents room and proceeded to pick up the inhaler. At 7:34 AM Staff G placed the inhaler on top of the medication cart without a barrier and then proceeded to unlock the medication cart and place the inhaler in the medication cart without sanitizing the inhaler. 2. On 1/8/20 at 7:47 AM, during an observation of administration of eye drops and an inhaler for Resident #30. Staff G entered the residents room and placed the inhaler and eye drops that were stored in plastic bags on the residents bedside table that also had the resident's lotion, water and remote on it. Staff G did not sanitize the surface prior to setting the treatments down. After completing the treatments, while walking back to the medication cart Staff G dropped the bottle of eye drops in the hallway. She placed them into the medication cart without sanitizing or changing out the bag. The Director of Nursing (DON) provided an undated and unsigned procedure titled, Administration of Ophthalmic Medications. The procedure directed staff to place a barrier on a clean and dry surface before setting down the bag with the ophthalmic drops. Approved barriers may include but are not limited to: a paper towel, a new clean plastic bag and tin foil or parchment paper. Review of Staff G's, Nurse Orientation Checklist, lacked education regarding inhalers and eye drop medication distribution. During an interview on 1/8/20 at 3:30 PM, the DON stated she would expect the nurse to use a barrier when setting down medications in a resident room and sanitize if anything is dropped on the floor. 3. The facility provided a policy titled, Infection Control Program Standard of Practice, dated 11/2016. During an interview on 1/8/20 at 10:10 AM, Staff C, Registered Nurse (RN), revealed this was their current infection control program. During an interview on 1/8/20 at 3:15 PM, the DON and Staff C revealed the facility did not know the facility was to review the policy annually. The facility provided the same policy, with no changes, signed by Staff C and a Doctor, dated 1/8/20. The facility failed to annually review their infection control policy. 4. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had moisture associated skin disorder, [MEDICAL CONDITION], and dementia. The resident required extensive assistance of one staff for toileting, hygiene and dressing. The MDS indicated the resident had frequent urinary and bowel incontinence. During observation on 1/8/20 at 7:52 AM, Staff E, Certified Nursing Assistant (CNA) ambulated Resident #2 to the shower room on the CCDI (memory care) unit. Staff [NAME] donned a pair of gloves and removed Resident #2's pants and brief. The resident sat down on the toilet. Staff [NAME] obtained washcloths, placed soap on the top washcloth, placed the washcloth into the bowl of the sink and turned on the water with her gloved hand. Staff [NAME] used the same gloved hand and pulled the soiled linen cart closer to the sink area. Staff [NAME] removed the resident's partially wet brief and then donned a clean pull up inside the resident's pants. At 7:55 AM, Staff [NAME] assisted the resident to stand by the toilet. Staff [NAME] took a wet washcloth from the sink and provided pericare. Staff [NAME] took another washcloth from the sink and cleansed the buttocks area. The resident's inner buttocks area had a reddened area. Staff [NAME] pulled the resident's pull up brief and pants up, then removed her gloves. During an interview 1/9/20 at 8:00 AM, the DON stated she expected staff take residents to the bathroom in the resident's room rather than use the bathroom in the shower room to toilet the resident and provide pericare. The DON reported she expected staff not place washcloths in the sink and then use those washcloths for pericare. The DON expected staff to change gloves when soiled or contaminated. In a policy titled Pericare, revealed the following: a. Assemble wash cloths and soap. Bring garbage bag to area. b. Perform hand hygiene and don gloves c. Remove soiled pad and place in trash can. d. Remove soiled gloves. Perform hand hygiene and don gloves. e. Wet washcloth with soap and water, wet another washcloth with warm water for rinsing, and prepare a dry washcloth f. Wash resident from least soiling to buttocks area. g. Dry thoroughly with dry cloth h. Doff (remove) soiled gloves and perform hand hygiene. 5. The MDS assessment dated [DATE] revealed Resident #49 had dementia. The resident required extensive assistance of one staff for toileting and dressing and limited assistance for hygiene. During observation on 1/8/20 at 8:03 AM, Staff D, CNA, ambulated Resident #49 to the toilet in the shower room. Staff D donned a pair of gloves and removed the resident's pants and underwear. Staff D reported the resident's underwear a little wet, turned the call light on in the shower room and requested another CNA to bring in a clean pair of underwear. At 8:06 AM, Staff D donned a clean pair of pull ups inside the residents pants. At 8:07 AM, Staff D used her same gloved hand, placed wash cloths in the sink, and turned on the water. At 8:09 AM, Staff D stood the resident up by the toilet, then took a wet washcloth from the sink and cleansed the resident's peri area. Staff D took another washcloth from the sink and cleansed the buttocks area. Staff D took a dry washcloth from the edge of the sink and dried the resident's front and backside. Staff D removed her gloves, then pulled the resident's pull up and pants up. Staff D had the resident wash her hands in the sink. Staff D then ambulated the resident to the recliner in the common area.

Based on record review and staff interviews the facility failed to have staff complete the Mandatory Reporter for Dependent Adult 2 hour class within 6 months of hire. The facility reported a census of 52. Findings include; According to the new hire list provided by the facility, Staff A, Certified Nursing Aide (CNA) had an employment start date of 3/20/19. Staff A provided a certificate for Mandatory Reporter: Child and Dependent Adult dated 7/25/2018 for 2 contact hours. During an interview on 1/8/2020 at 10:39 AM, Staff B, Accounting Assistant explained she did not have any other information for Staff A, CN[NAME] Staff B acknowledged information she had on Staff A showed her dependent adult abuse done 7/25/18 that is the same date on the certificate for 2 hours combined for child and adult. During an interview on 1/9/20 at 10:52 AM Staff C, Nursing Support acknowledged the facility knew the required 2 hours for adult only, for the Mandatory Reporter of Dependent Adult Training.

Based on facility record review and staff interview, the facility failed to provide Mandatory Denial Notice (Centers for Medicare Services (CMS) form ) for 2 of 3 skilled residents reviewed (Resident # 54 and #104). The facility reported a census of 52. Findings include: 1.The information provide from the facility documented Resident # 54 received skilled services at the facility from 9/25/19 through 10/18/19. Review of the documents provided for Resident #54, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) revealed the resident's therapy services would end 10/18/19. The facility failed to provide Mandatory Denial Notice form to Resident # 54 that would have notified the resident of the right to have a claim submitted to Medicare and of the standard claim appeal rights that apply if the claims denied by Medicare. 2.The information provided from the facility documented Resident #104 received skilled services at the facility from 6/23/19 through 7/1/19. Review of the documents provided for Resident #104, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) revealed the resident's therapy services would end 7/1/19. The facility failed to provide Mandatory Denial Notice form to Resident # 54 that would have notified the resident of the right to have a claim submitted to Medicare and of the standard claim appeal rights that apply if the claims denied by Medicare. During an interview on 1/9/2020 at 8:37 AM, the Staff H, Admissions Coordinator explained the vendor had changed the form they used last year. Staff H acknowledged she had not been using form since the change and only used the Detailed Explanation of Non-coverage. During a subsequent interview on 1/9/2020 at 9:47 AM, Staff H explained she printed the form and acknowledged she did get confused since the Detailed Explanation of Non coverage goes over the same things as the form . Staff H realized the Detailed Explanation of Non coverage did not give the resident the option of continuing the coverage for a cost, appealing the decision, or not to have the coverage.

Based on record review and staff interview, the facility failed to provide adequate supervision to Resident #7 in order to prevent falls. The sample consisted of 5 residents and the facility identified a census of 54 residents. Findings include: 1. Resident #7 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 5/9/17. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS recorded Resident #7's Brief Interview for Mental Status (BIMS) a score of 3. A score of 3 represented the resident had cognitive impairments. The MDS recorded the resident required extensive assistance of one staff member for bed mobility, transfers, dressing, hygiene and required total assistance of two staff members for toilet use. The MDS indicated the resident not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off the toilet and surface to surface transfers during the 7 day look back period. According to the annual MDS assessment with a reference date of 8/2/17, Resident #7's BIMS a score of 3, indicating severe cognitive impairment. The MDS recorded that Resident #7 required limited assistance of one staff member for transfers, walking and required total assistance for dressing, hygiene and toilet use. The MDS also recorded the Resident had not been steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off the toilet and surface to surface transfers during of the 7 day lookback period. Resident #7's Care Plan included a problem of impaired physical mobility with potential for injury related to a fractured right hip after a fall and Alzheimer's dementia with poor regards for safety. The Care Plan recorded approaches if fall occurs , assess for injury and notify doctor as needed, intervene with unsafe decision making, and staff should anticipate and provide his/her needs. Update to the Resident #7's Care Plan dated 7/17/17 indicated the resident had fallen in the bathroom during evening cares and received a laceration to the forehead and sent to emergency room and received sutures to his/her forehead. The Nurse's Note dated 5/13/17 recorded the Certified Nursing Aide (CNA) heard someone exclaim Oooh and went down the hall to find Resident #7 sitting on the floor mat. A fax to the physician dated 5/13/17 reported Resident #7 crawled or slipped out of the bed and on to the floor mat. The Care Plan dated 5/15/17 identified an update that the staff found the resident sitting on the floor mat next to the bed. The intervention directed staff to place a noodle device on the edge of the bed and change the mattress to a winged mattress. The Nurse's Note dated 6/10/17 (during the 2 P.M. to 10 P.M. shift) but recorded at 10:00 p.m. recorded the staff found the resident on the floor in the lounge with a laceration to the right side of his/her face and transferred to the hospital emergency room . The resident returned to the facility from the hospital at 7:50 P.M. The 6/10/17 CT head impression recorded a nondisplaced right nasal bone fracture and right supraorbital lateral laceration. The Care Plan identified an update on 6/10/17. The Care Plan indicated the resident had a right eye laceration due to a fall and had been sent to the emergency room and sutures placed. The Care Plan dated 6/12/17 referred to the 6/10/17 Nurse's Note and an intervention to educate the staff if the resident in the lounge area, then someone must be present. The Nurse's Note dated 7/17/17 recorded Resident #7 to be sent to the hospital emergency room . The facility Resident Incident/Accident Report recorded the CNA assisted Resident #7 with evening cares when the CNA turned to grab gloves and Resident #7 fell face first, with an open area on the right side of the forehead. The Nurse's Note dated 7/18/17 recorded Resident #7 returned from the hospital with 14 stiches on the Y shaped laceration. The Nurse's Note dated 7/19/17 recorded Resident #7 noted to be throwing up and received a new order to send to the hospital emergency room . The transfer form identified the recent fell with a head injury and with emesis and fixed pupils now. The note indicated the physician directed the nurse to send the resident to the hospital emergency room . On 8/23/17 at 2:58p.m. Staff B, CNA, was interviewed and stated he sat the resident on the toilet to do evening cares and removed the resident's clothing. Staff B explained he turned his back to the resident to wash his hands and obtain a wash cloth. Staff B acknowledged with his back to the resident, the resident stood up and fell . A fax to the physician on 8/14/17 reported shortly after assisting the resident to bed, found the resident lying on side and in a fetal position on the floor at the foot of the bed. The resident had no apparent injuries noted. A fax to the physician dated 8/16/17 reported Resident #7 sat in the lounge in a wheelchair, stood up and fell on his/her left side. The Care Plan dated 8/16/17 indicated the resident had fallen on 8/14/16 and an intervention added to keep the Resident #7 up until 8:00 p.m. and to use a body pillow in bed on the right side to prevent the resident from self- transferring. The resident's Care Plan identified an update on 8/17/17. The Care Plan indicated the resident had fallen 8/16/17 and received a new order for occupational therapy to make an evaluation for wheelchair placement.

Based on record review, staff interviews and review of the policy and procedures, the facility failed to provide adequate supervision and failed to utilize a planned assistive device when transferring Resident #2 in order to prevent injury to the resident. The sample consisted of 4 residents and the facility reported a census of 65 residents. Findings include: 1. Resident #2 had an admission Minimum Data Set (MDS) assessment with a reference date of 8/18/16. The MDS identified the resident had [DIAGNOSES REDACTED].#2. The same MDS documented the resident required extensive assistance of 2 staff persons for completion of transfer and hygiene, dependent for completion of mobility and toileting and had experienced falls in the past 2-6 months prior to admission to the facility. The certified nursing assistant (CNA) Care Card dated 8/15/16 contained the directive dated 9/17/16, to transfer the resident with an EZ lift (full body mechanical lift) with 2 staff assistants only at the nurse's decision. The Nurse's Notes entry dated 9/18/16 at 7 PM to 7 AM, documented at 7:30 PM on 9/17/16, the staff found the resident on the floor of the bathroom. The resident complained of buttock, neck, left shoulder and left hip pain. The resident stated she/he tried to go to the bathroom. The physician ordered a portable x-ray. The Patient Report dated 9/17/16 documented a non-displaced fracture at the junction of the left superior pubic ramus and acetabulum and a non-displaced fracture at the junction of the left superior pubic ramus and the pubic bone. The facility implemented 30 minute checks on the resident at the time of the incident to ensure safety. The Nurse's Note entry, completed by the Director Of Nursing (DON), dated 9/18/16 at 3:00 PM documented the intervention to transfer the resident with an EZ Lift and 2 assistants. The Nurse ' s Note entry dated 9/1/16 at 11:20 a.m. indicated the resident continued with pain to neck and pain to pelvis/hips with movement. The resident could move side to side with increased level of pain but tolerable using bed pain and when head of bed raised for meals. The physician ordered Norco 5/325 2 tablets every 6 hours as needed for pain. The Nurse's Note entry dated 9/19/16 at 10:00 AM documented therapy recommended the resident pivot transfer with 2 assistants. This entry also documented the nurse contacted the resident ' s responsible party to notify of the therapy recommendation. The responsible party requested the resident not stand and for the resident to remain transferred with a mechanical lift. The Nurse ' s Note entry dated 9/19/16 at 6:15 p.m. indicated the resident doing well with the increase of Norco. The resident slightly fatigue and easy to awaken. The staff feeding the resident in bed per resident request and up to the bed side commode for toileting. The Nurse's Note entry dated 9/25/16 documented the resident called the nurse over to him/her while seated in a wheelchair in the dining room at 7:00 AM. The resident stated his/her left arm hurt and stated she/he heard a pop when being assisted out of bed. The nurse documented no mechanical lift sling under the resident. A CNA stated another CNA told her the resident transferred with a gait belt pivot transfer. The nurse educated this CNA to the fact the resident should have been transferred with a mechanical lift. The Patient Report dated 9/25/16 documented the resident had an oblique fracture through the left proximal humerus (upper arm bone). On 10/10/16 at 6:54 PM, Staff A, CNA, stated Staff B, CNA, requested assistance to transfer the resident. Staff A stated she does not normally care for the resident, but Staff B cared for the resident the day before so she asked Staff B how to transfer the resident. Staff B told her the resident required a gait belt pivot transfer. Staff A stated she assisted the resident to sit on the edge of the bed, applied a gait belt, had the resident placed his/her arms on top of her arms, and assisted the resident to stand. Staff A stated Staff B pulled up the resident's slacks; she heard a pop; the resident said ow and stated his/her arm hurt. Staff A stated she transferred the resident to the wheelchair and Staff B then pushed the resident into the dining room. Staff A stated she notified the charge nurse of the resident's complaint. Staff A stated she failed to check the CNA Care Cards at the start of her shift, as required of all staff. Staff A stated she asked Staff B for direction as she worked with the resident the day before. On 10/11/16 at 1:52 PM. Staff B was interviewed and stated she failed to check the CNA Care Cards for each resident at the start of her shift on 9/25/16. Staff B stated she knew it is required to check the CNA Care Cards every time. On 10/10/16 at 4:40 PM the Assistant Director of Nursing (ADON) was interviewed and stated all new nursing employees are educated upon hire to review the CNA Care Cards for their assigned residents at the start of their shift. The ADON showed the nursing employee packet used in employee orientation contained a blank CNA Care Card.

Based on observation, record review, and family, staff and physician interviews and review of policy/procedures, the facility failed to assess and provide timely and appropriate interventions after a change in condition and notify the physician timely (Resident #1) and failed to appropriately insert a straight catheter (Resident #5). The sample consisted of 3 residents with a catheter. The facility identified a census of 54 residents. Findings include: 1. Resident #1 had an Minimum Data Set (MDS) assessment with a reference date of 2/19/13, which identified [DIAGNOSES REDACTED]. The assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 out 15. A score of 7 reflected Resident #1 sometimes had the ability to make self-understood and could understand others, dependent on 2 staff with dressing toilet use and personal hygiene, frequently in pain and had an indwelling catheter. A Care Plan dated 2/7/13, indicated the resident had a problem with altered pattern urinary and bowel elimination. The approaches included the following: a. Monitor for signs and symptoms of a urinary tract infection [MEDICAL CONDITION]. b. Encourage fluids with cares and contacts. c. Administer [MEDICATION NAME] and [MEDICATION NAME] as ordered. On 2/15/13 the [MEDICATION NAME] had been increased to BID (2 times a day). d. Monitor for abdominal distention, pain, and bowel sounds as needed (PRN). e. Irrigate the Foley (catheter) as ordered. f. Change the Foley (catheter)every month. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 5 milligrams (MG) 1 tablet by mouth at bedtime (used for [MEDICAL CONDITION]), [MEDICATION NAME] 0.4 MG capsule by mouth two times a day (BID) (used for difficulty urinating and an enlarged prostate), Aspirin 325 MG one tablet every day (QD). A Physician telephone order form dated 3/12/13, indicated the facility received an order to change the resident's Foley catheter with a 16 French 5 cc (cubic centimeter) bulb catheter. The MAR indicated [REDACTED]. The form directed staff to check the resident ' s vitals each day. The form revealed no assessment of the vital signs on the 3/13/3. The Nurse's Notes entries as dated and timed below revealed the following information: On 3/12/13 at 5:30 a.m. the catheter had been removed without difficulty. The resident tolerated the procedure well with no bleeding noted or concerns voiced. On 3/12/13 at 1:45 p.m. the resident had not voided during the shift so a 16 French 10 cc bulb catheter had been reinserted with a 75 cc (cubic centimeter) return of urine. The Foley had then been connected to a drain bag which contained urine and a small amount of red blood in the tubing of the catheter. On 3/12/13 at 5 p.m. the resident had voided 400 cc of dark red blood in the catheter bag. At 5:30 p.m. the resident had been noted to have a small amount of blood draining from the meatus. The nurse assessed and documented the Foley catheter as loose (meaning the Foley balloon had not been holding well). The nurse documented he removed and re-inserted a different catheter and the resident tolerated the procedure well. On 3/12/13 at 5 p.m. (actual entry had been dated 3/14/13 as a late entry) - The resident complained of pain and discomfort related to the Foley catheter. Upon examination of the catheter the nurse noted a small amount of blood draining from the meatus. The Foley had been changed utilizing a sterile technique with a return of 400 cc of dark red urine. The nurse documented the resident tolerated the entire process well and claimed to have felt much better after voiding. The entry indicated the resident's family had been waiting outside and had been aware of the situation. On 3/13/13 at 5 a.m. - (actual entry had been dated 3/14/13 at 8:30 a.m. as a late entry) The nurse had been called to assist the nurse on the skilled unit with a Foley catheter. The nurse checked the catheter and noted blood in the tubing and the drainage bag without the color of urine present. Additionally, a large amount of blood had been noted draining from the resident's meatus. The nurse documented the resident with a pale appearance who informed the nurse the Foley hurt and that he/she denied the need to urinate. The nurse indicated here had been no bladder distention observed during that assessment. The nurse then attempted to readjust the Foley with intent to remove any possible kinks in the tubing. The nurse then irrigated the catheter with 50 cc of sterile water while the resident confirmed having felt the liquid that had been inserted. The nurse documented there had only been possibly 1 inch return of a sanguineous liquid into the catheter tubing. The nurse then flushed the Foley catheter with 50 cc of sterile water with no return. On 3/13/13 at 5:10 a.m. - (actual entry had been dated 3/14/13 at 8:30 a.m. as a late entry) - The Foley tubing had been observed with a small amount of blood streaking present. The nurse then flushed the catheter with 50 cc of sterile water and per sterile technique. The nurse indicated the flush as difficult, without any return and that the resident complained of Foley catheter pain. On 3/13/13 from 11 p.m. to 7 a.m. (actual entry had been dated 3/14/13 as a late entry) The resident had slept well all night however at 5 a.m. the nurse noted the resident had not voided thru the shift so he called another nurse to assist him with Foley (catheter) irrigation. The nurse documented the Foley had been flushed with no return except for a small amount of blood, that resident complained of right hip pain and that pain medication had been given. At 6 a.m. the nurse documented the resident had been calm and claimed to have felt better. On 3/13/13 at 7 a.m. a large amount of blood had been noted in the Foley (catheter) drainage bag and tubing. The Foley (catheter) had been irrigated with 200 cc of normal saline with a return of 2 large blood clots. On 3/13/13 at 7:15 a.m. a new drainage bag had been attached to the Foley (catheter) with red blood tinged urine noted in the catheter tubing. On 3/13/13 at 7:20 a.m. the resident requested to get up and dressed with a desire to have breakfast in the dining room. On 3/13/13 at 7:30 a.m. the resident had a small liquid emesis after having been positioned on the toilet and assisted back to bed with the head of the bed elevated. The nurse assessed the resident with a temperature of 97 degrees and an oxygen saturation level of 97 % , as shivering with a denial of feeling cold or chilled and breathing rapid shallow breaths through his/her mouth. The nurse instructed the resident to slow down and deep breathe thru his/her nose and exhale thru his/her mouth. On 3/13/13 at 7:55 a.m. the resident continued to appear anxious and breathing shallow, rapid breaths with a temperature 97.2 degrees, an oxygen saturation level of 97 % . The nurse indicated the resident drank approximately 180 cc of liquid without difficulty and had bright red tinged urine in his/her catheter bag. On 3/13/13 at 8:15 a.m. the resident continued with bright red bloody urine in the catheter bag and anxious behaviors so the staff reminded the resident to take deep breaths. On 3/13/13 at 8:35 a.m. the resident had an emesis with a moderate amount of clear liquid with phlegm present. The head of the resident's bed had been elevated to 85 degrees. The nurse assessed the resident with an oxygen saturation level of 97 % at room air with rapid respirations. On 3/13/13 at 8:45 a.m. a message had been left with a urologist related to the resident's bloody urine. On 3/13/13 at 8:50 a.m. a message had been left with the resident's physician related to the resident's health status. On 3/13/13 at 8:55 a.m. the resident had been noted with a blank stare and not responding to verbal stimuli. The resident's blood pressure had been 80/42, pulse 102 with an oxygen saturation rate of 96 % at room air. On 3/13/13 at 9 a.m. a return call had been placed to the physician with an update given and an order received to send the resident to the emergency room at which time the nurse telephoned the ambulance. On 3/13/13 at 9:10 a.m. the ambulance had arrived. On 3/13/13 at 9:15 a.m., the resident had been transferred to the gurney, to the ambulance and sent to the emergency room . On 3/13/13 at 2:45 p.m. a call had been place to the hospital for a status report at which time the facility staff had been informed the resident had been admitted to the critical care ventilation unit and as not expected to survive. A IJSLC (Iowa Jewish Senior Life Center) MDS Documentation form dated 3/12/13 revealed the following documentation: At 1:40 a.m. - no documentation had been present related to the blood pressure, pulse or respirations. The Foley catheter removed at 5:30 a.m. with 450 cc's urine present. The documentation indicated the resident tolerated the procedure well but had not voided since. No time identified - no documentation had been present related to blood pressure, pulse or respirations. The nurse documented the resident with no urinary output so a catheter had been reinserted with a 75 cc return. At 9 p.m. -no documentation had been present related to the blood pressure, pulse or respirations but the catheter had a 400 cc output. A IJSLC MDS Documentation form dated 3/13/13 revealed the following documentation: At 4 a.m. - no documentation had been present related to the blood pressure, pulse or respirations but the Foley (catheter) had been present. No time identified - no documentation had been present related to blood pressure, pulse or respirations but the Foley (catheter) had been present. According to an ambulance report dated 3/13/13, the provider had been dispatched at 9 a.m., arrived on the scene at 9:09 a.m. and found the resident non responsive to verbal stimuli , minimally responsive to pain, no blood pressure had been captured, pulse as [MEDICAL CONDITION](above 100) and in the 120's with shallow respirations at 12 breaths per minute. The resident had a blank stare. Emergency treatment had been provided by the crew and at 9:24 a.m. the ambulance crew left the facility with the resident and arrived at the hospital emergency room at 9:29 a.m., in similar to better condition than when they arrived at the nursing facility. A History and Physical form dated 3/13/13, indicated the resident arrived at the hospital at 9:29 a.m. with a Foley catheter in place and blood around the penis. A Cat Scan of the abdomen and pelvis revealed a malpositioned Foley catheter with the bulb inflated in the bulbar urethra. There had been gas in the corporum of the penis which had been consistent with a urethral tear. The assessment and plan indicated the resident as in septic shock with multiple organ system dysfunction including renal, hematologic and neurologic dysfunction, acute kidney injury, a urethral tear and acute blood loss [MEDICAL CONDITION]. The form indicated the resident passed away on 3/13/13 at 3:02 p.m. due to a cardiopulmonary arrest which occurred as a result of the septic shock with multi system organ failure. According to a Comprehensive Metabolic Panel dated 3/13/13 at 9:45 a.m., the resident had a hemoglobin level of 9.6. (normal range had been 13.0 to 17.0) According to a Clinical Laboratory form dated 3/13/13 at 4 a.m., the resident had a hemoglobin level of 10.6. According to a Clinical Laboratory form dated 3/11/13 at 6:30 a.m., the resident had a hemoglobin level of 11.0. According to a Clinical Laboratory form dated 2/26/13 at 6:35 a.m., the resident had a hemoglobin level of 9.6. According to a Clinical Laboratory form dated 2/18/13 at 4:15 a.m., the resident had a hemoglobin level of 8.0. According to a Clinical Laboratory form dated 2/8/13 at 9:15 a.m., the resident had a hemoglobin level of 10.4. During an interview 4/26/13 at 1:30 p.m., a Urologist confirmed the following: ? The resident's catheter had only been inserted half way into the urethra when the bulb had been inflated which caused the trauma to the urethra. ? [MEDICAL CONDITION] (infection) the resident incurred resulted from the trauma to the resident's urethra and [MEDICAL CONDITION] could occur rapidly. ? The resident's medical outcome certainly could have been different if the resident had been treated more timely. ? Urine could have been present in the catheter and catheter bag even if the catheter had been placed in the urethra due to bladder overflow which occurred when the bladder became full. ? The catheter could have become dislodged but that would have been a painful process and there had been no evidence to validate dislodging. ? The physician confirmed he would have expected notification with any condition change which included abnormal blood in the urine and/or the inability to irrigate a catheter appropriately. On 4/25/13 at 10:30 a.m., the facility Medical Director confirmed the following: ? It would have taken a form of trauma to cause a urethral tear. ? A person could have [MEDICAL CONDITION] rapidly if there had been a blockage in the urinary system. ? The resident's medical outcome may have been different if diagnosed more timely. ? It would have been possible to have urine present in the catheter and/or tubing because the urine could have drained from the urethral tear. ? A catheter could have been dislodged by a resident. ? The Medical Director stated a physician should have been notified when a change in condition would have included abnormal blood in the urine and/or no urinary output. On 4/24/13 at 1:45 a.m. the resident ' s family member was interviewed and confirmed he/she had observed bright red blood in the Foley catheter bag following the catheter change at around 1:45 p.m. but had been unsure of the amount. The family member also stated he/she had been present when Staff A, Licensed Practical Nurse (LPN) and Staff B, LPN inserted the 2nd catheter at around 5:15 p.m. which took the staff at least an hour. When the family member returned the next morning at around 7:30 a.m. he/she found the resident on the stool in the bathroom and had been told by Staff C, LPN the resident had just finished vomiting. The family member confirmed he/she had been shaken by the appearance of the resident and when staff returned the resident to the bed, he/she could tell something had been wrong. At that point he/she called another family member to come to the nursing facility and it had not been to long after, that the resident began moving his/her arms so violently he/she along with an unknown staff member had to hold the resident in position to assure the resident would not injure self. The family member stated the resident had shook so violently that his/her eyes rolled back. The family member then asked Staff C if a physician had been notified. The staff member confirmed she had called a physician but left the room and placed a return call. At this point another family member had been present and the ambulance crew had arrived so he/she stepped out of the room to allow them room to work with his/her family member. When the resident arrived at the hospital he/she knew the hospital staff attempted to irrigate the catheter with no success because there had been too many clots present. The hospital staff placed a supra pubic catheter and he/she thought they had a return of approximately 900 cc of urine. On 4/24/13 at approximately 10:30 a.m., Staff C, LPN was interviewed and confirmed during report on 4/13/13, Staff A reported he had changed the resident's Foley catheter at approximately 5 p.m. The staff member informed her at 5 a.m. that he attempted to irrigate the resident's Foley catheter, and had been unable to do so. Staff C stated that Staff A requested the assistance of Staff D, Registered Nurse (RN). Staff A reported the resident had been also bleeding from his meatus at that time. At approximately 7 a.m., following report, the staff member went to the resident's room and cleansed a moderate amount of old and fresh blood from around the resident ' s meatus and inner thighs. The staff member confirmed there had been dark and deep red clotty blood on the resident's pad positioned on the bed. The staff member irrigated the Foley catheter with normal saline and had approximately 200 cc return of blood thru the catheter. The staff member noted a large clot in the tubing where the tubing connected to the bag, however, there had been no urine visible. The staff member continued to irrigate the catheter until all of the clots passed and then changed the catheter bag. At that point the resident requested to get up so Staff E, Certified Nursing Assistant (CNA) assisted the resident into the bathroom without incident. While the resident had been positioned on the stool, he had an emesis of a yellow liquid with no food particles. As Staff E and Staff C assisted the resident back into bed, the nurse indicated the following: ? The resident had been alert (but thought it had still been night). ? Steady on feet. ? Had a temperature within normal limits. ? Rapid shallow respiration but the pulse ? Oximetry had been fine so the staff member encouraged deep breathing. ? Denied nausea. ? Had bright red blood that continued to drain from the meatus so she cleansed the area. The staff member stated she then returned to the hallway and passed (administered) medications to the other residents. At approximately 8 a.m., Staff E informed her the resident had been staring funny. Staff C returned to the room, checked the resident's vital signs and his oxygen saturation level and called (telephoned) the resident's medical doctor, left him a message, returned to the resident's room and encouraged him to deep breath. The staff member stated the family had been present and at bedside when she again exited the resident's room and called and left a message with a urologist related to the resident's condition. The staff member stated that within 5 minutes she returned call to the resident's family physician, updated the physician and received an order to transfer the resident to the emergency room . She then called an ambulance service. The ambulance service arrived at the facility within minutes, found the resident unresponsive and with fixed eyes. The ambulance crew then intervened and transferred the resident to the hospital. The staff member denied she called the physician on 4/12/13 when she reinserted the resident's Foley catheter due to failure to urinate. On 4/19/13 at 1:25 p.m., Staff A, LPN was interviewed and confirmed on 4/12/13, Staff C encouraged him to watch the resident's Foley catheter as the resident had been having problems with clotting. The staff member indicated that at 5 to 6 p.m. a lady from physical or occupation therapy asked him to check the resident ' s catheter because the resident complained the area had been uncomfortable. When Staff A observed the resident he had been positioned in the bathroom with a small amount of blood on his penis and a small amount of clots in the catheter bag. The staff member moved the catheter tubing and felt there had been a lot of give so he called the medical doctor and received an order to change the catheter. The staff member then requested the assistance of Staff B, LPN with the catheter change. The staff members inserted the Foley catheter without problems and had 300 to 400 cc return of thin light red blood. The staff member indicated that just following the catheter insertion, the Director of Nursing (DON) entered the resident's room, asked if everything had been OK and congratulated the staff on their performance. During his shift, the staff member confirmed the following: a. The resident had no complaints. b. He assessed and checked the resident's catheter for clots every 2 hours. c. He observed what appeared to have been a herniated area around the resident's bladder but felt that had been normal due to the resident's [DIAGNOSES REDACTED]. d. He checked the resident's vitals and pain level. e. And he encouraged fluids to the resident. The staff member stated at round 5 a.m. he informed Staff D the resident had clots in the catheter bag so he asked Staff D for assistance to irrigate the catheter. The staff member indicated that he assisted Staff D with the irrigation of the Foley catheter, there had been no return, and the resident had confirmed having felt the flush and denied pain. On 4/24/13 at approximately 2:30 p.m., Staff B, LPN was interviewed and confirmed on 4/12/12 at around 5 p.m. or 5:30 p.m., Staff A requested her assistance to change the resident's catheter. The staff member stated she believed there had been bleeding around the meatus that Staff A cleansed. The staff member stated she conversed with the resident while Staff B inserted the catheter without resistance, she inflated the catheter balloon with 10 cc of normal saline and she noticed red tinged urine in the catheter tubing. Staff B described the urine as reddish/pink and the resident voiced discomfort with the insertion but it had been hard to tell what type discomfort. The nurse stated the resident had not been screaming in pain. On 4/24/13 at 1:10 p.m., Staff D, Registered Nurse, was interviewed and confirmed on 4/13/13 at 5 a.m. , Staff A asked for assistance with the resident's catheter due to no (urine) output. When the staff member observed the catheter, she noticed blood clots and streaks in the tubing and felt it required flushing. The staff member checked the tubing for kinks, if plugged and if the catheter could have been coiled in the resident's urethra but indicated she had barely moved the catheter tubing during the assessment. The staff member stated she gently flushed the catheter with 50-60 cc of normal saline, met no resistance and had a return of approximately 30 cc of clear fluid with some thready blood which had been further described as threads of dark red blood clots. The staff member then gently flushed the catheter again but questioned if the catheter had been occluded. At this point she felt clots may have formed at the end of the catheter and may have been absorbing the fluid but would have taken time to clear. She then told Staff A that the catheter may require changing but denied performing the procedure because there had not been the correct catheter size available. After a short break Staff D again flushed the catheter for a 3rd time with no return. At that point she knew it had been getting close to 6 a.m. so she wanted to give the resident a break and look for a right sized catheter and report off to the day nurse. During the irrigation process the staff member confirmed she had observed dried blood around the meatus with no blood on the resident's thighs or pad positioned under the resident and the resident complained the Foley had been sore. Review of a written statement (not dated), reflected on 3/12/13, the DON arrived at the facility around 5 p.m. when the resident's family member informed her Staff A and Staff B had been changing the resident ' s Foley (catheter) and she had been concerned. The DON entered the resident ' s room as the staff were gathering their supplies. The DON indicated she went to the resident ' s bedside and the resident appeared calm. The DON observed urinary output in the resident's catheter tubing that had been streaked red. The DON directed Staff A to monitor the resident's urinary output and she informed all of the Certified Nursing Assistants to encourage fluids with the resident. On 4/26/13, Staff F, CNA was interviewed and confirmed she had not been present when the catheter change was performed by Staff C but she had observed the catheter tubing post insertion with pretty dark colored fluid. Staff F stated she could not tell if there had been urine present in the catheter bag. Staff F denied the observation of any blood on the resident's meatus. On 4/25/13 at 11:05 a.m., Staff G, CNA was interviewed and confirmed she had worked 2:30 to 11 p.m. on 4/12/13 and noticed the resident had dried blood on the meatus following the 2nd catheter insertion and had 1/2 of the catheter bag full of a reddish brown liquid that Staff A emptied. On 4/25/13 at 11:35 a.m., Staff H, CNA confirmed she had worked 4/12/13 from 10:45 p.m. to 7 a.m. and overheard Staff A state the resident had blood in his/her urine and had not voided since the 2nd shift. 2. According to a MDS assessment form dated 4/3/12, Resident #5 had [DIAGNOSES REDACTED]. The assessment indicated the resident short and long term memory deficits, severely impaired cognitive skills and as dependent on staff with his/her activities of daily living. A Care Plan, indicated the resident had a problem with altered pattern urinary and bowel elimination related to Parkinson ' s, in complete ladder emptying, urine retention secondary to corticobasal ganglia degeneration and Parkinson ' s with a need for intermittent catheterization. The approaches included the following: ? The resident recognized the need to void and would ask to be placed on a commode but seldom had been able to void. ? Assist with changing of pads. ? Monitor for signs and symptoms of a urinary tract infection. ? Monitor for [MEDICAL CONDITION]. ? Assist with pericare two times a day and as needed with incontinent episodes. ? Straight catheterization as ordered, see flow sheet. ? Seen by a Urologist. A Treatment Administration Record (TAR) dated 4/1/13 through 4/30/13, reflected the resident had an order for [REDACTED]. A Straight Catheter Flow Sheet form with entries dated from 3/31/13 through 4/30/13, did not reveal any documentation on 4/24/13 related to the amount of urine voided, the use of a sterile technique, the residual amount, the appearance of the urine, the resident tolerance level and the nurse's name as directed on the form. According to a Clinical Laboratory report dated 4/6/13, the resident had a urinary tract infection with greater than 100,000 colonies of Escherichia coli. According to a Clinical Laboratory report dated 2/28/13, the resident had a urinary tract infection with greater than 100,000 colonies of [DIAGNOSES REDACTED] pneumoniae. An observation 4/24/13 at 1:25 p.m., revealed the resident as lying supine in bed Staff J, LPN stood on the right side of the resident and Staff K , CNA stook on the left side.. After the staff positioned the resident for the catheterization, Staff J leaned over the resident's bed and attempted to insert the intermittent catheter but failed to properly locate the urethra. During an interview following the procedure, the staff member confirmed she thought she had the intermittent catheter properly placed. According to a General Procedures and Treatment Modalities Guideline form provided by the facility, the preparatory phase for a male catheter insertion had been as follows: ? Lubricate the catheter well with lubrication or a prescribed topical anesthetic. ? Wash off the glans penis around the urinary meatus with an [MEDICATION NAME] solution. ? Grasp the shaft of the penis and elevate it. Apply gentle traction to the penis while the catheter had been passed. ? If resistance had been felt at the external sphincter, slightly increase the traction on the penis and apply steady, gentle pressure on the catheter. Ask the patient to strain gently (as if passing urine) to help relax the sphincter. ? When urine began to flow, advance the catheter another 1 inch. General considerations were as follows: ? Utilize a catheter that had been pre-connected to a closed drainage system. ? Advance the catheter almost to its bifurcation. ? Inflate the balloon according to the manufacturer's directions. Make sure the catheter had been draining properly before inflating the balloon, then withdraw the catheter slightly. ? Secure the indwelling catheter to the patient's thigh using tape, strap, adhesive anchor or another securement device. Allow some slack of the tubing to accommodate the patient's movements. Keep the tubing over the patient's leg. According to a General Procedures and Treatment Modalities Guideline form provided by the facility, the preparatory phase for a female catheter insertion had been as follows: ? Wash hands. Put patient at ease. ? Open catheter tray using aseptic technique. ? Place patient in a supine position with knees bent, hips flexed, and feet resting on the bed about 2 feet apart. Drape the patient. Direct light for visualization of genital area. Position on moisture-proof pad under patient's buttocks. Put on sterile gloves. Separate labia minora so urethral meatus is visualized. Clean around the urethral meatus with a [MEDICATION NAME]-iodine solution. Introduce a well-lubricated catheter 2-3 inches into the urethral meatus. Note: At the time of the complaint investigation, the complaint was coded at a "J" immediate and serious jeopardy. By 5/1/2013 the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The facility provided in-services to nursing staff for placement of an indwelling and straight catheter, Foley catheter irrigations, proper catheter care, assessment when the resident experienced a change in condition and timely notification to the physician. The facility provided in-services for review of the nursing process (assessment, diagnosis, planning, implementation, evaluation). As of the 5/9/2013 exit conference, the facility needed to continue inservices and monitor for compliance for proper catheter placement, complications, appropriate irrigation, catheter care, assessment, intervention and notification of the physician timely when the resident experiences a change of condition.

Based on observation, record review, staff and resident interviews and review of facility policy/procedures, the facility failed to protect and supervise residents against hazards and ensure equipment for personal care assistive devices are maintained in a safe condition in order to prevent falls. (Resident #8, #9, #10, #11 and #12). The sample consisted of 9 residents and the facility identified a census of 54 residents. Findings include: 1. Resident #8 had an MDS assessment with a reference date of 4/10/13, which identified the resident had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and as dependent on staff with activities of daily living (ADL'S). A Care Plan dated 4/18/13, indicated the resident had a problem with impaired physical mobility with potential for injury related to anxiety with agitation, delirium and ischemic [DIAGNOSES REDACTED]. The approaches included the following: a. EZ lift transfer with assistance of 2. b. Nonambulatory. An Assessment For Fall Risk form, indicated the following scores (a score of 10 or above placed a resident at high risk). a. 4/9/13 - 16 b. 1/15/13 - 16 c. 8/15/12 - 12 d. 8/2/12 - 10 An Iowa Jewish Senior Life Center Resident Incident/Accident Report form dated 12/17/12 at 7:10 a.m., indicated the Staff L, Certified Nursing Assistant (CNA) and Staff M, CNA transferred the resident and during the transfer, the PAL sling strap snapped off of the hook which resulted in the resident falling head first onto the leg of the PAL lift device. The resident received a laceration on the back of his/her head. During an interview and reenactment of the event on 4/19/13 at 8:45 a.m., Staff L and Staff M confirmed as they transferred the resident from the bed to a wheelchair via a PAL lift device. The sling loop on the left side had slipped off of the hooks which resulted in the resident falling to the floor head first, hitting his/her head on the base of the PAL lift which resulted in a head laceration on the back of the head. Staff L confirmed the PAL lift had not been safe and she refused to utilize the lift device again. During an interview on 4/26/13 at approximately 9:20 a.m., Staff N, Licensed Practical Nurse (LPN) confirmed she immediately responded to the staff members request for assistance and found the resident on the floor with his/her right leg still suspended up in the PAL lift sling, with the rest of his/her body on the floor and a pool of blood around his/her head. The staff member confirmed the entire left side of the PAL lift sling had been disconnected from the device itself. The resident had been assessed and transferred to the hospital via an ambulance for further testing. The staff member confirmed the resident received staples on his/her posterior head but had returned to the facility the same day. During an interview 4/30/13 at approximately 10 a.m., the Director of Nursing (DON) confirmed the facility staff continued to utilize the PAL lift device with transfers however, its use was minimal. An observation 4/26/13 at 8:30 a.m., revealed the PAL lift utilized for the resident's transfer with a gap present between the metal PAL sling hook and the plastic stopper device with any type movement which resulted in the sling loop having not been appropriately secured to the unit. During an interview 4/30/13 at 10 a.m., Staff I, Nursing Services confirmed the PAL lift device had been removed from the floor. During an observation at the same time, the device had been stored in the basement in a double locked cage only assessable by management staff. 2. According to a MDS assessment, with a reference date of 1/31/13, Resident #9 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 6 out of 15, dependent on staff with ADLs and had 2 falls since admission, re-entry or the last assessment. A Care Plan with a team conference dated 12/26/13 indicated the resident had a problem with impaired physical mobility with a potential for injury. The approaches included the following: a. Transfer and ambulate with the assistance of a walker and 1 staff assist. b. If a fall occurs, assess for injury and notify the physician as needed. c. Intervene with unsafe decision making. A Jewish Senior Life Center Resident Incident/Accident Report dated 12/8/13 at 4:30 a.m. and 4:50 a.m., indicated the resident had fallen however the family had not been notified. A Jewish Senior Life Center Resident Incident/Accident Report dated 12/9/13 at 4:40 a.m., indicated the resident had fallen however the family had not been notified. A Jewish Senior Life Center Resident Incident/Accident Report dated 12/12/13, indicated the resident had fallen however no intervention/treatment had been given. During an interview 4/26/13 at 10:15 a.m., the DON and the Memory Care Manager confirmed the facility failed to notify family of the 2 falls as stated above and failed to place an intervention or document a treatment provided to the resident post fall. 3. According to a MDS assessment form, with a reference date of 2/19/13, identified Resident #10 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 6 out of 15, required extensive assistance of staff with ADL's and had 2 falls since admission, re-entry or a prior assessment. A Care Plan dated 2/27/13, indicated the resident had a problem with impaired physical mobility with a potential for injury and a risk for wandering. The approaches included the following: a. If a fall occurs, assess for injury and notify the physician as needed. b. Intervene with unsafe decision making. c. Utilize a wheelchair for mobility with mobility alarms. d. The resident would remove alarms per self and attempt to self-transfer. e. Supervise the placement of alarms. f. Low bed with 1/2 side rails and a bed alarm. A Jewish Senior Life Center Resident Incident/Accident Report dated 12/20/12, indicated the resident had fallen however no documentation had been present related to the use of an alarm and/or an alarm sounding. A Jewish Senior Life Center Resident Incident/Accident Report dated 2/28/13, indicated the resident had fallen however no documentation had been present related to the use of an alarm and/or an alarm sounding. During an interview 4/26/13 at 10:15 a.m., the Director of Nursing (DON) and the Memory Care Manager confirmed the facility failed to document the use of alarms and/or the alarms sounding for the above stated falls. 4. According to a MDS assessment with a reference date of 2/12/13, Resident #11 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 4 out of 15, required extensive assistance of staff with transfers and limited assistance with ambulation. A Care Plan dated 2/20/13, indicated the resident had a problem with impaired physical mobility with a potential for injury and at risk for wandering. The approaches included the following: a. Transfer and ambulate with a walker and 1 staff assist. b. If a fall occurs, assess for injury and notify the physician as needed. A Jewish Senior Life Center Resident Incident/Accident Report dated 3/13/13, indicated the resident had fallen however a message had been left with the family 2 times with no documentation present to validate the family had been aware of the fall. During an interview 4/26/13 at 10:15 a.m., the DON and the Memory Care Manager confirmed the facility failed notify the family directly that the resident had fallen. 5. According to a MDS assessment form with a reference date of 2/26/13, Resident #12 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 3 out of 15, required extensive assistance of staff with transfers and ambulated in his/her room only once or twice with 2 staff assistance. A Care Plan dated 3/6/13, indicated the resident had a problem with impaired physical mobility with a potential for injury. The approaches included the following: a. If a fall occurs, assess for injury and notify the physician as needed. b. Utilize a wheelchair for mobility with mobility alarms. c. Transfer and ambulate with a walker and 2 staff assist. A Jewish Senior Life Center Resident Incident/Accident Report dated 12/11/12 at 10 p.m., indicated the resident had fallen however no documentation had been present related to the use of an alarm and/or an alarm sounding or speaking directly with the family. During an interview 4/26/13 at 10:15 a.m., the DON and the Memory Care Manager confirmed the facility failed to document the use of alarms and/or the alarms sounding for the above stated fall and failed to speak directly with the family. A Fall Prevention/Investigation policy form dated 7/19/12 indicated the residents would have appropriate fall prevention devices in place; any falls would have been documented and investigated to prevent further occurrences. The procedure included the following: Licensed personnel were responsible for initiation an d completion of the accident/incident reports interventions, if indicated would have been initiated by the supervising nurse. All new interventions would have been documented on the investigation forms. The Director of Nursing, Assistant Director of Nursing and the Memory Care Director would evaluate each fall/investigation to ascertain if additional follow up would have been required and revisions made to care plan/care agenda. Should adjustments in safety devices be indicated staff would initiate the Safety Device Discontinuance Assessment. The Life Center's Fall Protocol revised 4/25/13, included the following: a. The DON and the Memory Care Coordinator reviewed all incidents (including falls) on a daily basis and interventions were put into place to prevent recurrence of additional falls.

Based on record review and family and staff interviews, the facility failed to protect a resident against hazards to themselves by failure to identify Resident #2 as a safety risk associated with an electric lift recliner for 1 of 1 residents reviewed. Resident #2 had a high risk for falls and sustained a significant injury after falling from an electric lift recliner. The injury consisted of a fractured clavicle (collarbone).The facility identified a census of 56 residents. Findings include: 1. Resident #2 had an Admission Minimum Data Set (MDS) assessment with a reference date of 2/15/12. The assessment documented Resident #2 had difficulty expressing ideas and wants, and responded to simple/direct communication. The MDS documented the resident required total assistance of 2 plus staff with bed mobility and transfers. The MDS documented the resident unsteady and only able to stabilize with human assistance for moving from seated to standing position and surface-to-surface transfer (transfer between bed and chair or wheelchair. The MDS documented the resident had a prior history of falls in the last month and had a hip fracture. The MDS identified indicators of pain observed each day which included facial expressions (e.g., grimaces, whines, wrinkled forehead, furrowed brow, clenched teeth or jaw) and received routine and as needed (PRN) pain medications. The MDS reflected the resident had a BIMS (Brief Interview For Mental Status) scored of " 8 " (8-12 identified moderate impairment). The admission care plan dated 2/23/12 documented the resident with impaired mobility with potential for injury. The care plan documented the resident will transfer with assist of two without injury by 5/23/12. Approaches directed staff to advise the resident to move slowly and not rush, intervene with unsafe decision making, low bed with half side rails and bed alarm. A hospital discharge summary dated 2/3/12 documented a right hip fracture on 1/30/12 and a history of ORIF (an orthopedic surgery to pin the hip) surgery of the left hip in 2003. The discharge summary documented the resident had a right hip trochanteric femoral nailing The Admission Record [DIAGNOSES REDACTED]. The fall CAA documented the resident transfers with maximum assistance and non-ambulatory. The fall CAA documented will continue to monitor for safety, is placed on low bed with half side rails and bed and mobility alarms. A Fall Risk Assessment, updated on 3/2/12/12 identified the resident as a high risk for falls related to intermittent confusion, history of 1-2 falls in the past three months, chair bound, inability to assess gait, takes 3 to 4 medications that may place the resident at further risk for falls and 1-2 predisposing diseases that may contribute to fall risk factors. The therapy progress notes dated 3/13/12 documented the resident tends to lean forward on his/her wheelchair, tried wedge cushion today, but still falls forward. On 3/28/12 nursing staff documented on the admission care plan the bed alarm removed. On 3/30/12 nursing staff documented on the admission care plan when placed in electric recliner in room, please place controls in pocket of recliner and make sure call light within reach. Additionally, the care plan documented a non-displaced right clavicle fracture, monitor site for increased signs and symptoms of pain and monitor for nonverbal indicators of pain. The nurse's notes dated 3/26/12 on the 7-3 shift documented the resident continued to have periods of lethargy. The nurse's notes on 3/28/12 documented the bed alarm was removed. Remains on low bed with half side rail. No longer risk for exiting bed. Staff A, Assistant Director of Nursing (ADON) signed the notes. The clinical record lacked assessment and/or evaluation for safety with use of an electric recliner with remote. The nurse's notes on 3/30/12 reflected the following: At 9:30 a.m., the staff found the resident lying on the floor on right side in front of the electric lift recliner. The resident had an approximate 5 centimeter (cm) raised area with approximately 2.5 cm dark purple bruise in the center (right temple area). Staff repositioned the resident onto back and range of motion (ROM) performed which identified the extremities within normal limits (WNL). The resident had slight grimacing with ROM of the right upper extremity. Staff observed the right shoulder swelling. The staff assisted the resident up with 2 into bed. Ice applied to right temple area and right shoulder. The staff notified the physician and received an order to have the right elbow and shoulder x-rayed. A portable x-ray of the resident's right shoulder, dated 3/30/12 identified extensive degenerate changes noted in the humeral head and joints. The x-ray identified a subtle non displaced fracture of the clavicle. A resident/accident report dated 3/30/12 at 9:20 a.m., documented the occurrence in the resident ' s bedroom involved an electric lift chair. Mobility status prior to the incident/accident indicated to be assisted by 2. Type of injury; hematoma (bruise), swelling. Physician and family notified. The nurse's notes dated 4/2/12 at 10:15 a.m. indicated the resident complained of discomfort to the right shoulder. The resident received routine analgesics along with scheduled narcotic analgesic patch. The resident now required a mechanical lift to transfer. A quarterly incident report dated March 2012 indicated the second fall occurred when a resident (Resident #2) pushed the buttons on his/her lift chair and raised the chair and he/she fell out. The resident sustained [REDACTED]. The facility educated the staff to ensure the resident's safety and to keep the remote to the chair out of the resident's line of sight. Review of a document signed by the Assistant Director of Nursing (ADON) on 7/19/2012 at 12:35 p.m. revealed the family brought the electric recliner to the facility. The document indicated no formal evaluation of safety was completed. At 1:00 p.m. on 7/19/2012 the ADON continued to state all residents are assessed for safety at admission in regards to placement in bed and wheelchair. This assessment continues informally if new chair/equipment is introduced. There was no formal assessment made but, no concerns were brought forward in regards to the lift chair prior to 3/30/12. Physically the resident was safe and appropriate in the lift chair, however, fluctuations in mental status affected his/her decision making when utilizing the remote. This ultimately led to the fall. On 7/23/12 at 2:05 p.m., Staff L, Certified Nursing Assistant/Restorative aide was interviewed and stated she assisted Resident #2 on 3/30/12 to the electric recliner and recalled the resident had the remote control to position self independently. On 7/23/12 at 2:45 p.m., Staff J, Certified Nursing assistant, was interviewed and stated she recalled Resident #2 would ""play" with the control button of the electric recliner. The MDS quarterly assessment dated [DATE] lacked evidence of a fall with significant injury that occurred at the facility on 3/30/12.

Based on observation, record review and staff and resident interviews, the facility failed to prevent the development of a pressure sore by improper placement of a bed pan (Resident #1) and failed to reassess and evaluate pressure areas which did not see improvement (Resident #2, #11 and #12). The sample consisted of 4 residents and the facility reported a census of 56 residents. The facility reported a census of 56 residents. Findings include: 1. Resident #1 had an admission order from the physician on 6/4/2012. The orders identified the following Diagnosis: [REDACTED]. The facility nursing admission assessment and skin reports dated 6/4/12 documented the resident ' s skin on the coccyx and buttocks as intact, without redness. The MDS assessment, with a reference date of 6/10/12 documented the resident had an admission from an acute hospital on [DATE]. The MDS documented a BIM's score of 15 (cognitively intact). The MDS documented the resident required totally dependent of 2 plus staff for bed mobility, toilet use, and personal hygiene. The MDS documented the resident had limitations in both sides of the upper extremities and one side of the lower extremity. The resident had an indwelling bladder catheter per physician order [REDACTED]. The resident remained continent of bowel function. The MDS documented the resident at risk of developing pressure ulcer and had a 3.0 by 3.0 with 1 cm depth pressure ulcer with slough (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). The Pressure Ulcer Care Area Assessment (CAA) report dated 6/11/12 documented on 6/10/12 the resident developed a Stage 3 to the coccyx. The Urinary Incontinence and Indwelling Catheter CAA report dated 6/11/12 indicated on 6/5/12, a Foley re-inserted due to urine soiled episode of the brace. No bed pans are to be used for bowel movements due to pressure areas noted on coccyx on 6/10/12 The Braden Scale (test to determine risk of pressure ulcers) was performed on 6/4/12 and identified the resident at a moderate risk for the development of pressure ulcers. The Braden Scale identified a score of 14. A score of 13-14 identified a moderate risk. The Braden Scale updated on 6/11/12 identified a score of 18 which indicated a mild risk (15-18). The admission care plan dated 6/21/12 documented the resident had an open area to the coccyx and listed interventions including but not limited to: #3. Assist with repositioning every 2 hours and as needed (prn). The clinical record lacked documentation of repositioning the resident every 2 hours and as needed. #6. See skin sheet regarding open area of the coccyx. See dietary consults. Thin [MEDICATION NAME] to site. Multimix and house supplement. Multivitamin with zinc. Low air mattress and RoHo cushions. On 6/20/2012 the treatment was changed to aqua cell, increased house supplement and to administer Keflex (an antibiotic) as ordered. On 6/29/12 an appointment was set up with the wound center. On 7/11/12 the Wound center directed the facility to irrigate the wound with normal saline and apply silver alginate [MEDICATION NAME] and return in 2 weeks. The admission care plan dated 6/21/12 indicated the resident would have a bowel movement every third day and listed interventions including but not limited to: #6. Place resident on commode for adequate bowel evacuation. The nurse's notes dated 6/10/12 at 2:15 p.m., documented approximately a 3 cm by 3 cm open area noted on the coccyx area. The area had a whitish color with red surrounding tissue and left edge black in color. The staff sent a fax to the physician. The pressure ulcer assessment sheets documented: Stage III: Full thickness skin loss involving damage to or necrosis (dead tissue) of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue. Found on admission: No. The Initial assessment dated [DATE] identified a 3 by 3 cm with 0.1 cm depth, Stage III wound. Slough - yes. Eschar (thick, leathery, frequently black or brown in color, necrotic or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Pain - yes. Description; 3 cm wound - yellow black tissue to left edge of area. Subsequent assessment dated [DATE] described the wound as 3 by 2 cm with 0.1 depth, Stage III wound. Necrotic tissue - yes. Slough - yes. Eschar - yes. [DIAGNOSES REDACTED] (red and/or swelling) - yes. Pain - yes. Description; area 3 by 2 cm, white yellow tissue with 0.1 cm blackened area in crater. Subsequent assessment dated [DATE] described the wound as: 3 by 1.5 by 0.8 cm, Stage III wound. Necrotic tissue - yes. Slough - yes. Eschar - yes. Purulent (yellowish colored drainage, malodorous, resembling pus. [DIAGNOSES REDACTED] - yes. Maceration (softening of skin) - yes. Pain - yes. Subsequent assessment dated [DATE] described the wound as: 3 by 1.5 by 1 cm, Stage III wound. Necrotic tissue - yes. Slough - yes. Eschar - yes. Purulent drainage - yes. [DIAGNOSES REDACTED] - yes. Maceration - yes. Pain - yes. Subsequent assessment dated [DATE] described the wound as: 2.8 by 1.8 by 1.0 cm, Stage III wound. Necrotic tissue - yes. [DIAGNOSES REDACTED] - yes. Pain - yes. Subsequent assessment dated [DATE]: Wound center 6/29/12, treatment changed. 2.0 by 2.0 by 0.6 cm, Stage III wound. Slough - yes. [DIAGNOSES REDACTED] - yes. Pain - yes. Subsequent assessment dated [DATE] described the wound as: 2 by 2 by 0.6 cm, Stage III wound. Undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin) - yes. Maceration - yes. (Shearing- is the interaction of both gravity and friction against the surface of the skin. Friction is always present when shear force is present. Shear occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. Pain - yes. Subsequent assessment dated [DATE] described the wound as 2 by 2.1 by 0.5 cm, Stage III wound. Slough - yes. Exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. It may contain serum, cellular debris, bacteria and leukocytes. Pain - yes. Maceration - yes. physician's orders [REDACTED]. The June, 2012 Medication Administration Records (MAR) documented the resident received a narcotic [MEDICATION NAME] pain medication per request for complaints of coccyx pain on the following dates: 6/23/12 at 1:45 a.m., 6/23/12 at 8:30 p.m., 6/24/12 at 1:30 a.m., 6/25/12 at 1:30 a.m., 6/26/12 at 1:40 a.m., 6/26/12 at 9:50 p.m., 6/28/12 at 2:00 a.m., and 6/30/12 at 1:00 a.m. The discharge instructions from the Wound Healing Center dated 6/29/12 at 12:15 p.m., documented in part to Off Load, up for meals, hygiene only! Review of documentation provided to the survey team by Staff A, Assistant Director of Nursing (ADON) and Staff B, Registered Nurse (RN)/CCDI-Memory Unit Director, and dated 7/16/12 revealed: On 6/10/12, 2:15 p.m. the resident noted to have a 3 by 3 cm open area on coccyx with whitish colored surrounding tissue; left edge noted to have black eschar. Area noted when resident was taken off the bedpan. Staff educated to not place the resident on bedpan and to use bedside commode for bowel movements. Foley catheter in place. On 6/13/12 staff in serviced on proper bedpan placement per DON (Director of Nursing). Observation and resident interview on 7/17/12 at 7:05 a.m. revealed the resident seated upright in a wheelchair in his/her room. The resident stated, "There is a bed sore that was there because somebody put a bed pan in backwards, that's what I was told. It is very sore, it was very deep and it is very painful. It's been a long time ago. It was after I got here, I don't know for sure." Following the observation and interview, Staff G, Certified Nursing Assistant (CNA) entered the resident's room to provide assistance with propulsion of a wheel chair down the hallway to the dining room. Resident #1 stated to Staff G, "I don't know whether I should have told the truth about the bed sore or not." Staff G stated to the resident, "You always tell the truth." Observation during a pressure ulcer dressing change on 7/17/12 at 9:56 a.m., revealed Staff N, Licensed Practical nurse (LPN) removed the dressing located on the coccyx. Staff N described and identified the dressing as malodorous. At 9:58 a.m., Staff N stated the coccyx wound measured 1.8 centimeters (cm) by 2 cm, with 0.6 cm depth. Staff N described the center of the coccyx wound as whitish with a thin layer of slough (necrotic/avascular tissue in the process of separating from viable portions of the body and is usually light colored, soft, moist, and stringy at times) and the surround tissue was light red colored surrounded by a white edge. Staff N stated there was no active drainage and the odor resembled a moisture smell and/or yeasty. At the time of the dressing change the resident denied pain Staff N directed the surveyor to a sign posted on the wall above head board of the resident's bed stating "NO Bedpans Please" and a resident care agenda sheet posted on the bathroom wall stating "NO BED PAN" in red colored ink. The sign and resident care agenda sheet lacked date and time of the implementation. During a follow up interview on 7/22/12 at 3:15 p.m., the resident stated, "I did not have a sore on my bottom when I came here, I got it after being here a few days. I hurt very much. I've never had pain like this before, it's worse than having a baby. Nobody here knows what happened to me or that's what they're saying and I'm not going to let anybody think it's my fault." On 7/23/12 at 11:00 a.m., Staff H, Registered Nurse (RN) was interviewed and stated the clinical record lacked evidence that nursing assistant staff are repositioning the resident every 2 hours. On 7/23/12 at 11:05 a.m., Staff A was interviewed and acknowledged that Resident #1 clinical record lacked evidence that nursing and Certified Nursing Assistant staff repositioned the resident every 2 hours. Staff A stated residents who required assistance with repositioning should be assisted by nursing and certified nursing assistant staff every 2 hours. Additionally Staff A said, "This would be my expectation and standard." During an interview on 7/23/12 at 1:57 p.m., Staff B explained the facility lacked documentation of incident report regarding placing a bedpan incorrectly underneath Resident #1. Staff B stated, "I'm not doubting that the bed pan was not a contributing factor to the pressure area that resulted on the 10th." Staff A said facility policy directed nursing staff that anytime a skin condition develops an investigation and review in quality assurance would be conducted. Staff B continued, "Obviously, we dropped the ball on this facility acquired pressure ulcer." We have already put in place changes in wound conditions, investigations and quality assurance regarding skin documentation." On 7/24/12, at 9:25 a.m., the prior DON was interviewed by telephone and acknowledged Staff N brought the incorrect placement of a bed pan to her attention and the development of the open area with a dark edge on 6/10/2012. The prior DON stated, " this was a facility acquired pressure area that occurred after the resident had been placed (Resident #1) was placed on a bed pan and my assumption was the bed pan contributed to the pressure ulcer, definitely." He/she said, "(Resident #1) was predisposed to pressure areas because of immobility issues." The prior DON explained the standard of care for residents who required assistance with repositioning would be turning and repositioning every 2 hours and both the CNA's and nurses would be expected to turn and reposition Resident #1 every 2 hours but this would not be documented in the clinical record." During a telephone interview on 7/24/12 at 11:00 a.m., Staff N stated CNA staff G and E reported they removed a fracture bed pan, that had been placed incorrectly, under Resident #1 and when the bed pan was removed from the resident's buttock region, the resident complained of pain and voiced feeling uncomfortable upon removal. Additionally, Staff N stated when the CNA's asked him/her to assess the buttock region of the resident the CNA's stated it was a "bad area" and they did not know the amount of time the resident sat on the incorrectly placed bed pan. Staff N acknowledged he/she failed to complete an incident report and also stated the improper bed pan placement "caused the ulcer." During a telephone interview on 7/24/12 at 12:30 p.m., Staff E stated he/she answered the resident ' s call light on 6/10/2012. Staff E stated when he/she and Staff G rolled the resident to his/her side they noticed the bed pan improperly placed under the resident's buttock region, and the coccyx region laid directly on the hard surface of the improperly placed bed pan. Staff E stated when they removed the bed pan they "saw the area was red, and questioned whether it was opened." Staff E stated after they completed peri care, the resident's buttock region the area was "red" and "white in the center." Staff E reported the incident to Staff N immediately. During a telephone interview on 7/24/12 at 2:20 p.m., Staff G recalled the improperly place bed pan incident on 6/10/12. Staff G stated when he/she and Staff E answered the resident's call light; they found the bed pan under the resident "backwards". Staff G stated, the resident ' s buttock and coccyx region laid directly on "rough edge" of the bed pan. Staff G stated the resident did have a bowel movement and after they completed peri care, he/she automatically put the call light on to obtain the nurse (Staff N). Additionally, Staff G stated the resident was at risk for pressure areas due to limited mobility and limitations in repositioning due to the orthopedic brace on the resident's right leg. Staff G acknowledged they turned and repositioned the resident every 2 hours but this would not be recorded. Staff G stated, "In the past, repositioning used to be documented in the nurse's notes." Review of a facsimile dated 7/30/12 from the physician at the Wound Healing Center indicated certainly any significant pressure over a specific body area over 30 minutes can cause tissue injury and if fact the amount of pressure is minimal, things such as a bed pan, doughnut, even sitting on the side of the bed or recliner or a hard chair for more than 30 minutes in certain situations can create potential for the development of a stage I leading to more deep tissue. 2. The admission care plan dated 2/23/12 identified Resident #2 with a risk for impaired skin related to an abraised (a rubbed or scraped area on skin) areas to left buttock (on admission). The facility documented the areas would be resolved by 5/23/12. The area did not heal and the staff updated the goal date. The care plan directed nursing staff to monitor skin with cares, report changes to the doctor and attempt to prevent shearing with repositioning and transfer. The nurse's notes dated 5/5/12 reflected during skin assessment this morning, the resident ' s buttocks noted to be reddened right and left as well as top of buttock crack. Areas to right and top are just reddened. Left buttock is showing some shearing and is tender. A fax sent to the doctor requesting a new treatment Nursing staff documented on a fax dated 5/5/12 the resident's coccyx/upper buttocks reddened and close to opening. The staff requested an order for [REDACTED]. The nurse's notes from 5/6/12 to 6/26/12 lacked documentation of the status of the skin areas on the resident ' s left and right buttocks. The nurse's notes dated 6/26/12, at 1:00 a.m. documented a prescription ongoing with [MEDICATION NAME]; both buttocks remain with pink superficial skin, both buttocks have no open areas. Left buttock remains slightly sorer than right buttock. The nurse's notes from 6/26/12 to 7/16/12 lacked documentation of the status of the skin areas on the resident ' s left and right buttocks. The nurse's notes dated 7/17/12 documented new order received to discontinue [MEDICATION NAME] to buttocks TID and to apply a thin layer of critic-aide paste to buttocks until healed TID. The nurse's notes dated 7/18/12 documented resident has 2 oval, 10 centimeter (cm) red area on each buttock. The resident had a new order for critic-aide paste to be applied. Treatment Application Records (TAR's) dated 5/7/12 through 7/17/12 documented nursing staff applied [MEDICATION NAME] to buttocks TID. The skin report sheets and clinical record lacked evidence nursing staff notified the doctor for stagnation in healing and/or lack of resolution from the onset date of 5/5/12 to 7/15/12. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated butt hurts". Observation of assessment and administration of a topical treatment medication on 7/17/12 revealed: At 3:25 p.m. Staff I, Licensed Practical Nurse (LPN) entered Resident #2 room to assess the resident's bilateral reddened areas on the buttocks and gluteal crease. Resident #2 laid supine in bed with his/her eyes opened. At 3:30 p.m. Staff J, Certified Nursing Assistant (CNA) provided full assistance to position the resident on left side. Staff I, stated the size of the reddened/irritated areas on the left buttock measured 7 centimeters (cm) by 2 and 1/2 cm in diameters and the right buttock measured 5 cm by 2 and 1/2 cm. Staff J stated, "Both areas are bright red and excoriated in appearance." At 3:34 p.m. Staff J applied [MEDICATION NAME] topical cream to the resident's bilateral buttocks. Resident #2 denied pain at the time of the assessment and application of the topical cream. The pharmacological guideline "[MEDICATION NAME] Protectant Paste" documented if...symptoms do not get better within 7 days or if they get worse, check with your doctor. On 7/19/12 at 9:15 a.m. Staff S, the facilities consulting pharmacist was interviewed and stated "[MEDICATION NAME] should never be used for 3 months, it is only supposed to be used for about 7 days and the doctor should be notified if there's no improvement." Staff S, explained that nursing staff are responsible for updating the physician if there is no improvement of the skin when [MEDICATION NAME] is applied and another medication and/or ointment should be evaluated. Additionally, Staff S stated nursing staff are responsible for updating the physician to determine if the skin should be reassessed for the presence of an infection or irritation that should be treated with another medication either oral and/or topical. Staff S stated, "Nurses in this case, should have contacted a physician to review and reassess the resident's skin breakdown." On7/19/12 at 9:30 a.m., Staff F, LPN was interviewed and stated facility nursing staff received training to access (alterations in skin integrity) including red and/or excoriated areas weekly to determine if there are no changes or improvements of the status in one week to 10 days they (nursing staff) will ask the doctor to assess for further options of treatment. On 7/19/12 at 10:15 a.m., Staff B, Registered Nurse/Director of the CCDI (Dementia unit) was interviewed and stated facility nursing staff received training to assess excoriated or red areas frequently and/or more than required weekly assessments with dressing changes or cares. Additionally, Staff B stated he/she would expect treatments to show effectiveness in a week and if no changes or improvements (in skin areas) he/she would expect (facility nursing staff) would notify doctor and seek further options for wound and/or excoriated or red areas." On 7/23/12 at 8:30 a.m., Resident # 2 laid in bed, positioned on his/her left side with pillows. The resident was awake, alert to person, place and time. The resident ' s voice seemed soft and spoke clearly. The resident stated he/she had pain in his/her bottom (buttocks - gluteal fold) all the time and it hurt when the nurses are cleaning his/her bottom or when he/she is sitting up for a long time or when he/she is wet or had a bowel movement (in the incontinent pad)." 3. According to the Minimum Data Set (MDS) assessment tool dated 6/20/12 Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the resident demonstrated both short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS documented the resident as dependent of 2 staff for mobility, dressing, toilet use and personal hygiene. The Physician order [REDACTED]. The fax dated 10/29/10 revealed the initial date when the physician ordered the antifungal with thin layers of Calazyme as a [MEDICATION NAME] treatment. The care plan dated 6/28/12 directed the staff to attempt to prevent shearing of the resident's skin when repositioned or transferred. The care plan directed the staff to monitor the skin and report changes to the physician. The care plan directed the staff to apply the physician ordered treatment of [REDACTED]. The Braden Scale dated 6/19/12; evaluated and documented the resident scored an 8 and identified the resident as a severe pressure sore skin risk. The Nutrition assessment dated [DATE] documented the resident's perineal area as red, excoriated most of the time and on 6/25/12 documented the bottom as redness and sheared. The Nurse's Notes, Physician Orders, and Skin Reports reviewed from 5/27/12 through 7/19/12 revealed the facility failed to evaluate and to assess the physician ordered [MEDICATION NAME] tid treatment as identified by the pharmaceutical product recommendations for Calazyme. 4. According to the Minimum Data Set (MDS) assessment tool dated 6/28/12, Resident #12 had [DIAGNOSES REDACTED]. The MDS documented the resident demonstrated both short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS documented the resident as dependent of 2 staff for mobility, dressing, toilet use and personal hygiene. The care plan dated 7/05/12 directed the staff to monitor the resident's skin and to continue the [MEDICATION NAME] use of the physician ordered Calazyme (a skin protective paste used for moisture and minor irritation) treatment. The Braden Scale for skin assessment dated [DATE] documented the resident scored a 12 on the assessment that identified the resident as a high risk. The Physician order [REDACTED]. Dietary Progress Notes dated 4/5/12 documented the resident's skin as intact and on 7/2/12 described the skin as fragile but intact. The Skin Report dated 4/27/12 identified a new excoriated area located at the top of the coccyx. The report documented the area as intact and measured at .4 x .1 with no depth. The report documented on 5/9/12 the area as intact with 2 very small circular areas, not measurable and healing. The report documented on 5/15/12, the area as intact with a 1 inch slit and bigger than previous. On 5/22/12 the report documented the area as intact 1 inch surface tissue slit and healing. On 6/5/12 the report identified the area as healed. The report revealed from 5/15/12 the area larger in size and a 14 day duration of the treatment Calazyme used without the facility reassessment of the area documented. During an interview on 7/19/12 at 9:15 a.m. Staff S, the facilities consulting pharmacist stated, "[MEDICATION NAME] should never be used for 3 months, it is only supposed to be used for about 7 days and the doctor should be notified if there's no improvement."

Based on record review and staff interviews, the facility failed to ensure 1 of 6 residents reviewed for falls received adequate supervision and failed to plan for and direct the nursing services are met to meet the resident ' s needs (Resident #1). The facility reported a census of 52 residents. Findings include: 1. The Admission Record sheet dated 11/8/10, identified Resident #1 had an admission date of [DATE]. Resident #1 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) Assessment, with a reference date of 12/29/10, reflected the resident required extensive assistance of 2 staff for transfer, toilet use and personal hygiene. The MDS indicated the resident's Basic Interview for Mental Status scored 11 points with concerns identified with repetition of three words, temporal orientation and memory recall. The MDS assessment documented the resident had 2 falls with no evidence of injury, no complaints of pain and no change in resident behavior since admission. The Nurse ' s Notes dated 1/21/00 at 1:30 AM documented the staff heard a loud noise and ran to the resident's room at 11:20 PM this evening. The resident laid on the floor next to the head of the bed. The note indicated the resident stated "I didn't think it was so far down and I could stand". The staff checked the resident ' s vitals. The blood pressure registered at 112/50. The assessment revealed: range of motion times 4 extremities, flexion and extension times 4, strong and equal grips bilateral, small skin tear noted and documented. The skin tear edges approximated with steri strips applied. Resident denied hitting head but neurological examination started. The vital signs stable. Resident continued to deny pain or discomfort except for right knee "achy". An ice pack was applied but acetaminophen denied/refused by resident, no swelling, bruises or redness noted. The resident could bear weight without complaint of discomfort or pain. The resident used a commode before getting back into bed without complications or pain. The Nurse's Notes dated 1/22/11 at 9:15 AM documented the resident voiced pain with weight bearing to the right knee. The note indicated range of motion determined to be normal without complaint of pain. The assessment indicated the upper thigh muscle tight and voiced complaints of pain when touched. The physician was contacted and ordered an x-ray to the right leg. The Nurse's Notes dated 1/22/11 at 11 AM indicated staff notified the physician of the fractured femur. The physician ordered to send the resident to the hospital. The Portable X-Ray report dated 1/22/11 indicated a slight distraction of the fracture fragment. This is unchanged stable since prior study. However there is an obliquely oriented fracture of the midshaft of the femur which is thought to represent a new finding. Impression: apparent fracture of the midshaft of the femur. The Nurse's Notes dated 1/22/10 at 7 PM indicated the resident ' s POA ( Power of Attorney ) stated the resident ' s surgery planned for Monday or Tuesday and more than likely need to do a bone graft and insert a plate and/or wiring to repair the bone. The hospital Operative Report records dated 1/27/11, noted Resident #1 had surgery and had an open reduction internal fixation of the right superconductor and femoral shift fractures. The report identified the procedure as an extremely complicated fracture. The patient already had a femoral rod placated for previous hip fracture. The new fracture occurred around the rod. This made fixation difficult and challenging. A large amount of time was necessary to reduce the fracture and hold it with appropriate hardware. The hospital discharge and transfer form indicated the resident returned to the facility on [DATE] with orthopedic skilled nursing services needed. The Nurse's Notes dated 1/31/2011 at 11:30 AM indicated the resident was readmitted to the Memory Care unit, at the facility, via an ambulance at 11:15 AM. The Care Plan updated through 4/3/11, and in place at the time of the incident, directed staff to place the resident in a low bed with 1/2 rails with bed and mobility alarms The Incident Report dated 1/21/11 indicated Resident #1 was found on the floor of his/her room; staff heard loud noise, ran down hall and saw the resident on floor at head of the bed. The report did not indicate if the bed alarm worked. The facility statement documents; Certified Nursing Assistants signed activities of daily living sheet each shift prior to the incident stating that the alarms were on/working for the proceeding weeks prior to the incident. When staff were questioned regarding Friday 1/21/11, all interviewed stated they did not have any concerns regarding Resident #1's alarm during that shift. The bed pad had a 180 day warranty and was put in use 7/29/10. The facility procedures regarding maintenance checks on batteries: monthly check of alarm function and replacement of battery if indicator light shows that battery is low. All alarm batteries replaced a minimum of every 90 days. Nursing staff to monitor indicator light and replace batteries in between if needed. Battery was replaced by maintenance on 1/8/11. When alarm was checked after incident on 1/21/11 it was noted that there was no battery in place. Battery was replaced and alarm tested and functioned within normal limits. The Certified Nursing Aide activities of daily living check off report documentd the alarms for Resident #1 were not checked on the 3 PM to 11 PM shift on 1/21/11. During an interview on 2/16/11 at 10 AM, Staff A stated she/he worked the 7 AM to 3 PM shift on 1/21/11 and checked the bed alarm utilized by Resident #1. Staff A stated she/he normally checked the alarms while getting the resident up in the morning and when getting out of bed. The resident would usually get up in the morning and go to breakfast and then spend the rest of the day in the recliner in the day room. Staff A stated the alarm functioned properly when she/he got Resident #1 up the morning or 1/21/11. To her knowledge know one replaced the battery in the alarm on 1/21/11. During an interview on 2/16/11 at 2:55 PM Staff B stated she/he worked the 3 PM to 11 PM shift in the memory unit on 1/21/11. Staff B stated did rounds at 10:30 PM with the on coming Certified Nursing Assistant. Staff B stated she/he was not the staff member who did the rounds with the 11 PM to 7 AM Certified Nursing Assistant on 1/21/11. During a subsequent interview at 9:15 PM Staff B stated she/he was the Certified Nursing Assistant that put Resident #1 to bed on 1/21/11 and stated could not remember if the bed pad alarm worked when she/he put the resident to bed in the evening. During an interview on 2/16/11 at 2:40 PM, Staff C stated she/he worked the 3 PM to 11 PM shift on 1/21/11 in the memory unit. Staff C stated she/he was the staff member who did rounds at 10:30 PM with the oncoming Certified Nursing Assistant. When she/he had completed her shift Resident #1 was in bed sleeping with the bed in the lowest position, call light close to resident's hand on the bed and 1/2 side rails in an up position. The bed pad alarm was not checked because Resident #1 slept. During an interview on 2/16/11 at 3:20 PM Staff D stated she/he as the charge nurse during the 3 PM to 11 PM shift in the memory unit. Staff D stated the Certified Nursing Assistants normally do rounds with the oncoming Certified Nursing Assistant around 10:30 PM. Rounds were completed on 1/21/11 and nothing unusual reported to her/him by the Certified Nursing Assistants. During an interview on 2/16/11 at 10:25 PM Staff E stated she worked 10:30 PM to 7 AM on 1/21/11 for the memory unit. Staff E stated rounds are done with another Certified Nursing Assistant when her/his shift begins. About 10:35 PM on 1/21/11 she exited the resident ' s room. The resident was dry (not incontinent) and the bed in lowest positron, 1/2 side rails up but she had no knowledge if the bed alarm was functioning. Staff E stated normally she/he checked alarms throughout the shift. The alarms were not checked at 10:30 PM shift change on 1/21/11. During an interview on 2/16/11 at 10:50 PM, Staff F stated she/he worked the 11 PM to 7 AM shift on 1/21/11 when Resident #1 had the fall in his/her room. When the Certified Nursing Assistants do round at 10:30 PM the alarms should be checked. Staff F stated was in room 414 when heard a boom from a resident ' s room and an alarm did not sound. Observation revealed both half bed side rails in a up position and the bed in a low position. Staff F performed an assessment on Resident #1 and notified the physician of the incident. The neurological assessment was initiated and determined the resident moved all extremities without complaint of pain. Staff F stated observed no reason or signs or symptoms of a femur fracture as the resident had no complaints of pain, able to bear weight with the assistance of 2 staff persons and able to transfer from the floor. The resident could use the commode without pain. The resident ' s vital signs were stable throughout the shift and resident continued to be able to bear weight throughout the shift. Staff F denied any knowledge as to why the bed alarm did not have a battery. There was no battery found in the resident's room. Staff F stated a battery was replaced into the alarm device. The resident did have a complaint of pain to the right knee and ice was applied to the knee. The resident described pain as an "old ache", right foot turned inwards due to Parkinson's disease and no bruising or swelling noted. On 1/16/11 at 12:35 PM, Staff G was interviewed and stated he/she performed monthly alarm checks. Staff G stated on 1/8/11 the battery was replaced on the Medline pad alarm. The alarm check he/she did on 1/8/11 was the quarterly check. The monthly check consisted of checking the indicator light on the unit and to make sure the alarm worked and change battery as needed. On the quarterly check the battery would be replaced automatically regardless of the status of the indicator light on the alarm. Staff G further stated he had no knowledge of who, when or where the battery was removed from the Medline alarm pad alarm belonging to Resident #1. On 2/16/11 at 9:40 AM the Maintenance Director was interviewed and stated on 1/8/11 Staff F checked and changed the battery for the alarm for Resident #31. The Maintenance Director identified this to be the scheduled date to check this alarm. Maintenance personnel check all alarms which use a battery every month and on an as needed basis. Every 3 months the battery would be replaced no matter what condition of the battery. The Maintenance Director stated had checked the garbage cans and did not find the battery missing from the resident's pad alarm on the evening of 1/21/11. The Maintenance Director stated had also checked with the nursing staff and the battery had not been found. The alarm functioned after the battery was replaced. Resident #1 was interviewed 2/17/11 at 10 AM and stated he/she remembered the falll while tried to get out of bed and forgot to ask for help. The resident identified the leg as fine now.