Every finding on record at Lone Tree Health Care Center Inc

Based on clinical record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner following admission to hospice care for 1 of 2 residents reviewed (Resident #10). The facility reported a census of 33 residents. Findings include: The Clinical Census for Resident #10 revealed an admission date to hospice on 7/18/25. The MDS dated [DATE] for Resident #10 revealed it was a significant change assessment and the resident entered hospice care within the last 14 days. On 11/19/25 at 11:35 AM the Administrator confirmed a significant change MDS had not been completed within 14 days as she would have expected following Resident #10's admission to hospice care. The Administrator further revealed the facility did not have a specific policy/protocol related to completion of a significant change MDS as they follow the Resident Assessment Instrument (RAI) manual.

Based on clinical record review, policy review and staff interview, the facility failed to report an allegation of potential financial exploitation to the State Agency for 1 of 14 residents reviewed (Resident #33). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #33 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognition impairment. The MDS further revealed the resident did not have behavioral symptoms and did not have any psychiatric/mood disorders. The Care Plan initiated 8/25/25 revealed Resident #33 had an activities of daily living (ADL) deficit and required assistance from staff with toileting and transferring. Review of Progress Notes dated 8/23/25 at 9:45 AM for Resident #33 revealed she had been asked by staff if she would like to have her money placed in a lock box and she had refused. The Progress Notes further revealed the resident had declined to offer the amount of money she had in her possession and had stated she had enough. Review of Progress Notes dated 8/23/25 at 9:10 PM revealed both Power of Attorneys (POAs) reported to the nurse that Resident #33 had $350 cash in her room and it was now missing. Staff searched the room and cash was not found. The POAs had stated it was a sore lesson learned for their sister because she had not allowed staff to lock up all the money. The POA had reported the resident had given staff $90 to lock up but the resident initially had $350. On 11/19/25 at 3:28 PM, the Administrator revealed she did not report the allegation of missing money to DIAL because the sister could not confirm Resident #33 had actually been missing money as the amount missing had changed. During an interview 11/20/25 at 9:25 AM, Staff A, Certified Nurse Assistant (CNA) reported on 8/23/25 one of Resident #33's sisters had reported the resident had money that needed to be locked up so Staff A notified the nurse who had placed the money in a lock box. Staff A reported when she came back to work on 8/25/25 one of the sisters had reported to her later in the day that the resident had money missing. Staff A reported she notified a nurse of the missing money but she could not recall who she had notified. Review of undated facility policy titled, Lone Tree Health Care Center Policy And Procedure On Abuse Prevention And Identification, revealed misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Any staff member will immediately report to the administrator any alleged violation(s)concerning mistreatment, neglect, abuse, including injuries of unknown source, or misappropriation of resident property, or sexual abuse. The administrator will then report these allegations to the appropriate authorities.

Based on clinical record review, staff interviews, and facility policy review the facility failed to provide the tube feeding (TF) according to the physician's order individualized to the resident for 1 of 1 residents reviewed with tube feeding sampled (Resident #3). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #3 dated 10/20/23, listed diagnoses of malnutrition, anemia, and heart failure. The MDS identified Resident #3's Brief Interview for Mental Status (BIMS) score of 9 out of 15, moderate cognitive impairment. The MDS identified Resident #3 received a tube feeding. The Care Plan for Resident #3 dated 11/1/23, reflected Resident #3 required a tube feeding related to swallowing problems, stricture. The Care Plan directed she needed assist of 1 nurse with tube feeding and water flushes. See the Physician's order for current feeding orders. The Medication Administration Record (MAR) dated 12/2023, directed enteral feeding (tube feeding), Bolus feeding 240 millimeters (ml) five times a day (6 AM-6 PM) flush with 30 ml of water before and after. The Progress Notes dated 12/16/23 at 7:20 PM, reflected staff called the nurse to Resident #3's room, a Certified Nurses Aid (CNA) stated Resident #3's clothes and tube feeding site were soaked. Upon assessment staff found the tube leaked residual. More than 850 ml of residual drained from tube and more came. Vital signs stable, resident denied pain or discomfort. Placed a call to the resident's family, who wanted her sent to the hospital. Call placed to the physician and received an order to send Resident#3 for evaluation and treat at the hospital. The hospital record titled Anteroposterior (AP) (related to or directed toward both front and back) Spine dated 12/16/23, identified the indication for the exam concern for gastric outlet obstruction. PEG (tube feeding port) large volume of gastric content after feeding for 2 days. The impression listed they failed to find evidence for gastric outlet obstruction. The hospital After Visit Summary dated 12/17/23, revealed the feeding seemed to be functioning appropriately. It directed staff to be cognizant of the rate of the PEG tube feeding, the patient will likely do better with administering the volume of feeding slowly over several minutes as opposed to a quicker bolus. The MAR dated 12/17/23, ordered to give feeding slower over several minutes. On 4/11/24 at 10:58 Staff B, Registered Nurse (RN) revealed Resident #3 TF site leaked out fluid, she said that happened for a couple days. She revealed she would pour her feeding with the water, so it would go faster. She stated the Physician told the family not to add the water to the feeding, it made it too thin, and the feeding needed to go in more slowly. On 4/11/24 at 12:57 PM, Staff A, Licensed Practical Nurse (LPN) reported she follows the Physician's Order to administer a TF. She stated flushing before and after the feeding with water. She reported she's added water to the feeing when it ran too slow to thin it out. On 4/11/24 at 3:20 PM, the Assistant Director of Nursing (ADON) stated the nurses may add some water to the feeding, it may be plugged. She confirmed the policy directed to follow the Physician's Order's. The facility provided a policy titled Enteral Feeding (tube feeding) undated, it directed to flush the tube with at least 30-50 cubic centimeters (cc) one time per shift unless otherwise ordered. Before and after medications, flush with 30-50 cc of water. Flushing helps to loosen formula from sticking to the inside of the tube. After verifying correct tube placement, draw up 30-50 cc of water into syringe and flush tube using a moderate rate and constant pressure. The policy continued to initiating the feeding, Bolus method: Remove the plunger or the bulb from a catheter tip syringe. Attach syringe to end of tube and elevate to 18 inches. Pour the ordered amount of formula into the syringe per physician order. Let the formula run in slowly by gravity. To prevent air from getting into the stomach, add more formula to syringe before it empties. Adjust the height of the syringe to a lower position to run slower. Make sure the formula is at room temperature. It should take about 15 - 20 minutes to complete the feeding. After the feeding is complete, flush tube to prevent clogging.

Based on clinical record review,staff interviews, and facility policy review the facility failed to complete a Comprehensive Care Plan for 1 of 12 residents in the sample (Resident #3). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], listed diagnosis for Resident #3 included: Type 2 diabetes, fracture of left femur, and cardiac arrhythmia (irregular heart beat). The MDS assessed the two weeks prior the resident exhibited symptoms of feeling tired or having little energy, feeling bad about self/letting others down, and trouble concentrating on things 12-14 half or more of the days. And little interest/pleasure in doing things, feeling down/depressed/hopeless, and moving or speaking so slowly others have noted in 7 to 11 half or more days. The MDS listed the Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognition intact. A review of the Electronic Health Record (EHR) revealed a Physician Order, dated 5/2/22, for sertraline (antidepressant) 50 milligram (mg) tablet, give 1.5 tablets by mouth once a day for depression. A review of the Order Summary Report, with active orders as of 6/19/23, lacked documentation of a depression diagnosis. The Care Area Assessment (CAA) dated 5/2/23, indicated a trigger in the area of Mood State A review of the Care Plan, revealed a lack of a focus area on mood. During an interview on 6/21/23 at 11:17 AM, the MDS Coordinator stated if a resident is prescribed medication for depression this needs to be reflected in the Care Plan. After reviewing the residents plan in the EHR, the MDS Coordinator agreed the diagnosis is not listed for the resident and the Care Plan lacks the service area need for depression. During an interview on 6/21/23 at 11:23 AM, the Director of Nursing (DON) stated if a resident is prescribed an antidepressant she would expect the diagnosis listed and addressed on the Care Plan. A facility policy, dated 12/2016, titled Comprehensive Care Plan, Procedure Section #3 explained the Comprehensive Care Plan will be developed within 7 days after the completion of the Comprehensive MDS Assessment. The CAA's triggered by the MDS will be [the] basis for developing the Plan of Care.

Based on clinical record review, staff interview and facility policy review, the facility failed to revise/update the Comprehensive Care Plan after a resident experienced a significant change; and another resident had a fall for 1 of 12 residents (Resident #3). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], listed diagnosis for Resident #3 included: Type 2 diabetes, fracture of left femur, and cardiac arrhythmia (irregular heart beat). The MDS assessed the resident required extensive assistance of two staff for: bed mobility, dressing, and toilet use; and extensive assistance of one for dressing, and personal hygiene. The resident required total dependence for: transfers, and locomotion on unit and off the unit. Walking did not occur. The MDS listed the Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognition intact. The 5/2/23 MDS completed due to a significant change and identified as a Comprehensive Assessment. A review of the Electronic Health Record (EHR) revealed the resident fell on [DATE] which resulted in a fracture to her left femur. Prior to the fall, the MDS, dated [DATE], assessed the resident required limited assistance of one staff for bed mobility, dressing, toilet use and personal hygiene. The resident identified as independent for transfers, walking, and locomotion. A review of the Care Plan revealed an Activities of Daily Living (ADL) deficit for the resident, with the resident listed as independent for bed mobility, personal hygiene, toilet use, and transfers. Walking addressed under the ADL deficit care area. During an interview on 6/21/23 at 11:17 AM, the MDS Coordinator stated a Care Plan should be updated within 24 hours after a significant change is identified. The MDS Coordinator stated all changes are made in the EHR. The MDS Coordinator stated after the significant change the resident's Care Plan should have been updated to note the change in level of assistance needed for ADL's. A facility policy, dated 12/2016, titled Comprehensive Care Plan, Procedure Section, #6 directed staff to review and revise the Care Plan after each Comprehensive and Quarterly MDS.

Based on clinical record review, Menu review, observations and staff interview the facility failed to ensure foods were pureed to ensure appropriate portion size for two of three residents who received a pureed diet (Residents #9 and #17). The facility reported a census of 38 residents. Findings Include: Review of the Diet List revealed two residents, Resident #9 and Resident #17, received a pureed diet. The Physician Order for Resident #9 dated 8/24/22 documented, Regular diet pureed texture, regular consistency, thin liquids as tolerated with supervision. The Physician Order for Resident #17 dated 4/27/20 documented, Regular diet pureed texture, regular consistency, regular liquids. May have finger food per resident preferences. Review of the Menu for the noon meal for Week 2 Tuesday revealed the regular diet included #8 scoop of sweet pepper slaw. The mechanical soft diet included 4 ounces of steamed cabbage. The puree included 1 serving of puree sweet pepper slaw. Observation of the puree process for the lunch meal on 6/20/23 at approximately 10:30 AM, revealed Staff B, Cook puree cabbage slaw. Per Staff B, there were one and a half cups of cabbage slaw. Staff B pureed the cabbage slaw. Staff B explained there were two regular servings and one half serving. Staff B used a #16 scoop, which equaled two ounces, and scooped three full scoops, which would equal six ounces, into one dish. Staff B scooped just about one scoop into the other dish. Review of a chart from the facility's food vendor revealed for 3 servings and one and a half cups of total pureed food, a #8 scoop would be utilized. Also per the chart, a #8 scoop would equal four ounces, while a #16 scoop would equal two ounces. On 6/20/23 at 1:56 PM, the Dietary Manager acknowledged for the cabbage slaw the regular puree would be the four ounce, and that would be the gray #8 scoop. Per the Dietary Manager, the half portion would be the #12 scoop. The Dietary Manager acknowledged the wrong scoop was utilized. The Facility Policy titled Pureed Foods, undated, documented, in part, the following: 1. Place the number of servings (portions according to menu) in the blender. Weigh or measure prior to blending 3. Divide blended food into the number of dishes to serve the exact number of pureed diets so each serving matches that written on the menu. Volume may increase with the addition of liquid.

Based on clinical record review, staff interviews and facility policy review, the facility failed to screen residents for eligibility of the pneumococcal vaccine for 1 of 5 residents reviewed. (Resident #30). The facility reported a census of 38 residents. Findings include: Review of the Facility's Immunization Report revealed Resident #30 had unknown status for the pneumococcal vaccination, and documented the following admitted [DATE]. During an interview on 6/22/23 at 11:30 AM, the Infection Preventionist (IP) stated all residents' influenza, pneumococcal and COVID-19 vaccination status should be updated in the Electronic Health Record (EHR). When queried about the status of pneumococcal vaccination for Resident #30, the IP stated there is no documentation of the resident having had the vaccination or being offered the vaccination and declining. During an interview on 6/22/23 at 11:40 AM, the Director of Nursing (DON) stated resident immunizations are tracked at admission. The DON stated during Resident #30's admission the family informed the facility they did not know his medical history and had few records. The DON stated if there is no documentation in the resident's EHR then the status is unknown. The DON stated she does not know if the resident was offered the vaccination. The undated Facility Policy, titled Pneumococcal Pneumonia Vaccination Procedure section under General #3 documented the pneumococcal immunization status of all residents will be determined on admission. Residents currently residing in the facility will have their immunization status determined by reviewing available past and present medical records. Residents for whom the immunization status is unknown or unsure will be offered the vaccine.

Based on record review, staff interviews, and facility policy review, the facility failed to educate staff on the benefits of the COVID-19 vaccination and provide information on obtaining the vaccination. Findings Include: The facility presented a list of facility staff that documented staff vaccination status. On the list is a handwritten highlighted [yellow] = not vaccinated notation. During an interview on 6/22/23 at 12:45 PM, the Administrator stated the list is used to track staff COVID-19 vaccination status. The list revealed a total of 54 staff, with 11 highlighted to indicate not vaccinated for COVID-19. During an interview on 6/22/23 at 10:20 AM, the Infection Preventionist (IP) stated the Business Office Manager (BOM) completes a surveillance of staff COVID -19 vaccination status at hire. The IP stated employees can be employed without a COVID vaccination, and since May 2023 do not need an exemption. She added, if they are not going to get the vaccination they need to complete a declination. When queried about coordination with the BOM about staffs COVID vaccination status the IP stated she is not connected to the business office, and does not know who is vaccinated or not. The IP stated there should be a process in place so this is known. During an interview on 6/22/23 at 10:47 AM, the BOM stated at hire she asks each staff if they are vaccinated or not. The BOM stated the staff are asked to sign an undated form to indicate their COVID-19 vaccination status. The form provides two choices for staff to sign: a. I agree to receive the COVID-19 vaccine within 90 days of employment. I will be responsible to get any subsequent doses. OR b. I have received my COVID -19 vaccine. The BOM stated if the staff do not want to get vaccinated they are asked to complete and sign an undated form titled Vaccination Exemption Request. The BOM stated the form is completed,reviewed and approved the same day so the staff can start work immediately. When queried about providing education about the COVID-19 vaccination, the BOM stated I do not feel it is my job to give people medication advice, everyone knows about the vaccination as it has been out there for so long, it is common knowledge at this point. When queried about giving staff information about where they can get vaccinated, the BOM stated she assumes staff can get vaccinated at the facility. She stated she does not give out information on where to get a vaccination, but would if a staff member asked. During an interview on 6/22/23 at 10:56 AM, the Director of Nursing (DON) stated the facility can provide COVID -19 vaccinations. The DON stated she would arrange for the consulting Pharmacy to come on sight and provide the vaccination. The DON stated she had not been asked or informed there were staff who want to receive the COVID-19 vaccination. The facility policy, titled COVID 19 Policy and Procedure lacked direction for staff vaccination related education, information on where/how to get the vaccination or completing a declination.

Based on observation, staff interview, and clinical record review, the facility failed to ensure 1 of 1 residents reviewed(Resident #5) received routine dental care. The facility reported a census of 26 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment, dated 12/21/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident's cognition as moderately impaired and stated the resident required extensive physical assistance of one staff for personal hygiene. On 3/16/22 at 11:30 AM, observed Staff A, Certified Nursing Assistant (CNA) assisted the resident with morning cares. Staff A did not assist or offer to assist the resident with oral cares. After the observation, Staff A stated that the last time staff assisted the resident with oral care was 3/15/2022. A Care Plan entry, dated 6/17/19, directed staff to assist the resident with oral care. A 3/11/22 Speech Therapy Note stated the resident had poor oral care. The resident's Clinical Record lacked documentation of Dental Services. During an interview on 3/16/22 at approximately 4:00 p.m., the Director of Nursing (DON) stated the facility did not have documentation the resident received Dental Services during her stay. During an interview on 3/17/22 at 11:20 AM, the DON stated the facility failed to have a process in place for routine Dental Care. She added the families of residents typically assisted with dental appointments. The DON stated the facility attempted the use of a Consulting Dentist, however that was not successful due to their small census. The DON stated that she did not know the facility was responsible for the provision of dental services.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure staff carried out safe practices of medication administration for 1 of 8 residents reviewed for medications (Resident #128). The facility reported a census of 26 residents. Findings Include: 1. The MDS(Minimum Data Set), dated 10/12/21, documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 8/9/2021 Incident Note stated Resident #128 took Resident #127's medications while the Certified Medication Assistant (CMA) assisted Resident #127 in the bathroom. Resident #127's August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An untitled facility document, dated 8/10/21, stated the facility retrained Staff B, CMA regarding the importance of never leaving medications unattended. The form directed Staff Nurses to ensure CMAs observed residents taking medications. A facility Medication Administrating Monitoring Form, dated 8/11/21, stated the facility monitored Staff B for the correct procedure for the administration of medications. During an interview on 3/17/22 at 11:22 a.m., Staff C, Certified Nursing Assistant (CNA) stated she observed unattended medications. She stated she observed this as recent as the week before the survey started. During an interview on 3/17/22 at 11:43 a.m., the Director of Nursing (DON) stated Resident #128 took Resident #127's medications. She stated Staff B, CMA had Resident #127's medications ready and he looked like he was going to fall and while she assisted him, Resident #128 took Resident #127's medications. During an interview on 3/17/22 at 12:32 p.m., Staff B, CMA stated on the night of the medication error, she walked in the room with Resident #127's medications. She stated she sat the medications down on the bedside table in order to turn down the resident's bed and Resident #128 took the medications. She stated at the time, Resident #127 was in the bathroom with 2 CNAs and the error was not related to Resident #127 almost falling. During an interview on 3/17/22 at 1:06 p.m., the Administrator stated Staff B turned her back to prevent Resident #127 from falling and during that time period Resident #128 took Resident #127's medications.

Based on facility policy, record review and staff interviews the facility failed to provide interventions consistently before giving a resident an as needed (PRN) anti-anxiety medication. The facility also failed to obtain a doctor's order for a fourteen day limit for an anti-anxiety medication, for one of one residents reviewed for PRN anti-anxiety medications. The facility reported a census of 33 residents. Findings include: The Drug Regimen Review Policy dated 2/16 documented that as needed (PRN) order for [MEDICAL CONDITION] drugs are limited to 14 days unless the attending physician or prescriber believes that it is appropriate for the PRN order and indicates the duration of the PRN order. The Policy documented further that [MEDICAL CONDITION] medication is any drug that affects brain activities associated with mental process and behavior; these drugs include but are not limited to drugs in the following categories; Antipsychotic, Anti-depressant, Anti-anxiety, and Anti-hypnotic. Policy titled Administration of Antipsychotic Medications Ordered PRN dated 1/2021: directed staff as follows; Order may not extend beyond the 14-day limit. At least three interventions must be tried prior and there needs to be documented evidence. The Quarterly Minimum Data Set (MDS) Resident assessment dated [DATE] documented Resident#3 with the following [DIAGNOSES REDACTED]. The MDS documented the resident with short and long term memory loss, and that physical behavior directed towards others occurred 1-3 days a week. Medication Administration Records dated 12/01/20 to 1/31/21 documented that the resident had been given PRN [MEDICATION NAME] (an anti-anxiety medication) 0.5 milligrams nine times after the date of 12/29/20. The start date had been documented as 12/15/20. The Medication Administration Record [REDACTED]. The Nurses Progress Notes dated 12/29/20 to 1/05/21 lacked documentation of interventions prior to the PRN [MEDICATION NAME] medication administration. During an interview on 1/06/21 at 2:20 p.m., Staff A, Licensed Practical Nurse (LPN) reported that you should do three interventions prior to giving PRN anti-anxiety and antipsychotics. During an interview on 1/06/21 at 1:56 p.m., Staff R, Registered Nurse (RN) reported that you should do three interventions prior to giving PRN anti-anxiety or antipsychotic medication.

The following deficiency relates to intake -A. Based on record review and staff interviews the facility failed to ensure residents remain free from significant medication errors. (Resident #1) The facility reported census was 35. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a brief interview for mental status (BIMS) score of 4 indicating a severely impaired cognitive status. Resident #1 required supervision to limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. In an interview on 7/9/19 at 9:30 a.m., Staff A, Certified Medication Aide (CMA), stated on the morning of 4/14/19, the nurse was running behind with passing medications and Staff A offered to help. Staff A stated at around 10:30 a.m. she was popping out the morning medications for Resident #2 in a medication cup on the medication cart while Staff B, Registered Nurse was setting up the medications for Resident #1 also in a medication cup. Staff A stated a resident approached her stating Resident #1 was attempting to get up unassisted. Staff A stated she grabbed what she believed was Resident #1's medications and went to his room. As Staff A handed the pills to Resident #1, she realized there were too many and immediately attempted to get Resident #1 to spit them out, but Resident #1 refused. Staff A immediately went back up to the medication cart and informed Staff B. Staff B stated she went back down to Resident #1's room and checked his vital signs and then brought him up to the nurse's station where he could be more closely monitored. At 11:30 a.m. Resident #1 was sitting in the dining room when he started to become increasingly lethargic and they called an ambulance. Staff A stated Staff B was involved in observing and assessing Resident #1. In an interview on 7/9/19 at 9:57 a.m., Staff B, RN stated on the morning of 4/14/19 she was the charge nurse and assigned to pass medications. Staff B stated she was hired on 4/8/19 and this was one of the first times she was passing medications and noted she was not familiar and slow. As she was getting behind, Staff A offered to help and together they were setting up medications at the medication cart. Staff B stated she was setting up medications for Resident #1 while Staff A was setting up medications for Resident #2. At some point they had both become distracted and while Staff B was not watching, Staff A grabbed Resident #2's medication cup and took it to Resident #1's room. Staff A returned and stated I think I just gave the wrong meds to Resident #1. Staff B stated she looked at the remaining medication cup on the medication cart and confirmed the medications left were Resident #1's and Staff A had given Resident #2's medications in error. Staff B stated Staff A went back to Resident #1's room and checked his vital signs at about 10:45 a.m. and then brought him to the nurse's station. Staff B stated she gave Resident #1 his routine medications which were not duplicates from Resident #2's medications. Staff B stated the [MEDICATION NAME] was also held from Resident #1's supply and the remaining routine medications were destroyed. Staff B stated vitals checked at 11:25 a.m. were fine, but by 11:30 a.m. Resident #1 was sitting at a dining room table with his shirt pulled up, eyes open, drooling and unresponsive. Staff A stated she called an ambulance and had Resident #1 sent out. Staff B stated a physician was notified shortly after Resident #1 was sent to the emergency room . According to Resident #2's Medication Administration Record [REDACTED]. These were the medications given in error to Resident #1. According to the hospital discharge summary Resident #1 was a admitted with [MEDICAL CONDITION] (low blood pressure) related to medication. Resident #1 was apparently given another resident's blood pressure medication. Resident #1 only receives [MEDICATION NAME] 50 milligrams, but this morning received [MEDICATION NAME] 100 milligrams, [MEDICATION NAME] 5 milligrams and [MEDICATION NAME] 90 milligrams. In the emergency room resident was given 1 liter of fluid, 3 doses of [MEDICATION NAME], 1 dose of calcium chloride and 2 micrograms per minute of [MEDICATION NAME] ([MEDICATION NAME]). Poison control was notified. Admitting blood pressure 80/60 and pulse 90 beats per minute. EKG (electrocardiogram)showed sinus [MEDICAL CONDITION](elevated heart rate) with type 1 AV (atrioventricular) block. Resident was stabilized and remained overnight for observation. Resident #1 remained hospitalized 24 hours and returned to the facility the next day.

Based on observation, record review, policy review and staff interviews the facility failed to ensure that care plans were updated for 5 of 14 residents reviewed (#10, #21, #27 #32, and #286). The facility reported a census of 34 residents. Findings include: 1 The Minimum Data Set (MDS) for Resident #10 with a completion date of 2/1/19 listed [DIAGNOSES REDACTED]. The MDS documented a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated no cognitive impairment. The MDS documented that the resident needed extensive assist of two people for transferring and toilet use and Extensive assist of one person for bed mobility and dressing. During an observation on 3/27/19 at 7:20 AM, Resident was in bed with bilateral upper bed rails in the upright, (in use) position in bed. Review of the care plan revealed lack of documentation regarding bed rails. The facility failed to address the use of bed rails on the care plan. 2 The MDS for Resident #21 with a completion date of 2/22/19 listed [DIAGNOSES REDACTED]. The MDS documented a BIMS summary score of 09 which indicated moderate cognitive impairment. The MDS documented that the resident needed extensive assist of two people for bed mobility and transferring and total dependence of two people for dressing. During an observation on 3/27/19 at 7:22 AM, Resident was in bed with bilateral upper bed rails in the upright, (in use) position in bed. Review of the care plan revealed lack of documentation regarding bed rails. The facility failed to address the use of bed rails on the care plan. During policy review of Bed Rails/Side Rails Policy dated 11/2018. The policy revealed that the use of bed rails/side rails were to be addressed on the residents plan of care. During an interview with the DON on 3/27/19 at 01:38 PM she revealed that she would expect bed rails to be on the care plan. 3. In review of Resident #27 MDS dated [DATE] showed resident with a BIMS of 10 indicating moderately impaired cognition. Resident MDS [DIAGNOSES REDACTED]. In review of Physician order [REDACTED]. In review of [DIAGNOSES REDACTED]. In review of progress notes date 3/13/19 showed resident transferred to the hospital related to self-harm behaviors and returned to facility on 3/22/19. In review of care plan with initiation date of 2/7/19 showed no Focus, Goals or Interventions to specifically address Anti-depressant medication use and side effects, Anti-psychotic medication use and side effects, Target Behaviors related to Dementia or Target Behaviors related to self-harm behaviors. In an interview on 3/27/19 at 9:57 AM with DON agreed that Resident #27 care plan did not address use of [MEDICAL CONDITION] medications, target behaviors, dementia interventions or behaviors to observe for post hospitalization and those items should be on Resident's care plan. 4. In review of Admission Record for Resident #286 showed an admission date of [DATE] with a primary [DIAGNOSES REDACTED]. In an observation on 3/26/19 at 2:29 PM showed resident sitting in wheelchair beside bed. Resident's bed observed with both upper bed rails in the upright, in use, position. In an observation on 3/27/19 at 6:51 AM showed resident sleeping in bed with both upper bed rails in the upright, in use, position. In review of [DIAGNOSES REDACTED]. In review of Baseline Care Plan dated 3/18/19 showed resident did not use side rails on bed. In review of Nursing Admission Screening dated 3/18/19 showed no use of side rails on bed. In review of Bed Rail Consent showed Resident signed consent for use of upper half rails as a boundary marker or positioning device on 3/18/19. In review of Bed Rail assessment dated [DATE] showed Resident requested use of bed side rails to reposition self in bed with an intervention of half side rails per Resident request. In an interview on 3/27/19 at 9:52 AM with DON agreed use of bed rails for Resident #286 is not listed on Baseline Care Plan or on the Nursing Admission Screening which DON stated is used as part of the care plan upon admission until the comprehensive care plan is completed. DON stated the use of bed rails should be on the Resident's plan of care so staff is aware of their use. 5. A Minimum Data Set ((MDS) dated [DATE] for Resident #32 listed [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one person for bed mobility, transfers and ambulation and total dependence on one staff for dressing and toileting. The MDS identified the resident as being frequently incontinent of bladder and occasionally incontinent of bowels. A Brief Interview for Mental Status score of 7 indicated moderate cognitive impairment for decision-making. A record review of an incident description documented the resident had fallen on the following dates: 1/5/19-5:55 A.M.-found lying on the floor next to the bed-no new intervention added to the care plan. 1/9/19-6:24 A.M.-resident lying on the floor. Stated he was walking back to his chair from the bathroom and slipped on a blanket. No new intervention added to the care plan. 1/29/19-7:30 A.M.-resident on the floor on knees next to the bed. Stated he fell out of bed. No new intervention added to the care plan. 2/12/19-6:55 A.M.-found sitting on the floor in front of the recliner in room. Stated slid out of the recliner. No new intervention added to the care plan. 2/16/19-6:53 A.M.-found on floor in front of the recliner with gripper socks on. Stated he tried to get up himself and slipped. No new invention added to the care plan. 2/23/19-2:24 A.M.-found lying on back by recliner. No new intervention added to the care plan. Review of a document labeled Morse Fall Scale dated 3/3/19 documented a score of 55. A Fall Risk score of greater than 45 indicated high risk for falls. Review of a care plan with an initiation date of 11/20/18, revealed a focus area of resident is at risk for falls related to deconditioning, gait/balance problems, incontinence. Unaware of safety need. Last revised on 12/12/2018. Interventions added with the last revision date of 12/12/18 were: A. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. B. Ensure the resident is wearing appropriate footwear when ambulating. C. Resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, side rails as ordered, hand rails on walls, personal items within reach. No further revisions regarding fall prevention strategies. The resident has had 7 falls with no injury since the last care plan revision. During an interview on 3/27/19 at 12:45 P.M. with the Director of Nursing (DON) and the Administrator, both stated the expectation is that care plans be updated with changes in resident conditions and that an intervention is added to the plan of care after every fall.

Based on observation, record review, policy review and staff interviews the facility failed to ensure nursing assessments for bed rails were completed for 2 of 14 residents reviewed (#21 and #27). The facility reported a census of 34 residents. Findings include: 1 The Minimum Data Set (MDS) for Resident #21 with a completion date of 2/22/19 listed [DIAGNOSES REDACTED]. The MDS documented a Brief Interview for Mental Status (BIMS) summary score of 09 which indicated moderate cognitive impairment. The MDS documented that the resident needed extensive assist of two people for bed mobility and transferring and total dependence of two people for dressing. In review of Bed Rails/Side Rails Policy dated 11/2018, the policy documented if the resident or representative requested to use bed rails, the Bed Rail Assessment would be completed as part of the comprehensive assessment. Resident #21 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The Bed Rail Assessment was completed on 3/27/19. An interview on 2/27/2019 at 3:10 PM, Staff A, MDS Coordinator stated she had not had enough time to get the Bed Rail Assessments completed. During an interview with Staff A, on 3/27/19 at 03:47 PM, she stated that a bed rail assessment should be done upon initial admission, which is the day they come in, and then every 90 days after that. The facility failed to complete a Bed Rail Assessment upon admission to the facility. 2. In review of Resident #27 MDS dated [DATE] showed resident with a BIMS of 10 indicating moderately impaired cognition. MDS showed resident independent with bed mobility, transfers, walking in room and walking in corridor. [DIAGNOSES REDACTED]. In review of Care Plan with an initiation date of 2/7/19 showed resident with half side rails for safety during care provision, to assist with bed mobility and to observe for injury or entrapment related to side rail use. In review of documentation showed no bed rail assessment completed on resident for current admission at facility. In an observation on 3/25/19 at 2:50 PM showed resident bed with upper bed rails in the upright, in use, position. In an observation on 3/27/19 at 6:53 AM showed resident in bed with both upper bed rails in the upright, in use, position. In an interview on 3/27/19 at 9:57 AM with Director of Nursing (DON) stated facility does not have a bed side rail assessment for resident's current admission to facility. DON agreed a new bed side rail assessment should have been completed for this resident.

Based on clinical record review and staff interview, the facility failed to submit Minimum Data Set (MDS) with Registered Nurse (RN) signature of completion for three of four residents reviewed (Resident #2, #27 & #287). The facility census was 34 residents. Findings include: 1. The minimum data set (MDS) assessment dated [DATE], documented Staff A, licensed practical nurse, signed under the registered nurse section for completion of the MDS for Resident #2. 2. The MDS assessment dated [DATE], documented Staff A, LPN signed under the registered nurse section for completion of the MDS for Resident #27. 3. The MDS assessment dated [DATE], documented Staff A, LPN signed under the registered nurse section for completion of the MDS for Resident #287. During interview on 3/27/19 at 11:32 a.m., Staff A confirmed it was her electronic completion signature on MDS for the three residents.

Based on staff and public interviews and review of policy/procedures, the facility failed to report to the Iowa Department of Inspections and Appeals of an alleged resident abuse in the form of electronic pictures taken on an employee cell phone and then shared on social media (Snapchat). The facility failed to seperate and thoroughly investigate the allegation in order to prevent further residents from abuse. The facility reported a census of 33 residents. Findings include: 1. On 11/02/16 at 9:45 a.m. a Certified Nurses ' Aide (CNA) instructor reported that students approached her about two inappropriate Snapchats that were taken at the facility. The instructor reported the content of the Snapchats were inappropriate enough to make her call the Lone Tree facility Administrator immediately. On 11/02/16 at 10:29 a.m. the instructor was interviewed and reported the CNAs in the Snapchat were making fun of the residents, but they could not identify neither staff nor residents in the Snapchat. On 11/02/16 at 2:19 p.m. Staff K, CNA was interviewed and stated she worked mostly the second shift (2:00 p.m. to 10:00 p.m.). Staff K reported sometimes in the summer, she and Staff J, CNA sat in the dining room during their second shift dinner break from 6:30 p.m. to 7:00 p.m. Staff K stated she took a Snapchat of Staff J eating her dinner, and did not believe that anyone else had been in the picture. Staff K stated she never took Snapchat pictures of residents before. Staff K stated she did not send it to anyone, but put it on her story, which anyone who are her friends could view the picture. Staff K stated she had all the CNAs as friends on Snapchat. Staff K stated the Administrator called her into her office the next day and disciplined her for taking the Snapchat picture. Staff K stated the facility provided a mandatory in-service the next week about the usage of cell phones and staff were instructed to leave their cell phones in their cars or at home. On 11/01/16 at 12:38 p.m. Staff J, CNA was interviewed and stated during the summer time while on second shift dinner break at about 6:30 p.m. to 7:00 p.m. Staff K sat next to her at the dining room table. Staff J stated some residents were sitting next to the nurse ' s station and in view of the dining room area. Staff J stated she could not remember who the residents were. Staff J stated Staff K Snapchated a video of her. Staff J stated a student from the CNA course told her she reported the Snapchat to her instructor. Staff J stated the Administrator called her into the office about the Snapchat event. During an interview on 11/07/16 at 8:51 a.m. Staff J, C.N.A stated no staff were removed from their duties. On 11/3/16 at 1:04 p.m., Staff B, CNA was interviewed and stated the Administrator called her into her office about a Snapchat video taken at work with residents in the video pictures. Staff B stated she did not see the video and she had nothing to do with the video. Staff B stated an in-service was held more than a week later. Staff B stated no staff were separated from residents during the investigation. On 11/02/16 at 10:02 a.m. the facility Administrator was interviewed and stated she first heard about a Snapchat of residents taken on 6/02/16 by a call from a nurse aide instructor and an anonymous caller. The Administrator stated she never saw the Snapchat pictures. The Administrator stated the anonymous caller identified the staff involved. The Administrator stated she was told the pictures contained pictures of a bathroom, no naked residents and a resident laughing. The Administrator stated she spoke with her supervisor and legal counsel and directed to not identify the concern to the Iowa Department of Inspections and Appeals. The Administrator stated the staff involved brought in their phones, however, could not obtain the Snapchat. The Administrator reported she conducted an in-service on 6/6/16. The in-service directed the staff to not have their cell phones in the building when working. The Administrator stated the facility had a cell phone policy/procedure prior to this event. The Abuse Prevention, Identification, Investigation, and Reporting Policy dated 5/16 identified all residents have the right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility policy and procedures directed the Administrator or designated agent as responsible for forwarding the results of the investigation to the Department of Inspections and Appeals. This written report shall be forwarded to the department within 5 days of the initial report. If the investigation by the facility determines that the alleged abuse or any accident has resulted in major injury to a resident, the Administrator, Director of Nursing or designated representative shall notify the Department of Inspections and Appeal within twenty-four hours or the next business day. The administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident. The investigation portion of the policy directed the Administrator or designee to interview the person(s) reporting the incident and the alleged perpetrator and document witness statements, interview all witnesses to the incident and document all witness statements, interview all staff members on all shifts who have had contact with the resident(s) during the period of the alleged incident. The Abuse Check-List dated 11/15 directed the Administrator to complete the following within 12 hours; have all pertinent people ben interviewed with review of the schedule and evaluate, review the investigation findings with at least one key management/consultant, had disciplinary action been initiated with the alleged perpetrator, written report to Department of Inspections and Appeals. The facility did not provide written documentation of any staff interviews, resident interviews, or family interviews of this allegation of abuse. The Administrator provided the disciplinary action of the 3 CNAs. The facility Administrator provided an unsigned typed synopsis of the allegation and interviews with the facility legal counsel. During an interview on 11/03/16 at 2:22 p.m. the facility Administrator reported she did not feel anything else could have been done on the Snap- chat investigation, because there were no residents identified, and there was no pictures to review. The Administrator confirmed an allegation of abuse should be reported within 24 hours to the Department of Inspections and Appeals. The policy and procedure titled Cell Phone Usage Policy and posted date of 12/22/15 directed the staff not to have cell phones on your person when working. Your phone must remain in your car or purse and not with you when working. If you are on break it is fine to use your phone otherwise you should not be texting, answering, using or playing games on you while you are working. Any exceptions to this policy may only be made by the administrator. If you have or are waiting on a call please tell the sender to call the facility phone number. You could also ask them to just leave a message on your phone. I continue to hear that staff are playing on their phone while working rather than doing their job. If you have to go into an empty room or check it under the dining room table to use your phone that tells me that you know better. During an interview on 11/08/16 at 10:00 a.m. the Administrator stated she had no further paperwork to provide about the investigation other than the employee warnings and her statement on 6/2/16 that the survey team asked for. The Administrator reported she was informed of the incident on 6/1/16 by looking at the work schedule, because Staff K and Staff B were disciplined the day she was informed of the event, and Staff J had not been working that day. The facility policy and procedures titled Use of Cameras, Cell/Camera Phone, Electronic or Digital Recording an Electronic Communication Devices, (not dated) documented the nature of the policy is to protect the privacy and dignity of our residents, as to protect the rights and privacy of our staff. The policy directed staff as follows; the use of all types of electronic communication equipment, camera and recording devices other than that required to perform job duties will be strictly prohibited unless on break or in the case of emergency. These devices may be used on break time in the break room or outside of the building and may not be used on the units or in a resident's room. An Abuse Checklist dated 11/15 directed the Charge Nurse to separate the alleged perpetrator by suspending the individual so that there is not contact with the resident. Upon review of the employee files for Staff B, Staff K, and Staff J all C.N.A's the files lacked documentation the facility separated the staff members from the residents until an investigation had been completed and determined no abuse. On 6/8/16, the facility developed a policy and procedures titled Blogging and electronic Disclosure of Confidential Information and Cell Phones and provided a Mandatory in-service with all staff regarding the updated policy.

Based on observation, document review, policy review and staff interviews the facility failed to store and handle food, store equipment and serve food under sanitary conditions in order to reduce the risk of contamination and food-borne illness. The facility identified a census of 33 residents. Findings include: Observations during the initial kitchen environment tour, on 10/31/16 at 9:00 a.m., identified the following concerns: 1. The General Electric refrigerator stored a 5# open container of Kemps sour cream with a best by date of 10/23/16. During an interview at the time, Staff P, Dietary Manager, confirmed the product was well past the usable date. 2. Utensils stored as clean, noted to have dried food on the inside portion of the scoop, for 1 of 2 - #6 scoops, 1 of 4 - 2 ounce spoodles and 1 of 2 - #16 scoops (food portioning devices). During an interview at the time, Staff P confirmed the items were soiled. 3. 1 case of oranges and 1 case of apples stored on the floor. During an interview at the time, Staff P, Dietary Manager, confirmed the items needed to be stored off the floor, 4. The milk cooler stored large plastic storage containers labeled as follows: fruit cocktail dated 10/19/16 fresh spinach dated 10/19/16 cottage cheese dated 10/19/16 coleslaw dated 10/25/16 chopped lettuce dated 10/19/16 potato salad dated 10/16/16 During an interview at the time, Staff N explained the items were leftover from the salad bar served on Monday, Wednesday and Fridays. She reported normally stored items are discarded after 3 days if not used. Staff P, present at the time, clarified the maximum storage period would be 7 days, but reported the date on the containers may not be the most current date of product. She reported staff may add fresh product to the container for use the next time, and the label date would not be changed. 5. The Victory refrigerator stored the following items: 4 quart container of diced ham dated 10/19/16 Mrs Gerry's potato salad with an enjoy by date of 10/18/16 An unlabeled and undated container of sliced pears An unlabeled and undated container of cut honeydew During an interview at the time, Staff P confirmed the dated items were past their usable date. She reported the pears likely opened and served on October 26 and should be labeled and dated. Staff P acknowledged she cut up the honeydew melon and failed to label one of the 2 containers stored in the refrigerator. During an interview on 11/1/16, at 9:50 a.m., Staff P acknowledged it is her responsibility to check refrigerators to ensure items are labeled and dated, and expired products are removed from storage and should have identified the items in questions previous to the survey start. Staff P acknowledged dietary staff should not be adding fresh product to partially used containers from the salad bar. Review of a document titled Kitchen Inspection, dated 10/24/16, revealed the document identified the need for correction related to refrigeration storage to ensure all items are labeled/dated/covered with use by date. The document identified the need for correction discussed with staff. During an interview on 11/2/16, at 2:20 p.m., Staff P, Dietary Manager, reported the consultant dietitian completed a kitchen inspection each visit and documented the results in the computer. Review of an undated policy titled Food Storage revealed in part . all food or food items not requiring refrigeration shall be stored above the floor, on shelves, racks, dollies or other surfaces which facilitate cleaning . check expiration date of milk, prepared salads, and other dated foods . all foods must be labeled and dated: used within 72 hours of date . all leftover food will be dated by using a felt tip pen and writing the name of the food and date on the wrap or a label . 6. Observation of meal preparation on 10/31/16, beginning at 10:35 a.m., revealed Staff N, cook, loaded pans of sliced pork loin, mashed potatoes, gravy and vegetable blend into the steamtable. She then prepared the pureed meat, vegetable and ground meat. The steamtable pans used to hold these products sat on the stainless steel table, and after being filled with product, Staff N placed them on the stove burner to reheat. After each pan reached the appropriate temperature, Staff N placed the pureed and ground pork directly into the pan of sliced pork loin, with the liquid and some product touching the outside of the pureed and ground pork pans. Staff N placed the pureed vegetable pan directly into the steamtable pan of vegetable mix, with the liquid and some product touching the outside of the pureed vegetable pan. During an interview on 11/2/16, at 1:40 p.m., Staff P reported she saw Staff N place the pans of pureed meat, pureed vegetable and ground meat directly into a pan of food and acknowledged the outside of those pans would not be considered clean. 7. Observation during lunch meal service on 10/31/16, from 11:15 a.m. to 12:20 p.m., revealed Staff N used tongs to handle the bread for the hot pork sandwich. Staff N allowed the tongs to rest on a used potholder, bread loaf wrapper and counter multiple times in between use, during the meal service period. Staff N removed bread slices from the bread loaf wrapper but laid bread slices on top of the wrapper multiple times. During an interview on 11/1/16, at 9:50 a.m., Staff P acknowledged Staff N should place tongs on a clean surface in between use and would not consider a pot holder or bread loaf wrapper clean, and the counter would likely not be considered clean either. Review of a document titled Certificate of Achievement, dated 11/11/15, revealed Staff N completed Serv-Safe Food Handler Training (a program developed by the National Restaurant Association designed to teach foodservice employees about basic food safety, personal hygiene, cross-contamination and allergens, time and temperature, and cleaning and sanitation). 8. Observation during lunch meal service on 10/31/16, from 11:15 a.m. to 12:20 p.m., and breakfast meal service on 11/1/16, from 7:05 a.m. to 7:50 a.m., revealed dietary staff carried uncovered plates, through the building's main entrance area, to serve residents seated in the dining area of the living room. During an interview on 11/2/16, at 9:00 a.m., Staff O, dietary aide, reported residents eating in the dining area of the living room like to eat there as a group. She acknowledged dietary staff cover plates and beverages if a tray goes to a room but do not cover any items that travel through the main entrance area. During an interview on 11/2/16, at 1:40 p.m., Staff P, Dietary Manager, confirmed the process to serve residents in the dining area of the living room, included open plates and beverages. She acknowledged she had not considered the need to cover items traveling through the main entrance area, but acknowledged it would be similar to food/beverages traveling down a hallway to a room. During an interview on 11/2/16, at 3:30 p.m., the Administrator confirmed the residents seated in the dining area of the living room preferred this area to the main dining room. She acknowledged food/beverages served to the residents traveled uncovered through the buildings main entrance area. She reported she had not considered the potential concern for uncovered items traveling through a public area.

Based on observation, record review and staff interview, the facility failed to update the care plan with resident specific interventions to prevent falls for one of two residents with history of falls (Resident #1) and failed to update care plans for three of five residents to direct staff to document non-pharmacological interventions prior to the administration of prn (given as needed) antianxiety meds (Residents #3, #5, #6). Findings include: 1. Resident #1's Minimum Data Set significant change assessment completed 8/31/16 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident with a brief interview for mental status score of 12 of 15, required staff assistance with most activities of daily living and had 2 falls with minor injury. A review of incident reports revealed the resident had falls on the following dates and times and the following documentation: a. 6/17/16 at 9:15 a.m. found sitting on the floor, unable to recall events which lead to fall, resulted in 3 centimeter (cm) by 2 cm hematoma to the left side of his/her head b. 7/13/16 at 7:27 p.m. found sitting on the floor, stated a little boy helped him/her to bed, no in juries c. 7/18/16 at 7:40 p.m. found sitting on the floor in front of recliner, resulted in crescent shaped skin tear to right wrist d. 8/3/16 at 1:25 p.m. found sitting on the footrest of recliner and head on mattress of the bed, resulted in a 2 cm by 2 cm hematoma to the left side of his/her head e. 10/27/16 at 2:05 p.m. found on floor in front of his/her recliner, tried to get up and slid off recliner, no injuries noted A review of the care plan with the goal date of 12/14/16 identified the resident with the problem of the potential for fall and directed staff to: a. Notify the physician/family of any falls, assess for injury and cause b. Keep articles that the resident may need with easy reach for him/her. Remind resident to use call light to request help with transfers/toileting/needs and to wait for assistance to arrive, that he/she is not to transfer without assistance c. Monitor the resident for wearing of appropriate footwear when transferring/ambulating d. See ADL/mobility care plan for transfer/ambulation/mobility needs e. Use of bed and chair alarm to alert staff of attempts to self-transfer, does not always use call light effectively 6/17/16 due to increased confusion leading to fall - UA to rule out UTI 7/14/16 portable x-ray to left wrist 3 views - if needed may have dose of [MEDICATION NAME] 5/325 mg for pain prior to x-ray if Tylenol is not effective 7/14/16 physician response to report of fall & x-ray results - treat for comfort only with Tylenol prn 7/18/16 repeat wrist x-ray 7/19/16 x-ray right wrist completed revealed impacted fracture to left distal radius without displacement 7/21/16 Dr here and reviewed x-ray - new order for splint to left arm, OT evaluation for splint 7/22/16 splint arrived, OT placed on resident 8/3/16 cool cloth/ice applied to hematoma left side of face 9/1/16 splint to left wrist discontinued may wear as needed for comfort 10/27/16 currently receiving therapy services with attempt to clear the resident to be independent in his/her room 2. Resident #3's MDS admission assessment completed 10/10/16 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively impaired and required extensive staff assistance with most activities of daily living. The care plan dated of 10/21/16 identified the resident with the problem of PRN use of anti-anxiety medication and did not direct staff to document non-pharmacological interventions prior to the administration of the PRN anti-anxiety medications. A review of the medication administration records revealed an order for [REDACTED]. A review of the undated facility policy titled: resident assessment instrument and care planning revealed the following: a. The plan of care must contain information to meet the resident's needs. The goal should change, from quarter to quarter, as the resident changes. If the goal is not met, the approaches must change, as they were not all effective. 3. The Quarterly MDS assessment dated [DATE] documented that Resident#5 had the [DIAGNOSES REDACTED]. The MDS also documented that the resident required extensive staff assistance with most activities of daily living. The physician's orders [REDACTED]. The Care Plan dated 10/26/16 identified the resident with the focus of antianxiety medication use. The Care Plan lacked direction for the staff to provide or document non-pharmacological interventions prior to the administration of the as needed medication. A review of the residents Medication Administration Records (MAR's) for 7/2016 and 9/2016 documented that the as needed [MEDICATION NAME] had been given on two occasions on 7/11/16 at 6:50 p.m., and on 9/21/16 at 7:00 p.m The MAR's and the nurses notes for those dates and times lacked documentation that non-pharmacological interventions had been completed prior to administration of the [MEDICATION NAME]. 4. The Annual MDS assessment dated [DATE] documented that Resident#6 had the [DIAGNOSES REDACTED]. The MDS also documented that the resident displayed behavior fluctuations of inattentiveness, and disorganized thinking. The MDS also documented that the resident required extensive staff assistance with most activities of daily living. The physician's orders [REDACTED]. The Care Plan dated 10/5/16 identified the resident with the focus of anti-depressant medication use and [MEDICATION NAME] use for anxiety. The Care Plan lacked direction for the staff to provide or document non-pharmacological interventions prior to the administration of anti-anxiety medication. A review of Resident #6's October 2016 MAR indicated [REDACTED]. The medical record lacked documentation non-pharmacological interventions prior to administration of the medication.

Based on observation, record review and staff interview, the facility failed to ensure hazardous chemicals to be out of the reach of residents and failed to ensure foot pedals had been placed on the wheelchair prior to the transport of one of five residents observed being pushed in wheelchairs (Resident #7) and failed to pull up side rails for one of six residents observed during incontinence cares (Resident #4). The facility reported a census of 33 residents. Findings include: 1. Resident #7's Minimum Data Set quarterly assessment completed 8/31/16 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively impaired and required extensive assistance with most activities of daily living. A review of the care plan with the goal date of 12/14/16 identified the resident with the problem of impaired mobility and directed staff to assist with propelling in the wheelchair and encourage the resident to self-propel wheelchair if he/she wishes or is able for independent mobility. During an observation on 11/1/16 at 8:15 a.m., Staff G, RN pushed the resident in the wheelchair without foot pedals and with the resident's right foot skimming the floor during transport from the resident's room to the main dining room. 2. Observations of the unlocked cabinet under the sink in the bathroom of resident room 125 revealed a 15 ounce can of Raid Flying Insect spray on the following dates and times: 10/31/16 at 2:55 p.m. and 3:55 p.m. 11/1/16 at 6:30 a.m., 10:00 a.m., 12:00 p.m., 1:30 p.m. 11/2/16 at 7:15 a.m. and 4:00 p.m. 11/3/16 at 8:00 a.m., 10:00 a.m., 1:30 p.m. and 4:00 p.m. During an interview on 11/2/16 at 9:30 a.m. with the maintenance director reported pesticide storage should be in the basement secured and not in a resident room. A review of the undated policy provided by the facility titled: beauty shop chemicals and supplies, only identified chemicals to be stored in the beauty shop and did not identify proper storage of any pesticide sprays. A review of the undated policy titled: use of wheelchair directed staff to carefully replace leg rests, lower foot rests and place the resident's feet on the foot rests. Position feet and legs in good body alignment. During an interview on 11/3/16 at 8:15 a.m., Staff M, CNA reported when transporting a resident in the wheelchair she would ensure both feet are on foot pedals and hands aren't by the wheels. During an interview on 11/3/16 at 1:26 p.m., the Director of Nursing reported when transporting a resident in the wheelchair she would expect staff to place the resident's feet up on foot pedals. 3. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident#4 had been cognitively intact. The MDS documented the resident required extensive assistance of two staff members with bed mobility, transfers, toilet use, and personal hygiene. The MDS documented the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had frequent incontinence of bowel and bladder. The Care Plan with target date of 12/28/16 identified a focus as impaired mobility and self care deficits related to progression of multiple sclerosis. The Care Plan directed staff to encourage use of siderails as assistive devices for bed mobility. Observation on 10/31/16 at 8:18 a.m. revealed the resident laying in bed with Staff F, Certified Nurses Aide (C.N.A) and Staff I, C.N.A at the residents bed side. Staff F and Staff I were both standing to the residents left side of the bed assisting the resident with morning cares. Staff I and Staff F rolled the resident away from them onto the residents right side, and the resident stretch out his/her arms bracing himself/herself against the wall and window frame, that was above the baseboard heat unit. The staff did not raise the residents siderail for the resident to assist with bed mobility. When the staff rolled the resident to the left side the resident did use the side rail on the left side of the bed to assist with bed mobility. During an interview on 11/03/16 at 8:18 a.m. Staff M, C.N.A reported the resident uses both sides rail to help with moving in the bed. During an interview on 11/03/16 at 8:40 a.m. Staff D, C.N.A reported the resident uses siderails to hold onto for bed mobility, because the resident is nervous when turning, and is worried about rolling out of bed. During an interview on 11/03/16 at 1:28 p.m. the Director of Nursing reported she would expect staff to use a drawsheet , or use siderails if the resident is capable for bed mobility. During an interview on 11/02/16 at 1:36 p.m. the resident reported that she/he was scared when rolled in bed the other day would rather have the siderails up during cares.

Based on facility policy, staff schedule review, employee record review, and interview the facility failed to provide the service of cardiopulmonary resuscitation for 7 of 17 night shifts reviewed on the staffing schedule for the dates [DATE] to [DATE]. The facility reported a census of 33 residents. Findings include: Review of the undated facility policy titled Cardiopulmonary Resuscitation Procedures (CPR) documented the facilty must have one staff member who is certified in CPR per shift would permit prompt initiation of CPR. The policy indicated the facility must have all CPR certifications on file. The staff schedule dated [DATE] to [DATE] documented that Staff L, Registered Nurse (R.N.) and Staff R, Licensed Practical Nurse (L.P.N) worked the 6:00 p.m. to 6:00 a.m. shift on [DATE], and [DATE]. The staff schedule dated [DATE] to [DATE] documented that Staff R, L.P.N had been the only nurse on duty for the 10:00 p.m. to 6:00 a.m. shift for the dates [DATE], [DATE], [DATE], and [DATE]. The facility provided a CPR card for Staff R, however it was for adult, child, and infant CPR combination certification but did not have a CPR card on file for Staff L. Upon employee record review Staff L, R.N.'s file lacked CPR education. Upon employee record review of the certified nursing staff that worked the seven shifts mentioned, none of the certified nurses aides had adult CPR education. Upon employee record review Staff R, L.P.N's file included a CPR certification for the combination of adult, child, and infant dated [DATE] for issue, and a [DATE] renewal date The Job Description for the Charge Nurse with revised date of ,[DATE] directed the charge nurse to provide appropriate supervision to the nursing staff with responsibility and accountability for the assurance of quality services and nursing care, in compliance with the applicable rules and regulations, and laws, and adherence to facility policies, and procedures on the shift or unit. During an interview on [DATE] at 2:30 p.m. the Director of Nursing, and Administrator reported that a CPR certification couldn't be found for Staff L, Registered Nurse.

Based on observation, clinical record review and interviews, the facility failed supervise care plan directives to ensure Resident #10 received adequate supervision against hazard. Resident #10's care plan directed staff to supervised the resident and on 6/14/12, when the resident fell staff interviews determined no facility staff had been providing supervision to the resident. The facility reported a census of 29 residents with four residents reviewed. Findings include: The History and Physical dated 6/14/12 documented that Resident #10 had a [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident as moderately impaired for cognitive skills for daily decision making. The MDS indicated the resident required extensive assist of two staff members for transfers, bed mobility, toilet use, personal hygiene, and bathing. The MDS indicated that the resident did not ambulate. The MDS revealed that the resident had 2 falls with no injury and one fall with an injury since the last MDS assessment. The resident ' s balance during transition and walking revealed he/she as not steady, only able to stabilize with human assistance when moving from seated to standing position, or not stead when moving on and off toiled, and not steady and only able to stabilize with staff assistance during surface to surface transfers (transfer between bed and chair or wheelchair). The assessment listed Resident #10 had anxiety disorder and general muscle weakness. The Resident Care Plan with a start date of 3/21/12 identified a problem for the resident as a potential for falls related to a history of falls, weakness, no longer able to ambulate (independently or with assistance), need for assistance with transfers/cares. The care plan noted the resident used a wheelchair for locomotion, and his/her medications had potential side effects which would affect his/her balance and blood pressure. The resident also had confusion associated with progression of dementia. The Care Plan documented goal indicated the resident will remain free from injury if a fall should occur. The Care Plan approach directed staff to monitor him/her for signs of agitation/anxiety. The care plan directed staff when Resident #10 was restless/anxious, assess him/her for needs such as thirst, hunger, discomfort, fatigue, or his/her need to use the bathroom. The care plan directed staff that when Resident #10 was restless/anxious do not leave him/her in his/her room or an area where he/she can not be monitored. The care plan directed staff to locate Resident #10 in an area where he/she can be supervised. The same care plan also directed staff to use a reclining chair or Geri chair when Resident #10 was restless and unsafe unsupervised in his/her bed/ room. The plan directed staff to place the Geri chair/recliner at the nurse ' s station area so that Resident #10 can be monitored/supervised. The resident's care plan also directed staff to equip the resident with alarms at all times that monitors the resident rising from a bed or chair, and staff should monitor alarms for proper functioning and placement. On 6/11/12 the care plan directed staff to provide 1:1 if the resident was restless/agitated. The care plan directed some suggestions for 1:1, such as sit with him/her, hold his/her hand, offer reassurance, attempt to verbally sooth the resident, offer coffee, ice cream, snacks, take him/her for a wheelchair ride in/out of building, etc. On 6/12/12 the care plan directed staff to use a low bed, and directed staff to place the bed in the lowest position when Resident #10 was in bed or unattended/unsupervised. Review of the Fall Assessments documented that the resident had fallen on the following dates: 3/2/12, 3/5/12, 3/12/12, 4/21/12, 4/23/12, 6/7/12, 6/8/12, 6/10/12, and 6/14/12. The Fall Assessments indicated that none of the falls had been witnessed. The Fall Assessments documented the following injuries: an abrasion, a laceration, a hematoma, a fractured right hip. The Fall assessment dated [DATE] indicated the resident had been taken to the emergency room for complaints of right hip pain. The Fall Assessment form dated 6/14/12 with time of 6:50 p.m., documented the resident had fallen unwitnessed by the front door with no chair alarm sounding, a CNA found the resident on the floor with the lower extremities tangled within the pedals of the wheelchair, the resident had been agitated that shift, the resident's right leg had been shorter than the left, and with movement the resident had yelled out and screamed with pain, the resident had been transported via ambulance to the hospital for evaluation and treatment. The Major Injury Determination Form dated 6/14/12 documented Resident #10 had an unwitnessed fall out of his/her wheelchair on 6/14/12. The form identified the resident's alarm had been in place and still intact, but did not sound due to the resident being tangled up in the wheelchair. The form documented the resident had been unable to ambulate since February 2012. The Severity-Complexity Worksheet for Medicare with date 6/15/12 documented the chief complaint as a fall with a hip fracture. The x-ray [DIAGNOSES REDACTED]. The report documented Resident #10 had been admitted for pain management and monitoring overnight until decision could be made regarding need for surgical repair of his/her right hip fracture. Resident #10 received IV morphine overnight to help control his/her pain. The General Diagnostic report dated 6/14/12 findings documented as follows: that there was a complete fracture of the right femoral neck demonstrated with displacement. The margins of the fracture appeared somewhat blunted suggesting this represents a subacute injury. This fracture could not with certainty be seen on the prior study from September, however the pelvis appeared intact. The left femur appeared intact. The facility faxed the resident's physician on 6/26/12 and asked whether his/her fracture was subacute or even chronic. The physician documented resident had been complaining of right hip pain for some time so he agreed the fracture could have been present prior to admission, with the exact date unknown. (The same physician documented on a Progress Note dated a week prior (6/6/12), that Resident #10 had complaints of pain in his/her right hip and could not bear weight. The resident had been in the ER and the results identified no fracture found with complaints of his/her right hip pain at that time.) Staff I's written statement dated 6/18/12 regarding the fall on 6/14/12 documented the following: Resident #10 had been sitting quietly looking out the front door approximately 15 minutes before his/her fall. She noticed him/her there as she went to help another resident in the day room who required assistance. Due to Resident #10 being abnormally calm and content looking out the window and the fact that the nurse was just around the corner at the nurse's station and his/her chair alarm was in place, she made the decision to let him/her sit in the entry way and watch out the window. Staff I documented about 15 minutes later she was exiting a resident's room and another staff stated Resident #10 had fallen out of his/her chair. During an interview on 7/24/12 at 8: 47 a.m. Staff I reported Resident #10 was sitting calmly just inside the front entrance and she observed him/her for about 5 minutes. Staff I reported there were no staff in the dining room or living room, and Staff D was at the nurse's station.(This investigation determined Staff D had not been at the nurse's station to supervise Resident #10.) Staff I reported the time span from leaving Resident #10 to assist another resident had been 10-15 minutes, when she heard from Staff G that Resident #10 had fallen. Staff I stated if you're sitting at the nurse's station you cannot see the entire dining room or living room or front entrance even with the use of hallway mirrors. Staff I stated Staff D was usually at the nurse's station charting after mealtime and the Administrator was not in the building. During an interview on 7/24/12 at 8:24 a.m. Staff D reported Staff G did tell her when he went on break and at that time Resident #10 had been by the nurse's station in wheelchair. Staff D reported the resident had not been agitated. Staff D reported before Resident #10 had fallen she had last seen him/her about 30 minutes prior to the fall. Staff D stated Resident #10's fall (on 6/14/12) had been unwitnessed. Staff D stated Staff I and J had been down the hallway doing cares for resident(s). During an interview on 7/24/12 at 8: 36 a.m. Staff G reported Resident #10 had not been yelling out. Staff G reported prior to his break and he informed Staff D of his departure. Staff G reported he did not know where Resident #10 was at when he went on break. Staff G reported the time span when he went on break and finding Resident #10 after the fall may have been 20 minutes. Staff J reported on 7/24/12 at 9:07 that she did not know that Resident #10 had fallen until Staff D called 911(on 6/14/12). Staff J reported the last time she had seen the resident had been at the nurse's station about 15 minutes before being told he/she had fallen. Observation on 7/24/12 (no time) when the surveyor sat at the nurse's station she could not see the entire living room, dining room, or front door area where Resident #10 had been found on 6/14/12. The DON confirmed this as well. During an interview on 7/06/12 at 9:17 a.m. the Director of Nursing (DON) reported that Resident #10 could propel her/his high back wheelchair independently. The DON reported the resident usually had agitation in the evening shift, but in the last week before the residents fall on 6/14/12 the resident had started earlier in the day with more intense anxiety, all staff became more involved to assist with the resident. The DON reported that the Administrator would assist with visual supervision of residents (including Resident #10) whom sat frequently in the lounge area. The DON reported that other staff whom would assist included the activity staff, and CNA's and the DON would stay late to assist with one on one supervision with Resident #10 if needed. Additional Staff Interviews: During an interview on 7/06/12 at 11:05 a.m. Staff I, CNA reported that on 6/14/12 Resident #10 wanted to leave the facility, the toileted the resident frequently, and seemed to calm down after dinner. Staff I, CNA reported see the resident 15 minutes before the resident fell , the resident had been by the administration office in the living room (lounge area) looking outside. Staff I then took another resident to the bathroom then came out of the room 15 minutes later and Staff G, CNA reported Resident #10 had fallen. Staff I reported that Resident #10 had been intense with her/his anxiety in the last week prior to the fall on 6/14/12. During an interview on 7/05/12 at 2:00 p.m. Staff G, CNA reported that Resident #10 had been anxious on 6/14/12 on days, and evenings. Staff G reported he took the resident outside to the parking lot the resident had been looking for his/her car. Staff G reported he had offered the resident snacks, playing cards, and offered the resident snacks. Staff G reported when he came back from his break on 6/14/12 after dinner he had found the resident to the right of the front door with feet tangled in the wheelchair foot pedals, and the resident and the wheelchair were tilted forward, the chair alarm was under the residents buttocks and not sounding, when help arrived and the resident had been moved and the chair alarm sounded. Staff G demonstrated to the surveyor where and how the resident had been found. During an interview on 7/06/12 at 7:57 a.m. Staff D, RN reported Staff G, CNA notified her that Resident #10 had fallen on 6/14/12 after dinner. Staff D reported the resident had been in a wheelchair to right of the front door head leaning forward towards the wall with the wheelchair tilted to the right, the press alarm had been under the residents lower half of the body not sounding, the residents feet were tangled in the foot pedals of the wheelchair, then the staff assisted the resident to the floor. Staff G reported that she performed an assessment on the resident and noted an obvious deformity to the resident's right lower extremity, then called for a transfer to the hospital so the resident could be evaluated. Then Staff G called Hospice, family, the physician, and the Director of nursing, and completed the documentation for the incident. Staff D, RN reported that Resident #10 and three other residents needed to be kept under visualized supervision, for example at the nurse ' s station. During an interview on 7/05/12 at 1:59 p.m. Staff F, CNA reported that Resident #10 had no current illness, but had been very agitated during the day shift on 6/14/12. Staff F reported she worked the day shift on 6/14/12, and that she sat with the resident, gave the resident a beer, walked the resident outside because the resident thought his/her car had been in the parking lot, so she showed the resident his/her car had not been in the parking lot. Staff F reported when she left at 5:00 p.m. the resident was eating dinner. During an interview on 7/05/12 at 1:42 p.m. Staff E, Certified Nurses Aide (CNA) reported that Resident #10 always had alarms. Staff E, also reported that Resident #10's normal behavior could be described as restless, staff would try the following to help the resident calm down by play cards, and provide one to one attention. Resident #10 had no illness at the time of his/her last fall on 6/14/12. During an interview on 7/06/12 at 8:48 a.m. Staff H, CNA reported that she spent a lot of one to one time with Resident #10 a week before the 6/14/12 fall due to the resident's increased anxiety. Staff H reported that she even stayed over from day shift to help as visual supervision increased for Resident #10 due to increased anxiety behavior diversion activities included going outside, offering food, music, and picture books. Staff H reported that on 6/14/12 she stayed over (on other days) because the resident had been anxious, interventions attempted included change in location for the resident which were bed, chair, wheelchair, toileted the resident, and had taken the resident outside. Staff H, CNA reported she left at 3:30 p.m. on 6/14/12 and Resident #10 had been in the lounge area with a staff member. Staff H, CNA reported residents that need more visual supervision included Resident's #10, and that the Administrator helps the staff supervise these resident's in the lounge area during the day shift since his office is next to the lounge area.