Every finding on record at Luther Manor at Hillcrest

Based on observation, record review, staff interview and facility policy review the facility failed to follow fall interventions to prevent falls for 3 out of 4 residents reviewed with falls resulting in injuries. (Resident #11, #13 and #80). Staff failed to properly transfer Resident #11, resulting in a fractured ankle. The facility failed to follow fall interventions to prevent a fall for Resident #80, resulting in a hematoma and abrasion to forehead and a skin tear to left elbow. The facility failed to have interventions in place to prevent an abrasion to Resident #80's knee while in bed. The facility reported a census of 94 residents. Findings include. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #80 revealed a diagnosis of coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular accident and non Alzheimer's Dementia. The MDS revealed the resident had short and long term memory problem, with severely impaired decision making. The MDS indicated Resident #80 was dependent on staff for personal hygiene and dressing. Resident #80 needed substantial assist to roll left and right in bed, and had a history of falls. The Incident Report dated 2/1/26 at 5:30 PM revealed, Noted skin tear to left knee. Resident #80 was laying on his left side and Certified Nursing Assistant (CNA) states his knee where against the heater and the residents pants were pulled up to his knees. The Immediate Action Taken section of the Incident Report revealed, in part, Clean skin tear with soap and water and assist resident out of bed with 2x (two) person assist with hoyer lift (mechanical lift). No bleeding noted, skin bright red color and contact Administrator [Name Redacted] nurse on-call and notified new skin issue from the heater. Review of Resident #80's Nurses Note dated 2/1/26 at 6:27 PM revealed, in part, a certified nursing assistant notified the nurse at 5:30 PM about skin tear to left knee. Staff reported resident was laying on his left side and left knee and left was resting against the heater and resident pants pulled up to the left knee. Resident #80 turned on left side and noted skin tear to left knee. Skin tear measured 1 centimeter(cm) by 2 cm and 2 cm by 0.5 cm. Skin color pink, no bleeding noted and skin warm to touch .Contact [Name Redacted]-Administrator and notified the skin tear from heater and informed re-arrange the bed away from the heater. The Nurses Note dated 2/1/26 at 9:18 PM revealed the nurse reassessed area on left leg/knee and noted drainage on dressing and redness on leg. Total area of redness measured 13 cm x 5 cm with 2 abrasions measured 3 by 2 cm and and 3.5 cm by 1.5 cm with 0.1 cm depth. Staff noted resident facial grimacing and on call light frequently as needed pain medication given for comfort. Hospice notes from 2/3/26 revealed, left knee wounds appear to be popped blisters. Staff reports knees were resting on the radiator. The nurse progress note dated 2/8/26 at 5:15 PM revealed, skin issue #1 front left knee issue type was a burn, described in note as superficial burn that was in-house acquired on 2/1/26. 3 cm depth with a 1 cm depth. Skin issue #2 front left knee superficial burn wound acquired in house on 2/1/26 with a 3 cm depth and 1.5 cm depth. On 2/04/26 at 4:41 PM, utilized a heat gun from maintenance and the register in Resident #80's room was 109.5 to 119 degree Fahrenheit within a 15 minute interval. On 2/05/26 at 7:55 AM, Resident #80 lying in bed which has been moved to along the wall and no longer next to heater. He was lying on his right side facing the wall, and the left knee was exposed and 3 open red areas exposed to air. No dressing on left knee. On 2/5/26 at 10:22 AM, Staff Y, Registered Nurse (RN) stated the CNA came and told [Staff Y] there was a skin tear on Resident #80 left knee and the bed was in the lower position, and he was laying on his side with his left knee touching the heater. [Staff Y] observed there was 2 skin tear on the left knee and it was red there was no blister when [Staff Y] saw it. There was no drainage to the wound. It was like 73 degrees in the room and the metal was warm. There was 2 areas on the left knee and it measured 1 cm x 2 cm and then 2 cm x 0.5 cm. Its because it was touching the heating vent that caused the skin tear. The skin tear would be defined as open and you could see the inner skin. [Staff Y] would not say it was a burn because there is blister a burn should have a blister first. The skin might be rubbing off when he was doing it. The register was hot. The skin was warm and not scalding hot. [Staff Y] notified Hospice and the daughter and informed the Administrator. [Staff Y] did tell her (Administrator) the knee was touching the heater and let her know we repositioned the bed away from the heater. [Staff Y] also let the daughter know we moved the bed away from the heater. All burns have blister and this is why I thought it was a skin tear. On 2/05/26 at 10:57 AM, observed 2 CNAs position Resident #80 in bed and body pillow placed on left side. The heating unit metal part registers 113.9 degree Fahrenheit on the side metal part and the top part registers 139.1 where vents are located and the heat blows out of it. On 2/05/26 at 11:02 AM, Staff E, Licensed Practical Nurse (LPN)LPN and Staff Staff W, LPN provided wound care to Resident #80. Staff W stated did skin assessments on area like this, and considered it an abrasion. Staff W explained they came to conclusion the skin was abrased from 2 areas unknown etiology. [Staff W] stated [Staff W] feel like it could be an abrasion or it could be a rug burn from friction or shear. [Staff W] did not feel like heat caused it because there was no blistering. [Staff W] did state burns do not always have blisters. [Staff W] did not think it was a burn because it was an abrasion and the pictures from Sunday to Monday show the redness around the wound is gone. [Staff W] did clarify she was unsure what caused skin to be rubbed off, the heat could be a factor . Staff W further explained it could be from anything that would cause the skin to come off and by Monday morning there was no redness, and the third area was a more like a bruised abrasion area and it was not open. Staff E obtained the following measurements for open areas on the left knee of Resident #80, top wound on left knee measures 2.9 (centimeter) cm x 1.1 cm, The middle wound was 2.8 cm x 0.7 cm and the bottom area on the wound was 1.7cm x 0.3 cm. Each area has full thickness of skin removed and wound base was yellow with the peri wound red. The wounds were all irregular shaped. Staff E confirmed no drainage on the dressing with little bit of blood when she removed the dressing. On 2/05/26 at 1:39 PM, Staff II, Hospice Registered Nurse (RN) stated regarding Resident #80 left knee there were 2 open areas on his left knee, the on call nurse got a call from the facility on 2/1/26 stated he had 2 skin tears on his left knee. Staff II, Hospice RN did come observe the wound and the nurse changed the dressing and [Hospice RN] saw it. [Staff II] observed it on 2/4/26 and it appeared to be popped blister areas. She was not able to say what caused the area but Hospice was notified the knee was on the vent of the heater. She revealed she does think the heat may have caused the knee blisters. She stated she had not seen Resident #80 knees on the register but he is able to pull his legs up and move them side to side. [Staff II, Hospice RN] informed/made the comment to the facility nurse as she changed the dressing on the left knee those are not skin tears. On 2/05/26 at 2:48 PM, Staff E, LPN confirmed she did the dressing change to Resident #80 left knee today and yesterday. It does not appear to have changed much since yesterday. [Staff E] did talk to Hospice about the area and told her we are calling it an abrasion. [Staff E] would suspect it might be a mild burn and he was supposed to have pillows on both sides [Staff E] suppose if the heater got hot enough it could be a burn. It could be an abrasion or a rug burn. On 2/05/26 at 3:02 PM, Staff Z, RN stated got in report Resident #80 had an incident and he was in bed and he was close to the wall heater and he got to little skin tears. When [Staff Z] checked it was bleeding through and it was a larger area and then he he had some other areas. It was a lot bigger that what the previous nurse documented . [Staff Z] did not think it was a skin tear, from [Staff Z's] experience it looked like a burn from the heater. A lot of the area was redness and he had two area that were more open they were full thickness skin gone and appeared to be like a second degree burn. His bed was moved away from the radiator. On 2/05/26 at 3:23 PM, Staff AA, CNA explained took care of Resident #80 on 2/1/26. [Staff AA] checked on him at 2:30 PM he was on his back and then the nurse told [Staff AA] he was awake and he needed to get up for supper. [Staff AA's] partner and [Staff AA] went in to get him up from bed and his pant leg went up exposed the sore. It looked like a burn and his leg was hot it felt warm to the touch. It felt warmer than it should have been. It couldn't have been on there very long [Staff AA] checked on him at 2:30 PM. [Staff AA] suspected a burn right away because he was laying near the heater, the way he was laying made me suspect it. The left knee was next to the metal, they don't get hot but they do get warm. [Staff AA] moved the room because [Staff AA] told them the bed should not be there you never stick a bed next to the heater. [Staff AA] think it was an accident he was on his back and flipped over. Observation on 2/09/26 at 1:15 PM with Maintenance Director in Resident #80 room revealed flat metal part of heater temperature on infrared heat gun read 107.3 - 116 degrees Fahrenheit on the heating unit. The top part of the heating unit measured 117.3 degree Fahrenheit. He stated they do not take temperature on them and have not had issues with them. This is the hottest [Maintenance Director] have ever seen them, and [Maintenance Director] did not know how hot they potentially could get. On 2/09/26 at 3:50 PM, the Director of Nursing (DON) stated she did see the left knee area on Resident #80 maybe a day or so after it occurred. It looked like a friction shearing from the mechanical lift. The DON explained the following about the situation: it was not only Resident #80 was leaned up towards the radiator and the pants were up to the knee and there was bedding present also. It was a known origin and I considered it was known friction and shearing. His knee must have rubbed up and down against the surface with material like a volley ball floor burn. That is why [DON] felt it was friction and shearing. The DON did not feel like the heat from the radiator contributed. [DON] only got to see it one time and it did not appear to be a burn. [DON] interpreted the redness getting larger differently than the nurse assessing the appearance on the day of the event. It was described as an abrasion and [DON's] eyes went on it one time. That was why assigned a consistent assessor and it was Staff W, LPN, ADON she measured and documented on all wounds of that type. On 2/10/26 at1:09 PM, the DON explained the Nurse Practitioner providers that come to facility do not see him (resident), he had not been seen by a Provider, and there was no documentation regarding him being seen by a Provider. On 2/10/26, the Advanced Registered Nurse Practitioner (ARNP) from Hospice confirmed she had not seen Resident #80 she was aware of the wound on his left knee but had not seen the pictures. She revealed most patients are managed by their own attending physician. On 2/12/26 at 12:28 PM, the DON stated the abrasion on Resident #80 could have been prevented by more frequent repositioning. When [DON] looked at the electronic health record for documentation of when he was repositioned it was either not there or documented all at the same time. 2. Review of the Incident Report for Resident #80 on 2/2/25 at 6:30 PM revealed the resident was found laying face down in front of his wheelchair in his room. CNAs were assisting him with bedtime cares and left the room to go get the EZ stand (lift). Abrasion to left forehead and hematoma starting to form, bruise to nose and skin tear to left elbow. The Care Plan for Resident #80 dated 12/9/24 identified a focus area of High Risk for Falls related to gait/balance problems, incontinence, vision and hearing problems. The intervention dated 3/10/25 directed staff Resident #80 is a wheelchair star on the wheelchair to alert staff to keep resident out of room while in wheelchair due to high fall risk. On 2/10/26 at 1:33 PM, Staff R, CNA stated the star program is supposed to be little tags on back of wheelchair with a star and that means residents can't be left in their room in their wheelchair. They need to be in a recliner or bed due to self transfer risk. . On 2/10/26 1:38 PM, Staff EE, CNA states knew how the resident transfers by they have a sheet in the hall at the nurses station and at night time we will write a blank sheet with their transfer status and if you don't know you can ask the nurse. [Staff EE] didn't know anything about the star on the wheelchair. On 2/10/26 at 1:43 PM Staff T, CMA states they really don't do the star program any longer. They were a circle plastic thing and they would fall off and break. If intervention is for them not to be in wheelchair in their room it should be in the kardex or the wing sheet. On 2/10/26 at 2:00 PM Resident #80 wheelchair in room and no star observed on his wheelchair. Resident is in bed hospice provided wound treatment to left knee. On 2/10/26 at 4:20 PM Staff W, LPN, ADON stated regarding Resident #80 fall on 2/2/26 that a dietary aide walking past his room came and told me he was on the floor. Resident #80 was lying face down in front of his wheelchair and next to his bed. He is a wheelchair star - this star means the resident are not allowed to be left alone in the room by themselves. We still have the ones that were were previous to the current electronic health record. [Staff W] did not recall if the star was on his wheelchair that night. [Staff W] completed an assessment he had a hematoma and abrasion to his left upper forehead and skin tear to left elbow and left cheek was bruised. Staff W explained did not remember the root cause analysis for that fall, but I knew the intervention was a drop seat in his wheelchair. [Staff W] didn't know if education was provided but did talk to agency staff that night and let them know he was not supposed to be in his room up in his wheelchair by himself. On 2/12/26 at 12:24 PM the DON stated the wheelchair star program identifies the resident is not supposed to be left alone in room in wheelchair. There was a star on their wheelchair to identify they are at risk. Staff left Resident #80 alone to go get the equipment and he fell. The DON explained talked about falls in the morning meeting. [DON] did not check on his wheelchair but would expect for the star to be there. She revealed the staff did not follow the plan of care for Resident #80 and he fell. 3.The MDS dated [DATE] for Resident #11 revealed a diagnosis of hypertension (high blood pressure), diabetes, and depression. The Brief interview for mental status (BIMS) revealed a score of 7 out of 15 which indicated severe cognitive impairment. The MDS indicated the resident required maximal assistance from staff for transfers. The care plan intervention with a date initiated of 5/7/25 and a revision date of 8/27/25 revealed Resident #11 dependent on staff with assist of 2 with EZ stand (lift). An incident report dated 8/1/25 at 7:20 AM revealed CNA staff transferred Resident #11 by herself with the pull up bar, while resident is an assist of 2 with the EZ stand. Resident was eased to the floor by CNA staff because resident could not hold self up at the bar. No injuries from the fall. Facility provided education to staff on residents transfer status and if unsure to verify with nurse. An incident report dated 12/15/25 at 5:00 PM revealed Resident #11 told CNA she could walk and CNA pushed button on the recliner to raise it and when her partner saw this informed the CNA she was an EZ stand. Resident #11 started to slide and CNA could not hold the resident up and CNA assisted Resident #11 to the floor. Resident did not hit head. No visible injuries noted. Staff assisted resident #11 into the wheelchair per 3 assist and gait belt. The nurse progress note dated 12/16/25 at 7:13 AM revealed when Resident #11 woke for the day, staff noted her right ankle to be bruised, swollen and painful even to touch. She could not move her ankle at all. Condition report to nurse practitioner. Resident #11 sent to emergency room for evaluation and treatment. Review of the results of the x-ray of the right ankle revealed a mildly displaced obliquely oriented fracture of the lateral malleolus. The small bony knob on the outside of the ankle is broken at an angle, with pieces slightly shifted out of their normal position. On 2/04/26 at 2:20 PM, electric lift recliner chair in Resident #11 room. On 2/09/26 at 5:20 PM Staff BB, CNA stated on 12/15/25, was walking past Resident #11 room and observed another CNA getting ready to transfer the resident. She was in the recliner and and she was seated forward with her walker in front of her and had the lift chair in a raised position. [Staff BB] informed the CNA that is not how she transfers she needs the EZ stand, and [Staff BB] went to get the EZ stand and heard help help and by the time I got back to the room Resident #11 was on the floor. She revealed staff know how to transfer residents by they have little signs on the door. and some paper they call it a wing sheet it has their transfer status on it. If EZ stand lift need to use 2 staff for transfer. [Staff BB] was upset because had just told her that is not how we transfer her and why would she not have put her back down. On 2/10/26 at 8:21 AM Resident #11 Lying in bed, head elevated and eyes closed. No signs and symptoms of discomfort. On 2/10/26 at 8:27 AM Resident #11 Staff B, CNA and Staff C, CNA provided transfer from bed to wheelchair with EZ lift (mechanical lift) with out problems. Resident had boot on right lower extremity. During the transfer Staff C stated could always ask the nurse what a resident needs for transfer assist and usually there was something on the door but it is not always updated and recently they have not been updating them. On 2/10/26 at 9:29 AM Staff CC, CNA stated would ask the other staff what the resident transfer status was and the residents had their own gait belts. [Staff CC] asked the staff on Sunday when [Staff CC] started and when hour of orientation on Sunday they did not go over how they transfer or communicate this to staff. [Staff CC] used [electronic health record system, (EHR)] a lot for another facility so had access to [EHR] and can look up in there. [Staff CC] am not aware of any way specific way they communicate transfer status of residents to agency staff. On 2/10/26 at 10:15 AM Staff T, CNA/CMA stated they don't always use the wing sheets anymore and she is not sure how updated they even are anymore. She went to the electronic health record to check the resident transfer status. We have communication board in the electronic health record that we all can read. The communication board gives us anything new and recent and supposed to look at it every shift. On 2/10/26 at 2:27 PM Staff DD, CNA stated the fall Resident #11 had was about 430 there was a gait belt in her room so it made [Staff DD] think she walked normally. They would have a plaque on the door that tells you her transfer status that might have been right around the time they were going to stop them. So [Staff DD] lifted her power chair up and had the gait belt up and [Staff DD] tried to stand her up. Another CNA agency said she was an EZ stand so while [Staff DD] was putting the chair back down and was looking for the remote on the ground, Resident #11 slid out of the power lift chair. Her walker was not in her room, she had just moved from Bluff View so [Staff DD] grabbed another residents walker and it was in front of her and was going to pivot her into her wheelchair. [Staff DD] did have the chair almost all the way up and was attempting to have her bear weight but she was not able to bear weight and then the other CNA said she was an EZ stand. No one told us how to look for the transfer status and there was no education. [Staff DD] explained talked to the activity staff and asked her how [Staff DD] was supposed to know how to transfer her and she told me about papers in a binder and those have the transfer status on them and other information on them about the resident. Staff DD explained used them now. At one of our most recent staff meeting Administrator did talk about them being in the binders. She did not say any where else to find there transfer status. On 2/10/26 at 4:11 PM Staff W, LPN, who documented resident's fall on 8/1/25, stated it was in the Bluff View shower room and was called into the tub room. Resident #11 had fallen the staff member had transferred her with the grab bar and she should have been an EZ stand. The CNA knows to use the Kardex in the electronic health record to know their transfer status and how the CNA should transfer. On 2/10/26 at 5:16 PM the Administrator states the wing sheets are still available but they are not always the most current so she encouraged the staff to use the kardesx because that is the most current. On 2/11/26 at 3:05 PM Staff GG, LPN stated was the nurse to document Resident #11 fall on 12/15/25. The CNA said she tried to transfer Resident #11 by herself. The resident told her she could do it by herself and she was in the recliner chair. The CNA raised the chair because it was an electric chair and the resident started to slide out of the chair. The staff could not stop her and she slid right out of the chair. On 2/12/26 at 12:15 PM the DON stated [DON] called staff to take the witness statement on Resident #11 fall and it was a facility staff. She was getting Resident #11 up for a transfer. Resident #11 has dementia and she told staff she could walk so the staff went to get her up from the power chair. An agency staff saw her getting her up from the chair and told her no she is a lift and the staff was in there in a lifted position and resident lost balance and was lowered to the ground. The DON explained there were several ways they could know how to transfer a resident and because we have a system that is able to update live time the care plan, kardex and communication board is the full up to date information. So [DON] would expect them to go to the care plan, kardex or communication board these are the current active up to date areas to get the information. The DON further explained was working to phase out the other programs in place. The education was completed in December to use the kardex not the magnets on the door frames and we tried to go around and remove them but staff continue to put them in place. Communication board is a way to know what was changed. The facility provided a policy titled Safe Lifting and Movement of Patients with a last revision date of July 2017 it directed the residents current transfer status is to be found by using the KARDEX/Care plan located in the electronic health record. 4. The MDS assessment dated [DATE] for Resident #13 informed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS also revealed the resident had diagnoses of repeated falls, weakness, muscle weakness, difficulty in walking, unsteadiness on feet, and other abnormalities of gait and mobility. The MDS indicated Resident #13 had difficulty in walking and a need for assistance with personal care. The Care Plan instructed the Resident #13 needed assist of one for transfers and ambulation Ax1 with FWW in room and throughout the facility. The Care Plan also instructed to apply gripper socks (dated 3/21/25), auto-lock brakes to wheelchair (dated 9/10/25), and ensure wheelchair pedals are not attached, unless being propelled (dated 9/10/25). The Care Plan dated 1/22/26 instructed to remove white socks from room and only supply with gripper socks as the Resident removes shoes and gripper socks. The Fall Incident Report dated 2/10/26 at 9:00 AM Staff E, Licensed Practical Nurse (LPN) was called to resident room by Staff F, Certified Medication Aide (CMA). Staff F informed Resident #13 had been found on the floor kneeling on his knees, but upon entering the room resident got himself up and back in his wheelchair. Staff E, LPN started neuros and obtained vitals, resident was upset and yelled at Staff E, LPN. continued to state he did not fall, did not want to get vitals or assess him. The resident did not appear to have any red areas, bruising or open areas to his knees, and denied hitting his head and denied any pain or discomfort. An observation on 2/4/26 at 12:01 PM Resident #13 sat on the edge of his bed with no shoes on. wearing white socks. Observed no shoes or gripper socks in the resident's room. The resident informed he did not know where his shoes were. Wheelchair pedals were on the wheel chair. An observation on 2/9/26 at 9:14 AM, Resident #13 wearing white socks, no shoes, and no gripper socks. The resident proceeded to stand up at the side of his bed, did not know where his shoes were. An observation on 2/10/26 at 8:10 AM the resident lying in bed, door open, right foot hanging off of foot of the bed, white socks on without shoes or gripper socks on. An observation on 2/10/26 at 8:47 AM Resident #13 lying in bed, wearing white socks, no gripper socks or shoes. Wheel chair pedals were on his wheel chair. Staff F, CMA knocked on the door, entered the resident's room, turned on light, and told the resident that it was time to get up for breakfast. Staff F, CMA asked Staff HH, CNA to help assist him and that he is willing to get up. An observation on 2/10/26 at 9:01 AM Staff HH, CNA assisted Resident #13, with the door open, observed the resident stand up, pivot turn, and sat down in his wheel chair without a gait belt on and no gripper socks or shoes. Resident was wearing his white socks, a t-shirt, and a brief. Socks on standing to turn around and sit in a wheel chair, t-shirt, brief. Staff E, LPN entered the residents room door shut Staff HH, CNA and Staff E, LPN left the room at 9:04 AM. An observation on 2/10/26 at 9:06 AM, Resident #13 self-transferred from his wheel chair into his bed. The resident still wearing only his white socks, t-shirt, and a brief. An observation on 2/10/26 at 9:08 AM Multiple staff walked past his room. Resident #13 still had white socks on without gripper socks. The resident was sitting in his wheel chair drinking a can of pop. An observation on 2/10/26 at 2:02 PM, Resident#13 stood up on his own, walker not in reach, wheel chair pedals were on wheelchair, wheelchair did not have the brakes locked, resident turned around and sat down in his wheel chair. The anti-lock brakes on the resident's wheel chair did not prevent the wheelchair from rolling backwards and his wheel chair bumped into his dresser. The resident stood up, picked up his walker, moved the walker, then sat down in another wheel chair that was near the center of his room. The resident proceeded to propel himself out of his room. The resident informed he was not sitting in his wheelchair. The Resident's wheel chair remained in his room. The anti-lock brakes were not tight, the right brake was on, and the left brake was off. An interview on 2/10/26 at 2:08 PM with Staff D, CNA informed she will put a work order to fix the antilock brakes. In an interview on 2/11/26 at 10:55 AM, the Maintenance Supervisor looked at the wheelchair and fixed the anti- lock brakes. He was informed by the CNA that she was unsure what needed to be fixed on the wheel chair and she had told him it was the front brakes that were not working. The maintenance man informed he was going to have therapy to check the wheel chair brakes. In an interview on 2/11/26 at 11:10 AM with Staff E, LPN was unsure why Resident #13's wheel chair was not in his room and indicated they did not have an alternate wheel chair that did not have the anti-lock brakes on it. Staff E reported she would go to the therapy room to check on his wheelchair. In an interview on 2/11/26 at 11:12 AM with Staff E, LPN indicated the anti-lock brakes were fixed and working appropriately. Staff E indicated she would assist him into his wheel chair. An interview with on 2/11/26 at 1:50 PM with Staff G, Scheduler/Certified Medication Aide (CMA) informed staff bring their concerns to me if there is not enough training or skills to provide for resident cares. If there are questions on how a resident transfers, the nursing staff can use the kardex, or the magnets, we are phasing out the magnets. An interview with on 2/11/26 at 1:50 PM at with Staff G, scheduler informed staff bring their concerns to her if there is not enough training or skills to provide for resident cares. If there are questions on how a resident transfers, the nursing staff can use the kardex, or the magnets, we are phasing out the magnets. An interview on 02/12/2026 at 12:25 PM the Director Of Nursing, (DON) indicated Resident #13 was not supposed to be wearing white socks and they were supposed to have removed them from his room for his personal safety.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, review of the facility Quality Assurance and Performance Improvement (QAPI) documentation, QAPI policy review, and staff interview the facility failed to carry out QAPI activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting the facility. The facility reported a census of 94 residents.Findings include:The CMS 2567 Statement of Deficiencies dated 10/17/24 included the following concern: F812 Food Procurement, Store/Prepare/Serve-Sanitary.The CMS 2567 Statement of Deficiencies dated 12/30/24 included the following concerns: F812 Food Procurement, Store/Prepare/Serve-Sanitary; F865 QAPI Program/Plan, Disclosure/Good Faith AttemptThe CMS 2567 Statement of Deficiencies dated 7/25/25 included the following concerns: F689 Free of Accident Hazards/Supervision/Devices; F880 Infection Prevention & ControlThe current survey, conducted 2/04/26 through 2/12/26 also identified the above concerns.Review of QAPI Sign-In Sheets documented the facility held QAPI meetings on the following dates: 11/05/24, 2/13/25, 5/13/25, 7/01/25, 9/25/25, 10/22/25, 11/19/25, 12/17/25, and 1/14/26.The facility was unable to locate documentation for performance improvement activities covering the CMS-2567 forms above.During an interview with the Administrator on 2/12/26 at 1:23 PM she stated all department heads were involved with QAPI meetings since she started in September 2025. She expected the committee to use grievance forms, survey results, nursing notes, clinical review meetings, resident concerns, walk around audits, and staff concerns to develop and prioritize performance improvement activities. If there was a long term concern, the committee should use a performance improvement plan (PIP). She thought they were improving QAPI and acknowledged they had a ways to go with 32 PIPs in place. The Administrator indicated fall monitoring was an active PIP and they used a lot of data from their risk management reporting. They had not been doing very well so they created a new witness statement they were hoping would help. She thought tracking and trending was important for monitoring performance improvement and stated they had to start over because nothing was left by the prior administration. The Administrator stated she had not wanted to make a lot of additional changes until after the survey to see what else needed to be addressed. She stated she was very aware F812 and F880 were ongoing issues.A document titled 2025 Quality Assurance & Performance Improvement plan for the facility indicated the purpose was to take a proactive approach to continually improve the way they cared for and engaged with residents, caregivers, and partners. QAPI was used to make decisions and guide day to day operations. The QAPI plan included 4 goals: stable workforce, fall with major injury reduction, turnover reduction, and antianxiety/hypnotic medication reduction. A policy titled QAPI Program - Feedback, Data, and Monitoring section 3a. indicated annual survey results were a system used to identify, collect, and evaluate data. Section 4 documented that data and information collected would be reviewed by the committee and prioritized according to risk, volume, and potential problems.

Based on observation, record review, interviews, and policy review the facility failed to prevent physical contamination of food in the kitchen during 4 observations. Hair nets were improperly worn, the cleaning schedule was not followed, and staff did not adequately sweep and mop floors to remove dead cockroaches. The facility reported a census of 94 residents. Findings include:During a kitchen observation on 2/04/26 starting at 10:20 AM noted the following:Staff I, Dietary Director, wore a brown hairnet that left about 2 inches of hair exposed over each ear and about 3 inches exposed in the backStaff P, Dietary Aide (DA), wore a white hairnet with about 2-3 inches of hair exposed in the back.Staff N, DA, wore a hairnet with about 1-2 inches of hair exposed in the back and about an inch over each earStaff Q, Cook, wore a hairnet with hair exposed on the right side, about 1-2 inches out of hairnet over her earsStaff O, Cook, wore a hairnet with about 2 inches exposed in back and wisps out over both earsFreezer - Whipped cream sprayed on the right freezer wall. Staff I stated someone broke in before she started and sprayed it everywhere. She reported she started in September or October and just hadn't gotten around to it, but it was being cleaned on Saturday.Dry storage - Dry cereal under the can and cereal racks, additional pieces further out on the floor and partially crushed. Plate storage equipment next to the gelatin and pudding shelf had a white granular substance on it in addition to a clear sticky substance. There were 2 quarter size splotches of a yellowish orange substance under the pasta shelves and 3 smaller ones under the spices and baking products. Ice machine - A dry off-white film was found under the door, along with a sticky brown/orange substance on the inside rim.Floor - Observed dead roaches and debris under the pots/pans shelf, sanitizing sink, and dish machine.During a kitchen observation on 2/05/26 noted the following starting at 8:42 AM:Staff N, 3 inches of hair in back exposedStaff I, 2 inches of hair over both ears exposedStaff P, 2 inches of hair exposed on back left sideA blue paper was attached to a work surface in the kitchen with tape and plastic. The paper, plastic, and tape were pulled away from the surface leaving a sticky substance, the paper and plastic were jagged in appearance, and the tape had grey and brown substances stuck to it. The paper was discolored and showed dried moisture stains.Daily Cleaning Schedules dated 1/05/26 through 1/31/26 documented that out of 56 AM and 56 PM opportunities for the kitchen and dish room floors to be swept/washed, cleaning occurred 34 of 112 times. During the same time frame there were no cleaning entries for any task for 1/08/26 AM or PM, 1/09/26 PM, 1/10/26 AM or PM, 1/11/26 AM or PM, 1/12/26 AM or PM, 1/13/26 AM, 1/14/26 AM, 1/15/26 AM or PM, 1/16/26 AM or PM, 1/17/26 AM, 1/18/26 AM or PM, 1/19/26 AM or PM, 1/21/26 AM, 1/22/26 AM or PM, 1/23/26 PM, 1/24/26 AM or PM, 1/25/26 AM or PM, or 1/29/26 PM. The deep cleaning items listed on the bottom of schedules were cleaned 3 of 36 opportunities.During an interview on 02/05/2026 at 9:06 AM Staff I, Dietary Director did not confirm she had ever seen roaches in the kitchen. She stated pest control probably treated both the dry storage pantry and kitchen for roaches. On 2/05/26 at 9:18 AM confirmed that dead roaches remained in the kitchen under the sink, shelf, and dish machine.Upon follow up with Staff I on 2/05/26 at 9:22 AM, she stated she was not aware her hair was outside of her hair net and observed her attempt to tuck it in to a brown hair net. She stated she knew the brown hair nets slipped and she would have to make staff wear the bonnet style. She reported she would educate staff about the hair nets and ask them to change them if their hair was out. When asked about the dead roaches she stated she was not aware of them so could not say how long they had been there. She said staff should be sweeping and mopping according to the posted schedule. She thought staff probably didn't sweep far enough back to get them. Staff I then stated the facility had treated for roaches in the kitchen more than once and shrugged when asked why that was different than her answer before. She could not say if any other staff had seen the roaches.On 2/05/26 at 9:28 AM, the Administrator stated the roaches were sprayed and verified it was done by pest control on 1/20/26. She acknowledged that there had been multiple treatments and that if there were still live roaches the treatment was not yet effective. During a follow up about the roach activity in the kitchen on 2/05/26 at 1:05 PM, the Administrator stated kitchen staff were responsible for cleaning under the shelves and all around the kitchen.On 2/10/26 at 9:21 AM, Staff Q stated there was a cleaning schedule, and staff in the dish area should clean the floors in that area. Cooks cleaned the floors in their area. She reported seeing a live roach recently, and dead roaches the day before. Staff Q stated cleaning them up should be part of sweeping and mopping floors, which should be done at the end of every meal as part of clean up. She reported hair net policy was to have them on the minute they entered the kitchen and all hairs need to be tucked in with the hair nets over ears to make sure hair was not sticking out. During an interview with the pest control company on 2/10/26 at 5:02 PM, they confirmed treatments since November and stated it was significantly better, but still an issue. Treatments included the kitchen, hallways, dry goods, dining room, and the memory care eating area. He confirmed finding dead and living roaches in the kitchen when he treated on 2/06/26 and stated the kitchen was the source of the infestation. On 2/11/26 at 11:22 AM, Staff S, Assistant Dietary Director reported staff were expected to follow the cleaning schedule with initials to show it was completed. Staff should have their cleaning done by the end of their shift. She thought everyone participated. She acknowledged there had been live roaches in the kitchen recently and reported it was much improved. She stated she noticed dead roaches under the dish machine rack. Staff S stated staff were supposed to wear hair nets immediately when they entered the kitchen and they should cover all of their hair. On 2/12/26 at 10:56 AM during a follow up with Staff I to get the February cleaning sheets she stated staff were not good about signing off on the cleaning sheets and that they would have to get better at that. She acknowledged the January and February sheets were not completed accurately and it appeared the kitchen wasn't being cleaned. A kitchen policy titled Sanitation revised November 2022 documented the food service area was maintained in a clean and sanitary manner. All kitchens were to be kept free of garbage and debris, and protected from rodents and insects. Utensils, counters, shelves, and equipment were kept clean and in good repair. Ice machines were drained, cleaned, and sanitized. A policy titled Food Preparation and Service dated 2001 with no revision dates documented food preparation staff should adhere to sanitary practices to prevent the spread of foodborne illnesses. Cross-contamination could occur when harmful substances such as chemicals or disease causing microorganisms were transferred to food by hands or food contact surfaces not adequately cleaned. Food and nutrition services staff wear hair restraints so hair does not contact food.

Based on observation, invoices, resident and staff interviews, and policy review the facility failed to maintain a safe and sanitary environment for residents when the facility failed to keep vents between the kitchen and the dining room and in the dining room clean, failed to ensure facility windows, screens, and refrigerators were kept clean, and dead cockroaches from a prior treatment were found two days in a row in the family rooms in addition to sightings of live roaches. The facility reported a census of 94 residents. Findings include: 1. On 2/04/26 at 12:42 PM observed a live cockroach travel from the base of a cabinet under the sink in the family room to the inside of the cabinet. The cabinet contained a towel with brown and yellow stains on it that was stiff to the touch near the opening and damp towards the back. Where the water pipe entered the wall there was an approximately 1/4 inch gap between the wall and the sheetrock. On 2/04/26 at 5:16 PM the middle family room cabinets contained a live roach and 4 dead roaches surrounded by droppings. On 2/04/26 at 5:29 PM Resident #84 reported there had been mice and cockroaches in the building. On 2/05/26 at 8:13 AM observations included a live cockroach crawling on the cabinet under the sink in the family room. The dead cockroaches and droppings remained in the middle cabinet. On 2/05/26 at 10:11 AM, Resident #31 reported there was a black hard shell bug a couple of weeks prior on her curtain that dropped to the floor and crawled under her night stand. She has seen them in the dining room. On 2/05/26 at 1:07 PM, observed a dead roach in the refrigerator in the family room in the bottom shelf. The refrigerator contained a bottle of ketchup and two containers of yogurt. During a follow up about the roach activity in the family room on 2/05/26 at 1:05 PM, the Administrator stated housekeeping was responsible for cleaning the family room.Invoices dated 11/12/25, 12/09/25, and 1/20/26 revealed the pest control company treated for cockroaches in the kitchen, family room, and other living areas. A document provided with an additional invoice dated 2/06/26 (during the survey) titled What to Expect When Your Business has been Treated for Roaches indicated live roaches should be dead within 72 hours and to monitor for additional activity due to eggs in walls, cracks, and crevices hatching within the following 40 days. During an interview with the pest control company on 12/10/2026 at 5:02 PM they confirmed treatments since November and stated it was significantly better, but still an issue. Treatments included the kitchen, hallways, dry goods, staff break room, dining room, family room, memory care, and physical therapy. He confirmed finding dead and living roaches in both the kitchen and family room when he treated on 2/06/26 and stated the kitchen was the source of the infestation. 2. On 2/05/26 at 7:04 AM, entered the conference located next to the kitchen room after the light turned on walked over in front of the thermostat to check the temperature in the room. A cockroach fell and scurried across the top back of the blue chair and down the left side of the blue chair. On 2/10/26 at 9:15 AM, the 8 inch by 24 inch vent 100% covered in something black in the Dining room over the large white clock on the wall, between the main hall entrance and the door before kitchen serving door. The Maintenance man reported the vent looked black as a results of the paint. The other 3 vents in the dining room failed to look 100% black. On 2/10/26 at 9:15 AM, the ceiling vents located between the kitchen dirty door, the pop machine and the Dining room held 12 clumps of gray fuzz dangling from the vent grate 18 inches by 16 inches and 50% covered with gray fuzz on the 24 inches by 18 inches grate. On 2/10/26 at 11:02 AM the Maintenance man reported reported they clean the vents every 2 months. The vent looked clean. On 2/10/26 at 5:07 PM, the Administrator reported she knew of the dirty vents from the staff. On 2/11/26 at 11:20 AM, the Administrator reported the facility used a contract company for housekeeping services in the past and they are in the process of getting things in order. 3. On 2/12/26 at 9:25 AM, the refrigerator on Bluff View nurses station had large amount dried brown spills on bottom shelf and the bottom of the refrigerator. Observed a thick brown crusty substance on the grate on the front of the refrigerator. Spills on the door and expired items in the door included: -Thick & Easy apple juice dated 5/15 best if used by January 25, 2026 -Open container prune juice 11/25 dated -[NAME] jar with brown substance 1/3 full with no date -Applesauce on the shelf dated 1/30/26 -Paper plate with 3 slices of bread no date -Plastic container with meat no date on it The window screens at Bluff View nurses station had large amount of dirt and debris. The glass in the windows was covered in substance and appeared hazy. On 2/12/26 at 9:38 AM, Sunshine Valley nurses station refrigerator door shelves had large amount of dried brown substance on them. The shelves in the refrigerator had dried spills on them and container of cranberry juice dated 12/29/25 and open root beer dated 12/22. On 2/12/26 at 9:41 AM Staff X, Certified Medication Aide (CMA) stated had worked at facility for about 2 years and did not know who was responsible for the refrigerators at the nurses station. On 2/12/26 at 9:42 AM Staff V, Registered Nurse (RN) stated probable the night shift was responsible for the refrigerators at the nurses station. On 2/12/26 at 10:00 AM Staff W, Licensed Practical Nurse (LPN) stated the nurses were responsible for the refrigerators on the hallways, it was not assigned to a specific shift, and [Staff W] was not sure, would need to talk to maintenance, and was not sure who kept them clean or monitored expired outdated items. On 2/12/26 at 10:33 AM, the Maintenance Director stated the housekeepers would be responsible for the refrigerator. Per the Maintenance Director, had contracted service for environmental services and they were not taking care of it and then the nurses were responsible for it. Not sure who is responsible for it currently. The Maintenance Director explained thought housekeeper should be but as of now there was no plan. The windows in those area tried to do twice a year, spray the screens off, and clean the windows. On 2/12/26 at 10:43 AM, the Director of Nursing, RN stated the staff was on duty and the nurses have been instructed to clean the refrigerators. Per the DON, was in transition from environmental services staff, nursing had been cleaning them, but [DON] didn't know if there was an actual schedule or if anyone was doing temperature logs. The DON explained would expect them to be clean, food should dated, labeled and removed after a period of time.

Based on observation, record review, policy review and staff interviews, the facility failed to notify the physician when bilateral lower extremity reduction kit wraps (velcro cloth wraps for legs to help reduce swelling) were not applied as ordered by the physician for 1 of 1 residents reviewed (Resident #89). The facility reported a census of 94 residents. Findings include: Review of Resident #89's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status exam (BIMS) score of 13 out of 15, which indicated intact cognition. The MDS included diagnoses of anemia (reduced quantity of red blood cells), high blood pressure (condition where the force of blood pushing against your artery walls is consistently too high) and lymphedema (swelling of arms or legs caused by build up of lymph fluid).Review of Resident #89's Treatment Administration Record (TAR) January 2026 revealed the resident to wear bilateral lower extremity reduction kit wraps (velcro cloth wraps for legs to help reduce swelling) to be put on at 8:00 AM and removed at 8:00 PM. Review of Resident's #89's Progress Notes showed 18 of 31 days in January 2026 when staff did not apply reduction kit wraps due to legs being too swollen. On 1/6/26 the Provider wrote an order that the resident needed compression wraps on everyday. Review of Resident #89's Progress Notes lacked Provider notification of not applying reduction kit wraps to bilateral lower legs due to swelling.On 2/4/26 at 2:00 PM and 2/5/26 at 11:15 AM, resident was not wearing reduction kit wraps.On 2/5/26 11:15 AM, Resident #89 verbalized she doesn't mind wearing them (reduction kit wraps) the staff just haven't put them on.On 2/10/26 12:48 PM Staff E, Licensed Practical Nurse (LPN), verbalized Resident #89 had weeping edema on bilateral lower legs and she was to wear special leg wraps to legs, but when they weep were able to leave off the wraps so they won't be soiled by the drainage. Per Staff E, the physician was aware.On 2/10/26 1:40 PM, the Director of Nursing (DON) reported her expectation was that staff follow the orders as prescribed by the physician, and if the treatment was held the staff, would notify the physician for further instruction.On 2/11/26 9:49 AM, the Administrator verbalized her expectations of the staff to follow the orders as ordered by the physician and to notify the physician if treatments were not being done.The facility policy titled Acute Condition Changes-Clinical Protocol revision date March 2018 revealed the following per the Monitoring and Follow-Up section: The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. The physician will help the staff monitor a resident/patient with a recert acute change of condition until the problem or condition has resolved or stabilized.

Based on record review, staff interview, and policy review the facility failed to offer and/or administer the influenza vaccine for 2 of 5 residents reviewed (Residents #19 and Resident #64). The facility reported a census of 94 residents. Findings include:1. The annual Minimum Data Set (MDS) for Resident #19 dated 9/03/25 included diagnoses of personal history of pulmonary embolism (when a blood clot gets stuck in an artery in the lung, blocking blood flow) and localized edema. The Brief Interview for Mental Status (BIMS) assessment was blank and the staff assessment indicated the resident's cognitive skills for daily decision making was moderately impaired. An immunization consent form dated 10/29/25 documented the Infection Preventionist/Assistant Director of Nursing (IP/ADON) spoke to the resident's Power of Attorney (POA) who gave verbal consent for the COVID vaccine, influenza vaccine, and Respiratory Syncytial Virus (RSV) vaccines. A document titled Iowa Immunization Registry Information System (IRIS) revealed Resident #19 received the influenza (flu) vaccine in 2015, 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023, and January 2025. An email dated 2/10/26 at 1:22 PM from the IP/ADON indicated the facility had consent for the flu vaccine for fall of 2025 but Resident #19 and their spouse adamantly refused vaccination. The facility was unable to provide documentation that the resident or their spouse refused the vaccine after consenting. 2. The quarterly MDS for Resident #64 dated 12/10/25 revealed a Brief Interview for Mental Status (BIMS) assessment score of 11/15, which indicated moderately impaired cognition. The MDS revealed the resident did not receive the influenza vaccine in the facility for this year's influenza vaccination season, with none of the above as reason the influenza vaccine not received. The resident's IRIS revealed Resident #64 received the flu vaccine in 2017, 2018, 2019, 2021 (2020 variant), 2021, 2022, 2023, and 2024. An email dated 02/10/26 at 1:22 PM from the IP/ADON indicated the facility did not have consent for the vaccines on file, and the resident did not have a vaccine at the facility. Progress notes for resident #64 did not document why the resident was not offered or given the vaccine. An interview with the Director of Nursing (DON) and IP/ADON on 2/11/26 at 12:41 PM revealed resident vaccinations were completed in the fall. The facility used the IRIS documentation as part of the admission process for vaccination status and the facility would administer them in consultation with the physician. Verbal or written consent would be obtained prior to administration and documented. A policy titled Influenza Vaccine revised March 2022 documented all patients with no medical contraindications to the vaccine would be offered the influenza vaccine annually. The vaccine would be offered between October 1 and March 31 and/or within 30 days of the patient's admission to the facility. Refusal of the vaccine would be documented on the informed consent and placed in the medical record.

Based on clinical record review, therapy documentation, resident interview, and staff interviews the facility failed to provide required Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice forms (CMS 10055 and CMS 10123) at the completion of skilled services for 1 of 3 residents reviewed (Resident #61). The facility reported a census of 94 residents.Findings include:Review of Resident #61's Minimum Data Set (MDS) dated [DATE] for the end of Part A stay documented the resident's Brief Interview for Mental Status (BIMS) score was 15/15, which indicated intact cognition. A therapy note dated 11/21/25 revealed Staff H, Occupational Therapy advised the social worker of therapy recommendations for 24 hour care at the end of skilled services. During an interview on 2/11/26 at 10:13 AM, Staff H stated the resident's therapy ended 11/24/25. She confirmed the discussion with the social worker documented in the therapy note, and reported the social worker should have then prepared CMS forms 10055 and 10123 documenting the end of services. Staff H stated the facility could not find the resident's CMS forms. A review of progress notes from 11/19/26 through 11/24/26 determined the facility social worker spoke to the resident and a family member about discharge planning but did not include documentation that the appropriate paperwork was discussed, signed, or provided to the resident or family member. During an interview with Resident #61 on 2/11/26 at 10:32 AM, when asked about the end of therapy and if she recalled talking to a social worker or other staff about the costs that could be associated with ending therapy, she said no. She did not recall receiving or signing any paperwork. On 2/11/26 at 10:42 AM the administrator reported the social worker responsible for ensuring the CMS forms were completed timely no longer worked at the facility. She stated she was the current social services resource, she had already reviewed the former social worker's emails and paperwork, and they were unable to find the resident's CMS forms.

Based on observation, clinical record review and staff interview the facility failed to provide complete perineal care after incontinence for 2 out of 5 resident reviewed (Resident #11 and Resident #84). The facility reported a census of 94 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #11 dated 1/14/26 revealed the following diagnoses: Hypertension, Diabetes, Anxiety Disorder and Depression. The MDS revealed a Brief Interview for Mental Status score of 6 out of 15, which indicated severe cognitive impairment, and revealed the resident was dependent on staff for toileting hygiene and toilet transfers. The MDS reflected Resident #11 was always incontinent of bowel and bladder. The Care Plan intervention for Resident #11 dated 5/7/25 revealed the resident was frequently incontinent of bowel and bladder, utilize incontinent products for dignity. Provide incontinent cares as needed and utilize stock barrier ointment for skin protection from breakdown due to incontinence. On 2/10/26 at 8:27 AM, Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA provided perineal cares to Resident #11. Staff B wet two washcloths and placed on towel on night stand next to bed. Resident #11 observed in bed lying on back. Staff B used the washcloth to wipe right side and left side of abdominal fold into the perineum. Staff B then used second washcloth to wipe the middle of the perineum and failed to separate the skin folds. Staff C assisted Resident #11 to roll on right side. Staff B then wiped the center of the buttocks with the third washcloth and swiped across the the left buttock with the same area of the washcloth. Staff B failed to change the surface of the cloth. They assisted Resident #11 onto her back and placed a clean brief on the resident. Staff failed to wash the hip areas on the left and right side and never washed the right buttock. On 2/12/26 at 10:07 AM, Staff W, Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) stated staff should use soap and water in a basin when providing perineal cares. They should wipe both sides of the perineum and the middle. The abdominal folds should also be washed, rinsed and dried. She commented a clean surface should be used with each wipe of the washcloth. She would expect them to wash the buttocks and hips when staff provide perineal care. 2. The MDS for Resident #84 dated 12/3/25 listed diagnoses of the dementia and anxiety. The MDS reflected Resident #84 had short and long term memory problems, had severely impaired cognitive skills for daily decision making, was dependent on staff for toileting hygiene and toilet transfers, and was always incontinent of bowel and bladder. The Care Plan intervention for Resident #84 dated 2/22/25 directed a mandatory stand lift with assist of two staff for toilet transfers and assist of 1 staff with post-toileting hygiene tasks. The Care Plan intervention dated 2/22/25 identified Resident #84 was always incontinent of bowel and always incontinent of bladder. The Care Plan directed incontinent cares routinely and as needed. On 2/10/26 at 1:32 PM Staff C, CNA removed Resident #84's brief as it hung down appeared heavily soaked as she placed it into the trash can it plopped at the bottom of the trash can. On 2/10/26 at 1:39 PM Staff B, CNA stood Resident #84 up with the stand lift. Staff B used a wipe to swipe up her rectal area one time. Staff B failed to wash the front of Resident #84 and failed to wash her buttocks. On 2/10/26 at 1:43 PM Staff C reported they were to wash all the areas of the skin that got wet from incontinence. Staff C confirmed Staff B failed to wash Resident #84's front peri area. Staff C reported Resident #84 reported that she had a bath in the morning. On 2/11/26 at 1:20 PM, Staff T, Certified Medication Aide (CMA) reported if a resident was incontinent she cleaned them. Staff T explained a very wet brief that hit the trash can made a plop noise. Staff T said she uses soap and water to clean residents after incontinence provide care. On 2/11/2026 at 3:15 PM Staff M, Registered Nurse (RN) reported if she found a resident who is wet from urine the staff needed to clean them, clean all the area of the skin that was wet with urine. Staff needed to wash front to back change the cloth surface with each swipe, pat the skin dry. On 2/12/26 at 10:03 AM, the Administrator reported she expected the CNAs to provide incontinent care after each episode of bowel or bladder incontinence. She said the staff needed to wash all the areas that came in contact with the urine or bm (bowel movement). The Administrator stated she expected residents toileted every 2 hours or as they needed to go to the bathroom. The facility provided an undated Incontinent Care Checklist, undated, which directed to wash all soiled skin areas including hips. Ensure washing from front and back. Use clean area of the washcloth each stroke. Rinse and dry very well especially between skin folds.

Based on observation, record review and staff interview the facility failed to provide adequate assessment and intervention after a fall for 1 of 3 residents reviewed with a fall (Resident #11). The facility reported a census of 94 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 revealed a diagnosis of hypertension (high blood pressure), diabetes, and depression. The Brief interview for Mental Status (BIMS) revealed a score of 7 which indicated severe cognitive impairment. The MDS indicated the resident required maximal assistance from staff for transfers. An Incident Report dated 12/15/25 at 5:00 PM revealed Resident #11 told Certified Certified Nursing Assistant (CNA) she could walk and CNA pushed button on the recliner to raise it and when her partner saw this informed the CNA she was an EZ stand (mechanical lift). Resident #11 started to slide and CNA could not hold the resident up and CNA assisted Resident #11 to the floor. Resident did not hit head. No visible injuries noted. Staff assisted resident #11 into the wheelchair per 3 assist and gait belt. Review of the electronic health record failed to reveal any documentation of vital signs, skin or an assessment in the progress notes until 12/16/25 at 7:13 AM. The progress note revealed when waking up for the day Resident #11's right ankle bruised, swollen and painful to the touch. Resident #11 could not move her ankle. The resident's Provider was notified On 2/12/26 at 8:31 AM, Staff Z, Registered Nurse (RN) stated she did not recall Resident #11 having pain the night of her fall 12/15/25. Per Staff Z, would monitor for 72 hours after a fall and it is usually if they hit their head, and if unwitnessed fall would usually do neuros (neurological checks) every 15 minutes for the first hour, and follow up with skin check every 12 hours and vital signs every 8 hours. Staff Z explained they were told by the day shift nurse to do the 8 hours vital after fall first occurred and for 24 hours after the fall, and would be documented in the electronic health record if were completed. Staff Z did not recall a certified nursing assistant (CNA) told them Resident #11's ankle was swelling or bruised, and did not recall CNA telling [Staff Z] anything about pain. Per Staff Z, they (staff) were usually pretty good about telling [Staff Z] if there was pain. On 2/10/26 at 4:11 PM Staff W, Licensed Practical Nurse (LPN) stated after a fall, nurses document in the electronic health record. The vital signs should be documented in the vital section and a fall follow up in the nurse progress notes. The fall follow up protocol is for 72 hours there should be a neurological check, vital signs and body chart completed. Vital signs should be checked every 8 hours and skin needs to be documented on every 12 hours. On 2/11/26 at 3:05 PM, Staff GG, LPN stated remembered staff told [Staff GG] Resident #11 was on the floor so [Staff GG] went in her room. She (resident) did not complain of pain and [Staff GG] moved her arm and legs and she did not have any pain that night. No skin tears, no redness, no warmth or bruising. Staff GG explained worked the 6AM to 6PM that day, and another nurse came on after that. Per Staff GG, did pass it along to the other nurse, and could not remember who followed [Staff GG] that night. Staff GG further explained typically would document for assessment follow up, and it was different at this facility. Staff GG explained did the whole thing wrong because the next morning, they went into chart on it and [Staff GG's] assessment was wrong. The Administrator and Director of Nursing (DON) said they had to redo it because it was wrong, they had taken what [Staff GG] had written and put on the correct assessment. Per Staff GG, for follow up, nobody showed [Staff GG] how to do it correctly, and the next day [Staff GG] just went and did an nurses progress note and that is when [Staff GG] found her ankle. Staff GG further explained every shift after the fall should have an assessment included head toe, pain, vital signs with it and should do range of motion if complaints of pain. Per Staff GG, the next morning [Staff GG] started their shift and after report the CNA came to [Staff GG] and said her ankle really hurts her, it was already terribly bruised, swollen and she could not move it, and Staff GG explained could tell by looking at it was probably broke. Staff GG explained didn't know if she (resident) didn't complain of any pain through out the night but it was the first thing told CNA in AM. Staff GG explained they were a nurse at their (current facility's) sister facility, did not have orientation or training about anything, was asked me to fill in, and was given an overview of what needed to be completed but nothing with paperwork. Staff GG explained they just figured it was the same as the other facility, they have the same electronic health record, and further explained it was completely different at this facility. On 2/12/26 at 12:03 PM, the DON stated at the time of the fall, the staff who found the resident assist them to stay in place, immediately assess before moving, and do vital signs and provide for safety. They initiate neurological checks on head strike or unwitnessed falls. The DON expected staff to assess for pain and reassess pain post fall, and would go back more frequently with any fall follow up in an hour to two hours at the most. The DON explained should document that in the electronic health record. Normal fall protocol is every 15 minutes x 1 hour and 30 minutes for the next couple hours. Per the DON, had to look at it to make sure what it was exactly, it was a blank excel template. Per the DON, would expect vitals to be documented, the DON knew falls have been a concern, and it was an area that [DON] had identified for a performance improvement project. Per the DON, did have a fall process. The DON explained wouldn't know the answer to how often an assessment should be completed after a fall, the computer triggered it, and [DON] could see if I had the paper. They should have documented before the next morning on Resident #11. The Facility Policy titled Falls - Clinical Protocol revised March 2018 directed the staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall.

Based on observation, clinical record review, facility documentation, resident interview and staff interview the facility failed to ensure 2 of 3 residents observed for room trays received their meals in a timely manner (Residents #31 and Resident #104). The facility reported a census of 94 residents. Findings include: 1.The Minimum Data Set (MDS) for Resident # 31 dated 11/19/25 documented a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive impairment.During an observation on 2/5/26 beginning at 9:30 AM, Staff J, Restorative Aide, Staff K, Certified Nursing Assistant (CNA) and Staff L, CNA were heard at the nurses station on Bluff View discussing that Resident #31 just woke up and did not have a breakfast tray. During an interview on 2/5/26 at 10:30 AM, Resident #31 explained she did not get breakfast and no one woke her up for breakfast. She explained she does not get meals frequently and her son bought her a mini fridge for her room so she would always have food available. A mini fridge was observed between the bed and dresser. When asked if she wanted breakfast, she said since it was so close to lunch, she would have a doughnut for breakfast that her family provided. A gallon size zip lock bag was observed on her overbed table with 4 doughnuts with frosting and sprinkles. The facility document titled Documentation Survey Report v2 for February 2026 documented NA for breakfast on 2/5/26. Per the code at the bottom of the page on the report, NA meant not applicable. 2. The MDS for Resident #104 dated 2/2/26 revealed a BIMS score of 15/15, indicating no cognitive impairment. During an observation on 2/10/26, meal trays were delivered to Bluff View at 11:40 AM. At least 4 trays had orange sticky notes identifying the resident to get the tray, other trays had a meal ticket identifying the resident to receive the tray. The trays were distributed to residents. At 11:46 AM staff called dietary over the walkie talkie to report that Resident #104 did not have a tray on the cart. No response was received over the walkie talkie. At 12:11 PM, Staff R, CNA answered Resident #104's call light. The resident reported to Staff R that she had not had lunch yet. At 12:17 PM, Staff R delivered a room tray to Resident #104. Review of meal times document provided by the facility documents breakfast 7:15 AM to 9:00 AM and lunch 11:15 AM to 12:15 PM. During an interview on 2/10/26 at 12:18 PM, the Certified Dietary Manager (CDM) explained the dietary staff are notified a resident needs a meal tray by the meal ticket. If it is last minute, the CNAs call down on the walkies. She further explained meals are tracked by keeping the tickets and there has never been a problem with residents not getting served. On 2/11/26 at 2:51 PM, the Director of Nursing (DON) reported the CNAs were responsible for taking the trays to the rooms and documenting the intakes. She reported she expected residents to offered 3 meals a day.

Based on observation, record review and staff interview the facility failed to provide appropriate practices to prevent the spread of infection during wound care for 1 of 2 residents observed for wound care (Resident #80). The facility identified a census of 94 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for dated 1/14/26 revealed Resident #80 had severely impaired cognitive skills for daily decision making. Review of the Hospice order for wound care to Resident #80's left knee dated 2/4/26 revealed to cleanse left knee wounds with wound cleanser, apply triple antibiotic ointment, non adhesive dressing and wrap with cotton gauze twice a day and as needed. May discontinue when no longer draining and healed. On 2/05/26 at 11:02 AM, Staff E, Licensed Practical Nurse (LPN) provided wound care to abrasion on the left knee of Resident #80. Staff E removed the dressing from the left knee and cleansed the wounds. Staff E did not remove gloves or wash hands after she cleansed the wound Staff E used her index finger and applied triple antibiotic from the tube to each of the four areas on the left knee three of the areas were open skin. Staff E did not use a different finger or an applicator to put the ointment on the wound. On 2/12/26 at 8:54 AM, Staff U, Registered Nurse (RN) stated gloves should be changed after removal of soiled dressing for wound care and wash hands. He revealed he would use a sterile applicator for each area to put ointment on a wound. On 2/12/26 at 9:16 AM, Staff V, RN explained set up supplies, clean the wound, and take gloves off and wash hands. Per Staff V, they would put ointment with gloves on, and should change gloves with each area. If in same area could use the same gloves, take off gloves and wash hands, and apply clean dressing. On 2/12/26 at 10:03 AM, Staff W, LPN, facility wound nurse stated she noticed Staff E put the ointment for Resident #80's left knee wound on her gloved finger and she would have expected her to use an applicator. She also noted she should have cleaned her hands between cleansing the wound and applying the ointment. On 2/12/26 at 12:00 PM, the Director of Nursing stated staff should wash hands and change gloves between cleansing the wound and applying an ointment. Ointment should be applied with an applicator and each wound area should get a different applicator. The facility provided a policy titled Wound Care with a revision date of October 2010 which directed staff after removal of dressing to remove gloves, wash and dry hands thoroughly. The policy directed to use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers.

Based on observation, record review, and interview the facility failed to ensure nursing department staffing information was posted with the required information on a daily basis for 3 of 6 days of the survey. The facility reported a census of 94 residents. Findings include:Observations of the staff posting by the nurses station included the following: On 2/04/26 at 12:09 PM the staff posting was dated 2/02/26.On 2/05/26 at 10:54 AM the staff posting was dated 2/04/26.On 2/10/26 at 12:08 PM the staff posting was dated 2/09/26. On 2/10/26 at 11:05 AM, the staff posting on the wall outside of the SS Unit (memory care) showed a date of 2/06/26. On 2/11/26 at 1:04 PM the Director of Nursing (DON) stated the only staff posting was by the nurses station. She said the scheduler was responsible for emailing it to the charge nurse, including the weekend schedule for posting. The DON stated third shift usually took care of it and would not forget because they didn't want the aides asking about it all day. She was not aware there were postings missing. Documents provided by the facility for 2/01/26 through 2/11/26 titled [Facility Name] Report of Nursing Staff did not include a staff schedule for 2/03/26. Documents provided by the facility for 2/01/26 through 2/11/26 titled [Facility Name] - SS Unit Report of Nursing Staff did not include staff schedules for 2/01/26, 2/03/26, or 2/04/26. They documented Certified Nurses Aides (CNAs) assigned to the area and did not include Registered Nurse (RN) or Licensed Practical Nurse (LPN) coverage for the area. On 2/12/26 at 1:23 PM, the Administrator acknowledged the gaps in staff posting and stated the DON was aware of it and would address it.

Based on clinical record review, staff interviews and facility policy review the facility failed to remove a transdermal patch prior to administering a new patch on 1 of 1 resident (Resident #2) which caused increased confusion and required an admission to the hospital for treatment of acute encephalopathy. The facility reported a census of 90 residents.Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #2, dated 8/8/25, revealed a list of diagnoses which included coronary artery disease, hypertension, Parkinson's disease, and bipolar disease. The MDS indicated the resident experienced short term memory problems and difficulty with decision making. The MDS assessed the resident required extensive assist with toileting, bathing and dressing. Review of Resident #2 September 2025 Medication Administration Record (MAR) revealed an order for Rivastigmine Transdermal Patch (a medication in the neurotransmitter class that helps with memory and cognition that is delivered through a patch placed on the skin) 24 hour 13.3 MG (milligram). Apply 1 patch transdermally at bedtime for Parkinson's/Dementia. Take off old patch before applying a new one and remove per schedule. Start Date 12/2/24. Review of the electronic health record (EHR) revealed a Medication Administration note entered on 9/23/25 at 8:00 PM Rivastigmine Transdermal Patch 24 Hour 13.3 MG/24HR Apply 1 patch transdermally at bedtime for Parkinson's/Dementia, take off old patch before applying a new one and remove per schedule old patch was not there. Review of the document titled Medication Error, Date: 9/29/25 at 20:00 [8:00 PM] revealed: Resident [name redacted, Resident #2] .Incident Description: Nursing Description - Resident was standing naked in room holding on to closet door. Resident was breathing heavily. Resident was assisted to sitting position on his walker. When Med aide went behind resident, she noted he had two Rivastigmine patches on., They were immediately removed and vitals were taken. Immediate Action Taken: Resident was immediately assessed and vitals were taken. Resident was given HS (bedtime) with his Alprazolam. Resident was then assisted to the bathroom and washed up and dressed for bed. Resident was then assisted to bed. Resident has been assessed again at 2200 [10:00 PM]. Frequent checks have been performed on resident. Resident is resting in bed and is stable. Review of a document titled Psych Med Check Progress Note, dated 9/30/25 at 1:25 PM revealed, in part: History of Present Illness: he got an overdose of the rivastigmine patches, they did not take the old patch off and put the new one on, he was confused and agitated, last night, he has trouble in the right hand and his mouth felt worse, more confusion, hypertension, and hyper ventilating; they thought he had a UTI (urinary tract infection) few days ago, he did not have one, he seemed confused more than usual.Review of a Medication Administration note entered on 9/30/25 at 7:40 PM revealed in part.Take off old patch before applying new one and remove per schedule hold per DR (doctor) until side effects are gone. Review of a document titled Physician Visit Form (out of office) signed by [provider name redacted] on 9/30/25 revealed, in part: Reason for Visit: Routine Visit? had adverse reaction from Rivastigmine patches had 2 patches on 3 days in row. B/P: 155/90, 105, O2 (oxygen) 99% - hyperventilating - increased confusion -gave Xanax (anti-anxiety medication) then 1.5 hours later 93/62 - 83-O2 99%. Progress Note: Worse after OD (overdose) of Rivastigmine.Review of a hospital Discharge Summary revealed, in part: Date of Service: 10/3/25 at 12:46 PM [physician name redacted] admit date : [DATE]. discharge date : [DATE]. Summary of Hospitalization: Reason for Hospitalization: Patient is [AGE] year-old who was brought to the ER after developing confusion and having falls. He had been noted by family to have more falls and to have change in his overall mental status in the past 2 weeks. He had occasional hallucinations. No fevers, chills, dyspnea (shortness of breath). He has found at his nursing home to have 3 Exelon (brand name for rivastigmine transdermal patch). He was seen by his psychiatrist who felt that his symptoms could be from this, but he was brought to the ER for further evaluation.Diagnoses: Principal Problem: Acute encephalopathy (rapid onset of altered brain function).Hospital Course: Patient was admitted to the medical service. His Excelon was discontinued. He had gradual improvement in his mental status and appeared to be back to his baseline by discharge. Repeat head CT showed no evolving changes to suggest stroke. EEG ( an electroencephalogram - a test to record electrical activity in the brain to diagnose and monitor neurological conditions) showed no seizure activity. On 10/22/25 at 11:30 AM, the consultant pharmacist stated the facility had reached out to her and informed her of the medication error for Resident #2. She stated she did not feel the medication error contributed to his recent falls but it could have caused the acute encephalopathy. She stated she could see why the hospital physician is attributing to it because the hallucinations and confusion did clear after the patches were once removed. She stated the likelihood is the extra patch could have caused the Acute Encephalopathy.During an interview on 10/22/25 at 1:14 PM, Staff A, Certified Medication Aide (CMA) stated the night of 9/29/25, Resident #2 acted very confused and he self-transferred and did not have any clothes on when she found him. She stated she noticed he had two patches on his back. Staff A described the resident as very shaky and acting very out of it while she administered his medications. Staff A stated she and Staff D, Licensed Practical Nurse (LPN) sat him down and noticed he had two patches on his back. She stated one of the patches was dated from the night prior, and the other patch was not initialed or dated. Staff A stated we are supposed to initial and date the patch prior it to being placed on the resident. Staff A explained the behavior Resident #2 exhibited was not normal for him as he does not normally self-transfer and his eyes could not focus. On 10/22/25 at 2:07 PM, Staff B, CMA stated the process for a transdermal patch is to take the old patch off the resident and wash the area then put a new one on the opposite side. She explained you need to look to see if there are any other patches, and the patch should be dated and initiated. Staff B stated she thought she worked on September 27, 2025 and removed a patch and placed a new one on at that time. Staff B stated she labeled and initiated the new patch. She stated she placed it on the opposite side of the residents back. Staff B stated she didn't know where the extra patch was located or when it was put on his back, adding she did not see the extra patch. Staff B explained the patches are tan and a circle shape, and can be seen when taking it off. She stated Resident #2 was fine the night she saw him. Staff B recalled another CMA came over and let her know he had an extra patch on his back. She stated she told the CMA she had no idea he had more than one on his back. Staff B added the resident was in his recliner when I administered the medication. During an interview on 10/22/25 2:15 PM Staff C, CMA explained the process to administer transdermal patches is to take off the old patch and then put a new one on with initials and the date. She stated the patch needs to be signed out on the MAR, with the location of the new patch indicated and where the old patch was removed from. Staff C stated she did not notice any extra patches on Resident #2 on 9/25/25. She added she had not seen any extra patches on him at any time that she can recall. Staff C stated she always labeled with the date before she puts them on the resident. She stated she was off and when she came back on Tuesday they told staff to hold his patches so she did not administer it. She recalled the resident was out for an appointment on 9/30/25. On 10/22/25 at 3:37 PM Staff D, Licensed Practical Nurse (LPN) stated on 9/29/25 the CMA passed medications and she answered a call light and could hear someone making a noise and it was someone breathing really fast and they figured it was coming from Resident #2 room. She explained the resident was standing behind the door, holding onto the armoire. She explained the CMA was able to squeeze into the room and assisted him to sit down and that is when she noticed two transdermal patches on his back. Staff D stated they took the residents vitals and assessed him. She recalled they had him take deep breaths and he started to calm down and the vitals were stable. Staff D stated they did not reapply a patch. She stated the resident's wife was notified. Staff D stated she did not see where the patches were located because she was facing him and the CMA was behind him. She stated she immediately said to take them off. Staff D stated she thought one of the patches did have writing on it but she could not be 100% for sure what it had on it, and the other one did not have nothing written on it. Staff D stated she did frequent checks on him throughout the night. Staff D explained the process for administering a medication patch would be to wear gloves and take the old patch off and apply the new one to a different area. She added the date and staff initials should be on the patch and it should be documented where the new patch was placed and the location of where the old patch had been removed from. During an interview on 10/22/25 at 6:53 PM, Staff E, Registered Nurse (RN) stated the reason why she sent Resident #2 out on 10/1/25 to the emergency room was he was acting out, he had fallen and he had also fallen the previous night, and his blood pressure was elevated. She explained the resident was usually orientated to self, place and knew the staff and their names. Staff E stated the resident was confused to person and place. She stated she had not seen him since the multiple patches were found on him. She explained he was not his normal self. Staff E stated usually the CMA administered the Exelon patches. She stated if she administered the patch, she would remove the old patch and then put a new patch on with the date and her initials. She added she would document that she removed the patch and where she removed it from, and that she put another one and where the new patch placed. On 10/22/25 at 7:04 PM Staff F, CMA stated on 9/27/25 she put a patch on Resident # 2. She stated she searched everywhere for the old patch. She explained she had him lean forward and could not see it. Staff F stated sometimes the patches fell off and she couldn't find them. She stated she should have let the nurse know but she was busy so she just put a new one on his back. Staff F stated she heard he had three [patches] on and she was not sure how that happened. She stated the resident had been having a lot of falls prior to that week. Staff F stated she did not document that she removed it unless she did it by accident. She stated she didn't normally work down there and Resident #2 is the only one with a transdermal patch. Staff F stated we have a new system for charting so she could have documented it by mistake. She stated she felt like she put it in the progress notes she could not find the patch. Staff F stated the facility did talk to her about it and she did get written up. She added the facility also provided education. During an interview on 10/23/25 at 11:24 AM, the interim Director of Nursing (DON), RN stated the facility investigated the medication error for Resident #2 and did coaching with the medication aide. She stated staff did find 2 rivastigmine patches on the resident at one point. The DON stated we removed them and the medication was put on hold and then 3 days later the resident had the change in condition. Resident #2 was sent out to the hospital. The facility disciplined the CMA and educated her to the medication error. The DON stated would expect a transdermal patch to be removed by the nurse. She explained we learned the CMAs were applying and removing the patches, but the nurses should be doing this. The DON stated the nurse should be in charge of removing and administering patches going forward to mitigate reoccurrence. She explained nurses do not apply a new patch if unable to locate the old one. She added the nurse is expected to do a head-to-toe body inspection to confirm whether there is a patch. The DON stated if the patch is not found after a complete visual check of the body, the nurses should make note the patch was not found and reapply a new patch. The DON added patches should be labeled with the initials of who administered and the date. On 10/23/25 at 11:51 AM, the Administrator stated when she investigated the medication error for Resident #2, she determined on September 26, 2025, Staff F, CMA charted the transdermal patch incorrectly. She explained Staff F documented a Code 1 on the MAR, which indicated absence from home without meds, when Staff F should have documented in the progress notes that she could not locate the patch. The Administrator explained that Staff F, after not being able to find the patch, went ahead and administered a new patch on Resident #2. The Administrator stated on September 29, 2025 Staff A, CMA found and removed 2 rivastigimine patches from the residents back. During the investigation, the Administrator stated Staff F could not explain why she coded a 1 instead of documenting she could not find the patch. The Administrator stated she also interviewed Staff B, CMA who reported on 9/28/25 she took one patch off the resident's low back. The Administrator explained per review of the chart the patch should have been located on the resident's scapula. The Administrator stated she asked Staff B if she checked the chart for the documented location and she stated she did not. The Administrator stated this is the reason the staff received a verbal warning. When queried about the 9/23/25 note entered by Staff G, CMA not being able to find an old patch before administering a new patch, the Administrator stated she was not aware of the note. The Administrator stated her expectation is for staff to not place a new transdermal patch on resident until the other one is removed or a complete skin assessment has been done to confirm it is not on the resident's body. The Administrator explained since the incident with Resident #2, the facility implemented the practice of only nurses applying transdermal patches, and that all patches will be dated and initialed prior to placement. Review of review of employee records revealed:a. On 10/8/25 Staff B, CMA received the following written warning on 9/28/25.staff removed rivastigmine patch from Resident #2 and place a new patch on 9/29/25. After the resident fell, 2 patches were found, with one of the patches found being placed on his back by Staff B, and the other one placed on his left scapula. b. On 10/08/25 Staff F, CMA received the following written warning on 9/27/25. staff charted unable to find the Rivastigmine patch on Resident #2. She stated when asked she thought it fell off, at that time she placed another patch on the resident causing a medication error. On 10/23/25 at 12:19 PM, when asked for the facility policy on transdermal patch medication administration, the Administrator stated the facility does not have a policy. Review of a facility policy, titled Administering Medication, revised 2019, directed staff to administer medications in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, clinical record review, staff and resident interview, along with policy and procedures, the facility failed to treat and manage pain, for 1 out of 3 resident reviewed (Resident #1) Resident #1 ran out of pain medication on 8/13/25-8/18/25, for which resulted in the resident being sent out to the local Emergency Department on 8/16/25 and 8/17/25 for pain medications. The facility reported a census of 99 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 with a Brief Interview For Mental Status (BIMS) score of 15 for which indicated no cognitive impairment. The MDS documented the resident with diagnosis for which included Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Diabetes Mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy), absence of left leg above the knee and back pain. The MDS documented a scheduled pain medication regimen with an opioid (a class of drugs that reduce moderate to severe pain by binding to receptors on nerve cells in the brain and body) given every day in the 7 day look back period. The MDS documented the resident required dependence with showering/bathing, personal/ toileting hygiene and dressing and a wheelchair used for mobility.The Plan of Care dated of 7/31/25, documented I am on pain medication therapy and Oxycodone (opioid pain medication used to treat moderate to moderately severe pain related to disease process. Interventions include, administer medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Ask physician to review medication if side effects persist. Monitor/document/report adverse reactions to pain therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus (itching), respiratory distress/decreased respirations.The Discharge Summary Report dated 7/30/25 at 10:44 a.m., documented, patient discharge/transferred to a Skilled Nursing Facility. Diagnosis include; status post above knee amputation of left leg, peripheral vascular disease and generalized weakness. Medications include, Oxycontin 10 mg every 12 hours scheduled. The Internal Medicine Progress Notes dated 8/5/25, documented, Resident is seen today for a Skilled Care Admission. He reports pain 9/10 to left above-knee amputation site. Complex regional pain syndrome (chronic arm or leg pain developing after injury, surgery, stroke or heart attack, may involve abnormal inflammation or nerve dysfunction). Followed by pain clinic. No medication changes.The Internal Medicine Progress Notes dated 8/8/25, documented, His only complaint is of on-going pain. He notes pain in his left leg following the amputation. He also has pain in his right leg. He has a history of chronic pain. A review of systems is attempted with the patient. One point that the patient is most insistent on is one of chronic pain. He notes pain particularly from his left leg after the amputation, but also has pain in his right leg and other areas. He would like to have his pain medications given routinely at exactly 8 hour intervals. He believes with his anxiety, that antianxiety medications should be given with his pain medications to smooth things out'. No medication changes.The Internal Medicine Progress Notes dated 8/12/25, documented, Oxycontin 10 mg, one tablet every 12 hours for pain. Patient is rating pain 5/10 to left stump that is improved from last week, usually rating 9/10. Pain appears to managed. Continue with oxycontin 10 mg every 12 hours.The Medication Administration Note dated 8/13/25 at 9:26 a.m., reflected, oxycontin oral tablet, 10 mg every 12 hours, medication not available and waiting for script from the primary care provider.The Medication Administration Note dated 8/14/25 at 11:57 a.m., reflected, Oxycontin 10 mg oral tablet to be administered every 12 hours, medication not available. Awaiting script from Medical Doctor.The Social Services Note dated 8/14/25 at 3:23 p.m., documented, Resident reported that he was in pain and that he wanted his pain medications. Resident informed by nurse prior that he did not have any and that he needed to call the doctor to get more. The Internal Medicine Progress Notes with an encounter dated 8/14/25, documented, Patient is seen for follow-up from the nursing home. The patient primary complaint continues to be of pain. He notes in particular pain from his left leg after the above-knee amputation. He request stronger pain medications. He does note a history of anxiety. He notes that he is frequently using his call button at the nursing home because he is frequently lonely. He demonstrated mild confusion. He continues to have quite a bit of pain from the left leg as phantom pain. He insists on his need for stronger and more frequent pain medications. Will increase his antianxiety medications. Monitor things subsequently. They can call with problems.The Nurses Note dated 8/14/25 at 4:40 p.m., documented, Resident returned to the facility from Doctors appointment. No new orders for pain medication. A call made to orthopedic surgeon. Orthopedic surgeon deferred all pain medication orders to primary care provider. A facsimile sent to primary care provider asking for pain medication for resident. The Medication Administration Note dated 8/14/25 at 8:11 p.m., reflected that oxycontin oral medication 10 mg, to be given for pain every 12 hours, medication not available.The Nurses Note dated 8/14/25 at 8:30 p.m., documented, Resident angry at staff for not having his pain medication. Explained to resident that we do not have any here, that he does not have a prescription for any pain medications. That his primary care provider was notified of his request. The Medication Administration Note dated 8/15/25 at 10:22 a.m., reflected that oxycontin 10 mg, to give every 12 hours, medication not available, no script from the primary care provider.The Medication Administration Note dated 8/15/25 at 7:49 p.m., reflected that oxycontin 10 mg, to give every 12 hours, medication not available.The Medication Administration Note dated 8/16/25 at 12:17 p.m., reflected that oxycontin 10 mg, to give every 12 hours, medication on order.The Transfer to Hospital Summary Note dated 8/16/25 at 7:49 p.m., documented, Resident complaining of pain, as a 10/10. Resident visually upset, tossing around in bed, unable to get comfortable. Resident requested to be sent out to the Emergency Department (ED) for further evaluation and treatment. The Hospital Transfer form dated 8/16/25 at 9:08 p.m., documented, primary reason for transfer: Pain (uncontrolled).The Emergency Department Provider Notes dated 8/16/25 at 9:18 p.m., documented, Resident came for request of pain medication refill due to chronic renal pain syndrome (persistent, long-term kidney pain, for which presents as a dull ache in the upper back under the ribs, and can be on one or both sides). Resident takes Oxycontin 10 milligrams (mg) every 6 hours. He reports that he has pain to left leg, ongoing since surgery. This pain causes an increase in his baseline anxiety. I am just here for my medications. The long-term care facility is out of both medications. It sounds like prescriptions have been called into the pharmacy but they have yet to be delivered to the facility. Medications given as requested. One tab of each is sent to long-term facility with patient, refills should be available to patient as of tomorrow. Patient is discharged in stable condition.The Health Status Note dated 8/16/25 at 10:33 p.m., documented, Resident returned to facility via ambulance. Resident evaluated in the ED, no concerns at this time. While in ED, oxycontin given at 9:51 p.m. One dose of oxycontin sent back with resident to facility to help mitigate pain. The Nurses Note dated 8/17/25 at 7:19 p.m., documented, Resident initiated 911 call due to pain medication being unavailable in house at this time. Resident engaging in angry outburst with staff and reports pain as a 10/10. Resident transferred to the ED.The Hospital Transfer form dated 8/17/25 at 7:22 p.m., documented, reason for transfer, Pain (uncontrolled).The Emergency Department Provider Notes dated 8/17/25 at 7:33 p.m., documented, Patient arrived per ambulance. Patient with left leg pain. Patient is post amputation. Patient states I was here yesterday and got a script for pain medications but it never got filled. Patient states It's been at least 8 hours since I had my last pain pill. Encounter for chronic pain management. Oxycodone 10 mg given. Patient discharged in stable condition back to the long-term care facility.The Medication Administration Note dated 8/18/25 at 10:02 a.m., reflected, oxycontin 10 mg pain medication to be delivered from pharmacy.A facsimile dated 8/19/25, to the primary care provider, with no time, documented, Resident was sent to the emergency room on 8/16 and 8/17 for pain management. Resident complaining of pain, reporting pain as a 10/10. Resident visually upset, tossing around in bed, unable to get comfortable. Resident requested to be sent out to Emergency Department for further evaluation and treatment. Resident initiated 911 call due to pain medication being unavailable in house this time. Resident engaging in angry outbursts with staff and reports pain as 10/10. Observation on 9/16/25 at 8:30 a.m., Resident #1 sitting in wheelchair in their room. Call light with in reach. Resident appeared to be dressed appropriately. Interview on 9/16/25 at 8:30 a.m., Resident #1 explained that he had to call 911 to take him to the ED for his uncontrolled pain in his left leg. Resident stated that the facility did not have any oxycontin medication to give him from 8/13/25 until 8/18/25. Resident stated that his pain was a 10/10 and unbearable.Interview on 9/16/25 at 2:40 p.m., Staff D, Registered Nurse (RN) stated that the expectation of the nurses are to notify the primary care provider of any medications that are not available and to call the primary care provider every day until a prescription is obtained. The Pain-Clinical Protocol dated 10/22, instructed that, if the physician determines that opioid medication is an appropriate option for managing acute (or in some cases chronic) pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.

Based on clinical record review, staff interview, facility policy and procedure the facility failed to reconcile narcotic/controlled substance counts at the beginning and ending of every shift for one of three residents reviewed (Resident #2) for which resulted in a narcotic cassette missing. The facility census was 99 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 with a Brief Interview For Mental Status (BIMS) score of 15 for which indicated no cognitive impairment. The MDS documented the resident with diagnosis for which included heart failure, Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Diabetes Mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy), sepsis (a life-threatening complication of an infection) and chronic pain. The MDS documented a scheduled pain medication regimen with an opioid (a class of drugs that reduce moderate to severe pain by binding to receptors on nerve cells in the brain and body) given every day in the 7 day look back period. The MDS documented the resident required partial to moderate assistance with showering/bathing and dependent with toileting hygiene and dressing.The Plan of Care dated of 8/27/25, documented I am on pain medication therapy and received Tramadol (opioid pain medication used to treat moderate to moderately severe pain. Related to disease process of Osteomyelitis (inflammation of bone caused by infection, generally in the legs, arm, or spine) Interventions include:*Administer medications as ordered by physician. *Monitor/document side effects and effectiveness every shift.*Ask physician to review medication if side effects persist.*Monitor/document/report adverse reactions to pain therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus (itching), respiratory distress/decreased respirations.The Nurses Notes dated 8/29/25 at 9:23 a.m., late entry: Resident admitted around 11:55 a.m., on 8/26/25. Orders faxed to pharmacy. Resident complained level 4-8 pain to right heel and coccyx. Orders for oxycodone/Tylenol and Tramadol. At approximately 3:00-3:45 p.m., emergency medication removed for Emergency Box storage room and opened on counter at nurses' station. First large (tackle box) opened and medication was not in that box, box returned to medication room Second black box opened at nurses' station and oxycodone/Tylenol not in the inventory. Tramadol 50 milligram was in the box in a red cassette. One Tramadol removed and placed in a medicine cup. Red cassette returned to black box and black box put in medication room per facility guidelines. No extra lock tags where available in black box. RN (Registered Nurse) was sitting in front of this nurse when the above took place. Faxed a copy of the forms with the Tramadol that was removed and resident name and provider to pharmacy per facility guidelines. Interview on 9/16/25 at 1:30 p.m., Staff A, RN, confirmed and verified that a narcotic count was not completed prior to staff coming and going off of their shifts and that it is expected for staff to follow the facility policy and procedure for counting of narcotics.Interview on 9/16/25 at 3:30 p.m., Staff B, RN, confirmed and verified that a narcotic count was not completed prior to coming on and going off the shift with the resident narcotic count sheet, and it is the expectation of the nursing staff to count the narcotics per facility policy and procedure.Interview on 9/16/2 at 5:00 p.m., Staff C, LPN (Licensed Practical Nurse) confirmed and verified that no narcotic count was done prior to keys being exchanged between staff and that it is the expectation of the nurses to follow the facility policy and procedure for counting narcotics before coming on to your shift and prior to leaving your shift.Interview on 9/16/25 at 1:30 p.m., Staff D, RN confirmed and verified that the nurses are expected to count narcotics prior to coming and going off their shifts and it is the expectation of the nurses to follow the facility policy and procedures for counting narcotics.The Controlled Substances policy and procedure dated 4/2019, explained that the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled substances.Policy Interpretation and Implementation: Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.

Based on observation, staff interviews, and policy review, the facility failed to store, prepare, and distribute food in accordance with standards of food service safety. The facility reported a census of 96 residents. Findings include: Kitchen Observations on 12/30/2024 included: At 9:24 A.M. Staff B (cook) had no hair net on. Staff B donned the hair net at 9:28 A.M. The floor had a large amount of food spatters including grapes, crumbs, and cheese slices. The kitchen counters and shelves had crumbs, cereal boxes including Fruit Wheels and Crisp Rice open and without a date, peanut butter open and without a date, orange juice and red juice sitting in a tub of ice with no date. The stove had a large amount of food particles including egg, broccoli, oatmeal on the burners, and grease and food residue on the grill. The oven doors had brown spatters dripping down the doors to the floor. Three food prep spaces had a moderate amount of food particles and spatters. A fourth food prep counter had piles of flour present. Four trash cans placed in the kitchen area had no lids. Four bags of white bread, one raisin bread, and three bags of buns were open and without a date. Other food items open and without a date included pancake mix and two grape jelly containers. Lunch Service observations included: At 11:11 AM, the kitchen appeared mopped, however it contained a wet paper towel and carrot coins. One food prep area had crumbs and an empty pop bottle present. The stove had dried pasta and grease on the grill. The garbage containers remained uncovered and a brown sticky substance still leaked from the stove and pooled onto the floor. Another stove still had broccoli and oatmeal dried near the burner. The beverages currently had labels. An open container of coleslaw vegetable mix had no date. A container of shredded lettuce, partially used, had no date and wilted pieces of lettuce in the bag. At 11:21 A.M., Staff C, [NAME] used gloves to touch the ice scoop handle twice, then used same glove to put ice into 26 cups. Staff D, Dietary Manager, used gloves to touch the oven handles, drawer handle, scoops, the eating surface of the plate, and then touched 7 pieces of meat with the same gloves. Staff C moved food on plates with the same gloves after touching food lids and serving scoops, and continued to touch the drawer handle and whisk handle. At 11:38 A.M., Staff B, Cook, with gloves opened the oven door, placed bread rolls onto plates, and touched carrots on the plates. At 11:39 A.M., Staff D, used the same gloves to move carrots on plates as did Staff B. Staff B used gloves to place parchment paper, open the refrigerator, grab hamburger patties and place them on a tray and in the oven. Staff D, plated rolls by hand, and moved food on plates by hand. Staff D used the same gloves to grab new plates, and touched the eating surface. Staff B donned new gloves. Staff D plated 5 buns by hand, and placed lids on plates. Staff D with gloves, entered the refrigerator, removed a container of meat, and placed the meat onto the grill without changing gloves. Staff D changed gloves and touched plates and plate warmer bottoms, touched serving handles, and carrots on the plates. Staff B plated buns without changing gloves, then touched new plates and serving handles. Staff D plated meat patties by hand for 9 resident trays. Staff B touched the oven handle and the refrigerator door. Staff D, with gloves touched a food container and lid, plate lids, and resident plates while touching the eating surface of the plates. Staff D plated buns by hand for six residents, and then by hand plated meat and moved food on plates. Staff A used gloves to open the microwave, remove a plate, put four sandwiches in the microwave, take them out and then touched the sandwiches. Staff D plated beef by hand again with the same gloves. Staff B used hands to get a box of hamburgers from the freezer, place parchment paper on trays, and place hamburger patties by hand onto three trays. Staff D used gloves to take hamburgers from the box and place them on the grill. Staff A used gloves to move the hamburger box then used same gloves to plate a hamburger. Staff D used gloves to plate hamburgers and buns, grabbed more plates, touched paper menus, and plated more patties by hand. Staff A used hands to put hamburger on bun and plate them times three, touched the refrigerator handle, grabbed a piece of cheese by hand and placed it on a hamburger. Staff D grabbed hamburger buns with hands and plated hamburgers. Staff A used gloves to grab plate warmers, grab buns, and plated sandwiches. Staff D used gloves to grab a slice of cheese and plate a hamburger, cracked eggs with gloves on, threw shells away, touched paper menus, touched plate, plated bread by hand, and assembled egg sandwich without changing gloves. Staff A with gloves, opened the refrigerator and grabbed cheese, used same gloves to plate bread and cheese, assemble sandwich, and buttered bread. Staff A used the same gloves to place sandwiches on the grill. Staff D removed food from plates and put it back in the warmer with same gloves. Staff D touched the grilled cheeses on the grill with same gloves, plated and flipped by hand. Staff D touched meat grease on grill with gloves, grabbed clean plates, touched oven dials and spatulas, opened freezer and refrigerator, and put hamburgers on the grill by hand. Staff D then touched the grilled cheese with same gloves, grabbed more hamburger patties and placed them on the grill. Staff E, Maintenance, used gloves to touch the microwave, grab plates, and plated buns and hot dog with hands. Staff E grabbed another plate, plated cheese by hand, entered refrigerator, grabbed a container and then touched buns and roll by hand. Used same gloves to remove bun from bag, plate bun, cover hamburger. Staff E used the same gloves to touch bread bag, spatula, move sandwich on plate, and touch cheese to assemble a grilled cheese. Staff D used new gloves to place bread on the grill, touched butter container and spreader, spread butter holding bread in hand and placed on the grill for two sandwiches. Staff D touched cheese and placed on bread on the grill, touched the paper menu, touched cheese on the bread with same gloves. This happened multiple times throughout meal service until 1:13 P.M. Staff Interviews: On 12/30/2024 at 2:39 P.M., Staff D revealed she completed dietary manager classes and planned to take the state test in the next couple of weeks. Staff D had prior experience in the food service industry for [AGE] years. Staff D reported she checks the cleaning audits and they appeared to be going well. The kitchen staff has a daily cleaning schedule and Staff D checks it. The floors get mopped every night, the grill is cleaned two times or more as needed. Every food item must have a date on it and all food is dated when it is delivered. Staff D instructs staff to wash hands and change gloves often. Staff should wear gloves at all times, and should change gloves if they change tasks so they do not cross contaminate things. Staff D indicated the garbage containers had no lids that she knew of. On 12/30/2024 at 2:50 P.M., Staff F, Regional Supervisor of Health Services reported the garbage containers did have lids and staff needed to ensure they were used. Staff should not wear gloves in the kitchen, they should wash their hands and use utensils to handle food. They were working on correcting the issue and conducted a meeting to improve the situation. They planned to provide education and add staff with experience to work along with Staff D to manage the food service. Healthcare Services Group, Inc. and its subsidiaries HCSG Policy dated 5/2014 and revised 2/2023 included: Food: Preparation Policy Statement All foods are prepared in accordance with the FDA Food Code. Procedures 1. All staff will practice proper hand washing techniques and glove use. 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 3. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. 4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F, or per state regulation. 5. The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: * Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination; * Thawing the item in a microwave oven, then transferring immediately to conventional cooking equipment; * Completely submerging the item under cold water (at a temperature of 70 degrees F or below) that is running fast enough to agitate and float off loose ice particles; * Cooking directly from the frozen state, when directed. 6. Raw fruits and vegetables will be washed, as appropriate. 7. Separate cutting boards for meat, poultry, and produce will be maintained. 8. Only pasteurized egg products will be used for soft cooked egg items. 9. The Cook(s) will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. 10. Time/Temperature Control for Safety (TCS) hot food items will be cooked to a minimum internal temperature, as follows: * All poultry and stuffed foods 165 degrees F (<1 second instantaneous) * Ground meat 155 degrees F (for 17 seconds) * Eggs hot-held for service 155 degrees F (for 17 seconds) * Fish and shellfish 145 degrees F (for 15 seconds) * Pork, other meats 145 degrees F (and allowed to rest for at least 3 minutes) * Eggs for immediate service 145 degrees F (for 15 seconds) Healthcare Services Group, Inc. and its subsidiaries Dining Services Policy and Procedure Manual, c Original 5/2014, Revised 9/2017, 10/2022, 2/2023 Healthcare Services Group, Inc. and its subsidiaries HCSG Policy 016 11. When hot pureed, ground, or diced food drop into the danger zone (below 135 degrees), the mechanically altered food must be reheated to 165 degrees for 15 seconds if holding for hot service. 12. When reheating, foods will be rapidly heated to 165 degrees F for 15 seconds. If the food is not reheated within 2 hours it must be discarded. 13. All foods will be held at appropriate temperatures, greater than 135 degrees F (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding. 14. Temperature for TCS foods will be recorded at time of service, and monitored periodically during meal service periods. 15. All staff will use serving utensils appropriately to prevent cross contamination. 16. Prepared hot food items that are not intended for immediate service will be cooled using the following guidelines: * Place in shallow pans or cut/slice to promote rapid cooling. * TCS foods will be cooled from 135 degrees F to 70 degrees F within 2 hours. * TCS foods will be cooled from 70 degrees F to 41 degrees F within 4 hours * Total cooling time cannot exceed 6 hours. The clock starts at 135 degrees F. 17. All refrigerated, ready-to-eat TCS prepared foods that are to be held for more than 24 hours at a temperature of 41 degrees F or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7). Attachments 1. Service Line Checklist References: 1. A-0618, A-0620: ~482.28, CMS Conditions of Participation: Food and Dietetic Services 2. F812, ~483.60 Store, prepare, distribute, and serve food, CMS State Operations Manual, Appendix PP 3. FDA Food Code: https://www.fda.gov/food/fda-food-code/food-code-2022 4. Joint Commission: PC.02.02.03: The hospital makes food and nutrition products available to its patients Healthcare Services Group, Inc. and its subsidiaries Dining Services Policy and Procedure Manual, c Original 5/2014, Revised 9/2017, 10/2022, 2/2023

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies form, the facility Quality Assurance and Performance Improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 96 residents. Findings include: The CMS 2567, dated 10/17/24 listed, in part, the following concerns: F812 The current complaint survey, conducted 12/30/24 also identified the above concern. In an interview on 12/30/24 at 3:48 PM the Administrator explained the QAPI team met monthly to discuss the Performance Improvement Projects (PIP) and quarterly with the full team. Data was collected via an online program, suggestion boxes, grievance forms, and when the Department of Inspections, Appeals, and Licensing found a deficiency. The facility prioritized the issues that impinged on residents' quality of life or rights. She explained there was a PIP in place for the previous survey deficiency but they were still struggling. A review of the facility Quality Assurance and Performance Improvement (QAPI) Plan, revised 12/01/2024 documented the following: The QAPI team will review all sources of information to determine gaps or patterns that may exist in systems of care that could result in quality problems; or if there are opportunities for improvements. Potential areas that will be considered for review could be but are not limited to: ~State survey results, deficiencies and plans for correction Based on the review of data collected, the QAPI team will prioritize areas with opportunities for improvement taking into consideration prioritizing issues with high risk, high frequency and/or problem prone. The QAPI team will charter a PIP team to oversee the problem identified, focus on the facility mission, and to identify plans for correction or improvement to be implemented. The PIP team will monitor and report on successes and failures throughout the PIP team life span and will continue until the identified area of concern has been resolved or no longer remains an issue within the facility. The facility will utilize a systemic approach to determine when in-depth analysis is needed to fully understand the problem or area of concern which has been identified. This process will help the facility to identify the causes of the issue as well as implications of a change. The facility applies an in-depth and structured approach to determine how and why the identified problem occurred, the causes of the problem and issues which may have exacerbated the problem. The facility will apply a comprehensive approach to assessing all of the systems involved in the identified issue to prevent future issues and to promote sustainable change.

Based on observation, kitchen record review, staff interview, and policy review the facility failed to store foods according to professional standards, cover foods during hallway transport, and maintain effective sanitizing solution during 2 of 2 kitchen observations and 2 of 3 hallway observations. The facility reported a census of 97 residents. Findings include: During a kitchen tour on 10/14/24 at 10:12 AM observed the dry storage area. In the back left corner where two shelves met there was a plastic spoon on the floor, laying in a brown sticky wet substance about 2 feet long, extending to the back wall. It started at 8 inches wide, narrowing to 2 inches, and then widened along the base of the wall. The substance contained small pieces of a darker brown substance. The shelf above it contained boxes of fig bars on the left, pop to the right, and a silver CD radio combo perched between them. The radio was touching the boxes and was covered with a shiny, sticky brown substance, flecks of white powder, and food particles. During the same tour, observed the walk-in cooler and freezer. A box of hamburger with 24 patties remaining was left open, uncovered by the plastic wrapper in the box, and exposed to open air. The patties were covered in ice crystals and two of them in the bottom of the box were almost white on one side. Before leaving the kitchen, the sanitizer bucket was tested . Staff B, [NAME] attempted to fill the bucket two times and the chemical sanitizer did not register on any of the strips. Staff B stated the sanitizer had recently been adjusted because it was putting too much chemical in the water. She was not sure if it was tested after that. She said there was probably not enough chemical mixing with the water because it was not changing at all. She stated they would need to call somebody because they could not make the adjustment. On 10/14/24 at 11:39 AM 4 room trays on one cart were covered in heavy plastic covers. The drinks were not covered. At 11:43 AM food delivered to another hall revealed 4 trays with no covers on them. During room tray delivery on 10/15/24 at 12:33 PM observed 3 food carts going down the halls. The first cart had paper covering the coleslaw that blew off and was not replaced. The third cart had vegetables in cups that were not covered. On 10/16/24 at 10:32 AM observed the puree process for lunch with Staff A, Assistant Manager. She pureed 5 servings of pork loin with 5 scoops of a gravy base for 4 residents with a pureed diet. 4 servings of green beans with the addition of a vegetable base and 8 rolls with the addition of milk were also pureed. Staff A did not clean or sanitize her work space between meat and vegetables or vegetables and bread. During an interview with the acting Dietary Manager (DM) on 10/16/24 at 11:04 AM he stated there was a common cleaning schedule in a binder on the table. He opened the binder and the date at the top of the form was 5/19/24. He was unaware of the food left open in the freezer or the cleanliness issues in the storage room and stated staff would take care of it immediately. He stated there was another cleaning list but he didn't know where it was. He confirmed food should be covered in the hallway and was not sure why some of the items were missed. An email from the DM on 10/16/24 at 3:49 PM indicated they were unable to locate daily cleaning logs. A policy titled Environment, revised 9/2017, documented all food preparation areas, food service areas, and dining areas would be maintained in a clean and sanitary condition. The Dining Services Manager would ensure the kitchen was maintained in a clean and sanitary manner including floors, walls, ceilings, lighting, and ventilation and that all employees were knowledgeable in proper procedures. This included a routine cleaning schedule for all cooking equipment, food storage areas, and surfaces.

Based on observation during meal service, record review, and resident and staff interviews the facility failed to serve food at an appropriate temperature and in a palatable manner during two of two meals observed. The facility reported a census of 97 residents. Findings include: On 8/12/2024 at approximately 7:45 A.M. during the breakfast meal service, Staff A, CNA (Certified Nurse's Aide), served residents in the main dining room. The menu included french toast, oatmeal, and sausage patty. At 8:30 A.M., Resident #5 reported the food was not hot. A temperature check of a test tray at 9:00 A.M. revealed the oatmeal, french toast, and sausage all had temperatures at approximately 125 degrees Fahrenheit. Staff B, dietary aide, reported staff served breakfast from 7:15 A.M. until 9:00 A.M. At 9:25 A.M., Staff C, DON (Director of Nursing) revealed the facility used H.C.S. (Health Care Services) to manage the dietary department for the past year. Currently, they had no dietary manager in the facility. Testing of the steam cart at 11:00, prior to lunch service revealed the following temperatures: Chicken Fried Steak - 180 degrees Fahrenheit Mashed Potatoes - 170 degrees Fahrenheit Salisbury steak 162 degrees Fahrenheit. A temperature check of the test tray at 12:25 P.M., after residents were served, revealed Country Fried Steak at 120 degrees, carrots at 110 degrees, and mashed potatoes at 140 degrees Fahrenheit. Staff C, Dietary manager checked the steam cart food temperatures at 12:30 P.M. with the surveyor present. The Country Fried Steak temperature was at 138 degrees and carrots at 125 degrees. Staff C reported food needed to be served between 140 and 160 degrees Fahrenheit. Staff C indicated the Steam Cart temperature was turned up as high as it could go. At 2:00 P.M., Staff D, H.C.S. district manager revealed he checked the steam cart and had no concerns with it. The well temperatures were at 165 - 175 degrees Fahrenheit. Staff needed to cover the food trays in between serving residents. Staff D reported they hired a new dietary manager with a start date of 8/15/2024. Staff D presented the Food Temperature log book dated 6/17 - 8/12/2024. The log book revealed 38 missed opportunities from 6/17 - 8/12/2024 where dietary staff failed to complete the documentation of food temperatures prior to serving. On 8/12/2024 at 3:40 P.M., Staff E, facility dietician revealed H.C.S. managed dietary services at the facility. Staff E provided weekly assessments and H.C.S. staff approved the menus. Staff E indicated residents voiced concerns regarding food palatability, however the dietary manager who recently left had made positive changes. On 8/12/2024 at 2:10 P.M., Staff F, LPN (Licensed Practical Nurse) indicated the food service is slow. They have a microwave at the nurse's station that they often use to warm up resident's food since it is not hot when it arrives from the kitchen. On 8/12/2024 at 10:10 A.M., Resident #3 reported his breakfast food was not hot. At 1:50 P.M. the resident reported his lunch tasted terrible, staff forgot his roll, and the food was not hot. On 8/12/2024 at 2:00 P.M., Resident #4 reported the food was usually warm, but not hot. The Healthcare Services Group, Inc. food policy included: Food: Preparation Policy statement: All foods are prepared in accordance with the FDA Food Code. 13. All foods will be held at appropriate temperatures, greater than 135 F (or as state regulation requires) for hot holding, and less than 41 F for cold food holding. 14. Temperature for TCS foods will be recorded at time of service, and monitored periodically during meal service periods.

Based on observation and staff interview, the facility failed to provide housekeeping services in a manner to maintain a safe, clean, comfortable, and homelike environment. The facility reported a census of 97 residents. Findings include: Facility observation on 10/31/2023 at 11:30 A.M. included: Room BV-9 had debris on the floor including socks, papers, and trash. The floors appeared grimy with moderate scuff marks. The BV Nurse's station had used gloves and med cups on the floor. Room BV-17 had used gloves on the floor. Room BV-20 had trash on the floor. Rooms BV-28 and 25 had floors with heavy scuff marks, dirt, and debris. Room BV-2 had used linen and a resident gown on the floor. Room BV-11 had used linen on the bathroom floor. At 11:50 A.M. observation of WW hall revealed the following: WW-14 had debris on the floor. At 12:00 P.M. observation of the dementia unit revealed the common area had a moderate amount of dirt, food debris, scuffs, and grime on the floor. On 10/31/2023 at 11:45 A.M., Staff D, housekeeping, indicated she had no other housekeepers working with her today. Typically, they would have three scheduled. Recently, they have been working short staffed, 1 - 2 times per week. On 10/31/2023 at 3:30 P.M., Staff F, Maintenance, revealed a housekeeper called in today. He interviewed three new hires recently. Ideally, the facility had 3.5 housekeepers when fully staffed. Today, they have one housekeeper and one staff cleaning floors.

Based on observation, record review and family interview, the facility failed to ensure an anticoagulant (blood thinner) had been re-ordered for one of thirteen residents reviewed (Resident #18). The facility reported a census of 99 residents. Findings include: Resident #18's Minimum Data set quarterly assessment completed 3/10/17 had documentation of the following Diagnoses: [REDACTED]. The MDS also identified Resident #18 with cognitive impairments with a Brief Interview for Mental Status score of 5 out of 15. The resident required extensive staff assistance with most activities of daily living and able to walk, and could toileted with assistance. The care plan identified the resident with the problem of being at high risk for abnormal bruising or bleeding related to anticoagulation therapy use of Eliquis (with a start date of 11/1/16) and directed staff to administer Eliquis as ordered) The consumer guide for prescription medication Eliquis (or apixaban) recommended the indication for use to reduce the risk of stroke and blood clots in people who have [MEDICAL CONDITION], a type of irregular heartbeat, not caused by a heart valve problem. ELIQUIS is a prescription medicine used to reduce the risk of forming a blood clot in the legs and lungs of people who have just had hip or knee replacement surgery. A review of the Interdisciplinary Notes revealed the following documentation: On 3/19/17 at 8:41 a.m. the resident complained of abdominal pain, a golf ball sized bulge noted 2 inches below the belly button and taken to the hospital emergency department by ambulance. On 3/19/17 at 1:50 p.m. the resident returned to the facility with new orders to discontinue the Eliquis and set up surgery for [REDACTED]. On 3/22/17 at 12:45 p.m. the resident returned from the surgeon's office and did not want surgery. On 5/15/17 at 8:39 a.m. the resident had right sided weakness, unable to speak and answer questions, unable to move extremities on the right side of the body and with a visible droop to the right side of the face and taken to the emergency department by ambulance. On 5/15/17 at 8:39 a.m. the resident had been admitted to the hospital with [REDACTED]. A review of the progress note by the nurse practitioner (ARNP) dated 3/23/17 documented the resident had a history of [REDACTED]. The ARNP documented, she does well with her speech and her blood pressure was well controlled. The ARNP documented Resident #18 is on Eliquis. (The ARNP did not document the resident's recent Emergency Department on 3/19/17 or that Eliquis medication had been discontinued.) A review of the Medication Administration Records (MARs) revealed an order for [REDACTED].>March 2017 - medication had not been given from March 19 through the 31st. April 2017 - the medication did not appear on the MAR. May 2017 - the medication had not been given from May 1, 2017 through May 29th, 2017. A review of the physician orders [REDACTED].>On 2/20/17 Eliquis 5 mg one tablet twice daily. On 3/19/17 from hospital emergency department physician - contact the primary physician as surgery is on Monday and to stop the Eliquis. On 3/20/17 a facsimile from the facility to the primary care physician with the following documentation the resident was sent to the hospitalER on ,[DATE] for abdominal pain and new hernia. Now back in the facility, Eliquis discontinued and will set up surgical consult this week. Also, resident fell and hit head at 2:15 p.m. to toilet self and hit head. The resident sustained [REDACTED].? Physician responded no. On 3/22/17 physician visit form (out of office) from surgical consult (resident) had a ventral hernia, does not want surgery. The physician documented May restart [MEDICATION NAME] (oral blood thinner medication). (A review of the MARs from March 2017, April 2017 and May 2017 revealed the resident did not have an order for [REDACTED]. On 5/15/17 may send to the emergency department to evaluate and treat right sided weakness and decreased oxygen levels. On 5/15/17 admitted to the hospital with [REDACTED]. 6/29/17 Discharge to another facility. During an interview on 10/17/17 at 8:33 a.m., the Director of Nursing (DON) reported the resident had been taken off the Eliquis in March when they found the hernia. She was evaluated by the nurse practitioner shortly after the family decided they did not want the resident to have the surgery. The resident did not have the Eliquis reordered before being admitted to the hospital with [REDACTED]. The facility investigation sign 10/23/17 revealed the following: Resident #18 had an emergency room (ER) visit due to abdominal pain and the ER physician ordered to stop Eliquis on 3/19/17 due to surgical consult. After the surgery consult on 3/22/17, the family was determining if they were going to proceed with hernia surgery (then decided no surgery) and the physician ordered to restart [MEDICATION NAME], although the resident was not on [MEDICATION NAME]. The ER follow-up with the nurse practitioner (ARNP) occurred on 3/23/17. On 5/153/17 the resident went to the ER due with a [DIAGNOSES REDACTED]. In an interview on 10/17/17 at 11:20 a.m., the DON reported Staff A, RN, noted the order from the surgical consult 3/22/17 to restart [MEDICATION NAME]. The resident did not have [MEDICATION NAME] prescribed at that time. She would have expected Staff A to call the doctor to clarify the order and ask if he/she wanted to re-order the Eliquis again. The nurse practitioner, who saw the resident after being see in the ER, missed it also. The nurse practitioner (ARNP) did not return the surveyors calls. During an interview on 10/17/17 at 1:50 p.m., the consultant pharmacist reported she did not question the order to discontinue the Eliquis due to the resident's age and recent fall which resulted in a hematoma to the back of the head. The pharmacist reported the resident was having low hemoglobin and with her comorbidities this was not unusual to see Eliquis medication stopped. The fact that the resident did not receive the Eliquis from March to May could have been precipitated the stroke, however, no medication is 100% effective in preventing a stroke. In an interview on 10/18/17 at 8:20 a.m., Staff A, RN, she remember the Eliquis got stopped because she searched through the orders and found the order from the ER doctor to stop Eliquis. Staff A stated she did not recall what happened after that but if an emergency room physician discontinued a medication such as Eliquis, the nurse should inform the primary care physician and document in the interdisciplinary notes. She also reported she could not recall that she noted the order on 3/22/17 to restart the [MEDICATION NAME]. She also reported she would have notified the primary care physician of the Eliquis being discontinued and ask if he/she wanted to re-order or keep with holding it. She could not remember how long the resident did not have the Eliquis and felt the lack of the medication may have contributed to the stroke. During an interview on 10/18/17 at 11:05 a.m., the resident's family members reported the resident had been on Eliquis for 2.5 years for a prior stroke, which is the reason why the resident had been admitted to the facility in the first place. They reported the resident had another stroke in May 2017 when they realized the records showed he/she did not receive Eliquis from March through May. Prior to this last stroke, the resident had been able to ambulate with help, go out with family for meals at restaurants, participate in most activities, socialize with family and other residents, had been happy, peaceful and content. Now the resident cannot speak, friends don't visit as often as they can't have a conversation with him/her, terribly frustrated as he/she can no longer enjoy eating out as now on a pureed diet. Both family members began crying as they have seen the resident decline each day. The resident's primary care physician was contacted on 10/18/17 at 9:00 a.m. and her nurse returned the call on 10/18/17 at 1:30 p.m., and said the primary care physician reported there is always a risk of stroke with the resident not receiving the Eliquis, however, there is also a large risk of bleeding if they had surgery. Other factors that may have led to the resident's stroke included age and blood pressure. The nurse reported the physician was asked if she would have expected the nursing home staff to contact her and ask for clarification, and the physician did not respond to that question. In an interview on 10/18/17 at 1:54 p.m., Staff B, RN reported when a resident returns from the ER with orders to discontinue a medication such as Eliquis, the nurse should clarify this order with the primary care physician and document as such on interdisciplinary notes. During an interview on 10/18/17 at 2:08 p.m., Staff E, LPN reported When a resident comes back from the ER with orders to discontinue a medication such as Eliquis, the nurse should be clarify the order with the resident's regular doctor. When a resident comes back from a surgical consult and the surgeon had documented that the resident refused surgery and to restart [MEDICATION NAME] which the resident did not have orders for before, the nurse should call the doctor and clarify that also. An observation of the resident on 10/18/17 at 12:55 p.m. revealed the resident in a wheelchair with anti-tip bars with a sling to a mechanical lift under him/her in the main dining room attempting to eat pureed food with adaptive equipment (a spoon with a large handle bent at a 90 degree angle), the nurse aide had to assist the resident to eat as the resident became weak with continuous oxygen maintained at 4 liters per minute per cannula per concentrator unit. A cup containing a protein supplement and two glasses with thickened liquids had been included in the resident's meal. According to the Food & Drug Administration (FDA) medication guide : What is the most important information I should know about ELIQUIS? For people taking ELIQUIS for [MEDICAL CONDITION]: People with [MEDICAL CONDITION] (a type of irregular heartbeat) are at an increased risk of forming a blood clot in the heart, which can travel to the brain, causing a stroke, or to other parts of the body. ELIQUIS lowers your chance of having a stroke by helping to prevent clots from forming. If you stop taking ELIQUIS, you may have increased risk of forming a clot in your blood.

Based on clinical record review, observation and staff and resident interviews the facility failed to ensure the facility provided an environment that promoted safety and well being, and failed to ensure each resident received adequate supervision to prevent an elopement from the facility for one of four residents reviewed regarding supervision. (Resident #1). Record review identified Resident #1 with prior attempts to exit the nursing home. On 7/30/17, Resident #1 exited the facility and his/her alarm device sounded to alert staff. Staff turned off the alarm without identifying who alarmed the door and approximately 20 minutes later, staff discovered Resident #1 was missing. Resident #1 crossed two busy streets and arrived at the nearby grocery store. In addition, 1 hour prior to the elopement, staff interviews revealed they had witnessed Resident #1 enter the key code successfully on a different door and failed to ensure the resident would receive adequate supervision. The findings constitute an Immediate Jeopardy situation. The facility reported a census of 94 residents. Findings include: 1.Resident #1 admitted to the facility on [DATE] from an acute care setting. The hospital History and Physical (H & P) revealed the resident admitted to the hospital on [DATE] on a voluntary basis and had [DIAGNOSES REDACTED]. The H & P revealed the resident had progressively declined from a functional standpoint, had limited orientation, behavioral outbursts and had suicidal thoughts at home. The H & P also reported the resident had a childlike presentation consistent with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired decision making skills, cues/supervision required and short and long term memory problems. The MDS reported the resident had wandering and other behavioral symptoms not directed at others, transferred and ambulated in the room independently and required limited assistance at times in the corridor with the use of a walker. The Care Plan identified Resident #1 had a behavior problem initiated 6/13/2017, as evidenced by wandering. It directed staff to provide interventions including behavior monitoring program, intervene as necessary to ensure safety and privacy of resident and others, and reinforce appropriate personal boundaries with other residents. On 6/17/2017 the Care Plan added: Unit exit codes will be changed to prevent elopement. On 6/19/2017 the Care Plan added: Be aware of residents when going out of exit doors with code. On 6/20/2017 the Care Plan added: Redirect from doorway with music and i-pod when trying codes. On 7/30/2017 the Care Plan added: 15 minute checks with documentation to include if at the door. The Care Plan failed to include the resident had a Wanderguard/Roam Alert bracelet. The elopement/wandering assessment dated [DATE] revealed Resident #1 had an elopement/wandering risk. The Interdisciplinary (ID) Notes dated 7/30/3017 included: At 8:51 a.m. - Resident #1 had been exit seeking and had bag packed on his/her walker. Re-directed to family room. At 3:08 p.m. - Staff in SVS (Sunshine Valley Suites) unit could not find resident, code green called per protocol. See incident report for details. At 3:11 p.m. - Staff noted resident wore appropriate summer outfit with outside temperature at 79 degrees Fahrenheit. Water provided on return to facility for hydration. The ID Notes dated 7/17/2017 at 11:32 a.m. revealed staff observed the resident had no roam alert bracelet on and replaced it on the walker. The resident reported it bothered his/her leg. The ID Notes dated 6/17/2017 at 7:34 a.m. reported Resident #1 exited the facility. Alarms sounded indicating the SVS patio door had been opened. The roam alert sounded indicating the SVS patio door opened. Staff found the resident just outside the door on the cement slab. Staff redirected the resident to the building. Resident exited the unit door by entering the code. Staff were busy and the resident left unwitnessed. Staff believed the resident knew the codes to the tub door and the main door exits. Care Plan updated and codes will be changed. The July, 2017 Roam Alert form revealed staff observed Resident #1 had a Roam Alarm on July 29 and July 30. The Incident Report dated 7/30/2017 revealed Resident #1 eloped from the unit. The resident had been eating lunch when staff were toileting residents after lunch. Staff failed to find the resident and called a Code Green (Missing Persons) and staff were sent to assigned locations. One staff sent in car and located the resident between Fareway and Dollar Tree. The resident got into the car without incident and returned. The resident indicated he/she planned to go home. Staff initiated 15 minute checks upon return. The surveyor noted an approximate 0.2 mile distance between the facility and Fareway grocery store. The path from the nursing home to the grocery store showed two busy streets that Resident #1 would have crossed to arrive at the location where staff found him/her. The State Climatologist reported on 7/30/3017 at 1:00 p.m., Dubuque had 76 degrees Fahrenheit weather with calm winds and clear skies. Observation on 8/1/2017 at 2 o'clock p.m. revealed Resident #1 in the activity room watching television. The resident appeared calm, clean and neat with appropriate behaviors. At 3:55 p.m. the resident sat in the bedroom in a recliner chair with shoes off and feet up. The resident had eyes shut and appeared calm and restful. On 8/2/2017 at 3 o'clock p.m. the resident sat in the room in a recliner watching the i-pod. The resident responded to questions: Question: Have you been out of the facility lately? Answer: On Sunday I was out a little, I walked a little bit. I wanted to go to my house, I have a bird and a puppy. My sister has my puppy and we call her Molly. We took Molly to the doctor and she is happy. Question: Did you tell anyone? Answer: I can't do it any more. Bad. I had this thing (resident pointed to walker). Question: How did you leave here? Answer: I pressed that button and walked out. I put my stuff in a bag, but now I cannot do it anymore. Question: How come you cannot do it anymore? Answer: I don't know the numbers. Dr. said I could go home in winter. I want my puppy, bird and friends. Question: Did someone pick you up? Answer: One of the girls here, it was lunch and that's how they noticed it. I like Dubuque. Question: What is the name of this place? Answer: Can't remember. Question: What day is it? Answer: Wednesday. Question: Do you have children? Answer: No, I had a spouse but he/she was bad. During an interview on 8/15/2017 at 11 o'clock a.m., Resident #1's family member reported the resident had been picking at locks and poking at the key pad. The resident wants to go home and will continue to try. During an interview on 8/1/2017 at 11:50 a.m. Staff A, RN (Registered Nurse)/DON (Director of Nursing ), reported on Sunday, July 30 at approximately 12:30 - 12:40 p.m., Resident #1 exited the facility and walked to the Fareway grocery store. The DON stated the door alarm went off and an unknown staff said they had checked the door and did not see anyone. On 7/30/2017, Staff E, CNA (Certified Nurse Aide), Staff F, CNA and Staff G, CNA were in the unit. Staff E had been on break and Staff F and G served lunch trays. Staff C, LPN, assigned to the unit sat at the SV nurse's station at the time of the elopement. When staff noticed the missing resident, Staff C called a Code Green. Staff checked rooms and Staff E got in the car, found the resident and returned to the facility at 1:11 p.m. The resident easily redirected and had no injury when assessed. The resident had one prior attempt on 6/17/2017 when he/she exited the patio door, but the door alarm sounded and staff retrieved the resident. The DON stated they changed the code to the door after this incident (6/17/17). During an interview on 8/1/2017 at 2:50 p.m., Staff D, RN reported working on 7/30/2017 from 6 o'clock a.m. until 6:30 o'clock p.m.Staff D worked on the WW (Wendt Willows) wing. At 1:00 o'clock p.m. Staff D went into the break room and at 1:05 p.m. someone paged Code Green. Prior to that, while on the phone at the WW nurse's station, Staff D heard a door alarm and the notification board at the nurse's station identified it as the patio door. Somebody yelled all clear and Staff D canceled the alarm. When they noticed the missing resident (when passing lunch trays), Staff E, CNA got in the car, found the resident and returned at 1:15 p.m. Staff D assisted the resident out of the car. The resident had no injury and appeared fine. Resident #1 is smart and will stand near the exit doors in the unit and watch people. During an interview on 8/2/2017 at 1:30 p.m., Staff C, LPN reported working on 7/30/2017 at 6 o'clock a.m. until 6:30 p.m. on the SV (Sunshine Valley) and SVS (Sunshine Valley Suites/dementia unit). Staff C indicated at breakfast Resident #1 had a bag on his/her walker. At 10:00 a.m. the CNA's in the unit reported the resident pushed the keys on the door alarm and had figured out the code to the shower room door alarm. When Staff C observed the resident between 10:00 and 11:00 a.m., the resident sat in the room in the recliner talking to family. Staff C reported he/she never reported it to maintenance. At approximately 12:40 - 12:45 p.m., the elopement occurred. Staff C called maintenance to change the unit exit door alarm codes. When staff reported they failed to locate Resident #1, Staff C called a Code Green after checking the unit. Staff E, CNA brought the resident back to the facility and Staff C assessed the resident. The resident indicated he/she planned to go home. The resident's family verified the resident had been on the right path. Staff C never heard the alarms sound. Staff C returned from break around 12:30 p.m. Staff inside the break room, cannot hear the door alarms except for the one near the employee exit. Staff also cannot hear the alarm panel while inside the break room. Resident #1 ambulated independently with a walker. Staff C never witnessed the resident with exit seeking behaviors. Staff C revealed he/she should have called maintenance to change the codes when staff reported the resident knew the code at 10:00 a.m. Staff C underestimated the resident's ability. During an interview on 8/2/2017 at 9:30 a.m., Staff F, CNA, CMA (Medication Aide) reported working on 7/30/2017 from 6 a.m. until 2:30 p.m. in the dementia unit. Around 10 o'clock a.m. Staff F observed Resident #1 enter the alarm code on the shower room door key pad. The resident had figured out the code and said he/she wanted to go to exercise. Staff F reported it to Staff C, LPN immediately. Staff C indicated since it was a weekend, they needed to call the on call maintenance person and hopefully the resident would forget the code. Staff F told Staff C the resident would not forget the code. Staff F directed the other staff to keep eyes on the resident. Staff F went to lunch break at 10:50 a.m. until 11:20 a.m. and had observed the resident in his/her recliner. Staff G went to lunch at approximately 11:25 - 11:55 a.m. and Staff E at approximately 12:05 until 12:35 p.m. Staff F started passing medication and assisted Staff G in getting residents to the dining room table. Resident #1 was awake and seated in the recliner when Staff F went to assist a resident to the bathroom and the table. Staff G assisted residents with their clothing protectors and served coffee. Staff F never saw Resident #1 in the dining room, and assumed he/she would be coming. Dietary staff arrived and they passed lunch trays. When they failed to see the resident in the dining room or the bedroom, they checked therapy and notified Staff C. Staff did a room to room search as well as the parking lot and exits. Around 12:45 - 1:00 p.m. Staff C called a Code Green. Staff E returned from break and looked for the resident by car. When Staff E returned with the resident, the walker had the Roam Alert/Wanderguard bracelet intact. The resident must have exited through the shower room door, walked into the hall and out the patio door. The alarms or pages are not heard inside the unit. They assumed the resident exited through the East Patio door, down the side walk to Hillcrest road and crossed over towards Fareway where Staff E found him/her. Approximately 20 minutes had passed from the time they noticed the missing resident until he/she returned. They added motion detectors and 15 minute checks. During an interview on 8/1/2017 at 2:10 p.m., Staff G, CNA reported working in the dementia until on 7/30/2017 from 6:00 a.m. until 2:30 p.m. Staff G took lunch break from 11:25 - 11:55 a.m. Dietary brought food carts at approximately 12:20 p.m. Staff G observed Resident #1 when he/she notified the resident of lunch. The resident sat in the bedroom working on a puzzle. The resident came out and sat at a table using the walker. 10 minutes had passed and they went to pass Resident #1's tray and failed to find him/her. Staff G checked all resident rooms, notified the nurse and called a Code Green. Staff E got in the car and located the resident. When the resident returned he/she said hello, sat down and ate lunch and appeared fine. Nobody saw the resident leave the unit and they failed to hear the alarm. Only the fire alarm can be heard inside the unit. The resident often stood at the exit door alarm key pads and punched numbers. When the resident first admitted they had to change the code because he/she figured it out and got the door open. During an interview on 8/2/2017 at 2:35 p.m., Staff E, CNA reported working on 7/30/2017 at 6 a.m. - 2:30 p.m. During the day, Resident #1 sat on a chair in the unit between the main exit and the shower room exit and watched people. Earlier that morning, the resident went to the shower room key pad and punched in the numbers. Staff re-directed the resident and Staff F informed the nurse. The resident went to the bedroom and stayed there. When Staff E went to lunch at 12:10 p.m., the resident remained in the bedroom. At approximately 12:40 p.m., Staff E left the break room and heard the Code Green called. Staff E looked through rooms and then went by car. Staff E found the resident between Fareway and Dollar General, and returned with the resident at 1:11 p.m. The resident indicated he/she was going home. During an interview on 8/2/2017 at 11 o'clock a.m., Staff H, CNA / CMA reported working on BV (Bluff View) from 6:00 a.m. until 2:30 p.m. Around 12:55 p.m., Staff H passed medication and heart the SVS patio door and WW #14 door alarm sound. Staff H checked the WW exit door and observed the STOP sign still intact. Staff H went to the WW nurse's station and informed Staff D, RN that there were two door alarms going off. Staff D informed Staff H that he/she was on the phone, silenced the alarms and said nobody gave me the okay to turn them off. Staff H told Staff D that was because nobody had checked either door. Staff H started down SV hall and ran into Staff I, CNA. Staff H told Staff I to go and check the SVS patio door. Staff H returned to WW and looked out the windows. Staff F, CNA came up from the unit and said they could not find Resident #1. Staff D walked up from lunch and Staff H informed Staff D that one of the residents got out and he/she turned off the alarms. Staff H heard the Code Green and went outside to search for the missing resident. Staff E, CNA returned with the resident. Staff I later admitted to not checking the SVS patio door. During an interview on 8/2/2017 at 8:50 a.m., Staff J, Dietary reported working 7/30/2017. At approximately 12:20 p.m. dietary staff went to the dementia unit with lunch food carts. Dietary staff filled the trays and unit staff passed them. Staff J never saw Resident #1. When dietary staff finished filling trays, they left the unit, and noticed staff were looking for Resident #1. Staff J went on break and heard the Code Green called. During an interview on 8/2/2017 at 8:20 a.m., Staff K, Dietary reported working on 7/30/2017. Around 12:20 p.m. Staff K and Staff J went to the unit with the steam cart and plated food. Staff K never saw Resident #1. They left with the steam cart through the main doors between 12:35 and 12:40 p.m. Staff K never heard door alarms while in the unit. When they were leaving unit, staff were looking for Resident #1. Kitchen staff cannot always hear the Code Green if the dish machine is running. Staff K never heard the Code Green called. During an interview on 8/2/2017 at 10:40 a.m., Staff L, Maintenance reported he/she received a call from the facility at 1:42 p.m. on 7/30/2017. Staff L reported to the facility and changed the unit shower room/exit code. They added motion detectors and recently locked the shower room door where only staff has a key. The facility is looking at a key fob system for exit doors. Staff C, LPN and Staff D, RN received an Employee Warning violation for creating or contributing to unsafe working conditions related to Resident #1's elopement. The facility Elopement, Risk Prevention and Management of Missing Resident Policy effective 6/1/2014 included: Policy: The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement prevention strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission and conduct a missing resident procedure. Procedure: Assessment - An elopement risk assessment is completed by nursing staff on admission, quarterly and upon change of condition. Prevention: 1. Interventions that may be used for residents identified as high risk for elopement include: a. Designate resident as an elopement risk. b. Place a Wanderguard bracelet on c. Place a profile sheet indicating diversion activities d. Include activities that are in full view of staff e. Notify staff of residents at risk f. Develop an elopement care plan g. Update family h. Review weekly by Care Plan team i. Transfer to a secure CCDI unit 2. Verification of control systems. a. Each resident Wanderguard bracelet is checked twice daily and functioning is documented on the MAR (Medication Administration Record). b. Wanderguard door mechanisms are checked weekly. c. Door alarms are checked daily d. Wanderguard door alarm codes are changed as needed e. Key pad door alerts in CCDI unit are changed as needed. f. A sign in/out sheet is in place that requires responsible parties to sign the resident out when leaving. 3. Prevention strategies are listed on each resident's care plan and reviewed quarterly or with a change in condition. C. Intervention 1. Responding to an actual elopement a. All staff respond to active door alarms and return resident to their unit b. If a door alarm sounds and staff cannot determine who alarmed the door, an accountability of all residents will be completed. c. Any resident who leaves the facility should be approached according to acceptable guidelines. d. Diversion activities encouraged to prevent recurrence. e. Family and physician notified of the incident. f. Safety checks are documented while on increased supervision. g. Incident is reported to state authorities by Administrator or designee. 2. When a resident is determined missing. a. Note the time b. Assign staff to units c. Notify Administrator and Director of Nursing d. Staff will conduct a thorough search of the facility to locate the resident. If the resident has not been found, notify the police. 3. When the resident has been found: a. Examine for injuries, notify physician, update care plan, complete form and notify state authorities. The facility abated the IJ on 7/30/17 when they re-educated staff on the elopement prevention and code green policy. Staff not present were educated on 7/31/17. In addition on 7/30/17 -7/31/17 the facility also added elopement interventions that included the following : Resident #1 was placed on 15 minute checks; CCDI (unit) door codes changed by maintenance. The facility planned to add motion sensors to tub room and back stairway; Global Com came to research use of fob/card reader system for CCDI doors. In addition, the facility planned for the CCDI hallway patio doors secured East side locked and push bar removed. Motion sensors added to West side; CCDI shower door locked.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to ensure one of four residents received adequate supervision during transfers to protect against accidents. Resident #1 required one staff assistance with a gait belt and a walker for ambulation. Record review & staff interviews revealed staff let go of the gait belt and left the resident standing/unattended to tidy up the resident's bedding as Resident #1 fell and sustained hip & pelvic fractures. The facility census was 96 residents. Findings include The Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had no cognitive impairment, no speech, and usually made him/her self-understood and understood others. The MDS revealed Resident #1 ambulated and transferred with extensive assistance of one staff and used a walker and wheelchair for mobility. The assessment identified Resident #1's balance as unsteady and only able to stabilize with staff assistance; and impairments on one side of upper and lower extremities. The MDS reported the resident had [DIAGNOSES REDACTED]. The Care Plan dated 3/23/16 identified the resident had self-care deficit related to history of CVA, need for assist with Activities of Daily Living (ADL's) and a potential for falls related to unsteady gait, poor balance, history of falls. The care plan directed staff to provide set up assist as needed, encourage and praise, transfer with assist of one with gait belt above the chest and ambulate with hemi-walker and assist of one. The resident had a yellow plaque in the bathroom and staff to transfer with a gait belt. The wing sheets used by staff revealed the resident was a full code and transferred with one and a hemi-walker with the gait belt above chest. Nurse Notes dated 8/14/2016 at 7:11 p.m., documented the resident fell while being transferred from recliner to bed by nurse aide. The resident landed on right side of body, unable to speak, but did shake head yes to clarify that she/he was in pain. Resident first stated pain was in right hip, resident able to move lower extremities, but would not use either arm. Both hands were in fists, and resident denied pain to both arms. Resident then denied pain to hip. Resident breathing very labored, but 96% oxygen saturation on room air. Staff used a Hoyer lift to assist Resident #4 from the floor to bed. Resident then confirmed pain to right shoulder and had a small skin tear to right elbow. At 8:19 p.m., the resident transferred to the emergency room and admitted with a urinary track infection (UTI) and sepsis. The Incident Report dated 8/14/2016, revealed the resident fell while being assisted with transfer from recliner to bed. Resident had gait belt on, landed on right side of body. Resident unable to speak, only shook head yes or no to verify whether or not she/he was in pain and where pain was located. The nurse obtained vitals, assessed the resident's range of motion and attempted neurological checks. The resident had a small tear on the right elbow with bruising. The resident agreed to be seen at the hospital emergency room . The resident's spouse was notified as well. The Fall Risk assessment dated [DATE] revealed the resident had a high risk for falls. The History and Physical dated 8/16/2016 reported the nursing home indicated the patient fell and landed on his/her right shoulder. The family reported every time she/he had a fall or an event he/she most likely had a UTI. The nursing home reported the patient had no fever, chills or diarrhea. The computed tomography (CT) scan of the cervical spine, head and brain were negative. While in the emergency room he/she started having emesis and looked uncomfortable. The physician reviewed the shoulder x-ray and felt it did not reveal any acute fracture. The physician wanted to further evaluate the resident and ordered a CT of the resident ' s abdomen and pelvis. A CT of the abdomen and pelvis dated 8/15/2016, documented an acute appearing fracture through the proximal right femoral neck (hip fracture) with mild impaction. Potential chip fracture off the anterior aspect of the right acetabulum (hip joint). Acute appearing right inferior pubic ramus fracture (pelvic). Age-indeterminate left inferior pubic ramus fracture. The Discharge summary dated 8/18/2016 revealed the resident was discharged with principal [DIAGNOSES REDACTED]. Orthopedic consult determined the resident was not a candidate for surgery; and the resident's family indicated he/she would not want to live like this and made the decision for comfort care measures. Resident #1 would be transferred back to the nursing home for hospice care. The Use of Gait/Transfer Belt Policy, revised 8/29/2016, and received from the Director of Nursing on 9/2/2016 included: Responsibility: All nursing and rehab staff Purpose: 1. To safely transfer and ambulate residents. 2. To prevent unnecessary injuries to staff and residents. Guidelines: Keep the gait/transfer belt available at all times, you never know when you will need it to assist a resident. Review the manufacturers' recommendations for application and securing the belt. Supplies: Gait/transfer belt. Procedure: 4. Apply the gait/transfer belt around the waist and over clothing for all residents that require contact guard assist of 1 or 2. 5. The resident's plan of care will provide information on any differences to policy. During interview on 9/6/2016 at 1:45 p.m., the Administrator stated on August 14, 2016 she received an email from the facility reporting the residents fall. On Monday, the hospital called and said Resident #1 had a fracture. Initially it appeared the residents care plan had been followed. The Administrator state during interview Staff H, certified nurse aide, CNA said she was not sure how the resident fell and said she did not use a gait belt. Staff A, licensed practical nurse, LPN reported Staff H told him the gait belt was on. It did not add up. How did the resident fall backwards if Staff H held onto the gait belt. On August 24, 2016, they met with Staff H again and asked her to recount (review) the story again. Staff H reported she and Staff A put the gait belt on the resident. They terminated Staff H for safety related to not using the gait belt. Staff H told the Administrator that she had seen other CNA's fail to use a gait belt while transferring the resident. During interview on 8/26/2016 at 1:00 p.m., the Director of Nursing, DON reported Staff H transferred the resident with a walker and without a gait belt from the toilet to bed. Staff H was straightening the resident's bed blankets and left the resident standing alone. Staff H heard a crash and the resident was on the floor. Staff A responded, the resident complained of elbow pain mainly but they transferred the resident to the emergency room . When Staff A arrived on the scene the resident had a gait belt. Staff H admitted to putting the gait belt on after the fact. During interview on 9/2/2016 at 12:30 p.m. Staff A, Licensed practical nurse, LPN said he got called to the resident ' s room and saw the resident was on the floor on their right side in front of the recliner. Staff H was kneeling by the resident and said she was transferring the resident to bed, had been doing okay and then the resident fell backwards. Staff H was very worked up and the resident shook their head yes to pain and right shoulder pain. The resident ' s right elbow had bruising and his/her fists were clenched. They used a Hoyer lift and transferred the resident to bed. Staff A said he thought the resident had a gait belt on when he got to the room and he documented that. Staff H told Staff A she had transferred the resident with a gait belt. Later, Staff H admitted she transferred the resident without a gait belt. During interview on 9/2/2016 at 2:45 p.m., Staff B, LPN said she was called to the resident ' s room and saw the resident on the floor with a gait belt on. Staff B never witnessed Staff H not use a gait belt. Staff H told Staff B she was transferring the resident to the bed and had a gait belt on and the resident fell . It did not make sense as the resident had one good side and held onto the cane. Staff B said Staff H left the resident to fix the sheets. During interview on 9/6/2016 at 11:00 a.m., Staff C, certified nurse aide, CNA primarily worked on BV hall, but the night the resident fell , Staff C worked on WW hall and the resident was not on her list, but they all worked together. Staff C and Staff D had just finished assisting the resident ' s roommate and Staff H was going to assist Resident #1. Staff C and Staff D left the room to go chart. Staff C had taken care of the resident and knew the resident was an assist of one with a gait belt (placed high) and a hemi walker. Staff C never witnessed anyone not use a gait belt. During interview on 9/6/2016 at 2:12 p.m., Staff D, CNA stated the resident transferred with assistance of one staff, a gait belt and a four legged cane. Staff D had never witnessed Staff H transfer a one assist resident. Staff D had only assisted Staff H when residents required two assist. Staff D stated a lot of staff transfer residents without using a gait belt, but Staff D had never reported it. During interview on 9/2/2016 at 12:40 p.m., Staff E, CNA stated they had worked with the resident and knew the resident was an assist of one with a gait belt under the arms due to the resident's feeding tube and the resident used a cane. Staff E had never observed anyone not use a gait belt and stated facility policy was to always use a gait belt with any transfer and staff are told that upon hire. During interview on 9/2/2016 at 11:30 a.m., Staff F, CNA stated she had always transferred the resident with a gait belt underneath their arms due to the feeding tube and a hemi walker. Staff F stood on the right side of the resident and held onto the gait belt and elbow that was on his/her weak side. Staff F had never witnessed any staff not use a gait belt including Staff H. Staff F reported all staff are expected to use the gait belt with any resident that required assist of one to two. During interview on 9/2/2016 at 11:40 a.m., Staff G, CNA stated they cared for the resident on SV hall. Staff G stated the resident was an assist of one to transfer with a gait belt high around their chest and a cane. The resident had a yellow plaque in the bathroom which meant staff could leave the resident on the toilet, but remain in the room. The gait belt policy was explained upon hire and they were given a gait belt. Staff G would never let go of the resident as he/she was not steady. Staff G had worked with the resident often enough to know the resident was picky about their bed and Staff G would straighten out the bedding before she got the resident off the toilet. Staff G never saw Staff H transfer a resident without a gait belt. Staff H stated most residents on W/W were an assist of one. During interview on 9/13/2016 at 4:00 p.m., Staff H, CNA revealed she knew the resident and had worked with the resident a couple of times a week though the resident may not have been on her list. Staff worked together and answered lights. The resident had a roommate who Staff H assisted and had seen other staff assist the resident without the use of a gait belt. When Staff H was trained she was told to use a gait belt but it was not enforced. One aide told her to use it if necessary. There were times when Staff H entered the resident ' s room and he/she would be standing with the lift chair all the way up so she would walk with him/her without a gait belt. Staff H stated the night of the fall the resident had the call light on which meant the resident wanted to go to bed. Staff H transferred the resident from the lift chair and ambulated the resident to and from the toilet without using a gait belt. Staff H had a gait belt with her but did not put it on the resident. The resident had a yellow plaque in the bathroom which meant the resident could be left on the toilet but staff had to remain in the room. While the resident was on the toilet, Staff H pulled the bed sheets back, assisted the resident up from the toilet and walked the resident towards the bed. Staff H hovered around the resident ' s elbows and the resident had the walker. When they reached the bed, the resident pointed to the sheets. Staff H knew the resident did not like the way the sheets were crumpled and wanted it straightened because the resident kept pointing to it and would not move until Staff H fixed it. The resident seemed fine and steady so Staff H left the resident standing and straightened the sheets. That's when the resident fell .

Based on observation, clinical record review, family, resident and staff interviews, the facility failed to ensure planned intervention to prevent falls were in place for two of four residents reviewed. (Resident #1 and #3) The facility reported a census of 99 residents. Findings include: 1. The 30 day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had no cognitive impairment, transferred from one surface to another and ambulated in the room with extensive assistance of one person, and had unsteady balance that required staff assistance to stabilize. The MDS reported the resident had frequent urinary and bowel incontinence and [DIAGNOSES REDACTED]. The resident had no falls since admission or prior assessment. The Care Plan revealed the resident had a potential for falls related to weakness and a history of falls dated 1/31/14. It instructed staff to provide physical therapy, a red plaque, chair pad alarm in wheel chair and recliner, bed pad alert and transfer and ambulate with one staff and a platform walker. The updated Care Plan dated 3/4/14, instructed staff to provide therapy, a yellow plaque, chair pad alarm in wheel chair and recliner, bed pad alarm, transfer with EZ, mechanical lift and assist of two, no weight bearing on the left lower extremity chair to bed only, and ongoing ortho consult. The Fall Risk Evaluation dated 1/28/14 revealed the resident scored 12 points, indicating the resident had a high fall risk. A Progress Note dated 2/27/14 at 8:00 a.m., indicated the resident required contact guard assistance of one staff to ambulate from the bathroom to bed with a platform walker. A Progress Note dated 2/28/14 at 4:20 p.m., documented while transferring self resident was found sitting on the floor in the bathroom without apparent injury. The chair pad alarm failed to sound, but functioned correctly when tested . Staff A, Licensed Practical Nurse, LPN assessed the resident and assisted him/her back to bed. A Progress note dated 3/1/14 at 2:30 a.m., documented the resident was found by a certified nurse aide, CNA lying on the floor on his/her left side. The resident was assisted off the floor by two staff and Hoyer lift with no complaint of pain in left but did report left hip pain when turned. A Progress note dated 3/1/14 at 4:30 a.m., documented the resident complained of left leg and hip pain. The physician was called and the resident was transferred to the hospital and admitted with a fractured pelvis. The Hospital Emergency Department Notes indicated the resident had a fall, complained of hip pain and sustained a left acetabular fracture. An Incident Report dated 2/28/14, documented the resident fell in the bathroom at 4:20 p.m., and had a chair pad alarm in the wheel chair that failed to sound but functioned when tested . An Incident Report dated 3/1/14 at 2:30 a.m., documented the resident told staff he/she needed to go to the bathroom and forgot to call. Staff failed to hear the bed alarm and found the resident lying on the left side. The resident had white cotton socks on, staff transferred the resident back to bed with a mechanical lift and later he/she complained of pain. The Post Fall Checklist revealed the resident had bed and chair pad alarms and CNA's reported they failed to hear the alarm sounding, the resident needed non-skid socks in bed, the resident transferred to the hospital, and resident admitted with a fractured pelvis. The CNA information sheet undated revealed the resident transferred with a Hoyer (mechanical) lift, wore non-skid socks in bed and shoes when up, and had bed and chair pad alarms and a yellow plaque. The CNA QA (Quality Assurance) Checks form completed on 2/28/14 on third shift, revealed the resident had bed pad, wheel chair and recliner pad alarms and a yellow plaque. During interview on 3/12/14 at 12:00 p.m., Staff D, LPN indicated the resident had confusion, could use the call light and alarms were added for preventative measure when staff found the resident with his/her legs off the side of the bed. During interview on 3/12/14 at 2:40 p.m., the Director of Nursing, DON reported staff performed QA checks daily. Resident #3 had a bed and chair pad alarm. All bed alarms are tied into the call light system, alerting staff at the nurses station and the light outside the resident's room flashes white and red. During interview on 3/13/14 at 1:15 p.m., the ADON reported if staff connected the bed alarm to the call light system, the light outside the room flashed red and white, and the computer screen at the nurses station alerts staff. The only sound in the room comes from the alarm box. They encourage staff to connect bed alarms to the call light system, especially the high risk residents. Staff needed to check resident alarms daily as the QA (Quality Assurance) procedure required. Staff check the alarm with every transfer and during the shift to shift report. The red and yellow plaques in resident rooms require staff to remain in the resident's room or bathroom when on the toilet. During interview on 3/18/14 at 11:40 a.m., Staff F, CNA reported working the night shift on 2/28/13. Staff F stated they could not hear the alarms from Wendt Willows nurses station. Staff E, CNA and Staff F started rounds on Bluff View, Staff E heard the resident's alarm first and found the resident on the floor. Staff F observed the resident on the floor next to the dresser, approximately 10 steps from the bed. Staff observed the bed pad alarm not connected to the call light system and the call light not on. After they got the resident back to bed, Staff F attempted to add the call light connector to the alarm, however none were available. Staff F indicated all bed pad alarms should be connected to the call light system, the facility had 3 halls, often with four CNA's and two nurses on the night shift. In the past, they had five aides and two nurses outside of the memory care unit. The memory care unit had one CNA at night. If staff were at one end of the hall, they may not hear alarms at the other end of the hall. During interview on 3/12/14 at 3:15 p.m., Staff B, registered nurse, RN worked the night shift on 2/28 - 3/1/14 when the resident fell . The CNA's called Staff B to the resident's room. Staff B failed to hear the resident's bed alarm and worked away from the nurse's station, therefore not viewing the computer screen. Staff B indicated all bed alarms were tied into the call light system, lighting up the box outside the room and on the computer screen at the nurse's station. Staff B failed to recall which staff called for help, but knew he/she reported failure to hear the bed alarm. When they put the resident back to bed, they checked the alarm and it functioned. During interview on 3/17/14 at 3:45 p.m., Staff E, CNA reported working 3/1/14 at 2:00 a.m. Within minutes Staff F and Staff E began rounds and they heard a faint beeping and found the resident on the floor in a puddle of urine. The resident had no call light on and said he/she did not want to bother staff. Staff F failed to recall if the call light system included that bed alarm. Staff F had no knowledge which alarms were hooked into the call light system. The CNA Wing Sheets list resident alarms. During interview on 3/12/14 at 1:15 p.m., Staff G, CNA reported staff checked resident alarms daily during the shift to shift report. The resident used the call light and had no history of unplugging the alarms. During interview on 3/12/14 at 1:36 p.m., Staff H, CNA reported getting the resident up that morning with the help of Staff G. At approximately 10:30 a.m., they assisted the resident to bed to use the bed pan and back to the wheel chair. They placed the chair alarm pad on the seat and failed to recall if it beeped, letting them know it functioned. The resident had alarms due to a history of self transfer attempts. During interview on 3/12/14 at 4:00 p.m., Staff A, LPN reported working second shift on 2/28/14 when the resident fell in the bathroom. When Staff A checked the resident's chair alarm, it functioned. The resident had his/her walker near, had his/her slacks in a trash bag and shoes off. The resident sustained [REDACTED]. During interview on 3/17/14 at 8:45 a.m., Staff J, CNA reported working second shift on 2/28/2014, when the resident fell . Staff A, LPN passed pills and found the resident on the bathroom floor. The resident transferred from the recliner to the wheel chair and then to the bathroom. The pad alarm remained in the recliner but failed to sound. During interview on 3/17/14, Staff K, CNA reported working second shift on 2/28/14 when the resident fell between 4 and 4:30 p.m. The resident transferred from the recliner to the wheel chair and used the walker to ambulate to the bathroom. Staff observed the resident's slacks and wet brief in a garbage bag, shoes off and a new brief and clean slacks draped over the walker. The resident sat on the bathroom floor and denied injury. The chair pad alarm failed to sound. Staff K indicated not all bed alarms are connected to the call light system. Staff know to connect the bed alarm to the call light system if a connector is present. During interview on 3/17/14 at 10:00 a.m., Staff L, CNA reported all bed alarms get hooked up to the call light system. Staff check all alarms at the shift to shift change. During interview on 3/17/14 at 3:00 p.m., Staff I, CNA reported working third shift at the facility. They check alarms two times a week for the QA process. At the change of shift they check all resident alarms and make sure they are all hooked up and into the call light system. The call light system flashes on the computer screen at the nurse's station when a bed alarm sounds. Within the past two days, the computer screen now makes a sounding "beep". When staff does rounds and in resident rooms with the door closed, staff may not hear alarms depending on the location. Observation on 3/12/14 at 11:45 a.m., revealed the resident in the room, seated in the wheel chair with a Hoyer sling underneath and a pressure pad alarm not connected to the alarm box at the back of the wheel chair. The surveyor along with the Assistant Director of Nursing, ADON made the observation. The ADON connected the pressure pad cord to the alarm box at the rear of the wheel chair and it beeped, indicating it functioned. The ADON removed the cord from the alarm box and it sounded, indicating it functioned. 2. The MDS assessment dated [DATE], documented Resident #1 had no cognitive impairment, transferred and ambulated in the room with extensive assistance of one person and required staff assistance to stabilize during transitions and walking. The resident had [DIAGNOSES REDACTED]. The Care Plan identified the resident as at high risk for falls with a start date of 10/3/13 related to weakness, history of falls, recurrent UTI's (urinary tract infections), pneumonia and weakness. The Care Plan instructed staff to apply non-skid socks, provide a walker for ambulation and a wheel chair for long distances, provide one person for transfers and ambulation and call light is within reach. Added Care Plan interventions dated 1/5/14 documented the resident was to have a low bed and alarm wherever he/she sits. The Fall Risk assessment form revealed the resident scored 17 points on 12/18/13, indicating the resident as at high risk for falls. Nurse notes dated 2/23/14 at 8:30 a.m., documented the resident was heard yelling and was found on the floor next to bed on their left side. The resident complained of pain with movement. Staff M, LPN notified the resident's family and physician and transferred the resident to the emergency room . The resident was admitted to the hospital with [REDACTED]. An Incident Report dated 1/5/14 at 7:10 a.m., revealed the resident fell from the bed. Staff responded to the resident yelling out with no call light on and found the resident sitting on their buttocks next to the bed. The Plan of Prevention included: alarm wherever sits. An Incident Report dated 2/23/14 at 8:30 a.m., revealed the resident fell from the bed. Staff heard the resident yell for help, entered the room and found the resident laying on the floor on the left side and the bed in high position. The alarm sounded but staff failed to hear it from outside the room. The resident complained of left knee and left elbow pain, and transferred to the emergency department. The plan of prevention included instruction to put the bed pad alarm in the call system and bed controls out of reach. The resident admitted to the hospital with [REDACTED]. CNA QA Checks sheet dated 2/22/14 for the 2:00 p.m. -10:30 p.m. shift indicated the resident had yellow plaque, bed pad alarm and chair/recliner alarms and a low bed. CNA wing sheet undated indicated the resident had non skid socks at night, yellow plaque, bed pad alarm and chair alarms and a low bed. Update included Hoyer lift with two staff assistance to transfer and a right knee brace. Observation on 3/10/14 at 3:00 p.m. revealed the resident seated in the recliner with oxygen on per nasal cannula and a pressure pad alarm in the chair. The resident appeared alert and reported he/she fell out of bed. The resident had a right knee brace on. On 3/13/14 at 11:20 a.m., the resident's family reported the resident had other falls, he/she gets confused and sustained a fractured femur with the last fall. On 3/10/14 at 3:00 p.m. the Administrator reported the resident sustained [REDACTED]. The resident woke from a dream and thought a cigarette burned on top of the dresser. Staff can put the bed alarm into the call light system. The Administrator demonstrated when the bed alarm activated while hooked into the call light system, the light outside the resident's room flashed red and white. During interview on 3/12/14 at 3:OO p.m., the DON reported the resident had delusions and thought a cigarette burned on top of the dresser. The bed alarm must not have been connected to the call light system. The plan of prevention included connecting the bed alarm to the call light system. During interview on 3/12/14 at 2:15 p.m., Staff M, LPN heard the resident yelling on 2/23/14. Staff M observed the alarm not hooked into the call light system and failed to hear the alarm sound outside of the resident's room, near the nurse's station. Staff M passed medications, heard the resident yell and found him/her on the floor. When Staff M entered the resident's room, he/she heard the bed alarm sounding. Staff M observed the door open and the bed in the high position. The resident indicated he/she attempted to reach a cigarette on top of a cabinet. Staff M indicated the resident had a previous fall and they implemented alarms at that time. During interview on 3/12/14 at 2:00 p.m., Staff N, CNA reported working on 2/23/14 when the resident fell from the bed. Staff N observed the resident at the change of shift and saw the bed alarm in place. Staff N failed to recall if the bed alarm connected to the call light system. Staff M came to the dining room and asked for help as the resident had a fall. Staff N failed to hear the bed alarm when he/she entered the resident's room, and failed to see the call light "on". During interview on 3/12/14 at 1:20 p.m., Staff G, CNA reported working on 2/23/14 when the resident fell from the bed. The resident put the bed in the high position and had confusion and thought a cigarette burned on the dresser. Staff G failed to hear the resident's bed alarm sound outside the room.

Based on record review, resident and staff interviews, the facility failed to direct nursing provisions with adequate assessment and timely intervention for one twelve residents with a change in condition. Interviews and record review showed Resident #1 sustained a fall without any assessment for injury. A few days after the fall, the resident started complaining of pain and the X-ray revealed a small sacrum facture. The facility reported a census of 101 residents. Findings include: The Minimal Data Set (MDS) assessment tool dated 07/27/11 identified the resident with a score of 15 out of 15 on his/her Brief Interview for Mental Status (BIMS) test. The assessment showed Resident #1 oriented to year, month, day, and his/her memory recall intact. The assessment identified no [MEDICAL CONDITION], hallucination, [MEDICAL CONDITION] or other behaviors. The assessment revealed the resident required extensive assistance of 2 staff persons for bed mobility, transfers, ambulation in the room, dressing, bathing and toilet use. The assessment documented Resident #1 required staff assistance to stabilize his/her balance and unsteady when walking, moving from seated to standing position, when turning around, when moving on and off the toilet, and during surface to surface transfers. The MDS noted the resident had no pain or hurting at any time in the last 5 days. The Physician's Office note dated 09/02/11 identified Resident #1 with [DIAGNOSES REDACTED]. The Resident Care Plan dated 07/28/11 identified a problem with impaired physical mobility with an intervention that included transferring the resident with 1 staff person. The care plan indicated Resident #1 had ongoing consultation with Physical Therapy (PT) and Occupational Therapy (OT). Record Review of the Skilled Nurse's Progress Notes included the following: a. 07/27/11 at 9:20 a.m.: The resident working with PT and OT was involved in a dynamic weight shift bouncing a large ball when being cued once by the PT and continued therapy. The resident began to lean to the left and could not correct himself/herself, was caught by the OT and PT person but did not go down to the floor. Vitals signs were completed on the resident. At 10:50 a.m., the family was notified and a memo faxed to the physician. b. 07/27/11 at 2:55 p.m.: Received an order to increase the Tylenol pain medication due to the resident complaints of pain more often. On 07/29/11 at 4:30 p.m.: The resident had no complaints of pain. Record review of the resident's Incident Report dated 07/27/11 at 9:20 a.m. included the following: During an Occupational Therapy (OT) session, involving a dynamic weight shifting with a large bouncing ball, the resident began to lean to the left and could not right him/her. The resident was caught by the OT and Physical Therapist (PT); however the resident did go down to the floor. The incident report was signed by the OT (Staff TTT) and PT (Staff RRR). Record review of the Occupational Therapy Daily Documentation dated 07/27/11 signed by Staff TTT noted the resident fell without injury and filed an Incident Report. Record review of the resident's Incident Report dated 09/05/11 noted the incident occurred on 09/01/11 with an unknown time of when the incident occurred. The Incident Report included the following: Resident stated while in therapy, on the parallel bars, the resident's knees gave way and in the process of falling the OT staff person caught him/her, but the coccyx did hit the floor. The resident rated the pain as a level of 10 out of 10 (severe pain). There were no other injuries noted, range of motion was in normal limits but with pain. The Incident Report revealed documentation by Staff GG, Licensed Practical Nurse. Record review of the Occupational Therapy Daily Documentation dated 09/01/11 signed by Staff TTT lacked any documentation of a fall or Incident Report. A facsimile sent to the resident's Physician's dated 09/05/11 noted the resident fell on the coccyx while working with therapy on 09/01/11. There was no bruising, range of motion within normal limits but an increase of pain which was rated at a level of 10 out of 10(high). The resident noted the pain radiated into the right lower extremity/hip area. The resident was sent to the hospital on [DATE] and diagnosed with [REDACTED]. A facsimile of a Major Injury Determination Form dated 09/06/11 signed by the resident's Physician noted the Physician reviewed the injury, circumstances, and prognosis of the resident and believed the injury sustained was a major injury. The nursing home staff noted the resident's pain level of 10 out of 10. The Report of Radiology Procedure dated 09/05/11 stated the impression showed diffuse [MEDICAL CONDITION] with a questionable buckling deformity of the anterior cortex of the lower sacrum. The report documented this may represent a small fracture. Record Review of the Skilled Nurse's Progress Notes included the following: a.09/01/11 at 8:00 a.m.: The resident's gait is steady and able to complete morning cares and dressing, stated of feeling stronger. b.09/02/11 at 7:10 a.m.: The resident completed morning cares per self and denied any pain with movement. c. 09/03/11 at 2:00 a.m.: The resident complained of low back pain and stated it occurred with a fall. Tylenol was administered to the resident. The resident stated of falling on his/her buttocks when working on the parallel bars in therapy, maybe on Thursday (09/01/11), but wasn't sure. There were no bruises or red marks noted. The resident remarked the nurse was the one who applied lotion every night, to which the nurse replied of not being that person, thus felt the resident was confused. d.. 09/03/11 at 10:00 p.m.: The resident had no further reference to back pain. e. 09/04/11 at 10:00 p.m.: The resident had no complaints of pain. f. 09/05/11 at 4:15 a.m.: The resident used an assist of 1 staff person for transfers. g. 09/05/11 at 8:30 a.m.: The resident ambulated approximately 200 feet with 1 staff person and a walker. h. 09/05/11 at 10:00 a.m.: The resident stated on 09/01/11 of falling onto the floor hitting his/her coccyx when working in therapy. There were no bruises noted. The resident rated the pain of 10 out of 10 in the coccyx area which radiated into the right lower extremity. The resident was sent to the hospital for x-rays. i. 09/05/11 at 4:20 p.m., the resident returned to the facility with new orders for a soft cushioned toilet seat, a donut for sitting and [MEDICATION NAME] tablets for pain as needed. j. 09/06/11 at 2:00 a.m.: The resident had Tylenol and Aspercreme for pain to the coccyx and right lower leg after stating of experiencing severe pain. The resident noted if he/she didn't move much, it was okay. The resident noted of being relieved to have gotten an X-ray, even though there is no cure, at least is now aware a fracture was revealed. The resident continued to complain of pain on 9/6/11 and rated his/her pain at 5 out of 10 and on 9/7/11 his/her pain rated at 6 out of 10. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The month of September: Tylenol was given on 09/3-1 time, on 09/4-1 time, on 09/6-1 time. The rest of the month in September, [MEDICATION NAME] (a stronger pain medication) requested by the resident was given instead of the Tylenol on approximately 25 times from 09/07/11 through 09/21/11. Record review of the Occupational Therapy Interval Progress Report noted the resident continued Occupational Therapy 5 times a week through the month of August and through September to the current date. During an interview on 09/23/11 at 9:56 a.m., Staff TTT, Occupational Therapist, stated of working with the resident, who was alert and oriented. During a therapy session in July, with another Therapist present, the resident started to topple forward and lateral and went down to the floor. An Incident Report was filed after an assessment had been completed. On 09/01/11, in the Physical Therapy room, with only Staff TTT and the resident present, they were working on a parallel bar, doing side steps. The resident dropped down and was in a squatting position and could not pull himself/herself up to a standing position. With the gait belt already on the resident, Staff TTT lowered the resident to a thick cushion sitting on the floor. Staff TTT noted the resident appeared anxious and slightly embarrassed, so he/she remarked to the resident something like 'if you don't tell anybody, I won't tell anybody'. Staff TTT noted this was said to encourage the resident not to give up on the long term goal of getting home. They did another exercise and then Staff TTT wheeled the resident back to the room in the wheelchair. Staff TTT commented with lowering the resident to the floor, it did not appear to be a fall, thus did not report it as a fall. Staff TTT stated Staff GG called Staff TTT at home on the following Saturday and inquired about a fall in therapy which had been reported by the resident. Staff TTT informed Staff GG of what had happened. During an interview on 09/28/11 at 11:24 a.m., the resident noted of experiencing a near fall in July, but someone had caught him/her. The resident noted on 09/01/11 working in Therapy with Staff TTT on the parallel bars. The resident reported their knees suddenly gave out and began falling. Staff TTT had the gait belt on the waist area and held onto that while assisting the resident to the floor. The resident remarked, once the fall started, there was no chance of stopping, because the knees could not support his/her body and felt there would be no way a squat position could have been maintained. The resident noted the Therapist had him/her standing as soon as the buttocks landed on the floor. The resident does not remember a cushion present or if his/her buttocks hit the floor hard. The resident noted of having no real pain at the time but noted of feeling some tenderness in the buttocks area. Staff TTT, may have said something to the effect of not telling anyone, and wondered if it was meant to be a joke. There was no one else present in the therapy room at the time of this incident. The resident remarked of knowing for sure that the buttocks hit the floor and Staff TTT picked him/her up immediately. The resident commented the next day was Friday, which was bath day, and it felt so good, it minimized the pain to the buttocks. The pain started to slowly increase in strength on Saturday when the resident reported the pain and incident to Staff GG, and requested pain medications. The resident remarked of noticing the pain was worse when sitting too long and when expelling [MEDICATION NAME]. During an interview on 09/27/11 at 3:03 p.m., Staff QQ, Licensed Practical Nurse, stated Staff DDD, Certified Nursing Aide, reported the resident requested a pain medication for back pain sustained during a fall at Therapy. Staff QQ administered Tylenol for the pain and asked about the fall. The resident reported while working on the parallel bars, fell on to their buttocks. The resident commented that Staff TTT, Occupational Therapist said not to tell anyone. Staff QQ assessed the resident and found no redness or injuries. Staff QQ noted the resident may be dreaming. The resident also commented that Staff QQ was the usual staff person who applied to lotion to him/her every night, to which Staff QQ replied of not being that staff person, as this was not the usual shift they worked, therefore Staff QQ, believed the resident was confused. Staff QQ knew of a prior report of the resident's fall and believed the resident was referring to that fall, as the staff person had not heard of any recent fall. After another staff person reported the resident's fall of 09/01/11 on 09/05/11, Staff QQ removed the Incident Report that was written on 09/03/11 from the shred pile and gave it to the Director of Nursing. Staff QQ noted a lowering of a resident to the floor is always considered a fall and a report should be written. Staff QQ was under the understanding all staff at the facility knew a lowering to the floor was a fall and would report it as a fall. Staff QQ was unsure if a Therapist would just do their own assessment or if they would call for a nurse, but felt it should be reported to the nurse in any event. Staff QQ did not contact Staff TTT regarding the fall when reported by the resident, to verify the resident's story. Staff QQ commented it seemed strange someone would tell a resident not to tell anyone about a fall, because all staff knows to report a fall. During an interview on 09/28/11 at 2:00 p.m., Staff GG stated the resident reported of not sleeping for a few nights and felt the pain to the buttocks and hips had gotten worse. Staff GG saw no redness or bruising with completion of an assessment. The resident reported the pain level was at a 10 out of 10 level (extreme pain). The resident informed Staff GG of falling with the Therapist, Staff TTT, in therapy a few days earlier. The resident noted of working on the parallel bars when the knees buckled and the resident went down to the floor. Staff GG stated the resident was alert and orientated. Staff GG called Staff TTT at home to question the incident in order to further addresses the resident's needs. Staff GG remarked the resident was progressing well, with talk of going home and had no pain and then all of a sudden, the resident is reporting a pain level of 10. Staff TTT informed Staff GG of lowering the resident to the floor and felt the resident did not get hurt and even wondered if the resident had hit the floor. During an interview on 09/27/11 at 11:48 a.m., Staff Q, Certified Nursing Aide-CNA, stated lowering a resident to the floor, with or without a gait belt, is considered a fall. Staff is not to leave the resident, you call for help and don't move the resident until a nurse comes to assess the resident. During an interview on 09/27/11 at 11:50 a.m., Staff WWWW, CNA, stated anytime a resident is lowered to the floor, with or without a gait belt, or falls to the floor, it is considered a fall. Staff WWWW commented that one doesn't leave the resident, calls for help and the nurse will assess the resident before moving the resident. During an interview on 09/27/11 at 11:53 a.m., Staff H, Licensed Practical Nurse, noted a fall is a fall, whether the resident is assisted or unassisted to the floor by staff. The resident is not to be left alone and not moved until a nurse comes to assess the resident. The nurse writes up the report, usually writes in the names of staff involved, who found the resident and what happened. During an interview on 09/27/11 at 6:20 p.m., Staff O, Licensed Practical Nurse, noted any change of position for a resident is considered a fall and an Incident Report is filled out with assessments completed. All staff is aware of this, including the housekeepers, dietary and maintenance. Staff O remarked Therapists should be expected to know this procedure. During an interview on 09/28/11 at 9:46 a.m., Staff DDD, Certified Nursing Aide stated the resident had the call light on and wanted to go to the bathroom. The resident remarked to the staff person to be careful, as their buttocks hurt. The resident commented to Staff DDD, that he/she was not supposed to tell anyone there was a fall. Staff DDD reported the resident's comments to the nurse. During an interview on 09/28/11 at 11:45 a.m., Staff RRR, Physical Therapist was present in the therapy room while Staff TTT was working with the resident on 07/27/11. Staff RRR saw the resident leaning, looking like he/she was going down, went over and grabbed the resident around the waist and helped the resident to the floor. The resident landed left side of the right lateral thigh and buttocks with no complaints of pain. Staff RRR assessed the resident, took vitals, reported it to the nurse and signed an Incident Report form written by Staff TTT. During an interview on 09/29/11 at 8:25 a.m., Staff TTT noted the resident had been lowered to the floor and did not write up a report of the incident. It was noted the fall in July was written up and signed, a similar incident to the present fall that was not written up. Staff TTT remarked of not knowing that lowering a resident to the floor was considered same as a regular fall, thus did not write an Incident Report. During an interview on 09/29/11 at 10:10 a.m., the Director of Nursing (DON) interviewed Staff QQ about the resident requesting pain medication for a painful buttocks and a fall. The DON noted Staff QQ had believed the resident was confused at that time and was referring to a previous fall. The DON felt the resident imagined the Therapist telling the resident not to tell anyone. The DON commented Staff TTT did not know to report a lowering of a resident to the floor as a fall, requiring an incident form. The DON stated the fall in July was not similar to the fall that occurred on 09/01/11. The DON noted the first incident was with the resident losing balance and going down, with a Therapist catching the resident as the resident was going down. The incident on 09/01/11 was with the resident caught between standing up or going down and Staff TTT just placed the resident to the floor. Observation on 09/23/11 at 10:40 a.m., revealed the resident sitting in a recliner, on a plastic donut, eating and visiting with a friend. The resident remarked of going back to assisted living apartment in the middle of the coming week. Facility Policies: FALLS: Responsibility: Charge nurse, Director of Nurses, Administrator PURPOSE:1.To ensure that if a resident falls, a thorough assessment is completed and appropriately documented with interventions identified to prevent future falls. PROCEDURE: If a resident has fallen, staff are to leave resident as is until assessed by nurse. Nurse to complete a thorough head to toe assessment for injury. Complete ROM (range of motion) to determine possible injury. If any head involvement, complete neuro checks as per policy. If an unwitnessed fall and resident has cognitive problems complete neuro checks as per policy. Do not move resident until complete. Complete ortho-static blood pressures at the time of the fall along with a full set of vitals.If injury has occurred, depending on the injury use nursing judgment to assist resident up or to make the resident comfortable and leave on floor until ambulance arrives, i.e., hip pain, back pain, head injury, etc. Complete first aide to injuries that can be cared for in the facility, i.e., skin tear, bruise, etc. Notify the physician and family.Complete the Unusual Occurrences form. Complete the Fall Investigation and the Fall Assessment Record.

Based on observation, clinical record review and interviews with staff, family and physicians, the facility failed to plan for and provide adequate nursing supervision and interventions determined to keep Resident #7 safe and free from injury. The facility's documentation and staff interviews revealed Resident #7 had been repositioned by Staff RR and hit his/her head on the bed side rail, sustaining a forehead contusion and bruising. The resident also had swelling and abrasion on his/her right knee. The DON documented two staff should have repositioned the resident, however the care plan lacked this directive. Staff interviews revealed Staff RR was known to approach other residents when repositioning in a forceful manner. The facility also failed to provide adequate nursing supervision and interventions determined to keep Resident #3 safe. The facility identified a census of 101 residents with twelve residents reviewed. Findings include: 1.The Minimum Data Set, ((MDS) dated [DATE] documented Resident #7 had long and short term memory impairment and modified independence with cognitive skills in daily decision making, some difficulty in new situations only. The MDS reported the resident had trouble falling or staying asleep, tired with little energy nearly every day, and a worsened change in behavior or other symptoms. The MDS documented the resident required extensive assistance of two person physical assist for bed mobility to move to and from lying position, turn side to side and position body while in bed or alternative sleep furniture. The resident also required extensive assist of two to transfer between surfaces including the bed, chair, wheel chair and standing position, to ambulate, dress, use the toilet, personal hygiene care and locomotion off the unit. The resident required human assistance to stabilize when walking, moving from seated to standing position, turning around, moving on and off the toilet, surface to surface transfers, and no falls since the prior assessment. The MDS reported the resident had frequent urinary and bowel incontinence and [DIAGNOSES REDACTED]. At the time of the assessment the resident received anticoagulant medication. The CAA (Care Assessment) Report documented the resident had fall interventions including Red Plaque, pad alert, bed pad alert, chair tab alarm, last fell on ,[DATE], and required to staff to assist with all transfers and ambulation. The resident had a history of [REDACTED]. The MDS dated [DATE] revealed the resident had a fall since admission or prior assessment with no evidence of injury. The Fall Risk assessment dated [DATE] documented Resident #7 scored 13 points indicating the resident had a high risk for falls. The Care Plan with a team conference date of 08/11/2011 directed staff to implement approaches including allow time to make needs known, allow choices, avoid rushing, calm approach with cares, monitor medical reason for behaviors - history of urinary tract infections (UTI ' s), provide assist with cares, bed pad alarm, chair pad alarm recliner, red plaque in bathroom, Tab alarm on chair in day room, check and change at night, toilet during waking hours, transfer and ambulate with two hand in hand, and non skid socks on at night. On 09/21/2011 staff updated the Care Plan and directed staff to reposition every two hours at night with assist of two staff; ice as needed to forehead, and pad bed side rails. On 09/23/2011 staff added interventions including modified low bed and fall-eze (mat) on floor next to bed and recliner. On 09/21/2011 at 7:15 p.m. the physician ordered staff to transfer Resident #7 to the emergency room . The Nurse's Notes for Resident #7 included: a. 09/21/2011 at 12:30 a.m. - CNA (Certified Nurse ' s Aide) alerted nurse resident developed bump to left forehead after CNA bumped his/her head against the side rail of bed during repositioning. Large, round bump prominent with bruising starting, approximately 6 centimeters (cm) diameter. Resident alert, responding to nurse, able to focus, speech per usual. Unable to complete neurological assessment related to condition/lack of cooperation. Ice applied, Lortab elixir (pain medication) given for wincing/statements of pain. Message left for POA (power of attorney) to call. Will continue to monitor b. 09/21/2011 at 1:00 a.m. - Continues to respond as usual, ice relieved swelling to welt with decreased size. Resident getting sleepy. Will continue to monitor. c. 09/21/2011 at 2:00 a.m. - Sleeping, easily aroused. d.09/21/2011 at 5:10 a.m. - Call placed to hospice with condition report, continues to complain of headache. Hospice nurse directed staff to follow family wishes. e.09/21/2011 at 5:40 a.m. - Spoke to POA, does not want resident sent to hospital for evaluation, continue to utilize pain medication and monitor, will visit in the morning and voiced concern related to injury. f. 09/21/2011 at 7:10 a.m. - Padded side rails added to prevent future injury. g.09/21/2011 at 9:25 p.m. - Sitting at table eating, alert, and bruise and swelling evident on forehead. Will request ice to forehead from hospice, will reposition with two staff during night. h.09/21/2011 at 10:30 a.m. - Allowed to sit in recliner after breakfast, denied nausea, ice applied. i. 09/21/2011 at 11:00 a.m. - doctor per telephone aware of incident. j. 09/21/2011 at 6:00 p.m., POA here to see resident, took photos and asked the resident be sent to the emergency room . k. 09/21/2011 at 7:30 p.m. -The resident transferred to the emergency room via ambulance. l.09/21/2011 at 7:35 p.m., staff noted at 7:00 p.m. while in the bathroom, the resident had a small abrasion to the left knee and slightly swollen. m. The resident admitted to the hospital with [REDACTED]. The Iowa EMS Report dated 09/21/2011 documented at 7:13 p.m. they dispatched to the facility for a resident who had an incident and hit his/her head on the bed rail while being adjusted by staff in bed. Staff also reported the resident had an abrasion to the right knee. Observation upon arrival to the facility revealed the resident in the recliner, breathing non labored with warm, pink, dry skin, not able to answer questions appropriately with speech garbled. Patient had a visible hematoma to the left side of the forehead enclosing the bruising, and bruising around eyes. Abrasion on knee inspected with visible swelling noted. Staff said swelling of knee not normal for the patient, abrasion about a half inch long. The hospital Physician Admission Order dated 09/21/2011 documented Resident #7 transferred from the facility with head injury, complaints of pain to forehead above left eye, large bump and bruising to forehead and around eye, and also small abrasion to right knee. The Hospital Nursing Progress Notes documented Resident #7 admitted from the emergency room for a fall and UTI, with a 4 cm ecchymotic area on forehead, nursing home claims from a fall. The hospital Emergency Department Physician Notes dated 09/21/2011 included: Complaint: Head Injury. History: Brought from nursing facility for evaluation of injury to head. Paramedic's stated the resident suffered a fall, complains of pain to right shoulder, right chest wall, and has obvious large contusion and hematoma to forehead. Resident ' s baseline induced dementia, does not interact very much, and does not provide any history. The review of symptoms revealed pain in the right shoulder and chest wall. Examination of the head revealed a large contusion with ecchymosis over left frontal region, no laceration, and slight amount of swelling over right lateral upper lip, bruising noted. Examination of the extremities revealed a small amount of swelling and abrasion to the right knee. The resident admitted to the hospital with [REDACTED]. The hospital History and Physical dated 09/22/2011 included Assessment: Patient with advanced dementia, and now some soft tissue injuries of unclear etiology. A hospital progress note dated 9/22/11 documented Resident #7 had been swinging at staff, pulling off his/her oxygen and a few minutes later the resident only responded to pain. Hospital Coagulation lab results dated 09/21/2011 reported the resident had an INR of 1.9 and PT (prothrombin time) of 21.1 seconds. The report documented an INR target range of 2.0-3.0. The hospital CT scan of the Head report dated 09/21/2011 at 8:41 p.m. documented the resident had no acute findings, a small hematoma overlying the left frontal bone and no abnormal intracranial blood. Reason for exam: head trauma. The hospital Discharge Summary dated 09/23/2011 included, Diagnoses: [REDACTED]. Operations and Procedures: CT scan of the head showed a small hematoma overlying the left frontal bone. Physician Interviews: During a phone interview on 10/05/2011 at 8:30 p.m., Physician #1, reported treating Resident #7 in the emergency roiagnom on [DATE] and heard two different stories. The paramedics said the resident fell as reported by the facility, and family said the facility said the resident sustained [REDACTED]. The resident had a significant bump to the head, abrasion to the knee and a sore shoulder. The resident said to the family not the physician that he/she fell . Residents get turned two times a night and there is many residents on Coumadin (blood thinner), but don't see those types of injuries from side rails. The family had a concern about the amount of force that must have occurred to cause injuries. Physician #1 understood the family's concern. Physician #1 had no more to say, other than what the emergency room note documented. During a phone interview on 10/04/2011 at 12:50 p.m., Physician #2 reported discharging Resident #7 from the hospital on [DATE]. Physician #1 saw the resident in the emergency room . The resident had a hematoma to the left forehead, and right upper lip, knee and shoulder pain and injury. The resident received Coumadin therapy and therefore more prone to bleeding. The ecchymosis appeared raised and firm and measured about 6 cm. The resident could have bruised the head from the side rail; however that failed to explain the lip, knee and shoulder injuries. During a phone interview on 10/04/2011 at 10:45 a.m., Physician #3's nurse reported the physician had not seen Resident #7 in the hospital or since the incident. The facility notified the office and asked for a verbal order to send to the emergency roiagnom on [DATE]. The physician ' s office had no documentation of contact on 09/20 or 09/21/2011 with the facility regarding the injury to Resident #7, only the request to transfer. The Progress Notes Admission worksheet revealed Resident #7 returned to the facility on [DATE] at 8 p.m. Staff LLLL documented the resident had a 11 cm bruise to the left eye with a 3 cm round raised area, right shoulder swollen with 7 cm pink area, right knee with 7 cm by 4 cm discoloration and edema, and edema right side foot. The resident returned with an order for [REDACTED]. The MAR (Medication Administration Record) directed staff to administer ice to forehead (left) every 20 minutes as needed beginning 09/21/2011. According to the MAR, no staff applied ice on 09/21/2011. Resident #7's Neurological Assessment Flow-sheet documented staff performed assessments on 09/21/2011 at midnight - unable to assess, ten thirty a.m. - refused, four p.m. - unable to assess. The ADL (Activity of Daily Living) Detailed Entry Report included: On 09/21/2011 Staff RR (CNA) provided one person physical assist for bed mobility and toileting assistance at 1:01 a.m. and 5:21 a.m. The resident had total dependence on staff to perform the activity and no transfer activity occurred. Staff Interviews: During an interview on 09/28/2011 at 4:40 p.m., Staff OOOO, RN (Registered Nurse) reported working the night shift on the SV (Sunshine Valley) and SVS (Sunshine Valley Suites - dementia unit) when Resident #7 sustained a welt to the left forehead. At approximately 11:40 p.m. Staff RR, CNA (Nurse's Aide) worked in the unit and contacted her via walkie talkie and reported finding a bump on Resident #7's head. Staff OOOO stated she asked Staff RR, " did you bump his/her head? " and Staff RR responded, " No " . (Staff OOOO stated another nurse, Staff O, LPN (Licensed Practical Nurse) heard the report as well.) Staff OOOO went to the unit to do an assessment for the resident and found Staff RR at the kiosk charting, and reported that she must have hit his/her head, but did not remember it happening, did not hear it, but she must have. Staff OOOO stated the unit lights were turned down low and when she entered Resident #7's room and turned the light on, staff observed the resident in bed on his/her back and the right side rail up, not the left. Staff OOOO observed a prominent welt to the left of midline on the forehead. Staff RR appeared nervous and stood at the head of the bed during the assessment. Resident #7 did not respond when asked what happened, but winced and turned his/her head back and forth stating " my head, my head hurts". The welt measured approximately 6 cm round with intact skin and bruising started. Staff OOOO found no other injuries at the time of the assessment, retrieved and ice pack and asked Staff RR to write a statement regarding what happened. Staff O also came to the unit and observed the resident. Staff OOOO attempted to call the resident's family and did not reach anyone. Staff OOOO reviewed Staff RR's statement that reported he/she repositioned the resident and bumped the resident's head against the side rail at approximately 10:45 p.m. When she (Staff RR) later checked on Resident #7, around 11:30 p.m., she found the bump on the resident's head. Later, family returned the call; Staff OOOO explained the incident and family asked to speak directly to Staff RR. Family asked her to continue to give pain medication to keep Resident #7 comfortable, not to send to the emergency room and call them back with changes in condition. Staff OOOO stated the family member stated she had witnessed Staff RR get physical with her loved one before. Staff OOOO stated the family member reported Staff RR picking up Resident #7 and put him/her back in bed, when Resident #7 was trying to get up. The family member reported being very concerned and would be there later that morning. Staff OOOO documented the incident in the Nurse's Notes, sent an e-mail to the DON regarding the incident and of Staff RR's statement and placed the hand written statement in the DON's mailbox at her doorway. Staff OOOO reported Resident #7 was usually alert, but confused and drowsy at times with difficulty to transfer. At times the resident had delusions with confusion to time and place. The resident had the ability to move around in bed and attempted to get out of bed. Usually the resident can answer simple questions, and verbalize pain. Prior to the incident, Resident #7 required the assistance of two staff to transfer. At night, staff provided incontinence cares for Resident #7 while in bed, doing checks and changing incontinence products. Should the resident get up out of bed, two staff are needed for transfer and ambulation. Rarely had Staff OOOO been called to assist with the resident on the night shift. Staff OOOO stated she had no conflicts with Staff RR. Prior to this incident, Staff OOOO had discussed Staff RR's approach with another resident (Resident # 12), in the unit. Staff OOOO stated that resident (Resident #12) is difficult to turn in bed and he/she was often resisted being moved. Staff OOOO stated on three different occasions she assisted Staff RR with the other resident ' s cares and had to ask Staff RR to slow down and be gentler. Staff OOOO stated Staff RR would rush into the resident ' s room, take a hold of him/her and push him/her somewhat forcefully with turning. Staff OOOO stated for that reason two staff assists with reposition that resident. Staff OOOO stated that resident had never been injured during any of these incidents. Other staff (CNAs) reported similar concerns and when Staff OOOO had been informed, she observed Staff RR and corrected him/her on this behavior. No further complaints or observations were reported. A follow up interview with Staff OOOO, on 10/3/11 at 3:30 p.m. she stated she did not complete an incident report of what occurred with Staff RR and Resident #7. Staff OOOO stated facility staff did not complete incident reports when they know how the injury occurred since the CNA, Staff RR was there and wrote a report saying how it occurred in his/her own words, which had been turned into the DON. Staff OOOO stated because of Staff RR's inconsistency with the explanation, she completed a full body assessment and did not see the abrasion on the resident's knee at that time. Resident #7' s clinical record lacked an incident report/fall report. A hand written statement with by the DON reported she had talked with Staff RR about the incident with Resident #7. Staff RR demonstrated how she had turned Resident #7 and how she normally turned the resident. Staff documented, " Staff RR agrees using two staff for repositioning is appropriate since Resident #7 does not assist with transfers or repositioning. Prior to the incident, the resident ' s care plan lacked any directive for two staff to assist in repositioning. During an interview on 09/29/2011 at 10:16 a.m., the DON indicated the facility had a policy regarding staffing in the CCDI unit, they have three aides during the day shift, one is a medication aide and the charge nurse goes back and forth. On second shift there are two aides and one medication aide passes medications. On third shift (nights), there is one aide present in the unit. On 10/04/2011 at 11:45 a.m. the DON reported the facility had no CCDI unit orientation checklist, new staff mentors or shadows a current staff. They require six hours of training for all staff, and they must be employed at the facility for six months prior to working in the unit. The DON directed staff to transfer, check and change and reposition with the assistance of two staff after that incident. One of the other two aides on SV should have gone back to the unit on 09/20/2011 to assist Staff RR, The charge nurse should have directed them. Two residents including Resident #7 require the assistance of two staff to transfer, ambulate and bed mobility. All other residents are independent or require the assistance of one staff. Staff did report that Staff RR turned the lights down low in the unit, the DON reported investigating the allegation and since then had no problem. The DON reported telling staff to document facts when writing statements. Staff OOOO did report to the DON that he/she discussed with Staff RR concerns regarding the treatment of [REDACTED]. night shift charge nurse for SV, also in charge of the CCDI unit. On 09/29/2011 at 10:20 a.m. in a written statement, the Administrator indicated on 09/21/2011, staff reported during the night Staff RR, assigned to the dementia unit, repositioned Resident #7 at 10:45 p.m. on 09/20/2011 and accidentally hit the resident's head on the side rail. The resident required the assistance of two staff for transfers out of bed, but not unusual for staff to transfer or repositioned with one staff. 45 minutes later, Staff RR returned to the resident's room to check on the resident and observed a contusion to the left side of the resident's forehead and notified the nurse, Staff OOOO, who then notified the family. Staff applied ice and when the family returned the call at 5:40 a.m., they asked staff to monitor the resident. At that time, padded side rails were added to the resident's bed and any repositioning would be done with two staff. When family came that evening, they requested the resident be transferred to the emergency room . The resident admitted to the hospital with [REDACTED]. When the resident returned to the facility on ,[DATE], the resident had a different hospice provider. During an interview on 09/29/2011 at 10:10 a.m., the Administrator reported Staff RR, CNA indicated he/she attempted to turn Resident #7 towards the right side without a draw sheet underneath and in the process the resident hit his/her head on the side rail resulting in a soft tissue injury and no fracture. Staff RR told Administration he/she should have used two staff to reposition the resident. Other staff Interviews: During an interview on 09/28/2011 at 4:00 p.m., Staff BBB, CNA reported working second shift, from 2-10:30 p.m. on 09/20/2011. Resident #7 had no injury on second shift. From 10 - 10:30 p.m. second shift staff and third shift do resident rounds together. Staff BBB and AAAA had resident room curtains and doors open, and night lights on. Resident #7 woke up from a bad dream and Staff BBB and AAAA calmed the resident down around 9:45 p.m. When night shift Staff RR arrived on the unit at 10:00, appeared agitated and stated she just talked to the police, DON and HR director. Staff BBB reported Staff RR would say residents were supposed to sleep and turned lights off. Since Staff RR was gone, the resident's lights stay on and there have been no more falls according to Staff BBB. During an interview on 09/28/2011 at 3:30 p.m. and 10/04/2011 at 10:30 a.m., Staff AAAA, CNA reported working 09/20/2011 on second shift, and assisted Resident #7 to bed that evening. Two staff need to ambulate the resident, and two staff were present during toileting and cares in the bathroom, Staff AAAA and Staff BBB. That night Resident #7 woke up around 9:45 p.m. and talked during sleep. Staff AAAA and BBB changed the resident's brief and provided incontinence cares. When Staff RR arrived to work, Staff AAAA reported they had repositioned and provided cares for Resident #7 at 9:45, and there would have been no reason for Staff RR to reposition the resident before the normal midnight rounds. Staff RR was in a bad mood when he/she arrived to the unit. Staff AAAA reported how Staff RR turned down the lights in the unit. On 09/20/2011 the police arrived at the facility to speak to Staff RR and that is the night Resident #7 got hurt. During an interview on 10/03/2011, Staff GG, LPN reported working on 09/21/2011 on the day shift from 6 a.m. - 2:30 p.m. on SV and SVS (dementia) units. When Staff GG arrived to work that day, Staff OOOO reported Resident #7 hit his/her head when Staff RR rolled the resident. Staff OOOO filled out an incident report; Staff GG recalled reviewing it. Before 7 o'clock a.m., Staff GG observed the resident's injury and was shocked that it could have occurred during a side to side roll. After the resident had a bath, staff reported the knee abrasion. Staff GG wondered where that came from since the bed had a short rail. Staff GG stated Staff OOOO reported Staff RR changed his/her story about which directions he/she rolled the resident. Resident #7 required two staff for bed mobility, transfer and ambulation. Staff GG occasionally worked at 3:00 a.m. would relieve Staff RR for breaks and would observe the lights turned down low, but still safe. Staff RR never once called for help. Staff GG reported the staff that completes the incident report notifies the physician. Staff RR would have contacted the family and physician when Resident #7 sustained the injury. During an interview on 10/03/2011 at 4:25 p.m., Staff LLLL, LPN reported working second shift on 09/21/2011. When Resident #7's family came to the facility, they were very upset at the injury, and asked that the resident be sent to the emergency room . Staff obtained a physician's orders [REDACTED]. Staff LLLL observed the resident and saw the area on the forehead protruded a couple of inches. Staff had reported Staff RR turned the resident in bed and hit the resident's head on the side rail. Staff LLLL found that hard to believe, and along with the knee injury, felt the resident had a fall. During an interview on 10/03/2011 at 3:55 p.m., Staff O, LPN reported observing Resident #7 on the night shift of 09/20/2011. Staff O thought the bruise and bump was exceptionally large on the explanation of how it occurred from a side rail. One staff provided cares for the resident prior to this required two staff to transfer and ambulate. During an interview on 09/29/2011, Staff U, CNA reported working the day shift on 09/21/2011. Staff RR reported Resident #7 hit his/her head on the side rail. Staff U did not believe it when he/she observed the large bump with bruising. Occasionally Staff U worked at 3:00 a.m., relieved Staff RR for breaks and observed the dementia unit lights turned low, too low for resident safety. Staff U turned the lights on and reported concerns to the nurse and medication aide Staff U reported not feeling safe in the unit alone. When staff toilets a resident with a red plaque (a resident not to be left alone), Staff U felt uncomfortable. No additional staff reports to the unit to assist with rounds during the night. Staff U never observed Staff RR mistreat residents; just that he/she wanted all residents in bed. After all, it is an Alzheimer's unit staff should adapt to their schedule. During an interview on 09/28/2011 at 2:00 p.m., Staff MMMM, CNA reported working during the day shift on 09/21/2011. Staff OOOO reported Staff RR rolled Resident #7 to change him/her and hit the resident's head on the side rail. Staff MMMM observed a large dark purple goose egg on the left forehead. Resident #7 could hold onto the side rail if talked to. Staff MMMM had completed cares for the resident in bed alone and reported Resident #7 does crawl out of bed. During an interview on 09/28/2011 at 2:30 p.m., Staff RR, CNA reported working on 09/20/2011 on the night shift in the dementia unit. Staff RR stated she did the two hour turn on Resident #7 at approximately 10:45 p.m. Staff RR described the resident ' s bed as the left side was against the wall, no side rail and the right side had a metal side rail. When Staff RR turned the resident towards the right side with a turn sheet, he/she failed to realize the resident lay close to the side rail. When Staff RR pulled the sheet, the resident accidentally hit his/her head on the side rail, and did not yell. Staff RR observed the bump on the resident's head when she went to turn the resident again. Staff RR called the nurse right away. Staff RR stated the nurse called the family member who asked to speak to Staff RR and accused Staff RR of not liking the resident. Staff RR stated she had worked at the facility for [AGE] years and never had any abuse allegations or disciplinary actions regarding residents. Staff RR stated Resident #7 typically sleeps most of the night. Staff RR stated she would never intentionally hurt any resident. Staff RR reported one staff in the unit on the night shift was not really safe since they have six residents with alarms. Staff RR stated typically the residents are very good for Staff RR, and he/she can call for help if needed. Staff RR ' s written statement dated 9/21/11 documented " she was turning Resident #7 to the right at 10:45 and accidently hit his/her read on the side rail. Staff RR documented she went in to turn him/her at 11:30 pm and found a large bump on his/her forehead. During an interview on 09/29/2011 at 10:50 a.m., the HR (Human Resources) director reported on 09/20/2011 the police came to question Staff RR at the facility prior to her shift. The POLICE DEPARTMENT incident/offense report dated 09/20/2011 documented an officer met with Staff RR at the facility just prior to beginning her shift. During an interview on 09/29/2011 at 9:00 a.m., the resident's family reported during the hospital stay the resident had a very lucid moment and looked at the clock on the wall and identified the time. When family asked the resident what happened, the resident replied "I called, and called, and called " . When family asked the resident where he/she hit his/her head, the resident replied "the floor" .The resident's family reported during a care conference meeting the facility asked that they move the resident out of the dementia unit. The family declined because they liked the first and second shift staff and the supervision on those shifts. They had tried moving the resident out of the unit prior, and the resident attempted to elope from the facility. At that time the resident's physician agreed the resident should remain in the dementia unit. The resident has chronic UTI's and attempts to get up out of bed, and did attempt to exit the bed while at the hospital. The resident transferred from and bed and ambulated with two assist, and did not use a walker or wheel chair. Weeks prior to this incident the facility called to ask if they could trial an antipsychotic medication for the resident due to physical and verbal abusive behaviors towards the night shift. Family declined due to adverse symptoms experienced when tried previously. Surveyor observations of Resident #7 included: On 09/27/2011 at 11:30 a.m. hospice staff visited the resident in the main area. The resident had an alarm in place, ted hose stockings, non-skid slippers on and dressed nicely. The resident incoherently mumbled difficult to understand answers to questions such as " Where do you live? " The resident ' s left forehead had yellow and blue discoloration and approximately 2 cm in diameter shiny raised area, and approximately 1 cm in height. The resident answered " not really, only pain " when asked if it hurt. On 09/29/2011 at 5:55 a.m., the resident lay in bed with the head of bed raised; padded half side rails raised and left side of the bed against the wall. The floor had a blue mat near the bed on the right side. Staff 4-0, RN reported the resident had congested lungs and not his/her usual self. Staff 4-0 indicated the hospice nurse would be notified of the residents change in condition. 2. A Physician's Progress Report dated 07/14/11 identified Resident #3 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool dated 09/16/11 identified the resident with short and long term memory loss and moderately impaired with making daily decisions and extensive assistance of 2 staff persons for bed mobility and transfers and 1 staff person for dressing and limited assistance of 1 staff person for bathing and toilet use. The Resident Care Plan dated 06/30/11 and 09/22/11 identified a problem with impaired physical mobility with a history of falls with interventions that included the resident was independent in the room with supervision, to wear non skid socks daily and have a bed pad alarm. The Fall Risk Assessment report dated 01/18/11 and 04/04/11 noted the resident at a high risk for falls with a score of 13 (a score of 10 or higher-represents High Risk). Observation on 09/27/11 at 12:25 p.m., revealed the resident wheeling self from the dining room to the room. The resident had on gripper socks and shoes. Upon entering the resident's room observed the bathroom immediately to the right and the resident's bed on the far side of the room by the window. Observation on 09/28/11 at 2:58 p.m., revealed the resident lying on top of the bed, wearing regular socks (not gripper socks) and shoes. Record review of the Incident Report dated 09/17/11 at 10:05 p.m., noted the spouse in the hallway waving at staff. Upon entering the room the resident was noted lying on his/her stomach, in front of the toilet. The resident was w

Based on record review, observation and interviews the facility failed to ensure one of four resident's reviewed received appropriate care and supervision according to the resident's care plan. Resident#1's care plan directed staff to place the recliner chair remote control out of reach and the facility staff failed to follow this intervention on 1/16/11 and during the onsite visit on 2/1/11. The care plan lacked the directives for staff to unplug the recliner chair and this was also found during the onsite observation. The facility reported a census of 99 residents. Findings include: 1. Resident #1 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS) assessment dated [DATE] the resident had severe cognitive impairment. The assessment documented the resident ambulated and transferred independently. The MDS revealed Resident #1 had [DIAGNOSES REDACTED]. The resident had no falls in the facility prior to the assessment date. The Care Plan dated 12/09/2010 and with a goal date of 3/9/2011 documented Resident #1 had altered thought related to his/her [DIAGNOSES REDACTED]. The care plan specified that Resident #1 ambulated independently with front wheel walker (FWW) in his/her room and hallway. The care plan included the following updates: a.On 01/11/2011: Medication review. b. On 1/12/2011: Urinalysis and half hour checks. Red plaque in bathroom and pad alarm to recliner and wheelchair. c. The care plan update on 1/14/11 directed staff to place the (recliner) chair remote (control) out of reach. d. On 1/16/2011: Non-skid pad in recliner e. The care plan directed staff would transfer the resident with the assistance of two (staff) as of 1/25/2011. The care plan indicated the resident would receive PT (physical therapy) and OT (occupational therapy) ongoing, with a date of 1/25/2011. Record review identified the following falls: a. According to the Incident Report dated 1/07/2011 at 11:00 a.m. staff found resident on buttock in front of rocking chair. The resident denied hitting his/her head and moved all extremities. The incident report documented the resident stated he/she tried to stand up and had been rushing for lunch when he/she slipped. The incident report documented a plan of prevention to educate the resident to take time. Staff would also recheck the resident ' s orthostatic blood pressure, and review his/her medication(s). The Nurse's Notes dated 1/07/2011 at 11:00 documented staff found the resident on the floor in front of the rocking chair in the room. The resident stated he/she slipped when stood to go to lunch. The resident denied hitting his/her head and moved all extremities. Staff observed the resident had on multiple layers of undergarments but became upset when encouraged to remove. Staff notified family and physician. b. According to the Incident Report dated 1/11/2011 at 5:45 p.m., staff heard the resident yelling for help, responded to find the resident on his/her back on the floor of the bathroom doorway. The report documented staff observed blood on the floor under the resident's head with two abrasions and a raised area to the back of the head. Staff assessed the resident and notified the family and faxed the physician. The plan of prevention revealed an order for [REDACTED]. The Nurse's Notes dated 1/11/2011 at 5:45 p.m., staff heard a cry for help and found the resident on the floor on his/her back with broken bottom dentures in his/her hand. Two abrasions with small amount of bleeding noted, and pupils equal and reactive. Staff assessed the resident, applied ice to the head and notified family and physician. At 6:15 p.m. family asked staff to not send to the emergency room and observe the resident. c. According to the Incident Report dated 1/12/2011 at 1:20 p.m. the resident fell in the main dining room after rising from a strait back chair. Staff found the resident on his/her stomach with his/her head up against cabinet. The report document the resident hit his/her front area of head above forehead, and no bump or bruise at this time. Staff notified the family and faxed the physician. Staff documented the chair pad alert had alarmed. The resident reported he/she tried to get up to take dishes to the kitchen. The plan of prevention directed staff to use alarms when in recliner (chair), wheelchair and red plaque. The plan also documented treated for [REDACTED]. The Nurse's Notes dated 1/12/2011 at 2:05 a.m., documented staff the resident had an increase in confusion and slow to respond and neurologically sluggish with complaints of head, back and neck pain. The staff documented the resident could have bleed due to fall on second shift and the resident very sleepy. Staff notified the family and sent the resident to the emergency room . At 6:30 a.m. the resident returned with medication orders. The hospital Emergency Physician Record signed 1/12/2011 documented the following: Chief complaint, injury to head/neck. fell from standing position and history of multiple falls. The report documented injuries to head and neck with a hematoma to the back of the head. The report documented no acute new fracture. Impression: Cervical strain, hematoma scalp, UTI. The hospital recommend antibiotic for ten days. (Bactrim), and Prednisone Treatment. The hospital transferred the resident back to the nursing home. Major Injury Determination Form signed by physician on 01/12/2011 - Injury sustained not a major injury. Radiology Report: CT Spine Cervical - No definite acute fracture identified, multilevel arthritic changes. Chronic type II odontoid fracture. The Nurse's Notes dated 1/12/2011 at 1:20 p.m., the resident fell in the main dining room after getting up per self and hit head on the cabinet - above forehead. Staff observed no bruising or bumps and the resident moved all extremities without difficulty. The resident had a pad alarm in recliner, wheelchair and bed and a red plaque in the bathroom. Staff notified the family and faxed the physician. The Nurse's Notes dated 1/12/2011 at 4:30 p.m., documented staff received orders from the primary physician related to the emergency room visit, and scheduled a follow-up visit on 01/18/2011. The Nurse's Notes dated 1/13/2011 at 3:20 p.m., documented resident denied headache but complained of neck stiffness. Right pupil sluggish to respond to light, and hand grips weak. The Nurse's Notes dated 1/13/2011 at 11:05 a.m., documented neuro's (neurological status) within normal limits for resident. Medication review sent related to orthostatic blood pressure and past to falls. Remains on antibiotic for UTI. Temperature: 96.8 degrees Fahrenheit, blood pressure at lying - 140/90; sitting - 160/04; standing - 140/80. d. The Incident Report dated 1/14/2011 at 2:50 p.m., staff heard the alarm sound and found the resident sitting on the floor in front of the recliner with his/her back resting against the chair cushion. The assessment revealed the resident did not hit his/her head and denied pain related to the fall. The incident report documented previous to the fall the resident had been observed sitting in the recliner relaxed with his/her feet resting in the up position with call light nearby. Staff notified the family and faxed the physician. The plan of prevention directed staff to place the chair lift button out of reach. The Care Plan dated 12/09/2010 documented an intervention on 1/14/2011 for the chair remote out of reach. The Nurse's Notes dated 1/14/2011 at 4:00 a.m. documented confusion noted, no pain, neurological assessment within normal limits (WNL). The Nurse's Notes dated 1/14/2011 at 2:50 p.m., documented alarm sounded and found sitting on floor in front of recliner, without apparent injury. The notes documented did not hit head and range of motion within normal limits for this resident. Staff assessed the resident, notified family and physician and educated the resident to use the call light. The Nurse's Notes dated 1/15/201 at 2:15 a.m., documented the resident ' s temperature at 100.2 degrees Fahrenheit, blood pressure at 142/90, neuro's unchanged, complained of nausea. At 9:40 a.m. the resident ' s neuro's were WNL, no complaints of pain. Abrasion to back of head scabbed and bruising. Called in temperature during night. Final urine culture showed sensitive to antibiotic currently prescribed (Bactrim). If temperature continues, may need to go to emergency room over the weekend. At 10:00 a.m. the resident ' s temperature at 97.5. At 2:50 p.m. - confusion noted, with a temperature of 94.2. (F). and the resident ' s family notified. e. The Incident Report dated 1/16/2011 at 11:10 p.m., staff responded to a sounding alarm and observed the resident slid out of the recliner onto the floor with no injury or pain. Staff notified the daughter and faxed the physician. The plan of prevention documented staff would unplug the recliner chair when the resident was sitting in it and non skid pad in recliner. Staff sent the resident to the emergency room at for increased confusion and an elevated blood sugar. The incident report documented the resident had [DIAGNOSES REDACTED]. During an interview on 02/01/2011 at 10:15 a.m., Staff F reported working third shift on 01/16/2011. Staff F heard Resident #1's chair alarm sound and observed the resident sliding out of the chair. The resident did not hit the floor and did not hit his/her head, but had increased confusion and rambled. Staff F used the remote located on the right arm of the chair to raise the chair and staff assisted the resident. The nurse told Staff F to unplug the chair. A progress note to the physician dated 1/16/11 documented the resident ' s last fall on 1/16/11 at 11:10 p.m., that he/she had been playing with the remote for the recliner chair and the recliner chair was now unplugged. The report documented no injuries noted. The Care Plan intervention started on 1/14/2011 for the chair remote out of reach had not been followed. During an interview on 02/03/2011 at 9:15 a.m., Staff A, LPN (licensed practical nurse) reported working the night shift on 01/16/2011. Third shift CNA's (Certified Nurse's Aide's) do resident rounds with second shift CNA's. Earlier that week Resident #1 had a fall on second shift, and Staff A sent him/her to the ER during third shift due to increased confusion and sluggish pupils. Staff continued Neurological examinations and the confusion and sluggish pupils continued. The resident had a UTI and received an antibiotic. Staff A informed the family that staff would unplug the chair. The resident would be able to reach the remote no matter where staff placed it because of the way it hooked to the chair. The resident refused to sleep in the bed. The Nurse's Notes dated 1/16/2011 at 6:00 a.m. documented neuro's unchanged with his/her temperature at 99.3(F) and pulse at 104 (high). At 2:50 p.m. the resident ' s temperature at 99.7 (F), continues on antibiotic for UTI, no complaints, and liquids encouraged. At 11:10 p.m., the alarm chirping and staff found resident on the floor. Resident continues confusion. Family notified. At 11:10 p.m., the resident ' s family aware of falls and confusion, and appointment on 01/18. The notes documented yells rather than uses call light, does not understand that he/she cannot get up per self. The Nurse's Notes dated 1/17/2011 at 6:35 a.m., documented the resident confused, shaking, talking to self, and not coherent. The resident ' s family was notified. His/her blood pressure at 160/92, blood sugar at 380, and pulse at 104. The resident transferred to emergency room . At 10:45 a.m. - Hospital informed staff of resident admission with abnormal labs, and possible subdural hematoma. The Nurse's Notes dated 1/18/2011 at 10:25 a.m., documented staff spoke with hospital staff and will have physician sign Major Injury form. The neurological assessment flow sheet revealed staff assessed the resident's neurological status from 01/11 - 01/17/2011 and documented sluggish pupil responses from 01/12 - 01/27/2011. The Nurse's Notes dated 1/26/2011 at 2:30 p.m., documented new orders received including speech therapy evaluation and treatment. The Hospital Records, Discharge Summary documented the patient admitted on [DATE] and discharged home on[DATE]. Final Diagnoses: [REDACTED]. 2. Confusion and agitation secondary to #1. 3. Falls resulting in a small subdural hematoma parietal occipital area in the left side. 4. Hypertension 5. Coronary artery disease 6. Diabetes mellitus type 2 7. Pseudogout 8. Dementia 9. Episodic atrial fibrillation, resolved. 10. Severe arthritis of the neck and shoulders resulting in chronic pain for which he/she is using narcotic medications. Hospital Course: The patient is having increasing cognitive decline and had an episode of falls and increasing confusion and agitation. The problems most notable - the [DIAGNOSES REDACTED]which was new and in rapid onset and also the confusion. CT revealed the subdural hematoma. The neurologist felt this was small and not a surgical problem and is treated conservatively. The resident ' s mentation cleared somewhat as bladder infection treated. Observations included: a.On 2/01/2011 at 11:00 a.m., Resident #1 sat in the recliner/lift chair with the foot rest in the up position, chair alarm and a pressure sensitive call light within reach. The resident had the chair remote near his/her right hand and the lift chair electrical plug in the wall outlet. The resident was lethargic but responsive and answered questions when asked. Question: Were you in the hospital? Answer: Sort of. Question: Does anything hurt? Answer: Shook head "yes" and pointed to left eye and said "my eye". Question: Did you fall? Answer: Oh, my yes. I had fallen quite a bit. Staff C entered the room at 11:05 a.m. The surveyor asked Staff C to check the recliner's remote and electrical cord. Staff C verified the remote situated at the resident's right hand functioned and the electrical cord was plugged in the outlet behind the chair. Staff C denied assisting Resident #1 transfer to the chair. At 11:10 a.m. Staff D reported assisting Staff B transfer Resident #1 to the chair after his/her bath. Staff D stated if the resident had the remote, they unplug the chair. Since the resident's falls, staff place the remote control out of reach. Staff D observed the remote with the surveyor and moved it to the pocket on the right hand side of the chair, and placed the call light in the resident's hand. The Care Plan intervention started on 1/14/2011 for the chair remote out of reach had not been followed. During an interview with Staff E on 2/1/11 at 11:25 a.m., she denied assisting the resident transfer to the chair; he/she would put the call light within reach and the chair remote in the side pocket for safety. Staff E said he/she observed the resident where he/she almost fell out of the chair including the time after returning from the hospital. Staff E said staff look to their assignment sheets to check resident needs. Staff E and the surveyor observed Resident #1's mini care plan on the assignment sheet and saw the resident had alarms in the wheelchair, bed and chair, transferred with the assistance of two, ambulated with a walker and cued at meals. Observation revealed no staff direction to unplug the chair or place the remote out of reach. Staff E said Resident #1 had increased confusion, nobody told him/her to place the remote out of reach, it just made sense. Staff E did not assist the resident to transfer to the chair, he/she would have placed the call light within reach and the chair remote in the side pocket for safety. At 11:38 a.m., Staff B reported never witnessing Resident #1 use the chair remote. Staff D and Staff B transferred the resident to the recliner chair earlier. Staff B placed the remote near the resident because that "is what we always do". Staff B had no knowledge of any falls from the recliner. Resident #1 was not on Staff B's assignment sheet, but was on Staff E's assignment sheet. Staff work together. Staff can also look at the resident care plans kept at the nurse's station. The nurse's update the assignment/report sheets and also relay information during staff report. At 11:45 a.m. the surveyor notified the DON (director of nursing) that Resident #1's remote sat near the resident's right hand and the chair functioned and had the electrical plug in. The DON reported the resident changed since returning from the hospital, but staff did need to follow the care plan. During an interview on 02/03/2011 at 12:20, Staff L reported Resident #1 had increased confusion and decreased ambulation recently. Staff L worked when the resident fell in the bathroom, and at the time the resident ambulated independently. The resident knew how to use the remote and Staff L always put the remote in the pouch on the side of the chair. Staff L did not have the resident on his/her assignment sheet since the week prior, however nobody told him/her to unplug the chair. During an interview on 02/03/2011 at 11:05 a.m., Staff H reported working second shift on 01/16/2011. Staff H recalled assisting Resident #1 prepare for bedtime and assisted the resident to the recliner. Staff H thought he/she put the chair remote in the pouch at the side of the chair, and did it all of the time. Staff H did not think the resident could remove the remote from the pocket. Staff H did not unplug the chair, and had not been told to do so. During an interview on 02/03/2011 at 12:15 p.m., Staff I reported working third shift on 01/16/2011 and did rounds at the change of shift. Resident #1 had alarms and that night the chair was plugged in. After that night, staff were instructed not to plug the chair in. Staff I could not recall seeing the remote. The Care Plan dated 12/09/2010 lacked any interventions for staff to unplug the recliner chair. On 02/03/2011 at 11:25 a.m., the ADON informed the surveyor staff updated the CNA worksheets, and added changes for Resident #1 that included unplugging the recliner, hospice, assist to meals, and half hour checks. Staff added the changes "the other day" after observation of the chair plugged in.