Every finding on record at Linn Manor Care Center

Based on staff interview, clinical record review, facility investigation review, and facility policy review the facility failed to ensure all staff responded appropriately to a sounding door alarm for 1 of 3 residents reviewed for inadequate nursing supervision (Resident #1). On 3/24/26 a confused, ambulatory resident (Resident #1), known to have exit seeking behaviors, exited the facility's East door unattended and was seen by staff walking in the road away from the facility. The facility failed to ensure the staff member who responded to the door alarm initiated resident checks to ensure all residents were accounted for after the door alarm sounded, and failed to communicate that no one was seen at and outside the door. The facility reported a census of 35 residents. The facility corrected the deficient practice per past noncompliance through the following actions: -Hourly then 15 minute checks for Resident #1 upon return to the facility-Stop sign redirections added to doors-Staff education on door alarm response on 3/25/26-Elopement drill 3/26/26 with repeat elopement drill on 3/27/26-Addition of secondary louder alarms on 3/27/26Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated severe cognitive impairment. The list of diagnoses included non-Alzheimer's dementia, anxiety disorder, Coronary Artery Disease (CAD), and Peripheral Vascular Disease (PVD). The MDS indicated Resident #1 transferred and ambulated independently without an assistive device and had 2 or more falls since the previous Assessment. Per this assessment, the resident had not wandered.Review of the Care Plan initiated 2/05/25 revealed a Focus area that Resident #1 experiences wandering. The Goal initiated 2/5/25 revealed Resident #1 would wander safely within specified boundaries. Interventions instructed the following, in part:a. Approach from the front. Walk in step with resident first before redirecting. Date initiated: 2/05/25. b. Assure resident has proper fitting and appropriate foot attire. Date initiated: 2/05/25. c. Avoid overstimulation (Noise, crowding, other physically aggressive residents). Date initiated: 2/05/25. d. Convey an attitude of acceptance toward the resident. Date initiated: 2/05/25. e. Develop a pathway for resident to follow. Keep pathway free from obstacles. Date initiated: 2/05/25. f. If resident looks for family/significant other, reassure that others know where to find him/her. Date initiated: 2/05/25. g. Maintain a calm environment and approach to the resident. Date initiated: 2/05/25. h. Monitor for signs/symptoms of Urinary Tract Infection (UTI) when increased attempts at going out the door(s) are noted. Date initiated: 2/05/25. i. Redirect resident from exit doors as needed. Date initiated: 2/05/25.j. Remove resident from other resident's room and unsafe situations. Date initiated: 2/05/25. k. Resident is exit seeking when wife requests to be taken to the casino. Toy slot machine bought to be used for wife upon casino request. Date initiated: 3/16/26. l. Resident is on 15 minute checks. Date initiated: 3/25/26. m. Stop signs to all doors for redirection. Date initiated 3/25/26. n. Motion sensor door bell put in place from 5:00 PM to 8:00 AM to alert staff when resident wanders at night. Date initiated: 5/15/26.Review of Wandering Risk Scale Assessments completed for Resident #1 revealed on 8/15/25 and 11/15/25, the resident scored 11 on the assessment, and was assessed at high risk of wandering. On 2/16/26, the resident scored 8 on the assessment, and was assessed at low risk of wandering. On 6/1/26, the resident scored 12 on the assessment, and was assessed at high risk of wandering. Review of Resident #1's Progress Notes dated March 2026 revealed, in part, the following: The Progress Note dated 3/2/26 at 2:39 PM revealed the resident put on his coat and tried to leave the facility, he stated he wanted to go to the bank. The Progress Note dated 3/4/26 at 11:03 AM revealed in part, staff asked Resident #1 if he would like to go outside for a walk, he said he would like that, and they walked around half of the building. The resident said he had a car here somewhere just did not know where. The Progress Note dated 3/11/26 at 10:41 PM revealed, the resident was caught exiting through the R wing door that he was heading to the back to withdraw money so his spouse can use it at the casino. The resident was redirected to meaningful activity. The Progress Note dated 3/18/26 revealed the resident tried to elope from the facility he stated he was going to the bank. The Progress Note dated 3/23/26 at 12:58 PM revealed, in part, the resident was upset about not getting mail, he wanted to go to the post office and stated a building outside was the post office, it was explained that was not the post office. Review of a Progress Note dated 3/24/26 at 12:54 PM revealed the following: Resident is yelling at staff and peers, he was trying to run over other residents with his wife in her wheelchair, stated they were in his way, staff had to glide his wife's wheelchair around the other resident. He got mad at staff and tried to hit staff, he did not make contact, staff explained that they were trying to help. He refused his PRN (as needed medication), he got mad because he did not get mail and thought staff was stealing his mail and glasses. Staff found his glasses under his pillow. Review of an Incident Report completed by the Assistant Director of Nursing (ADON) dated 3/24/26 at 4:20 PM described the following: At about 4:00 PM, I [ADON] clocked out and was walking out the back door when Staff A, former facility Administrator, asked me to go with him to pick up Resident #1 because he saw him walking outside the building without any of our staff. I [ADON] got in [Staff A's] car and we drove around the block. We met Resident #1 in [redacted] restaurant parking lot at about 4:05 PM .We kindly asked him to get in the car so that we can give him a ride home. He refused and insisted that he wanted to go to [Store Redacted]. I [ADON] walked with him across the street, with Staff A drove to [Store Redacted] and waited on us .Resident #1 felt guilty and agreed to let us take him home .Staff A drove us back to the facility and Resident #1 went to talk to his wife. He seemed very sad about what he did and apologized to us on the way back. Upon return to the facility at about 4:15 PM, we met Staff C, CNA, in the hall and told her what had happened and asked her to let the other staff know so they can all keep an eye on him every hour.Review of a facility provided email from Staff A, dated 3/25/26 at 1:17 PM, documented the following witness statement for Staff A: On Tuesday March 24th at about 2:30 PM, in the afternoon, [Resident #1] was wanting to go outside to go to his bank. He was at the door in the front of the building. I took him outside, we walked around the front of the facility and watched the construction that was going on at the time. He talked about going inside to get his coat as it is cool outside, we walked back into the building. Resident #1 seemed calm as he walked down to his room. At about 4:00 PM, I heard the door alarm go off, I went to the window to see Resident #1 walking in the street, I grabbed my coat and ran after him asking our ADON to come with me as I left the building. We drove up the street and brought Resident #1 back to the building. He was cooperative as we returned to the facility. Review of a facility provided document dated 3/25/26 at 1:15 PM titled, Phone Interview with [Staff B], CNA revealed the following questions asked by the Director of Nursing (DON) and answers provided by Staff B:-Question (Q): You were seen on camera on R- Hall (East) checking the exit around 4:00 PM on 3/24/26. Did you hear a door alarm? Answer (A): Yes. -Q. Did you check outside the door? A. Yes, I opened it and looked outside. I thought it was a delivery. -Q. Did you see a resident outside? A. No, I didn't see anyone. -Q. Did you do anything after that? A. I reset the door alarm but no, I did not do anything else. During an interview on 6/09/26 at 3:30 PM, Staff C, CNA, said she was told by ADON that Resident #1 had been outside and to start checks, on the evening of Resident #1's elopement. Staff C stated she was unable to remember if there was a door alarm sounding prior to being told Resident #1 was outside. Staff C reported that if a door alarm is heard, staff are expected to go and check the door, open the door and look outside and if no one is outside, then do a head count of residents to ensure all are present. During an interview on 6/10/26 at 11:25 AM, Staff D, CNA, reported that Resident #1 had increased exit seeking behaviors around the time he exited the facility. When queried about interventions in place to prevent elopement, Staff D stated that staff would try to redirect Resident #1 but there were times that it took 3 to 4 staff to get him turned around. Resident #1 would grab at staff and hold onto their arms. Staff D said when Resident #1 was trying to go out the front door, staff would go with him out to the patio and stay with Resident #1. Staff D explained typically when working on the North Hall it had been difficult to hear the East Hall door alarm, and explained that another, louder, alarm was added to the hallway exit doors following this incident. Staff D explained that when a door alarm was heard, staff were expected to go to the door and check for residents, and if no one is seen, a resident count was done to ensure all residents were present in the facility. During an interview on 6/10/26 at 2:19 PM, Staff E, CNA recalled coming in to work on 3/24/26 around 5:00 PM and stated she was not aware until the next day 3/25/26 at a 2:00 PM stand up meeting that Resident #1 had an elopement, and did a training. Staff E stated that around the time Resident #1 had exited the facility he had more persistent exit seeking behaviors.During an interview on 6/10/26 at 2:23 PM, the ADON confirmed telling only Staff C, CNA, that Resident #1 had been outside and to start hourly checks on Resident #1. During an interview on 6/10/26 at 2:45 PM, the Director of Nursing (DON) said she was notified by ADON on the morning of 3/25/26 that Resident #1 had left the faciity on the evening of 3/24/26. The DON stated following knowledge of elopement she implemented 15 minute checks on Resident #1 and began to collect staff statements of the incident. The DON revealed expectation that staff immediately respond to door alarms, and communicate via walkie talkies when door alarms are answered. If no one is seen when checking the door alarm, staff need to initiate a resident count to ensure all residents are present. The DON stated that if staff were to see Resident #1 outside, were to immediately go to him and stay with him, communicating via walkie talkie for assistance. Review of the facility policy titled Door Alarms, dated 1/2024, revealed the policy intent to provide guidance related to responding to door alarms. The Section titled, Procedure, instructed the following: 1.Staff will immediately respond to all door alarms. 2.Staff should assume that a resident exiting the facility caused the alarm to sound and investigate as if a resident has left the building. Open the door and check if a resident is in sight. Walk outside and check the grounds and scan the surrounding area. a. Do not assume that if a staff member or visitor is in sight that they caused the alarm, consider that a resident could have exited the building at the same time as someone else. Ask appropriate follow up questions such as, Did your exit sound the door alarm? and Did anyone else exit with you?3. If the cause for the door alarm cannot be determined, or if there is any doubt in what caused the alarm, staff will immediately initiate a head count. 4. If a resident is unaccounted for, staff will immediately search the entire building room to room and the facility grounds. The charge nurse should remain inside and coordinate staff including a communication plan during the search (i.e. the use of walkie talkies). 5. If the missing resident cannot be located inside the facility or the property, the staff should proceed to steps in The Elopement Policy. 6. If nursing management or administration is not on site, both will be notified by staff as soon as possible.

Based on clinical record review, staff interview and policy review, the facility failed to obtain informed consent for psychotropic medications that have black box warnings (safety warning used by the Food and Drug Administration (FDA) and requires the healthcare provider to have a comprehensive discussion with the resident/representative about the risks, benefits and alternatives for use) for 2 of 5 resident reviewed for psychotropic medications (Resident #12, and Resident #13). The facility reported a census of 36 residents.Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 11/27/25, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Resident #12's diagnoses included anxiety disorder, depression, and non-Alzheimer's dementia. The MDS identified that Resident #12 received antidepressant medication. Review of the Order Summary Report revealed an order for antidepressant medication Zoloft (sertraline), increased from 50 milligrams (mg) every morning to 100 mg every morning, started on 9/27/25. Review of Resident #12's medical records lacked documentation of informed consent for psychotropic medication provided to Resident #12 or resident representative. 2. Review of Resident #13's Social Service Note dated 12/18/25 revealed a BIMS score of 14 out of 15, which indicated intact cognition. Review of Resident #13's Medical Diagnosis sheet in the electronic health record included diagnosis of generalized anxiety disorder, added 4/20/24, and major depressive disorder, recurrent, moderate, added 1/26/24. The review of Resident #13's physician orders included an order to increase her antidepressant medication (venlafaxine) starting 1/22/26. The Electronic Health Record (EHR) for Resident #13 lacked documentation related to psychotropic consents. On 2/11/26 at approximately 1:30 PM, Staff B, Nurse Consultant stated that they did not have consents for Residents #12 and Resident #13 when their psychotropic medications were increased. The Policy titled Psychotropic Medication Management dated 2025 stated that before initiating or increasing a psychotropic medication, the facility must ensure that the resident, or their legal representative, is fully informed of and has the right to participate in or refuse treatment.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to update and revise the care plan to reflect the presence of an indwelling catheter, Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for 2 of 12 residents reviewed for Comprehensive Care Planning (Residents #24 and Resident #29). The facility reported a census of 36 residents.Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #24 had diagnoses of traumatic spinal cord dysfunction, C5-C7 incomplete quadriplegia, and kidney stone.The Nurse's Progress Notes dated 2/8/26 indicated Resident #24 returned to the facility from the hospital with an indwelling catheter for infected kidney stone until follow-up appointment with her Urologist.On 2/10/26 at 7:32 AM, observation revealed the resident had a catheter. The Care Plan initiated 9/18/19 lacked documentation that Resident #24 had an indwelling catheter or that she was in EBP. On 2/11/26, the resident's Care Plan was updated to include both after the Director of Nursing (DON) was questioned about it.2. The MDS assessment dated [DATE] revealed Resident #29 scored 10 out of 15 on a Brief Interview for Mental Status exam, which indicated moderately impaired cognition. The Nursing Progress Notes indicated that Resident #29 was diagnosed with Respiratory Syncytial Virus (RSV) on 2/7/26. During on observation on 2/9/26 at 11:32 AM, a droplet isolation sign was noted on Resident #29's door, indicating that he was in TBP. The Care Plan initiated 8/3/23 lacked documentation that Resident #29 was in TBP. The Care Plan was updated to include TBP of droplet isolation on 2/11/26, after the DON was questioned about it. In an interview on 2/11/26 at 3:43 PM the DON stated that EBP, TBP and an indwelling catheter should be documented on the Care Plan.The Facility Policy titled Care Planning Procedure, undated, indicated a guide to comprehensive care planning which included catheters, infections and isolation precautions.

Based on observation, staff interview, and clinical record review the facility failed to apply foot pedals to the wheelchair when transporting 1 of 3 residents reviewed for accidents (Resident #27). The facility reported a census of 36 residents. Findings include: Review of the Admission/readmission Nursing Assessment, dated 2/02/26, revealed that Resident #27 was readmitted to the facility for skilled nursing services post fall with right hip fracture and surgical repair. Resident #27 required assistance of 2 staff for bed mobility and toileting, 1 staff assistance to transfer. Review of the Care Plan, date initiated 8/21/25, revealed that Resident #27 was at risk of falling and listed an intervention to utilize wheelchair for mobility. During an observation on 2/11/26 at 2:32 PM, Resident #27 asked a Certified Nursing Assistant (CNA) to push her in the wheelchair, resident stated she could hold her legs up if that was okay, CNA responded okay. The CNA pushed Resident #27's wheelchair, without foot pedals attached to the wheelchair, as Resident #27 held legs up above the ground. The CNA transported Resident #27 from her room, located near end of C hallway, through the hallway to the common area, approximately 150 feet. Upon arrival to common area, Social Services Designee approached Resident #27, removed foot pedals from a bag hung on the back of wheelchair, and applied the foot pedals to wheelchair. During an interview on 2/11/26 at 2:40 PM, Social Services Designee reported that she intervened with Resident #27's wheelchair transportation because foot pedals were not on the wheelchair. Social Services Designee stated that transportation of residents in wheelchair without foot pedals was not allowed because a resident could fall out or get injured if their feet go down. During an interview on 2/12/26 at 2:11 PM, Director of Nursing (DON), stated that Resident #27 would not be able to safely hold her legs up due to weakness of lower extremities following recent hip fracture. The DON reported that the CNA who transported Resident #27 without foot pedals attached to the wheelchair had been provided with education.

Based on observation, staff interview, clinical record review, and facility document review, the facility failed to ensure an opened insulin vial was not expired prior to administration for 1 of 1 resident (Resident #12) reviewed for insulin. The facility reported a census of 36 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included diabetes mellitus. The MDS indicated that Resident #12 received insulin injections for 7 out of 7 days during the look back period. Review of the Care Plan, initiated on [DATE], revealed of Focus area for diabetes mellitus with the goal that Resident #12 would have no complications related to diabetes. Review of the Order Summary Report revealed an active order, started on [DATE], for Novolog (insulin Aspart) 100 units per milliliter (mL) solution with instructions to inject subcutaneously per sliding scale, as follows: a. For a blood sugar readings between 150 and 199, give 2 units.b. Blood sugars 200-249, give 4 units.c. Blood sugars 250-299, give 6 units.d. Blood sugars 300-349, give 8 units.e. Blood sugars 350-399, give 10 units.f. Blood sugars [PHONE NUMBER], give 12 units.The order additionally instructed to hold the medication if not eating and administer dose per pre meal blood sugar for diagnosis of type 2 diabetes mellitus. Review of the Medication Administration Record (MAR) dated February 2026 revealed on [DATE], Resident #12 had a blood sugar reading of 194 and was given 2 units of Novolog (insulin Aspart) sliding scale for the resident's 11:30 AM dose. During an observation on [DATE] at 11:32 AM, Staff F, Licensed Practical Nurse (LPN), prepared and administered Novolog insulin, injecting the insulin subcutaneously into Resident #12's right lower quadrant abdomen. The Novolog insulin had an opened date of [DATE], written on the outside of box which vial was stored inside. Following administration of Novolog insulin, Staff F returned the insulin vial and box to the medication cart. During an interview on [DATE] at 12:00 PM, Staff F reported that a document to identify medication expiration dates was kept on front of a binder on top of each medication cart. Staff F reviewed medication expiration document and stated that Novolog insulin would be expired 28 days after opening. When queried about the opened date for Resident #12's Novolog insulin, Staff F checked the box and confirmed that the opened date was [DATE]. Staff F stated she would get rid of the insulin and obtain an new vial of Novolog insulin for Resident #12 due to being expired. During an interview on [DATE] at 2:11 PM, the Director of Nursing (DON) revealed the expectation of nursing staff to check open date of insulin prior to administration to ensure it had not expired. The DON reported that Resident #12's Novolog insulin had been discarded and replaced with a new vial and stated that the provider was notified of incident. Review of the facility provided document titled, Suggested Drug Storage Policies (per manufacturer specifications), updated [DATE], revealed Novolog insulin vial would expire 28 days after opened or removed from the refrigerator.

Based on facility record review, staff interview, and policy review, the facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities were necessary. The facility identified a census of 36 residents. Findings include:Review of the facility QAA sign in sheets revealed the Administrator, Medical Director, Director of Nursing (DON), and at least two other staff were present at the meetings. The Infection Preventionist was not present at the April 2025 or the December 2025 quarterly meetings. On 2/12/26 at 12:40 PM, Staff E, Corporate Nurse reported at the quarterly meetings in April and December there was no Infection Preventionist present at the meeting. She reported that the previous Assistant Director of Nursing (ADON) was the Infection Preventionist in April 2025 but she was not listed on the April QAA sign in sheets either.The facility's Quality Assurance and Performance Improvement (QAPI) Plan lacked information that indicated the Infection Preventionist should be at the quarterly meetings.

Based on clinical record review, observation, staff and resident interviews, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed for EBP (Resident #24) and demonstrate proper hand hygiene practices to prevent cross contamination for 1 of 12 residents reviewed for infection control (Resident #24). The facility reported a census of 36.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had diagnoses of traumatic spinal cord dysfunction and C5-C7 incomplete quadriplegia.The Nurse's Progress Notes dated 2/8/26 indicated that Resident #24 returned to the facility from the hospital with an indwelling catheter for infected kidney stone until follow-up appointment with her Urologist.The Care Plan initiated 9/18/19 lacked documentation that Resident #24 had an indwelling catheter or that she was in EBP. The Care Plan was updated to include both on 2/11/26 after the Director of Nursing (DON) was questioned about it.During an observation on 2/10/26 at 10:04 AM, Staff A, Certified Nursing Assistant (CNA) was in Resident #24's room and made the bed. She then leaned over her and placed her flat call light in reach. Extra trash bin noted in room and EBP sign now on the wall next to room. She was not wearing a gown or gloves.During an observation on 2/11/26 at 3:01 PM with the DON present, Staff C, CNA touched Resident #24's bed linen, shirt and pants without gloves. She then went out of the room for a pad still without gloves on, touching various things without hand hygiene. She went out again for a new battery for mechanical lift again without hand hygiene. She then performed hand hygiene and applied gloves. Staff C then drained Resident #24's catheter. After draining the catheter, she had gloves on and touched various items and went into the bathroom twice with the same gloves on. Staff D, CNA performed catheter care and changed gloves twice without performing hand hygiene prior to donning a new pair.In an interview on 2/10/26 at 10:05 AM, Staff A questioned about new trash bin in Resident #24's room. She didn't answer and then looked out of the room door and motioned Staff B, Nurse Consultant into the room. Staff B stated she wasn't sure about the trash bin but observed the EBP sign on the door and stated she would ask the DON. The DON stated she was in EBP for her catheter and that was the reason for the trash bin. Added that Resident #24 had just returned from the hospital.In an interview on 2/10/26 at 10:10 AM, Resident #24 stated that staff were not wearing gowns during her morning cares but did not feel they needed to. She added that the trash bin was also new and had not been there before.In an interview on 2/11/26 at 3:18 PM the DON stated that Staff A should have had gloves on to begin Resident #24's cares. She also stated that hand hygiene should be performed between doffing and donning gloves. Finally, she stated that gloves should be changed after performing a procedure like emptying a catheter, and hand hygiene should be performed.The Facility Policy titled Enhanced Barrier Precautions (EBP) revised 10/2024 indicated the Personal Protective Equipment (PPE) required for EBP would be a gown and gloves with high-contact activities including any care activities that place caregivers in close physical contact with a resident and/or secretions which may include: bathing, dressing and hygiene, linen changes, transfers, wound care, device care, and therapy services requiring close contact.

Based on clinical record review, staff interviews, and facility policy review the facility failed to provide adequate supervision to prevent a fall, resulting in a hip fracture for one out of three residents reviewed (Resident#1). The facility reported a census of 35 residents. Findings include:The Minimum Data Set assessment dated [DATE] for Resident #1 listed diagnoses of dementia, heart failure, Atrial fibrillation (irregular heart beat), malnutrition, adult failure to thrive. The MDS included a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicted severe cognitive impairment. Per the MDS, the resident had falls since admit, entry, reentry, or prior assessment, and had two or more with no injury.The Care Plan dated 1/15/25 identified Resident #1 at risk for falls. Interventions dated 1/15/25 included, Assess resident for needs prior to leaving the room. Ensure resident always has proper footwear when transferring, i.e. gripper socks or shoes. Keep personal items and frequently used items within reach. Provide toileting assistance before and after meals, at HS (evening), and as needed. Resident's call light to be within reach and encourage it to use it for assistance as needed. Transfers with assistance of one staff, gait belt, and walker.The Fall Scale Completed 8/29/25 reflected Resident #1 at high risk of falling.The facility provided the Accident reports for Resident #'1 falls dated 1/12/25, 1/16/25, 3/9/25, 5/12/25, 5/28/25, 6/2/25, 9/7/25, and 9/8/25. The Unwitnessed Fall report dated 1/12/25 at 8:00 PM revealed staff found on floor in his room, assessment completed, gait belt applied, assisted into wheelchair. The Unwitnessed Fall report dated 1/16/25 at 2:20 PM revealed, nurse called to Resident #1 room by Physical therapist, resident found on the floor sitting upright with legs and arms stretched out. Resident #1 stated that he slid in his buttocks.The Unwitnessed Fall report dated 3/9/25 at 12:00 AM reflected, Resident #1 found on the floor near his bed with his wheelchair behind him and his walker in front of him.The Witnessed Fall report dated 5/12/25 at 12:00 AM revealed, Resident was walking to wheelchair and fell before staff reached him. Resident #1 reported he was going to dinner. The Unwitnessed Fall report dated 5/28/25 at 4:35 PM revealed, Resident found sitting on the floor in front of his wheelchair in his room. Resident unable to give description of event.The Unwitnessed Fall report dated 6/2/25 at 5:20 PM, reflected Resident #1 found by Certified Nurse Aide (CNA) in the bathroom doorway in his room. Resident sitting with back against bathroom door, fully clothed. Resident #1 said he was coming from the bathroom.The Progress Note dated 6/4/25 at 9:31 PM revealed the new intervention placed following the incident: Resident#1 can't be left in a w/c (wheelchair) in his room. The Unwitnessed Fall report dated 9/7/25 at 11:16 AM revealed, Resident #1 found yelling for help in his bathroom. Resident #1 sat on the bathroom floor with his back up against the wheelchair, wheelchair propped in the door frame. Resident#1 pants were on, he reported he already took himself to the bathroom but fell trying to turn back around to sit in the wheelchair. The report revealed, Resident #1 should not be left alone in his room in a wheelchair. The Unwitnessed Fall report dated 9/8/25 at 6:15 AM revealed a CNA heard Resident #1 yelling for help and found him in his room laying on his left side, he was between the bed and the bathroom, his wheelchair was at his side, wheels locked. Resident #1 complained of 10 out of 10 pain to his left hip. Resident had self-transferred Resident failed to have anything on his feet. Resident #1 stated this was the worst pain he had ever had. Resident #1 transferred to the ER (Emergency Room) for evaluation. The Facility Incident Summary dated 9/08/2025 reflected the ER notified the Director of Nursing (DON) of a left hip fracture and Resident #1 would remain at the hospital for surgical repair. The summary revealed staff checked on the resident in his bathroom shortly prior to the fall, and cued him to use his call light when finished. The summary identified none of the staff assisted Resident #1 off the toilet. The facility investigation read Resident #1 took himself to the bathroom and fell attempting to go back to his bed from his wheelchair.The Health Status Note dated 9/11/25 at 1:33 PM revealed, in part, Report received from [Hospital Name Redacted]; Resident is to be transferred to [Facility Name] around 1400 (2:00 PM) today. He has a closed left hip FX (fracture), post surgery. On 9/14/25 at 9:01 AM Staff E, CNA revealed she did rounds with Staff A and they found him in the bathroom on the toilet. She said she asked him if he needed help, but he declined. She stated he took himself into the bathroom. She stated she reminded to use the call light and she and Staff A finished rounds on the hall. She reported Staff D alerted her of the fall when Staff D found Resident #1 on the floor. On 10/13/25 at 4:09 PM Staff A, CNA reported at shift change on 9/8/25 6 AM, she and Staff E found Resident #1 in his bathroom. She reported she failed to help him into the bathroom. She stated she left him with Staff E to care for him. She confirmed Resident #1 attempted to self transfer before. She stated they used a touch call light, placed it next to him in bed, so they would know if he was getting up the light would come on.On 10/14/25 at 1:29 PM Staff H, Licensed Practical Nurse (LPN) reported Resident #1 had several falls they were due to him getting up from the wheelchair. He reported he's seen him (resident) attempt to get out to the wheelchair a few times.On 10/14/25 at 1:58 pm, Staff D, CNA reported on 9/8/25 he got to work at 6 AM and went to help a resident that called out for help further down the hall then Resident #1. He reported he heard Resident #1 calling out for help and went to find Resident #1 on the floor in his room. He alerted the nurse of the fall. He reported the other CNA assigned to the hall got report from the off going shift. He said he failed to know Resident #1 was out of bed before finding him on the floor. Staff D reported he would never leave Resident #1 on the toilet alone. On 10/14/26 at 9:45 AM Staff F, Licensed Practical Nurse reported after the fall Resident #1 had on 9/7/25, she wouldn't have left him sitting on the toilet. On 10/15/25 at 9:15 AM, the DON reported the intervention from the fall on 9/7/25 day before he fell and fractured his left hip, directed staff do not leave unattended in his room in the wheelchair. She stated she failed to know the difference from leaving him in the w/c or on the toilet in his room unattended. She failed to know staff used the do not leave unattended intervention on the fall from the w/c in Jun 25, 2025. She reported when staff found him on the toilet on 9/8/25, the staff should not have left him on the toilet.The Facility provided a policy titled Fall Prevention, undated, revealed the following: Risk factors for falls include: Previous falls, problems with mobility and walking, fear of falling, irregular heart beat, blood pressure that drops significantly upon standing, dizziness, confusion, problems with seeing or hearing, multiple medications, inappropriate footwear, pathological fractures. Over 40% of nursing home residents fall each year. Five percent of these falls can result in a serious injury .After each fall, complete an incident report. Look for trending. Identify the possible reason for the fall and make appropriate changes to the plan of care.

Based on clinical record review, staff interviews and facility policy review the facility failed to provide individualized Care Plan interventions to address resident trauma one out of one resident reviewed (Resident #1). The facility reported a census of 35 residents.Findings include:The admission Minimum Data Set assessment dated [DATE], listed diagnoses of Atrial fibrillation (irregular heart beat), pneumonia, urinary tract infection (UTI), malnutrition, adult failure to thrive. The MDS included a Brief Interview for Mental Status (BIMS) score of 5 (severe cog impairment).The MDS revealed Resident#1's behaviors were physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others 1 to 3 days in the 7 day look back period. Wandering, and rejection of care1-3 days. The Trauma Informed Care assessment dated [DATE], revealed Resident#1 reported repeated disturbing memories, thoughts or images of a stressful experience from the past and he confirmed upsetting dreams about the event. The note on the assessment stated Resident#1 repeatedly talked about his time in the military special forces and how his memories are very vivid. He stated he saw some pretty bad things during his time, he chooses not to talk much about it, however reports remembering them is all he likes to do. He denied triggers, he just remembered what happened.The bottom of the form held a blank area for the Physician to complete, if psychological services are needed.The Care Area Assessment (CAA) for Resident#1 undated identified Resident noted to be resistive to cares between 1 and 3 days during the lookback period (See Point of Care (POC) behavior documentation and nurses' notes). Contributing factors include newly admitted to facility, dx of pneumonia, UTI, malnutrition, failure to thrive, and impaired cognition, and the use of antidepressant medications (See PCC dx list, ARNP notes, nursing notes and assessments, dietician notes and assessments, social work notes and assessments, POC documentation, and January 2025 MAR).The CAA reflected behavior symptoms addressed in the Care Plan and listed the impact on the resident. Resident#1 is at risk for unmet needs, depression and/or anxiety, frustration, agitation, physical or verbal behaviors, falls, decline in ADL functions, social isolation, and decreased quality of life related to behavioral symptoms.The Care Plan for Resident#1 dated 1/20/25, reflected the goal behavioral symptoms not directed to others (e.g. hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The Care Plan interventions dated 1/20/25 included: Assess whether the behavior endangers the resident and/or others. Avoid over-stimulation (e.g. noise, crowding, other physically aggressive residents). Convey an attitude of acceptance toward the resident. Maintain a calm environment and approach to the resident.Remove resident#1 from group activities when behavior is unacceptable. The updated Care Plan intervention dated 7/21/25, directed when Resident#1 becomes socially inappropriate/disruptive, move to a quiet, calm environment.An updated Care Plan intervention dated 8/13/25, reported Resident#1 to use plastic silverware for mealtimes. The Care Plan updated 7/14/25, reflected Resident#1 received psychotropic medications (antianxiety). Resident is prescribed psychotropic medications for behaviors that included: Aggressive actions such as raising fists in the air towards staff, swinging butter knife in the air directed towards staff, cursing, refusing care, medications, and medical treatments, agitation, and restlessness. The Behaviors documented by the Certified Nurse Aid (CNA) on 10/4/25, 9/26/25, 9/23/25, and 9/20/25, 9/15/25, 9/2/25 included grabbing others, kicking others, hitting others, scratching others, accusing others, cursing, screaming, threatening, physically aggressive to others and expression of frustrations or anger at others. Agitated, anxious/restless, screaming not at others, panic and wandering.On 10/15/25 at 9:15 AM the Director of Nursing (DON) reported with Resident#1's combativeness, the approach needs to be delicate related to his PTSD.On 10/14/25 at 9:34 AM Staff J, CNA stated Resident#1's behaviors include hitting and yelling. She reported he has PTSD from war. On 10/14/26 at 09:45 AM Staff I, LPN reported Resident#1's showed combative behaviors with care. On 10/14/25 at 1:29 PM Staff H, LPN reported Resident#1 showed combative behavior when staff tried getting him ready for bed, especially when doing cares. Staff H reported Resident#1 thinks he needed to kill Staff H. Staff H stated he's confused and doesn't know what he was talking about. On 10/14/25 at 1:38 PM, Staff G, Registered Nurse (RN) reported Resident#1 experienced PTSD-like symptoms when he acted out at the staff while they cared for him. She reported he failed to like other men near him much.10/15/25 at 2:03 PM Staff E, CNA reported Resident#1 slapped at the staff with cares. She reported he does better with male staff. She reported the facility failed to train them to stop when he has the behaviors.On 10/15/25 at 3:03 PM The Registered Nurse Consultant (RNC) provided the Tasks and confirmed they listed a lot of behavior types not specific or detailed of the situation. On 10/15/25 at 3:53 Staff B, CNA reported Resident #1's behaviors are when things trigger him. She said the staff think it's related to the war. Staff B said he asked if they heard the gun shot or bang. She revealed one time he grabbed her hand when he was mad but they redirected him. She stated she squatted down to look him eye to eye and talk to him before she does anything with him. She said the facility told the CNAs a while ago when Resident #1 hit to get the nurse. She said if he started talking about the war, they needed to try to calm him down and not irritate him more. She reported he is strong. On 10/16/25 at 10:12 AM the Social Service staff reported she completed the Trauma Informed Care assessment and it was filed in the record. She reported the nursing department completed most of the Care Plan, she completed the Care Plan related to Advanced Directive and discharge. She reported some of the staff told her about his combative behaviors but no one directly told her about his comments related to war and guns. She reported she completed the Patient Health Questionnaire (PHQ9) (assess the severity of depression) and if that score is over 5 she will let the provider know, but that is the only time she sends things to the provider. She reported the facility noticed Resident #1 did better with a group of staff go into care for him. She thought that was related to his history of military service.On 10/16/25 at 11:00 AM the Director of Nursing (DON) reported there was no formal policy for Care Plans. She reported updates are mentioned in individual policies as applicable. Care Plans are developed in accordance with guidance for Comprehensive Person-Centered Care Planning. The Facility Policy titled Care Plan-Baseline dated 5/2024 revealed, in part, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: Initial goals based on admission orders and discussion with the resident/representative; Physician orders; Dietary orders; Therapy services, Social services; and Behavioral interventions .The baseline care plan is used until the comprehensive assessment and development of an interdisciplinary person-centered comprehensive care plan is created (no later than 21 days after admission) The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. The Care Planning Procedure, undated, revealed the following: MDS coordinator will be responsible for creation of the care plan. Other staff that may make changes to the care plan include the restorative nurse, dietitian, activities staff, social services and charge nurses. Staff will be notified of changes to the care plan via a communication tool .Any triggering CAA you determine needs addressed should be included. The Care Planning Procedure included a list that may be used as a guide for comprehensive care planning and is not all inclusive. The list included PTSD and trauma informed care.

Based on record review, staff interviews, and policy review the facility failed to ensure safe transfers for 2 of 5 residents reviewed for mechanical lift transfers (Residents #5 and #11). The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #5 documented a Brief Interview of Mental Status of 3, indicating severely impaired cognition. The MDS documented she was dependent on staff to assist her with transfers, toileting, moving herself in a wheelchair, and dressing. The MDS also documented her primary diagnosis of stroke and also has dementia, depression, and anxiety. Record review of an untitled fall report document for Resident #5 dated 4/12/24 documented she had a fall with two (2) staff present during a mechanical lift transfer. During the transfer Resident #5 sat up and leaned through the lift straps and fell out head first. She was taken to the local hospital due to a head laceration. Record review of Resident #5 Care Plan with a print date of 5/20/24 documented the facility implemented fall interventions for previous falls. During an interview on 5/22/24 at 9:45 AM, with the Director of Nursing (DON) revealed during her investigation Resident #5 was being transferred by Staff A, Certified Nursing Assistant (CNA) and Staff B (CNA) from her bed to her wheelchair and jerked forward and fell through the side. She revealed this is the first fall Resident #5 had from a mechanical lift and she never expected she would do that. She then revealed she had sustained a laceration to her head as a result of the fall. 2. The MDS for Resident #11 dated 3/3/24, documented a BIMS of 15 indicating no cognitive impairment. The MDS informed he was dependent on staff for transfers, dressing, and bathing. The MDS documented primary diagnosis of traumatic brain dysfunction and diagnoses of dementia, quadriplegia, and bladder disorder. Record review of an untitled fall report document for Resident #11 dated 4/14/24 at 9:30 PM revealed Staff F, CNA altered a nurse that Resident #11 fell out of a mechanical lift during a transfer she performed with his family member. During an interview on 5/22/24 at 9:45 AM, the DON revealed Resident #11 was being transferred by Staff F and Resident #11 family. She revealed Staff F was a newer employee and Resident #11 family members insisted she could do the mechanical lift transfer. She revealed Staff F assisted Resident #11 family member and Resident #11 fell out the side of mechanical lift sling because it wasn't placed properly by Resident #11 family. She then revealed Resident #11 family did not want Staff F to tell the facility staff and said she could get him up. During an interview on 5/22/24 at 4:55 PM, Staff F revealed on 4/14/24 Resident #11 family member was aggressive and grabbed the Hoyer mechanical lift and said she needed to help her transfer him. When we were raising him up in the air it didn't feel safe and I told her we needed to lower him down, he then fell on to his right side and hit his head. She revealed she was so scared and was told she couldn't tell anyone. She then informed during the transfer she initially thought Resident #11 family member was an employee of the facility with the way she was acting. During an interview on 5/22/24 at 9:45 AM, the DON revealed Interventions were put in place for Resident #5 and Resident #11 after fall from mechanical lifts and did a very thorough education with all employees. She also informed them they updated the facilities policy to ensure employees were to hold one hand on the residents back and one hand on the residents chest. Record review of the facilities policy titled, Falls, last updated 4/2024 revealed the facility failed to follow their policy for Residents #5 and #11 with falls from mechanical lifts.

Based on record review, staff and physician interviews, and policy review the facility failed to document routine assessment and interventions completed by the facility for 1 of 6 residents reviewed (Resident #8). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) for Resident #8 dated 11/24/2023 documented a Brief Interview for Mental Status (BIMS) of 14 indicating he was cognitively intact. The MDS informed he was independent with toileting and walking. The MDS documented a primary diagnosis of other neurological conditions and also diagnoses of diabetes, anemia, malnutrition, and Parkinson's. Record review of Resident #8 Assessments in his Electronic Health record (EHR) lacked documentation of complete assessments related to a decline in condition from 12/13/23 to 12/17/23. Record review of Resident #8 Progress Notes and Point of Care Records in his EHR revealed the following: 12/13/23 - Resident #8 had a medium formed bowel movement. 12/14/23 - Resident #8 had an emesis and the facility notified his Doctor of his decline with no new orders. 12/15/23- Resident #8 abdomen was assessed and soft. Resident #8 had a medium loose bowel movement. 12/16/23 - Resident #8 had a headache 12/17/23 - Facility gave him magnesium laxative in the morning, and sent him to the local hospital to be evaluated due to a decline in condition. Record review of the local hospital Emergency Department (ED) Provider Note on 12/17/2023 at 10:14 AM revealed he was diagnosed with a small bowel obstruction, acute respiratory failure, acute renal failure, aspiration pneumonia due to gastric secretions, and sepsis. During an interview on 5/22/24 at 9:45 AM the Director of Nursing (DON) revealed the facility would notify the physician if adverse symptoms occurred depending on the severity, if there was a further change in condition like a decline, they would either call or fax the physician depends on the situation. During and interview on 5/22/24 at 3:30 PM With Staff E, Licensed Practical Nurse (LPN) revealed Resident #8 would always tell staff if there was a problem and he was normal all night the last night she worked with him on 12/16/23 going into 12/17/23. Last time I was with him, he was acting normal and went out to church. Last night I worked with him and he was normal all night long. He was very with it, but was slow to act, I think he would have told someone if he wasn't having BM's because he would always tell someone. During an interview on 5/22/24 at 4:35 PM With Staff D, Registered Nurse (RN) revealed resident #8 was independent around the facility and able to take himself to the bathroom. He would let us know if he went, his normal bowel movements were loose and large. She then revealed he had a previous bariatric surgery and if he ate too much of the wrong food it could upset his stomach and make him kind of sick. She informed his symptoms would be lots of phlegm, upset stomach, and dry heaving. She then informed he would not normally vomit food substance, just saliva not bile. She revealed she was working on 2/16/23 before he went to the hospital and assessed him. He was under the weather, but very adamant he didn't want to go to the hospital and just wanted to wait it out. She then informed on 12/17/23 she went and check on him in the morning and he had sunken in eyes and a low blood pressure and she suspected he was dehydrated, she informed she attempted to keep him comfortable in the beginning, she then informed he would want to go to the hospital if his POA was ok with it. During an interview on 6/4/24 at 11:04 AM with Staff C, Physician revealed in his line of work bowel obstructions can form very rapidly and sometimes in a matter of hours (3-4 hours). He then revealed a bowel obstruction does not have to evolve slowly over days. He revealed Resident #8 Advance Directives was comfort care (control pain and other symptoms so the patient can be as comfortable as possible) while living at the facility. Record review of the facilities undated policy titled Bowel Management Program instructed the following: a. Each resident will use the toilet/commode/urinal bedpan as per care plan. b. The nursing staff, (CNA's) will record the bowel movements. Residents that are independent with toileting will be asked if they have had a bowel movement (BM) by the CNA's every shift. If the resident does not have a bowel movement, that will be documented. c. The 10:00 - 6:00 AM nurse will run a BM list towards the end of his/her shift. Residents will be identified who have not had a bowel movement in two (2) or more days. d. The 6:00 - 2:00 PM Nurse or Certified Medication Aide (CMA) will administer an oral laxative or stool softener as ordered to the residents who have been identified as not having had a bowel movement in two days. e. Following administration, Nurse/CMA will monitor which residents have not had a bowel movement. f. If a resident has not had a BM by morning of the 3rd day, the night shift or day shift Nurse will administer a suppository or an additional laxative aide as ordered for elimination needs. g. If no results from the second intervention, the nurse will complete an abdominal assessment. Document assessment. Notify the physician in a timely manner. h. Nurses and CMAs are to document any medication or treatment interventions given on the Medication Administration Record or Treatment Record. i. Document on the 24-hour Nurse Hand off sheets and communicate in change of shift nurse report when bowel aides are needed and given as well as the results. j. Residents who are getting PRN bowel management medications on a frequent basis should be considered to have any scheduled bowel management medications re-evaluated.

Based clinical record review, staff interview, and facility policy review, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) Program that focuses on indicators of the outcomes of care and quality of life. The facility reported a census of 34 residents. Findings Include: A review of the Summary Statement of Deficiencies and provider's Plan of Correction (POC) dated 7/18/22, with corrections initially dated 8/18/22 and revised to 10/1/22, identified the following deficiencies: a. F609 - Reporting of Alleged Violations. b. F657 - Care Plan Timing and Revision. c. F684 - Quality of Care. d. F689 - Free of Accident Hazards/Supervision/Devices. e. F727 - Sufficient Nursing Staff. f. F868 - QAA Committee. The POC documented a plan to audit Incident Reports according to a schedule and to report and address identified concerns in QAPI Committee Meetings. The POC revealed training that instructed staff to immediately report allegations of abuse to the Administrator who would use the facility reportable decision tree to determine reportable occurrences. Staff were trained through Relias (computer program) on preventing, recognizing, and reporting abuse. A new schedule of quality assurance meetings was put in place. A document labeled [NAME] Manor QAPI dated 1/13/23, documented the topics of the QAPI meeting as quality measures, facility focus, clinical review (mock), re-hospitalization s, Pharmacy Report, recruitment/retention, staff satisfaction, Therapy, Environmental, and Dietary. The facility failed to assign a responsible party to topics of quality measures, clinical review, re-hospitalization s, recruitment/retention, and staff satisfaction. Infection control, nursing home compare, policies, orientation, incident reports/safety, resident council, and complaints/concerns remained blank. An untitled document dated 4/14/23, revealed topics of the QAPI Meeting included medication errors, new hire retention, turnover, Pharmacy, and call offs. The committee failed to review resident care outcomes, quality of life indicators, audit results, or reportable incident topics. A document titled QAPI, dated 10/13/23, documented the topics of the QAPI meeting included medication errors, new hire retention, agency hours, a medication storage inspection, and hazardous drug review. The committee failed to review resident care indicators, quality of life, audit results, or reportable incident topics. A document titled Self-Identification and Correction Form dated 11/6/23, revealed that on 9/18/23 the facility identified Care Plan reviews not being kept up to date as a deficient practice. This was not reviewed at the 10/13/23 QAPI meeting. On 11/09/23 at 12:22 PM, the Administrator stated he expected the QAPI Committee to review prior survey results at the first meeting after a survey and discuss approaches to ensure deficiencies did not happen again. Tasks should be assigned to the correct department head. Those staff monitored for compliance and revisited the issue until they found a solution that worked. The Administrator indicated the committee had not been very good at monitoring, had not been consistent with documentation, and had not been documenting follow up. He indicated the program needed to be revamped to include documentation of resident care and quality of life topics. There were no surveillance documents available for review. A policy titled Quality Assurance and Performance Improvement (QAPI) Plan approved and adopted 8/2017 documented the company-wide performance improvement process included identifying and implementing opportunities to improve the quality of resident care and quality of life. Section V. 6) documented that performance improvement was an ongoing cycle of measuring resident outcomes and that monitoring results was essential.

Based on observations, clinical record review, staff and resident interviews and facility policy review, the facility failed to assess for the safety and competency of self-administration of inhalant medications for 1 of 7 residents observed during medication administration (Resident #25) . The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 9/06/23, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of indicating intact cognition. The MDS included diagnoses of chronic respiratory failure with hypoxia, shortness of breath, dyspnea, and generalized muscle weakness. The Care Plan, revised 08/30/23, revealed a focus area for impaired Activities of Daily Living (ADLs) and mobility independence related to chronic respiratory failure with hypoxia. The Care Plan lacked focus area or intervention for the self administration of medications. The Medication Administration Record (MAR), dated November 2023, revealed the following medication orders: a. Breyna (Budesonide-Formoterol Fumarate Dihydrate) Inhalation Aerosal 160-4.5 micrograms (mcg) per actuation (ACT), inhale 2 puffs orally twice a day. Rinse mouth after use. b. Symbicort Aerosol 180-4.5 mcg/ACT, inhale 2 puffs orally twice a day. Rinse mouth after use. c. Ipratropium-Albuterol inhalation solution 0.5-2.5 milligrams (mg) per 3 milliliters (ml), inhale 3 ml orally four times a day; d. Albuterol Sulfate inhaled aerosol solution 108 mcg/ACT, inhale 2 puffs orally every two hours as needed for shortness of breath or wheezing. Use inhaler when away from nebulizer. On 11/08/23 at 9:04 AM, observed Staff G, Certified Medication Aide (CMA), enter Resident #25's room with three vials of Ipratropium-Albuterol (also known as Duoneb) inhalation solution, typically used with a nebulizer as a breathing treatment. The order instructed inhalation of one vial (3 ml) four times a day related to Chronic Obstructive Pulmonary Disease (COPD). Staff G placed the three vials of Duoneb solution into a plastic container in Resident #25's room, on the overbed table. The container label indicated Ipratropium-Albuterol and listed the times: 7:30 AM, 11:30 AM, 3:30 PM, 7:30 PM, 11:30 PM, and 3:30 AM. Staff G stated Resident #25 received three vials to complete breathing treatments independently though the shift. Three additional medicated inhalers located on Resident #25's nightstand. Staff G informed that Resident #25 performed all inhalant medications independently. On 11/08/23 at 9:45 AM, Resident #25 verified he performed self-administration of all inhaled medications kept at bedside. Resident #25 stated he used the Duoneb nebulizer treatment every 4 hours; two puffs of the albuterol inhaler as needed; two puffs of the Breyna inhaler twice per day; and two puffs twice per day of the Symbicort inhaler, but notified he is not currently utilizing this inhaled medication. Resident #25 denied need to rinse mouth after use of Breyna or Symbicort inhaler as indicated in the Physician's orders. On 11/08/23 at 10:00 AM, the Director of Nursing (DON) stated she expected these inhaled medications be in a lock box in Resident #25's room, due to a roommate. The DON confirmed she expected an assessment for self-administration of medication completed prior to a resident self-administering. The DON confirmed she failed to complete the assessment for Resident #25. The facility policy titled Self-Administration of Medications, no date, revealed that medications kept in the resident's room must be in a locked container. The policy informed that the Interdisciplinary Team will assess the resident's cognitive, physical, and visual ability to determine if it is safe for the resident to self-administer medications. The facility policy further instructed to document all teaching and instruction provided to the resident and give the resident copies of instruction.

Based on clinical record review, observations, resident and staff interviews, review of a Maintenance Work Order, the facility failed to maintain good repair of a floor heating register in resident room for 1 of 8 resident's rooms screened for a homelike environment (Resident #21). The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 7/07/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed diagnoses of late-onset cerebellar ataxia, multi-system degeneration of the autonomic nervous system, adjustment disorder with anxiety, and depression. The MDS, revealed Resident #21 required extensive assistance of two staff for bed mobility, transferring, and toileting and non-ambulatory. Review of facility form titled Maintenance Work Order revealed on 8/02/23, the Administrator requested a work order for a heat register cover off in Resident #21's room. Order signed and marked as done by Maintenance staff on 8/02/23. On 11/06/23 at 11:50 AM, half of floor heating register cover sat on the floor just under Resident #21's bed. The bed, located next to wall, had left side parallel to wall, cover for floor register observed in disrepair underneath the length of the bed. Noted sheets, blankets, and a tissue near the exposed heating unit underneath resident bed. On 11/06/23 at 12:00 PM, Facility Administrator arrived at Resident #21's room to view disrepair of heating register cover. Administrator notified that the heat in Resident #21's room does work and informed that Maintenance Staff would be made aware to provide repair of the floor heating cover. On 11/07/23 at 8:29 AM, the cover to the floor heat register lied on the floor underneath the head of bed. The head of bed alongside the wall perpendicular to wall with original floor heat register cover in disrepair. On 11/08/23 at 8:42 AM, the cover to floor heat register lied on the floor underneath the head of Resident #21's bed. Resident #21 reported the heat register sat in disrepair for a couple of months and stated she noticed the heat unit sounded loud. On 11/08/23 at 9:50 AM, Staff J, Housekeeping Staff, informed the facility had Maintenance Work Order Forms to be completed with any requested repairs. Staff J reported she had witnessed heat register covers off and lying on the floor before and that she will put them back on unless they get too bent then the facility will order a new one. Staff J indicated she had witnessed Resident #21's heat register cover off before as her bed bumps it. On 11/08/23 at 10:12 AM, the Director of Nursing (DON) arrived at Resident #21's room to view disrepair of the heat register cover. The DON stated the cover should not be left like that and informed he would find out if the broken register cover would be fixed or replaced. On 11/08/23 at 10:32 AM, the DON reported that Maintenance Staff was working on fixing the broken cover at this time.

Based on clinical record review, staff interviews, employee file review, and facility policy review, staff failed to report to the facility and the facility failed to identify situations as an alleged violation involving abuse and to report allegations within required regulatory time frames for 3 of 3 residents reviewed (Residents #9, #26 and #28). The facility reported a census of 34 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #9 signed 10/12/23 revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Section I signed 10/24/23 documented diagnoses of cancer, anxiety disorder, and encephalopathy (change in brain function). A document titled Self-Report dated 2/1/23 revealed another resident touched and patted Resident #9 on the breast on 1/12/23 in a common area of the facility. The report indicated Staff H, Licensed Practical Nurse (LPN), and the former Director of Nursing (DON), Staff B, were aware of the incident on 1/12/23. Staff B investigated the incident, and she did not find the other resident had intentionally had inappropriate contact with Resident #9. On 1/31/23 Staff I, Health Services Supervisor, learned of the incident and determined it should have been reported regardless of the investigation results. The time frame between the incident and the report was 20 days. On 11/08/23 at 10:15 AM, the Administrator confirmed he was not here when this incident occurred. He stated at the time of this incident the resident received 15-minute checks for safety. He expected staff would report potential abuse within 2 hours. On 11/08/23 at 10:41 AM, Staff H stated the 15-minute checks started when the other resident began touching female residents. She revealed she witnessed this incident and it upset her the most because she believed the individual needed a higher level of care and 15-minute checks were a start but were not enough. Staff B stated the resident knew what he was doing when he touched Resident #9. On 11/08/23 at 2:33 PM, Staff B stated the other resident's behaviors became more aggressive and territorial over time. She believed he knew staff were watching him because he was aware of the checks and they upset him. He had to be redirected and walked away from the area after he touched Resident #9. 2. The MDS Assessment for Resident #26 dated 8/25/23 revealed the resident scored 12 out of 15 on a BIMS exam, which indicated moderate cognitive impairment. Section I of the MDS listed diagnoses of Parkinson's disease, non-Alzheimer's dementia, and anxiety disorder. A Care Plan area dated 5/6/22 documented Resident #26 became confused and easily over-stimulated due to Parkinson's and dementia, and staff should assess and anticipate needs. Another Focus Area with the same date indicated the resident was at risk for falls. On 7/18/22 an intervention was added that the resident was easily startled and needed time to become aware of someone's presence. A Progress Note dated 2/8/23 created by Staff K, labeled MD/Nursing Communications, with the return fax signed by Staff H, LPN documented Resident #26 was found laying on his back with his head on the closet door. He reported he did not hear his roommate come up behind him, and the roommate made a loud noise that scared me to death. The roommate admitted he came up behind the resident and clapped his book together loudly to be 'funny'. A Progress Note dated 3/9/23 by Staff H, revealed Resident #26 was standing in his room without assistance when his roommate startled him causing him to sit next to his bed on the floor. A document titled Self-Reports documented no self-reports were completed between 2/1/23 and 7/24/23. On 11/08/23 at 10:15 AM, the Administrator stated at the time of this incident the resident who caused Resident #26 to fall received 15-minute checks for safety. He expected staff would report potential abuse within 2 hours and did not have documentation these resident-to-resident incidents were reported. On 11/08/23 at 10:41 AM, Staff H confirmed the 15-minute checks were in place. She believed the resident who caused the falls was high risk and needed a higher level of care. She did not believe 15-minute checks were effective because his behaviors would happen when staff walked away. She stated Resident #26 startled easily and the other resident would make him fall. Staff H stated there were two incidents they knew of where the other resident made Resident #26 fall, but indicated there could have been more they didn't know about because the residents shared a room. She stated the resident causing the falls knew what he was doing, and that staff later heard him laugh with another resident about what he did. On 11/08/23 at 2:33 PM, Staff B, Registered Nurse (RN)/Former Director of Nursing (DON) stated the other resident's behaviors became more aggressive and territorial over time. She believed he knew staff were watching him because he was aware of the checks and they upset him. Staff B indicated the resident should have had 1:1 intervention in place sooner to prevent additional incidents. 34821 3. The MDS for Resident # 28 dated 8/8/23, included diagnoses of dementia and anxiety disorder. The BIMS for Resident #28 showed a score of 6 out of 15, indicating severe cognitive impairment. The MDS reflected Resident # 28 required extensive assist of two staff for bed mobility, transfer, dressing and personal hygiene. The Care Plan for Resident # 28 dated 8/06/23, directed she needed help from one staff to dress. Totally dependent on one staff for personal hygiene, bed mobility and a full body lift for transfers. The Incident Report note dated 9/3/23, described a situation on 8/23/23 Staff C, Certified Nurses Aide (CNA) reported as they cared for Resident #28 she screamed in distress. She revealed she witnessed Staff D, CNA grab Resident #28's hand from her and told Resident #28 to shut up. Staff D continued to hold Resident #28's wrists and forced her arms through her clothes to get her ready for bed. The note continued Staff C failed to report this incident to her supervisor until 9/3/23. The Employee Performance Expectation Disciplinary Action for Staff D, CNA dated 9/7/23, reflected staff reported on 9/4/23 she witnessed physical and verbal abuse along with some disturbing behavior. The Employee file for Staff C included a document titled New Hire Acknowledgement Receipt dated 8/23/23, indicated she received a copy of the facility policy on Reporting Suspected Crimes under the Federal Justice Act. The Reporting Suspected Crimes under the Federal Justice Act dated 2010, directed at point # 2 All new staff, as part of their orientation to work at the facility shall receive a copy of their obligation to comply with the law and this policy and procedure. The Nursing Schedule dated 8/27/23, showed Staff A, LPN worked on the 2-10 shift. On 11/08/23 at 1:23 PM, Staff A denied knowledge that Staff C reported any incidents with Staff D. Staff A stated she expected staff to report such incidents and concerns to her. On 11/08/23 02:23 PM, Staff B, Registered Nurse (Director of Nursing at the time of the report) stated she expected the CNA to report concerns like this to Management immediately. On 11/09/23 at 11:15 AM, the DON reported he expected staff to report any concerns with other staff interaction with residents to him immediately. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy dated October 2022 documented that all residents had the right to be free from abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Sexual exploitation included touching of a clothed or unclothed breast. Resident-to-resident physical contact that occurred is considered resident-to-resident abuse. Resident-to-resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility would presume instances of abuse caused physical harm, 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. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to complete a thorough investigation of alleged violations of abuse, maintain documentation, and prevent further incidents. (Residents #9 and #26). The facility reported a census of 34 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #9 signed 10/12/23 revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Section I of the MDS signed 10/24/23 documented diagnoses of cancer, anxiety disorder, and encephalopathy (change in brain function). A document titled Self-Report dated 2/1/23 revealed another resident touched and patted Resident #9 on the breast on 1/12/23 in a common area of the facility. The report indicated Staff H, Licensed Practical Nurse (LPN), and the former Director of Nursing (DON), Staff B, were aware of the incident on 1/12/23. Staff B investigated the incident, and she did not find the other resident had intentionally had inappropriate contact with Resident #9. On 1/31/23 Staff I, Health Services Supervisor, learned of the incident and determined the incident should have been reported regardless of the investigation results. The time frame between the incident and the report was 20 days. A fax sent 2/1/23 and returned 2/2/23 confirmed the incident had not been reported to the other resident's provider. That resident was documented as oriented to person, place, and time with impaired memory. On 11/08/23 at 10:15 AM, the Administrator confirmed he was not here when this incident occurred. He stated at the time of this incident the resident received 15-minute checks for safety. He expected staff would investigate immediately and report potential abuse within 2 hours. On 11/08/23 at 10:41 AM, Staff H stated the 15-minute checks started when the other resident began touching female residents. She revealed she witnessed this incident and 15-minute checks were a start but were not enough. Staff B stated the resident knew what he was doing when he touched Resident #9. On 11/08/23 at 2:33 PM, Staff B stated the other resident's behaviors became more aggressive and territorial. She believed he knew staff were watching him because he was aware of the checks and they upset him. He had to be redirected and walked away from the area after he touched Resident #9. 2. The MDS Assessment for Resident #26 dated 8/25/23 revealed the resident scored 12 out of 15 on the BIMS exam, which indicated moderate cognitive impairment. Section I of the MDS listed diagnoses of Parkinson's disease, non-Alzheimer's dementia, and anxiety disorder. A Care Plan area dated 5/6/22 documented Resident #26 became confused and easily over-stimulated due to Parkinson's and dementia, and staff should assess and anticipate needs. Another focus area with the same date indicated the resident was at risk for falls and had poor safety awareness. On 7/18/22 an intervention was added that the resident was easily startled and needed time to become aware of someone's presence at his door. A Progress Note dated 2/8/23 created by Staff K, labeled MD/Nursing Communications, with the return fax signed by Staff H, LPN documented Resident #26 was laying on his back with his head on the closet door. He reported he did not hear his roommate come up behind him, and the roommate made a loud noise that scared me to death. The roommate admitted he came up behind the resident and clapped his book together loudly trying to be funny. A Progress Note dated 3/9/23 by Staff H, labeled MD/Nursing Communications revealed Resident #26 was standing in his room without assistance when his roommate startled him causing him to sit next to his bed on the floor. The Progress Notes failed to address this as a possible cause for other Resident #26 falls. An untitled Quality Assurance and Performance Improvement (QAPI) document dated 4/14/23 failed to provide a Root Cause Analysis for resident falls or resident to resident interactions. On 11/08/23 at 10:15 AM, the Administrator stated at the time of this incident the resident who caused Resident #26 to fall received 15-minute checks for safety due to inappropriate behavior with other residents. He expected staff would report potential abuse within 2 hours. On 11/09/23 at 12:22 PM the Administrator indicated the QAPI Committee had not been very good at monitoring, had not been consistent with documentation, and had not been documenting follow up. He indicated the program needed to be revamped to include documentation of resident care and quality of life topics. On 11/08/23 at 10:41 AM, Staff H stated she believed Resident #26's roommate was high risk and needed a higher level of care. She did not believe 15-minute checks were effective because his behaviors would happen when staff walked away or in his room. She stated Resident #26 startled easily and his roommate would make him fall. Staff H stated there were two incidents staff knew of where the other resident made Resident #26 fall, but there could have been more they didn't know about because they shared a room. She stated he knew what he was doing when he caused the falls, and that staff later heard him laugh with another resident about what he did. On 11/08/23 at 2:33 PM, Staff B stated the other resident's behaviors became more aggressive and territorial. Staff B indicated the resident should have had 1:1 intervention in place sooner to prevent additional incidents. A policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy dated October 2022 documented that following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections & Appeals. This written report shall be forwarded to the Department within five days of the initial report. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to conduct a Comprehensive Assessment of a resident in accordance with the timeframes specified for 1 of 1 residents reviewed (Resident #138). The facility reported a census of 34. Findings Include: A Minimum Data Set (MDS) 3.0 Assessment Summary in the Electronic Health Record, labeled Entry with a target date of 10/26/23, revealed 33 questions remained with a status of 'in progress' and 7 days overdue. An MDS Assessment for Resident #138 dated 11/1/23, revealed an unsigned document with Section K completed 11/7/23, Section F completed 11/8/23, and Sections C and D completed 11/8/23. The remaining assessment sections were incomplete. The MDS summary revealed 365 questions remained with a status of 'in progress' and 1 day overdue. The Baseline Care Plan for Resident #138 dated 10/26/23 indicated the resident was oriented to person, place, and time and communication was within normal limits. A document titled Clinical Physician Orders dated 11/8/23 documented that the resident's next order review was 3 days overdue. An interview with the Director of Nursing (DON) on 11/08/23 at 10:26 AM, revealed that a former employee was responsible for MDS completion and the facility was going through a transition. He stated that he and Staff E, Registered Nurse (RN) were responsible for MDS completion as needed during this time. An interview with Staff F, Facility Consultant, on 11/9/23 at 9:09 AM, confirmed the resident's MDS assessments were in process but not completed. She acknowledged the assessments were late. An undated policy titled Resident Assessment Instrument and Care Planning documented that the Resident Assessment (identified as MDS 2.0) would be used to identify areas that needed further evaluation and develop a Plan of Care. Guidelines included the initial assessment must be completed by the 14th day of a resident's stay.

Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to implement interventions, monitor for effectiveness, and modify interventions to minimize the likelihood of falling for 1 of 2 residents reviewed for accidents (Resident #12). The facility reported a census of 34 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 8/28/23, revealed Resident #12 required limited assistance of one staff for transfers, locomotion and required extensive assistance of one staff for toileting, dressing, and personal hygiene. The MDS indicated Resident #12 unsteady with transfers or ambulation but able to stabilize without staff assistance. The Care Plan, initiated 8/21/23, listed diagnoses of dementia and anxiety initiated. The Care Plan, revealed a Focus Area for impaired activities of daily living (ADL's) and mobility independence related to impaired safety awareness and recent decline at home. Interventions included: assist of one with transfers and resident to use a walker with tray, staff to provide assistance with her walker and help direct the walker to keep it near the center of the hallway. The Care Plan revealed a Focus Area, initiated 9/03/23, for risk of falls related to injuries from a history of fall with fracture, impaired safety awareness related to dementia and indicated resident will get up without calling for help. Interventions related to risk of falls included: a. Ensure bed is in low position prior to leaving room. b. Frequent staff checks - staff to check on resident when in bed in the morning to see if resident needs assistance, staff to assist resident out of the dining room as close to the time she's finished eating to prevent resident from getting up on her own, and frequent checks of resident while in the common area to help prevent getting up unassisted. The Morse Fall Scale Assessment completed on 8/15/23, revealed Resident #12 at a high risk for falling. Subsequent Morse fall Scale Assessments completed 10/20/23 and 11/05/23 revealed resident remained at high risk for falling. Facility provided Incident Reports from Resident #12's fall occurrences, dates included: 08/18/23, 09/17/23, 09/18/23, 10/10/23, 10/20/23, 10/25/23, 10/27/23, and 11/05/23. Incident Reports included date, time, location, description of incident, and immediate action taken. The Incident Reports failed to include a root cause analysis, indicate an intervention to prevent future falls, or evaluate for effectiveness of fall interventions. On 11/06/23 at 11:55 AM, Resident #12 attempted to get up from her bed. The resident leaned forward reached for shoes with blanket wrapped around waist and walker turned backwards near the foot of bed. The staff stated resident technically independent and entered her room and provided assistance. On 11/07/23 at 9:06 AM, Resident #12 walked in hallway independently with her walker, shuffled gait and veered to the left nearly missed the mechanical lifts and walls of hallway. On 11/07/23 at 10:33 AM, the Director of Nursing (DON) reported Resident #12's current transfer status as independent with transferring and ambulation. The DON determined this status from a recommendation from Therapy, initiated 10/03/23, and confirmed the conflict between current transfer status and resident's Care Plan. DON stated the Care Plan would be updated to reflect current status. When asked for interventions put into place following the independent transfer status for the following falls on 10/10/23, 10/20/23, 10/25/23, 10/27/23, and 11/05/23, the DON informed that all interventions related to falls would be located within the Incident Reports and resident's Care Plan. On 11/09/23 at 10:35 AM, the DON provided Incident Reports and wrote on the reports the intervention implemented for the corresponding fall. The DON informed there was no intervention implemented for fall on 10/10/23 and stated that not all interventions on Resident #12's Care Plan were still applicable. DON indicated an expectation that interventions be removed from Care Plan when no longer applicable. The undated facility policy titled Falls, revealed the purpose of the policy is to ensure that if a resident falls, a thorough assessment is completed and appropriately documented with interventions identified to prevent future falls. Policy instructed responsible staff: Charge Nurse, DON, and Administrator, to determine potential causes for the fall and add teaching and/or interventions to the plan of care to prevent another fall from occurring. The facility policy titled Incident Report Policy, revised 7/15/23, revealed incidents to be assessed in 24 hours, and 1 week, unless needed more frequently. The policy instructed that the DON will monitor documentation and completion of incident reporting, Health Services Supervisor will review Care Plan and update as appropriate within 72 hours, and Administrator will sign and lock incidents upon full completion.

Based on record review, staff and resident's responsible party (RP) interviews, the facility failed to have sufficient staff with appropriate competencies and skills sets that included caring for residents with mental and psychosocial disorders, to provide nursing and related services to assure resident safety, and attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident, for 2 of 4 residents reviewed. This failure resulted in a resident's attempted suicide that required transfer to the hospital for a higher level of care (Resident #1), and a resident's continued inappropriate and unsolicited sexual behaviors of touching female residents in a sexual manner (Resident #2). The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 31 residents. Findings Include: 1. The 8/8/22 Minimum Data Set (MDS) Assessment Tool revealed Resident #1 admitted to the facility 5/31/22 with diagnoses that included diabetes, hemiplegia (paralysis on 1 side of the body), anxiety depression, essential tremor and suicidal ideation's. The MDS documented the resident scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated no cognitive deficits or symptoms of delirium present, The MDS identified the resident required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed or chair, dressing, bathing, toileting and personal hygiene, able to feed herself with staff supervision or limited assistance, and unable to stand or ambulate. A Pre-Admission Screening and Resident Review (PASRR) Assessment (an assessment required prior to any long-term care admission) completed 5/30/22 resulted in a Level II determination that indicated the resident appropriate for long-term care, but required specialized services due to a recurrent and severe major depressive disorder, that included a history of making statements about ending her life, and 2 psychiatric hospitalization s for suicidal ideation had occurred in February, 2018 and August, 2019. The PASRR directed the facility was required to: a. Ensure the resident received ongoing services by a Psychiatrist or Psychiatric Nurse Practitioner for psychiatric medication management and assessment of ongoing need for additional behavioral health service requirements. b. Ensure the resident received individualized therapy by a behavioral health professional. c. Develop a Crisis and Safety Plan, that would assist staff to determine when the resident had symptoms of worsening depression, and identify interventions to decrease the resident's depressive symptoms and reduce the risk of hospitalization . d. Provide socialization/leisure/recreation activities appropriate to current skills or adapted to promote optimal resident participation. e. Facilitate family involvement in the resident's care and care plan development, including inviting family for regular visitation and participation in care conferences. Physician Orders directed staff to administer psychoactive medications that included: a. Fluoxetine (antidepressant) 60 milligrams (mg) oral daily, ordered 6/1/22. b. Buspirone (anti-anxiety) 5 mg oral twice daily, ordered 5/31/22 The Nursing Care Plan included: 1. A problem The resident has a psychosocial well-being problem related to Major Depressive disorder, initiated 6/7/22, with interventions: a. Monitor/document resident's feelings relative to isolation, unhappiness, anger and loss, initiated 6/7/22. b. Initiate referrals as needed or increase social relationships, initiated 6/7/22. c. Provide opportunities for the resident and family to participate in care, initiated 6/7/22. 2. A problem PASRR has identified I may benefit from Specialized Services, initiated 8/17/22, with interventions: a. Ongoing medication management by a Psychiatrist or a Psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services), initiated 8/17/22. b. Resident seen by Psychiatry at the hospital. Appointment set up by Social Services at [NAME] Manor. Frequency to be determined by Psychiatrist. Length of treatment determined by Psychiatrist, initiated 8/17/22. 3. A problem PASRR Rehabilitative services: Socialization/recreation activities, initiated 8/17/22, with interventions: a. Initial Activity review completed upon admission to determine resident preferences. One on one with Activities and Social Services at various times offering different activities and encouraging participation in activities and socialization, initiated 8/17/22. The undated resident's Crisis and Safety Plan document stated My depression may be worse if I am displaying the following: a. Decreased meal intake. b. Make increased negative statements. c. Declined mood. d. Flattened affect. e. Isolate myself in my room. And, Things that my make me feel better when I am displaying increased signs and symptoms of depression include the following: a. Enjoys visits from family. b. Enjoys visiting with the staff. c. Enjoys spending time outside as weather permits. d. Enjoys group activities, especially Bingo and various crafts. Crisis and Safety Plan directed staff to: a. Encourage ongoing family involvement by helping the resident charge her phone as needed, encourage visits via phone, Zoom or Facetime, and provide opportunities for the resident and family to participate in care. b. Invite resident to scheduled activities. c. Modify daily schedule to accommodate activity participation. d. Observe and report changes in usual routine, sleep patterns, decreased functional abilities, withdrawal or resistance to care. e. Monitor/document the resident's feelings relative to her feelings of isolation, unhappiness, anger and depression. f. Consult with Social Services regularly. Progress Notes included the following entries: a. On 6/7/22 at 12:12 p.m., recorded by Staff A, the facility's Social Service designee (SSD), stated resident reported some depression due to not able to do anything, unable to live her life as she use to and frustrated with her life situation. She stated she has thoughts she would be better off dead or hurting herself, but knows she will not. Psychiatrist office contacted for an appointment, waiting for response from them. Will also set up 1:1 visits with Social Services and Activity staff in facility to allow resident to do things she wishes. b. On 7/23/22 at 3:28 p.m. recorded by Staff B, Licensed Practical Nurse (LPN), stated resident expressed feelings of increased depression and suicidal thoughts and ideation's. Resident admits I just want to die today. I have thought of every way but since I cant stand and my hands don't work I couldn't do it. Resident tearful during conversation. Resident expresses frustrations towards family who does not visit more frequently. Resident admits I hate my life, I have no purpose. c. On 7/31/22 at 3:33 p.m. recorded by the Director of Nursing (DON), stated resident requested to be escorted outside and left there to die. Reports she has not eaten in 2 days, or drank anything in 1 day. Resident stated she thinks about suicide often but she doesn't have the physical ability to execute any plans. Resident reported being depressed because her family didn't come to visit, [NAME] like she would have more interaction with staff if she had Covid, felt she was too young to be in long-term-care, unable to do activities like reading, knitting, and crafts because her head shook and she couldn't use her hands like she used to. Resident was encouraged to come out of her room and socialize with staff and other residents, find a new hobby, set goals for herself, and change her perception of her circumstances. Resident has restarted seeing her Psychiatrist with an upcoming appointment scheduled, will correspond with them on resident thoughts and their recommendations. d. On 7/31/22 at 6:12 p.m. recorded by Staff B, LPN, stated received phone call from the Police regarding resident self reported suicidal ideation's, resident requested to be taken to hospital, resident transferred to the hospital in stable condition. Physician notified. e. On 8/1/22 at 5:22 p.m. recorded by Staff C, LPN/Health Services Supervisor, stated resident returned from hospital, held under observation and returned within 24 hours. Upon arrival she was tested for COVID-19 and was positive, placed in isolation/droplet precautions. f. A late entry, documented as effective 8/4/22 at 11:51 a.m., recorded 8/5/22 at 11:54 a.m. by Staff A, SSD, stated due to increased depression, and additional thoughts of self harm, both Staff C, Health Services Supervisor and Staff A thought it was in the best interest for the resident to remove all sharp or potentially harmful things from resident's reach. Resident understood, will monitor and talk with the resident again to see how she felt. Family was to come to visit this afternoon to cheer resident due to her continued Isolation for up to 10 days related to Covid infection. g. On 8/6/22 at 8:56 a.m., recorded by Staff B, LPN, stated CNA (Certified Nursing Assistant) reports resident refused to eat breakfast and drink fluids other than iced coffee. Resident stated, I would rather just die. CNA offered to sit with resident while she ate which resident deferred. Will continue to monitor. h. On 8/6/22 at 12:59 p.m., recorded by Staff B, LPN, stated CNA reported spending time with resident during noon meal and encouraged resident to eat, resident refused to eat, reported ongoing feelings she wished to die. CNA encouraged adequate intake. Will continue to monitor. i. On 8/8/22 at 12:48 p.m., recorded by Staff A, SSD, stated reports wants to just die, expressed she does not have an active plan however she would self harm if she could. Resident reported she was upset and hurt by family not visiting her more often and being away from family members. Resident also stated she has felt this way for sometime, and saw no way to change it. This has been reported to Nursing for communications with her physician. j. On 8/9/22 at 8:15 a.m., recorded by Staff A, SSD, stated resident said she felt depressed, had a poor appetite, felt bad about herself and thought she just wanted to die for half to most of the previous 14 days. Her depression answers and scores were reported to nursing and will be sent to the physician. k. On 8/11/22 at 10:51 a.m., recorded by Staff D, LPN, stated resident continued to want to leave this place, 1:1 given, spoke with resident regarding family and past hobbies. Resident would like to try painting again. This was something she enjoyed to pass time. This nurse will pass along information to Activities department, DON, Assistant Director of Nursing (ADON) and Administrator. Resident resting in recliner chair with call light in reach. l. On 8/13/22 at 11:28 a.m., recorded by Staff B, LPN, stated suicide attempt via hanging in room. Resident found in electric recliner in elevated upright position with call light cord wrapped around neck 4 times. Call light cord was taught. Resident had recliner remote in hand attempting to elevate recliner higher. Resident stated you should have left me like this I would have been better off and stated to CNA nothing ever works. Resident was alert and oriented to 4 spheres, poor eye contact, withdrawn and flat affect. Resident admitted to Paramedic I want to die. Resident noted to have redness to anterior neck from cord. Sent to hospital via Emergency Medical Services. The Hospital emergency room (ER) Provider Notes dated 7/31/22 revealed facility staff transferred the resident to ER for further evaluation after she disclosed a plan to hang herself with suicidal ideation. The resident reported she thought of hanging herself or cutting herself for a long time but didn't think she had the means to do so. The resident made a phone call while at the facility that day, Police were made aware the resident was suicidal and they called the facility and alerted staff to check on her. While in the ER, the resident was evaluated by a Psychiatrist physician who determined the resident had chronic suicidal ideation, the resident admitted she wasn't any more or less likely to harm herself now than at any point in the last many years, didn't have access to lethal means, and medications were controlled at the nursing home. Given the resident had established care with a Psychiatrist and had a supportive environment at the nursing home, the Psychiatrist determined the resident should continue current care at the nursing home, continue follow-up with Psychiatrist, and was to return to the ER for new or worsening concerns or any concerns of safety. The facility's Suicide Prevention and Response policy dated 7/17/13 directed staff: a. Each resident will be assessed for their emotional needs before admission through the pre-screening process and periodically during their stay in the facility. The evaluation process can be through personal interview, MDS assessment process and staff interview for potential needs. b. Any statement of suicide that a resident makes will be reported to the charge nurse immediately. c. The Charge Nurse, DON or designee, and/or Social Worker will investigate statement of suicide by interviewing the resident. d. The physician will be notified and it will be discussed as to if the resident needs a psychological consult or if admission to psychiatric unit is appropriate. e. The resident will be checked on frequently and encouraged to stay in a supervised area. Sharp or potentially dangerous items will be removed from the room. f. Family will be notified as well as other staff members that are directly involved in the resident's care. g. Documentation in record will reflect the above information. h. Plan of Care will be updated and ongoing documentation in the Nurse's Notes and Social Service notes will occur until threat is resolved. Staff interviews revealed: a. On 8/22/22 at 2:31 p.m., Staff A, SSD, stated the resident had been at the facility before, she would have down days but would come out for activities, arts and crafts, and was followed by a psychologist for her mental health needs. When the resident returned, she made an appointment for her at the same psychology physician group where she had gone before, but was seen by a different provider and the resident refused to return. The resident progressively got more and more depressed. The biggest things that effected the resident was her belief that her family didn't visit enough, and being placed in isolation when she had Covid. The SSD made arrangements for a friendly visitor, the resident had the same visitor before, they became friends and she enjoyed the visits, and the family found a private Psychiatrist to assume her care, but they were not able to establish those things before the resident's Covid infection and suicide attempt. b. On 8/23/22 at 6:00 a.m. Staff B, LPN, stated two weekends prior to 8/13/22, the resident made statements she would be better off dead, when assessed if she had a means to carry out the plan the resident stated she had thought of every possible way to kill herself at the facility but would not be able to due to her lack of mobility. Staff B sent the resident to the hospital, she was there less than 24 hours and returned, the hospital staff determined she was not suicidal. Staff B was on duty on 8/13/22 when the resident put the call light around her neck. The resident was found awake, stated leave her alone and let her die. There was some redness on her neck but no ligature marks, vital signs were normal and she called 911. On 8/13/22, the CNA said the resident was feeling down that morning, but didn't say she wanted to kill herself. She instructed the aides to keep an eye on her and let her know if she voiced anything, to peek in on the resident when they were down there by her room, and there were no regular or scheduled assessments of the resident related to her increased signs of depression. Staff B did not know if the resident had a Crisis Intervention plan or where it was located if there was one. c. On 8/23/22 at 8:12 a.m., Staff D, LPN, stated when the resident said she was feeling down, or depressed, she would try to spend 1 on 1 time with her, talk about her interests and things she could do. She would ask her if she had a plan or how she would carry out her suicidal thoughts and the resident would say she could do it if she could leave the facility, but the resident couldn't leave. There was a list of things on a crisis plan that they could bring up, and she would document what she had done in the Progress Notes. When the resident had COVID and isolated, that was the worst time. She spent 1:1 time with her, had the CNA's and SSD also, if the shower room and staff were available that was also a good option as she enjoyed that. She would tell the SSD when the resident expressed negative feelings. They boxed things from her room that could be potentially harmful but had not removed the call light. What helped the resident the most when she was down was 1:1 attention, from anyone. d. On 8/23/22 at 10:44 a.m. Staff E, CNA, stated around 6 weeks before the resident's suicide attempt she started saying things like she doesn't want to live like that anymore and would say that every day/every time she worked. Staff E reported that to the nurse, staff were supposed to tell the nurse anytime she made those kind of comments. On 8/13/22, the resident ate breakfast in the dining room, went to her room after breakfast, staff toileted her, then transferred her to her recliner chair per usual routine. Staff E made sure the resident had everything she needed, that included her call light before she left the room. On that day, the resident hadn't used the call light to go to the bathroom, which was unusual, normally she made that request about every 45 minutes to hour. About 20 minutes after staff put her in the recliner chair, the resident's call light was on, she went in the room with Staff G, CNA, they found the resident in her lift chair with it up as high as it went, the call light cord pulled out of the wall socket, and wrapped around the resident's neck 4 times. They called for the nurse on their cordless communication device and she came right away. The resident said she did it because there was nobody that would do it for her, she didn't need their help, didn't want to go to the hospital, wanted them to leave her alone and let her die. e. On 8/23/22 at 1:03 p.m., Staff F, CNA stated the resident would say she didn't want to go on like that to her, and Staff F would talk to her and talk her out of it. Staff were to tell the nurse when she spoke that way. Resident had the call light on about every hour, so they were down to her room a lot, but no set schedule. When this employee was in the hall she would check on the resident, would go into her room and talk to her, see if she needed anything. Sometimes she was sleeping, sometimes her eyes were closed but she would hear them come in her room. The resident couldn't have real silverware due to her suicidal comments, but it was okay for her to have the call light, it was pinned to her clothing. Staff F stated they didn't have to do any extra 1:1's with the resident when she was in isolation with COVID. f. On 8/23/22 at 10:28 a.m. Staff G, CNA, stated on 8/13/22, she answered the resident's call light, her chair was all the way up and the call light cord wrapped around her neck. She used her cordless communication device to call the nurse, who came right away. When the resident said things like she wanted to die, staff were to report that to the nurse. g. On 8/23/22 at 1:30 p.m. Staff H, CNA stated she hadn't heard the resident say she wanted to die, it was she didn't want to be at this facility, she wanted to be back home. She reported the resident's negative comments to the nurse or the Administrator as instructed, she was never directed to check on the resident any more than what she put her call light on to request care, that was usually about every 30 minutes. There were a few times, if the resident was feeling down, she would try to talk to her if she had the time, would offer feeding assistance, the resident couldn't eat as fast as she wanted to so wanted staff to feed her/assist her. h. On 8/24/22 at 7:28 a.m., when asked what she expected staff to do if a resident made suicidal remarks, the DON expected staff to assess the resident's room for hazards, assess the resident and document the resident's abnormal remarks. After the emergency room (ER) visit on 7/31/22, they weren't constantly assessing her or asking her questions related to suicide risk and she didn't know what the nurses assessed on their shifts as there wasn't a standard assessment to do. The DON stated the resident couldn't dial a number on her cell phone, her arms shook when they transferred her with the lift, so they didn't believe she was able to harm herself. The DON didn't think the resident was at high risk for suicide based on the doctor's assessment in theER on [DATE], and statements by her family. The determination to remove sharp objects from the resident's room was based on her ability to carry out a plan. During the interview the DON acknowledged the resident called the Police independently with her cell phone on 7/31/22, and used her arms, without anyone's assistance, to wrap the call light cord around her neck 4 times on 8/13/22. i. On 8/24/22 at 8:27 a.m., the Administrator stated she expected staff to let the charge nurse know if a resident had a behavior, expected the charge nurse to assess that resident and use an intervention from the resident's care plan. The Administrator wasn't sure if the charge nurse could identify a new intervention to put in the care plan, they would have to have a management meeting to address that. The Administrator expected staff to communicate pertinent resident information in their shift to shift reports, that information should be the most up-to-date for care requirements and what staff should utilize for their care of the residents. The Administrator stated that any change in the resident's care should be passed along in report between staff. j. On 8/24/22 at 2:33 p.m., the Administrator and Staff C, Health Services Supervisor stated they didn't have a Nursing Skills Checklist or Nursing Competency Checklist of required skills, that was something they were developing. k. On 8/22/22 at 7:27 p.m., the resident's responsible party and Power of Attorney (POA) was interviewed by phone, didn't have concerns related to the resident's suicide attempt at the facility, the resident tended to be a negative person, often attention-seeking and dwelled on the things she could no longer do. The POA thought the facility should exercise more caution when it came to assisting the resident, It might have taken the resident a half hour to self-propel her wheel chair to the dining room, but she had nothing else to do, staff should let her do that because when they pushed her there or other similar actions, the resident lost more and more of her independence and then she focused on that loss. The POA acknowledged it was a challenging situation because they knew how the resident could be. After the facility was notified of the Immediate Jeopardy for residents and the requirement for abatement, the facility developed a Resident Suicide Threat Checklist form and a Suicide Observation Note form in the electronic record on 8/25/22, and instructed staff on utilization of the documents on 8/25/22. Nurses and the SSD assessed all facility residents for suicide risk on 8/25/22 and determined 1 resident had some indicators for suicide risk, implemented interventions and scheduled assessments of the resident that day. The facility also developed a Suicide Alert and Precautions policy, a Change in Condition Form, and a Suicide Risk Assessment form in the electronic record, educated staff, and provided copies of all forms on 8/29/22. The State Agency notified the facility of the Immediate Jeopardy on 8/25/22 at 11:30 a.m. The Immediate Jeopardy situation started on 7/23/22. The facility removed the Immediate Jeopardy on 8/25/22 by the following actions: a. Initiated staff education to all nurses on 8/25/22 that they must assess a resident's risk for suicide or self-harm when the resident talks of suicide, or voices a plan for suicide, or has actually attempted suicide, and requirement for documentation of the event and staff interventions related to the event b. Initiated staff education to all Nursing Staff on required interventions to initiate when a resident talks of suicide, appropriate documentation of all interventions utilized and when utilized, and requirement for ongoing assessment of the risk for self-harm or suicide until the identified resident no longer posed a risk for self-harm or suicide action. c. Initiated staff education to all nurses on 8/25/22 to notify the physician and responsible party immediately of the resident's potential for self harm, and to notify all Nursing Staff of the resident's condition and risk for self-harm. d. Initiated staff education to all Nursing Staff on 8/25/22 to inspect a resident's room and remove any possible items that may be used in suicidal attempts when a resident talks of suicide The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education. 2. The 7/8/22 Minimum Data Set (MDS) Assessment tool revealed Resident #2 admitted to the facility 10/16/18, diagnoses included Alzheimer's disease, anxiety and depression, scored 10 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment tool, that indicated moderate cognitive impairment, without symptoms of delirium present, no identified moods, behaviors that included physical and verbal behaviors directed towards others that occurred from 1 to 3 days of the 7 days that preceded the assessment, and required extensive assistance of at least 1 staff for bathing, and minimal staff supervision for dressing, eating and personal hygiene. The Nursing Care plan included: 1. A problem The resident is/has potential to be verbally aggressive, initiated 4/11/19, with interventions: a. When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, If response is aggressive staff to walk calmly away and approach later, initiated 4/11/19. b. Monitor/document/report as needed any signs or symptoms of resident posing danger to self and/or others, initiated 4/11/19. 2. A problem The resident has potential to be exhibit negative behaviors related to diagnosis of dementia and complicated interpersonal relationship. Resident has been found touching female residents intimately, exhibiting sexually inappropriate behaviors, initiated 7/19/22, with interventions: a. Resident is monitored frequently for location in the facility, staff is aware re-direct and separate this resident from other female residents as needed, initiated 7/15/22. b. Resident is monitored every 15 minutes for location in the facility, staff is aware re-direct and separate this resident from other female residents as needed, initiated 8/16/22. Progress Note entries included the following: a. A Late Entry note, effective 6/28/22 at 3:25 p.m., created by Staff C, LPN, Health Services Supervisor on 7/15/22 at 10:02 p.m., stated at 3:28 p.m., therapy staff reported to the Director of Nursing (DON) Resident #2 was fondling a female resident in her room and looked to be kissing her. The therapist separated the residents and directed Resident #2 out of her room. The suggested intervention at the time of the event was all staff, all departments, and all shifts alerted and instructed to be vigilant. b. On 6/30/22 at 8:38 a.m.,, Staff D, LPN, stated she observed Resident #2 in the common area, rubbing his left hand on a female resident's breast on top of her shirt. The female resident said Get your hands off of me. Staff D instructed Resident #2 that he could not touch people like that, Resident #2 responded she did not have a bra on. The suggested intervention was all staff were aware of Resident #2's inappropriate behaviors and educated to notify the nurse of any situation regarding Resident #2 and another resident. c. On 7/7/22 at 11:45 a.m., Staff C, LPN, Health Services Supervisor, stated a Nursing Instructor and Student Nurse observed Resident #2 in a female resident's room holding hands, alerted the closest staff member at once, that staff member went into the resident's room and directed Resident #2 out of her room. The suggested intervention was a medication review. Physician orders dated 7/13/22 directed nursing staff: a. Discontinue Sertraline (an antidepressant medication) 50 milligrams (mg) administered oral daily. b. Start Sertraline 25 mg administered oral daily for 7 days, then discontinue on 7/21/22. c. On 7/21/22, start Prozac (a different antidepressant medication) 20 mg administered oral daily. d. Monitor for behaviors every shift (8 hours) that included sexual inappropriateness, itching, picking at skin, restlessness, agitation, hitting, increase in complaints, cussing, delusions, hallucinations, psychosis, aggression or refusing care. Staff were to indicate with a N = none observed, or Y= yes, behaviors are present. If yes, staff were to describe the behavior in the Progress Notes. Observations revealed: a. On 8/23/22 at 8:12 a.m., resident currently seated in his chair in the family room located in front of the facility, appeared comfortable and kept to himself. Other residents were seated in the surrounding area and staff were nearby for supervision. b. On 8/24/22 at 2:40 p.m., the resident was seated by himself at a table in the common area and played Solitaire with a deck of cards. Other residents were seated in the common area and staff located within the area for supervision. c. On 8/30/22 at 4:25 p.m., the resident was seated in his chair in the common area and worked on a Word Search puzzle, appeared calm, comfortable and kept to himself. Staff were available in the area for supervision. Staff Interviews revealed: a. On 8/23/22 at 8:12 a.m., Staff D, LPN, was familiar with Resident #2's behaviors, they were to monitor his whereabouts and document them every 15 minutes. If he had behaviors, they documented with a Y in the TAR (Treatment Administration Record), and she would document in the Nurse's Progress Notes what the behaviors were. b. On 8/23/22 at 1:03 p.m., Staff F, CNA, stated they have to watch where the resident is all the time. He's not supposed to go in any resident's room, they are to redirect him out of there and tell the charge nurse about it. She has not seen any inappropriate activity in the last few weeks. c. On 8/23/22 at 10:28 a.m., Staff G, CNA stated they have to be aware of where the resident is all the time, and check every 15 minutes. He is not supposed to go into anyone else's room. A while ago they put the stop sign banner in the doorway of a female resident's room, she thought it was to keep Resident #2 out of there. They were to always tell the nurse if he had any behaviors. d. On 8/23/22 at 1:30 p.m. Staff H, CNA stated the resident was on 15 minute checks, all staff worked on this together so they know he's not going into resident rooms. He's been found in a female resident's room and why the stop sign banner is up there. e. On 8/23/22 at 10:44 a.m. Staff E, CNA stated everyone was to track the resident's whereabouts every 15 minutes, redirect him out of resident's rooms, and make nurse aware of the behavior, or other behaviors that he had. The resident had been touching female residents inappropriately as long as she had worked there (hired 7/1/22), that was not new, staff were always supposed to separate them and t [TRUNCATED]

Based on observations, record review and staff interviews, the facility failed to ensure that all residents remained free from the potential for dependent adult abuse, that included physical and sexual abuse, when they failed to identify and implement appropriate interventions after they identified a resident touched another resident inappropriately in a sexual manner, and resulted in the resident's continued behavior of touching other residents inappropriately on at least 2 other occasions after the initial incident was identified (Resident #2). The facility reported a census of 31 residents. Findings Include: The 7/8/22 Minimum Data Set (MDS) Assessment Tool revealed Resident #2 admitted to the facility 10/16/18, diagnoses included Alzheimer's disease, anxiety and depression, scored 10 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment tool, that indicated moderate cognitive impairment. The resident identified without symptoms of delirium present, no identified moods, behaviors that included physical and verbal behaviors directed towards others that occurred from 1 to 3 days of the 7 days that preceded the assessment. The MDS documented the resident required extensive assistance of at least 1 staff for bathing, and minimal staff supervision for dressing, eating and personal hygiene. Review of the Nursing Care plan included: 1. A problem The resident is/has potential to be verbally aggressive, initiated 4/11/19, with interventions: a. When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, If response is aggressive staff to walk calmly away and approach later, initiated 4/11/19. b. Monitor/document/report as needed any signs or symptoms of resident posing danger to self and/or others, initiated 4/11/19. 2. A problem The resident has potential to be exhibit negative behaviors related to diagnosis of dementia and complicated interpersonal relationship. Resident has been found touching female residents intimately, exhibiting sexually inappropriate behaviors, initiated 7/19/22, with interventions: a. Resident is monitored frequently for location in the facility, staff is aware re-direct and separate this resident from other female residents as needed, initiated 7/15/22. b. Resident is monitored every 15 minutes for location in the facility, staff is aware to re-direct and separate this resident from other female residents as needed, initiated 8/16/22. Review of Progress Note entries included the following: a. A Late Entry note, effective 6/28/22 at 3:25 p.m., created by Staff C, Licensed Practical Nurse (LPN), Health Services Supervisor on 7/15/22 at 10:02 p.m., stated at 3:28 p.m., Therapy Staff reported to the Director of Nursing (DON) Resident #2 was fondling a female resident in her room and looked to be kissing her. The Therapist separated the residents and directed Resident #2 out of her room. The suggested intervention at the time of the event was all staff, all departments, and all shifts alerted and instructed to be vigilant. b. On 6/30/22 at 8:38 a.m.,, Staff D, LPN, stated she observed Resident #2 in the common area, rubbing his left hand on a female resident's breast on top of her shirt. The female resident said Get your hands off of me. Staff D instructed Resident #2 that he could not touch people like that, Resident #2 responded she did not have a bra on. The suggested intervention was all staff were aware of Resident #2's inappropriate behaviors and educated to notify the nurse of any situation regarding Resident #2 and another resident. c. On 7/7/22 at 11:45 a.m., Staff C, LPN, Health Services Supervisor, stated a Nursing Instructor and Student Nurse observed Resident #2 in a female resident's room holding hands, alerted the closest staff member at once, that staff member went into the resident's room and directed Resident #2 out of her room. The suggested intervention was a medication review. Physician Orders for Resident #2 dated 7/13/22 directed Nursing Staff on the following: a. Discontinue Sertraline (an antidepressant medication) 50 milligrams (mg) administered oral daily. b. Start Sertraline 25 mg administered oral daily for 7 days, then discontinue on 7/21/22. c. On 7/21/22, start Prozac (a different antidepressant medication) 20 mg administered oral daily. d. Monitor for behaviors every shift (8 hours) that included sexual inappropriateness, itching, picking at skin, restlessness, agitation, hitting, increase in complaints, cussing, delusions, hallucinations, psychosis, aggression or refusing care. Staff were to indicate with a N = none observed, or Y= yes, behaviors are present. If yes, staff were to describe the behavior in the Progress Notes. The following observations revealed: a. On 8/23/22 at 8:12 a.m., resident currently seated in his chair in the family room located in front of the facility, appeared comfortable and kept to himself. Other residents were seated in the surrounding area and staff were nearby for supervision. b. On 8/24/22 at 2:40 p.m., the resident was seated by himself at a table in the common area and played Solitaire with a deck of cards. Other residents were seated in the common area and staff located within the area for supervision. c. On 8/30/22 at 4:25 p.m., the resident was seated in his chair in the common area and worked on a Word Search puzzle, appeared calm, comfortable and kept to himself. Staff were available in the area for supervision. Staff Interviews revealed the following: a. On 8/24/22 at 7:28 a.m., when asked if there was a system for monitoring resident's with behaviors, the Director of Nursing (DON) stated resident's that have behaviors have Medication Administration Records and Treatment Administration Records (MAR's/TAR's) that direct staff to monitor the behaviors. She has implemented something new, if someone reports a new resident behavior to her, she puts it on the TAR for 2 days for staff to monitor, she was going to instruct the Nursing Staff of this at a Nurse's meeting, to make sure they all knew how to put that on the TAR if needed. This wasn't a policy, it was her idea and her guidance to address the issue. b. On 8/30/22 at 7:08 a.m., when asked why staff didn't implement interventions to address the Resident #2's behaviors when they were identified on 6/28/22, the Administrator stated they thought they were an exception or isolated occurrence. The facility's Abuse Prevention, Training, and Investigations Policy, dated revised 12/30/20, directed staff: 1. Interdisciplinary team members monitor and intervene in situations where abuse, neglect and/or misappropriation of resident property are more likely to occur. 2. Employees are required to report incidents at the time of the occurrence, to their supervisor or person in charge of the facility for further investigation, regardless of whether the incident results in obvious or visible injury. 3. An investigation will be conducted by the facility to identify the cause of any resident incident. 4. Employees are required to immediately intervene to distract, halt and/or prevent harm to the extent that they can do so without placing themselves at risk for injury if they observe what they suspect is abuse to be occurring. 5. Employees are required to report allegations or suspicions of abuse immediately and without hesitation directly to the person in charge of the facility at the time. If that person is not the Administrator, the employee is required to report the allegation to the Administrator within one hour of first becoming aware. 6. The person in charge of the facility shall immediately: a. Separate the alleged perpetrator from the victim and maintain this separation without exception, pending completion of the investigation, b. Assess the victim for injury requiring immediate medical assistance and provide or arrange for needed care and treatment. c. Interview the victim, if possible, for his/her statement related to the occurrence. d. Interview the alleged perpetrator, if known and on-site, to obtain a statement of his/her knowledge and involvement. e. Notify the victim's attending physician if the allegation could impact the resident's physical or mental well-being. f. Document all of the above. 7. Every abuse allegation needs to be thoroughly investigated, including: a. Interviewing all potential witnesses to the occurrence. b. Interviewing other persons who might have witnessed similar events where the alleged behavior could have occurred with the same likeliness as this one. 8. Upon completion of the investigation, the Administrator should prepare a written summary report containing a description of the allegation, steps taken for investigation, and overview of the findings. 9. If the incident is a reportable as suspected dependent adult abuse, the Administrator will follow the Mandatory Reporting Policy.

Based on record review and staff interviews, the facility failed to obtain a Physician's Order for 1 out of 1 resident reviewed for a Cardiopulmonary Resuscitation (CPR) Code Status (Resident # 34). The facility reported a census of 34 residents. Findings included: The Face Sheet for Resident # 34 dated [DATE], listed [DIAGNOSES REDACTED]. Review of the Intermediate Care Facility(ICF) assessment dated [DATE] at 1:45 a.m., listed the Resident's vitals as: pulse 63 beats per minute, respirations 20 per minute, blood pressure ,[DATE], oxygen saturation 94% on room air. The note reflected the resident is alert, oriented to person, place, and situation. The ICF Assessment note on page 6 documented the resident awoke easily, was pleasant and cooperative. The note further identified lung sounds clear, no cough but shortness of breath while at rest. The note addressed no other complaints or concerns form the resident. Review of the Health Status Note for Resident # 34 dated [DATE] at 8:14 am, identified at 5:30 a.m. the resident in bed unresponsive, cold to touch without a pulse and not breathing. The documentation further identified the nurse notified the resident's wife at 5:45 a.m., the palliative care Physician at 5:55 a.m., the facility Administrator/Director of Nursing at 6:20 a.m., and the On-Call Physician for the resident's primary Physician. Review of the Baseline Care Plan dated [DATE], shown Section [NAME] for Resident # 34 is blank under the Advance Directives and Code Status Section. Review of Face Sheet dated [DATE], lacked documentation of the resident's Advance Directive for Resident # 34. The Physician Order sheet dated [DATE], lacked direction for the resident Code Status signed by the Physician on [DATE]. Review of the Transfer/ Discharge form for Resident # 34 dated [DATE] at 7:58 a.m., lack identification of the resident's Advance Directives. Review of the Health Status Notes from [DATE] through [DATE], lacked indication of the resident Code Status. During an interview on [DATE] at 12:59 p.m., the Director of Nursing (DON) stated expected all resident information scanned into the Point Click Care system. The DON indicated a need to verify with Medical Record that all of Resident #34's information is in the system. The Administrator and the DON provided an IPOST dated [DATE] that lacked a Physician's signature for Resident # 34. During an interview on [DATE] at 1:44 p.m., Staff I Social Services/LPN reported completing all the new admission paper work with the resident and the family. Staff I reported putting the sticker on the residents door to indicate what the resident's code status is when the order comes back from the Physician. Staff I indicated faxing the IPOST to the Physician and the order is normally back in 2 days. During an interview on [DATE] at 1:46 p.m., the DON stated the nurses can look at other documentation in the resident's record to check the code status for example: hospital documents with previous orders. During an interview on [DATE] at 1:53 p.m., the DON stated the expectation is staff provide CPR if a resident is found pulseless, not breathing, has Full Code Status indicated on the resident record or if the resident's Code Status of the is unknown. During an interview on [DATE] at 3:05 p.m., the Administrator acknowledged the facility failed to obtain a Physician's order for the Code Status on Resident # 34. During an interview on [DATE] at 4:07 p.m., Staff L, Licensed Practical Nurse (LPN), stated upon entering the room of resident # 34 around 5:00 a.m. on [DATE] to administer morning medications, she found the resident unresponsive and cold to touch. Staff L reported asking a Certified Nurses Aide (CNA) to bring the vitals equipment. Staff L stated the resident lacked a pulse and blood pressure. Staff L indicated the resident's skin looked very yellow in color and no other skin discoloration noted, Staff L also stated the resident dressed in a pajama top and bottoms and reported the CNA double checked the vitals and she (Staff L) completed the Death Check List. During an interview on [DATE] at 4:30 p.m., Staff L reported not initiating CPR because she unable to find a Code Status or Advance Directive for resident #34. Staff L stated the Resident's record lacked direction for a Code Status, no Iowa Physician order for [REDACTED]. Staff L further stated notifying the resident's wife, the Physician and calling the funeral home. Staff L reported an uncertainty of the Dot System used in the facility, verbalizing the Red Dot directs staff the resident is a Full Code and unclear of the meaning of the Green Dot. During an interview on [DATE] at 3:56 p.m., the Administrator reported Staff L notified her of Resident # 34's death on [DATE] and not thinking anything about it. The Administrator confirmed with the nurse they completed all the required tasks related to a death. The Administrator stated informing the DON later that morning. During an interview on [DATE] 4:51 p.m., Staff M, CNA reported helping Staff N, CNA clean Resident #34 after passing on [DATE]. Staff M stated no obvious discoloration of the resident 's skin color and the resident's body felt warm not cold or cool. Staff M stated feeling like the resident just passed. During an interview on [DATE] at 11:15 a.m., Staff N, CNA reported helping Resident # 34 to the bathroom around 4:00 a.m. and the only complaint the resident reported was difficulty going to the bathroom. Staff N stated caring for the resident after passing around 5:00 a.m., and described the resident's skin as pale, no other discoloration. Staff N verified obtaining the vitals equipment for the nurse and checking the resident's pulse to verify with the nurse the resident had passed. Review of the Employee file for Staff L included a Basic Life Support card dated [DATE]. The Employee file contained education completed titled Protecting Resident Rights in Nursing Facility dated [DATE] Review of the Admission Packet provided by the facility included Residents Rights dated ,[DATE], directing on page 2 (c)(6) the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive. Review of the facility policy titled CPR Policy and Procedure dated ,[DATE], directed CPR will be initiated when the resident/or legal representative wishes to have CPR initiated and has a Full Code status form on file signed by the physician in the Medical Record. The policy continues, CPR will be initiated if the resident is observed going unresponsive or is found unresponsive, with no respirations and/or pulse. Also if the CPR responder is unable to locate signed documentation for the resident's Code Status, CPR must be initiated unless assessment reveals signs of irreversible death. The Procedure Section of the CPR Policy documents the following: Step 1. Develop a format for communication to alert staff to resident's desire for CPR and those that want comfort care. This need to be an immediate response. Step 2. Resident is witnessed or found unresponsive. Tap on the collarbone and call name for responsiveness. Step 3. Call for help and instruct someone call emergency support ( 911). The CPR policy concludes with the American Heart Association Signs of Irreversible Death as the following: a. Postmortem lividity: When the blood stops flowing, gravity takes over. The Latin term is livor mortis or blue death. Blood settles in the lowest points of the body, which depends on the position the body is in at the time of death. If someone dies in bed, the purple streaks on their backs-similar in color to bruises-will follow the wrinkles in the sheets and show that blood hasn't been circulating for quite a while. Lividity can show up in as little as 15 minutes. b. Postmortem rigidity: There's a reason dead people are called stiffs. Once the last little bit of energy is used up in muscle cells they get stiff until enzymes created through decomposition begin to break them down. The Latin term is rigor mortis or hard death. The chemistry is complicated, but rigidity starts soon after death and lasts for days, depending on heat and humidity.

Based on observation, record review, family, staff, and physician interviews and review of facility policy/procedures, the facility failed to administer medication as prescribed and ordered by the physician for one of four residents reviewed (Resident #1). The facility reported a census of 39 residents. On [DATE] at approximately 5:45 p.m., Staff A administered medications to Resident #1 which were physician ordered for Resident #2. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment, with a reference date of [DATE], which reflected the resident scored a 15 on the Brief Interview for Mental Status (BIMS) test. A score of 15 identified no cognitive problems. On [DATE] at 6:00 p.m. Resident #1 had [DIAGNOSES REDACTED]. A Medication Error Report form identified on [DATE] at 6:00, Resident #1 received another resident ' s medications. The medications received in error were: [MEDICATION NAME] (for fluid retention) 25 milligrams, carvedilol (for elevated blood pressure and heart failure) 6.25 milligrams, sennosides (for constipation), [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram, [MEDICATION NAME] (lowers blood pressure) 40 milligrams, [MEDICATION NAME] (treats [MEDICAL CONDITION]) 300 milligrams and [MEDICATION NAME] (lowers the chance for blood clots forming by increasing clotting time) 4 milligrams. The report indicated the nurse notified the physician of the error and obtained direction. The physician telephone orders revealed the physician directed the nurse to administer no medications for the rest of the day but may give insulin (as ordered). The physician requested the resident ' s blood pressure be taken every 2 hours until morning and then check the blood pressure every 4 hours till [DATE]. If the systolic pressure fell below 100 then to call the physician. The physician ordered a BMP (Basic Metabolic Panel- laboratory test) Review of the blood pressure at 6:15 p.m. identified to be ,[DATE]. At 8:15 p.m., the blood pressure registered ,[DATE]. The Nurses Notes revealed the following on [DATE], following administration of the medications in error: At 10:30 p.m. the resident ' s blood pressure registered ,[DATE]. The resident voiced complaints of her/his right eye not working well. The resident stated must close the right eye to be able to see well. At 11:40 p.m., the resident report he/she is having difficulty with writing with right hand. At 11:58 p.m., the resident activated the call light and staff responded at 11:59 and found the resident lying on the floor in a prone position with head resting on forearms, under the window, near the bathroom door. The resident was determined to be unresponsive, bluish hue to hand and face. CPR (Cardiopulmonary Resuscitation) started immediately. Registered Nurse supervised CPR, oxygen given per nasal cannula, first responders arrived and transported to the hospital at 11:45 p.m. The Emergency Department Report dated [DATE] revealed EMS (Emergency Medical Services) was called and the initial rhythm identified was asystole (no heart beat). The resident was intubated and given [MEDICATION NAME]. After the resident was shocked, he/she gained a pulse. Upon arrival, the resident received [MEDICATION NAME] (medication) for [MEDICAL CONDITION] (low blood pressure). The resident was comatose and unresponsive but in no distress. The Rehab (Rehabilitation) Care Communication to Nursing form reflected Resident #1 returned to the facility on [DATE]. Prior to the incident, the Care Plan identified Resident #1 had a problem with self- care deficit and the approach directed 1 staff person needed to assist with transferring the resident. The care plan did not reflect a mechanical lift was required prior to the incident. The facility Administration of Oral Medications policy, revised on [DATE] identified the following: Purpose- To provide a medication regimen safely and effectively and to administer medications in as simple a route as possible for the resident. Responsibility- Licensed Nurse, Certified Medication Aide. Procedure included- 1. Review medication record for prescribed medications and times of administration. 2. Explain the procedure of mediation administration to the resident. Identify the resident by name and pictures available in the medication record. 3. Wash your hands. 4. Set up the ordered medications for the specific time for which medications are being passed. Compare the medication record to the label on the medicine container. Lock the drug cart, if out of sight. Take the medication to the bedside, or to the resident. Observation on [DATE] at 12:10 p.m. revealed Resident #1 in bed with oxygen on via nasal cannula, bilateral foam boots, bed alarm in place, and call light within reach. The resident had fading bruises to the right eye and chin and a laceration to the right forehead. Two staff transferred the resident from the bed to a wheel chair using the Hoyer mechanical lift. Staff brought the resident to the dining room and then returned the resident to bed at his/her request. The resident had no recall of the fall on [DATE]. During an interview on [DATE] at 4:00 p.m., Resident #2's family member stated the resident had a three week stay at the hospital due to a [MEDICAL CONDITION]. Hospital staff told the resident the medication mix up didn't contribute to the [MEDICAL CONDITION]. In 2011 the resident had a [MEDICAL CONDITION] and a stroke since then that impaired the resident's vision. The resident had been doing well and self- transferring without difficulty. During an interview on [DATE] at 1:50 p.m. Resident #1's primary physician said the error in medications probably was partially responsible for the resident's [MEDICAL CONDITION], it's hard to say. The resident had some pneumonia, and that in conjunction with the additional beta blocker the resident received may have precipitated the event. During an interview on [DATE] the Administrator checked the computerized MAR (Medication Administration Record) and reported Staff A, LPN (Licensed Practical Nurse) signed out medications belonging to Resident #2 and administered to Resident #1 on [DATE] at 5:24 p.m. The Administrator had no information regarding orientation of Staff A. The administrator stated the former administrator orientated new staff without a checklist. Currently, the facility has an orientation checklist form used with new hires. During an interview on [DATE] at 11:27 a.m., the DON (Director of Nursing) reported he/she provided one to one education with nursing staff regarding medication administration and completed audits to ensure correct medication administration procedures. The facility added staff to answer the phone for the first part of 2nd shift, and a zone of silence to reduce distractions for the nurse while passing medications. Since the incident, staff receives an alert on the resident's MAR indicated [REDACTED]. During an interview on [DATE] at 1:45 p.m., Staff A, LPN (Licensed Practical Nurse) reported working the second shift on [DATE]. Staff A stated she didn't know Resident #1 and Resident #2 had room changes, with Resident #1 moving to R wing, and Resident #2 moving to C wing. Staff A stated since she worked at the facility for two years, she knew the residents. Staff A passed C wing medications, and gave Resident #1, currently on R wing, medications belonging to Resident #2, currently on C wing. As soon as she administered the medications, she realized the error and reported it to the DON and called the physician. Now the computerized MAR indicated [REDACTED] During an interview on [DATE] at 3:40 p.m., Staff B, RN revealed she took Resident #1's blood pressure at approximately 10:30 p.m., recorded it at ,[DATE] and decided to check the resident's blood glucose prior to calling the physician, thinking the physician would request it since his/her blood sugars can go very high. Staff B went to the nurses ' station to call the physician, however, had to attend to another resident first. At approximately 10:59 p.m., staff summoned Staff B to Resident #1's room, found the resident unresponsive and they initiated CPR, called 911 and the physician and family. During an interview on [DATE] at 4:00 p.m., Staff C, CNA reported she worked second shift on [DATE], on R wing where Resident #1 resided. During final rounds at approximately 10:30 p.m., the resident appeared fine, had no complaints and no requests. Close to 11 o'clock p.m. the resident's call light went on and Staff C responded, walked into the room and turned off the call light. Staff C found the resident on the floor, attempted to get a response, and called for help. They initiated CPR and continued until the ambulance arrived. Staff C heard the following day that the resident received the wrong medications.