Every finding on record at Laurens Care Center

Based on the review of the Quality Assurance Performance Improvement (QAPI) sign in sheets, staff interview and policy review, the facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 28 residents. Findings include: Review of the QAPI Meeting Attendance sign-in sheets from March 2025 to April 2026 revealed all required team members did not attend a quarterly QAA meeting since 5/27/25.On 4/15/26 at 12:40 PM, the Director of Nursing (DON) acknowledged not all required team members have attended the QAA meeting quarterly. She said there have been staff members that have come and gone along with changes in leadership positions. She said the Infection Preventionist has had to work the floor as a charge nurse and has not been able to attend the meetings at times. The facility QAPI Plan updated 3/1/26 documented the facility would meet monthly to discuss ongoing or new issues in the nursing home. Involved in the QA meetings include the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director (at minimum every 3 months), Activity Director, Social Worker and Dietary Manager.

Based on record review, staff interviews and observation the facility failed to provide professional standards of care by administering medications for 1 of 12 residents reviewed (Resident #4). The facility reported a census of 30 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of hypertension, heart failure, anxiety and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment.On 04/15/26 at 7:35 am, Staff E, a Certified Medication Aid (CMA), was observed administering the Ipratropium-Albuterol Inhalation Solution (0.5-2.5 MG/3 ML) via nebulizer to Resident #4.During the administration of the Ipratropium-Albuterol Inhalation Solution (0.5-2.5 MG/3 ML) via nebulizer, Staff E handed Resident #4 the Budesonide-Formoterol Fumarate Inhalation Aerosol (160-4.5 inhaler). Resident #4 removed the nebulizer mask and immediately inhaled two puffs of the inhaler before returning it to Staff E.Staff E failed to instruct Resident #4 to wait until the nebulizer treatment was complete, or to wait one minute between puffs, or to offer mouth-rinsing after the inhaler was administered.Review of the manufacturer's instructions for Budesonide-Formoterol Fumarate Inhalation Aerosol (160-4.5 inhaler) instructs to rinse your mouth out with water (without swallowing) after use to prevent oral thrush. The facility does not have a policy related to medication administrations.During an interview on 04/15/2026 at 9:30 am, the Director of Nursing (DON) stated she had no prior knowledge of the action. She confirmed the expectation is for staff to wait five minutes between administering medications and to offer an oral rinse after the inhaler.

Based on resident, staff interviews and record review, the facility failed to provide a restorative program to a resident with mobility concerns for 1 of 1 resident reviewed (Resident #6). The facility reported a census of 30 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of quadriplegia, depression, bipolar disorder and cerebrovascular accident (CVA). The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of the Care Plan with an initiated date 9/12/2012 revealed the restorative rehab program includes: Shoulder pulleys 2.5# plate each side, 3 sets for 5 reps each 2-3 times a week bilateral upper extremities (BUE) proximal range of motion (PROM): Remove arm braces. 10 reps each - Slow 3-5 seconds, Hands, use table, layout digits for extension 10-15 seconds, wrist - flex, extend Forearm - supination/pronation Elbow - flex, extend shoulder - flex, extend horizontal abdomen. (across body) scapular retractions (when in chair) hands at shoulders, gentle pressure, pull back hold 10-15 seconds shoulder abduction/adduction x 10 reps x 3 sets with yellow theraband 2-3 times a week. Lower extremity range of motion, stretch only to point of resistance, no further. Each of the stretches should be performed for 10 reps of 10 second holds each: Stretches may be performed supine in bed or seated in wheelchair. 1)hip flexion 2) hip adduction 3) hip internal rotation 4) knee flexion 5) knee extension 6) ankle dorsiflexion Complete 5-7x per week.During an interview on 04/13/2026 at 1:48 pm, Resident #6 disclosed that the facility was not providing her with restorative therapy five days a week. Resident #6 explained that she does not receive the therapy when the restorative aide is off duty, stating that a backup should be in place.Review of the electronic health record for last 30 days from 3/18/26 to 4/15/26 revealed Resident #6 did not receive restorative therapy on March 20th, March 25th, March 27th, March 30th and April 10th. During an interview on 04/16/2026 at 9:30 am with Staff A, restorative aid, disclosed that she works Monday through Friday except when she has to work every 3rd weekend as a certified medication aid (CMA), then she is off that Friday and Monday. Staff A stated that the aids on the floor are to complete the restorative therapy, there are instructions in the electronic health record. Staff A stated that she will look when she returns to work to see if it got done. During an interview on 04/16/2026 at 11:39 am with Staff C, Certified Nursing Assistant (CNA), disclosed that she wasn't aware they were supposed to do restorative therapy with Resident #6 if the restorative aid was gone. During an interview on 04/16/26 at 11:46 am with Staff D, CNA, disclosed that they don't provide restorative nursing with Resident #6, she stated she recognizes there is an as needed button in their electronic health record but doesn't utilize it.During an interview on 04/16/26 at 11:20 am with the Director of Nursing (DON), she revealed the restorative aid will talk with the staff and let them know she will be gone so they know they need to complete it. The DON stated that it would be her expectation to have staff complete the same routine as the restorative aid. The facility has no policy regarding restorative therapy.

Based on clinical record review, staff interview, Centers for Disease Control and Prevention (CDC) guidelines the facility failed to screen for eligibility, offer, provide education, and document vaccine consent or refusal for the pneumococcal immunizations for 3 of 5 resident reviewed (Residents #6, #22, and #27) for immunizations. The facility reported a census of 30 residents. Findings include:1)The Minimum Data Set (MDS) dated for 2/7/26, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 indicated intact cognition. Review of the Immunization tab in the electronic health record revealed the last Pneumococcal Immunization was PVC 13 (pneumonia vaccine) on 10/5/2015. The clinical record failed to document that Resident #6 was educated about, offered, or consented to (or refused) pneumonia vaccinations (PCV20, or PVC21). 2) The Minimum Data Set (MDS) dated for 4/1/26, Resident #22 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. Review of the Immunization tab in the electronic health record revealed the last Pneumococcal Immunization was Pneumo 23 on 10/15/2017.The clinical record failed to document that Resident #22 was educated about, offered, or consented to (or refused) pneumonia vaccinations (PCV20, or PVC21). 3) The Minimum Data Set (MDS) dated for 1/28/26, Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of the Immunization tab in the electronic health record revealed the last Pneumococcal Immunization was PVC 13 on 9/26/2017. The clinical record failed to document that Resident #27 was educated about, offered, or consented to (or refused) pneumonia vaccinations (PCV20, or PVC21).The CDC Recommendations dated March 2025 for adults 50 years or older who have received the PCV13 recommended giving one dose of PCV20 or PVC21 at least one year after the PCV13. The CDC Recommendations dated March 2025 for adults 50 years or older who have received the PPSV23 recommended giving one dose of PCV20 or PVC21 at least one year after the PPSV23 or the PCV15. On 4/15/26 at 12:50 pm, the IP (Infection Preventionist) verified the facility relies on physicians to track and notify staff when pneumococcal vaccines are due, as there is currently no internal process for managing these.An undated facility policy titled Vaccines/Immunizations revealed the facility will offer vaccines per physician order and following the current recommendations by the CDC or Iowa Department of Public Health.

Based on observation, record review, and staff interview, the facility failed to ensure residents were free from abuse for 2 of 3 residents reviewed (Resident #2 and #3) by another resident (Resident #1). Resident #1 touched Resident #2 inappropriately on the chest on 2 separate occasions, and Resident #3 on 1 occasion. The facility reported a census of 27 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required partial to moderate assistance wheeling self in wheel chair 50 feet and making turns, and when wheeling self 150 feet in a corridor or similar space. The resident's diagnoses included aphasia (language disorder affecting a person's ability to communicate), non- Alzheimer's dementia and traumatic brain injury.The Care Plan revised 11/21/24 identified Resident #2 had impaired cognitive function/dementia or impaired thought processes related to (r/t) dementia and a history of traumatic brain injury. Interventions included: a. Using Resident #2's preferred name, identifying yourself at each interaction, facing her when speaking and making eye contact, reducing any distractions, turning off the TV, radio, close door etc. providing her with necessary cues, stop and return if agitated. b. Supervision/assistance with all decision making. c. Keeping routine consistent and trying to provide consistent care givers as much as possible in order to decrease confusion.The Progress Notes documented the following:On 5/6/25 at 7:30 p.m. the nurse heard Resident #2 calling for help. When she entered the living room, she observed a male resident in a wheelchair reaching over hugging Resident #2 with his right arm and his left hand was under Resident #2's shirt touching her right breast. Resident #2's bra was in place between his hand and her breast. The male resident immediately removed from the area. Resident #2 taken to room to be assessed. Resident #2 voiced he grabbed her. No red or bruised areas noted to breast area. When asked resident if she felt safe at facility resident responded yes.On 5/7/25 at 8:48 a.m. Resident #2's family member called to speak with the DON regarding the incident. The DON relayed information regarding what had occurred. The family member voiced understanding and stated that she had worked in healthcare for many years. She was aware accidents happened and that they were doing everything they could to ensure it did not happen again. On 9/25/25 at 9:35 a.m. Resident #2 sat in her w/c in the living room, when a CNA noted a male resident (Resident #1) touching her chest over her shirt. The CNA snapped her fingers and said Resident #1's name to get his attention away from Resident #2. The CNA then removed Resident #1 from the living room. No anxiety was noted with Resident #2 and she smiled at the nurse when asked if she was okay and if she felt safe. The Social Worker would visit with Resident #2's family member.On 9/2625 at 9:23 a.m. Resident #2 was pleasant smiled when spoken to continuing to smile when asked if she felt safe. No appearance of distress. During an observation on 10/06/25 at 11:22 a.m. Resident #2 in sat in the dining room at the assist table, receiving cues from a CNA to pick up her fork and start to eat. Resident #2 picked to the left of her plate at table cloth, nothing there and brought her hand to her mouth as if to eat something but had nothing in her hand. A CNA guided her hand and fork to the plate. The CNA instructed her to pick up a glass to drink. She reached for salt. The CNA continued to guide Resident #2, and give cues to self feed.On 10/06/25 at 11:35 a.m. Resident #1 entered the dining room away from Resident #2 at a table near the window with back facing residents. No contact noted. 2) According to the MDS assessment dated [DATE], Resident #3 scored 10 on the BIMS indicating moderate cognitive impairment. The resident required substantial to maximal assistance wheeling self in wheel chair 50 feet and making turns, and when wheeling self 150 feet in a corridor or similar space. The resident's diagnoses included Parkinson's disease. The Care Plan dated 6/27/22 and revised 5/20/25 identified Resident #3 had impaired cognition related to dementia. Interventions included: a. Identifying yourself at each interaction, facing her when speaking and make eye contact, reducing any distractions, turning off the TV, radio, close door etc. b. Engaging Resident #3 in simple, structured activities that avoided overly demanding tasks. The Care Plan revised 9/10/23 identified trauma informed care and indicated past physical abuse endured while staying with a former friend. Interventions included Resident #3 tried not to think about past abuse, that was her coping mechanism. The Progress Notes dated 5/25/25 documented at 11:20 a.m. a CNA reported she walked residents down the hall to lunch when she noticed another resident's wheel chair (w/c) very close to Resident #3's. The CNA approached the residents and noticed the male resident touching Resident #3's breast over the top of her blouse. The CNA advised the male resident (Resident #1) he needed to keep his hands to himself, and he refused, continuing to touch her breast. When moving Resident #3 she said something the CNA did not catch. When the nurse spoke to Resident #3 she stated she wheeled herself down to eat when Resident #1 grabbed her w/c and started grabbing her breasts. Resident #3 stated she asked Resident #1 to keep his hands to himself and he refused and continued to touch her. Resident #3 was tearful, but said okay. Resident #3 denied any injuries or further concerns. She requested to go to the dining room to eat. The nurse reassured her they would continue to monitor her and to let them know if she had any concerns or felt unsafe at any time. 3) According to the MDS assessment dated [DATE], Resident #1 scored 4 on the BIMS indicating severe cognitive impairment. The resident required partial to moderate assistance wheeling self in wheel chair 50 feet and making turns, and when wheeling self 150 feet in a corridor or similar space. The resident's diagnoses included non- Alzheimer's dementia.The Care Plan identified Resident #1 had a history of making sexual comments/advances towards staff and residents initiated:4/6/25 and revised 5/6/25 with a goal to have fewer episodes. Interventions included: a. Intervening as necessary to protect the rights and safety of others. b. Approaching/Speaking in a calm manner. c. Diverting attention. d. Removing from situation and taking to alternate location as needed. Date Initiated: 04/06/2025 CNA e. 15 minute checks would be done to keep watch on my location and who I am around. Date Initiated: 05/26/25. f. Administration working with the chief of police and case manager of to develop a plan to ensure the safety of other residents. Date Initiated: 05/26/2025. g. Continuing to remind him any hugging or physical contact with staff or residents was not appropriate. Date Initiated: 05/07/2025. h. A police officer has been doing walk throughs to ensure support of preventing any further incidents. Date Initiated: 05/26/25. i. Increased monitoring 1700-2200. Date Initiated: 05/07/25. j. Med review and telehealth appt. completed 9/26/25 resulting in medication changes. Date Initiated: 09/26/25. k. Room change to 104. Date Initiated: 05/07/25. The Progress Notes documented the following:On 4/16/25 at 7:35 p.m. another resident approached the nurse at the med cart down 200 hallway. The other resident was tearful, stating Resident #1 needed to stop. She said Resident #1 touched her arm and it made her feel uncomfortable. She said Resident #1 said he loved her. The nurse told the other resident to stay with her. The nurse went in to a resident room to start a treatment, and when she came out the other resident was next to the med cart, and Resident #1 was right next to her and attempting to hold her hand. The nurse intervened and asked Resident #1 to go up front to the living room or down his hallway. Resident #1 refused to do so and stated he could be there. The nurse told Resident #1 he made the other resident feel uncomfortable. Resident #1 said he didn't care. Attempted to take Resident #1 to the living room and put his feet down. Again the nurse told Resident #1 he needed to leave the other resident alone. The nurse told the other resident to go past the med cart and go down the hall. The nurse had to lift Resident #1's feet up on to the wheelchair (w/C) pedals and he kept them there until got to the sitting area, then he put his feet down again. Resident #1 stated he loved the other resident and was going to marry her. He said you can't help love. Resident #1 then attempted to go down the 200 hall again. The other resident was in her room. Told Resident #1 behavior was unacceptable and he could not do this. Attempted to redirect and able to move resident further over by the time clock. Placed the med cart across the 200 hall so if he did come down he could not get through. The nurse spoke with the other resident and assured her she would try her best to keep him off the 200 hallway. Spoke with staff and they were able to take Resident #1 to his room. Resident #1 then refused bedtime (HS) cares. Another CNA attempted and he refused cares also. A 3rd CNA was able to get his cares done but he would not leave his w/c. The other resident stated Resident #1 touched her left shoulder/arm area and was rubbing his hand on her. Resident #1 sat in his w/c with a blanket over his head, refusing to go to bed or his recliner. Attempts were made throughout the shift. On 4/1725 at 8:24 p.m. Resident #1 propelled himself down the 200 hall trying to reach the same resident from incident on 4/16/25 stating he wanted to talk to her and make sure she was okay. The nurse explained to Resident #1 the other resident didn't want to talk to him, and he was assisted back to his room. Resident #1 becomes agitated and uncooperative and continued to state he just wanted to make sure she was okay, because he didn't think she was. Attempted to explain to Resident #1 we need to respect other resident's wishes and not talk to her. Resident #1 refused to leave the hall and went to room doors that were closed pushing them open. Resident #1 redirected back to the lobby where he sat. When the nurse was out of his sight he attempted to go back down the 200 hall. Staff provided 1:1. Resident #1 then propelled himself down the 100 hall attempting to open closed resident doors and yelling he didn't do a damn thing, they were all lying. The nurse allowed the resident to wheel up and down the 100 hall with supervision. The resident then propelled himself to his own room down the 300 hall and allowed a CNA to assist him with HS cares and transfer into bed. Resident pleasant to CNA during this time.On 4/18/25 at 12:38 p.m. placed a call to Resident #1's family member regarding continued unwanted behavior towards a fellow resident. Explained that staff intervention had been unsuccessful and he had been very challenging to redirect. To the facilities knowledge, no inappropriate comments or contact had occurred. The resident being bothered simply did not like it. The family member expressed understanding regarding this and stated she was sorry that this happened and another family member would be there after 5 p.m. to speak with the resident regarding his behavior.On 4/29/25 at 9:24 a.m. sent a fax to the Primary Care Provider (PCP) to advise per the family request for a mood stabilizer. The resident continued to yell out et difficult to redirect, threatening staff and disrupting in the dining room.On 4/30/25 at 8:55 a.m. the fax returned signed by the PCP citing the resident could be seen on rounds, make an office visit, or refer to the Psychiatric (Psych) Nurse Practitioner (NP). The resident's family member opted to have the resident seen at the facility On 5/5/25 at 2:47 p.m. the Psych NP gave a new order for Lorazepam (antianxiety) 0.5mg every day at 4 p.m. and every 4 hours as needed. Follow up in 2 weeks. Call placed to family member and she approved of the medication changes. Resident interactions: 1) On 5/6/25 at 7:30 p.m. the nurse heard a female resident (Resident #2) calling for help. When entered the living room observed Resident #1 in his wheelchair leaning over hugging Resident #2 with his right arm, and his left hand under her shirt touching her right breast. A bra was intact between Resident #1's hand and Resident #2's breast. Resident #1 removed immediately from the area and taken to his room. Explained to him the behavior was inappropriate. Resident #1 was agitated voicing he owned the place and and they were all fired. They would provide increased monitoring for any further behaviors.On 5/6/25 at 9 p.m. the resident agitated wheeling up and down the halls opening resident's room doors. When attempt to redirect, the resident became more agitated stating to leave him alone, and put his arm making a fist at a CNA. Resident reapproached by another staff member, offered toilet and snack prior to administering medication.On 5/7/25 at 8:01 a.m. the Director of Nursing (DON) spoke with the resident regarding his behaviors the previous night. Resident #1 stated he did not remember that happening. When let him know his actions, he agreed this would not happen again because it was highly inappropriate and made others feel uncomfortable. He agreed not to do this again.On 5/7/25 at 8:54 a.m. the Psych NP returned phone call regarding behaviors. She recommended increased monitoring, and reminding the resident at this point any hugging or physical contact with staff/other resident's was not appropriate. She was reviewing medications for the resident and would call back with any changes.On 5/7/25 at 1:44 p.m. a CNA reported when helping the resident with toileting cares in the afternoon. Resident #1 placed his hand on her buttock and grabbed. The CNA advised the resident it was inappropriate and to please stop. The CNA reported to the nurse and the DON.On 5/7/25 at 3:33 p.m. received phone call from the Psych NP with a verbal order to start the resident on Sertraline (antidepressant) 50 mg daily for anxiety. Family notified and agreeable to plan.On 5/9/25 at 10 a.m. Resident #1 denied any problems with new room. When asked if he liked the room he responded it's okay. On 5/17/25 at 4:47 p.m. checked on Resident #1 and monitored frequently. Noted the resident approaching a female resident and reached for the female resident's hand. The nurse removed the female resident from the area. Reminded Resident #1 he needed to keep a distance from other residents, and not to touch anyone. He expressed understanding. The female resident denied any contact with male resident and said he did not touch her hand.On 5/18/25 at 4:19 p.m. continued with increased monitoring of resident. Family in to visit this pm. No behaviors noted.On 5/19/25 at 2:33 p.m. Resident #1 seen on rounds of the Psych NP. The resident continued to have some behaviors and new orders for Lorazepam 0.5 mg to be scheduled for 4 p.m. and 8 p.m. and continue as needed order. 2) On 5/25/25 at 11:20 a.m. a CNA reported she walked residents down the hall to lunch when she noticed Resident #1's wheelchair very close to Resident #3's wheelchair. The CNA approached the residents and noticed Resident #1 touching Resident #3's breast over the top of her blouse. The CNA advised Resident #1 that he needed to keep his hands to himself. He refused and continued touching her breast. While staff moved Resident #3, she stated something that CNA did not catch. Resident #1 called the resident being currently assisted to the dining room and the CNA fat bitches. Resident #1 became very verbally aggressive and attempted to kick his feet while yelling that the nurse was a dumb expletive. Resident #1 continued yelling and insisted that he was going to the dining room. Staff offered Resident #1 a room tray, and he accepted. Resident ate in the family room where he would be highly monitored. Called and spoke to the DON, followed up with a call to the Administrator, and the Police Department (PD). Both parties' families were notified of the occurrence and the actions that were taken, prevalent to their family member. Resident #1's family present at bedside and he appeared calm with no concerns currently. An officer with the PD phoned Chief of Police along with the Mental Health and Substance Abuse Case Manager. All staff were notified to continue 15-minute monitoring and checks on resident 24 hours daily until further notice. Resident #1 to be monitored constantly to verify there be no interaction between both parties and limited/monitored with any female interaction. Night nurse to always sit with hall and room in view when available.On 5/25/25 at 11:35 a.m. called: Resident #1's family member and updated on Resident #1''s behavior of touching another resident inappropriately in the hallway. Resident #1 touched another resident on the breasts over her clothes. Informed family the Police were notified and coming to the facility. The Administer also updated. On 5/27/25 at 12:23 p.m. phone conversation with the Psych NP regarding Resident #1's behaviors. Discussed the interventions they were currently doing: 15 minute checks, med recommendations from pharmacy consultant, utilizing PRN medications, educating the resident behaviors were not appropriate, police rounding, asked the family to do PRN visits as able, removing from a situation that may result in an incident, room change, etc. The Psych NP ordered Depakote 250 mg every HS for mood lability/impulsivity. Contacted a family member and she verbalized consent for use of the medication. Stated she would be coming to the facility soon to sign and discuss the resident's care.On 5/27/25 at 12:35 p.m. had a Zoom meeting with the Mental Health Coordinator at 10 a.m. to discuss Resident #1's health and behavioral history, and steps to develop a more detailed plan of care around his hypersexual behavior. The DON, ADON, MDS Coordinator, and Administrator participated in the meeting. Conversation focused around resident's health and behavioral history prior to admission, cognitive diagnosis, potential pharmaceutical interventions to decrease resident's hypersexual behaviors, and review of interventions currently in place as they planned and coordinated his care for a more effective, long-term intervention(s). The Administrator sent an email summary of the meeting to the resident's family to include a request for family assistance through evening visits that occur in his room, as their visits helped him maintain a positive mood and kept him occupied. Resident #1's family were on the way to the facility to visit with resident and also meet with facility leadership for further discussion of incident that lead to a second self-report Sunday May 25, 2025.On 5/28/25 at approximately 1:15 p.m. CNA staff were having a difficult time attempting to redirect Resident #1from heading into the front living room, where facility Resident's #2 and #3 were. Resident #1 spoke loudly saying get out of the way, that was his ex-wife and he was going to talk to her, and pointed to Resident #3. Efforts to reassure him that Resident #3 was not his ex wife, did not deter him and he planted his feet down to prevent anyone from moving his wheelchair. Reminded him that law enforcement officers had been coming to visit with him frequently the past few days, and tasked him if he would like an officer in to visit with him. Resident#1 looked angry, but allowed a CNA to move him in his wheelchair and wheel him to his room to rest in his recliner.On 6/1/25 at 2:46 p.m. Resident #1's family there and wanted to sit at table in the living room towards the west wall. A female resident sat at the table on the East side of the living room. The nurse passed and heard someone say he could not go over there. Resident #1 yelled at family and tried to wheel himself over there and family held the wheelchair. Resident #1 said to just leave him alone and wheeled himself towards the other resident with his family present. Staff intervened and took Resident#1 back to the table towards the west wall, and the resident sat at the table with family.On 8/31/25 at 5:32 p.m. a CNA reported Resident #1 approached women in the living room. The CNA attempted to redirect the resident and he refused to leave the living room. He became upset and began screaming at the CNA. The female residents were assisted from the living room. The two female residents reported the resident only talked with them. 3) On 9/25/25 at 9:35 a.m. a CNA noted Resident #1 in the living room. When the CNA turned, she saw Resident #1 in front of Resident #2, touching her chest over her shirt. The CNA snapped her fingers and said his name to get Resident #1's attention away from Resident #2. The CNA went to the living room and assisted Resident #1 into his recliner in his room. The nurse discussed this behavior with Resident #1 and reminded him that it was not appropriate. He responded okay and looked at the nurse. Administrator was notified. Left message at 10:35 for the family to return call.On 9/25/25 at 10:35 p.m. a CNA voiced Resident #1 became agitated at the evening meal yelling at his table mate accusing the tablemate of touching him. CNA's reported the residents were not close enough to touch. They said Resident #1 raised his fist at the tablemate, but no contact was made. They removed Resident #1 from dining room and assisted with HS cares and placed him in his recliner. No further behaviors noted or reported.On 9/26/25 at 1:22 p.m. Resident #1 seen virtually by the Psych NP with new orders to increase Depakote from 250 mg daily to 250 mg in the morning and 500 mg at HS, and notify if changes in mood, behavior, or medication side effects, including sedation or unsteady gait.Observations:On 10/6/25 at 11:10 a.m. Resident #1 sat in a w/c in in room. He talked about working for the railroad and being injured. He said they treated him good at the facility and he liked it, and denied any problems.On 10/6/25 at 2:15 p.m. Resident #1 slept in the recliner.On 10/6/25 at 5:10 p.m. Resident #1 in the dining room eating supper. Sat across from another male resident.On 10/7/25 at 8:10 a.m. Resident #1 awake in recliner, stating ready to get up.On 10/7/25 at 11:45 a.m. Resident #1 eating lunch. Nursing staff supervised the residents.On 10/7/25 at 11:55 a.m. went to resident's' room to set door bell off. Could not hear door bell. Went to nurses station to listen while Staff E Licensed Practical Nurse (LPN) walked over the threshold. Could barely hear it in the nurses station. Staff E had the Maintenance Man look at it, and the volume had been turned down.On 10/8/25 at 10:35 a.m. stood by CNA room while another person walked in and out of Resident #1's room. The nurse's station door was closed and could faintly hear the tone of the door bell. Staff H RN working at the med cart stated they did not leave the door open when no one was in the nurse's station, but they were usually right there.Staff interviews included:On 10/7/25 at 9:05 a.m. Staff A Registered Nurse (RN) stated Staff B CNA reported Resident #1 was touching Resident #2 inappropriately. She had separated the residents. Staff A said Resident #1 had a door bell at the entrance of his room, and they kept the doors to the living room shut so he couldn't see who was in there, and enter there. She said she had walked by his room when coming up from the dining room and saw the resident in his room at 9:20 a.m. and the doors to the living room were closed. She said they were doing different things to try and deter this from happening again. She said they did a med review. They tried having him sit in a recliner in the lounge area close to the nurses station but he did not like it. 10/7/25 1 p.m. Staff A stated she did not hear the doorbell prior to that incident. She may have gone down the 200 hole to pass some pills so she would not have heard it.On 10/7/25 at 9:23 a.m. Staff C CNA stated when the incident occurred she was in the CNA room and Staff B was in there with her, the door was partially open. When Staff B turned to walk out she could see right into the living room. Staff C did not see it. She said she was well aware of the issues with Resident #1 approaching the women and inappropriate touching, and they needed to keep him away from the women. Staff C said the interventions were in place were 15 minute checks, a doorbell, and closing first doors to the living room. She said it depended on where you were whether you could hear the doorbell or not.On 10/7/25 at 9:40 a.m. Staff D CNA stated she filled out the 15 minute checks for Resident #1 the day of the last incident. She said she had seen him at 9:30 a.m. in his room with the TV on. The next thing she knew, Staff D asked for help getting him to his recliner. She did not hear a doorbell and was unsure about the double doors.10/7/25 10:19 a.m. Staff E Licensed Practical Nurse (LPN) stated she did not recall the second incident. She said she was aware that Resident #3 had made gestures like reaching for a staff member, so they were aware they had to continually remind him that that was inappropriate behavior. She said the police officers had been there on occasions and talked with Resident #1 She said they did 15 minute checks and the doors to the family room on that hall were to be so Resident #1 couldn't see who was in the family room, and he had a doorbell in the doorway of his room so if somebody went in or out, they tried to run and see where he was, or where he was going so they could keep an eye on him. She said they had tried a recliner in the lobby area where he would be in visual sight of the nurses station but he did not like that.On 10/7/25 at 10:40 a.m. Staff F CNA stated she had been on night shift and recently came to day shift. Staff F said she knew Resident #1 usually went to his recliner after meals and he liked to watch TV. She knew about incidents that had occurred.On 10/7/25 at 12:50 p.m. Staff B CNA stated Resident #1 was probably in his room or in the hallway prior to the incident occurring. She said she was not in the CNA room, she was outside holding the door open when she looked over and saw Resident #1 in the family room. She said he would have had to have slipped in through the first doors that are on his hall for her not to have seen him. Staff B said the doors were not closed. She said unless he opened the doors himself and got in, but she did not feel that he would be able to do that without slipping out of his wheelchair. She did not hear the doorbell. She said they were still doing the 15 minute checks, and they tried to watch him if he was out of his room, but they couldn't watch him 24/7.On 10/8/25 8:05 a.m. Staff G CNA (last day of work 9/24/25) stated she did witness the incident in late May and she walked up the 100 hall to the dining room and she saw Resident #1 with his hand in Resident #3's lap and the other hand under her shirt. She immediately moved the resident's apart. She said as soon as she got them apart she notified nurse on duty about what had happened, and the nurse took over from there. She said the nurse called dispatch for the police and they had to talk to them about the situation. She said after they put Resident #1 on 15 minute checks, and if he was out of his room they tried to keep an eye on him to make sure he wasn't getting close to any female resident. She thought that was working fairly well.On 10/8/25 at 9:15 a.m. the Administrator stated if they had known Resident #1 had these kind of behaviors they would have considered carefully whether they would have taken him. And after the first incident and they got Interventions in place he had the second incident. They put the 15 minute checks in place. She said she wasn't for sure when the doorbell started. When she did the report to state and then the follow up she had written on the timeline that they hadn't had to start it yet. But they had set it up and she found out later that it had been put in place. The doorbell was above his door frame so when they went in or out it sounded in the nurses station. If there was nurse in there the door was usually open. It was unusual for them to have it shut if they were in there, except when they needed to discuss confidential information. She said they had done so much to try and prevent this from happening again, and then it happened the third time. She said they couldn't make him stay in his room all the time, he still had rights also. She struggled with how they could prevent this with their current situation. They had increased some staffing. They have an afternoon activity person who comes in and is in the front area around the living area so if Resident #1 wanted to be out for activities, she's there to supervise, and also for some of the other residents that need some things to do. She had contacted the ombudsman and the healthcare association to see if they had any ideas that might help with their current situation.The facility Abuse Prevention, Identification, Investigation, and Reporting Policy revised 4/18/17 documented Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Sexual abuse was non-consensual sexual contact of any type with a resident. Resident-to-resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility would presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary.

Based on record review and staff interview, the facility failed to ensure residents and/or their representatives had the right choose a pharmacy for 1 of 3 resident's reviewed (Resident #4). The facility reported a census of 27 residents.Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included diabetes, Alzheimer's disease, anxiety disorder, restlessness and agitation. The resident's drug regimen included antianxiety, antiplatelet, and hypoglycemic medications. The Care Plan identified the resident on Antiplatelet therapy (Aspirin) revised 4/7/25, antianxiety medication (lorazepam) initiated 5/7/25, and antidepressant medication (Trazadone) initiated 9/23/25. An admission Information form dated 3/28/25 documented yes for Resident #4 being a veteran and yes for Veterans Administration (VA) meds. The Progress Notes documented the following:On 7/23/25 at 1:38 p.m. the Social Services Coordinator (SSC) received a phone call from the Clinic on behalf of Resident #4's spouse requesting his VA benefits be reviewed. The caller shared the resident paid full price for multiple medications, and the spouse questioned if VA insurance would cover the cost of the medications. The SSC shared the inquiry with the administrator and Director of Nursing (DON). The SSC would follow up as needed.On 7/30/25 at 12:39 a.m. call placed to pharmacy, and they were unable to find prescriptions with VA for Resident #4. He was seen on 6/12/25 and had advanced dementia - Dr through Veteran Affairs and local Primary Care Provider (PCP) Physician Assistant Certified (PA-C). Per pharmacy send Medication Administration Record (MAR)/Treatment Administration Record (TAR) to VA provider so she could order medications through VA. At 1 a.m. fax prepared and sent to provider at VA attaching her faxed orders, 2, from visit on 6/12/25, copy of face sheet and copies of Resident #4's MAR and TAR. At 1:27 a.m. Fax completed and 19 pages confirmed sent.On 8/1/25 at 3:18 p.m. call from VA informing Resident #4 approved to see provider closer to his home at local clinic scheduled for 8/18/25 PA:C and she could send orders to VA and would get meds sent, but if needed sooner let VA know and a provider would okay for 30 day supply until seen by PCP.On 8/18/25 at 2:42 p.m. Resident #4 out of facility in van to appointment at clinic at 2:15 p.m. Returned to facility at 2:25 p.m Appointment had been cancelled 8/17/25 by text confirmation. Appointment scheduled for [DATE] at 4 p.m.On 9/2/25 at 5:22 p.m. appointment with PA-C, initial community care for VA visit. Due for labs this month.The record lacked any additional information r/t VA meds.On 10/6/25 at 5:05 p.m. Staff E Licensed Practical Nurse (LPN) stated they had 2 residents on VA meds, but not Resident #4.On 10/8/25 at 9 a.m. the Administrator stated she went to the resident's home to do the admission paperwork. She marked yes on the form for VA meds. She gave the paperwork to the Assistant Director of Nursing (ADON) (no longer employed by the facility) to process. She assumed it would be taken care of appropriately. She said then they received a call in July about getting him on VA meds. She said the previous DON was working on the VA meds for Resident #4, and then she left suddenly. She assumed this was taken care of. She did not realize they still did not have VA meds. They still needed to get his meds through the VA. The Administrator admitted with the staff changes this had been missed. She planned to take the paperwork to the clinic.

Based on record review and staff interview, the facility failed to provide to the resident and the resident representative, written notice of the bed hold policy when on hospital leave, which specified the duration of the bed-hold policy and reserve payment, for 3 of 3 residents reviewed (Resident #8, #11, and #2). The facility reported a census of 26 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident had diagnoses including Alzheimer's disease. The Census page showed the resident on hospital leave from 10/30/24 to 11/4/24. The Progress Notes dated 10/30/24 at 1:35 p.m. documented the resident sent to the hospital, and the bed hold signed by her family member. A Bed-Hold Notice dated 10/30/24 documented a verbal consent from the resident's family to reserve the room for the resident, signed by the charge nurse. The notice contained the Administrator's name and a number to contact with any questions. The notice lacked the daily rates to reserve the room. On 3/18/25 at 3:45 p.m. the Business Office Manager (BOM) stated she did not give the resident/resident representative a copy of the bed hold. She acknowledged the notice had a carbon copy attached and both were retained by the facility. 2) According to the MDS assessment dated [DATE], Resident #11 scored 14 on the BIMS indicating no cognitive impairment. The resident had diagnoses including chronic diastolic heart failure. a) The Progress Notes dated 1/27/25 at 2:35 p.m. documented an order to transfer the resident to the hospital, family notified, and a bed hold obtained. The Census page showed the resident on hospital leave from 1/27/25 to 2/3/25. A Bed-Hold Notice dated 1/27/25 documented a verbal consent from the resident's family to reserve the room for the resident, signed by the charge nurse. The notice contained the Administrator's name and a number to contact with any questions. The notice lacked the daily rates to reserve the room. b) The Progress Notes dated 2/19/25 at 10:25 a.m. documented receipt of an order to transport the resident to the hospital by ambulance to have evaluated in the emergency room (ER). The resident's family member gave a verbal okay for a bed hold. The Census page showed the resident on hospital leave from 2/19/25 to 2/25/25. A Bed-Hold Notice dated 2/19/25 documented a verbal consent from the resident's family to reserve the room for the resident, signed by the charge nurse. The notice contained the Administrator's name and a number to contact with any questions. The notice lacked the daily rates to reserve the room. On 3/20/25 at 12:36 p.m. the Director of Nursing (DON) stated they were getting the verbal consent (for bed holds) because people were usually in a hurry to get to the hospital. The facility plan of correction from their last survey 3/21/24 included Ftag 625 bed holds. It was the intent of the facility to provide a resident or their responsible party with written information regarding notice of the bed-hold policy before a resident transferred to a hospital or went on therapeutic or recreational leave. 3. The MDS assessment dated [DATE] for Resident #2 documented diagnoses of quadriplegic, seizure disorder, depression, bi-polar and post traumatic stress disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of Resident #2's Electronic Healthcare Record (EHR) revealed Resident #2 was in the hospital from [DATE] to 2/3/25, 11/12/24 to 11/14/24, 9/6/24 to 9/17/24, 8/31/24 to 9/1/24, and 8/16/24 to 8/22/24. Further review of the EHR page titled, Clinical Census confirmed the Resident was in the hospital on these dates. Review of the bed holds dated for 1/20/25, 11/12/24, 9/6/24, 8/31/24, and 8/16/24 revealed verbal authorization from Resident #2's representative but lacked a resident or representative signature. Review of the bed holds for these dates also lacked the cost of the room.

Based on record review and staff interview, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents reviewed for psychotropic medications (Resident #21). The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #21 scored 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had diagnoses including an unspecified nutritional deficiency. The resident received antidepressant medication. The Care Area Assessment (CAA) for psychotropic medication use documented the resident received antidepressant medication for a treatable medical condition. Adverse consequences of antidepressants exhibited by the resident were an increased risk for falls. The CAA documented psychotropic drug use would be addressed on the care plan to avoid complications, minimize risks, and symptom relief. The Clinical Physician's Orders in the Electronic Health Record showed the resident had an order for Mirtazapine (antidepressant) 7.5 mg at bedtime for failure to thrive dated 9/23/24. The resident's Care Plan lacked any identification of the antidepressant use. On 3/20/25 at 12:36 p.m. the Director of Nursing (DON) stated the Mirtazapine should be addressed on the care plan. At 1:43 p.m. the DON confirmed the Mirtazapine had been missed on the care plan. The DON responded to an email on 3/19/25 indicating the facility did not have a policy on care plans, but followed the Code of Federal Regulations on comprehensive person-centered care planning. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment.

Based on observation, record review, and staff interview, the facility failed to ensure a resident's care plan was reviewed and revised after each assessment for 2 of 11 residents reviewed (Resident #8 and #14). The facility reported a census of 26 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 had long and short term memory problems and severely impaired skills for daily decision making. The resident required substantial/maximal assistance with eating. The resident had diagnoses including Alzheimer's disease. The Care Plan revised 11/14/23 identified the resident had an Activity of Daily Living (ADL) self care performance deficit related to Alzheimer's. The interventions included the resident ate/drank independently. On 3/18/25 at 7:50 a.m. and 12:10 p.m. the resident was fed by staff. On 3/20/25 at 12:36 p.m. the DON confirmed the resident had declined with eating, and the care plan should be updated to reflect the resident's current status. The DON responded to an email on 3/19/25 indicating the facility did not have a policy on care plans, but followed the Code of Federal Regulations on comprehensive person-centered care planning. The regulations directed the care plan would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 49056 2. The MDS assessment dated [DATE] for Resident #14 documented diagnosis of non-Alzheimer's dementia, diabetes mellitus, and renal insufficiency. The MDS showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. The MDS also revealed Resident #14 was independent with eating. Review of the Care Plan with an initiated date of 7/17/2023 showed Resident #14 was able to feed self independently. Review of the Visual/Bedside Kardex Report revealed Resident #14 was able to feed self independently. Review of the Electronic Health Record Response History from 2/19/25 to 3/19/25 revealed staff have documented Resident #14 needs limited assistance (residents highly involved in activity, staff provide guided maneuvering of limbs or other non weight bearing assistance) 27 out of 30 days.

Based on observation, record review, and staff interview, the facility failed to ensure a resident who needed Oxygen (O2) had documentation when they received oxygen for 1 of 2 residents reviewed (Resident #11). The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #11 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had diagnoses including pneumonia. The Clinical Physician's Orders showed the resident had the order for Oxygen, inhale 2-4 liters/minute as needed to keep sats above 90% dated 2/26/25. The Care Plan identified the resident had oxygen therapy related to Congestive Heart Failure (CHF) revised 3/5/25. The interventions included continuous O2 at 2 liters, may increase up to 4 as needed to keep sats >90% revised 1/22/25. The Treatment Administration Record (TAR) for March 2025 showed the only day documented for the use of O2 was on 3/4/25 at 9:03 a.m. but did not document how many liters. On 3/17/25 at 2:34 p.m. the resident had O2 at 2 liters on per nasal cannula. On 3/18/25 at 7:50 a.m. the resident sat at breakfast with O2 on at 2 liters per nasal cannula. On 3/18/25 at 1:20 p.m. the resident continued with the O2 at 2 liters per nasal. The TAR lacked documentation of the use of the O2. On 3/20/25 at 12:36 p.m. the Director of Nursing stated if the order was for as needed O2 it should be documented on the TAR if the resident received it, and how many liters it was set on. The DON responded to an email on 3/19/25, that the facility did not have a policy for as needed O2, they went by the physician's orders.

Based on personnel file review, interviews, and review of the Direct Care Worker (DCW) Registry the facility failed to verify and assure a student certified nursing assistant (CNA) actually became certified and registered after completing the CNA course and taken the written exam for 1 of 5 CNAs reviewed (Staff G). The facility reported a census of 30 residents. Findings include: The personnel file for Staff G, student CNA documented a hired date of 3-23-23. Review of the personnel file lacked documentation Staff G, student CNA was registered on the Iowa Direct Care Worker Registry (DCW) The personnel file documented Staff G had passed the skills competency exam on 8-10-23 and the written exam with a 71% final score on 9/18/23. Review of the DCW registry on 3/20/24 at 10:43 AM revealed Staff G was not on the registry. The status documented No Test and no certification date. A facility form titled Skills Competency Checklist of Environmental Aides who have taken CNA course documented the following competencies where completed with Staff G on 8/3/23: feeding, dressing (top half of resident who transfers with mechanical lift), oral cares, application of ted hose or other compression wear, application of lotion, washing or resident hands/face. On 3/20/24 at 12:15 PM, Staff F, Business Office Manager reported Staff G, student CNA took the CNA class in either June or July 2023. Staff F stated she had periodically checked the registry and again on the evening of 3/19/24 and the registry documented Staff G had no test. Staff F stated Staff G was hired to be a housekeeper and then switched over to be a CNA. Staff F stated that the Director of Nursing (DON) was going to message the college to inquire about the registry. On 3/20/24 at 12:20 PM, the DON reported she had been in contact with the college. The DON stated she was trying to get copies of the written exams that Staff F has taken. She stated the tests results the college had were not lining up with the test results the facility had that were provided by Staff G. The DON stated Staff G was hired as an Environmental Aide in March and then switched over to be a CNA after the facility had sent her to the CNA class. The DON reported Staff G had been taken off work at this time. On 3/20/24 at 12:30 PM, the DON reported Staff G has taken the written exam three different times. Review of the written exam test results provided by the college and Staff G revealed the following information: *8/10/23- 1st test- Did not pass with a 67% result- Both test copies match *8/17/23- 2nd test- Did not pass with a 69% result- Both test copies match *9/18/23- 3rd test- Discrepancy with the test results. The test exam the college provided documented a 67% result which indicated Staff G did not pass (time stamped on 9/18/23 at 1:20 PM). The copy of the test exam Staff G provided documented a 71% result which indicated Staff had passed the exam (time stamped on 9/18/23 at 1:47 PM). The DON reported she did not know why the copies of the third exam are not the same. She stated she received a text message from Staff G on 9/18/23 stating she had passed. The DON reported she does not do the registry part so she was not aware Staff G was not on it until 3/19/24. The DON stated Staff G denied changing or altering the third test exam. On 3/20/24 at 1:08 PM, Staff F, Business Office Manager reported Staff G was changed to a CNA on 9-25-24 after she had notified the facility she had passed her exam and provided a copy of the pass results. Staff F stated she would have expected Staff G to have been on the registry within a couple of weeks after passing the exam. Staff F stated the facility has had issues in the past with the registry so that is why the facility makes sure to get copies of the passed results from the staff. Staff F stated last night (3/19/24) she was going through the employee files and rechecked the Direct Care Worker Registry for Staff G and learned she was still not on the registry. On 3/20/24 at 1:55 PM, Staff G, student CNA stated she started working at the facility in the middle of March as an environmental aide. She reported she went to the college for the CNA class in June or July and finished either the end of July or in August. Staff G reported she took the written exam three different times and on the third attempt she passed with a 71%. Staff G stated she gave the pass results to Staff F in the business office. She stated after the facility received her results she was changed to a CNA and put on the floor to train. She stated she does not know why her copy of the third exam results does not match the college results. She stated she text the DON on the day she passed the test. Staff G denied changing the test results. On 3/20/24 at 2:02 PM, the DON reported the facility does not have a policy on the nurse aide registry checks. On 3/20/24 at 2:37 PM, The DON verified Staff G had worked full time as a CNA on the 2-10 shift and had been active on the schedule. On 3/20/24 at 4:05 PM, the College Health Industry Trainer Programmer reported the Direct Worker Registry showed Staff G failed the exam three times. She stated the college submits the results to a third party and they give the written scores to the DCW registry. She reported she compared the written exam results from college to the written exam results that Staff G provided the facility. She stated the form that Staff G provided the facility has different format/spacing and wording. She stated it appeared the document had been recreated. A form called DCW Test Scores revealed Staff G failed the written exam on 8/10/23, 8/17/23 and on 9/18/23.

Based on clinical record review, staff interviews and review of Medicare guidelines, the facility failed to provide a notice of Medicare Non-coverage 48 hours in advance of services ending for 1 of 3 residents reviewed (Resident #2). The facility also failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) form for 2 of 2 residents (Resident #2 and #6) whose skilled stay ended and continued to reside in the facility. The facility reported a census of 30 residents. Findings include: 1. Resident #2 ' s Minimum Data Set (MDS) dated [DATE] assessment identified Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #2 was dependent on two persons with bed mobility and transfers. Resident #2 ' s MDS included diagnoses of neurogenic bladder (lack bladder control due to nerve damage), urinary tract infection in the past 30 days, quadriplegia (paralysis that affects all limbs and body from the neck down), seizure disorder, and respiratory failure. The Clinical Census revealed Resident #2 was readmitted to the facility on [DATE] for a Medicare Part A Skilled stay. A Progress Note dated 9/28/23 at 2:39 PM revealed Resident #2 returned to the facility for SNF (Skilled Nursing Facility) level of care post hospitalization for pneumonia. A Progress Note titled Social Services Note dated for 10/4/2023 at 4:27 PM revealed the social worker was advised on 10/4/23, Resident #2 ' s last covered day for SNF level of care was on 10/2/23. The note documented the social worker completed the notice paperwork and apologized to Resident #2 for the notices being completed late. The note documented Resident #2 stated understanding and signed the notice forms. A CMS (Center of Medicare and Medicaid Services) form (10123-NOMNC)(Approved 12/31/2011) titled Notice of Medicare Non-Coverage documented Resident #2 SNF services would end on 10/2/23. Resident #2 signed the form on 10/04/23. Resident #2 signed the CMS form (CMS-R-131) (Exp. 6/30/2023) titled Advance Beneficiary Notice of Non-coverage (ABN) on 10/04/23. 2. Resident #6 ' s Minimum Data Set (MDS) dated [DATE] assessment identified Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS identified Resident #6 required partial to moderate assistance with bed mobility and supervision/touchin assistance with chair/bed to chair transfers and toilet transfers. Resident #6 ' s MDS included diagnoses of anemia, hypertension (high blood pressure), pneumonia, and cerebrovascular accident (CVA/stroke). The Clinical Census revealed Resident #6 was readmitted to the facility on [DATE] for a Medicare Part A Skilled stay. A Progress Note titled Social Services Note dated 8/29/23 revealed Resident #6 ' s last covered day for SNF level of care was on 9/1/23. The note documented Resident #6 stated understanding and signed the notice forms. Resident #2 signed the CMS form (CMS-R-131) (Exp. 6/30/2023) titled Advance Beneficiary Notice of Non-coverage (ABN) on 8/29/23. On 3/19/24 at 10:46 AM, Staff C, Social Worker verified and acknowledged the wrong SNF ABN form had been given to Resident #2 and #6. Staff C also verified the Notice of Medicare Non-coverage was given late to Resident #2. Staff C stated she was notified on 10/4/23 that Resident #2's SNF services ended on 10/2/23. On 3/19/24 at 11:14 AM, the Administrator reported the facility does not have a policy for administering the Advance Beneficiary Notices (ABNs). The Administrator reported the facility follows CMS regulations. The Administrator reported the general rule of thumb was written notification to be issued within 48 hours of discharge from skilled services.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by resident and or the resident's responsible person when residents transferred out of the facility for 2 of 4 residents reviewed (Residents #4 and #35). The facility reported a census of 30 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #35 documented diagnoses of spinal stenosis, heart failure and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicated no cognitive impairment. The Clinical Census for Resident #35 revealed the following: a. 1/23/24- active b. 1/29/24- hospital c. 1/30/24- resumed stay The Progress Notes for Resident #35 revealed the following information: a. On 1/29/24 at 1:51 PM, Resident #35 sent to the Emergency Department (ED). b. On 1/29/24 at 5:16 PM, Resident #35 will be admitted to the hospital for intravenous antibiotics. The clinical record lacked a Bed Hold form for Resident #35 regarding the ED and hospital stay that occurred on 1/29/24. The undated facility policy identified upon admission the facility provides information regarding facility bed hold policy and also at the time of temporary absence from hospital to the Residents or responsible party. Residents are eligible to request that their bed be held while out of the facility overnights and/or for an indefinite number of days. When the Residents shall be charged the then current Bed Hold Rate. Residents who are hospitalized or therapeutic leave exceeds the bed-hold period under the state rules, will be readmitted to the facility immediately upon the first availability of a bed in a semi private room if the Residents: Requires the services provided by the facility and, is eligible for Medicaid nursing facility services. 46875 2. Resident #4 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 12, indicating moderately impaired cognition. Resident #4 's MDS included diagnoses of anemia, hypertension (high blood pressure), renal disease (kidney), neurogenic bladder (lack bladder control due to nerve damage), pneumonia, diabetes mellitus and a cerebrovascular accident with hemiplegia (stroke affecting the right side). The Clinical Census revealed Resident #4 was on a hospital leave that began on 12/8/23. A Progress Note dated 12/8/23 at 12:39 PM revealed Resident #4 was admitted to the hospital for a urinary tract infection and intravenous therapy (give fluid/medications directly into the vein). The clinical record lacked documentation the facility provided a bed hold notice to Resident #4 and/or resident representative upon discharge to the hospital. On 3/19/24 at 1:40 PM, the Administrator reported she could not locate a bed hold notice for Resident #4 for 12/8/23. In an interview on 3/19/24 at 2:12 PM, the Director of Nursing (DON), indicated the facility lacked a completed Bed Hold form for Resident # 4 and #35. When asked if the DON expected staff to complete Bed Hold forms for those residents transferred out of the facility, she replied, They should have had one done.

Based on observation, infection control policy, and staff interview, the facility failed to use personal protective equipment (PPE) and perform hand hygiene when exchanging water pitchers for residents suspected of having the Norovirus for rooms 208, 209 and 213. The facility reported a census of 30 residents. Findings included: In an interview on 3/18/24 at 9:00 AM, the Administrator reported some residents required isolation precautions due to a possible norovirus outbreak. Observation on 3/18/24 at 10:20 AM showed PPE supplies, a contact isolation sign that stated PPE requirements of a gown, gloves and designed equipment required for contact isolation located outside of room [ROOM NUMBER]. Staff A, Certified Nurses Aide (CNA), observed to enter room [ROOM NUMBER] without PPE, placed a water pitcher on the bedside table, picked up the used water pitcher, and secured the used pitcher against herself by using her forearm. Staff A exchanged the other water pitcher and exited the room. Staff A next placed the used water pitchers on the second shelf of a wheeled cart and proceeded to the next room without performing hygiene. Staff A then pushed the cart to room [ROOM NUMBER], placed a water pitcher on the bedside table, picked up the used water pitcher, and secured the used pitcher against herself by using her forearm. Staff A exchanged the other water pitcher and exited the room. Staff A next placed the used water pitchers on the second shelf of a wheeled cart and proceeded to the next room without performing hygiene. room [ROOM NUMBER] also showed PPE supplies, a contact isolation sign that stated PPE requirements of a gown, gloves and designed equipment required for contact isolation located outside of the room Staff A observed to enter room [ROOM NUMBER] without PPE, placed a water pitcher on the bedside table, picked up the used water pitcher, and secured the used pitcher against herself by using her forearm. Staff A exchanged the other water pitcher and exited the room.Staff A next placed the used water pitchers on the second shelf of a wheeled cart and proceeded to the next room without performing hygiene. Staff A then pushed the cart to room [ROOM NUMBER], placed a water pitcher on the bedside table, picked up the used water pitcher, and secured the used pitcher against herself by using her forearm. Staff A exchanged the other water pitcher and exited the room. Staff A next placed the used water pitchers on the second shelf of a wheeled cart and proceeded to the next room without performing hygiene. room [ROOM NUMBER] also showed PPE supplies, a contact isolation sign that stated PPE requirements of a gown, gloves and designed equipment required for contact isolation located outside of the room. Staff A observed to enter room [ROOM NUMBER] without PPE, placed a water pitcher on the bedside table, picked up the used water pitcher, and secured the used pitcher against herself by using her forearm. Staff A exchanged the other water pitcher and exited the room.Staff A next placed the used water pitchers on the second shelf of a wheeled cart and proceeded to the next room without performing hygiene. In an interview on 3/18/24 at10:50 AM, Staff B, Licensed Practical Nurse (LPN), reported the residents in rooms 208, 209 and 213 required contact isolation precautions due to symptoms of suspected norovirus. Staff B reported PPE of a gown and gloves required for contact isolation. In an interview on 3/18/24 at 11:01 AM, the Infection Preventionist (IP) reported test results were pending for the norovirus. The IP explained residents experienced symptoms of nausea, vomiting and diarrhea. In an interview on 3/18/24 at 3:14 PM, the Director or Nursing (DON), and the IP confirmed rooms 208, 209 and 213 required PPE for contact isolation precautions. When asked if the DON expected staff to follow contact isolation precautions every time staff entered rooms [ROOM NUMBER], the DON replied, yes. The email regarding the possible norovirus information provided by the IP on 4/18/24 at 11:24 AM showed residents isolated to rooms as symptoms start: a. 3/13/24-rooms [ROOM NUMBERS] b. 3/14/24- rooms 213 Standard Precautions The Standard Precautions/Transmission based precaution system is designed to prevent the transmission of infectious agents. It requires the use of work practice controls and protective apparel for all contact with blood and body substances, but uses airborne infection isolation, droplet, and contact precautions for patients with diseases known to be transmitted in whole or in part by these routes. Standard precautions include consistent and prudent prevention measures to be used at all times regardless of their patient''s known affection status and include: Hand hygiene: Practice hand hygiene: practice hand hygiene after touching blood, body fluids, secretions, excreations, or contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. Gloves: Wear gloves (clean, non sterile gloves are adequate) when touching blood, body fluids, secretions, excretions, or contaminated items. Put on clean gloves just before touching mucous membranes and non intact skin. Change gloves between tasks and procedures. Practice hand hygiene whenever gloves are removed. Gown: Wear a gown (a clean, non sterile gown is adequate) to protect skin And to prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of food, body fluids, secretions, or excretions. Carefully, remove a soiled gown as promptly as possible, to avoid contamination of personal clothing, and wash hands.

Based on personnel file reviews, facility policy review and staff interview, the facility failed to provide the required 2 hour dependent adult abuse training within 6 months of hire for 2 of 9 employees reviewed (Staff D and E). The facility identified a census of 30 residents. Findings include: 1. The personnel file for Staff D, Certified Nursing Assistant (CNA) documented a hired date of 3-23-23. Review of the Dependent Adult Abuse Mandatory Reporter Training Certificate documented Staff D, CNA completed the 2 hour training on 11/24/23. 2. The personnel file for Staff E, CNA documented a hired date of 5/15/23. Review of the Dependent Adult Abuse Mandatory Reporter Training Certificates documented Staff E, CNA completed the 2 hour dependent adult abuse training on 11/24/23. The facility policy titled Abuse, Prevention, Identification, Investigating, and Reporting Policy revised 4-1-17 revealed each employee shall be required to complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment. On 3/20/24 at 1:54 PM, Staff F, Business Office Manager verified and acknowledged Staff D and Staff E completed the dependent adult abuse training late and not within 6 months of hire.

Based on facility policy and staff interview, the facility failed to ensure the Dietary Manager was certified. The facility reported a census of 28 residents. Findings include: In an interview on 2/6/23 at 11:18 AM , the Dietary Manager (DM) reported she had 10 of 17 modules completed and had to complete 3 tests to obtain her Certified Dietary Manager (CDM) certification. In the same interview, the DM reported that worked in this position at the facility since November 2021. In an interview on 2/8/23 at 10:26 AM, the Business Office Manager (BOM) reported the Dietary Manager was hired on 11/16/21 for the position of DM. In an interview on 2/8/23 at 2:17 PM, the Administrator reported the the DM was in the process of taking course work to complete her certification, that other facilities did not have certified DMs in the area, and that if the facility was out of compliance with this regulation the facility would plan on correcting this.

Based on observation, staff interview and record review, the facility failed to update the resident's care plan to accurately reflect the resident for 2 of 12 reviewed (Residents #13 and #19). The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of arthritis, neurogenic bladder and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The Care Plan with a revision date of 2/6/23 revealed Resident #13 currently has an indwelling catheter and was currently taking tramadol for pain management. The Progress Notes revealed the following information: On 1/5/23 at 11:10 a.m., order received to discontinue Tramadol. On 1/6/23 at 6:05 p.m., fax returned and catheter may remain out per physician. Interview on 2/8/23 at 1:02 p.m., with the Director of Nursing revealed the care plans should have been updated with the change in medication and with the discontinuation of the catheter. 44475 2. The Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately intact cognition. The resident had diagnoses of Parkinson's disease, mood disorder due to known physiological condition, and intermittent explosive disorder. The Physician Order Summary dated 12/28/22 signed by a physician revealed an order for melatonin, 3 milligrams (mg) to be taken at bedtime. The Care Plan did not include the use of the melatonin or adverse side effects to monitor for. In an interview on 2/8/23 at 2:43 PM, the Director of Nursing (DON) reported the facility does not have a policy for including melatonin on care plans. In the same interview, the DON reported that she will talk with the facility's contracted care plan company about including melatonin on care plans.

Based on observation, facility records, and staff interview the facility failed to provide infection control practices to prevent the transmission of infectious agents for 4 of 32 residents reviewed (Residents #13, #14, #3, and #130). The facility reported a census of 32 residents. Findings include: 1. Observation on 9/13/21 at 12:35 PM of no goggle use by the staff in the building. The Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 3/29/21 from the Centers for Disease Control and Prevention (CDC) directed eye protection use in areas with moderate to substantial community transmission during patient care encounters. In an interview on 9/13/21 at 2:49 PM, the Director of Nursing (DON) reported goggle use is not required unless there is a resident that is either suspected of having COVID-19 or has tested positive for COVID-19. In the same interview the DON reported she had not received information from the association (Iowa Healthcare Association) to direct her that goggle use is indicated when county positivity rates are in the moderate or high levels. In an interview on 9/13/21 at 2:49 PM, Staff D, Registered Nurse (RN) and the facility's Infection Preventionist (IP) reported the county positivity rate on 9/13/21 was 23.7% which placed the county at a high level of COVID-19 positive population in the county. 2. Observation on 9/13/21 at 12:35 PM of facility screening logs for visitors and staff noted it did not contain information screening results were verified. An electronic screening kiosk including temperature was used to screen employees that used the time clock. The paper screening logs used for employees and visitors revealed out of a total of 426 entries, 219 entries were not verified. 5 entrants failed screening, 42 entries were not complete, 68 employees selected no to reflect they did not wear a mask or used hand sanitizer before entering the facility. In an interview on 9/13/21 at 2:49 PM, the Director of Nursing (DON) reported the facility chose to have screening results verified by a person at the entrance to the facility, but have been unable to obtain a staff person or a volunteer to fill this need. When asked if the DON attempted other methods of providing verification, she did not respond. 3. The MDS dated [DATE] revealed a Brief Interview of Mental Status score of 14 indicating Resident #13 had intact cognition. The MDS revealed the resident required limited assistance of 1 with bed mobility and extensive assistance of 1 with transfers and toilet use. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation on 9/15/21 at 11:16 AM, the Director of Nursing (DON) did not perform hand hygiene before putting a barrier on a bedside table. The DON then applied gloves without performing hand hygiene first and placed part of the resident's wound care supplies on the barrier. The DON then went into the shower room with the resident and placed the remaining would care supplies from a plastic bag the resident took into the shower room with her when she had a shower. The DON directed Staff E, Certified Nurse Assistant (CNA) to ask Staff F, Licensed Practical Nurse (LPN) to obtain wound cleanser and to bring a face shield. Staff E returned with the items. The DON placed the wound cleaner on an area of the bedside table not covered by the barrier. Staff E held the resident's right leg while the DON removed the dressing. The DON threw the dressing away in a trash can. The DON changed her gloves without performing hand hygiene. The DON did not clean the pressure ulcer. The DON then applied wound gel to the new [MEDICATION(S)] foam dressing, and applied the dressing to the resident's right heel. The DON then removed her gloves and used alcohol based hand rub. Resident #13 had an order dated 9/15/21 for [MEDICATION(S)] Foam 4, apply to right heel topically every day shift every Mon, Wed, Sat with wound gel. The undated Standard Precautions policy revealed to practice hand hygiene after touching body fluids or contaminated items, to wash hands immediately after gloves are removed, and when otherwise indicated to avoid transfer of microorganisms. In an interview on 9/22/21 at 12:08 PM, the DON admitted she did not perform hand hygiene before resident care, that she did not change gloves and perform hand hygiene after she removed the dressing and before she applied the new dressing, and that she did not clean the pressure ulcer because she did not have gauze. 4. Observation on 9/15/21 at 10:29 AM revealed Staff A, Certified Nurse Assistant (CNA) did not perform hand hygiene and applied gloves. Staff A put a paper towel on the floor in front of Resident #13 and placed container and alcohol wipes on it. Staff A cleaned the end of the catheter bag tubing with an alcohol wipe and emptied the urine from the resident's catheter bag into the container. Staff A wiped the end of the of the catheter bag tubing with an alcohol wipe and secured the tubing on the catheter bag. Staff A picked up the soiled paper towel and container from the floor. Emptied the urine from the container into the toilet, cleaned the container and threw away the paper towel that was used on the floor. Staff A then took off her gloves and did not perform hand hygiene. Staff A then touched the resident's clean clothing as she prepared to take the resident to the shower room. The undated Standard Precautions policy revealed to practice hand hygiene after touching body fluids or contaminated items, to wash hands immediately after gloves are removed, and when otherwise indicated to avoid transfer of microorganisms. In an interview on 9/22/21 at 12:08 PM, the DON reported she expected staff to perform hand hygiene before and after resident care and after gloves are removed. 5. The MDS dated [DATE] revealed a BIMS of 13 which indicated Resident #14 had intact cognition. The MDS revealed the resident required extensive assistance of 2 persons with bed mobility, was totally dependent for assistance with transfers and toileting, and was independent with eating. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 9/13/21 at 1:52 PM revealed an oxygen concentrator in the resident's room with nasal cannula oxygen tubing attached to it. There was no label with a date on the oxygen tubing. The Progress Notes dated 4/17/21, 5/3/21, and 5/18/21 revealed the resident had oxygen on at 2 liters per minute (lpm) per nasal cannula. In an interview on 9/16/21 at 1:29 PM, Staff A, Certified Nurse Assistance (CNA), reported the resident used oxygen every night. In an interview on 9/16/21 at 1:31, Staff B, Licensed Practical Nurse (LPN) reported the resident used oxygen every night. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 9/22/21 at 12:13 PM, the DON reported the facility's standard of practice was to change oxygen tubing every 2 weeks and that oxygen tubing changes would not happen if there was no order to change oxygen tubing. 6. The MDS dated [DATE] revealed a BIMS of 13 which indicated Resident #14 had intact cognition. The MDS revealed the resident required extensive assistance of 2 persons with bed mobility, was totally dependent for assistance with transfers and toileting, and was independent with eating. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on at 9/13/21 at 4:24 PM, the resident reported her recent [CONDITION(S)] is getting better. In an interview on 9/14/21 at 9:52 AM, the resident's representative reported the resident was incontinent of urine, had chronic issues with UTIs, and had been on a prophylactic antibiotic to manage the chronic UTIs. In an observation on 9/16/21 at 11:09 AM, Staff A, Certified Nurse Assistant (CNA), applied gloves without performing hand hygiene first to assist resident with perineal cares. Staff C, CNA, applied a glove on the right hand without performing hand hygiene. The resident was sitting on a bed pan. The resident rolled to her left side and Staff C removed the bedpan with her bare left hand. Staff C did not perform hand hygiene or change her glove and took a clean washcloth out of the basin of water. Staff C then folded the washcloth into fourths and cleaned from the perineum to the anus on the right side then across the top of tailbone area and back from the perineum to the anus area. Staff C turned the washcloth to a clean area, wiped from the perineum to the anus on the left side and across the tailbone area. Staff C then cleaned across the buttocks from the right side to the left side back to the right side and from the perineum to the anus area without turning the washcloth. Staff C placed the dirty washcloth into a basket with a bag in and did not change gloves or perform hand hygiene. The resident rolled onto her back. Staff C took a clean washcloth out of the basin. Staff C wiped down the left side leg crease down to the perineum and continued to wipe up into the vaginal area, turned the washcloth and wiped down the right leg crease down to the perineum and continued to wipe up into the vaginal area, turned the washcloth and wiped up from the perineum into the vaginal area up to the lower abdomen without turning the washcloth. Staff C wiped from the left side of the abdomen to the right side of the abdomen then turned the washcloth to a clean area and wiped down from the vaginal area to the perineum. Staff C removed gloves, did not perform hand hygiene, pulled up the resident's brief and secured the tabs. Staff A assisted the resident to roll to pull up the resident's pants. Staff C cleaned up the water basin and performed hand hygiene. The Progress Note dated 9/9/2021 at 5:12 PM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Coli- continue same ATB. The Care Plan with an initiated date of 6/1/17 Resident #14 revealed the resident was incontinent of urine, please assist the resident with periods of incontinence so she was clean and dry and she was often incontinent of urine and utilized incontinence products. Please assist her with periods of incontinence and provide incontinence products as needed. The Care Plan with a revision date of 4/27/21 revealed she had chronic UTIs. Please offer and encourage fluids throughout the day. She had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's current Medication Orders did not contain a prophylactic antibiotic. The Nurse Aide Skills Checklist Unit V dated 08/12 revealed hand hygiene would be performed before applying gloves and after removing gloves. The undated Standard Precautions policy revealed to practice hand hygiene before providing resident care, after touching body fluids or contaminated items, to wash hands immediately after gloves are removed, and when otherwise indicated to avoid transfer of microorganisms. In an interview on 9/22/21 at 12:08 PM, the DON reported she would expect staff to perform hand hygiene before a procedure and with glove changes. 7. The MDS assessment for Resident #3, dated 8/29/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) and [MEDICATION(S)] (artificial opening for urinary to drain out). A BIMS score of 15, indicated no cognitive impairment for decision making. During an observation on 9/14/21 at 10:50 AM, Staff G, RN (Registered Nurse) washed hands, donned gloves, and wiped area on coccyx with a towel. Staff G, RN removed her gloves, did not complete hand hygiene, and applied new gloves. Staff G, RN applied treatment and covered wound per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G, RN placed scissors, used to cut dressing, in her pocket and then removed scissors and cleansed with hand sanitizer. Staff G, RN removed gloves, washed hands, applied new gloves and removed resident's [MEDICATION(S)] bag. Staff G, RN cleansed the [MEDICATION(S)] and area surrounding with a wet cloth, and changed the bag attached to the catheter, did not change gloves or perform hand hygiene after cleansing. With the same gloves, Staff G, RN applied treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G, RN placed scissors in treatment cart. 8. A MDS assessment dated [DATE], for Resident #130, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had a Stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence). A BIMS score of 8 indicated moderate cognitive impairment for decision-making. During an observation on 9/15/21 at 9:46 AM, the DON was in Resident #130's room with gloves on and supplies on a tray table. The DON cleansed the wound on the right side of buttock by spraying saline wound wash spray on the wound, touching the wound with the wound wash can and dried the wound with gauze pads. The DON changed gloves, no hand hygiene performed and applied treatment as ordered by the physician. The DON removed her gloves, used hand sanitizer, and placed the wound wash can in the treatment cart. Review of undated facility policy titled Standard Precautions documented: a. Hand Hygiene - Practice hand hygiene after touching blood, body fluids, secretions, excretions, or contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. b. Gloves - Change gloves between tasks and procedures. Practice hand hygiene whenever gloves are removed. During an interview on 9/22/21 at 12:08 PM, the DON stated expectation was for hand hygiene to be completed when changing gloves.

Based on record review and staff interview the facility failed to ensure the code status was the same in the electronic health record and the paper health record for 2 of 16 resident charts reviewed, (Resident #3 and #4). The facility reported a census of 32. Findings include: 1. Review of Resident #3's record revealed a facility form titled Authorization and Order for Withholding Cardiopulmonary Resuscitation documented a do not resuscitate order signed by the resident on [DATE] and the physician on [DATE]. Review of Resident #3's record documented an Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Order Summary Report, signed by the physician on [DATE] documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 12:04 PM, Staff G, Registered Nurse (RN) stated when checking for a resident's code status she looks in the computer first in their orders as it is usually there, the resident also has a sheet in their chart, and there is a list of residents that are full code hanging in the nursing office. Staff G, RN showed list of full code residents and Resident #3 not on the list. During an interview on [DATE] at 2:20 PM, the Director of Nursing (DON) stated expectation that IPOST/DNR form and order match and be correct. During an interview on [DATE] at 3:00 PM, the DON stated physician had reviewed code status with resident in [DATE] and resident changed status to Full Code, so that makes the order on the resident's order summary report correct. DON stated she had just went and spoke to the resident and resident wanted to be a full code so that order is correct and we would have to agree to disagree. Staff G, RN stated resident was being added to the full code list now in the nursing office. 2. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 6 which indicated Resident #4 had a severe cognitive impairment. Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Electronic Health Record (EHR) revealed an order dated [DATE] that directed Resident #4 was a full code (Cardiopulmonary Resuscitation [CPR] would be performed if indicated). The Facility Do Not Resuscitate (DNR) form dated [DATE] revealed Resident #4's wishes were that no CPR would be performed if indicated. The Order Summaries reviewed dated [DATE] and signed by Advanced Registered Nurse Practitioner (ARNP) on [DATE], and [DATE] and signed by Certified Physician Assistant (PA-C), revealed the resident's wishes were to be a full code (CPR would be performed if indicated).

Based on clinical record and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASARR) with accurate information for 1 of 2 residents reviewed (Resident #13). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status score of 14 indicating the resident had intact cognition. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinic record revealed Resident #13 was admitted to the facility on [DATE] and that a PASARR dated 1/3/17 revealed the resident was exempt from PASARR. In an interview on 9/20/21 at 2:57 PM, the Director of Nursing (DON) reported the PASARR dated 1/3/17 was the most recent PASARR submitted. In an interview on 9/21/21 at 2:00 PM, the DON reported that she forgot to include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, staff and resident interviews and review of facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards to self and failed to implement interventions as directed by the care plan in order to prevent accidents for 2 of 4 residents (Resident #1, Resident #3) reviewed. The facility reported a census of 28 residents. Resident #1 was blind and needed staff assistance in guiding his/her walker during ambulation. He/she had a history of [REDACTED].#1. The resident suffered a fall when getting up without assistance. Staff did not assure the pressure alarm was on and functioning prior to leaving Resident #1 seated and unattended. Resident #1 sustained a fractured humerus which resulted in pain, an increased need for assistance with activities of daily living (ADL's), a decline in mobility requiring Physical Therapy (PT) and Occupational Therapy (OT), confusion and increased incontinence. Resident #3 had a history of [REDACTED]. Observation revealed the resident without an alarm. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 10/15/12 which identified a Brief Interview for mental Status (BIMS) as no cognitive impairment. Resident #1 demonstrated minimal difficulty hearing and severely impaired ability to see in adequate light. Resident #1 required extensive assistance of 1 person with activities of daily living including transfers, ambulation, and bathing. Resident #1 was unsteady with moving from a seated to standing position, turning around, moving on and off the toilet, and surface to surface transfers. Resident #1 normally used a walker. Resident #1 had occasional urinary incontinence. The MDS documented Resident #1 had not experienced pain the previous 5 days. Resident #1 had 2 falls since the previous assessment with no injuries. Resident #1's [DIAGNOSES REDACTED]. The fall history identified the following: a. An Incident Details report dated 05/17/12 at 5:15 p.m. documented he/she slipped or fell back and sideways onto the left side, transferring self from a chair to standing. The immediate intervention put in place was an alarm. The results of the investigation were; pressure alarm necessary to alert staff. b. An Incident Details report dated 06/23/12 at 8:40 a.m. documented staff found him/her on the floor with the wheelchair tipped to the side. The alarm sounded. Staff noted the call light on the floor and reminded staff to assure the call light was in reach. c. A Resident Fall Assessment Sheet dated 07/25/12 at 1:15 a.m. documented a CNA responded to the sensory bed alarm sounding. When the CNA reached the room Resident #1 was on his/her hands and knees with his/her bottom by the side of the bed and he/she crawled towards the dresser. Resident #1 ended up lying on his/her left side with his/her bottom slightly under the bed by the head of the bed. Resident #1 had a small bump above the left eye. The Fall Committee Review dated 07/27/12 documented no changes in the resident, he/she fell frequently. d. A Resident Fall Assessment Sheet dated 07/26/12 at 5:15 p.m. documented staff spotted Resident #1 on his/her knees, with pressure alarm going off. The Fall Committee Review dated 07/27/12 documented all alarms discontinued except the chair pad alarm to alert staff of Resident #1 rising. On 07/28/12 the chair pad alarm used while sitting up unattended. e. A Resident Fall Assessment Sheet dated 09/01/12 at 8:10 p.m. documented Resident #1's alarm sounded. Resident #1 slid from the chair on to his/her knees intentionally to look for his/her cell phone. The Fall Committee Review dated 09/05/12 documented Resident #1 was blind and declining with dementia. f. A Resident Fall Assessment Sheet dated 09/20/12 at 6:45 p.m. documented Resident #1 crawled out of his/her chair on to the floor to search for candy. The call light and chair pad alarm were on the chair. The Care Plan dated 10/16/12 identified Resident #1 with the focus of injury. The interventions directed staff to perform the following: a. Resident #1 had a pressure alarm under him/her when he/she was seated and unattended. Please assure the alarm is on and functioning properly. b. Resident #1 required assist of 1 and the wheeled walker for ambulation. The care plan identified the focus of ADL/mobility. The interventions included: a. When walking with Resident #1 please make sure to tell him/her what direction to go. Due to his/her poor vision, Resident #1 sometimes veered off to one side. A Doctor's Orders and Progress Notes dated 10/17/12 regarding an eye exam documented Resident #1 had declined to no light perception. Resident #1 legally blind still, near total. A Progress Note dated 10/22/12 at 1:04 p.m. documented Resident #1 mostly continent of bowel and bladder with occasional incontinent episodes. Resident #1 had a pressure alarm on when unattended to alert staff when he/she attempted to self-transfer. A Physical Therapy Rehab Screening dated 10/22/12 documented Resident #1 alert and oriented times 3, and followed commands. Resident #1's upper and lower extremity range of motion within full limits. Resident #1's upper and lower extremity strength within full limits. Resident #1 demonstrated independence in bed mobility, 1 to 2 person assist with transfers and ambulation. Resident #1's sitting balance good, while standing was poor. Resident #1 wore an alarm secondary to very poor eyesight. According to the Fall Risk Assessment scoring, 0 to 5 indicated low risk, 6 to 15 indicated moderate risk, and 16 to 60 indicated high risk. Resident #1's Fall Risk assessment dated [DATE] scored Resident #1 at 15 indicating moderate risk. The section regarding medication use failed to identify Resident #1 received an antihistamine (Benadryl), hypoglycemic agents (Glipizide, Onglyza, Metformin), NSAIDS (Celebrex), and psychotropics (Paroxetine, Alprazolam) which would elevate his/her score to 19 indicating high risk. Each drug category scored 1 point. A Resident Fall Assessment Sheet dated 10/28/12 at 9:25 a.m. documented Resident #1 fell at the front entrance. Resident #1 got up from a chair with his/her walker and fell by the front entry door on his/her right side with his/her left arm wrapped around the back. The pressure alarm on the chair was not plugged in and it did not sound. The report documented Resident #1 had impaired vision and an unsteady gait. A History and Physical dated 10/28/12 documented Resident #1 got up him/herself, somehow tripped and fell , landing on the floor on his/her left shoulder. Resident #1 had severe pain in the left shoulder. Resident #1's left shoulder showed marked bruising anteriorly and tenderness over the proximal hummers. A left shoulder x-ray showed a comminuted slightly displaced fracture of the proximal humerus. Resident #1 fell at the nursing home with the fracture, status [REDACTED]. A hospital Transfer Sheet dated 10/29/12 documented Resident#1 had a left shoulder fracture, with a sling. No weight bearing of the extremity (no lifting, pulling, or pushing with the left arm). The facility pain scale, The Wong-Baker Faces Pain Rating Scale indicated 0 equaled no hurt, 2 equaled hurt a little bit, 4 equaled it hurt a little more, 6 equaled it hurt even more, 8 equaled it hurt a whole lot, and 10 equaled hurting the most. The Progress Notes dated 10/29/12 at 3:10 p.m. documented Resident #1 returned to the facility per van. Resident #1 had a shoulder immobilizer in place to the left shoulder. Resident #1 had a large area of bruising to the left upper arm. Staff were not able to measure the bruising with the immobilizer in place. At 5:13 p.m. staff assisted Resident #1 to the bathroom. The resident had no sense of balance when standing or sitting on the toilet, and required assist of 2 staff persons. At 6:37 p.m. Resident #1 received Acetaminophen with Codeine for left shoulder pain. Resident #1 could not rate the pain. The Progress Notes dated 10/30/12 at 9:44 a.m. documented Resident #1 received Acetaminophen with Codeine for complaints of shoulder/left arm pain. At 10:38 a.m. Resident #1's balance extremely poor on the toilet and standing, and required assist of 2. At 4:36 p.m. Physical Therapy saw Resident #1 for an evaluation. They would continue 3 times a week with gait and transfer training, therapeutic activities, and patient and staff education. At 6:53 p.m. Resident #1 received Acetaminophen with Codeine for complaints of left shoulder/arm pain. The Progress Notes dated 10/31/12 at 4:57 a.m. documented Resident #1 assisted up to the commode 4 times during the night with unsteady balance. Resident #1 transferred with assist of 2 and the gait belt. Resident #1 was incontinent of urine each time and voided 2 times in the commode. At 1:17 p.m. Occupational Therapy (OT) saw Resident #1 for 23 minutes. OT performed modified edema management to decrease edema in the left upper extremity... Resident #1 required frequent rest breaks... At 1:59 p.m. Resident #1 received Tylenol with Codeine for left arm pain at #8 (hurts a whole lot). At 10:34 p.m. Resident #1 complained of pain of the left arm 1 time with transfer. Pain medication given. Resident #1 unable to rate the pain. The Progress Notes dated 11/01/12 at 9:02 a.m. documented Resident #1 received Acetaminophen with Codeine for left arm pain at #9. At 10:17 a.m. Resident #1 said the pain medication helped reduce pain to a #8. Resident #1 said it didn't hurt if he/she didn't move it. At 1:58 p.m. Resident #1 received Acetaminophen with Codeine for left arm pain at #8. At 3:41 p.m. PT documented Resident #1 complained of left arm pain when moving. Resident #1 seen for 20 minutes of treatment consisting of 15 minutes gait training and 5 minutes of therapeutic activities. Resident #1 required minimal to moderate assist to stand from a lift chair, was unsteady on rising and needed significant support to maintain balance. With hand hold and strong contact guard to support trunk, Resident #1 walked 50 feet with assist of 1, shuffling, with poor foot clearance and very short stride. Resident #1 required constant guidance due to blindness. Resident #1 needed verbal cues for stand to sit to align him/herself and to lower him/herself into the lift chair. Resident #1 continued to have significant deficits in mobility compared to his/her prior level of function. At 11:05 p.m. Resident #1 received Acetaminophen with Codeine for left shoulder pain at #9. The Progress Notes dated 11/02/12 at 9:18 a.m. documented Resident #1 seen by OT for 17 minutes. Resident #1 appeared to resist PROM due to pain. At 9:47 a.m. Resident #1 received a pain pill earlier in the morning for complaints of shoulder/arm pain and was effective. Resident #1 used the wheelchair for mobility; balance very poor. At 2:32 p.m. Resident #1 found on his/her knees in front of the lift chair. The personal alarm remained attached to his/her sweater. Medication given for pain. At 3:18 p.m. a second pain med given and ice applied to Resident #1's shoulder. At 10:00 p.m. Resident #1 voiced no further complaints of pain, other than with movement of the left shoulder. The Progress Notes dated 11/03/12 at 9:52 a.m. documented Resident #1 had bruising noted across the upper chest, shoulder, left upper arm, forearm, and both breasts The Progress Notes dated 11/04/12 at 11:58 a.m. documented Resident #1 received a pain pill for comfort. The bruising continued to most of the upper body. They noted increased swelling in the left hand; rings removed. They noticed increased incontinence, especially during the night. The Progress Notes dated 11/05/12 at 8:38 a.m. documented Resident #1 received Acetaminophen with Codeine for left shoulder pain at #9. At 3:04 p.m. OT documented Resident #1 reported pain, even with light touch to the left shoulder. Resident #1 continued to have limited elbow ROM, mainly limited by pain. Resident #1 demonstrated slow progress with ADL's and ROM. At 3:55 p.m. Resident #1 received Acetaminophen with Codeine for left shoulder pain at #9. At 4:14 p.m. Resident #1 received Tylenol with Codeine 2 times for pain at #9 with some relief. At 11:57 p.m. Resident #1 received Acetaminophen with Codeine for complaints of left shoulder/arm pain at #8. The Progress Notes dated 11/06/12 at 12:34 p.m. documented Resident #1 stated he/she felt sore, but felt better than the previous day. At 4:20 p.m. they repeated medication for comfort. Resident #1's conversations were more inappropriate, oriented for a short time only. At 10:06 p.m. Resident #1 complained of pain when repositioned or with movement. The Progress Notes dated 11/07/12 at 2:09 a.m. documented Resident #1 up to use the bedside commode and complained of pain in the left shoulder. Resident #1 grimaced when repositioned. At 9:42 a.m. his/her balance remained poor. At 10:59 a.m. the family called and questioned Resident #1's confusion, and if they had something else available for pain. At 1:11 p.m. PT documented Resident #1 making slow progress. The progress depended on pain management and went well secondary to getting a pain pill prior to the session. A facsimile (fax) dated 11/07/12 notified the physician Resident #1 took Tylenol with Codeine 4 to 5 times a day. The family wondered if there was something that would cause less confusion, for pain. The physician responded with a new order to try Gabapentin 100 mg every bedtime, and could continue the Tylenol #3 PRN. The Progress Notes dated 11/08/12 at 8:00 a.m. documented Resident #1 received Acetaminophen with Codeine for left shoulder pain at #9. At 3:49 p.m. PT documented Resident #1 continued to complain of left shoulder pain when touched or with movement. Resident #1 seen for 20 minutes of therapeutic activity... Resident #1 needed support to maintain standing balance at all times. He/she also fell back once seated as he/she thought he/she was in a chair rather than on the side of the bed. Resident #1 continued to have limited mobility and balance issues following a fall with a left humeral fracture. At 7:56 p.m. Resident #1 received Acetaminophen with Codeine for left arm/shoulder pain at #8. The Progress Notes dated 11/09/12 at 3:34 p.m. PT documented Resident #1 had numerous complaints of his/her arm and shoulder hurting. Resident #1 progressed slowly toward goals secondary to cognition and pain. The Progress Notes dated 11/10/12 at 12:19 a.m. documented Resident #1 demonstrated confusion and hallucinations that his/her family member was in the room. The Progress Notes dated 11/12/12 at 3:22 p.m. documented Resident #1 woke up in the wheelchair was more confused and attempting to take his/her shirt and immobilizer off. Staff sent a fax to the physician if a different pain medication would cause less confusion. On 11/14/12 at 12:56 p.m. Resident # 1 was interviewed and stated he/she remembered the day of the fall and breaking her/his arm. The resident stated had gotten ready for church and wanted to get his/her gloves off the shelf. He/she walked and just fell and didn't know why. Resident #1 stated he/she crushed the shoulder and broke his/her arm. Resident #1 stated it hurt really bad when it moved or someone touched it. On 11/14/12 at 1:50 p.m. Staff A was interviewed and stated she did showers that day because the showers didn't get done on Saturday, due to being short (in staff). She did not assist Resident #1 (that day) prior to stopping to help him/her. She put the other resident's clothes on a counter. Resident #1 needed the bathroom or his/her coat. She took Resident #1 to his/her room to use the bathroom. Then the resident stated he/she needed his/her coat. Staff A stated she sat Resident #1 in the chair. Both chairs had alarms on them. Resident #1 sat in the chair. Resident #1 stated he/she needed gloves and a hat. Staff A stated she would help Resident #1 in 15 minutes at the most. Staff A stated some alarms made a loud noise and some made a clicking noise. She stated usually when someone sat down in the chair it would beep. Staff A did not check the alarm. Staff A stated Resident #1 told her he/she would wait. Staff A then stated Resident #1 didn't normally get up on own. Staff A stated when she assisted Resident #1 up to go to the bathroom from the nurse's station, he/she did not have an alarm. Staff A stated she could not remember which pressure alarm was in the chair Resident #1 sat in. Staff A also wrote a written statement of the incident. On 11/14/12 at 2:35 p.m. Staff D (Registered Nurse- RN) was interviewed and stated she tended to Resident #1 after the fall so she did not check the alarm right away. One of the CNA's reported the cord was unplugged. Staff D stated it was not unusual for Resident #1 to stand up and try to go on own- he/she did it all the time. Resident #1 did what he/she wanted to do. Staff D pointed out where they found Resident #1 the day of the incident on the rug in front of the door (approximately 15 feet from the chair). Staff D stated it was lucky Resident #1 didn't hit the glass. On 11/14/12 at 5:22 p.m. Staff B (CNA) was interviewed and stated she took Resident #1 out to breakfast, and she didn't think he/she had an alarm at breakfast. Staff B did not place the alarm when Resident #1 sat by the nurse's station after breakfast. After break she passed water pitchers. She saw Resident #1 right after break, and another resident sat next to Resident #1. Shortly after going down the 200 hall to pass water pitchers she heard her name and when she went back up she saw Resident #1 on the floor by the front door and Staff C sat next to her. Staff B did not hear any alarm sound. When Staff B checked the alarm she found the cord not plugged in to the box. She checked the alarm by plugging it in the cord into the box and it worked. She also tried to remove the cord from the box without pressing the tab, but it would not come out until she did (press it), so it was not broken. The alarm sounded when she removed the cord until she silenced it. Staff B stated she received no training on the different alarms. Staff B also documented a statement of the incident. On 11/15/12 at 9:04 a.m. Staff C (CNA) was interviewed and stated when she came back from break she saw Resident #1 laying on the floor. The resident ' s head lay toward the door and feet toward the nurse's station on his/her side and back. The walker lay down by his/her feet. Resident #1's left hand was under the buttock area. Staff C could see something wrong with Resident #1's shoulder. Staff C had Staff B go and get the nurse. The nurse assessed Resident #1 and they did not move the resident. Resident #1 did have a gait belt around his/her waist. No alarm sounded. Resident #1 said he/she went to look for his/her coat and gloves. Staff C stated when the alarm is on and someone sits on it; it beeps twice which indicates that it's working. She stated Resident #1's walker may have caught on the rug in front of the door. The resident ' s head was about a foot from the glass. Resident #1 would try to get up on own, and had a history of [REDACTED]. Resident #1 had a hard time walking with the walker anyway. When walking with the resident, the staff had to guide the walker for the resident. Staff C documented a statement of the incident. During an interview on 11/15/12 at 10:13 p.m. Staff E (CAN) stated Resident #1 used the alarm the evening before the incident. Resident #1 made attempts to get up and they would have him/her sit back down. Staff E stated she did not unclip the cord from the box. She stated Resident #1 used the walker but did not navigate it him/herself. Staff had to guide the walker. During an observation on 11/14/12 at 2:57 p.m. staff transferred Resident #1 to the chair that he/she sat in prior to the fall. When Resident #1 sat on the alarm pad it beeped 2 times. At 4:05 p.m. staff assisted Resident #1 to stand and the alarm sounded. After the transfer to the wheelchair, staff turned the alarm off by pressing a button on the back of the box. 2. Resident #3 had a Minimum Data Set (MDS) assessment with a reference date of10/22/12. The MDS identified a score of 7 on the Brief Interview for Mental Status (BIMS). This score identified a cognitive impairment. Resident #3 required extensive assistance with ADL's (Activities of Daily Living) including transfers, dressing and toilet use. Resident #3 demonstrated unsteadiness moving from a seated to a standing position, turning around, moving on and off the toilet, and surface to surface transfers. Resident #3' [DIAGNOSES REDACTED]. Resident #3 had the following history of falls: a. A Resident Fall assessment dated [DATE] at 9:10 p.m. documented staff found Resident #1 lying on the floor in his/her room on his/her back, parallel to his/her bed. The Fall Committee review documented increased resident confusion. b. A Resident Fall assessment dated [DATE] at 11:40 a.m. documented staff took Resident #3 to his/her room to change his/her shirt after getting hair done. After changing Resident #3's shirt went to the bathroom. Resident #3 fell backwards landing on his/her buttocks, and bumping his/her head on the dresser. c. A Resident Fall assessment dated [DATE] at 4:00 a.m. documented when turning to sit on the toilet, Resident #3 became unsteady on his/her feet. A CNA lowered him/her to the floor, bumping his/her legs on his/her walker. The Fall Committee Review dated 09/21/12 documented the new intervention of a an alarm. d. A Resident Fall assessment dated [DATE] at 6:30 a.m. documented Resident #1's alarm sounded and Resident #1 called for help. Staff found him/her sitting on his/her buttocks with his/her legs in front of him/her. Resident #1's buttocks were near the edge of the bed, the walker across the room, bare footed, and lights off. The Fall Committee Review dated 10/10/12 documented Resident #3 declined, a lot of falls lately. The Care Plan for Resident #3 identified the focus of injury. The interventions included: a. Resident #3 experienced recent falls and needed a pressure alarm in the chair and in bed. b. Resident #3 required assist of 1 and the walker for ambulation. If unsteady required assist of 2. During an observation on 11/15/12 at 7:28 a.m. Resident #3 sat in a chair across from the nurse's station. There did not appear to be an alarm. The Director of Nursing (DON) stated Resident #1 did not have his/her teeth and went to his/her room. When the DON returned, the surveyor asked if Resident #3 had an alarm and she verified Resident #3 did not. At 7:34 a.m. a staff member walked by and the DON asked if he got Resident #3 up. The staff member stated he did get Resident #3 up. The DON informed the staff member Resident #1 did not have an alarm. The facility Accidents and Supervision policy described an avoidable accident meant a resident had an accident and the facility failed to implement interventions, including adequate supervision, consistent with the resident's needs, goals, plan of care and recognized standards of practice in order to reduce the risk of an accident. .

Based on observation, record review and staff interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision against hazards. Staff transferred Resident #1 from his/her bed to wheelchair without using a gait belt when the resident fell and sustained fractures of his/her right hip and elbow. The facility reported a census of 33 residents with four residents reviewed for falls. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The MDS further indicated Resident #1 required extensive physical assistance of 1 person for transfers, and limited physical assist of 1 person for ambulation in the room. Resident #1 did not ambulate in the corridor. Resident #1 demonstrated unsteadiness, and as only able to stabilize with human assistance when moving from a seated to a standing position, turning around, moving on and off the toilet, and surface to surface transfer (transfer between bed and chair or wheelchair). Resident #1 demonstrated unsteadiness, but could stabilize without human assistance when walking (with assistive device). Resident #1's [DIAGNOSES REDACTED]. Resident #1 had a history of [REDACTED]. The resident scored a 22 on the Falls Data Collection Tool, dated 06/15/11 and 07/15/11. A score of 12 or more equaled high risk for falls. The assessment indicated Resident #1 had a balance problem while standing and walking, and a decrease in muscular coordination. An Incident Details report, dated 05/03/11, documented staff found Resident #1 on the floor after he/she attempted to transfer from the bed to the hallway. The comments indicated staff found Resident #1 in his/her bedroom lying flat on the floor. He/she was very unsteady on his/her feet and required an assist of 1 when ambulating. An Incident Details report, dated 05/04/11, documented staff found Resident #1 lying flat on the floor beside the bed. Resident #1 had attempted to ambulate without using the call light and asking for assistance per usual. The new intervention included the implementation a personal body alarm. A Transfer Lift Assessment for Residents dated 06/15/11 documented Resident #1's special transfer needs: Up with a gait belt and standby assist with a walker. The assessment indicated to ensure the care plan appropriately reflected the assessment. The Comprehensive Care Plan, dated 06/23/11, identified Resident #1 with a self-care deficit with approaches including: a. Remind resident to use the call light to request assistance. The care plan identified the resident had impaired mobility with approaches including: b. Transfer with assist of 1 staff. The care plan identified a potential for falls with approaches including: c. Do not leave resident unattended in the bathroom or on the commode. d. Personal alarm on resident at all times. e. Assist of 1 staff with all transfers and ambulation. f. Cue and encourage the resident to call for assistance with all transfers. The ADLs (activities of daily living) Record, dated 07/10/11 to 07/16/11, documented Resident #1 required extensive assistance with transfers 13 out of 20 times documented in that time frame, and limited assistance the remaining 7 times. The Interdisciplinary Progress Notes, dated 07/16/11 at 8:00 a.m., documented Resident #1 complained of hallucinations, appeared very nervous, anxious, and shaky. The note indicated the Resident #1 had exhibited the same symptoms when on antibiotic therapy, and when he/she had taken a stronger dose of a Fentanyl patch (pain medication). The note stated the Resident #1's Fentanyl patch had been changed the previous night and that the patch contained the correct dosage of medication. The note reflected the weather was hot and humid, and that the resident had COPD and received continuous oxygen. Staff administered a prn (as neededed) dose of Alprazolam (antianxiety medication) to help decrease the resident's anxiety and indicated staff would continue to monitor the resident's condition. Progress notes written throughout the day contained the following information: At 10:00 a.m., the resident's family came to visit the resident. Staff notified them of the resident's condition. Resident #1 visited with family and then ate lunch in the dining room. At 3:00 p.m., a CNA (certified nurses' assistant) reported Resident #1 had fallen in his/her room and bumped his/her head and elbow. The nurse went to the room and assessed Resident #1. She observed no outward signs of injury to Resident #1's head, but he/she had guarded, and complained of pain in the right elbow. Resident #1 demonstrated the ability to move the arm at the elbow with full passive range of motion, but with a lot of pain. Staff notified the family of concerns with Resident #1's sudden confusion and the fall. The family came and took Resident #1 to the hospital for evaluation. At 5:40 p.m., Resident #1's family called and informed the facility Resident #1 had a fractured elbow and would be transferred to another hospital for surgery. The nurse called to confirm this information with the hospital. On 07/17/11 at 9:45 a.m., staff called the family for an update of the resident's condition and was informed the resident had surgery to repair the fractured elbow and he/she also had a right hip fracture. The resident needed to have an MRI to determine if the Resident #1 needed hip surgery. An Incident Details report, dated 07/16/11 at 3:00 p.m., documented Resident #1 slipped and fell in his/her room when assisted by 1 staff during a transfer from the bed to the wheelchair. Resident #1 was noted sitting upright, on the floor, holding his/her right elbow. The report documented a CNA had assisted the resident from the bed to the wheelchair because Resident #1 had attempted to get out of the bed to go see his/her family. Resident #1 had been confused and hallucinating throughout the day which was unusual for him/her. Resident #1 wore a personal alarm that was turned off during the assisted transfer by the CNA. Resident #1 got his/her feet tangled in the oxygen tubing. Resident #1 went to the emergency room for evaluation. Staff immediately implemented the following interventions: Use a gait belt when transferring the resident when he/she demonstrated confusion, and ensure oxygen tubing was out of the way of the resident's feet when ambulating. A Resident Transfer sheet, dated 07/16/11, documented the reason for Resident #1's transfer: Acute new onset confusion. Woke up hallucinating this morning. At 3:00 p.m. Resident #1 fell and hit his/her head and right elbow. Complained of right elbow pain. Resident #1had a Fentanyl patch changed every 72 hours and also had taken 1/2 of a 0.25 milligram (mg) Alprazolam as needed for anxiety related to chronic COPD, however, these weren't new medications and he/she usually tolerated them well. An emergency room Report, dated 07/16/11, documented Resident #1 presented to the hospital after falling earlier that day. The report documented x-rays of the right elbow showed an olecranon fracture, mildly displaced, and the right hip showed an avulsion fracture of the greater trochanter. Resident #1 transferred to another hospital for further evaluation and management. An operative report, dated 07/17/11, documented resident underwent [REDACTED]. An operative report, dated 07/20/11, documented Resident #1 underwent gamma nailing of a right intertrochanteric femur fracture. An Investigation report, dated 07/16/11, documented a CNA had witnessed Resident #1 fall and notified the nurse. The investigation indicated the resident had fallen before, but this last incident was probably due to a medication reaction. Resident #1 did not normally demonstrate confusion and had never tried getting out of bed on his/her own. The resident was usually an easy 1 person assist. Resident #1 had several medication allergies [REDACTED]. Resident #1 got his/her feet tangled in the oxygen tubing. The corrective action to taken to prevent recurrence of the incident: a. Employee education/training or reinstruction. b. Would try using a gait belt if transferring the resident when he/she appeared confused. c. Added the use of gait belt when transferring to the resident's care plan. d. Ensure resident's oxygen tubing was not in the path where the resident walked. The results of the investigation: Awaiting results of the ER evaluation to see if medications or an illness such as a urinary tract infection caused confusion. Otherwise, everything was done correctly as far as a 1 person assist with transfers and personal alarm. Would add to care plan to use a gait belt when transferring while resident confused. The CNA stated Resident #1 tried to switch his/her oxygen tubing from the room oxygen to the wheelchair oxygen and somehow got his/her feet tangled in the oxygen tubing which caused the fall. During an interview on 08/02/11 at 9:15 a.m., Staff C, CNA, stated around 2:30 p.m. on 7/16/11, she answered Resident #1's call light. Resident #1 asked about his/her family and seemed really confused. He/she wanted to get up. Staff C stated Resident #1 didn't stand very well. Staff C asked Resident #1 if he/she wanted to use the wheelchair. When they walked to the wheelchair Resident #1 took the oxygen tubing off his/her face and tripped on it. Resident #1 fell sideways and Staff C tried to grab him/her around the waist but he/she slipped. Resident #1 hit his/her head on the night stand and fell to the floor. Staff C stated if she had used the gait belt she may have been able to ease the fall, but didn't think she could have kept him/her upright. Staff C stated she did not know Resident #1 had demonstrated confusion throughout the day. Staff C stated now they use a gait belt on everyone. During an interview on 08/02/11 at 2:15 p.m., Staff D, CNA, stated she had worked the day Resident#1 fell . She came to work at 2:00 p.m. She could not remember if it had been reported to her that Resident #1 was confused and hallucinating throughout the day. Staff D stated resident #1 had demonstrated confusion on and off lately. Staff D stated Resident #1 did not act like him/herself prior to the incident. Staff D went in Resident #1's room before the incident and Resident #1 requested an ice pack for a headache. Staff D had reported the resident's request to the nurse. Staff D stated prior to Resident #1's, fall she used a gait belt when assisting him/her with a transfer or ambulation. She didn't know if everyone did. Staff D stated they were supposed to use a gait belt for residents who needed assistance with transfer and ambulation. Staff D stated she used a gait belt on everyone who needed assistance. Staff D stated she assisted a woman one time who didn't require a gait belt. The resident didn't feel well and fell . Staff D further stated that if she had used a gait belt on that resident, she could have prevented that resident's fall, or at least reduced the impact of it. During an interview on 08/02/11 at 2:28 p.m., Staff A, Registered Nurse (RN), stated the day Resident #1 fell , he/she had problems with confusion and hallucinations, and had a history of [REDACTED]. Staff A stated Resident #1 had been confused and wanting to get out of bed that day, but hadn't attempted to do so prior to his/her fall. Staff A stated Staff C didn't use a gait belt to transfer the resident because Resident #1 had never had problems with transfers or ambulation before. Staff A stated when she assisted Resident #1, she grabbed the back of his/her britches. Staff A then stated Resident #1 transferred and ambulated on his/her own; he/she just needed someone in the room with him/her because she really wasn't a 1 person assist. Staff A stated now they used gait belts on everyone. During an interview on 08/02/11 at 2:41 p.m., Staff B, CNA, stated she worked the day Resident #1 fell . She came to work at 2:00 p.m. Staff B stated during report they said Resident #1 was "okay." Staff B stated she usually put the gait belt on Resident #1 to transfer or ambulate with him/her because he/she was wobbly and not very steady. Staff B stated it depended on what the resident stated hurt that day. If Resident #1 complained of his/her side hurting, she didn't put the gait belt on. During an interview on 08/03/11 at 8:07 a.m., Staff H, CNA, stated Resident #1 hallucinated off and on. The nurse told him Resident #1 had had his/her pain patch changed, and to watch him/her. He really didn't remember much from that day (that she fell ). Staff H stated he used a gait belt when transferring and ambulating Resident #1 because he/she wasn't very steady on his/her feet. Staff H stated gait belts were used on everyone who needed assistance. During an interview on 08/03/11 at 8:12 a.m., Staff G, CNA, stated she worked the day shift 07/16/11, but she really didn't remember anything from that day. Staff G stated she used the gait belt with all transfers and ambulation with Resident #1. She assisted Resident #1 to the bathroom with his/her walker and wheeled him/her to the dining room for meals in the wheelchair. Resident #1 was not steady on his/her feet and had periods of weakness. During an interview on 08/03/11 at 8:19 a.m., Staff F, CNA, stated Resident #1 did get unsteady. Staff F stated she used the gait belt when she transferred or ambulated Resident #1. Resident #1 was unsteady when he/she stood up. Resident #1 would get dizzy when he/she sat up at times. Staff F stated she used the gait belt because it provided increased safety for the resident. During an interview on 08/03/11 at 1:35 p.m., Staff I, CNA, stated she didn't remember working the day Resident #1 fell . Staff I stated Resident #1 transferred with 1 person assistance, the walker, and a gait belt. Staff I stated most of the time she worked with Resident #1 he/she was steady, but was occasionally weak and wobbly. Staff I always used the gait belt when assisting Resident #1 with transfers and ambulation. During an interview on 08/03/11 at 8:30 a.m., the Director of Nursing stated a gait belt should have been used when Resident #1 fell . She indicated a gait belt should be used for all assisted transfers and ambulation unless there was a reason not to use it. The DON stated it did not matter if the care plan didn't specifically direct staff to use a gait belt with the transfer. The facility policy called for the use of a gait belt with all assisted transfers and ambulation. An Occupational Therapy (OT) Evaluation and Plan of Treatment dated 07/27/11 documented Resident #1 referred to OT after orifice of elbow and hip. Resident #1's dominant upper extremity had been affected causing decreased independence with most activities of daily living (ADL's), and the hip/elbow fracture decreased the resident's functional mobility. A Therapy Daily/Weekly Documentation note dated 08/02/11 documented Resident #1 continued to have pain in the right elbow and right hip and needed a lot of encouragement to participate in therapy. A Physical Therapy Evaluation and Plan of Treatment dated 07/26/11 documented Resident #1 had limited mobility secondary to hip and elbow fracture on the right, needed help with transfers, not walking yet. A Therapy Daily/Weekly Documentation dated 07/28/11 documented Resident #1 had significant pain in the arm, neck, and hip. During an interview on 07/29/11 at 1:35 p.m., Resident #1 laid in bed positioned with pillows. He/she had a sling on the right arm. Resident #1 stated he/she hurt during therapy, but felt comfortable at that time. During an observation 08/02/11 at 11:42 a.m., Staff A and Staff I assisted Resident #1 to transfer to the wheelchair. Staff I moved Resident #1's legs to the side of the bed and assisted him/her to a sitting position. Staff I applied a gait belt and Staff A and Staff I transferred Resident #1 to the wheelchair. Resident #1 took a few short steps during the transfer. The facility's Gait (Transfer) Belt policy, revised 01/09, identified the purpose: a. To safely transfer or ambulate residents. b. To aid resident in maintaining balance. c. To avoid injury to both resident and staff member. Note: Gait belts used unless medically contraindicated.