Every finding on record at Lakeside Lutheran Home

Based on record review and staff interview, the facility failed to ensure residents who used psychotropic drugs received a Gradual Dose Reduction (GDR), unless clinically contraindicated, 2 times the first year, in 2 separate quarters (with at least one month between the attempts) unless the provider documented the rationale for 1 of 5 residents (Resident #5) and once a year after for 1 of 5 residents (Resident #1). The facility reported a census of 39 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 12 on the Brief interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included anxiety disorder. The resident received multiple high risk medications including an antianxiety.The Care Plan revised 7/19/25 identified Resident #1 used anti-anxiety medication related to anxiety disorder. The interventions included giving anti-anxiety medications ordered by the physician and monitoring/documenting side effects and effectiveness. The February 2026 Medication Administration Record (MAR) showed Resident #1 received Buspirone (antianxiety) 10 mg at noon, afternoon, and bedtime every day with a start date of 8/5/24 A letter to the Physician from the Pharmacist dated 7/3/25 documented the use of central nervous system medications was always a potential area of concern to state regulators. The letter asked the physician to please review Resident #1's medications to determine future use. It was recommended to only make one major medication change at a time so they knew the effect of each medication change.The letter inquired about GDR for Buspirone 10 mg 3 times a day, Melatonin (hormone affecting sleep) 10 mg every day, and Olanzapine (antipsychotic) 10 mg every day. A check marked GDR to decrease melatonin to 5 mg at bedtime. A check also marked under a GDR not being indicated due to other medication being changed. The clinical record lacked a rationale why a GDR would be contraindicated for the psychotropic medications. On 2/24/26 at 4:27 p.m. the Director of Nursing (DON) stated she saw the provider had decreased melatonin but not the psychotropics. She talked to the pharmacist about not putting the melatonin with the psychotropic medications. Resident #1 did have one of his psychotropic medications decreased after a hospitalization. The antianxiety had not been addressed. On 2/26/26 at 12:15 p.m. the DON verified they did not have a policy regarding psychotropic medications. They followed the regulation. 2) According to the MDS assessment dated [DATE], Resident #5 scored 14 on the BIMS indicating no cognitive impairment. The resident's diagnoses included anxiety disorder, bipolar disorder, and post traumatic stress disorder. The resident received multiple high risk medications including antipsychotic, antianxiety, and antidepressant medication. The Care Plan dated 4/13/25 identified Resident #5 used antidepressant medication related to Bipolar disorder, and borderline personality. The Care Plan identified the resident anti-anxiety medications related to anxiety disorder. Interventions included giving anti-anxiety medications ordered by the physician, monitoring/documenting side effects and effectiveness. Antianxiety side effects included drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Paradoxical side effects included mania, hostility and rage, aggressive or impulsive behavior, and hallucinations. The Care Plan identified the resident used psychotropic medications, antipsychotic related to behavior management. Interventions included consulting with pharmacy, and physician to consider dosage reduction when clinically appropriate. The Physician's Orders printed 2/26/26 included:Perphenazine 4 mg, 2 tabs 4 times a day dated 4/9/25.Trazadone 50 mg, give 1/2 tab at bedtime dated 4/8/25.Risperidone 0.5 mg, give 1/2 tab 3 times a day. dated 4/8/25.Divalproex 500 mg, give 2 tabs 3 times a day. dated 4/8/25. The Medication Administration Record for October 2025 showed the resident received Quetiapine 400 mg, 2 tablets in the evening initiated 4/8/25 and continued 10/29/25, after receiving Quetiapine 400 mg 1 time on 10/28/25. A letter to the Physician from the Pharmacist dated 10/31/25 documented the use of central nervous system medications was always a potential area of concern to state regulators. The letter asked the physician to please review Resident #1's medications to determine future use. It was recommended to only make one major medication change at a time so they knew the effect of each med change. The letter inquired about GDR for Quetiapine (antipsychotic), Trazadone (antidepressant), Divalproex (anticonvulsant), Risperidone (antipsychotic), and Perphenazine (antipsychotic). The provider responded no changes, with no rationale given. On 2/25/26 the DON confirmed the provider did not give a rationale for no GDR on for the psychotropic medications.

Based on observation, record review and staff interview, the facility failed to complete the Minimum Data Set (MDS) assessment accurately for 2 of 13 residents reviewed (Resident #19 and #31). The facility reported a census of 39 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #19 scored 6 on the Brief interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's diagnoses included heart failure, renal insufficiency, and chronic respiratory failure. The MDS documented the resident had an indwelling urinary catheter.On 2/23/26 at 3:30 p.m. Resident #19 sat in her recliner and had no catheter.The Care Plan dated 2/23/26 identified Resident #19 had mixed bladder incontinence related to diuretic therapy. Interventions included the resident used disposable briefs.The Care Plan lacked documentation the resident had a catheter.The Progress Notes dated 9/12/25 documented Resident #19 admitted skilled after right hip fracture repair, with a catheter. The Progress Notes dated 9/15/25 at 12:37 p.m. documented receipt of an order to discontinue the urinary catheter. At 12:50 p.m. a nurse removed the resident's urinary catheter.The Progress Notes dated 9/16/25 at 3:36 p.m. documented the resident voiding without concerns after the was catheter removal.On 2/25/26 at 1 p.m. the MDS Coordinator stated she marked the MDS incorrectly (regarding the catheter). On 2/25/26 at 5 p.m. the Administrator stated the MDS should be coded accurately. They did not have a policy for coding them accurately. 2) According to the MDS assessment dated [DATE], the facility marked no to question A1500 indicating Resident #31 was not considered by the state level 2 Preadmission Screening and Resident Review (PASRR) process to have serious mental illness. A Notice of PASRR Level 1 Screen Outcome dated 11/8/23 documented Resident #31 Level 1 positive, with no status change. The PASRR .showed the resident had evidence of a serious mental illness. The services identified in the previous PASRR remained appropriate. Since the evaluation determined the resident the resident had a PASRR condition, the facility should mark yes to question A1500 on the MDS. On 2/24/26 at 1:10 p.m. the Social Services Supervisor stated they coded Resident #31's MDS incorrectly regarding PASRR.

Based on record review and staff interview the facility failed to immediately separate an alleged abuser from all potential victims. The facility reported a census of 34 residents. Finding's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 09:10 a.m. documented Resident #1 accused the bath-aide of being rough and rushing her during shower (she pinched her breast with the gait belt, and jammed the toothbrush in her mouth). On 5/20/25 at 9:30 a.m. Staff B Certified Nursing Assistant (CMA) stated Resident #1 told her that Staff A Certified Nursing Assistant (CNA) was rough in the bath. Her boob got pinched when she applied the bath chair safety belt. Staff A refused to turn the jets on. She also jammed the toothbrush in her mouth. Staff B went to the charge nurse, who was from a temp agency. Together they called the Director of Nursing (DON). They made Staff A work away from the resident. On 5/19/25 at 3:20 p.m. the DON said Staff A was taken off of baths and moved to north hall away from Resident #1 on Saturday, worked Sunday, and was suspended on Monday. The facility undated Abuse Prevention, Identification, Investigation and Reporting Policy documented upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility should immediately implement measures to prevent further potential abuse of residents from occurring while the investigation was in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents.

Based record review and staff interview, the facility failed to ensure residents were allowed to choose schedules, clothing, or bathing preferences for 2 of 4 residents reviewed (Resident #1 and #4). The facility reported a census of 34 residents. Findings include: 1.) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Care Plan identified the resident had an activity of daily living self care performance deficit. The interventions included she required one staff assistance for completion of bathing. The Progress Notes dated 4/26/25 at 9:10 a.m. documented Resident #1 accused the bath-aide Staff A Certified Nursing Assistant (CNA) of being rough and rushing her during shower and making her wait on her jewelry, commenting she didn't have time to pamper her right then. An undated note titled Staff B Certified Medication Aide (CMA)'s Statement documented the resident said Staff A refused to use the jets (in the whirlpool) and would not pamper her the same as everyone else. A note titled Resident #1's Statement with the Administrator and Director of Nursing (DON) included the resident said when Staff A put her in the bath she didn't turn the bubbles on and she said she didn't have time for them. A note titled Staff A's Statement included the resident said something about bubbles. Staff A told resident #1 she couldn't [NAME] around, she had other resident's baths to do. On 5/19/25 at 1 p.m. Resident #1 stated Staff A was mean. She said Staff A wanted to do her bath last, but they told her it had to be done before breakfast. She took her to the bath and only filled it up to her knees and would not run the jets. Staff A said she didn't have time for that. On 5/20/25 at 12:24 p.m. Staff A stated that morning they kept bringing people to her for a bath, and pressing her to get them done. She was told she was not doing them fast enough. So she didn't turn on the jets so the baths wouldn't take so long. 2) According to the MDS assessment dated [DATE], Resident #4 scored 15 on the BIMS indicating no cognitive impairment. The resident required substantial to maximal assistance with upper/lower body dressing, and was dependent for transfer to bed. The resident's diagnoses included heart failure and morbid obesity. The Comprehensive MDS assessment dated [DATE] documented it was somewhat important for Resident #4 to choose what he wanted to wear and choose his own bedtime. The Care Plan dated 4/1/22 identified the resident had altered respiratory status related to obstructive sleep apnea and used a Continuous Positive Airway Pressure (CPAP) machine at night. The Care Plan dated 2/20/24 identified the resident had a psychosocial wellbeing problem or potential related to illness/disease process and decline in health, but mentally aware. Interventions included allowing him time to answer questions and to verbalize feelings, perceptions, and fears, and encouraging participation from resident who depends on others to make own decisions. Explain all procedures, all changes, rules, and options. The Care Plan revised 4/1/22 identified the resident had an ADL self care performance deficit related to limited physical mobility. Interventions included total mechanical lift with assist x 2 for all transfers. A Disciplinary Action Report dated 9/16/24 documented on the weekends of 9/2/24 and 9/11/24 the specific work rule identified resident rights. Staff A made the resident go to bed at 8 p.m. and wear a gown after he asked not to. Staff A put the resident's CPAP on wrong and wouldn't listen to the resident. A note Written by Staff B Certified Nursing Assistant (CMA) and attached, included the resident reported to her that Staff A made him go to bed at 8 p.m. Staff A told him he had to wear a hospital gown because he was passing a lot of gas and they couldn't have that and that was why he had to be put in bed. She also put his CPAP on wrong and he tried telling her. No, he didn't want to go to bed and he didn't wear a gown. But she wouldn't listen. The report was signed by the Director of Nursing (DON) and Staff A. On 5/20/25 at 12:24 p.m. Staff A stated she did not recall the write up. On 5/22/25 at 11:45 p.m. the DON stated Staff A signed the write up with no rebuttal. The facility undated Resident's [NAME] of Rights included self-determination. The resident had the right to and the facility must promote and facilitate resident self- determination through support of resident choice, including but not limited to: The resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident.

Based on record review and staff interview, the facility failed to notify the physician, and the resident's representative immediately of a resident's allegation of rough treatment for 1 resident (Resident #1). The facility reported a census of 34 residents. Findings's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 9:10 a.m. documented Resident #1 accused the bath-aide (Staff A Certified Nursing Assistant (CNA) of being rough and rushing her during shower (her breast got pinched with a gait belt, and jammed toothbrush in her mouth). The resident also complained of pain in her breast radiating to the back of her shoulder, feeling weak, and unable to walk. The resident assisted to her room via wheelchair. Vital Signs and Blood Sugar checked and within normal limits. No evidence of injury noted to left breast at this time. Would continue to monitor. The Director of Nursing (DON) notified of the incident. An Incident Report dated 4/26/25 documented the resident stated Staff A was rough with her during her bath on Saturday. She pinched her breast while she had her in her shower chair with the shower chair belt, jammed her toothbrush into her mouth and wouldn't turn the jets on. The Physician notified on 4/28/25 at 11:53 a.m. the Administrator notified on 4/28/25 at 7:56 a.m. and the family notified on 4/28/25 at 12 p.m. A fax dated 4/28/25 notified the physician of Resident #1's allegation. On 5/21/25 at 4:20 p.m. the DON confirmed the physician and resident representative were notified 4/28/25. They should have been notified the day the resident reported it.

Based on record review and staff interview the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of an allegation of potential abuse within the required time frame for 1 resident reviewed (Resident #1). The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 09:10 a.m. documented Resident #1 accused the bath-aide of being rough and rushing her during shower (she pinched her breast with the gait belt, and jammed the toothbrush in her mouth). On 5/20/25 at 9:30 a.m. Staff B Certified Nursing Assistant (CMA) stated Resident #1 told her that Staff A Certified Nursing Assistant (CNA) was rough in the bath. Her boob got pinched when she applied the bath chair safety belt. Staff A refused to turn the jets on. She also jammed the toothbrush in her mouth. On 5/19/25 at 3:20 p.m. the (DON) said Staff A was taken off of baths and moved to north hall away from Resident #1 on Saturday, worked Sunday, and was suspended on Monday. On 5/22/25 at 11:45 a.m. the Administrator stated they reported to the state on 4/28/25, and confirmed they had not reported the incident to the state agency (DIAL) timely. The facility undated Abuse Prevention, Identification, Investigation and Reporting Policy documented all allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation was made, if the events that caused the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that caused the allegation involved neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of resident property, but do not result in serious bodily injury.

Based on record review and staff interview the facility failed to ensure appropriate transfer techniques to prevent injury for 1 of 3 resident's reviewed (Resident #6). The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #6 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The resident required partial to moderate assistance with sitting to standing. The resident's diagnoses included cancer, anemia, atrial fibrillation, and heart failure. The Care Plan dated 7/24/24 identified the resident had an activity of daily living self care performance deficit related to weakness and cancer. The interventions included the resident had chronic pain at varied levels, and having 2 staff present with cares and mobility, may help with gentle moving and tasks to alleviate pain. The Progress Notes dated 10/7/24 at 11:06 a.m. documented Resident #6 had skin tears to his right forearm The surrounding skin was warm and dry, and blood noted from each skin tear. The areas measured: a. 4 cm by 1cm, b. 2.5 cm by 1 cm, c. 2 cm by 1 cm. Op-site (clear dressing) applied to each area. Education provided to staff on not grabbing the resident's arms because he had fragile skin. A Disciplinary Action Report dated 10/7/24 documented Staff A Certified Nursing Assistant (CNA) violated a specific work rule by grabbing Resident #6's wrist instead of the gaitbelt, resulting in skin tears to his right forearm. Staff A signed the report. On 5/22/25 at 11:55 a.m. the Director of Nursing (DON) stated Staff A signed the disciplinary action with no rebuttal.

Based on clinical record review, staff interviews, and facility record review, the facility failed to provide adequate fall follow up and pain assessments after a fall for 1 of 1 residents reviewed (Residents #35). The facility reported a total census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #35 documented diagnoses of non-Alzheimer ' s Dementia, non-traumatic brain dysfunction (a complex condition that occurs when the brain is damaged by internal factors, rather than an external force to the head), restlessness and agitation. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognition. The MDS revealed Resident #35 was independent with transfers, was substantial/maximal (helper does more than half the effort, helper lifts or holds trunk or lungs and provides more than half the effort) with upper and lower body dressing, and partial/moderate (helper does less than half the effort. helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) assistance with putting on/taking off footwear. Review of facility reported incident dated 11/22/24 revealed Resident #35 was walking with staff around the living area and crossed one foot over the other and caught her sock/slipper and fell . Resident #35 bumped her head on the cabinet. Resident #35 was alert and disoriented at the time of the fall, which is her normal status. Resident #35 was assessed and assisted to a standing position, her sock/slippers were removed and gripper socks were applied. Review of the incident report under the predisposing situation factors improper footwear was not marked. Review of resident Care Plan with initiated date of 11/13/24 intervention revealed to ensure that Resident #35 was to be wearing appropriate footwear when ambulating or mobilizing in a wheelchair and required the assistance of one staff member for dressing. Review of resident Care Plan with initiated date of 11/22/24 intervention revealed to wear gripper socks or shoes when up. Review of facility Progress Notes revealed the facility failed to assess resident after the fall on these dates: On 11/22/24 at 16:45 PM revealed that Resident #35 refused to allow staff to do neurological assessment. On 11/22/24 at 19:59 PM revealed Resident #35 refused blood pressure (BP) to be taken for a fall neurological assessment. On 11/22/24 at 23:45 PM revealed Resident #35 refused BP to be taken. On 11/23/24 at 19:50 PM revealed Resident #35 had no behaviors reported as of this time. On 11/23/24 at 23:46 PM revealed Resident #35 refused BP to be taken. Review of facility Follow Up Assessment revealed on: On 11/23/24 at 11:46 PM this assessment was incomplete. On 11/23/24 at 1:20 AM this assessment was incomplete. On 11/24/24 at 10:53 PM this assessment was incomplete. On 11/25/24 at 7:55 AM this assessment was incomplete. Review of facility provided document titled Fall Risk Assessment for Resident #35 dated 11/6/24 scored a 5 indicating moderate risk for falls. Review of facility provided document titled Fall Risk assessment dated [DATE] scored a 9 indicating moderate risk for falls. Review of facility provided document titled Fall Risk assessment dated [DATE] scored a 20 indicating high risk for falls. Review of Progress Notes dated 11/27/24 at 4:58 AM revealed Resident #35 was wandering in the hallway crying and awakening peers. Resident #35 sits on her bed rocking back and forth and grabbing at imaginary items on the floor. Resident #35 refuses to answer staff when questioned and is inconsolable. The staff walked with the Resident #35 and encouraged her to communicate why she is crying. Resident #35 continued to sit on bed rocking back and forth and not responding to staff at this time. Review of Progress Notes dated 11/29/24 at 10:04 AM revealed Resident #35 complained of right leg pain. Review of Progress Notes dated 11/30/24 at 3:44 PM revealed Resident #35 does seem to be having pain but unable to identify where pain is located. Resident #35 is utilizing two staff for assistance with transfer. Review of Progress Notes dated 12/1/24 at 12:45 PM revealed Resident #35 appears to have pain but unable to identify where pain is located. Resident #35 was given as needed acetaminophen which seemed effective. Review of Progress Notes dated 12/2/24 at 10:46 AM revealed Resident #35 had been having right leg pain, no bruising, redness, swelling, no rotation to her leg noted. Resident #35 needed help to get out of bed and chairs. Resident #35 needed assistance from one person for walking. Resident #35 does not want to place all of her weight on her leg. Resident #35 does have a limp and has facial grimacing when getting up. States the longer she walks the steadier and even her gait is. Resident #35 had been walking independently prior to the leg pain. Resident #35 has been utilizing her as needed acetaminophen. A fax was sent to the physician. Review of the MD/Nursing Communication form on 12/2/24 at 10:51 AM was a copy of the progress note as above. The communication to the physician lacked notification that Resident #35 had fallen previously. Review of Progress Notes dated 12/2/24 revealed the facility received orders for a physical therapy referral for right leg pain. Review of Progress Notes dated 12/3/24 at 9:44 AM revealed Resident #35 had been walking with assistance of one staff person. Resident #35 continued to complain of pain to her right leg. Staff gave as needed acetaminophen to help with the pain. Review of the Physical Therapy Treatment Encounter note dated 12/5/24 revealed Resident #35 was having a very hard time weight bearing on the right lower extremity and having a lot of facial grimaces and grabbing of the right hip. Resident #35 limited in her hip active and passive range of motion due to pain and requires a moderate assist of 2 staff members. Physical Therapy recommends nursing staff get a hold of the doctor for the x-ray of her right hip due to her fall and presentation today. Review of Progress Notes dated 12/5/24 at 3:21 PM revealed a fax was sent to the physician requesting an order for an x-ray of the right leg per request of Physical Therapy (PT). Review of Progress Notes dated 12/6/24 at 12:25 PM revealed the facility received an order for Resident #35 to have an x-ray of her right leg, at 2:46 PM the facility received the results of the x-ray. Review of the x-ray report dated 12/6/24 revealed a mildly displaced subcapital right femoral neck fracture. At 3:45 PM Resident #35 was transferred to the emergency room and admitted to the hospital to have right hip surgery. On 1/23/25 at 11:45 AM interview with Staff H, Licensed Practical Nurse (LPN) revealed that Resident #35 didn't complain of pain right away. Staff H revealed she wasn't working when she started to complain of pain. On 1/23/25 at 12:15 PM interview with Staff B, Registered Nurse (RN), revealed that she was called into the unit and the staff stated someone was walking with Resident #35 and she bumped her head on the cabinet. Staff B revealed that she was sitting on the floor with her back against the wall. Staff B revealed that she did an assessment on Resident #35 and assisted her off the floor. Staff B stated that Resident #35 was able to ambulate at that time and did not show any signs of pain. Staff B stated that they are to do fall documentation on every shift times 8 shifts and if it is an unwitness fall, they are to do neurological assessments every 15 minutes x 4, every 30 minutes x 4, every 1 hour x 4 and every 4 hours x 4. Staff B stated that they are also to do a Skilled Nursing Facility (SNF) nursing note and notify physician and family. On 1/23/25 at 2:00 PM Staff C, Certified Medication Aid (CMA)/Certified Nursing Assistant (CNA) and Staff G, CNA, revealed that if they would try to move Resident #35 she wouldn't be able to stand, they don' t remember any crying episodes. They don't remember when she started showing signs of pain. They stated they reported it to the nurse and they stated the nurse gave her pain medication and would notify the physician. On 1/23/25 at 10:30 AM the Director of Nursing (DON) revealed the facility did not to an internal investigation regarding Resident #35's right hip fracture. The DON revealed her expectation would be to have nursing staff do follow up fall documentation for 72 hours and to document pain, and anything that is different than the normal for the resident, if gait is steady. On 1/23/25 at 2:00 PM the MDS Coordinator revealed the expectation is to document and assess the resident, talk to staff and see what may have prevented the fall. Staff are to document every shift for 72 hours. Staff are to do neuro's if the fall was unwitnessed and if the resident is refusing neuro's to notify the physician. Staff are to document range of motion, gait, ambulation, and vital signs. If there is a change in condition, the expectation would be to notify the physician. Staff are to document the interventions for the fall. The MDS Coordinator revealed that Resident #35 had fuzzy socks on due to family bringing them in so they had them removed and educated staff. The MDS coordinator stated that new interventions get passed on in the huddles during the morning and afternoon shifts from the communication sheets and staff also have access to the kardex in the electronic health record. Review of the undated facility policy titled Fall Policy revealed: Immediate Response: Upon discovery of a fall: do not move resident until vital signs and range of motion (ROM) are done. Assessment: Immediate resident assessment: Take vital signs Note any ROM issues and complaints of pain. Treat any injuries Use a lift for extensive assistance Call for an ambulance if needed Complete Neuro checks for unwitnessed falls Complete Risk Management Report Follow up Actions: Unusual Occurrence Assessment: Initiate a skin sheet if there's an injury. Follow up after fall: Conduct follow ups every shift for 72 hours (include interventions and pain assessment) Care plan update: Update the care plan to reflect new interventions. Communication: Notifications: Inform the Family, Director of Nursing (DON), Administrator, and Physcian

Based on personnel time card records and staff interview, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data. The facility reported a census of 39 residents. Findings include: The facility Payroll Based Journal (PBJ) Staffing Data Report for fiscal year quarter 4 2024 (July 1 - September 30) showed an area of concern triggered. The facility failed to have licensed nursing coverage 24 hours a day on 7/5, 7/6, 7/7, 8/2, 8/10, 8/11, 8/15, 8/24, 8/25, 9/7, 9/8, and 9/22/24. The facility provided time card information for facility staff working the days above, and agency staffing invoices documenting agency staff working the same day above, showing the facility had a nurse on 24 hours per day. On 1/22/25 at 5:02 p.m. the Administrator provided documentation they had 24 hour staffing on the days that were lacking on the PBJ report. She understood this needed to be reported accurately.

Based on personnel record review, staff interviews and policy review the facility failed to provide appropriate screening prior to employment for 2 of 5 employees reviewed for background checks. The facility did not receive approval for the employee to work after the criminal background check revealed the employees had a past criminal history. The facility reported a census of 39 residents. Findings include: 1. The personnel file for Staff E, (Certified Nursing Assistant) documented a start date of 7/29/24. The Single Contact License and Background Check (SING) dated 7/15/24 indicated a criminal history record was found and required further research. The Iowa Criminal History results revealed Staff E had been charged with operating while intoxicated, 1st offense. The personnel file for Staff E lacked documentation that a record check evaluation was conducted and an approval to work was obtained through the Iowa Department of Human Services. Review of current nursing schedules revealed Staff E was an active CNA at the facility. 2. The personnel file for the active DON (Director of Nursing) documented a start date of 5/13/24. The Single Contact License and Background Check (SING) dated 5/3/24 indicated a criminal history record was found and required further research. The Iowa Criminal History results revealed the DON had been charged with operating while intoxicated, 1st offense. The personnel file for the DON lacked documentation that a record check evaluation was conducted and an approval to work was obtained through the Iowa Department of Human Services. During the survey, the DON was actively working. On 1/23/25 at 12:20 PM, the Administrator reported the facility did not have any documentation indicating the employees had been approved to work. She stated since it has been more than 30 days since the background checks had been completed the facility was not able to obtain any additional information from the Iowa Department of Human Services. The Business Office Manager (BOM) was present and reported after the facility received the criminal background check history, the facility did not do anything further. The Administrator acknowledged the facility abuse policy did not address screening of new employees or completing background checks. The Administrator reported she did not have any other policies or procedures that address completing background checks. A facility policy title (facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. The policy failed to include direction on screening of new employees and when/how to conduct background checks on new employees.

Based on clinical record review, staff interviews and policy review, the facility facility failed to protect a resident from verbal and physical abuse by a staff member for 1 of 12 residents reviewed for abuse (Resident #24). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #24 dated 12/10/24 identified a Brief Interview for Mental Status (BIMS) score of 03, indicating severely impaired cognition. The MDS identified Resident #24 was dependent on staff for bed mobility, toileting and transfers. The MDS documented Resident #24 had physical and verbal behavioral symptoms directed toward others 1 to 3 days per week. The MDS included diagnoses of hypertension (high blood pressure), pneumonia, diabetes mellitus, Alzheimer's disease, cerebrovascular accident with hemiplegia (stroke affecting one side), non-Alzheimer's dementia, anxiety, depression and adjustment disorder with mixed disturbance of emotions and conduct. The Care Plan with a revised date of 12/4/24 documented Resident #24 had behavior problems related to anxiety and revealed Resident #24 may yell or strike out at staff who provide care. The Care Plan directed the following interventions: -Staff to approach and explain the care that was going to be provided. Staff to give Resident #24 choices as needed. If Resident #24 irritated or agitated, staff to attempt to learn why. Staff to address Resident #24 personal needs such as pain, hunger and temperature. Staff to offer diversional activities and topics such as travel, fishing, working as a mechanic and farmer. Staff to use firm kindness and not to argue with Resident #24. -If reasonable, staff to discuss Resident #24 behavior and explain why the behavior was not appropriate and unacceptable. - Staff to intervene as necessary to protect the rights and safety of others. Staff to approach and speak in a calm manner and divert attention. Staff to remove Resident #24 from the situation and take to alternate locations as needed. On 1/16/25 at 1:50 PM, Staff A, CNA (Certified Nursing Assistant) reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone to Resident #24's room to check his blood sugar. Resident #24 attempted to bite Staff B and Staff A helped stop him by grabbing his hand and when she did, he pulled his head away from Staff B. Staff B stated, If you bite me I will knock all the teeth out of your mouth and raised her hand to strike him. Staff A responded Hey and Staff B put her hand down. On 1/16/25 at 2:10 PM, Staff B, RN reported when she got angry she might say she wanted to hit something but had never said anything to a patient. Staff B stated she thought she should take up boxing to help her get rid of some frustrations. Staff B said she would never say she wanted to hit something in a patient's room, she stated she had said it at the desk. Staff B said she had been a nurse for [AGE] years and would never want to hit a patient. An Incident Report titled Alleged Neglect dated 1/16/25 at 5:18 PM documented a state official reported to nursing that a nursing staff yelled and raised a hand at Resident #24. The immediate action was the staff member was suspended. A hand written statement completed by Staff C, CMA (certified medication aide) dated 1/16/25 documented he was down South and heard Staff B, RN say to Resident #24 if you hit me, I ' m going to smack you back. Staff C documented the incident happened in front of the nurses station where Resident #24 was parked before the staff brought him down for meals. A handwritten statement completed by Staff A, CNA dated 1/20/25 documented she was in Resident #24's room and Staff B, RN came into the room. Staff B grabbed Resident #24's finger and he went to put his mouth on Staff B's hand. Staff B raised her hand. Staff A documented she told Resident #24 to hold still and let Staff B get his blood. Staff B put down her hand and said if you bit me I will knock every tooth out of your mouth. Staff A documented later on Staff B was at the nurses station telling everyone there what she said to Resident #24 that morning, I will knock every tooth out of your mouth. On 1/21/25 at 10:30 AM, Staff C, CMA reported the statement written on 1/16/25 was about a previous incident that had happened. Staff C reported he had heard Staff B say to Resident #24, if you hit me, I'm going to smack you back. He reported it happened when Staff B was trying to obtain Resident #24's blood sugar in front of the nurses station where Resident #24 sat before going down for meals. Staff C reported he did not say anything to anyone about what he had heard. He reported he did not think Staff B would actually hit someone. Staff C reported he did not think any other staff members were around or heard it. He said the aides were down the hallways. He reported Staff B claimed that she liked to joke around. Staff C stated he did not remember the exact date the incident happened but thought it was either on a weekend or a Friday as that was when he worked as a medication aide with Staff B. He reported Staff B does get frustrated at times. He said one time when the aides had reported a resident had fallen and Staff B was needed in the resident room, she said, God Damn and then slammed the medications down on the medication cart. Staff C also reported he had seen Staff B smack her fist down on the table when she got frustrated. He said Staff B does not like to work by herself and gets upset when there was not a second nurse. On 1/21/25 at 12:45 PM, Staff A, CNA reported she had gone back, looked at the schedule and determined the incident occurred on Monday,1/6/25 as she was giving baths that day and Resident #24 was scheduled for the bath. She stated she took the bath chair into the room with her and was going to get him up. She stated Staff B, RN came into the room to get Resident #24 blood sugar. She stated Staff B leaned over Resident #24, grabbed his hand and he tried to bite her. Staff A reported Staff B told Resident #24, Don't you dare bite me, I am going to knock every tooth out of your mouth. She stated Staff B raised her right hand in the air like she was going to slap him but she did not. She stated Staff B did not explain what she was going to do prior to trying to get his blood sugar. Staff A reported she was able to get Resident #24 to calm down and he did let Staff B do the blood sugar. She stated Staff D, CNA heard noises coming from outside the room and she came in. Staff A reported she told Staff D what had happened. Staff A reported Staff B was at the nurses station later on repeating what she had said to Resident #24. On 1/21/25 at 2:30 PM, Staff D, CNA reported on 1/6/25 she had heard some noise coming from Resident #24's room and she went into the room to see if they needed any help. She stated Resident #24 was having his normal behaviors which was hitting and yelling. She stated Staff A, CNA and Staff B, RN were in the room and were either trying to get Resident #24's blood sugar or give medications. Staff D stated she was not sure which one but she knew something with nursing was taking place as Staff B was in the room. She stated she left the room and later returned to help Staff A transfer Resident #24 into the shower chair. Staff D stated later around lunch time Staff A had told her that the way Staff B was talking to Resident #24 made her uncomfortable. Staff D said she told Staff A that if it made her uncomfortable that she needed to report it. Staff D reported Staff A did not tell her what it was that Staff B had said that made her uncomfortable. Staff D reported Staff B was not nice to the staff. She stated Staff B would talk about staff behind their backs. The untitled, undated, unsigned investigation summary provided by the facility on 1/21/25 documented on 1/16/25 a state surveyor entered the building regarding a complaint against Staff B, RN towards Resident #24. The summary revealed Staff B was suspended pending investigation on 1/16/25 when the Director of Nursing (DON) was informed of the allegation. On 1/22/25 at 7:20 AM, the Administrator reported she learned of the abuse allegations on 1/16/25. She stated she was out of the building and got a text that the nurse was being walked out and suspended. She stated the DON started the investigation on 1/16/25. On 1/22/25 at 7:52 AM, the Administrator said she would expect staff to make sure the resident was safe and not in danger, report the allegations of abuse to the nurse or supervisor immediately, follow up/make sure the allegations were taken care of and if not tell someone else or report to the state themselves. A facility policy titled ( facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by the following: a. Not using verbal, mental, sexual and physical abuse, corporal punishment, or involuntary seclusion. b. Not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. c. Reporting any knowledge of actions by a court of law against an employee for service as a Nurse Aide, or other nursing facility staff to the State Nurse Aide Registry of Licensing Authorities. d. Ensuring that all alleged violations involving mistreatment, neglect, or abuse including, injuries, injuries of unknown source, and misappropriation of resident property are reported to officials in accordance with Federal and State laws and also to the Administrator, DON, and the Resident Services Director. e. Providing evidence that all alleged violations are thoroughly investigated and thereby preventing further potential abuse while an investigation is in process. f. Reporting results immediately to the State Survey Agency g. Taking corrective action in cases where alleged abuse is verified.

Based on staff interview, personnel record review, facility investigation review, and policy review the facility failed to notify DIAL (Department of Inspection, Appeals and Licensing) of an alleged verbal and physical abuse for Resident #24 that occurred on 1/6/25 at 7:00 AM in a timely manner. The CNA (Certified Nursing Assistant) reported she told the DON (Director of Nursing) of the allegations of abuse later that afternoon on 1/6/25. The DON denied being told or hearing of the allegation of abuse. The facility investigation for the alleged abuse was initiated on 1/16/25 after DIAL entered the facility and notified the DON of the allegations. The facility reported the incident to DIAL on 1/16/25 at 3:34 PM. The facility reported a census of 39 residents. Findings include: On 1/16/25 at 1:50 PM, Staff A, CNA reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone to Resident #24's room to check his blood sugar. Resident #24 attempted to bite Staff B and Staff A helped stop him by grabbing his hand and when she did, he pulled his head away from Staff B. Staff B stated, If you bite me I will knock all the teeth out of your mouth and raised her hand to strike him. Staff A responded Hey and Staff B put her hand down. Staff A reported Staff D, CNA had come into Resident #24's room right after the incident because she had heard raised voices. Staff A reported she had told Staff D what had happened and Staff D told her that it was inappropriate and to tell the DON. Staff A reported it was a really busy day so she told the DON around 3 PM and the DON said she would deal with it. When asked if the DON had done anything, Staff A reported she never went back to follow up. Staff A reported she had worked the following weekend and Monday and Staff B had also worked the weekend. Staff A reported she had also told Staff E, another CNA about the incident. On 1/16/25 at 2:10 PM, Staff B, RN reported when she got angry she might say she wanted to hit something but had never said anything to a patient. Staff B stated she thought she should take up boxing to help her get rid of some frustrations. Staff B said she would never say she wanted to hit something in a patient ' s room, she stated she had said it at the desk. Staff B said she had been a nurse for [AGE] years and would never want to hit a patient. Review of the document titled Intake revealed the facility filed allegation of abuse with DIAL for Resident #24 on 1/16/25 at 3:34 PM. An Incident Report titled Alleged Neglect dated 1/16/25 at 5:18 PM documented a state official reported to nursing that a nursing staff yelled and raised a hand at Resident #24. The immediate action was that a staff member was suspended. A hand written statement completed by Staff C, CMA (Certified Medication Aide) dated 1/16/25 documented he was down South and heard Staff B, RN say to Resident #24 if you hit me, I ' m going to smack you back. Staff C documented the incident happened in front of the nurses station where Resident #24 was parked before the staff brought him down for meals. The untitled and unsigned facility investigation summary provided by the facility on 1/21/25 documented on 1/16/25 a state surveyor entered the building regarding a complaint against Staff B, RN towards Resident #24. It was reported Staff B was reported to have an allegation of abuse and it was reported to the DON and nothing was done. The summary documented the incident had not been reported to the Administrator at any time. The summary revealed Staff B was suspended pending investigation on 1/16/25 when the DON was informed of the allegation and an incident report was filed with DIAL. A facility form titled Disciplinary Action Report dated 1/20/25 for Staff A, CNA documented the violation occurred on 1/6/25 as Staff A did not report alleged abuse immediately so it could be reported to DIAL. Staff A, CNA stated she watched Staff B raise her hand and yell at the resident. Staff A did not turn into supervisor immediately, which is policy, so the incident can be reported within 2 hours. The form was signed by the DON and Staff A on 1/20/25. On 1/21/25 at 10:30 AM, Staff C, CMA reported the statement written on 1/16/25 was about a previous incident that had happened. Staff C reported he had heard Staff B say to Resident #24, if you hit me, I'm going to smack you back. He reported it happened when Staff B was trying to obtain Resident #24's blood sugar in front of the nurses station where Resident #24 sat before going down for meals. Staff C reported he did not say anything to anyone about what he had heard. He reported he did not think Staff B would actually hit someone. Staff C reported he did not think any other staff members were around or heard it. He said the aides were down the hallways. He reported Staff B claimed that she liked to joke around. Staff C stated he did not remember the exact date the incident happened but thought it was either on a weekend or a Friday as that was when he worked as a medication aide with Staff B. He reported Staff B does get frustrated at times. He said one time when the aides had reported a resident had fallen and Staff B was needed in the resident room, she said, God Damn and then slammed the medications down on the medication cart. Staff C also reported he had seen Staff B smack her fist down on the table when she got frustrated. He said Staff B does not like to work by herself and gets upset when there is not a second nurse. On 1/21/25 at 11:31 AM, Staff E, CNA reported she had heard from Staff A, CNA that Staff A and Staff B, RN were getting Resident #24 up and Staff B said to Resident #24, I will knock out all of your damn teeth out of your mouth, if you try to bite me again. She said Staff A reported Staff B raised her right fist in the air. Staff A reported she thought it had happened on a Thursday and she heard about it the following day when she was working on 1/10/25. Staff E reported Staff A told her that she had reported the incident to the DON. Staff E reported Staff B had been mean before. When asked what she meant by mean, Staff E stated Staff B was not directly mean to the residents but would talk about them at the nurses station. On 1/21/25 at 12:45 PM, Staff A, CNA reported she had gone back, looked at the schedule and determined the incident occurred on Monday,1/6/25 as she was giving baths that day and Resident #24 was scheduled for the bath. She stated she took the bath chair into the room with her and was going to get him up. She stated Staff B, RN came into the room to get Resident #24's blood sugar. She stated Staff B leaned over Resident #24, grabbed his hand and he tried to bite her. Staff A reported Staff B told Resident #24, Don't you dare bite me, I am going to knock every tooth out of your mouth. She stated Staff B raised her right hand in the air like she was going to slap him but she did not. She stated Staff B did not explain what she was going to do prior to trying to get his blood sugar. Staff A reported she was able to get Resident #24 to calm down and he did let Staff B do the blood sugar. She stated Staff D, CNA heard noises coming from outside the room and she came in. Staff A reported she told Staff D what had happened. Staff A reported Staff B was at the nurses station later on repeating what she had said to Resident #24. Staff A reported she could not recall who else was sitting at the nurses station. She stated later that week, she thought on Friday,1/10/25, Staff E, CNA asked her about the incident so she told Staff E what had happened. Staff A reported she had told the DON about the incident later that day on Monday 1/6. She stated the DON was busy and she was not sure the DON totally understood what she was talking about. She stated the DON told her that she would look into it. On 1/21/25 at 2:30 PM, Staff D, CNA reported on 1/6/25 she had heard some noise coming from Resident #24's room and she went into the room to see if they needed any help. She stated Resident #24 was having his normal behaviors which was hitting and yelling. She stated Staff A, CNA and Staff B, RN were in the room and were either trying to get Resident #24's blood sugar or give medications. Staff D stated she was not sure which one but she knew something with nursing was taking place as Staff B was in the room. She stated she left the room and later returned to help Staff A transfer Resident #24 into the shower chair. Staff D stated later around lunch time Staff A had told her that the way Staff B was talking to Resident #24 made her uncomfortable. Staff D said she told Staff A that if it made her uncomfortable that she needed to report it. Staff D reported Staff A did not tell her what it was that Staff B had said that made her uncomfortable. On 1/21/25 at 3:20 PM, The DON reported she found out about the allegations of abuse the day DIAL entered the facility for a complaint on 1/16/25. She reported that was why the date of the incident was uncertain. She stated initially she was told that the incident occurred the week before on a Thursday or Friday. She said during the facility investigation and staff interviews she identified the incident occurred on 1/6/25. She reported during the investigation she learned Staff A was in Resident #24's room getting him up for a bath. Staff B, RN came in the room and took his finger to do blood sugar, he struck out and she raised her hand. She stated the investigation was unclear on what Staff B had said in the room. She reported the location of the incident was also unclear. She stated at first it occurred at the nurses station, then in the Resident #24's room in the wheelchair and then in the room in the bed. She stated Staff B did not admit to anything. She said Staff B reported she has been in nursing for [AGE] years and had never raised a hand to a patient. When asked if Staff A had reported allegations of abuse to her, the DON stated no. She stated Staff A did not come to her office and if Staff A said anything in passing she did not hear it. The DON stated if something had been reported to her, she would have done something immediately and started an investigation. She stated the normal process was to separate/suspend, report to DIAL, start an internal investigation, and notify family/physician of the allegations. On 1/22/25 at 7:20 AM, the Administrator reported she learned of the abuse allegations on 1/16/25. She stated she was out of the building and got a text that the nurse was being walked out and suspended. She stated the DON started the investigation on 1/16/25. On 1/22/25 at 7:52 AM, the Administrator said she would expect staff to make sure the resident was safe and not in danger, report the allegations of abuse to the nurse or supervisor immediately, follow up/make sure the allegations were taken care of and if not tell someone else or report to the state themselves. Review of the facility's internal investigation lacked documentation that the police were notified of the allegations of abuse. On 1/22/25 at 4:30 PM, the Administrator reported the facility did not notify the policy of the allegations of abuse. A facility policy title (facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by the following: a. Not using verbal, mental, sexual and physical abuse, corporal punishment, or involuntary seclusion. b. Not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. c. Reporting any knowledge of actions by a court of law against an employee for service as a Nurse Aide, or other nursing facility staff to the State Nurse Aide Registry of Licensing Authorities. d. Ensuring that all alleged violations involving mistreatment, neglect, or abuse including, injuries, injuries of unknown source, and misappropriation of resident property are reported to officials in accordance with Federal and State laws and also to the administrator, DON, and the Resident Services Director. e. Providing evidence that all alleged violations are thoroughly investigated and thereby preventing further potential abuse while an investigation is in process. f. Reporting results immediately to the State Survey Agency g. Taking corrective action in cases where alleged abuse is verified. The policy further documented in cases where there was suspected or known sexual/abuse or in incidents where there is serious physical injury or incidents of theft, law enforcement should be notified first and then other sources notified. In all cases, evidence should not be handled until law enforcement has arrived.

Based on staff interviews, facility investigation review, time card detail, and policy review the facility failed to separate a staff member from dependent residents accused of alleged physical and verbal abuse that occurred on 1/6/25 at 7:00 AM for Resident #24. The CNA (Certified Nursing Assistant) reported she told the DON (Director of Nursing) of the allegations of abuse later that afternoon on 1/6/25 and the DON denied being told or hearing of the allegation of abuse. The staff member worked full shifts on 1/6/25, 1/7/25, 1/9/25, 1/11/25, 1/12/25, 1/15/25 and a partial shift on 1/16/25. The facility investigation for the alleged abuse was initiated on 1/16/25 after DIAL (Department of Inspections, Appeals and Licensing) entered the facility and informed the DON of the alleged abuse. Two staff members interviews reflected inappropriate behavior with the nurse and Resident #24. The facility reported a census of 39 residents. Findings include: On 1/16/25 at 1:50 PM, Staff A, CNA reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone to Resident #24's room to check his blood sugar. Resident #24 attempted to bite Staff B and Staff A helped stop him by grabbing his hand and when she did, he pulled his head away from Staff B. Staff B stated, If you bite me I will knock all the teeth out of your mouth and raised her hand to strike him. Staff A responded Hey and Staff B put her hand down. Staff A reported Staff D, CNA had come into Resident #24's room right after the incident because she had heard raised voices. Staff A reported she had told Staff D what had happened and Staff D told her that it was inappropriate and to tell the DON. Staff A reported it was a really busy day so she told the DON around 3 PM and the DON said she would deal with it. When asked if the DON had done anything, Staff A reported she never went back to follow up. Staff A reported she had worked the following weekend and Monday and Staff B had also worked the weekend. Staff A reported she had also told Staff E, CNA about the incident. On 1/16/25 at 2:10 PM, Staff B, RN reported when she got angry she might say she wanted to hit something but had never said anything to a patient. Staff B stated she thought she should take up boxing to help her get rid of some frustrations. Staff B said she would never say she wanted to hit something in a patient's room, she stated she had said it at the desk. Staff B said she had been a nurse for [AGE] years and would never want to hit a patient. Review of the document titled Intake revealed the facility filed allegation of abuse with DIAL for Resident #24 on 1/16/25 at 3:34 PM. An Incident Report titled Alleged Neglect dated 1/16/25 at 5:18 PM documented a state official reported to nursing that a nursing staff yelled and raised a hand at Resident #24. The immediate action was that a staff member was suspended. Review of Staff B Time Card Report dated 12/29/25 to 1/11/25 revealed Staff B worked full 12 hours shifts on 1/6/25, 1/7/25, 1/9/25 and 1/11/25. Review of Staff B Time Card Reported dated 1/12/25 to 1/15/25 revealed Staff B worked full 12 hours shifts on 1/12/25 and 1/15/25. On 1/16/25 Staff B worked a partial shift and left the facility at 2:58 PM. A hand written statement completed by Staff C, CMA (Certified Medication Aide) dated 1/16/25 documented he was down South and heard Staff B, RN say to Resident #24 if you hit me, I ' m going to smack you back. Staff C documented the incident happened in front of the nurses station where Resident #24 was parked before the staff brought him down for meals. The untitled and unsigned facility investigation summary provided by the facility on 1/21/25 documented on 1/16/25 a state surveyor entered the building regarding a complaint against Staff B towards Resident #24. It was reported Staff B was reported to have an allegation of abuse and it was reported to the DON and nothing was done. The summary documented the incident had not been reported to the Administrator at any time. The summary revealed Staff B was suspended pending investigation on 1/16/25 when the DON was informed of the allegation and an incident report was filed with DIAL. On 1/21/25 at 10:30 AM, Staff C, CMA reported the statement written on 1/16/25 was about a previous incident that had happened. Staff C reported he had heard Staff B say to Resident #24, if you hit me, I'm going to smack you back. He reported it happened when Staff B was trying to obtain Resident #24's blood sugar in front of the nurses station where Resident #24 sat before going down for meals. Staff C reported he did not say anything to anyone about what he had heard. He reported he did not think Staff B would actually hit someone. Staff C reported he did not think any other staff members were around or heard it. He said the aides were down the hallways. He reported Staff B claimed that she liked to joke around. Staff C stated he did not remember the exact date the incident happened but thought it was either on a weekend or a Friday as that was when he worked as a medication aide with Staff B. He reported Staff B does get frustrated at times. He said one time when the aides had reported a resident had fallen and Staff B was needed in the resident room, she said, God Damn and then slammed the medications down on the medication cart. Staff C also reported he had seen Staff B smack her fist down on the table when she got frustrated. He said Staff B does not like to work by herself and gets upset when there is not a second nurse. On 1/21/25 at 11:31 AM, Staff E, CNA reported she had heard from Staff A, CNA that Staff A and Staff B, RN were getting Resident #24 up and Staff B said to Resident #24, I will knock out all of your damn teeth out of your mouth, if you try to bite me again. She said Staff A reported Staff B raised her right fist in the air. Staff A reported she thought it had happened on a Thursday and she heard about it the following day when she was working on 1/10/25. She reported Staff A told her that she had reported the incident to the DON. Staff E reported Staff B had been mean before. When asked what she meant by mean, Staff E stated Staff B was not directly mean to the residents but would talk about them at the nurses station. On 1/21/25 at 12:45 PM, Staff A, CNA reported she had gone back, looked at the schedule and determined the incident occurred on Monday,1/6/25 as she was giving baths that day and Resident #24 was scheduled for the bath. She stated she took the bath chair into the room with her and was going to get him up. She stated Staff B, RN came into the room to get Resident #24 blood sugar. She stated Staff B leaned over Resident #24, grabbed his hand and he tried to bite her. Staff A reported Staff B told Resident #24, Don't you dare bite me, I am going to knock every tooth out of your mouth. She stated Staff B raised her right hand in the air like she was going to slap him but she did not. She stated Staff B did not explain what she was going to do prior to trying to get his blood sugar. Staff A reported she was able to get Resident #24 to calm down and he did let Staff B do the blood sugar. She stated Staff D, CNA heard noises coming from outside the room and she came in. Staff A reported she told Staff D what had happened. Staff A reported Staff B was at the nurses station later on repeating what she had said to Resident #24. Staff A reported she could not recall who else was sitting at the nurses station. She stated later that week, she thought on Friday,1/10/25, Staff E, CNA asked her about the incident so she told her what had happened. Staff A reported she had told the DON about the incident later that day on Monday 1/6/25. She stated the DON was busy and she was not sure the DON totally understood what she was talking about. She stated the DON told her that she would look into it. On 1/21/25 at 2:30 PM, Staff D, CNA reported on 1/6/25 she had heard some noise coming from Resident #24's room and she went into the room to see if they needed any help. She stated Resident #24 was having his normal behaviors which was hitting and yelling. She stated Staff A, CNA and Staff B, RN were in the room and were either trying to get Resident #24's blood sugar or give medications. Staff D stated she was not sure which one but she knew something with nursing was taking place as Staff B was in the room. She stated she left the room and later returned to help Staff A transfer Resident #24 into the shower chair. Staff D stated later around lunch time Staff A had told her that the way Staff B was talking to Resident #24 made her uncomfortable. Staff D said she told Staff A that if it made her uncomfortable that she needed to report it. Staff D reported Staff A did not tell her what it was that Staff B had said that made her uncomfortable. On 1/21/25 at 3:20 PM, The DON reported she found out about the allegations of abuse the day DIAL entered the facility for a complaint on 1/16/25. She reported that was why the date of the incident was uncertain. She stated initially she was told that the incident occurred the week before on a Thursday or Friday. She said during the facility investigation and staff interviews she identified the incident occurred on 1/6/25. She reported during the investigation she learned Staff A was in Resident #24's room getting him up for a bath. Staff B, RN came in the room and took his finger to do blood sugar, he struck out and she raised her hand. She stated the investigation was unclear on what Staff B had said in the room. She reported the location of the incident was also unclear. She stated at first it occurred at the nurses station, then in the Resident #24's room in the wheelchair and then in the room in the bed. She stated Staff B did not admit to anything. She said Staff B reported she has been in nursing for [AGE] years and had never raised a hand to a patient. When asked if Staff A had reported allegations of abuse to her, the DON stated no. She stated Staff A did not come to her office and if Staff A said anything in passing she did not hear it. The DON stated if something had been reported to her, she would have done something immediately and started an investigation. She stated the normal process was to separate/suspend, report to DIAL, start an internal investigation, and notify family/physician of the allegations. On 1/22/25 at 7:20 AM, the Administrator reported she learned of the abuse allegations on 1/16/25. She stated she was out of the building and got a text that the nurse was being walked out and suspended. She stated the DON started the investigation on 1/16/25. On 1/22/25 at 7:52 AM, the Administrator said she would expect staff to make sure the resident was safe and not in danger, report the allegations of abuse to the nurse or supervisor immediately, follow up/make sure the allegations were taken care of and if not tell someone else or report to the state themselves. A facility policy titled (facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by the following: a. Not using verbal, mental, sexual and physical abuse, corporal punishment, or involuntary seclusion. b. Not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. c. Reporting any knowledge of actions by a court of law against an employee for service as a Nurse Aide, or other nursing facility staff to the State Nurse Aide Registry of Licensing Authorities. d. Ensuring that all alleged violations involving mistreatment, neglect, or abuse including, injuries, injuries of unknown source, and misappropriation of resident property are reported to officials in accordance with Federal and State laws and also to the administrator, DON, and the Resident Services Director. e. Providing evidence that all alleged violations are thoroughly investigated and thereby preventing further potential abuse while an investigation is in process. f. Reporting results immediately to the State Survey Agency g. Taking corrective action in cases where alleged abuse is verified. The policy further documented the alleged abuser will be immediately suspended from work pending the completion and results of the investigation, depending on the allegation.

Based on record review and staff interview, the facility failed ensure residents on antibiotics were re-evaluated for excessive duration, for 2 of 3 residents reviewed (Resident #7 and #8). The facility reported a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including cardiorespiratory conditions and anxiety. The Care Plan revised 5/7/24 identified Resident #7 on routine antibiotic therapy for preventative measures secondary to a history of chronic urinary tract infections (UTI's). Interventions included administering medication as ordered, and taking Cephalexin daily at bedtime for prevention. Antibiotics were non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis. Observe the resident for possible side effects to antibiotic therapy. The Medication Administration Record (MAR) for January 2025 showed Resident #7 on Cephalexin 500 mg 1 capsule by mouth at bedtime for prevention related to UTI, with a start date of 4/23/22. The resident's clinical record lacked documentation the physician had re-evaluated the antibiotic for continued use. On 1/22/25 at 8:02 a.m. Resident #7 stated she had 3 bladder surgeries and went through a very difficult time. She had UTI's and drank a lot of cranberry juice. She had not had a UTI in awhile. She said she could not say what medications she took. She did not know if she took an antibiotic. On 1/23/25 at 8:48 a.m. the Pharmacy Consultant stated some people go on prophylactic antibiotics long term and some for the rest of their lives. He said the prophylactic antibiotic dose was usually a lower dose of 250 mg of Cephalexin. He would look into the residents dose of 500 mg. He had not been looking at the long term antibiotics with his med reviews. On 1/23/25 at 2 p.m. the Infection Preventionist (IP), stated she started in December of 24. She looked at Resident #7's record and the Cephalexin had not been reviewed in the last year. The undated facility Antibiotic Stewardship for Nursing Homes information documented up to 70% of nursing home residents received one or more systemic antibiotics every year. Studies showed that 40-75% of antibiotics used in nursing homes may be unnecessary or inappropriate. Risks of impairment from antibiotic overuse were high for older adults residing in nursing homes. Potential risks included infections, adverse drug reactions and colonization or infection with antibiotic-resistant organisms. 49056 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of anxiety, schizophrenia, seizure disorder, and heart failure. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. Review of the Care Plan with a revision date of 2/22/24 revealed Resident #6 on antibiotic therapy prophylactically related to history of frequent urinary tract infections and to monitor/document for side effects and effectiveness. Review of the Physician Orders revealed Resident #6 started on the prophylactic antibiotic on 10/19/23. Review of the facility Progress Notes revealed Resident #6 was to have a urology appointment on 5/5/2024. The Director of Nursing acknowledged and verified that Resident #6 did not go to this appointment and she wasn't sure why.

Based on observations, clinical record review and policy review the facility failed to give medications according to manufacturer's instructions for 1 out of 6 residents observed during medication pass (Resident #8). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #8 dated 1/13/25 identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS identified Resident #8 was independent with bed mobility, transfers and walking. The MDS included diagnoses of cerebral palsy, non-alzheimer's dementia, seizures and moderate intellectual disabilities. The January 2025 Medication Administration Record (MAR) directed staff to administer Fosamax (used to treat or prevent osteoporosis) 70 MG (milligrams) one tablet by mouth one time a week in the AM on Thursday related to specified disorders of bone density and structure. The order lacked specific directions on how the medication should be administered. On 1/23/25 at 7:58 AM, observed Resident #8 sitting at the dining room table and she had finished eating her breakfast. Staff F, CMA (Certified Medication Aide) prepared Resident #8 morning medications which included the Fosamax. The CMA administered all the medications at the dining room table with a glass of water. Staff F verified Resident #8 had finished eating breakfast when the Fosamax was given along with the other medications. Staff F reported the January MAR directed the Fosamax to be given during AM medication pass. The CMA reported sometimes Resident #8 will take her medications in her room before breakfast and other times take them in the dining room during or after breakfast. During observation with the morning medication pass on 1/23/25 with Resident #8 and review of January 2025 MAR revealed the following medications were given at the same time as the Fosamax: -Levothyroxine Sodium (treat hypothyroidism) 50 MCG (Micrograms). The Levothryroxine was scheduled on the January 2025 MAR as Early and according to manufacturer's guidelines was also to be given on an empty stomach. -Calcium Carbonate (antacids) 2 tablets in the morning for an upset stomach. -Ferrous Sulfate (Iron supplement) 325 MG one tablet in the morning. -Fluoxetine HCL (Antidepressant) 30 MG in the morning. -Vitamin D3 (supplement) 2000 IU (international units) in the morning. -Lamotrigine 25 MG 2 tablets in the morning for seizures. - Myrbetriq Extended Release 50 MG in the morning for overactive bladder. -Omeprazole Delayed Release 20 MG in the morning every other day for vomiting. -Phenytoin Sodium Extended 100 MG in the morning for seizures. -Multivitamin with minerals (supplement) 1 tablet in the morning. The Fosamax medication manufacturer's instructions instructed patients to swallow the medication whole with 6 to 8 ounces plain water at least 30 minutes before the first food, drink or medication of the day and not to lie down for at least 30 minutes after taking the medication and until after food. The manufacturer's instructions documented calcium supplement, antacids, vitamins or other oral medications can interfere with the absorption of the Fosamax. On 1/23/25 at 8:30 AM, the DON (Director of Nursing) reported she would expect the Fosamax medication to be given 1/2 hour before eating or taking any other medications and to sit up right 1/2 hour after taking the medication. An undated facility policy titled Medication Disbursement Policy documented the purpose of the policy was to establish guidelines to promote the health and safety of persons served by ensuring the safe assistance and administration of medication and treatments or other necessary procedures. The policy further documented that staff administering medication must know or be able to locate medication information on the intended purpose, side effects, dosage and special instructions. The policy directed staff to compare the medication sheet with the label of each medication for the following: right person, right medication, right time, right date, right route, right dose, and right expiration date.

Based on clinical record review and staff interviews, the facility failed to ensure resident ' s current code status was available for 1 out of 15 residents reviewed (Resident #42). The facility reported a census of 41 residents. Findings include: Resident #42 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #42 ' s MDS ' s documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), renal disease, pneumonia, thyroid disorder, anxiety and depression. The clinical record review revealed Resident #42 was admitted to the facility on [DATE]. Review of a form titled Iowa Physician Orders Scope of Treatment (IPOST) revealed Resident #42 ' s legal representative chose Resident #42 to be DNR status (Do Not Attempt to Resuscitate) with comfort measure only. The IPOST documented comfort measures included the use of medications by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. No transfer to hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in the current location. The IPOST was signed by the physician on [DATE] and by Resident 42 ' s legal representative on [DATE]. Review of Physician Orders and the Care Profile on the top of the page/screen in the clinical record lacked documentation of the DNR order or comfort measure. On [DATE] 11:30 AM, the Director of Nursing (DON) reported each resident should have their IPOST scanned in the medical record. She stated the code status should be listed at the top of the page in the medical record and also in the Physician Orders. On [DATE] at 2:05 PM, Staff B, Licensed Practical Nurse (LPN) stated if a resident was to code she would look for the resident code status at the top of the screen in the medical record. She stated if the code status was not listed there she would look for the IPOST scanned in the medical record. On [DATE] at 9:38 PM, Staff C, LPN reported if a resident was to code he would first go to the computer and look at the top of the screen for the code status. He stated if the code status was not listed there then he would look for a doctor note for more information or in the Physician Orders. He stated if he could not locate the code status he would call the Director of Nursing (DON) right away. On [DATE] at 7:45 AM, Staff D, CMA stated if a resident was to code, the first place she would look for the code status was at the top of the page in the medical record. She stated if it was not listed there she would go to the nurse. On [DATE] at 8:00 AM, the DON reported her expectation was for each resident ' s code status to be listed on the top of the screen in the medical records. She acknowledged and verified Resident #42 ' s code status was not put in the Physician Orders and was not at the top of the screen in the medical record. The DON stated the facility screwed up and she would fix it right away. She stated it was her responsibility to make sure the code status was listed. She stated that she expected the code status to be put into the physician orders on admission and to double check the order when the order/IPOST comes back signed by the physician. An undated facility policy titled Facility CPR (Cardiopulmonary Resuscitation) Policy documented each resident ' s resuscitation status will be maintained in the clinical record.

Based on clinical record review and staff interview the facility failed to notify the physician regarding a significant weight loss in 1 out of 1 residents reviewed for nutritional needs (Resident #17). The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 documented diagnosis of Alzheimer's disease, renal insufficiency, and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS indicated that Resident #17 was coded for weight loss and not on physician prescribed weight loss regimen. Review of Care Plan with a revised date of 1/9/24 revealed Resident #17 had potential for nutritional problems related to a therapeutic diet, variable intake by mouth and cognitive deficits. Review of Resident #17 ' s clinical record reviewed the following information: On 11/21/2023, the resident weighed 153.6 pounds. On 12/26/2023, the resident weighed 145.4 pounds which is a -5.34 % Loss in 30 days. Review of Resident #17 ' s clinical chart lacked documentation of the physician being notified regarding significant weight loss. Review of facility provided policy titled Weight Change/Monitoring with a revised date 10/16/08 revealed the following: Residents ' weights will be monitored weekly by the Consultant Dietitian. All significant or severe weight changes will be reported to the physician. A significant weight change sheet is filled out. The Consultant Dietitian will evaluate all weight changes on a weekly and quarterly basis. The weight will be recorded in the dietary weight record and documented over time for evaluation Interview at 2/14/24 at 11:20 a.m., with the Dietician revealed that when the weights are looked at, the Dietician then sends an email or report to the facility with recommendations and the facility is responsible to report weight loss to the physician. Interview at 2/14/24 at 4:00 p.m. with the Director of Nursing (DON) revealed the physician should have been notified of the significant weight loss.

Based on clinical record review and staff interviews the facility failed to develop a care plan to address risk factors and interventions for 1 out of 15 residents (Residents #42) reviewed for comprehensive care plans.The facility reported a census of 41 residents. Findings include: Resident #42 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #42 ' s MDS ' s documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), renal disease, pneumonia, thyroid disorder, anxiety and depression. The MDS documented Resident #42 received anticoagulant (blood thinner) medication for 7 days during the lookback period. A Physician Order dated 1/23/24 directed staff to administer Warfarin Sodium (Coumadin) (anticoagulant) 1.5 mg (milligrams) by mouth in the evening every Monday and Friday and 3 mg in the evening on Tuesday, Wednesday, Thursday, Saturday and Sunday for blood clots related to essential hypertension. Review of Resident #42 ' s Care Plan with target date of 2/5/24 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 2/14/24 at 9:30 AM, Staff E, MDS Coordinator acknowledged and verified the anticoagulant was not addressed on the plan of care. She stated she does not routinely address the anticoagulant medications on the care plan. She stated she would do an audit and address it right away. On 2/14/24 at 3:06 PM, the Administrator reported the facility does not have a care plan policy. She stated they follow CMS and state guidelines.

Based on observation, staff interview, and clinical record review the facility failed to provide appropriate catheter care for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 41 residents. Findings include: Resident #1 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #1 required partial/moderate assistance with bed mobility and substantial/maximal assistance with chair/bed to chair transfers. The MDS identified Resident #1 was dependent on staff with transfer to the toilet. The MDS indicated that Resident #1 has an indwelling catheter. Resident #1 ' s MDS included diagnoses of heart failure, hypertension, neurogenic bladder, diabetes mellitus, and schizophrenia. The Care Plan with revised date of 8/15/23 identified Resident #1 had an indwelling catheter due to atonic bladder (muscle in bladder loses it ability to contract, making emptying the bladder difficult) and flaccid neurogenic bladder (lack bladder control due to nerve damage). On 2/12/24 at 1:26 PM observed Resident #1 sitting in the recliner in her room with the catheter bag inside a dignity bag lying on the floor next to her recliner. On 2/13/24 at 12:45 PM observed Resident #1 sitting in the recliner in her room with the catheter bag inside a dignity bag hanging on the side of the garbage can. The garbage can was tipped to the side, leaning up against the recliner and the catheter bag inside the dignity bag was sitting on the floor. The catheter bag was full of urine and caused the garbage can to tip. On 2/13/24 at 1:15 PM Staff A, Certified Nursing Assistant (CNA) emptied Resident #1' s catheter bag and then hung the catheter bag inside a dignity bag on the garbage can that had garbage in it. Staff A reported she normally hangs the catheter bag on the garbage can unless Resident #1 was in bed or in the recliner. On 2/14/24 at 10:01 AM, the Administrator reported the facility does not have an indwelling catheter policy. She stated they follow the CDC guidelines. On 2/14/24 3:39 PM, the Director of Nursing (DON) reported she would expect the catheter bag not to be hung on a garbage can and not to be touching the floor. The DON stated she was looking at some other options for hanging the catheter bag when in the recliner.

Based on observations, clinical record review, and staff interviews, the facility failed to assure a medication error rate of less than 5%. During observation the facility had 2 errors out of 28 opportunities for error resulting in an error rate of 7.14% (Resident #14). The facility reported a census of 41 residents. Findings include: A Physician order dated 10/6/2019 for Resident #14 directed staff to administer Cholecalciferol (vitamin d3) 5000 units one tablet by mouth in the morning for supplement. A Physician order dated 3/3/2022 for Resident #14 directed staff to administer Calcium 500 mg (milligrams) with Vitamin D 200 units one tablet by mouth one time a day for supplement. On 2/14/23 at 7:13 AM observed Staff B, Licensed Practical Nurse (LPN) administer the following medications to Resident #14 during morning medication pass: A. Calcium 600 mg with Vitamin D3 400 international units (IU) one tablet B. Vitamin B-12 500 mcg (microgram) one tab by mouth On 2/14/24 at 12:00 PM, Staff B LPN acknowledged and verified she did not give the correct medications during morning medication pass. On 2/14/24 at 12:45 PM Staff B, LPN reported she had told the Director of Nursing (DON) about the two medications errors. She stated she had received disciplinary actions for the medication errors. On 2/14/24 at 12:50 PM, the DON reported she had completed disciplinary action with Staff B. The DON stated she showed Staff B where the correct stock medications were located in the medication cart. She stated she was going to do a medication administration audit with Staff B. The DON reported she informed Resident #14 about the medication errors as she is her own responsible party. An undated facility policy titled Medication Administration Policy documented the purpose of the policy was to establish guidelines to promote the health and safety of persons served by ensuring the safe assistance and administration of medication and treatments or other necessary procedures. The policy directed staff to compare the medication sheet with the label of each medication for the following: a. Right person b. Right medication c. Right date d. Right time e. Right route f. Right dose g. Expiration date The policy further directed staff to compare the label with the medication sheet for a second time and a third time before administering the medication to the person.

Based on observation, interview and chart review the facility failed to provide adequate nursing assessments and intervention to treat residents experiencing constipation, for 4 of 7 residents reviewed, (Residents #1, #5, #6 and #7). The facility failed to monitor the bowel habits and assess for signs and symptoms of severe impaction which caused one resident to suffer from fecal impaction and eventual death, (Resident #1). The facility reported a census of 37 residents. Findings include: 1) A Minimum Data Set (MDS) dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive deficit. The MDS showed the resident required extensive assistance with the help of two staff for bed mobility, transferring and toileting. According to the MDS, she had a urinary catheter and was always incontinent of bowel. According to a Nursing Note on 2/24/21 at 12:15 p.m., the resident was admitted to the facility earlier that day with orders for Physical Therapy (PT) and Occupational Therapy (OT) post-surgery after a right [CONDITION(S)]. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan initiated on 2/24/21 included a focus care area of bowel incontinence related to limited physical mobility and staff were directed to provide incontinence cares and to monitor intake and output as per facility policy. A Nursing Noted dated 3/24/21 at 11:37 a.m. described Resident #1 as diaphoretic, unresponsive, cool to the touch with pale skin tone, and the resident was noted to be drooling. Vital signs included: temperature 96.8, pulse 55, respirations 20, blood pressure 68/37, and oxygen level at 88% on room air. The note indicated she had wheezes to bilateral lobes with a cough, and her abdomen was distended with bowel sounds in all four quadrants. The family was notified and emergency transport arranged. According to the emergency room Report initiated by a Physician's Assistant (PA) and signed by a Medical Doctor (MD) on 3/27/21 at 9:24 p.m., the resident presented to the emergency roiagnom on [DATE] at 12:41 p.m. with [CONDITION(S)], [CONDITION(S)], fecal impaction, pneumonia, dementia and systemic [CONDITION(S)] response syndrome. A facility Nursing Note dated 3/24/21 indicated the resident passed away in the hospital at 6:00 p.m. on that date. The Death Certificate for Resident #1 showed the immediate cause of death was small bowel obstruction. A review of the facility clinical chart for Resident #1 revealed the following: a) Skilled Nursing Forms completed twice daily included areas of assessment for all-body systems. Specific symptoms were listed in each category and the nurse could check those that applied. From 3/20/21 through the morning of 3/24/21 the category of gastrointestinal included documentation that indicated the bowel sounds were present in all four quadrants and the abdomen was soft with no distention. In the category of the respiratory system, it was documented the resident did not have a cough or shortness of breath. b) The Bowel Movement (BM) documentation form found in the facilities electronic charting showed Resident #1 did not have any bowel movements on March 21, 22, 23 or 24. c) A Nursing Note entered on 3/24/21 at 12:34 p.m. but timed at 7:00 a.m. on 3/24/21, indicated the residents abdomen was non-distended and soft, bowel sounds were present in all four quadrants, the resident did not have a cough and lungs were clear. d) Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] suppository 10 milligrams (mg) insert 1 suppository rectally every 72 hours as needed to promote bowel movements, dated 2/24/21. Milk of Magnesia Suspension, (MOM) give every 24 hours as needed to promote stool, dated 2/24/21. Polyethylene [MEDICATION(S)] as needed for constipation once daily, dated 2/24/21. According to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) An MDS dated [DATE] showed Resident #5 had a BIMs score of 3 out of 15, indicating severe cognitive deficit. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The document showed the resident required extensive assistance with the help of two for bed mobility, toilet use and personal hygiene and that he was frequently incontinent of bowel. A Care Plan updated on 8/10/18 included a focus area of self-care performance deficit related to lower body weakness and lacked references to, or directions related bowel functioning. In an observation on 3/30/21 at 8:20 a.m., Licensed Practicing Nurse (LPN) Staff A administered medications to Resident #5. She asked him if he had any pain and went to the electronic chart to document. After looking through his chart, she then went back into the room and offered him MOM because he hadn't had a bowel movement for two days. He refused at that time. A review of the clinical chart for Resident #5 revealed the following: a) The resident had a BM on 3/8/21 and none on 3/9, 3/10, 3/11 or 3/12. Nursing Notes lacked any reference to offering a [MEDICATION(S)]. b) The resident had a bowel movement on 3/19/21 and none on 3/20, 3/21, 3/22 or 3/23. Nursing Notes lacked any reference to offer of medication to promote bowel movement in that time frame. c) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 3/30/21 at 10:38 a.m. for MOM to be given every 24 hours as needed to promote stool. Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .m 3) An MDS dated [DATE] showed Resident #7 had a BIMS score of 0 out of 15, indicating severe cognitive deficits. The MDS indicated the resident required extensive assistance with the help of two staff for transfers, bed mobility, toileting needs and the resident was always continent of bowel. The Care Plan last updated 12/20/19 for Resident #7 indicated she had some bowel incontinence related to mental status, and staff were directed to provide clothing that was easy to remove for incontinence cares. The Care Plan lacked direction to monitor bowel movements for constipation. The Care Plan included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical chart revealed the following: a) A Physicians' Order for two scheduled laxatives was entered 10/11/19 at 7:00 a.m.; Senna 8.6 mg. 2 tablets daily, and polyethylene [MEDICATION(S)] 17 grams daily. On 1/9/19 at 11:15 a.m. a as needed (PRN) order for [MEDICATION(S)] suppository 10 mg to promote stool was added. On 2/17/21 at 6:00 p.m. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . b) The electronic bowel movement record indicated the resident did not have a bowel movement on 3/19, 3/20 or 3/21. c) The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4) An MDS assessment for Resident #6 showed the resident had a BIMS score of 0, indicating severe cognitive deficits and required extensive assistance with the help of two staff for bed mobility, transfer and toileting. The MDS showed the resident was frequently incontinent of bowel and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the census page in the electronic chart, Resident #6 was admitted to hospice service on 10/29/20. A Care Plan updated on 1/7/21 indicated the resident had self-care performance deficits related to altered mental status and included a focus area of occasional bladder and bowel incontinence related to confusion. The Care Plan lacked interventions related to monitoring of bowel movements. A review of the electronic chart revealed the following: a) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b) The bowel movement charting showed Resident #6 had no bowel movements on 3/27, 3/28 or 3/29. c) Nursing Notes lacked documentation that PRN laxatives had been offered on 3/28 or 3/29. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 3/30/21 at 9:00 a.m. Emergency Medical Technician (EMT), Staff G said she was one of the two EMTs that transported Resident #1 to the emergency roiagnom on [DATE]. She said when she walked into the resident's room, the resident had been sitting on the side of the bed. She said the resident was confused and the staff had reported that the change in condition had just happened. Staff G recalled the resident abdomen was distended and compared it to the size of a 7-8 month pregnancy. Staff G said she helped change the resident's clothing when they got to the hospital and remembered the resident clenched and called out as if in pain when she was transferred. During interview on 3/30/21 at 9:10 a.m. EMT Staff H recalled having assisted with the transfer to the hospital for Resident #1. He thought there were 3 or more staff in the room with the resident when they arrived and the resident was lethargic but awake. He remembered the very low blood pressures and when they moved the resident from the bed to the cot he had noticed the distension of the belly and described it as firm. During interview on 3/30/21 at 9:45 a.m. Licensed Practicing Nurse (LPN) Staff A said that before breakfast she did the skilled assessment for Resident #1 and described the resident as being alert, talking and eating. She added that her vital signs were all within normal limits. Staff A said the resident had participated in therapy that morning and she had visitors but then, close to lunch time, one of the aides came and told her that the resident was diaphoretic and unresponsive. Staff A said she then did another assessment and found the blood pressure to be very low, the abdomen was distended and firm, bowel sounds hypoactive and her oxygen level was very low. Staff A said she had worked with the resident the day before and there was nothing out of the ordinary on that day. She went on to say that after Resident #1 went to the hospital, the facility established a new protocol for bowel movement monitoring with the overnight nurse documenting on a form which residents have not had BM for 2 days and give this to the day shifts. She said they were to offer MOM after 2 days of no BM and a suppository after 3 days of no BM. During interview on 3/30/21 at 10:00 a.m. Certified Med Aide (CMA) Staff B said Resident #1 had been friendly, laughing and joked with them the morning of 3/24/21. She hadn't seen anything unusual that morning or previous days leading up to the hospitalization . She said Resident #1 had some leg pain and would grimace once in a while when they transferred her, but Staff B maintained that she never saw or heard her complain of pain in her belly. Staff B said that she hadn't notices an increase in the size or firmness of the resident's abdomen. Staff B said she documented the BM's and reported to the nurse if a resident had gone for 2 or more days without BM. She said if a resident had loose stools after days of no BM she would report this also, knowing that this is a sign of impaction. During interview on 3/30/21 at 10:15 a.m. Physical Therapist, Staff C and Occupational Therapist, Staff D recalled having worked with Resident #1 the morning that she went out to the hospital. They said that they both had worked with her for about 15 minutes each and Staff C said that they had worked on sit to stand exercises. Staff D worked on some exercises with resident while she was sitting in her wheel chair. Staff C and Staff D denied having seen anything out of the ordinary for her. They said that the resident had a bit of an abdominal pouch upon admission, but they did not notice that this had gotten larger, more firm or that the resident complained of abdominal pain. Staff C said the resident was able to make her needs known, she would say if it was difficult for her to do the therapies. During interview on 3/30/21 at 10:20 a.m., Certified Nursing Assistant (CNA) Staff E stated she had gone into the room of Resident #1 the morning of 3/24/21, cleaned her up and had gotten her dressed. She said she did not remember any grimacing or anything different about the resident. She said that she hadn't noticed anything different about the resident's abdomen. Staff E remembered Resident #1 had visitors that morning and that therapy had worked with her. Staff E said the resident had been in her wheel chair at the nurse's station waiting for lunch when another aide motioned to her to assist because the resident went limp. She said that they took the resident to her room and put her on the bed, and the resident was cold to the touch and not very alert. She said the nurses took vitals and called the ambulance. Staff E said she always documented the resident's BM's and reported to the nurse if a resident had gone for a couple of days without a BM. In an interview on 3/30/21 at 10:40 a.m., CNA Staff F said she typically worked afternoons on the weekends. She said she hadn't noticed anything different about Resident #1 leading up to the hospitalization . She said that she would turn the resident a couple of times through the night and had done brief changes but said it was normal BM, nothing out of the ordinary. Staff F said she would report any runny stools or abnormal BM patterns to the nurses. During interview on 3/30/21 at 9:00 a.m. the Physician's Assistant (PA) said she had been working in the Emergency Department (ED) the day Resident #1 came to the hospital. She said she primarily worked in the emergency department but had seen the resident in the clinic previously, so she was familiar with her. The PA recalled that when she first saw Resident #1 in the ED her abdomen was extremely firm and distended. She compared it to the size of a 9 month pregnancy. The PA said the resident moaned when she touched the abdomen and the X-Ray had shown that she had impacted fecal matter the size of a football in her intestine. The PA said the resident's husband said he had just visited her in the nursing home that morning and that she had been drooling, which was unusual for her. The PA stated they had offered to take the resident to surgery to remove the impaction but the family opted not to do that. The plan of care was to provide intravenous fluids and with the use of naso-gastric tubing to remove contents of the stomach. The PA said they removed copious amounts of matter from the stomach, and the low blood pressures were very concerning. She added that the buildup of fecal matter had been pushing on the vena cava, causing the decrease in blood flow. She said the resident never did make it to the Med-Surg department and had passed away in the ED. The PA said that in her opinion, the buildup of fecal matter in the resident's digestive systems would have happened over many days or weeks. She believed that the distended, firm abdomen would have been evident in the days leading up to 3/24/21. She said that nursing staff may have seen and increase in weakness, a decrease in intake and pain in the abdomen. During interview on 3/30/21 at 3:55 p.m. the Director of Nursing (DON) said the facility did not have a policy related to PRN [MEDICATION(S)] use or specific directives to monitor bowel movements. She said the expectation had been that on day two with no BM the nurses were to offer MOM and on day three without a BM, they were to offer a suppository. During interview on 3/31/21 at 10:00 a.m., the DON said the facility initiated a new performance improvement plan initiated on 3/26/21 related to monitoring of BMs. When asked why this had been started, she said it was because they discovered that one of the residents had not been monitored for BM's per protocol. The performance improvement plan initiated on 3/26/21 indicated the goal is that no resident would go beyond 2 days (of no BM) without intervention. On 3/31/21 at 10:30 a.m., the DON said she was unable to find education of staff on bowel monitoring. She said they were working to get something assigned right away to their electronic education service. During interview on 3/31/21 at 6:45 a.m. LPN Staff K said the expectation is after 2 days of no BM, the nurses are to offer MOM and after day 3 offer a suppository. She said that sometimes the residents may refuse and they also try to offer prune juice as well. During interview on 3/31/21 at 12:50 p.m., LPN Staff L said after 2 days of no bowel movement she would offer MOM or prune juice, if the resident goes 3 days without BM, she would offer a suppository. During interview on 3/31/21 at 1:30 p.m. RN Staff M said he works the overnight shifts. He said that he would often do the skilled assessment at the beginning of his shift from 6pm-6am. Staff M said he had not noticed anything different with Resident #1 before her hospitalization and that her abdomen had been within normal limits with no distention or firmness. He said if a resident would go for two days without a bowel movement he would offer MOM and a suppository after three days of no bowel movement.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision to protect residents from falls and injury for 2 of 6 residents reviewed (Resident #5 and #4). Record review revealed the facility used personal alarms to alert staff of Resident #5 and Resident #4s' need to self-transfer. Resident #5 fell on [DATE] when his/her alarm had not been attached correctly and sustained a left hip fracture. Observation of Resident #4 showed staff failed to attach Resident #4's personal alarm to alert staff of his/her needs. The facility reported a census of 45 residents. Findings include: 1. An Minimum Data Set (MDS) assessment tool dated 1/3/16, identified Resident #5 with short and long term memory impairment, moderately impaired cognitive skills for daily decision making, unclear speech, rarely or never able to make self understood. The MDS identified the resident required limited assistance from 1 staff to ambulate in the hall, and extensive assistance from 1 staff to transfer, ambulate in the room, and toilet. The MDS identified the resident required staff assistance to balance during transitions and walking and only able to stabilize with staff when moving from a seated positon to a standing positon. The MDS revealed the resident without any range of motion impairment, and used a walker for mobility. The MDS revealed the resident's [DIAGNOSES REDACTED]. The resident's care plan dated 7/14/15 and with a target date of 4/2/16, identified the resident with a potential for falls due to poor communication and comprehension and a gait and balance deficit following a stroke. The care plan interventions to prevent a serious injury included to apply a TABS alarm when not accompanied by staff (dated 7/14/15). The care plan directed staff to not leave the resident reclined in his/her recliner as he/she may try to get up (forgets he/she needs assistance). An Unusual Occurrence 2 report, dated 12/30/15 at 5:45 p.m., documented while the resident sat in the assisted dining area, staff heard the resident's alarm sounding and saw the resident slide the chair back away from the table and slide off the chair on to his/her buttocks. The resident had no injury and the new intervention included to apply a non skid gripper pad to the chair. An Unusual Occurrence 2 report, dated 1/30/16 at 12:45 p.m., documented staff found the resident lying on the floor on the left side in the dining room and the resident yelled when staff attempted to move his/her left leg. The report revealed the resident had an order for [REDACTED]. The report revealed the resident yelled out when staff attempted to touch or move the left leg. A Nursing Progress Notes entry dated 1/30/16 at 1:21 p.m. documented the resident had been found on the west side of the table, with the walker next to the chair yelling out. The resident's entire alarm unit had been attached to the resident and the alarm not sounding. The notes revealed the facility had the resident transferred to the hospital via ambulance. An entry dated 1/30/16 at 4:40 p.m. revealed the resident had a femur fracture An Incident Witness report dated 1/30/16 revealed Staff H, CNA (Certified Nursing Assistant), stated he/she present in the dining room at the time of fall, the resident ' s alarm unit remained attached to the resident's shirt. An Incident Witness report dated 1/30/16 revealed Staff C, CNA, sat at a table and heard the chair slide back and was unable to get to the resident in time to prevent the fall. Staff C stated the resident had not hit head. A care plan entry dated 1/30/16 documented staff educated on the importance of hooking the alarm to the chair. Another entry after the fall dated 1/30/16 directed staff to please put a pressure alarm in his/her chair when in the dining room. An External Radiology Note dated 1/30/16 revealed the resident had a comminuted, impacted, and varus angulated intertrochanteric fracture of the left femur and generalized osteopenia. A hospital Consultation report dated 1/30/16 documented the resident required a nailing of the left hip surgical procedure. A Progress Notes dated 2/3/16 at 2:09 p.m. revealed the resident returned to the facility. Progress Notes revealed the resident received Tylenol 500 mg. (milligrams) 2/3/16 at 5:05 p.m. for left hip pain and relief obtained. A Progress Notes entry dated 2/4/16 at 1:33 p.m. revealed the physician notified the resident in tears due to pain. An entry 2/4/16 at 1:52 p.m. revealed the physician directed staff to administer Hydrocodone (same as Lortab) 7.5/325 mg. every 4 hours when needed for pain. The Progress Notes revealed the resident received Lortab 2/4/16 at 4:35 p.m., 2/5/16 at 8:34 a.m. and 12:35 p.m., and 2/6/16 at 3:25 p.m. for left hip pain with relief obtained. Observations 3/14/16 at 3:15 p.m. and 4:10 p.m. revealed the resident in bed with an alarm on. Observations 3/15/16 at 9:22 a.m. and 10:00 a.m. revealed the resident sat in a chair by the nurse's station with a pressure pad alarm on. During an interview 3/15/16 at 1:30 p.m. Staff C stated at the time of the 1/30/16 fall, he/she sat in the dining room behind the resident recording dietary intakes when he/she heard the resident's chair move, the resident stood partially, grabbed for his/her walker, and fell to the left side. Staff C stated the alarm tab remained attached to the resident's back near a shoulder and the alarm box remained on the chair unattached to any part of the chair. Staff C stated she was not sure if the alarm would sound if the resident had stood completely and the alarm box had been attached. During an interview 3/16/16 at 12:40 p.m., Staff I, RN (Registered Nurse), stated he/she had not seen the fall on 1/30/16, assessed the resident after the fall, the tab part of the alarm remained attached to the resident's back and the alarm box was not attached to anything. Staff I stated he/she had heard the fracture possibly pathological and not sure if this documented anywhere. During an interview 3/17/16 at 9:40 a.m. the Medicare Coordinator (MC)stated the care plan in place at the time of the 1/30/16 fall documented a tabs alarm required when the resident not accompanied by staff and 2 CNA's present in the dining room at the time of the fall. The MC had been asked if the alarm box should have been attached and failed to verbalize whether or not he/she believed the alarm box needed to be attached at the time of the fall. The MC stated the new interventions after the 1/31/16 fall included staff education on importance of attaching the alarm to the chair and for staff to place a pressure pad alarm in the resident's chair in the dining room. During an interview 3/17/16 at 9:50 a.m., Staff C stated his/her back was toward the resident while documenting dietary intakes at the time of the fall. Staff C stated he/she could not reach the resident in time to prevent the fall. Staff C stated Staff H had his/her was feeding another resident at the time of the fall and had his/her back towards the resident. 2. The MDS dated [DATE] identified Resident #4 had severe cognitive impairment and had been [DIAGNOSES REDACTED]. The MDS revealed Resident #4 required one staff assistance for bed mobility, transfers, and ambulation, and two staff assistance for toileting. The MDS revealed the resident not steady, but able to stabilize for balances during transitions and walking. The resident had no range of motion impairment, had not required any devices for mobility, and 1 fall without injury during the previous assessment period. The resident's care plan dated 4/5/15 and with a target date of 4/8/16 revealed the resident had a potential for falls related to wandering and had a chair alarm when not accompanied by staff. During an observation 3/15/16 at 4:00 p.m. the resident walked out of bedroom independently, closed the door, walked towards the common area in the CCDI (Chronic Confusion and Dementing Illness) unit, and the alarm failed to sound. Staff J, CNA, quickly went to assist the resident when he/she reached the common area. Staff J assisted the resident to a chair in the unit and went to the resident's room to check the alarm. Observation revealed a pressure pad on the bed and attached to the alarm box. Staff J checked the alarm box and stated he/she forgot to turn the alarm on after assisting the resident to bed shortly before this.

Based on record review and staff interviews, the facility failed to ensure each resident received adequate supervision during resident to resident altercations for 3 of 5 residents reviewed. Record review established Residents #1 and #2' s aggressive behaviors would precipitate physical harm to others, and facility failed to provide adequate supervision or take precautions to meet residents' safety needs for Residents #1, #2 and #5. The facility identified a census of 54 current residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. A total score of 13 to 15 indicated intact cognition. The MDS identified the resident required assistance of one staff for dressing and the resident independent with transfers. According to the MDS the resident had physical and verbal behavioral symptoms directed toward others. The progress notes identified Resident #1 had been admitted on [DATE]. The progress notes dated 7/24/14, at two different times 5:36 p.m., and 6:18 p.m. identified Resident #1 had been aggressive with staff when redirected, and in one instance grabbed staff and ripped the staff's shirt. Review of the Unusual Occurrence assessment dated [DATE] at 8:46 PM revealed the resident had an altercation with another resident (Resident #2). Resident #2 had got to close to resident #1's spouse and resident #1 told him/her to leave him/her alone. Resident #1 then put his/her hands on resident #2's neck and pushed him/her hard against the wall. Staff interceded immediately. No intervention addressed. Review of the Progress notes dated 7/26/14 at 8:43 p.m. revealed Resident #1 had altercation with Resident #2. Resident got to close to resident #1's spouse and Resident #1 told Resident #2 to leave him/her alone. Resident #1 put his/her hands on Resident #2's neck and pushed the resident hard against the wall. Staff interceded immediately. On 7/27/14 at 8:31 p.m. Resident #1 got into a scuffle with Resident #2. The residents started wrestling to the ground. No punches occurred and staff split the residents up. When asked what happened, Resident #1 reported Resident #2 had been standing in front of Resident #1's spouse, trying to fool around with his/her spouse. The care plan dated 7/28/14 directed staff to monitor and record occurrence of behavior symptoms. The care plan identified the resident became angry when men too close to his/her spouse and to intervene when necessary. The care plan also directed 2 (two) staff members available when the resident was awake to avoid confrontations with other residents. Review of the posted note dated 7/28/14 directed staff to ensure that there are to be 2 staff members in the memory unit at all times, including break times. If Resident #2 comes up to Resident #1 or his/her spouse, need to have attention diverted by staff with activities, snack, toileting, walking etc. Please do not sit Resident #2 next to Resident #1 or his/her spouse at mealtime. A progress note dated 7/29/14 documented Resident #1 came to the center following a complex set of circumstance including psychiatric hospitalization and court order. The progress noted identified the resident had exhibited both physical and verbal behavioral symptoms, particularly when another resident comes close in proximity to his/her spouse, who was also a resident at the nursing home. The physician nursing home note dated 8/6/14 documented Resident #1 was in the special care unit, locked ward, on count committal because of aggressive behaviors, threatening to use guns, and elope with his/her spouse. The physician noted a week or so ago he had received a call regarding a tussle with another resident and that Resident #1 had pulled a staff's shirt. The physician noted Resident #1 was still showing evidence of agitation and aggressiveness and increased the resident's Risperdal medication. Review of the Unusual Occurrence assessment dated [DATE] at 2:40 PM revealed an altercation between Resident #1 occurred with Resident #2 without provocation. The progress note dated 8/13/14 at 2:40 p.m. staff documented Resident #1 aggressive towards another resident (Resident #2) without provocation that resulted in bodily harm to the other resident. The nurse made an attempt to intervene and unable to do so. Review of the Employee verbal Warning dated 8/13/14 revealed Staff A, LPN (Licensed Practical Nurse) and Staff B, CMA (Certified Medication Assistant) instructed that spoons could be gotten by calling the kitchen and have them delivered, so there can be 2 staff in the unit. The written warning to the employees noted one employee left to get spoons from the kitchen and the incident took place with one staff present. During an interview with Staff A, LPN on 8/27/14 at 4:00 p.m. she stated that Resident #1 had been sitting at the table with his/her spouse. Resident #2 had been near the recliners and started to walk towards the table. Resident #1 stood and grabbed resident #2 around the neck and pushed all the way to the window. She stated that she was right there and unable to separate. She pushed the panic button and staff entered the memory unit to help. Staff A reported she did not recall any previous altercations. During an interview with Staff B, CMA on 8/28/14 at 1:30 p.m. she stated that her and Staff A were in the memory unit and ready to pass snacks. Staff did not have spoons. She asked Staff A if she could exit the memory unit to get spoons. She left the unit to go to the main floor nurses station. Had not made it to the nurse ' s station and heard the panic alarm. Entered the unit and Resident #1 sat in a chair and Staff A with Resident #2 on the floor. During an interview with the MDS coordinator on 9/3/14 at AM she stated that an intervention on the care plan due to the care plan not developed yet. She stated the intervention on the daily staff report sheet dated 7/27/14 that directed staff to watch Residents #1 and #2 due to a physical confrontation. 2. According to the MDS dated [DATE] Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident with a brief interview for mental status score of 3. A total score of 0-7 indicated severe cognitive impairment. According to the MDS the resident one staff assistance with bed mobility and transfers. The MDS identified the resident exhibited physical behavioral symptoms directed toward others. The care plan dated 9/30/13 directed staff to intervene before agitation escalates; guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. On 7/29/14 the care plan updated and directed staff to be sure 2 staff members in the memory unit and to redirect if attempt to have contact with resident #1 and spouse. On 8/14/14 the care plan updated and directed staff that the resident moved out of the memory care unit and to provide an alert alarm on at night when in bed and a wanderguard on at all times. On 8/30/13 the care plan updated and directed staff to provide 1 on 1 supervision to be provided at all times. Review of the Imaging Exam Report dated 8/13/14 revealed impression of the lumbar spine with no acute fracture or evidence of malalignment. The thoracic spine also with no acute fracture or evidence of malalignment. The progress notes dated 8/14/14, Resident #2 had pain of his/her lower back. Review of the Unusual occurrence dated 8/30/14 at 6:30 PM revealed Resident #2 had taken Resident #5 by the throat and threw him/her to the ground when he/she tried to open the private room door for Resident #2 to exit the room. Review of the Progress Notes dated 8/27/14 at 6:30 PM staff documented the resident had moved chairs around and start to go through another resident's basket on the walker. The other resident told him/her to leave it alone and the resident cursed and raised his/her fist towards the other resident. The resident redirected. On 8/27/14 at 6:35 p.m. staff documented the resident reached over and touched another resident's wheelchair. The other resident yelled and raised a fist towards the resident. The resident then raised his/her fist and yelled back. Staff redirected the residents. On 8/30/14 at 6:30 p.m. staff documented the resident had another resident (Resident #5) by the neck and taken him/her to the floor. 1 on 1 supervision provided with the resident. During an interview with Staff A, on 9/2/14 at 4:15 a.m., she stated that called to Resident #5's room on 8/30/14 at 6:30 PM. Resident #5 found lying on the floor by his/her doorway. The resident with blood on the right pinky finger and his/her nose. Resident #5 had stated that Resident #2 entered his/her room and sat on the bed. Resident #5 got up and showed Resident #2 the door. Resident #2 took Resident #5's neck and threw him/her to the floor. Intervention included 1 on 1 supervision of Resident #2 right away. She also stated that the resident had an alarm at all times when transferred out of the unit but discontinued due to the resident became agitated by the alarm. 3. According to the MDS dated [DATE] Resident #5 had [DIAGNOSES REDACTED]. The MDS identified the resident had Brief Interview for Mental status score of 15. A score of 13 to 15 indicated intact cognition. The care plan dated 1/19/13 directed staff that the resident able to ambulate independently in room and will use call light for assistance if weak. Review of the Progress Notes dated 8/30/14 at 6:30 PM revealed staff called to the resident's room and found the resident on the floor in the doorway. The resident stated that another resident (Resident #2) had taken him/her by the throat and threw him/her to the ground. The resident had tried to open the door for Resident #2 to exit the room. Resident #2 had wandered into the resident's room. Staff provided cares to stop the bleeding from the right pinky finger and the bridge of the nose where the resident's glasses were. The resident stated had minimal pain at the time. The note documented 1 on 1 supervision given to Resident #2 to ensure safety to other residents. The progress notes dated 9/1/14 documented Resident #5 complained of facial pain & pain to his/her finger. A note to the physician dated 9/2/14 documented Resident #5 had been sent to the hospital and had 4 stitches placed in his/her finger. During an interview with Resident#5 on 9/3/14 at 9:30 AM she stated that he/she had been sitting in the recliner in his/her room. Resident #2 entered the room and sat on the bed. The resident got up to show Resident #2 the door. He/she opened the door and Resident #2 behind the resident and grabbed him/her by the neck and pushed him/her to the floor. He/she stated that had to have 4 stitches to the right little finger and his/her finger was pretty sore. Resident #5 reported he/she has had bruising before but it took this many years to get black eyes but have them now. Resident #5 denied current facial bruising hurt.

Based on observation, record review, and staff and manufacturer sales representative interviews, the facility failed to provide adequate supervision to ensure against hazards during a transfer with a mechanical lift for 1 of 4 residents reviewed (Resident #1). The facility identified a census of 54 residents. Resident #1 sustained a cervical fracture, a laceration requiring staples, and multiple skin injuries when transferred with an EZ lift (mechanical lift) to a Geri chair from the side of the chair. The lift legs were opened only part way and staff pulled on the lift handles which caused the lift to tip and the resident fell on to the floor. Findings include: 1. Resident #1 had a quarterly Minimum Data Set (MDS) assessment with a reference date of [DATE] which identified Resident #1 had demonstrated long and short term memory problems and modified independence with daily decision making. Resident #1 depended upon the assistance of 2 staff members for transfers. The MDS documented Resident #1 had not experienced pain the previous 5 days. Resident #1's [DIAGNOSES REDACTED]. A Care Plan, revised on [DATE], identified Resident #1 had problems with unsteadiness with transfers. The interventions included: a. Use of the Geri-chair for better positioning. b. Use of the EZ lift (mechanical lift) for transfers. The Progress Notes dated [DATE] at 3:45 p.m. documented a Certified Nursing Assistant (CNA) called the nurse to Resident #1's room. On arrival to the room, the nurse noted Resident #1 lying supine (on back) on the floor with blood noted from the back of the head. The CNA reported they were transferring Resident #1 with the assistance of 2 staff members to the Geri chair. With Resident #1 properly secured in the lift, the CNA reported the lift started to tip over and that having 1 leg under the Geri chair, the lift did not completely overturn, with the resident hanging in the sling. One CNA held the resident in the sling while the other attempted to stabilize the mechanical lift. Resident #1 slid out of the sling onto the floor. Resident #1 had multiple skin tears to the right and left posterior hand, right shoulder, forearm, and a large scalp laceration to the back of the head. At 4:00 p.m. Emergency Medical Services arrived, assessed Resident #1 and transferred Resident #1 to the hospital. A History and Physical dated [DATE] documented Resident #1 had a serious injury when he took a fall from a Geri chair while being transferred. Resident #1 had a large laceration that had been repaired, on the right parietal area. A CT scan identified a non- displaced, what appeared to be a type 2 dens (second cervical vertebrae) fracture. A Major Injury Determination Form dated [DATE] documented Resident #1's injury of 14 staples on his/her scalp, and den fracture of the neck. Resident #1 fell out of the sling during transfer. The physician documented after reviewing the circumstances, injury, and prognosis of the patient, he believed the injury sustained was a major injury. The Transfer Orders/Instructions from the hospital dated [DATE] directed Resident #1 must keep the cervical collar on at all times. A Progress Note dated [DATE] documented a wound progress note, referred to multiple skin tears secondary to a fall. The areas included: a. Left hand skin tear 2.4 by 0.6 centimeters (cm) with a red moist base. b. Left elbow skin tear 2.0 by 0.8 cm. c. Right forearm 1.3 by 1 cm with a red base. d. Right hand 1.2 by 0.4 cm with a red base. e. Right shoulder skin reattached to skin tear overall measured 5.2 by 4 cm with peri ulcer skin ecchymotic. f. Laceration with staples to the top of head. The MAR for [DATE] to [DATE] documented Resident #1 had an order for [REDACTED]. The MAR showed Resident #1 did not take the medication ,[DATE] to [DATE]. Resident #1 received the medication after the fall on [DATE] at 8:25 p.m., [DATE] at 8:23 a.m., [DATE] at 7:30 a.m., and 12:15 p.m., [DATE] at 8:16 a.m., [DATE] at 5:42 p.m., [DATE] at 9:25 p.m., [DATE] at 7:32 a.m., [DATE] at 8:19 a.m., 4:36 p.m., and 8:39 p.m. The MAR for [DATE] to [DATE] documented Resident #1 had an order for [REDACTED]. The MAR showed Resident #1 did not take the medication ,[DATE] to [DATE]. Resident #1 received the medication after the fall on [DATE] at 9:55 a.m., [DATE] at 7:47 a.m., [DATE] 4:45 p.m., [DATE] at 5:19 p.m., [DATE] at 12:02 p.m., [DATE] at 8:45 a.m., [DATE] at 8:14 a.m. and 7:53 p.m., and [DATE] at 8:02 a.m. The MAR for [DATE] to [DATE] documented Resident #1 started Tramadol 50 mg two times a day, and Acetaminophen 325 mg 2 tabs 2 times a day routinely for pain on [DATE]. The Therapy Notes dated [DATE] documented the EZ lift could be used safely with Resident #1. They (staff) needed to make sure the sling was at shoulder level and the base of the EZ lift was at its widest position when positioning Resident #1 over the Geri chair from the side, and to use 2 (staff) assist at all times. A note dated [DATE] read all staff were required to view (review) the EZ stand training video. It would be shown following the in-service that day, or could be watched at another time on own, but must be completed by [DATE]. During an observation on [DATE] at 2:57 p.m. staff performed a reenactment of the incident on [DATE]. Staff A CNA and Staff B CNA performed the transfer, and Staff F Certified Medication Aide (CMA) acted as the person transferred. Staff positioned a medium back sling under Staff F. They (staff) placed the loops in the hooks using black loops on top and green loops on the bottom. They lifted Staff F off the bed and pulled the lift away from the bed and to the Geri chair. They pushed the legs of the lift under the Geri chair to the left side. One of the lift legs under the Geri chair, and 1 under the raised footrest of the Geri chair in front of the Geri chairs front wheels. They had the legs (of the chair) open ,[DATE] way. Staff B stood beside the Geri chair to Resident #1's right and took hold of the middle and right handles on the lift sling. Staff B stated she pulled back mostly on the middle handle and the lift tipped toward the resident. When it tipped, Resident #1 swiveled to the right and went over the side of the chair on his/her head. Both staff stated the leg of the lift caught on the footrest (of the Geri chair) and it did not go over all the way. Staff A stated she had not started putting Resident #1 down in the chair when Staff B pulled on the sling and the lift tipped. During an observation on [DATE] at 10:43 a.m. Staff H CNA and Staff I CNA had lift sling under Resident #1, and placed the lift over Resident #1 in bed. Staff put the loops of the lift sling on the lift bar hooks. The right lower loop was not in the hook. Staff moved to the Geri chair and put the legs of the lift under the side of the Geri chair. They moved the spreader bar to the right opening legs to the widest position. Staff I CNA positioned Resident #1 in the Geri chair with the sling handles as he/she lowered to the chair. Resident #1 cried out when positioned a pillow under his/her head. Resident #1 had 14 staples to the laceration on the top of Resident #1's head. During an observation on [DATE] at 1:20 p.m. Resident #1 sat in the Geri chair in his/her room. Staff H and Staff I came to the room and told Resident #1 they would lay him/her down on the bed. Staff hooked (the sling) loops to the lift hooks. The lift legs were spread apart and diagonal to the Geri chair. They transferred Resident #1 to the bed. During an observation on [DATE] at 3:43 p.m. Staff A CNA and Staff B CNA transferred Resident #1. After lifting Resident #1 off the bed, they moved the lift to the front of the Geri chair and opened the legs (of the lift) all the way. They lowered Resident #1 to the Geri chair with the foot rest in a down position. During an observation on [DATE] at 8:32 a.m. Staff G CNA and Staff H CNA transferred Resident #1 from the Geri chair to the bed. The lift was to the side of the Geri chair to Resident #1's right. The legs of the lift were closed. Staff lifted the resident from the Geri chair and moved him/her to the bed. The legs of the lift caught on a cord under the bed and Staff H had to maneuver it before they could get the lift over the bed, and lower Resident #1 to the bed. During an observation on [DATE] at 10:50 a.m. Staff G and Staff H transferred Resident #1 from the bed to the Geri chair. Staff lifted Resident #1 off the bed and put the lift on the right side of the Geri chair with 1 leg under the chair and 1 leg under the foot rest. Staff G pulled back on the straps to bring Resident #1 back further from Resident #1's right side. Staff G confirmed the legs of the lift were not opened during the transfer. During an interview on [DATE] at 3:10 p.m. Staff A CNA stated she had never actually worked with a Geri chair prior to working at this facility. She did it (transferred) like everyone else was doing it. As far as she knew they (staff) only had to open the legs of the lift half way. She said they usually held the 2 outside straps (of the sling) when moving Resident #1 back. She said (now) she will only transfer Resident #1 to the Geri chair from the front with the foot rest down. She did not know what other staff did. She stated she didn't think it would work to put the legs all the way out when transferring from the side; she didn't think there was enough room. During an interview on [DATE] at 3:22 p.m. Staff B CNA stated her experience was going to the Geri chair from the side. She stated it was easier to get the resident comfortable in the chair. She stated she did the transfer the same way in other care centers. She stated the legs were open ,[DATE] or all the way; she had done it both ways with no problems. She stated if she were strictly behind it (the chair) she would pull the 2 side handles (of the sling). She stated there wasn't room to get behind (the chair) so she was to Resident #1's right (during the incident). She stated her right hand was more steadying Resident #1. She stated now she transfers from the front with the footrest down, and she usually ran the lift. She stated they told them after the incident to have the legs completely open. During an interview on [DATE] at 4:20 p.m. Staff E Licensed Practical Nurse (LPN) stated he worked the evening Resident #1 fell from the lift. The aides stated he/she came out of the sling head first. He stated they transferred with 2 CNA's, 1 steadied the resident and 1 maneuvered the lift. One CNA stood behind the chair and held the 2 outside handles as the lift went down to hold in place. He stated usually they had 1 leg under the chair and 1 spread and underneath the foot rest of the chair, usually in the widest position. He stated on the (EZ lift) video they didn't always spread the legs to the widest position, but agreed they didn't show a transfer to the Geri chair or positioning the lift from the side of a chair. During an interview on [DATE] at 9:37 a.m. the Physical Therapist stated the facility wanted her to check the lift after the incident and she could find nothing wrong with it (EZ lift). She stated according to what they told her, they may not have had the legs spread to their widest position, and they may have moved Resident #1 outside the base of the legs when positioning him/her. She stated they shouldn't have to pull them so far it would tip the lift. She stated she attempted to tip the lift, and it would be nearly impossible to tip if the legs were spread to their widest position. During an interview on [DATE] at 4:37 p.m. Staff D CNA stated she always had the lift face the Geri chair with the legs spread to the widest position. She stood behind the chair and held the 2 outside straps, and sometimes stood to the side of the Geri chair. She had seen them just hold the middle strap from the side of the Geri chair. She said she had seen them put the legs under the chair from the side and not open the legs. She said she did not do it that way. She did not see the EZ lift video when she started, and had not yet seen it. During an interview on [DATE] at 5:03 p.m. Staff C CNA stated she transferred Resident #1 1 time before he/she fell . She hooked him/her up to the Hoyer, and with the chair forward went straight to the chair. She went behind the chair and used the 2 outside handles to position Resident #1, with the (lift) legs opened to their widest. She said she had seen them transfer to the side of the Geri chair keeping the legs together, between the wheels of the chair, with the chair reclined. She said she learned to do the transfer forward (not from the side) when she took CNA training, and was not comfortable doing it any other way. She stated they tried teaching her how to do it during orientation. They never said how to do it, or not to do it. She stated everyone did it different. Some stood to the side and not the back to maneuver the resident in the chair. During an interview on [DATE] at 4:14 p.m. Staff F CMA stated she had assisted with transfer with the lift to the Geri chair. She thought they did it from the side, and thought she learned it in CNA class. She stated she always had the legs wide open because it was more steady and always had 2 people (to transfer). She stood behind and took the 2 outside handles of the sling. Staff F didn't know if they changed anything after the incident regarding transfers from the bed to the Geri chair with the lift. The EZ Lift Operating Instructions included: a. For positioning the EZ Lift, make sure there were no cords or other objects under the bed that could obstruct the wheels of the lift. b. Put the loops of the sling on the hooks of the lift. For lifting the resident, once there is tension on the loops double check the loops to make sure they are securely in the hooks. b. For adjusting the legs, use the spreader bar to adjust the legs of the lift to go around the wheel chair. Position the wheelchair under the resident. Stand behind the wheelchair and hold (not pull) both of the side handles on the back of the sling, or the middle handle. This would ensure the resident would be seated in an upright position when fully seated in the wheelchair. The EZ Lift Training Video showed/narrated the spreader bar adjusted so the legs fit around even a recliner. The video directed to double check the loops of the sling to make sure they were in the hooks. The video directed to spread the legs wide enough to straddle the wheelchair, and showed the lift positioned in front of the wheelchair. The video directed when 1 inch from the seat grab the handle and position the patient comfortably in the wheelchair. The video did not show a transfer to a Geri chair or transferring to a chair from the side. During an interview on [DATE] at 8:14 a.m. a service department staff at EZ Way Lift Company stated you are not supposed to pull on the handles of the lift sling when someone was in the sling sideways to the lift. At 8:17 a.m. a Sales Manager of the EZ Way Lift Company stated they could transfer to the Geri chair from the side if they were just going to lower the person into the chair. He stated you never pull on the sling handles if the resident is sideways to the lift, because it is going against the center of gravity and the lift could tip. He stated when lowering the person you only need 1 inch of clearance to adjust them into position. He said they are available to provide training to facilities regarding transfers with the lifts in unorthodox situations. During an interview on [DATE] at 9:45 a.m. the Director of Nursing (DON) stated they had an in-service and those who attended watched the EZ lift video and everyone else had to watch by [DATE]. She stated no new staff could go on the floor until they watched the video. The DON acknowledged the video did not cover transfer to the Geri chair from the side, and there was no specific training for this type of transfer, the CNA's showed other CNA's. The DON stated the facility did not telephone the lift sales company after the incident.

Based on observation, record review and staff and family interviews, the facility failed to ensure Resident #1 remained active and failed to provide restorative services so the resident's activity of daily living skills did not decline. Six residents were reviewed for rehabilitative/restorative care. The facility identified Resident #1 was awake at night and then would sleep during the day. Instead of accommodating the resident ' s sleep cycle, the facility attempted rehab therapy during the hours of 6 a.m. to 2 p.m. when the resident was sleepy from being awake at night. The facility then administered [MEDICATION NAME] in the evening. The resident did not receive adequate therapy for approximately 6 months with declines noted. The facility reported a census of 55 residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] following a [MEDICAL CONDITION]. A Minimum Data Set assessment with a reference date of 10/4/11 assessed the following: moderately impaired vision, usually understands messages from others but may miss some part/intent of message, usually makes self understood difficulty communicating some words and finishing thoughts, brief interview for mental status (BIMS) score of 7 (severe impairment), extensive staff assistance with bed mobility, transfers, ambulation, dressing, eating, toileting, personal hygiene and bathing. The MDS did not identify functional limitation impairments of the upper or lower extremities. The resident used a wheelchair. The resident utilized antianxiety medications during the last 7 days of the assessment. The MDS identified [DIAGNOSES REDACTED]. The Physical Therapy (PT) documentation identified the resident received PT from 3/31/11 through 4/30/11. A PT updated plan of progress for rehabilitation stated the resident "has been making progress with range of motion (ROM) and ambulation ability", but required continued PT to increase range of motion in lower extremities for more upright stance and more functional gait. The PT evaluation identified the resident with decreased strength throughout body, limited hip extension and flexed posture. On 4/29/11 PT discharged the resident to the facility restorative nursing program. The restorative program consisted of the following: Nu Step for 15 minutes 3 to 5 times per week, lower extremity supine bridging 15 to 20 reps (repetitions) 3 times per week, hip and knee flexion/extension 3 sets of 10 with hip stretch for 30 seconds on #10, bilateral lower trunk rotation 15 to 20 reps 3 times per week, hip abduction/extension 15 to 20 reps 3 times weekly, lie prone with towels above knees crescent pillow under head 10 to 15 minutes 3 times weekly and ambulation 6 days a week. Restorative records identified the following: May 1-12/2011 the resident ambulated 8 times with the last ambulation distance recorded as 40 feet. The resident ambulated one time between 5/13/11 and 5/31/11 and used the NuStep machine 5 times. The resident ambulated 15 feet on 5/24/11. Seven dates between 5/13/11-5/31/11, staff identified the resident as "sleepy" or "very sleepy " and no therapy provided. Review of the resident's nurses notes, dated 5/20/11 identified the facility received a telephone order at 2:20 p.m. from the physician. The facility notified the resident's son, who was not durable power of attorney (DPOA). Review of the May 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) every 2 to 4 hours as needed (PRN). The facility administered the [MEDICATION NAME] medication twice on 5/20/11, once on 5/22/11, 5/23/11, 5/25/11, 5/28/11, 5/30/11 and 5/31/11. Other than on 5/30/11 at 6 p.m., nurses notes failed to identify other interventions offered to the resident such as bathroom, snack, and diversional activity before administering the [MEDICATION NAME] to ensure the medication was used as a last resort. A behavior record identified on 5/20/11 and 5/22/11 staff left the resident alone as an intervention with negative outcome. The behavior record identified staff administered medication on 5/28/11, talked to and toileted the resident and laid the resident down. June 2011 restorative records identified staff ambulated the resident 4 times with the last time being 25 feet on 6/23/11. The resident used the Nu Step 5 times. On 13 occasions staff identified the resident as sleepy or too tired to do the exercises or ambulate. Review of the resident's June 2011 MAR indicated [REDACTED]. PLO (topical) 18 times. Staff changed the [MEDICATION NAME] order to administer the medication every night at 7 p.m. on 6/29/11. The nurses notes did not identify the facility attempted other measures such as toilet, snack, diversional activity to ensure staff administered the [MEDICATION NAME] as a last resort. Behavior records identified staff administered medication and sat with the resident on 6/7/11, 6/8/11, 6/9/11, 6/14/11, and 6/15/11. On 6/18/11 and 6/19/11 staff provided one to one and toileting. On 6/21/11, 6/22/11 and 6/23/11 staff provided one to one, toileting and medication. On 6/29/11 staff provided one to one. Restorative records identified the resident complained of pain on 6/15/11 and 6/23/11. Staff administered [MEDICATION NAME] on 6/15/11 but no pain medication. A physician progress notes [REDACTED]. On 10/25/11 at 9:30 a.m., Staff A (the Director of Nursing) stated the resident did not sleep at night. Restorative work hours are 6 a.m. to 2 p.m. so when it was time to exercise, the resident was too sleepy. The surveyor asked Staff A if staff could have walked the resident at night when the resident was awake. Staff A stated the resident would be too agitated. On 6/30/11 at 12:30 a.m. a nurse ' s note entry stated the resident sat in a recliner at the nurses ' station and refused to go to bed despite staff encouragement and one to one. Staff then administered PRN [MEDICATION NAME]. The July 2011 restorative records identified the resident did not ambulate that month. The resident rode the Nu Step once. The resident exercised twice that month. On 18 occasions staff identified the resident as too sleepy or too tired to exercise or ambulate. Review of the July 2011 MAR indicated [REDACTED]. PLO at 7 p.m. every night until 7/19/11. The medication resumed on 7/28/11 at 4 p.m. daily. On 10/25/11 at 2:30 p.m., the Administrator stated the pharmacy refused to send the medication during this period of time (7/20/11 to 7/28/11) because the resident's DPOA objected to the use of the medication. A nurse ' s note entry dated 7/26/11 at 2:50 p.m. and documented by the Administrator stated she discussed the [MEDICATION NAME] with the resident's DPOA. At that time, the DPOA stated he did not want the medication used for the resident and wanted the resident to receive PT. The Administrator informed the DPOA that was not realistic and not going to happen and if the DPOA was not happy the facility would be happy to find alternate placement. The August 2011 restorative records identified the resident ambulated one time on 8/5/11. The resident ambulated 30 feet. The resident did not exercise or ride the NuStep on any date. On 9 occasions, staff wrote "sleeping" as the basis for the resident not exercising or ambulating. The August 2011 MAR indicated [REDACTED]. at 4 p.m. all month. The resident received a "PRN" dose on 8/21/11 and 8/31/11. The behavior record did not identify any behaviors on 8/21/11 or interventions to assist in alleviating behaviors. On 8/31/11 staff talked with and toileted the resident for the resident screaming "help", as well as administering [MEDICATION NAME]. On 8/11/11 a physical therapy aide (PTA) changed the resident's restorative plan to PRN but to continue to offer 5 days a week. The PTA did not direct staff to provide passive range of motion or active assistive range of motion. When asked why this type of therapy was not provided the PTA stated, on 10/25/11 at 3:10 p.m. she did not know. The September 2011 restorative records identified the resident did not ambulate, exercise or ride the NuStep on any date. On 13 occasions, staff wrote "sleepy" as the rationale for not exercising or ambulating. The other reason was "hollering". The September 2011 MAR indicated [REDACTED]. daily at 4 p.m. The resident received 11 doses of PRN [MEDICATION NAME] during the month. The MAR indicated [REDACTED] On 9/2/11, 9/3/11 behavior records did not identify behavior issues or interventions provided by staff for behavior. On 9/12/11 the behavior was paranoia and screaming. Staff attempted reassurance and redirection with no improvement. On 9/13/11 the behavior was screaming and hitting. Staff attempted reassurance redirection, laying down and using 2 staff with no improvement. On 9/14/11 the behavior was screaming. Staff attempted redirection with no improvement. On 9/22/11 the behavior was screaming. Staff attempted bathroom and relocation with positive results. On 9/24/11 the behavior was yelling crying and hitting. Staff attempted bathroom with positive results. On 9/25/11 the behavior was yelling and crying. Staff attempted bathroom and relocation with no results recorded... On 9/29/11 and 9/30/11 the behavior was yelling crying and hitting. Staff attempted bathroom and relocation with positive results. A 9/7/11 physician progress notes [REDACTED]. On 9/21/11 an occupational therapist saw the resident and noted a decline in left upper extremity hand and digit motion. A hospital discharge summary identified the resident entered the hospital on [DATE] for pneumonia. Hospital progress notes, dated 10/12/11 stated the resident's DPOA expressed the facility "drugs up" his parent so the resident cannot perform any type of therapy in order to get better and leave the nursing home". During the hospital stay, the physician discontinued the [MEDICATION NAME]. Upon return to the facility on [DATE] the physician ordered a physical therapy consultation. The physical therapy consultation performed after the resident returned to the facility on [DATE] revealed the resident's prior level of function was assist of 2 for transfers, unable to ambulate and lower extremity contractures. The current evaluation showed the resident could not bear weight or stand upright or pivot for transfers. The resident has hip contractures, and lacks the ability to extend knees fully. The resident's elbows are limited and hands are contractured. The ability to lift arms above shoulder is limited. The posture is flexed with contractures. Therapy records identified the facility provides passive range of motion and active assistive range of motion since 10/21/11. The resident's DPOA stated on 10/24/11 at 7:50 a.m. the resident did not receive exercises at the facility and now can ' t walk. The therapists at the hospital told him by now the resident has [MEDICAL CONDITION]. On 10/19/11 a therapy alert directed staff to apply a blue terrycloth finger divider/palm protector in the resident ' s hands daily and off during meals only. The record lacked evidence the facility informed the physician of the resident's lack of receiving therapy. On an 8/26/11 progress note, the physician stated the resident can only work the bicycle and do some exercise. This is mistaken as the resident did not perform therapy during that period of time. Observation on 10/24/11 at 8:08 a.m. identified two staff members transfer the resident with a gait belt. The resident bore minimal to no weight for the transfer. On the same date at 10:48 a.m., the occupational therapy aide provided range of motion to the resident's left upper extremity. The resident could not bend the fingers of the left hand. On the same date at 11:30 a.m. Staff E (Licensed Practical Nurse) provided passive range of motion to the extremities. Staff E stated when she started employment at the facility in March 2011 the resident could ambulate a few steps with maximum assistance. On 10/25/11 at 10:10 a.m., Staff D (Restorative and Licensed Practical Nurse) identified she wrote entries regarding the resident and "sleeping" in the past. Staff D stated she would try and awaken the resident and the resident became combative. Staff D stated the resident's ability declined. The resident sat in a regular wheelchair but sat leaned forward with head tucked and they could not feed the resident. Staff D stated the staff changed the resident's wheelchair after he/she returned from the hospital on [DATE]. Staff D stated the resident used to move the wheelchair with his/her legs but doesn't do that any longer.

Based on record review and staff interviews the facility failed to provide adequate supervision to ensure against hazards from self or elements in the environment and failed to plan for and direct the nursing care and services so each resident ' s needs are met (Resident #2, #3 #4, #6). The sample consisted of 15 residents and the facility identified a census of 57 residents. Findings included: 1. Resident #6 had a Minimum Data Set assessment with a reference date of 4/6/10 because of a significant change in condition. The assessment reflected Resident #6 had short term memory problems with moderately impaired cognitive skills for daily decision making skills. The resident required extensive assistance with transfers and ambulation in his/her room and had a [DIAGNOSES REDACTED]. An Incident Assessment form dated 10/12/10 and noted at 3:20 p.m., indicated Resident #6 had been found in his/her room lying on the left side. The resident voiced complaints of left hip and shoulder pain. The form noted the resident ' s safety alarm did not sound. Interventions were put in place to prevent further falls were to use a blue plastic clip with the personal safety alarm and the assistance of two to transfer upon return from the hospital. The Online Abuse or Incident Reporting document dated 10/13/10, indicated on 10/12/10, Staff W was administering medications and came to Resident #6's room and found the resident on the floor lying on left side between the bed and the door. Staff O had been summoned to the room where a full assessment had been performed as well as the environment. Staff O was able to determine the resident had removed the personal safety alarm from his/her clothing where it had been attached. The alarm did not sound and was connected to the base on the bed where the resident had been resting. The resident was care planned for assist of one to transfer and personal safety alarm at all times. Resident #6 had been transferred to the hospital and diagnosed with [REDACTED]. The facility also reported the resident does not have a history of removing the tabs unit from clothing. The Nurse ' s notes reflected the following: On 3/29/2010 at 10:45 a.m. the resident fell in the dining room and then was sent to the clinic. The resident had a fractured left shoulder and voiced pain at 10 on a scale of 1 to 10. The resident returned to the facility on [DATE] at 2:05 p.m. with an immobilizer to the left arm and dressing to left shoulder. The resident required skilled nursing care. On 6/7/2010 at 12:50 p.m. the resident had attempted to ambulate independently while carrying the Tabs Alarm. The resident fell and hit head. The resident voiced complaints of left rib pain. The resident was sent to the physician clinic at 3:00 p.m. for an evaluation of the rib pain. At 4:50 p.m., the resident returned to the facility with an order to administer Lortab (analgesic) 5/500 one or two tablets every 6 to 8 hours. On 6/12/10 at 4:50 p.m., the Certified Nursing Assistant (CNA) reported Resident #6 was tampering with the tabs alarm and detached the alarm from his/her clothing. The nurse instructed the CNA to attach the alarm to the clothing where it is less accessible to the resident. On 7/1/10 at 6:40 p.m., the CNA reported the resident had removed the tabs unit two times and taken self to the bathroom. The note reflected the staff had educated the resident about the need to utilize the call light for assistance. During an interview on 12/2/10 at 9:50 a.m. Staff P (Certified Nursing Assistant) described Resident #6 as not cooperative with alarms and never had been. Staff P stated if the resident can reach the alarm then would remove the alarm. Staff P tried to keep it where the resident could not reach it and encouraged the resident to use the call light. Staff P stated the facility had switched from a clip to blue attachment but can still remove that alarm but not as easily. During an interview on 12/2/10 at 1:00 p.m. Staff W (Certified Medical Assistant) stated there had been a couple times when Resident #6 had removed tabs alarm from clothes. When the resident would remove it Staff W would explain why he/she needed it and would try to place the tabs back further on the residents back so the resident would not be able to take it off. During interview on 12/2/10 at 5:55 p.m. Staff O (Licensed Practical Nurse) stated Resident #6 had a history of [REDACTED]. The resident would unclip the alarm from his/her clothes. Staff O stated she/he thought the resident would remove the alarm at least every shift. Staff O stated she/he questioned why the blue clip had not been implemented earlier; the resident does not remove the blue clip now. 2. Resident #2's March 20, 2010 Discharge Summary documented the resident had [DIAGNOSES REDACTED]. A September 7, 2010 Clinic Note documented the resident had experienced a fall at the facility three days prior. The resident had come to the emergency room where x-rays showed no fracture. The note documented on the way back to the facility in the facility transportation van the resident had taken a "tumble", going forward with the wheelchair coming down on top of him/her. The x-rays revealed a fracture of the left third rib and multiple contusions as a result of the fall in the van. A written investigation of the incident provided by the Administrator stated the resident had tipped over in the wheelchair while being driven back to the facility from the hospital. The brakes had been locked on the chair but the straps had not been attached to the chair. An in-service on van safety had previously been held in July 2010. On September 6, 2010 the Maintenance Supervisor conducted another in-service for night shift staff including how to secure the two doors, how to use the remote control to lower and raise the lift device, how to back the resident onto the loading ramp, how to put on the safety strap and put the wheelchair brakes on when on the loading ramp, how to load into the van and place the resident in between the four sets of security hooks, how the latches and security hooks worked and where they should be attached to the wheelchair , how to apply the seat belt around the resident and explained to drive the van slowly for safety of the resident. During an interview on December 1, 2010 at 10:46 a.m. the Administrator stated on September 5, 2010 the resident's wheel chair had tipped over in the wheelchair van. The Administrator stated in July the facility had provided in-service training to staff related to van safety, but Staff U1, Certified Nursing Assistant, had not been in attendance. The Administrator stated the CNA had told the nurse she/he wasn't trained to drive the van, but the nurse had insisted she/he go pick up the resident at the hospital. The Administrator stated the CNA had received a Written Warning. The nurse had received a verbal warning with no written documentation. She stated the facility had no policies or procedures related to how to transport residents or who could transport residents in the facility vehicles. During an interview on December 2, 2010 at 8:32 a.m. Staff U stated the nurse had asked her if she had driven the van before. She told her "no". The nurse told her she needed to go pick up Resident #2 anyway. She stated, "I did what I was told. " On December 1, 2010 at 8:12 a.m. the resident stated the rib fracture did hurt but it was better now. 3. According to the Minimum Data Set with assessment reference date of 8/31/10 Resident #3 had short term memory problems and moderately impaired cognitive skills for daily decision making. The resident had extensive assist of two staff with bed mobility and transfers and total dependence on staff assist for walking in the resident ' s room. Resident #3 had [DIAGNOSES REDACTED]. An Incident Assessment form dated 8/13/10 noted at 5:30 a.m. Resident #3 was laying on the floor, on right side, next to the bed. The TABS personal alarm attached to gown. Resident #3 had removed the gown per self. The TABS alarm did not sound. The intervention implemented to prevent future falls was to assist the resident in wearing clothing that are secure fitting to attach the TABS. An Incident Assessment form dated 8/19/10 and noted at 5:30 a.m., Resident #3 had tried to get up and slid to the floor. Resident #3's alarm had not sounded; the resident had removed the gown. The intervention implemented to prevent future falls was a bed alarm while in bed. An Incident Assessment form dated 8/19/10 noted at 11:30 a.m. Resident #3 was found on the floor, call light on bed, not pulled. The resident ' s head toward foot of the bed with resident lying on his/her back. The alarm had not sounded; the alarm was on the bed and not on the resident. An Incident Assessment form dated 8/19/10 and noted at 4:00 a.m. Resident #3 was found sitting/laying on the fall mat. No new interventions were implemented to prevent future falls. An Incident Assessment form dated 8/25/10 and noted at 8:05 a.m., indicated Resident #3 was found on the floor and on a tumble mat on his/her back with legs pulled up. The alarms did not sound. The Incident Assessment did not note what alarms were in place or why alarm had not sounded. On 12/3/10 at 12:00 p.m., Staff A stated the facility had no information on what alarms were in place or why the alarms had not sounded. An Incident Assessment form dated 8/28/10 and noted at 6:45 p.m. indicated Resident #3's alarm sounded and the resident was found sitting on the floor in front of the recliner in the resident ' s room. The new intervention to prevent falls directed staff to not leave resident alone in room while up in the recliner. An Incident Assessment form dated 8/30/10 and noted at 12:00 p.m. indicated Resident #3 attempted to ambulate in the resident ' s room and fell . The new intervention directed staff to prevent falls by putting the resident back into bed following meal and do not leave resident in recliner. This intervention was to have been implemented after the residents fall on 8/28/10. The Incident Assessment form did not note if alarms sounded. An Incident Assessment form dated 9/1/10 and noted at 7:40 a.m. indicated the housekeeper heard the resident talking. The housekeeper peeked in the resident ' s room and found Resident #3 lying on stomach on tumble mat. The Incident Assessment form did not note if alarms had sounded. An Incident Assessment form dated 10/5/10 and noted at 1:18 p.m. indicated Resident #3 took self out of chair in the resident ' s room, alarm sounded and the resident was found on the floor. On 8/28/10 the new intervention to prevent falls was to not leave resident alone in room up in recliner. The intervention implemented after the fall on 10/5/10 was to communicate with the resident to decide where the resident wanted to sit after eating lunch. An Incident Assessment form dated 11/10/10 and noted at 10:44 a.m. indicated Resident #3 stated he/she had tried to stand up and fell hitting head on the floor. The resident ' s body landed on the fall mat in front of the chair. During an interview on 12/2/10 at 1:00 p.m., Staff W stated she did not think Resident #3 could verbalize if the resident wanted to get in bed or sit in the chair. Staff W stated she/he would not want to leave the resident in the chair because the resident would not use the call light if wanted to get up and move. On 12/3/10 at 12:00 p.m., Staff A stated the facility had no information to provide with raised concerns about alarms that had not sounded, alarms in place or interventions not implemented or additional interventions not put into place after the fall. 4. According to the Minimum Data Set assessment with a reference date of 5/23/10, Resident #5 had short term and long term memory problems and severely impaired cognitive skills for daily decision making. The resident required limited assistance of two staff persons for transfers and ambulation. Resident #5 had [DIAGNOSES REDACTED]. An Incident Assessment form dated 8/20/10 and noted at 11:18 a.m. indicated Resident#5 took self out of the recliner and then fell on to the floor in a seated position. No intervention had been put in place to attempt to prevent further falls. The Incident assessment dated [DATE] at 2:00 a.m. indicated the nursing assistant ambulated the resident to the bathroom and the resident became weak so was lowered to the floor with a gait belt. The resident had no apparent injury. The intervention directed staff to use a wheelchair as needed to and from the bathroom when weak. The Incident assessment dated [DATE] at 2:00 a.m. indicated the nursing assistant ambulated the resident to the bathroom. The resident became weak and the assistant sat the resident on the floor. The resident had no apparent injury. The intervention directed staff to use two staff members to ambulate the resident. A Major Injury Determination and Incident Assessment form dated 9/15/2010 indicated the resident attempted to stand up from the couch, lost balance and hit head on the column beside the couch. The form indicated the resident required the assistance of 1 staff member with ambulation. The intervention directed staff to try the geriatric chair for short periods. The Incident assessment dated [DATE] at 8:40 p.m. indicated the resident became weak and was lowered to the floor. The resident had no apparent injury. The intervention directed staff when the resident bends knees during the ambulation, use the gait belt and safely assist to a sitting position. The resident displayed weakness and the facility staff did not utilize the planned interventions (use wheelchair to take to bathroom, use 2 staff person to ambulate the resident, etc) so the resident did not sit on the floor and risk further falls and possible injury.