Every finding on record at Lamoni Specialty Care

Based on clinical record review, Individual Narcotic Records, Controlled Drugs-Count Records and staff interviews, the facility failed to report 4 milliliters of morphine missing from a resident's supply. (Resident #5) The facility reported census was 31. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #5 was Independent with transfers, mobility, dressing, toilet use and personal hygiene needs, occasionally incontinent of bladder and always incontinent of bowel. Resident #5's diagnosis included atrial fibrillation, coronary artery disease, diabetes mellitus, emphysema. According to the Individual Narcotic Record (INR), Resident #5 received a 30 milliliter bottle of Morphine Sulfate 20 milligrams per milliliter on 12/24/24. The initial dose of 0.5 milliliters every two hours as needed for pain was administered that same day. Doses were administered as ordered with no math errors noted through 1/9/25 at which time 4 milliliters should have been remaining. A photo provided of 30 ml bottle of liquid has clear markings visible at 3 milliliter increments. In an interview on 4/24/25 at 3:00 p.m. Staff D, Registered Nurse, stated she recalled the evening (1/9/25) in which Staff I was unable to get the entire dose (0.5 ml) of Morphine Sulfate from Resident #5's bottle. Staff D stated the usage record indicated there was 4.25 milliliters remaining, but there were only 0.25 milliliters that could be drawn from the bottle. Staff D stated she assumed the missing morphine was the result of spillage over time. Staff D stated she signed off on the Individual Narcotic Record (INR) with Staff I indicating the count was corrected and she then discarded the bottle. Staff D stated she was unaware that missing narcotics should be reported immediately to the DON. Staff D stated she was working a 2:00 p.m. to 10:00 p.m. shift on 1/9/25 and completed a narcotic count at the 2:00 p.m. shift change and signed indicating all narcotics were accounted for. Staff D stated she did not complete a shift change narcotic count with Staff I at 4:00 p.m. before handing over the medication cart keys to her. In an interview on 4/24/25 at 10:39 a.m. Staff I, Licensed Practical Nurse, stated she was working a 4:00 p.m. to 8:00 p.m. shift (1/9/25), noting it was very hectic. Staff I admitted she had not completed a narcotic count with Staff D at 4:00 p.m. before receiving the medication cart keys. That evening, while preparing to give a dose (0.5 ml) of morphine to Resident #5 (7:52 p.m.) she discovered the bottle of liquid morphine only had about 0.25 milliliters in it, while the Individual Narcotic Record (INR) indicated 4.25 milliliters should have been available. Staff I consulted with Staff D and initialed the INR as corrected despite 4 milliliters that were unaccounted for. In an interview on 4/24/25 at 1:58 p.m. Staff H, Registered Nurse, stated on 1/10/25, Staff C and another aide had brought to her attention an Individual Narcotic Record for Resident #5's liquid morphine which should have had 4.0 milliliters remaining was documented as completed. Staff H stated she reviewed the page for errors and after finding none, contacted the DON. In interviews on 4/24/25 and 4/28/25 the Director of Nursing (DON) stated on 1/10/25 at 4:48 p.m. she was informed by Staff H that there were 4 milliliters of liquid morphine missing from Resident #5's supply (bottle). The DON stated when investigating, she discovered Staff D had used the last of the bottle and discarded it, not aware of what would warrant concern and a need to immediately report the discrepancy. The DON stated she questioned most of her staff (Staff K, Staff B, Staff D, Staff H) and all reported no issues with spillage and did not notice the count to be off. Staff M stated she did not notice the count to be off on 1/8/25. Staff reported the clear liquid was difficult to read. On 1/10/25 at 9:12 p.m. Staff I contacted her and reported two incidents in which she had spilled morphine. Once on 12/25/24 and again on 1/1/25. The DON stated the manufacturer's instructions stated a 30 milliliter bottle may have as much as 2.5 milliliters missing from the start. (Manufacturer's instructions estimated volume variance for a 30 milliliter bottle may have a plus or minus 2.5 milliliter variance). The DON stated based on the manufacturer's instructions the original bottle may have been 2.5 milliliters short, that left only 1.5 milliliters unaccounted for. When Staff I called and stated she spilled the morphine twice, it appeared a reasonable explanation for the discrepancy. The DON stated since there was an explanation for the discrepancy, she did not think there was any drug diversion and did not report it to the State Agency.

Based on clinical record review, Individual Narcotic Records, Controlled Drugs-Count Records and staff interviews, the facility failed to ensure an accurate reconciliation of all controlled medications. (Resident #5) The facility reported census was 31. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #5 was Independent with transfers, mobility, dressing, toilet use and personal hygiene needs, occasionally incontinent of bladder and always incontinent of bowel. Resident #5's diagnosis included Atrial fibrillation, coronary artery disease, diabetes mellitus, emphysema. According to the Individual Narcotic Record (INR), Resident #5 received a 30 milliliter bottle of Morphine Sulfate 20 milligrams per milliliter on 12/24/24. The initial dose of 0.5 milliliters every two hours as needed for pain was administered that same day. Doses were administered as ordered with no math errors noted through 1/9/25 at which time 4 milliliters should have been remaining. A photo provided of 30 ml bottle of liquid has clear markings visible at 3 milliliter increments. In an interview on 4/24/25 at 3:00 p.m. Staff D, Registered Nurse, stated she recalled the evening (1/9/25) in which Staff I was unable to get the entire dose (0.5 ml) of Morphine Sulfate from Resident #5's bottle. Staff D stated the usage record indicated there was 4.25 milliliters remaining, but there were only 0.25 milliliters that could be drawn from the bottle. Staff D stated she assumed the missing morphine was the result of spillage over time. Staff D stated she signed off on the Individual Narcotic Record (INR) with Staff I indicating the count was corrected and she then discarded the bottle. Staff D stated she was unaware that missing narcotics should be reported immediately to the DON. Staff D stated she was working a 2:00 p.m. to 10:00 p.m. on 1/9/25 and completed a narcotic count at the 2:00 p.m. shift change and signed indicating all narcotics were accounted for. Staff D stated she did not complete a shift change narcotic count with Staff I at 4:00 p.m. before handing over the medication cart keys to her. In an interview on 4/24/25 at 10:39 a.m. Staff I, Licensed Practical Nurse, stated she was working a 4:00 p.m. to 8:00 p.m. shift (1/9/25), noting it was very hectic. Staff I admitted she had not completed a narcotic count with Staff D at 4:00 p.m. before receiving the medication cart keys. That evening, while preparing to give a dose (0.5 ml) of morphine to Resident #5 (7:52 p.m.) she discovered the bottle of liquid morphine only had about 0.25 milliliters in it, while the Individual Narcotic Record (INR) indicated 4.25 milliliters should have been available. Staff I consulted with Staff D and initialed the INR as corrected despite 4 milliliters that were unaccounted for. Staff I stated the next evening (1/10/25), she was directed to call the DON. Staff I recalled being on the phone with the DON that evening trying to explain the discrepancy. Staff I stated during their conversation, she remembered a time or two in which there may have been some morphine spilt, but not nearly to the amount that was missing. Nevertheless the DON persisted at pressuring her to admit she spilled the morphine, stating if she did not, the police might need to get involved. Staff I stated she was a new nurse and feared for her license so agreed to indicate she had spilled the morphine. In an interview on 4/23/25 at 12:29 p.m. Staff M, Registered Nurse, stated on 1/10/25 it was discovered Resident #5 was missing 4 ml of morphine. Staff M stated Staff I called her upset, following her conversation with the DON. Staff I stated she was the last person to administer the morphine (1/9/25 at 7:52 p.m.) and she had also failed to complete a narcotic count with Staff D at shift change. Staff I told Staff M that she felt coerced by the DON into falsely claiming she had spilled the morphine in order to account for the discrepancy. Staff I stated she denied spilling the morphine, but was told by the DON if she did not claim she had, they would have to get the police involved. In an interview on 4/24/25 at 1:58 p.m. Staff H, Registered Nurse, stated on 1/10/25, Staff C and another aide had brought to her attention an Individual Narcotic Record for Resident #5's liquid morphine which should have had 4.0 milliliters remaining was documented as completed. Staff H stated she reviewed the page for errors and after finding none, contacted the DON. In an interview on 4/24/25 at 1:30 p.m. the Director of Nursing (DON) stated on 1/10/25 at 4:48 p.m. she was informed by Staff H that there were 4 milliliters of liquid morphine missing from Resident #5's supply (bottle). The DON stated when investigating, she discovered Staff D had used the last of the bottle and discarded it, not aware of what would warrant concern. The DON stated she questioned most of her staff (Staff K, Staff B, Staff D, Staff H) and all reported no issues with spillage and did not notice the count to be off. Staff M stated she did not notice the count to be off on 1/8/25. Staff reported the clear liquid was difficult to read. On 1/10/25 at 9:12 p.m. Staff I contacted her and reported two incidents in which she had spilled morphine. Staff I was educated on the importance of having a witness during these instances and documenting on the Individual Narcotic Record. In a follow up interview on 4/28/25 at 4:05 p.m. the DON stated upon hearing of the discrepancy she contacted her Regional Manager and initiated an investigation which included reviewing Resident #5's morphine use records. The DON stated she found no error in doses or documentation errors. The DON stated she sent out a group text asking if anyone was aware or could explain why there were 4 milliliters missing. The DON stated that was when Staff I called her and stated she may have spilled some twice. Once on 12/25/24 and again on 1/1/25. The DON stated the manufacturer's instructions stated a 30 milliliter bottle may have as much as 2.5 milliliters missing from the start. (Manufacturer's instructions estimated volume variance for a 30 milliliter bottle may have a plus or minus 2.5 milliliter variance). The DON stated based on the manufacturer's instructions the original bottle may have been 2.5 milliliters short, that left only 1.5 milliliters unaccounted for. When Staff I called and stated she spilled the morphine twice, it appeared a reasonable explanation for the discrepancy. The DON stated since there was an explanation for the discrepancy, she did not think there was any drug diversion and did not report it to the State Agency. The DON was asked if her assertions were true and the spillage and variance accounted for 4 milliliters of missing morphine as of 1/1/25, why was the missing morphine not discovered during 45 shift change narcotic counts prior to the bottle being empty on 1/9/25. The DON shrugged her shoulders and indicated she did not know.

Based on clinical record review, Individual Narcotic Records, Controlled Drugs-Count Records and staff interviews, the facility failed to ensure medical records were accurately documented. The facility reported census was 31. Findings include: In an interview on 4/24/25 at 3:00 p.m. Staff D stated she was working a 2:00 p.m. to 10:00 p.m. on 1/9/25 and completed a narcotic count at the 2:00 p.m. shift change and signed the Controlled Drugs-Count Records indicating all narcotics were accounted for. Staff D stated she did not complete a shift change narcotic count with Staff I at 4:00 p.m. before handing over the medication cart keys to her. In an interview on 4/24/25 at 10:39 a.m. Staff I, Licensed Practical Nurse, stated she was working a 4:00 p.m. to 8:00 p.m. shift (1/9/25), noting it was very hectic. Staff I admitted she had not completed a narcotic count with Staff D at 4:00 p.m. before receiving the medication cart keys. According to the Controlled Drugs-Count Records (shift change narcotic count record), Staff D and Staff I both signed the record dated 1/9/25 at 4:00 p.m. despite both acknowledging the count was not completed.

Based on clinical record review, resident interview, staff interview and facility policy review, the facility failed to accurately transcribe a physician order, resulting in the order not being fully completed in a timely manner, for 1 of 1 residents (Res #14) reviewed. The facility reported a census of 35. Findings include: The Minimum Data Set (MDS) of Resident #14, dated 1/30/25 identified a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. On 2/10/25 at 11:30 am, Resident #14 stated she is hard of hearing and has had a lot of wax build up in her ears. She stated the Nurse Practitioner gave an order to the facility to have ear drops in her ears for five days, and then her ears were to be flushed. She stated she got the drops but nobody ever flushed her ears. She reported she had asked multiple staff members to flush her ears but nobody had completed it. She additionally reported she would like to make an audiology appointment to have her hearing aids adjusted but she cannot do this until her ears are clean of built up wax. The Medication Administration Report (MAR) for Resident #14 for February of 2025 reflected an order for Debrox Otic Solution (Earwax removal drops), instill five drops in each ear, one time a day for wax build up for six days. Flush on Day six. The MAR revealed documentation the order was written for the drops to be administered 2/1/25-2/6/25. There was no separate entry for the ears to be flushed. The MAR documented the drops were given for five days, 2/2/25 - 2/6/25. On the first day, 2/1/25 they were held with an indication to see progress notes. A review of progress notes from 2/1/25 documented the medication was not available. Review of the nursing schedule for 2/6/25 and 2/7/25 revealed Staff A, Licensed Practical Nurse (LPN) was the nurse on duty for day shift on both of those days On 2/11/25 at 1:59 pm, Staff A, LPN stated she was the nurse who placed the order into the Electronic Health Record (EHR) but she had not flushed Resident #14's ears. She stated the drops were started on day two of the order, once they arrived from the pharmacy. After reviewing the order, Staff A stated Resident #14's ears should have been flushed on 2/7/25. Staff A stated she was the nurse on duty on 2/7/25 but she had transcribed the order incorrectly so the need to flush the resident's ears did not come up as an order on 2/7/25. She stated she should have placed one order in the EHR for the drops and a separate order to flush the ears. Staff A also stated Resident #14 had not mentioned this to her until 2/10/25. She stated she had notified the Nurse Practitioner of this and the resident would be seen by the Practitioner later in the week when she was in the building. On 2/11/25 at 2:32 pm, Staff A, LPN stated she had now flushed the resident's ears and got discharge results from one of her ears only. On 2/11/25 at 2:50 pm, the Director of Nursing (DON) stated the facility had spoken to the Nurse Practitioner regarding the situation. She stated her expectation was for the order to have been placed as two separate orders to ensure the flush was completed. The Communication with Physician Note dated 2/11/25 at 2:56 pm documented Staff A had notified the Nurse Practitioner and received an order at that time to flush the resident's ears and this order was carried out. The facility policy titled Medication and Treatment Orders, Revision date July 2016 documented the following: Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing. Point 9: Orders for medications must include: a. Name and strength of the drug; b. Number of doses, start and stop date, and/or specific duration of therapy; c. Dosage and frequency of administration; d. Route of administration; e. Clinical condition or symptoms for which the medication is prescribed; and f. Any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.).

Based on clinical record review, facility document review, hospital record review, staff, pharmacy and physician interviews, the facility failed to accurately transcribe and implement physicians orders for 1 of 1 residents reviewed (Resident #4). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) of Resident #4 dated 2/15/24 identified a BIMS score of 14 which indicated cognition intact. The MDS documented diagnoses that included hyponatremia (low sodium), non Alzheimer's dementia, Parkinson's disease, schizophrenia, anxiety and depression. The undated facility document chronicled the following: On 12/15/23 the Director of Nursing (DON) notified by the Advanced Registered Nurse Practitioner (ARNP) that during a review of orders for Resident #4 she noticed an order she had submitted on 12/1/23 for Fluconazole (an antifungal medication) for 300 mg once per week for 4 weeks had incorrectly been transcribed. The facility wrote the order into the resident's Electronic Health Record (EHR) as 300 mg daily for 14 days. On Wednesday 12/13/23, Resident #4 sent via ambulance to the county hospital for shortness of breath, unsteady gait, and change in mental status. While at the county hospital, Resident #4 had a seizure and experienced cardiac arrest. The hospital life flighted him to a larger hospital in the closest metropolitan city. They determined the resident had a drop in sodium levels which caused the mental status change and lead to the seizure. The Physician Order form for Resident #4 dated 11/30/23 revealed a hand written order, authored by the ARNP to start Fluconazole, 300 mg, by mouth, once weekly for four weeks. Staff A, Licensed Practical Nurse (LPN) noted the order on 11/30/23. The orders section of the EHR documented Staff A entered the order as Fluconazole tablet, 150 mg, give 2 tablets one time a day for 14 days (300 mg total). The Medication Administration Record (MAR) of Resident #4 for December, 2023 revealed the resident received 300 mg of Fluconazole daily from 12/1/23 to 12/13/23. The hospital records from a kidney specialist physician dated 12/18/23 documented the resident had been on a thiazide diuretic medication and this was the cause of the hyponatremia. On 3/19/24 at 8:29 am, the facility Pharmacist stated the dose of 300 mg a day is not out of normal dosing range for the medication. She stated the resident should not have had any adverse side effects due to the transcription error. She stated while the dose the facility prescribed is different than received, it is not an inappropriate dose per the drug manufacture's safe dosage recommendations. On 3/19/24 at 1:48 pm, Staff A, LPN stated she is not sure of why she transcribed the order incorrectly. She said she believed she just read the order wrong. She also said that once the error had been discovered, she replayed that day over and over in her head and stated she thinks about it daily and the error has traumatized her. She said that since the error, the facility put into place that each new order is double noted by two nurses and additionally when orders are written by the doctor, the nurse reads it verbally to the physician to verify it is correct. On 3/20/24 at 9:28 am, the ARNP stated the resident was not on the medication long enough for the error to be the cause of his hospitalization . She stated he had candida (a yeast/fungi infection) and ringworm on his chest and under his abdominal folds following a trip home with family and this was systemic and was the reason for the Fluconazole order. She stated she hand wrote the order and handed it directly to the nurse. On 3/20/24 at 2:30 pm, the DON stated her expectation is to have 2 nurses double note all orders for accuracy. She stated she also reviews all antibiotic or antifungal medication orders personally. The Medical Information for Fluconazole from the drug manufacturer documented a maximum daily dosage of the medication for adult patients to be 400 mg.

Based on clinical record review, facility policy review, and staff and provider interviews, the facility failed to ensure full implementation of nutritional assessments and interventions for one of three residents reviewed for assessment and intervention (Resident #5). The facility identified a census of 23 current residents. Findings include: According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #5 entered the facility on 11/7/22. The resident's diagnoses included high blood pressure, other fracture, Non-Alzheimer's dementia, malnutrition, chronic lung disease, other emphysema, unspecified dementia with mild and moderate behavioral disturbances and muscle weakness. The assessment documented she had a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment. Resident #5 required setup only to eat and required the assistance of one staff member while walking and during locomotion via walker and wheelchair. The MDS documented she had no weight loss prior to admission, weighed 109 pounds on admission and received a therapeutic diet. Resident #5's Care Plan, initiated on 11/7/22, contained a Focus area beginning 11/10/22 that her nutritional status was at risk related to dementia, high blood pressure, gastroesophageal reflux disease and emphysema. The Care Plan instructed staff to monitor her appetite and meal intake, offer her between meal snacks and fluids, provide house supplement if needed as ordered and provide her diet as ordered. Resident #5's admission orders dated 11/7/22 instructed that staff provide Ensure (a nutritional drink) TID (three times daily). The resident's Medication Administration Record (MAR) for 11/22 documented she received Ensure as ordered from 11/8 - 11/15/22, with a change in her ordered supplement to House Supplement 4 oz (ounces) TID on 11/16/22. The 11/22 and 12/22 MARs documented staff administered the House Supplement 4 oz TID until 12/22/22. Resident #5's Treatment Administration Record (TAR) of 11/22 directed staff to obtain Resident #5's weight upon admission, then for the next 3 weeks for a total of four weekly weights. The TAR documented she weighed 104.5 pounds on 11/14/22 and then no weight measurements on 11/21/22 and 11/28/22. The entries for 11/21 and 11/28 documented '9': other/see the progress notes. Resident #5's 12/22 TAR documented she weighed 97.4 pounds on 12/5/22. A Progress Note dated 11/7/22 at 6:02 PM documented the nurse did a mini nutrition assessment. The resident scored seven, indicating malnourishment. A Progress Noted dated 11/8/22 at 1:54 PM documented Resident #5 ate 25% or less for two or more meals in the day; the resident refused to eat breakfast. Resident #5 stated 'it looks like s***', she just wanted to leave and get out of there. The admission Registered Dietician (RD) Note dated 11/10/22 at 5:56 AM documented Resident #5 weighed 109.2 pounds on 11/7/22 with a BMI (body mass index) of 20.6 (normal). Resident #5 consumed a heart healthy, regular texture diet with thin fluids and ate 25-75% during all meals, drank 240-480 milliliters of fluid per meal and refused evening snacks since admission. She ate with supervision, cueing, had upper and lower dentures and no chewing, swallowing or gastrointestinal issues noted. The resident received Ensure TID for added calories and protein. She had no recent edema noted. The 11/7/22 mini nutritional assessment indicated the resident as malnourished related to a moderate decrease in oral intakes. Her weight loss was not significant per MDS guidelines, recent acute stress, BIMS 0, and BMI of 20.6. Resident #5 had fair oral intakes. The RD recommended her diet to be liberalized to regular, no added salt due to fair oral intakes. Resident #5 would benefit from slow trending weight gain due to her BMI for her age. The RD could not evaluate a change in weight due to the absence of her weight history. The RD recommended House Supplement 4 oz. TID for added calories and protein and to discontinue the Ensure order and a NIP (Nutritional Intervention Program) for added cal/pro. Please notify the RD of any changes. The RD Note dated 11/16/22 at 6:58 PM documented the RD spoke with Interdisciplinary Team and learned Resident #5 was not eating well and was a picky eater. The RD recommended the resident receive Magic Cup (another nutritional supplement) BID (twice daily) for added calories and protein. The RD asked to notify her of any changes. Review of the resident's MARs, TARs, Progress notes and task notes revealed no documentation she received the Magic Cup. The Nurses Note date 11/19/22 at 12:08 PM documented Resident #5 tested positive for COVID-19 and isolation was in place. Resident #5 did not display symptoms at the time and her vital signs measured within normal limits. Remained on iso until 11/30 at 2044 (documented as out for supper). The Nurses Notes documented Resident #5 ended isolation on 11/30/22. Resident #5's 12/22 TAR documented staff measured the resident's weight next on 12/5/22 at which time she weighed 97.4 pounds. Review of Resident #5's food intake records revealed: a. In 11/22 - No refusals, 0-25% intake during 18 meals, 25-50% for 19 meals, 51-75% during 16 meals and 76-100% for five meals. b. In 12/22 - 26 refusals, 0-25% intake during 26 meals, 25-50% for three meals, 51-75% during four meals and 76-100% for one meal. A Progress Note dated 12/7/22 at 1:30 PM contained a weight change notification from the RD to the resident's Advanced Registered Nurse Practitioner (ARNP). The resident had a significant loss in 30 days related to varied intake. The resident's intakes measured 25 - 75% with all meals with one refusal. Staff offered a daily evening snack and she refused 50% of the time. The RD recommended increasing her House Supplement to 6 oz TID. The ARNP acknowledged notice but gave no new orders. The resident's 12/22 MAR showed she continued to receive 4 ounces of House Supplement, not the 6 ounces recommended by the RD. The RD Progress Note dated 12/21/22 at 11:30 AM documented the resident continued to lose weight with an 11% loss in 30 days. Resident #5 ate very little if any. She refused most meals and fluids and if she ate, it was less than 25%. She received NIP and 4 oz of House Supplement TID currently and usually drank the House Supplement. Interview on 1/26/23 at 10:37 AM with the Director of Nursing stated that with weekly weights for an isolated resident, staff would normally bring a scale in the room, sanitize it and then exit. The DON stated she'd look to see of a reason why Resident #5 was not weighed. When implementing RD recommendations, the DON stated the RD would email her and she would review the recommendations. Any recommendation that required a doctor's order went in a binder and he'd sign if the change would require an order. For NIP changes and House Supplements, nursing implemented those. She provided an internal QA (Quality Assurance) effort regarding communication with RD. An email dated 1/26/23 documented the DON could not locate the resident's missing weight measurements on 11/21 and 11/28/22. Interview on 1/26/23 at 2:25 PM with the facility's former RD revealed weekly resident weight measurements would have been beneficial in her decision-making towards recommendation for Resident #5. When asked, the former RD remembered two recommendations that weren ' t ' implemented (increasing the House Supplement and adding Magic Cup). When asked regarding the system to relay RD recommendations, the former RD stated she emailed the Dietary Services Manager, Administrator, DON and Regional RD of her recommendations. She was not sure who relayed the recommendations to the resident's Primary Care Provider. She remembered there were nursing staffing challenges at the time so that maybe affected relay of the information. When asked if the loss was avoidable, the former RD stated that it was hard to say as it depended on whether the resident consumed the supplements. Also the resident ' s behavior and refusals likely had an impact. Progress Notes documented Resident #5 transferred out of the facility on 12/22/22. During interview on 1/30/23 at 1 PM, when asked about the resident's weight loss, the resident's ARNP remembered that at the beginning of her stay, Resident #5 was pretty lucid and could clearly say what she wanted. She became less so as her dementia progressed. The ARNP also stated that COVID-19 can decrease the appetite. The resident began refusing cares and food, but that was towards the end of her stay, not at the beginning. They thought the resident may have a urinary tract infection, but could not obtain a urine sample. They were almost to the point of straight cathing her when she transferred. Review of the facility's undated NIP guidelines detailed that the RD would routinely evaluate approximate extra calories and protein provided by the NIP. It did not dictate methods of communication amongst staff and the measurement of resident weights.

Based on observations, clinical record review, and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed (Resident #4 and #9). On 11/16/21, staff attempted to remove the Hoyer sling under Resident #4 after their shower while the resident was still sitting in the shower chair. This caused Resident #4 to slide forward in the shower chair as the resident's leg started to bend to the side. Although staff kept the resident from falling to the floor, the resident sustained a right lower leg fracture. On 6/2/22, staff found Resident #9 on the floor in their room. The fall resulted in a left wrist fracture that required a cast, an orthopedic consult, and pain control. The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 10/27/21, documented Resident #4 scored 8 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated moderately impaired cognitive abilities. The MDS revealed the resident required extensive assist of 2 staff for bed mobility & dressing and was dependent on 2 staff for transfers, toilet use, and personal hygiene. The MDS revealed the resident had diagnoses that included [CONDITION(S)] and muscle contracture. The Care Plan revised on 9/16/19, identified Resident #4 required assist with ADL's (activities of daily living) due to contractures and diagnosis of [CONDITION(S)] (MS). The Care Plan documented the Resident #4's condition would continue to decline due to the MS. The care plan directed staff: a. Provide assist with wheelchair mobility (9/20/18) b. Provide assist of 1 staff for eating and bathing (5/29/19) c. Provide assist of 2 staff for dressing, personal hygiene, and bed mobility (5/29/19) d. Provide assist of 2 staff and Hoyer lift (full body mechanical lift) for all transfers (9/20/18) The Care Plan dated 11/16/21 documented Resident #4 fell and directed staff to utilize a (mechanical lift) sling designed for the shower and leave it under the resident during their shower. Review of the Care Plan revealed no documentation that addressed Resident #4's risk for falls or any staff directives or interventions in place prior to the fall on 11/16/21. The Fall Risk Evaluation dated 7/31/21, identified a score of 10 or above represents a high risk. The form directed initiate care plan with a score of 10 or more. The form showed the resident scored 10 and was chair bound, required assist with elimination, and had poor vision. Resident #4's Progress Notes revealed: a. On 11/16/21 at 10:33 AM, an incident/accident/unusual occurrence note identified staff gave the resident a shower. Afterwards they attempted to remove the sling from under the resident while they were still in the shower chair. The resident then slid forward from the chair and staff lifted the resident back. The resident complained of right leg pain with flexion and extension. b. On 11/16/21 at 10:57 AM, a Hospice note documented the spiritual counselor visited and the facility charge nurse reported the resident had slipped from the Hoyer sling. However, the facility staff kept the resident off the ground. c. On 11/16/21 at 12:06 PM, staff documented a verbal order received for tibula/fibula (2 lower leg bones) x-ray to the right leg. d. On 11/16/21 at 3:11 PM, a focused evaluation revealed the resident had slipped out of the shower chair this morning following a transfer with the Hoyer lift and the resident complained of pain to the right leg. An X-ray was obtained and staff were the awaiting results. e. On 11/16/21 at 3:55 PM, the x-ray revealed a subtle fracture to the anterior cortex of the tibia and the proximal fibula. Hospice recommended an increase in the resident's [MEDICATION(S)] (narcotic for pain control). The Witnessed Fall Investigation form dated 11/16/21 at 9:37 AM, identified the facility staff attempted to remove the sling under Resident #4 while the resident sat in the shower chair. The resident slid forward in the shower chair, the facility staff lifted the resident back, but the resident's right leg started to bend to the side. The resident immediately complained of pain to the right leg with flexion & extension. The assessment revealed Resident #4 had no visible injury or deformity noted at that time. a. Immediate Action - staff assessed Resident #4 for injury. Care plan updated to reflect the need to use a shower sling and leave it under the resident while showering b. No injuries observed at time of the incident c. Pain rated at 4 due to negative vocalization, facial expression, and body language. d. Mental status - orientated to person, place & situation e. Injuries post incident - fracture right lower leg f. Predisposing situation factors - during transfer The X-Ray report dated 11/16/21, revealed Resident #4 sustained a subtle fracture of the anterior cortex of the tibia as well as a subtle fracture of the proximal fibula. On 8/24/22 at 4:31 PM, Staff C, Certified Nursing Assistant (CNA) reported Resident #4 required the Hoyer lift and assist of 2 staff for all transfers. Staff C stated technically one staff could remove the sling under the resident while they were up in the wheelchair, shower chair, or bed. However; it would be safer with 2 staff while the resident was in the wheelchair. On 8/24/22 at 4:49 PM Staff D, CNA stated Resident #4 transferred with the Hoyer lift, sling, and assist of 2 staff. Staff D stated if they had to remove the sling under the resident while the resident was sitting in the wheelchair, they utilized 2 staff. On 8/25/22 at 10:32 AM, Staff E Certified Medication Aide (CMA) stated Resident #4 transferred with assist of 2 staff and the Hoyer lift. Staff E stated if they had to remove the sling under the resident if the resident was sitting up in the wheelchair, they utilized 2 staff. On 8/25/22 at 10:59 AM, Staff F CNA stated Resident #4 transferred with a Hoyer lift and 2 person assist. Staff F stated they would use 2 staff to remove the sling under the resident. On 8/25/22 at 11:09 AM, Staff G stated they needed to transfer Resident #4 from the shower chair to the wheelchair. Staff G stated at times, they had to remove the sling under the resident while in they were in the wheelchair or shower chair. This was because they did not have the right sling in place or they needed it out of the way so they could clean the resident better. Staff G they attempted to lift Resident #4 forward to put the sling under the resident, and the whole shower chair tipped forward and the resident slid. Staff G stated a former co-worker, Staff J, CNA assisted with the transfer at the time of the incident with Resident #4. Staff G stated they leaned Resident #4 forward in the shower chair to replace the sling and the resident slid out. Staff G stated the Hoyer lift transfers required assist of 2 staff. Staff G reported the shower chair was not made for Resident #4 and added it was soapy & slick at the time of the transfer and Resident #4 slipped out of the shower chair. On 8/25/22 at 11:18 AM, Staff B CNA stated she worked the day Resident #4 fractured their lower leg, however, did not assist with the transfer. She reported the resident transferred with assist of 2 staff and a Hoyer. She also reported she only removed the Hoyer sling from under the resident while they were in bed and used 2 staff to do so. On 8/25/22 at 11:24 AM, Staff I, CNA stated Hoyer transfers required 2 staff. Staff I reported they only removed a sling when Resident #4 was in bed and used 2 staff. On 8/25/22 at 12:14 PM, the Director of Nursing (DON) stated she would not added a fall risk care plan for Resident #4 prior to the fall because she did not move and falls had not been a problem for her before the fracture. The DON reported she expected staff to leave the shower sling underneath the resident during a shower and not remove it because that was the safest route. On 8/29/22 at 9:38 AM, Staff J, CNA verified assisting Staff G with Resident #4 in the shower on the day the resident fractured their lower leg. Staff J said they were told to remove the sling from underneath Resident #4 prior to the shower and replace it after the shower, however, Staff J had not wanted to remove the sling. Staff J reported being unsure why they were to remove the sling or if the shower sling had been used that day, but assumed if they had used a shower sling they would have left the sling under the resident during the shower. Staff J commented they did not know if the facility didn't have enough slings or if the sling had not been washed and the sling had to be removed to reuse after the shower. Staff J stated they washed Resident #4 while Staff G held the resident in the shower chair during the process. Staff J stated they leaned Resident #4 forward while in the shower chair while Staff G attempted to place the sling lift behind the resident. Then, the resident slid forward from the shower chair and Staff J & Staff G lifted Resident #4 back into the shower chair - it happened so quickly. Staff J reported Resident #4 did not hit the ground with their full weight, but with enough pressure to fracture the leg. Staff J stated did not hear anything at the time of the incident and there had been no extreme pressure while Staff G attempted to place the sling under Resident #4. On 8/23/22 at 12:10 PM, Resident #4 sat in the main dining room in a high backed wheelchair with a cushion in place and a lift sling lift under the resident. On 8/25/22 at 9:17 AM, Staff A, CNA and Staff B CNA transferred Resident #4 to bed via Hoyer lift. Staff B maneuvered the lift and Staff A guided the resident onto the bed and removed the sling under the resident by rolling them from side to side between the 2 CNA's. 2. The MDS assessment dated [DATE] documented Resident #9 had diagnoses that included hypertension, [CONDITION(S)] accident (stroke), non-Alzheimer's dementia, and [CONDITION(S)]. The MDS identified a BIMS score of 6 (severe cognitive impairment) and revealed the resident required extensive physical assist of 1 staff for bed mobility & toilet use and limited physical assist of 1 staff for transfers, dressing, & personal hygiene. The MDS identified Resident #6 used a walker and wheelchair for mobility and required supervision and oversight of one staff for ambulation (walking). The MDS also identified that her balance during transitions and walking was not steady and at times she required assistance of staff to stabilize. The MDS documented Resident #9 demonstrated occasional bowel and bladder incontinence and was not on a toileting program. The MDS revealed the resident experienced delusions (misconceptions or beliefs that are firmly held contrary to reality) and displayed verbal behavioral symptoms directed toward others on 1-3 days within the last 7 days. The MDS also identified the resident had a history of falls since the prior assessment; 2 with no injury and 1 with an injury. The Care Plan initiated 1/20/22 identified Resident #9 required staff assist for all ADL's and directed: a. Provide assist of 1 staff with bathing, dressing, transfers, toilet use and personal hygiene (1/20/22) b. Provide assist with cares as needed due to incontinence. Resident #1 attempts to transfer herself to the bathroom without calling for assistance from the staff. Moved to a room closer to the Nurse's Station - Room #1. (5/26/22) c. Demonstrated Left sided weakness (1/20/22) d. Added four-wheeled walker and assist of 1 staff to walk short distances and resident to use wheelchair for long distances (5/5/22) The Care Plan revised on 5/4/22 identified Resident #9 fell . The care plan interventions included: a. Staff to anticipate and meet needs (1/20/22) b. Scoop mattress added to bed (5/5/22) c. Call light cord extended and clip added - nursing staff to ensure they clip the call light to the resident (clothing) prior to exiting the room (4/12/22) d. Encourage Resident #9 to wear gripper socks (4/17/22) e. Check the resident frequently throughout the night (5/5/22) f. Gripper strips added to the floor in front of the bed (3/6/22) g. Apply gripper socks to Resident #9's feet when not wearing shoes (3/6/22) h. Ensure the resident wears appropriate footwear (8/4/22) i. Move bed into the lowest position when the resident rests in bed (7/6/22) j. Pressure brakes applied to the wheelchair (5/26/22) k. Physical therapy and occupational therapy to evaluate and treat (8/4/22) l. Staff to ensure the resident's bed is in the lowest position while in bed (8/4/22) The Progress Notes for Resident #9 revealed: a. On 6/2/22 at 6:30 PM, incident/accident/unusual occurrence note revealed staff found Resident #9 lying on her stomach in her room between the foot of the bed and the closet. The resident reported she hit her head and when she shifted, her left wrist was turned outward and she complained of pain in that area. The resident's family transported her to the emergency room for x-rays. b. On 6/2/22 at 11:00 PM, the hospital called the facility and reported the resident had fractured her wrist and now wore a splint and sling. She also had a follow-up appointment with a specialist and a new order for pain medication as needed. c. On 6/6/22 at 11:34 AM, Resident #9 had an appointment with the orthopedic specialist that gave new orders: elevate the left extremity about the shoulder and perform range of motion exercises. d. On 6/14/22 at 11:53 AM, Resident #9 returned from an orthopedic appointment with a short cast to the left wrist with new orders: non-weight bearing on left hand/wrist and use platform walker. e. On 6/23/22 at 8:59 AM, staff documented they found the resident on the floor in her room halfway between the bed and the bathroom. The resident had been incontinent. f. On 7/6/22 at 5:44 AM, resident found on the floor next to the bed in their room. The resident reported she went to the bathroom and slid off the edge of the bed. g. On 7/12/22 at 12:44 PM, resident returned from orthopedic appointment with a Velcro wrist brace on her left wrist and an order to continue with range of motion and increase activity as tolerated. A Fall Risk Evaluation dated 4/22/22, identified Resident #9 scored 12 points (high risk) related to: cognition, history of falls, ambulation, elimination status, diagnosis, medications, and an inability to evaluate gait & balance. A score of 10 or higher = high risk for falls. The Un-witnessed Fall Investigation dated 6/2/22 at 6:30 PM revealed staff found Resident #9 on the floor in her on her stomach. The resident denied pain until turned over and then complained of left wrist pain & the noted her wrist turned outward. The resident wore no shoes and her wheelchair was at the top of the bed. The resident stated had fallen off the bed. a. Immediate action: head to toe assessment, neurological assessment, and the resident stood with assist of 2 staff. b. Injuries observed at time of incident: hematoma c. Pain level: 10/10 d. Mental Status: oriented to person e. Injuries report post incident: no injuries observed post incident f. Predisposing environmental factors: none g. Predisposing physiological factors: confused, gait imbalance, weakness/faint h. Predisposing situation factors: ambulated without assist Review of the Imaging Report from the local hospital dated 6/2/22 revealed Resident #9 sustained a transverse comminuted impacted fracture of the distal radius. Review of the Medication Administration Record (MAR) dated June 2022 for Resident #9 revealed an order dated 6/3/22 for [MEDICATION(S)]/Acetaminophen (opioid pain medication) 5/325 mg (milligrams) every 4 hours as needed for left wrist fracture. Documentation revealed Resident #9 received the pain medication 1-3 times per day from 6/3-6/30/22, with the exception of 6 days where not medication administered. Review of the MAR dated July 2022 for Resident #9 revealed the resident received the [MEDICATION(S)]/Acetaminophen 5/325 mg as needed order 1-2 times per day from 7/1 - 7/20/22, with the exception of 6 days where no medication had been administered. Review of the Un-witnessed Fall Investigation forms dated 6/23/22 and 7/6/22 revealed staff found Resident #9 on the floor and identified she had attempted to transfer herself to go to the bathroom. Observation on 8/24/22 at 4:20 PM, revealed Resident #9 lay in bed with her covers pulled to just under the chin, call light clipped to the top of the covers and bed in low position without the scooped mattress in place. The resident's was parked at the bottom side of the bed and contained a cushion. On 8/25/22 at 8:05 AM, Resident #9 sat in her wheelchair in the main dining room while facility staff encouraged her to eat. The resident wore gripper socks, a black brace on her left wrist, and a wander guard bracelet on her right wrist. On 8/25/22 at 8:25 AM, Resident #9 remained in the dining room. Observation in the resident's room revealed no scooped mattress on the bed. On 8/25/22 at 10:23 AM, Resident #9 lay in bed with the head of her bed elevated and the bed in the lowest position. Resident #9's feet hung over the edge of the bed without a scooped mattress in place. She wore a blouse, an incontinence brief, and gripper socks. The call light was clipped to the blankets, which lay off to the side of the resident and against the wall. Her wheelchair brakes were on and the wheelchair was parked at the head of the bed. On 8/25/22 at 11:04 AM, Resident #9 sat up on the edge of the bed with her feet on the floor, call light attached to the blankets against the wall. Closer observation revealed no scooped mattress on the bed or gripper strips on the floor beside the bed. In an interview on 8/24/22 at 4:31 PM, Staff C CNA stated they used an EZ stand (sit-to-stand) lift to transfer Resident #9. She added that depending on the day, the resident could transfer with assist of 1-2 staff. Staff C stated the resident's participation fluctuated and this led to staff using the sit-to-stand at times vs. transfer with assist of 1-2 staff. Staff C stated Resident #9 had always required transfer assistance for as long as they had worked at the facility (6 months). However, due to the resident's dementia she did not always wait for staff to assist her. She commented the resident believed she could transfer by herself. Staff C reported she had worked the overnight shift when Resident #9 had fallen and fractured wrist. Staff C added that facility staff attempted to drape the call light over the resident's legs, so the call light would turn on if she moved her legs or the covers. On 8/24/22 at 4:50 PM, Staff D CNA stated had been employed at the facility for 6 months, but was unsure if Resident #9 transferred with the use of the EZ stand or with assist of 2 staff but knew she did well with both. Staff D said she thought the resident could transfer herself, however the CNA's preferred to transfer the resident. Staff D stated when Resident #9 fell on [DATE] supposed to have assistance with transfers. She reported she had not worked the day Resident #9 fell and broke her wrist, but knew the resident had tried to transfer without assistance before the fall and fracture, also. Staff D said the resident used to live in Room #1 - closer to the nurse's station - and staff would leave the door open and could see with the mirror into the resident's room to frequently check on her throughout the day. Staff D stated the resident lived in Room #11 now, but did not try to get up by herself anymore. On 8/25/22 at 10:33 AM, Staff E CMA stated she started working at the facility after Resident #9's fall and fracture but did work there when she had a cast on her wrist. Staff E stated Resident #9 had history of getting up independently from bed without waiting for staff assistance. Fall interventions included check and change the resident to keep her comfortable, living in Room #1 close to the Nurse's Station then so staff could respond immediately if she yelled out and check her frequently during the shift. She added staff also checked the resident for incontinence and changed her if needed to keep her comfortable. On 8/25/22 10:59 AM, Staff F CNA stated had been employed at the facility since January 2022, however, had not worked on the day Resident #9 had fallen and fractured wrist. Staff F stated the resident was not patient, did not wait for staff assistance to transfer, and would be out of her bed in 2 seconds. Staff F reported the resident used to be in room #1 and last week the facility moved her to Room #11 because Room #1 was a private room. Staff F added that Resident #9 continued to get up by herself in Room #11. Staff F said she didn't really know of any interventions to prevent falls for Resident #9, but she probably would try to keep the resident at the nurse's station if she was frequently up & down. She also said she would have staff sit with the resident one-to-one if that had enough staff, but not often due to not enough staff. On 8/25/22 at 11:09 AM, Staff G CNA they worked at the facility for 4.5 years and stated Resident #9 had a history of trying to transfer herself without waiting for staff assistance and still continued to attempt to do so. Staff G stated after breakfast the resident had hollered out and had her feet out of the bed, so staff attempted to redirect and re-position her and then the resident seemed okay. Staff G again stated Resident #9 continued to attempt to transfer herself. Staff G said facility staff remind Resident #9 what the call light is for and place the bed in low position. Staff G commented that after that, there was not a lot the facility could do to prevent Resident #9's falls without the family permission. Staff G reported staff took her to the bathroom with the EZ stand when they helped Resident #9 up because she head increased difficulty trying to stand. Staff G said they also took the resident to the toilet before & after breakfast and lunch. On 8/25/22 at 11:18 AM, Staff H CNA stated they had not worked the day Resident #9 had fallen and fractured her wrist. Staff H reported Resident #9 tried to get up on her own and fall interventions included: frequently check on the resident and place the call light across the resident when she was in bed & when she moved, the call light would activate. Staff H added that Resident #9 got up without assistance to go to the bathroom. Staff H stated Resident #9 toileted in the morning and before & after meals. Staff H added she had recently seen Resident #9 sit up on the side of the bed, but had not observed her try to transfer herself recently. On 8/25/22 at 11:24 AM, Staff I CNA stated they had not worked the day Resident #9 fell and fractured her wrist. Staff I reported Resident #9 did not attempt to get up without help as often as she previously had; she would wiggle a little like wanted to get up, but would not. Staff I added prior to the wrist fracture, staff knew if Resident #9's call light had activated or she started to holler they needed to get there ASAP as she would try to transfer herself to go to the bathroom. Staff I reported fall interventions included: place the resident where the staff could observe her in the dining room, don't leave her alone in the wheelchair, and check her frequently. Staff I said staff attempted to clip the call light to the blankets or the resident legs so if the resident moved, it would activate the call light. On 8/25/22 at 12:16 PM, the Director of Nursing (DON) reported Resident #9 fell & fractured their wrist, but she was not sure of the interventions implemented to prevent the resident from falling. After the DON reviewed the resident's care plan, the DON confirmed the resident's bed did not contain a scooped mattress at this time, there were no gripper strips on the floor beside the resident's bed, and the resident did not currently live in Room #1. The DON reviewed Resident #9's progress notes and confirmed the resident had a history of falls, a history of attempting to transfer themselves, and had previously lived in Room #1 as a fall intervention.

Based on observation, policy review and staff interview the facility failed to label and store food items appropriately, in order to reduce the risk of contamination and food-borne illness. The facility reported a census of 34. Findings included; During initial tour of the kitchen on 8/16/21 at 09:16 AM included the following items; a. bag of frozen fried chicken 12 piece not dated or labeled. b. bag of frozen dough 32 pieces not dated or labeled. c. part bag of frozen diced chicken not dated or labeled ( approximately 1 pound). d. bag of 12 frozen pre made omelets not dated or labeled. e. part bag of frozen cooked sausage 5 lbs 1/4 full not dated or labeled. f. bag of frozen fish 12 piece not date or labeled. g. 16 glasses of water in refrigerator not covered or dated. h. container of sugar with a pitcher( used as a scoop) inside touching the sugar. Policy Food Storage -Refrigerated Foods dated 2/16 Policy Perishable foods shall be refrigerated in a manner which optimizes food safety, nutrient retention and aesthetic quality. Procedure: Refrigerated foods will be covered, labeled, and dated (month, day, year) Policy Storage of Frozen Foods dated 2/16 Policy Perishable foods shall be refrigerated in a manner which optimizes food safety, nutrient retention and aesthetic quality. Procedure: All frozen products will be sealed. labeled and dated (month,day, year), Including items removed from original packaging. Policy Storage of Non-Perishable Foods : All Non-Perishable foods shall be stored in a manner which optimizes food safety, nutrient retention and aesthetic quality, and food safety. Procedure: a. Non- Perishable foods will be dated upon delivery indication date (month, day, year) product was received. b. Open boxes or cans will be stored in sealed containers or zip lock bags for a period not exceed the use by or expiration dates. c. Bins used for storage for storage of staples should be labeled on top and side for contents. Measuring utensils will not be stored in bins with food products. During an interview with the Administrator on 8/16/21 at 9:40 AM he stated he would throw the things away, they should be dated and the pitcher (scoop) should not be in the sugar.

Based on observation, facility policy review, and staff interview, the facility failed to provide Covid-19 screening for visitors, failed to ensure staff properly wore the face covering (mask covering mouth and nose) while in the facility. The facility reported a census of 34 residents. Findings Include: On arrival to the facility, staff took the state survey team team through the facility without conducting a Covid-19 screening prior to entering the building. Policy review of the facility's Covid-19 Employee/Visitor Screening Process directed staff to screen all staff and visitors before they entered the building. An interview with the Director of Nursing (DON) stated she expected staff to screen all visitors and employees Covid-19 before they entered the building. During an observation on 8/16/21 at 11:57 AM, Staff A, Dietary Aide wore a face covering (surgical mask) in a manner which exposed her nose while she passed out drinks in the dining room. The COVID-19 Re-Opening Plan dated 2/15/21 policy directed staff needed to follow Core Principles during each Phase of the Re-Opening Plan which included wearing Face Coverings or a mask over their mouth and nose. On 8/19/21 at 1:34 PM, the Administrator stated he expected staff to wear the face covering properly by covering their nose and mouth.

Based on clinical record review, observations, policy review, resident and staff interviews the facility failed to follow professional standards for safe medication administration practices for 2 of 5 residents reviewed (Resident #5 and #7). The facility reported a census of 34 residents. Findings included; 1. The quarterly Minimum Data Set(MDS) dated [DATE] reported Resident #5 scored 11 of 15 possible points on the Brief Interview for Metal Status (BIMS) test, which meant the resident demonstrated moderately impaired cognitive abilities. The MDS documented the resident remained independent with transfers and also documented she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified she had 1 fall with minor injury. The MDS also identified she took anti-anxiety and antidepressant medication on 7 of 7 days during the look back period. Resident #5's Care Plan updated 7/20/21 documented a risk for falls due to a history of stroke and identified she experienced an unwitnessed fall on 4/3/21. The Care Plan directed staff to encourage the resident to call for assistance during illness or as needed. The Medication Administration Record (MAR) for Resident #5 dated 4/21/21 revealed the following mid morning medication: [MEDICATION(S)], tablet 0.5 mg give 1 tablet by mouth three times a day for anxiety disorder( antianxiety). An incident report dated 4/3/21 at 1:01 pm documented Resident # 5 had an unwitnessed fall today at 11:55 AM The resident reported she thought she had dropped a pill. She moved her recliner by herself to look for the pill rather than using her call light to request assistance. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/18/21 at 1:33 PM, Staff B Licensed Practical Nurse (LPN) stated she had helped Resident # 5 look for the pill the day she fell . Staff B explained it was not lost it was in the med cup on her overbed table. Staff B stated it was her [MEDICATION(S)] that she always wants right away. She reported the med aide must have left it there. During an interview on 8/18/21 at 2:21 PM, the Director of Nursing (DON) reviewed the initials on the MAR and explained if the medication aide passed pills then she would have signed the MAR with her initials. The DON reviewed the MAR and determined the initials belonged to Staff B. The DON said that meant Staff B had given the mid-morning [MEDICATION(S)] found in the resident's room. In a subsequent interview on 8/18/21 at 2:30 PM, Staff B LPN verified the initials on the MAR and stated she did not remember passing the pills that day, but confirmed the resident looked for her [MEDICATION(S)] when she fell . She explained that usually they had a Certified Medication Aide (CMA) passing medications. On 8/18/21 at 3:04 PM, the DON produced the payroll information for 4/3/21 and reported Staff B had worked on the medication cart on that date. 2. Resident #5's Care Plan revised on 3/15/20 documented she had taken anxiety medication for a long time and sees a practitioner for psychiatric services to manage her depression and anxiety. An observation on 8/18/21 at 7:47 AM revealed a medication cup full of medications located on the bedside table in Resident #5's room. Alerted the Corporate Nurse Consultant and she removed each medication from the cup and placed each in a separate pill cup. She then had Staff C, CMA obtain the medication cards so the could identify the medications. Staff C verified she had left the medication with the resident in her room. The Corporate Nurse Consultant identified each medication. The cup Staff C had left unattended in the resident's room had contained the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Amloldipine [MEDICATION(S)] 10 mg 2. [MEDICATION(S)] 100 mg . 3. [MEDICATION(S)] 20 mg 4. Vitamin D3 1000 unit 5. [MEDICATION(S)] 1500 mg 6. [MEDICATION(S)] 0.1 mg 7. [MEDICATION(S)] HCI 10 mg 8. [MEDICATION(S)] 150 mg 9. [MEDICATION(S)] 0.5 mg The Corporate Nurse Consultant put the medications back into the cup and took them to the resident's room for her to take at that time. She explained the resident did not have an order to keep the medications at bedside due to her BIMS of 11. The Medication Administration Record (MAR) for Resident #5 dated August of 21 included the following morning medications; a. [MEDICATION(S)] 10 mg (milligrams) give 1 tablet by mouth daily for hypertension. b. [MEDICATION(S)] capsule 100 mg give 1 capsule by mouth daily for constipation. c. [MEDICATION(S)] 20 mg give 1 tablet by mouth daily for hypertension. d. Vitamin D 3 tablet 1000 units give 2 tablets by mouth daily for nutrient deficiency. e. Calcium Carbonated tablet 1500 mg give 1 tablet by mouth twice a day for nutrient deficiency. f. [MEDICATION(S)] 0.1 mg give 1 tablet by mouth twice a day for hypertension. g. [MEDICATION(S)] tablet 10 mg give 1 tablet by mouth twice a day for cognition. h. [MEDICATION(S)] capsule 150 mg give 1 capsule by mouth twice a day for [CONDITION(S)] (blood thinner). i. [MEDICATION(S)], tablet 0.5 mg give 1 tablet by mouth three times a day for anxiety disorder( antianxiety). Policy Medication Administration dated 1/2015 Purpose included the following: a. To assure that each resident receives the proper medication at the correct time as ordered by their physician. b. To provide correct medications in correct dose to correct resident. c. To establish a systematic approach of administering medications to the resident. Guidelines: d. Administer the medication (if the resident refuses medications, indicate by circling on the MAR and charting on the the reason for refusal). e. Observe the act of swallowing; f. Record the medication given on the MAR by initialing the proper square. g. Medication are not to be left in a resident's room unless there are specific orders for medication at bedside. Medication must be maintained in a locked box and addressed on overall plan of care. During an interview on 8/18/21 at 9:57 AM Staff C CMA stated she should not have left the medications in the room with Resident #5 this morning and swill not so do again. During an interview on 8/19/21 at 7:45 AM Resident # 5 stated they use to leave my medications on the side table and I always took them later. They have not left them the last day or so. 3. The quarterly MDS dated [DATE] reported Resident # 7 had a BIMS score of 14 (intact cognitive abilities) and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed he received insulin injections 7 out of the 7 days during the lock back period. Resident #7's Care Plan dated 2/1/21 documented he used insulin/hypoglycemic medications related to diabetes and directed staff to monitor blood glucose as ordered and monitor for side effects (low blood sugar, headache, weakness, sweating and [CONDITION(S)]) and effectiveness. Resident #7's MAR for May Insulin [MEDICATION(S)] Solution (short acting insulin) inject subcutaneously per sliding scale four times a day. The MAR included a blood sugar on 5/13/21 at mid-morning of 208 and documented not given. Resident #7's Order Summary Report for May 21 included [MEDICATION(S)] Solution inject subcutaneously per sliding scale four times a day, sliding scale 0-150 =0, 151-200 =2 units, 201-250= 3 units, 251- 300 =4 units, 301-350 = 6 units, 351-400= 9 units, 401-999=12 units and contact physician. Incident report dated 5/13/21 at 11:38 AM documented gave the resident incorrect insulin. Gave 30 units of Novolog (rapid -acting insulin). Reported to DON charge nurse and physician in the house at the time of incident. New order: Blood Sugar checks every 4 hours and monitor for hypoglycemic symptoms. Blood Sugar at the time: 208. Sliding scale insulin held and not given. Progress note dated 5/13/2021 at 3:11 PM noted gave resident incorrect insulin - Novolog 30 Units given During an interview on 8/18/21 at 4:07 PM with the DON acknowledged when asked about the resident inadvertently getting 30 units of Novolog. She explained she talked to the nurse about triple checking the insulins and how important it was to administer the correct dose. DON explained Resident #7 had gotten some body else's insulin dose. During an interview on 8/19/21 at 9:56 AM Staff D Registered Nurse (RN) explained she gave the wrong dose of insulin; it was her 2nd day on the job and the nurse orientating her asked if she would do the insulins since the doctor was there rounding and had question of the other nurse. Staff D acknowledged she caught it right away and the doctor gave orders. She said the identification pictures on the MAR were not very good to use to identify the resident. She said she asked if she was (other resident's name) and Resident #7 stated yes to the other name, so she administered the insulin.

Based on office file review, staff interview, and facility policy review the facility failed to compile a complete criminal background check for 1 of 5 staff members reviewed. Findings include: Review of a list provided by the facility of new hires in the last 6 months revealed Staff A, Housekeeping had a hire date of 4/17/19. Review of Staff A's employee file revealed a Single Contact License & Background Check completed on 4/11/19, that directed the facility to initiate record check evaluation process by completing form [PHONE NUMBER] and submitting it to the Department of Human Services (DHS). Review of Staff A's employee file with the Business Office Manager revealed form [PHONE NUMBER] was not completed after receiving Staff's background check results. In an interview on 8/25/19 at 3:05 p.m., the Business Office Manager stated she had not completed background checks for a long time. During a follow up staff interview on 8/27/19 at 2:06 p.m., the Business Office Manager stated Staff A was only in training while working in the facility, never worked on the floor as a housekeeper on her own, and is not presently employed at the facility. The Employee Punch Report provided by the facility documented Staff A punched in and out on the following dates and times: a. 4/17/19 from 9:00 a.m. - 10:30 a.m. b. 4/18/19 from 5:00 a.m. - 12:01 p.m. c. 4/20/19 from 5:00 a.m. - 11:40 p.m. d. 4/21/19 from 5:00 a.m. - 10:45 a.m. e. 4/22/19 from 5:00 a.m. - 11:33 a.m. f. 4/23/19 from 5:00 a.m. - 11:20 a.m. g. 4/24/19 from 4:58 a.m. - 10:30 a.m. h. 4/25/19 from 5:13 a.m. - 11:01 a.m. i. 4/26/19 from 6:11 a.m. - 7:29 a.m. j. 4/28/19 from 4:47 a.m. - 10:28 a.m. k. 4/29/19 from 4:49 a.m. - 11:20 a.m. l. 4/30/19 from 5:03 a.m. - 11:32 a.m. m. 5/1/19 from 5:00 a.m. - 9:34 a.m. n. 5/2/19 from 4:52 a.m. - 11:57 a.m. o. 5/3/19 from 4:39 a.m. - 11:16 a.m. p. 5/6/19 from 4:58 a.m. - 11:51 a.m. q. 5/7/19 from 4:54 a.m. - 11:47 a.m. r. 5/8/19 from 4:47 a.m. - 11:30 s. 5/9/19 from 4:28 a.m. - 10:44 a.m. t. 5/30/19 from 5:37 a.m. - 11:06 a.m. u. 5/31/19 from 5:21 a.m. - 9:53 a.m. v. 6/3/19 from 5:22 a.m. - 11: 06 a.m. w. 6/4/19 from 5:18 a.m. - 11:00 a.m. y. 6/5/19 from 5:23 a.m. - 11:21 a.m. z. 6/6/19 from 7:14 a.m. - 11:38 a.m. Review of the facility's Dependent Adult Abuse Protocols with a revised date of 5/2017 revealed directed facility staff to screen all potential employees for history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of [REDACTED].

Based on clinical record review and facility and hospital staff interviews, the facility failed to allow return of one of three residents reviewed after an emergency room visit (Resident #31) . The facility reported a census of 28 at the time of the survey. Findings include; 1. The Minimum Data Set assessment dated [DATE] for Resident #31 recorded he had verbal behaviors symptoms director toward others and the behavior occurred one to three days during the week long assessment period. The resident independently completed his activities of daily living. The MDS further identified [DIAGNOSES REDACTED]. (indicating moderately impaired cognition). Resident # 31's Care Plan dated 1/19/17 identified a problem of depression and suicidal ideation and instructed to redirect the resident when upset and support his decisions and choices. The Nurse's Notes dated 6/17/17 at 12:15 PM documented Resident #31 as up per usual with a pleasant mood, oriented to self and his speech clear. The Nurse's Notes dated 6/22/17 at 8:00 PM noted the Resident #31 had no behaviors this shift. The Nurse's Notes dated 6/30/17 at 9:00 AM recorded Resident #31 slapped his roommate on the arm and when they were asking Resident #31 to stand to make the bed. Resident #31 acted as if he was going to put his pillow over his roommate's face. At The Telephone Order form dated 6/30/17 at 9:05 AM documented a new order to send Resident #31 to the hospital for a psychiatric evaluation due to escalating behavior. The Nurse's Note of 6/30/17 at 9:10 AM recorded staff called the local emergency room to notify of Resident's #31 transferred for a psych evaluation. The notes documented he left the facility via ambulance at 9:40 AM and did not return to the facility after that date. During an interview on 5/23/18 at 1:53 PM, the Director of Nursing (DON) and nurse consultant stated Resident # 31's discharge was complicated. The facility made a self-report to The Department of Inspection and Appeals (DIA) on 6/30/17 that Resident # 31 attempted to put a pillow over another resident's face due to being very angry and staff had to intervene to get him to quit. The DON reported they sent the resident to the hospital and the resident had mental health issues. The resident then transferred to another facility. She stated they did not refuse to take the resident back; they were not asked to. During an interview on 5/24/18 at 9:38 with the Chief of Nursing Operations (CNO) and the Chief Executive Officer (CEO) with the Resident #31's receiving hospital revealed a time line for Resident #31 during his stay at the hospital. The CNO later provided a printed time line as follows; · 6/30/17 at 10:02 AM, the resident presented to ER for escalating behaviors. · 7/1/17 at 8:10 AM, the medical director of tele psych planned to call the facility to discuss Resident #31's return to the facility. · 7/1/17 at 9:08, the doctor recorded the nursing home refused to take the patient back and he did not meet criteria for in-patient mental health placement. · 7/1/17 the paramedic from the hospital contacted the facility's DON who refused to take Resident #31 back to the facility until he received treatment at an in-patient psych (the resident did not meet in-patient psych criteria). · 7/3/17 PASSR started - triggered level 2, that can take 8-10 days to get back. · 7/7/17 the level 2 PASSR completed. · 9/18/17 Resident #31 transferred to another Long Term Care Facility. During further interview on 5/24/18 at 12:38 PM, the DON acknowledged the facility did not have any documentation on Resident #31 about the hospital calling to return him back to the facility and he did not return after he had been sent out to the hospital.

Based on clinical record review and staff interviews, the facility failed to provide bed hold notice before transferring two of three sampled residents (#31 and #81) to the hospital. The facility reported a census of 28. Findings include; 1. The Minimum Data Set assessment dated [DATE] for Resident #31 recorded he had verbal behaviors symptoms director toward others and the behavior occurred one to three days during the week long assessment period. The resident independently completed his activities of daily living. The MDS further identified [DIAGNOSES REDACTED]. (indicating moderately impaired cognition). Resident # 31's Care Plan dated 1/19/17 identified a problem of depression and suicidal ideation and instructed to redirect the resident when upset and support his decisions and choices. The Nurse's Notes dated 6/17/17 at 12:15 PM documented Resident #31 as up per usual with a pleasant mood, oriented to self and his speech clear. The Nurse's Notes dated 6/22/17 at 8:00 PM noted the Resident #31 had no behaviors this shift. The Nurse's Notes dated 6/30/17 at 9:00 AM recorded Resident #31 slapped his roommate on the arm and when they were asking Resident #31 to stand to make the bed. Resident #31 acted as if he was going to put his pillow over his roommate's face. At The Telephone Order form dated 6/30/17 at 9:05 AM documented a new order to send Resident #31 to the hospital for a psychiatric evaluation due to escalating behavior. The Nurse's Note of 6/30/17 at 9:10 AM recorded staff called the local emergency room to notify of Resident's #31 transferred for a psych evaluation. The notes documented he left the facility via ambulance at 9:40 AM and did not return to the facility after that date. During an interview on 5/24/18 at 12:01 PM, the Director of Nursing stated the facility did not provide Resident #31 a notice of the facility's bed hold policies. 2. The MDS assessment for Resident #81, dated 11/6/17, documented he had no mood or behaviors symptoms during the 7 day look back period. The MDS identified he required the assistance of one staff for bed mobility, transfers, dressing and toileting and displayed independence with personal hygiene. The MDS further identified [DIAGNOSES REDACTED]. The assessment documented a BIMS score of 12 out of 15 that indicated moderately impaired cognition. Resident #81's Care Plan dated 8/18/17 identified a problem of difficulty speaking and directed staff to give him time to respond, ask simple questions and to respect his wishes to spend time as he had chosen. The Nurse's Notes dated 10/21/17 at 3:00 PM recorded a Certified Nursing Aide (CNA) went into Resident #81's room to offer snacks and juice and found the resident lying on the bed with a plastic trash bag around his head. The CNA reported to the nurse and nurse went into the resident's room and asked what had happened. The resident reported he was trying to kill himself since nobody understands his disease. Staff placed the resident on one-to-one supervision and obtained an order to send him to the hospital. The Telephone Order form dated 10/21/17 at 3:00 PM ordered to transfer Resident #81 to the hospital by ambulance for a psychiatric evaluation. During an interview on 5/24/18 at 12:01 PM, the Director of Nursing stated the facility did not provide Resident #81 a notice of the facility's bed hold policies.

This deficiency relates to facility self report -I. Based on record review and staff interviews, the facility failed to ensure one of four residents were free from abuse; and provided adequate supervision in accordance with Resident #1's care plan. On 4/19/16, staff did not immediately intervene when they noticed Resident #1 entering Resident #2's room; and later found Resident #1 inappropriately touching Resident #2. Staff interviews revealed they were unaware of Resident #1's care plan provisions to protect residents from abuse. The facility reported a census of 33 residents. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 2/25/16, Resident #1 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #1 required limited assistance with bed mobility, transfers and toilet use and extensive assistance with dressing and personal hygiene. Resident #1's [DIAGNOSES REDACTED]. Nurse's notes dated 11/5/15 at 12:40 p.m. documented Resident #1 observed touching Resident #2 inappropriately, making the other resident feel uncomfortable while in the dining room. Resident #2 stated, No and guarded him/her(self). Resident #1 ignored staffs verbal request to stop touching Resident #2 and again touched Resident #2. Resident #2 stated, No and again covered him/her(self). The nurse escorted Resident # 2 to his/her room and Resident #1 patted Resident #2 ' s buttocks as he/she stood up. Resident #2 again told Resident #1 No , and walked away. The nurse reported Resident #1 ' s behavior to the Administrator, DON and Social Service. The notes identified staff asked Resident #1 not to touch Resident #2 and he/she was uncomfortable with this, and Resident #1 voiced an understanding. Resident #1's care plan dated 11/5/15 indicated a problem with inappropriate sexual behavior with another resident and interventions which included: *Staff will monitor whereabouts and activity of Resident #1. *Staff will monitor interactions with residents of the opposite sex to ensure there are no further incidents of inappropriate behaviors. According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 2/18/16, Resident #2 had a brief interview for mental status (BIMS) score of 13 indicating intact cognitive skills for daily decision making. Resident #2 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #2's [DIAGNOSES REDACTED]. Nurse's Notes dated 4/19/16 at 7 p.m., documented Resident #1 pushed another resident's wheelchair (Resident #2) into his/her room and entered behind. The nurse reported she watched when Resident #1 did not come back out of the resident's room. The nurse heard Resident #1 say, is this ok?; and did not hear the other resident's reply. The nurse stepped into the room and Resident #2's shirt had been pulled up with Resident #1 holding Resident #2's breast in his/her hand. The nurse asked Resident #1 to step out (of the room) and Resident #1 did not reply, and left the room. Resident #2 informed the nurse he/she did not want Resident #1 in his/her room. The nurse documented she spoke with Resident #1 and requested he/she not touch Resident #2 ever again. The nurse documented Resident #1 turned his/her head away as if he/she did not hear the nurse. The nurse documented they started 15 minute monitoring. In an interview on 5/10/16 at 3:18 p.m. Staff A, certified nurse aide, stated on the evening of 4/19/16 she had been in the dining room and noticed Resident #1 pushing Resident #2's wheelchair towards Resident #2's room. Staff A stated she didn't think much of it, but continued to watch. Resident #1 then pushed Resident #2 into his/her room and followed. Staff A peeked in the room and saw Resident #2 facing his/her bed and Resident #1 sitting and facing Resident #2's left side. Staff A did not enter the room and did not know where Resident #1's hands were. Staff A went across the hall to the break room and informed Staff B of Resident #1's whereabouts. Staff B immediately responded and entered Resident #2's room. Staff B said something like, we'll take care of Resident #2 and Resident #1 propelled him/herself out of the room. Staff A stated she was in the doorway and not aware of what Resident #1 had been doing. Staff A stated afterwards Resident #1 was placed on 15 minute checks. Staff A stated she knew of an incident in which Resident #1 had touched a resident inappropriately. Staff A stated she was unaware of Resident #1's care plan interventions regarding supervision when interacting with residents of the opposite sex. In an interview on 5/11/16 at 9:23 a.m. Staff B, Licensed Practical Nurse, stated at around 7:00 p.m. on 4/19/16 she was in the break room when Staff A came in and informed her Resident #1 was pushing Resident #2's wheelchair into Resident #2's bedroom. At first Staff B thought it looked sweet. Within seconds Staff B noticed a scowl on Resident #2's face. Staff B entered the room and saw Resident #2's shirt lifted and Resident #1 grabbing his/her left breast. Staff B immediately separated the residents and questioned Resident #2 who was clearly disturbed with what had occurred. Resident #2 indicated he/she did not want Resident #1 in his/her room. Staff B moved Resident #2 into another hallway away from Resident #1 and placed Resident #1 on 15 minute checks. Staff B stated it all happened within seconds. Staff B stated she was unaware of the care plan intervention to monitor Resident #1 around Residents of the opposite sex. In an interview on 5/10/16 at 4:25 p.m. Staff C, certified nurse aide, stated she was working the evening shift on 4/19/16 and was on another hall when Resident #1 went into Resident #2's room. Staff C stated it has always been known Resident #1 can be a little handsy and needed watched. Staff C stated she knew of times Resident #1 had been in other resident rooms and was redirected without incident. He/she had a friendship with another resident and they held hands. There was also a resident that felt uncomfortable around Resident #1. Staff C knew of no instances in which Resident #1 was inappropriate with residents or staff. In an interview on 5/11/16 at 10:30 a.m., the Director of Nursing (DON), stated she received a call on 4/19/16 informing her of the incident between Residents #1 and #2. The DON indicated the residents were separated and Resident #2 was moved to another hall. The DON spoke with Staff A and Staff B explained she was uncomfortable that a resident had been allowed to enter the room of a resident of the opposite gender. The DON also pointed out Resident #1's care plan interventions requiring staff to monitor Resident #1's interactions with residents of the opposite gender. The DON stated she provided a 5 minute in-service for staff pointing out Resident #1's care plan and the necessity to monitor Resident #1's whereabouts every 15 minutes.

Based on record review and staff interviews, the facility failed to provide supervision in accordance to a resident's written plan of care. (Resident #1) The facility census was 33 residents. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 2/25/16, Resident #1 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #1 required limited assistance with transfers and toilet use and extensive assistance with dressing and personal hygiene. Resident #1's [DIAGNOSES REDACTED]. Nurse's notes dated 11/5/15 at 12:40 p.m. documented Resident #1 observed touching Resident #2 inappropriately, making the other resident feel uncomfortable while in the dining room. The resident was saying, No and guarding him/herself. Resident #1 ignored staffs verbal request to stop touching this resident and repeated the behavior before staff escorted Resident #1 back to his/her room. Nurse's notes dated 4/19/16 at 7:00 p.m. documented Resident #1 observed pushing a female resident in the wheelchair into her room. When Resident #1 did not come back out of the room, the nurse heard Resident #1 state is this ok, the nurse then stepped into the room and the female resident's shirt was pulled up and Resident #1 was holding the resident's breast. The nurse prompted Resident #1 to leave the room. After visiting with the female resident, the nurse informed Resident #1 the female resident would not let him back into her room and did not want to be touched by him ever again. Resident #1 turned his head away as if not to hear. Was informed the Administrator would talk to him in the morning, 15 minute checks begun. Resident #1's care plan dated 11/5/15 indicated a problem with inappropriate sexual behavior with another resident and interventions which included: *Staff will monitor whereabouts and activity of Resident #1. *Staff will monitor interactions with residents of the opposite gender to ensure there are no further incidents of inappropriate behaviors. In an interview on 5/10/16 at 3:18 p.m. Staff A, Certified Nurse Aide (CNA), stated on the evening of 4/19/16 she was in the dining room and noticed Resident #1 pushing Resident #2 in the wheelchair towards that resident's room. Staff A stated she didn't think much of it, but continued to watch. Resident #1 then pushed the resident into his/her room and followed. Staff A peeked in the room and saw Resident #1 sitting and facing Resident #2's left side. Staff A did not enter the room and did not know where Resident #1's hands were. Staff A went across the hall to the break room and informed Staff B, Licensed Practical Nurse (LPN) of Resident #1's whereabouts. Staff B immediately responded and entered Resident #2's room. Staff B said something like, we'll take care of him/her and Resident #1 propelled him/herself out of the room. Staff A stated she was in the doorway and not aware of what Resident #1 had been doing. Staff A stated afterwards Resident #1 was placed on 15 minute checks. Staff A stated she knew of an incident in which Resident #1 had touched a resident inappropriately. Staff A stated she was unaware of Resident #1's care plan interventions regarding supervision when interacting with residents of the opposite gender. In an interview on 5/11/16 at 9:23 a.m. Staff B, LPN, stated at around 7:00 p.m. on 4/19/16 she was in the break room when Staff A came in and informed her Resident #1 was pushing Resident #2 in a wheelchair into that resident's bedroom. At first Staff B thought it looked sweet. Within seconds Staff B noticed a scowl on the other resident's face. Staff B entered the room and saw that resident's shirt lifted and Resident #1 grabbing his/her left breast. Staff B immediately separated the residents. The second resident was clearly disturbed with what had occurred and indicated he/she did not want Resident #1 in his/her room. Staff B stated it all happened within seconds. Staff B stated she was unaware of the care plan intervention to monitor Resident #1 around residents of the opposite gender. In an interview on 5/10/16 at 4:25 p.m. Staff C, CNA, stated she was working the evening shift on 4/19/16 and was on another hall when Resident #1 went into Resident #2's room. Staff C stated it has always been known Resident #1 can be a little handsy and needed watched. In an interview on 5/11/16 at 10:30 a.m., the Director of Nursing (DON), stated she received a call on 4/19/16 informing her of the incident between Resident #1 and #2. The DON indicated the residents were separated and Resident #2 was moved to another hall. The DON spoke with Staff A and Staff B explaining she was uncomfortable that a resident was allowed to enter the room of a resident of the opposite gender. The DON also pointed out Resident #1's care plan interventions requiring staff to monitor Resident #1's interactions with residents of the opposite gender. The DON stated she provided a 5 minute inservice for staff pointing out Resident #1's care plan and the necessity to monitor Resident #1's whereabouts every 15 minutes.

Based on observation and interviews, the facility failed to maintain sanitary conditions in the kitchen in the area of food preparation and to keep the ice machine used for resident and facility use in a clean/sanitary condition for 31 of 31 residents. The facility reported a current census of 31 residents. Findings include: 1. During the initial dietary tour on 3/14/16 at 2:15 PM, observations of the food preparation area revealed the hand washing sink right next to an open shelf that contained cooking utensils (measuring devices) and with splatters of water over the utensils and containers of products. At the same time, a 1 cup measuring device found with white dry substance on the inside of the container. In an interview during the initial tour, the Dietary Supervisor stated that she had just taken down the aluminum foil they had at the end of the open shelf. 2. During observation in the dining room, the ice machine contained a black substance along the inside top cover. The Administrator and the Dietary Supervisor both stated that it needed cleaned. During an interview on 3/14/16 following the initial tour at approximately 2:30 PM, the Administrator and the Dietary Supervisor stated the ice machine did need cleaned. Review of the Ice Machine cleaning documentation revealed the machine had been cleaned last on January 5, 2016. During an interview on 3/14/16 at approximately 2:30 PM, the Maintenance Supervisor stated that he cleans the ice machine quarterly and would get it cleaned right away.

Based on clinical record review, observation and interview, the facility failed to maintain the privacy of a resident's body during perineal care for 1 of 10 current residents reviewed (Residents #3). The facility reported a census of 31 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 identified pertinent [DIAGNOSES REDACTED]. The assessment documented Resident #3 had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment. The resident required the extensive assistance of two staff for bed mobility, transfers, toilet use, dressing and the assistance of one staff with personal hygiene. Resident #3 experienced frequent bladder incontinence. The care plan for Resident #3 found to be incomplete and no date when initiated. The care plan contained no problem of incontinence nor a problem that the resident required assistance to use the toilet. An observation on 3/15/16 at 1:50 PM, revealed Staff A, a certified nursing assistant (CNA), and Staff B, CNA, in the resident's room preparing to complete incontinence care. Neither of the staff closed the window curtain or the privacy curtain in the resident's room. During the time of perineal care, the resident's roommate noted siting up semi-fowlers facing the foot of Resident #3's bed, in full view of the resident's genitalia, while staff cleansed Resident #3. During an interview on 3/16/16 at approximately 2:40 PM, Staff E, CNA, stated that privacy is to be provided during cares by closing the window curtains, the privacy curtain and then cover body parts when not cleansing them.

Based on record review, staff interviews, and facility policy, the facility failed to report an incident of questionable physical contact between 2 residents (Resident # 10 and #11) in the specified time frame when staff failed to report an event to their supervisor in a timely manner. The resident sample included 10 residents. The facility reported a census of 31 residents. Findings include: 1. The Admission Minimum Data Set (MDS) with an assessment reference date of 11/13/2015 for Resident #10 documented a Brief Interview for Mental Status score of 4 which indicated severe long and short term memory deficits. The MDS noted such behaviors as hitting, kicking, and pushing others. Resident #10's functional status included staff assistance with dressing, toilet use, and personal hygiene. The resident remained independent with ambulation. [DIAGNOSES REDACTED]. The plan of care with a problem onset date of 11/05/2015 directed staff to monitor the location of the resident throughout the day while propelling self around the facility or ambulating with a walker, to monitor interactions with other female residents, and redirect if demonstrates any sexual overtures. The Quarterly MDS with an assessment reference date of 01/21/2016 revealed Resident #11 demonstrated both long and short term memory deficits with poor decision-making abilities and requiring supervision. Staff assisted the resident with toilet use, personal hygiene, dressing, and eating. The MDS lacked any evidence of behavioral outbursts. [DIAGNOSES REDACTED]. Resident #11 had an admission date of [DATE]. The plan of care with no specified problem onset date directed facility staff to cue Resident #11 as needed, monitor for a safe environment, and redirect away from Resident #10. Resident #11 suffered from progressive [MEDICAL CONDITION] (difficulty speaking). Resident #11 wore a WanderGuard device to alert staff if trying to leave the building. Resident # 11 ambulated independently. A review of the facility Incident/Accident/Unusual Occurrences Form of 11/10/2015 revealed an incident on 11/05/2015 between 2 same gender residents (Resident #10, #11), during which Resident #10 attempted to remove Resident #11 pants. The incident occurred in Resident #11's room. A follow-up report revealed Staff E, at that time an Environmental Aide, entered the doorway of Resident #11's room and noted Resident #10 and Resident #11 both seated on one of the beds. Staff E observed Resident #10 to be removing Resident #11's pajama bottoms. The nurse on duty was summoned to the room. The incident occurred on 11/05/2015 with a report received by The Department of Inspections and Appeals on 11/10/2015. During an interview on 03/15/2016 at 9:00 A.M., the facility Registered Nurse Consultant verbalized not being informed of the incident until 10 days after it occurred. She then reported the incident to The Department of Inspection and Appeals. At the time, the facility did not have a Director of Nurses. The facility Dependent Adult Abuse Protocols dated December 2015 identified sexual abuse as, but not limited to, sexual harassment, sexual coercion, or sexual abuse. The facility reporting requirements included reporting both alleged violations and the results of investigations to the State survey agency. The abuse policy directed facility staff to immediately report any incidents to the charge staff or agent who will report the allegation within 24 hours to the Iowa Department of Inspection and Appeals.

Based on record review, observations and interviews, the facility failed to complete the Resident Care Plan within 14 days of admission for 1 of 10 current residents reviewed. The facility reported a census of 31 current residents. Findings include: 1. The FaceSheet identified Resident #3 as admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] identified pertinent [DIAGNOSES REDACTED]. The assessment documented Resident #3 had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment. The resident required extensive assistance of two staff members for bed mobility, transfers, toilet use, dressing and the assistance of one staff with personal hygiene. Resident #3 experienced frequent bladder incontinence. The care plan for Resident #3 found as incomplete and no date when initiated. The care area assessment, documented the following problems that needed to be addressed, providing staff direction for: a. Cognitive impairment, b. Activities of Daily Living function, c. Urinary incontinence, d. Falls, e. Nutritional Status, f. Pressure Ulcer, g. [MEDICAL CONDITION] Drug Use. An observation on 3/15/16 at 7:45 AM revealed the resident in the dining room, sitting in a wheelchair with his/her feet on foot pedals and required the assistance of one staff to eat his/her meal. An observation on 3/15/16 at 1:50 PM, revealed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, in the resident's room preparing to complete incontinence care. The resident required assistance to turn in bed, assistance for hygiene, dressing and transferred by use of a mechanical lift. During an interview on 3/16/16 at 9:10 AM, the MDS Coordinator/Care Plan nurse stated that she had 4 admissions the week Resident #3 was admitted and she just had not gotten it finished and was currently working on the care plan.

Based on observation, record review, and the Nursing 2016 Drug Handbook, the facility failed to administer medicated eye drops correctly for Resident #5 and failed to obtain an ordered laboratory test for Resident #2. The resident sample included 10 residents. The facility reported a census of 31 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 for Resident #5 which indicated no long or short term memory deficits. The MDS identified [DIAGNOSES REDACTED]. The plan of care with a problem onset date of date of 11/01/2007 alerted facility staff to a decrease in vision due to right eye [MEDICAL CONDITION] which reduced the resident's eyesight. The March 2016 physician's orders [REDACTED]. During a medication pass observation on at 03/15/2016 at 07:50 A.M., Staff F, Licensed Practical Nurse (LPN) entered Resident #5's room, placed the eye drop bottle on a clean barrier then washed hands and gloved. Resident #5 sat up in bed and leaned her/his head back. Staff F placed a drop of the eye solution in the right eye without touching the eye or lid and handed the resident a tissue. Staff F recapped the bottle, removed her gloves, and washed her hands. After the administration of the eye drops, Staff F did not hold the lacrimal sac (at corner of eye) for at least a minute as directed in the facility medication handbook. The 2016 Nursing Drug Handbook utilized by the facility as a medication resource manual directed licensed staff to hold the lacrimal sac of the eye for at least 1 minute after installation of the medicated drop to minimize systemic absorption, not to touch the dropper to the eye or the surrounding tissue, and be aware of an increased risk of adverse cardiac issues. 2. The MDS assessment dated [DATE] documented Resident #2 had pertinent [DIAGNOSES REDACTED]. The assessment revealed a Brief Interview for Mental Status score of 14 (represents intact cognition) and frequently incontinent of bowel and bladder. The MDS revealed the resident required extensive assistance of two staff members for hygiene and toilet use. Review of the physician's orders [REDACTED]. Record review revealed the most recent A1C test done on 5/4/15 with the next test projected date of completion 6 months later in November 2015. The record did not have any A1C test results for November 2015. During an interview on 3/16/16 at 8:20 AM, the Corporate Nurse Consultant stated the laboratory test not completed and the doctor notified of the omission. The laboratory test would be completed on the scheduled lab day, Friday 3/18/16.