Every finding on record at Lutheran Living Senior Campus

Based on clinical record review, staff interviews and facility policy review the facility failed to report an injury of unknown origin that resulted in serious bodily harm to the State Agency within the two-hour requirement for 1 of 1 resident (Resident #1) reviewed. The facility reported a census of 125 residents.Findings include: Review of the Facility Reported Incident submitted to the State Agency revealed:Date of Report: 6/29/26:Date of Event: May 7, 2026Resident: [Name redacted, Resident #1]Nature of Report: Late self-report of an unwitnessed resident death with positional findings; reported upon supplemental QAPI (Quality Assurance and Performance Improvement) . During an interview on 7/20/26 at 12:08 PM, Staff C, former Administrator stated the facility did complete a full investigation and timeline after the incident. He explained after reviewing with the facility physician, the thought was Resident #1 passed away from natural causes and chose not to report the incident to the State Agency. Staff C stated in June the facility received a legal notice and the management company directed the incident be submitted as a self-report. He added the facility attorney advised a self-report also be submitted. During an interview on 7/20/26 at 12:12 PM, Staff B, former Director of Nursing (DON) stated she had discussed reporting the 5/7/26 incident to the State Agency, however Staff C, former Administrator stated he did not feel it was necessary. Staff B stated she deferred to Staff C as he did all of the reporting. Staff B added the facility assumed Resident #1 had a natural death and after they learned there was going to be an autopsy decided to wait until the results were available. During an interview on 7/21/26 at 12:30 PM, the Regional Director Quality and Clinical Services (RDQCS) stated she had a concern the May 7, 2026 incident of Resident #1's death had not been reported to the State Agency. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation dated 11/2024 revealed, in part: It is the policy of this community to take immediate steps to prevent the occurrence of Abuse, Neglect and Misappropriation of resident property.It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property ( alleged violations) are reported immediately to the administrator of the community. If the events that caused the allegation involve abuse or serious bodily injury, it must be reported to the State agency immediately but no later than 2-hours after forming the suspicion per State and Federal regulation.Definitions: Injury of unknown source: Any injury should be classified as an injury of unknown source when both of the following conditions are met:a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident;b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.Reporting:a. Any employee who suspects an alleged violation immediately notifies the administrator. The administrator notifies the appropriate state agency immediately in accordance with state law.b. The results of all investigations are reported to the administrator and to the appropriate state agency, as required by state law and / or within five (5) working days of the alleged violation.c. The community reports to the State Nurse Aide Registry and licensure authorities any knowledge it has of any actions by a court of law which would indicate an employee does not or may not meet the requirements to work in a skilled nursing facility.d. The administrator, or his / her designee, notifies the resident's representative regarding the alleged violation and assessment findings and reassures the resident's representative that an investigation has been initiated and appropriate action will be taken. Note: Immediately means as soon as possible, but ought not exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.

Based on clinical record review, hospice contract review, and staff interview, the facility failed to ensure that a hospice service agreement was signed with 1 of 2 hospice providers currently serving 1 of 4 residents on hospice (Resident #1); and failed to ensure required language addressing immediate notification of hospice administration in the event of alleged abuse by hospice staff was included in 1 of 1 signed agreement for a provider currently serving 3 residents (Resident#2, #3 and #5). The facility reported a census of 125 residents. Findings include: 1. Review of the Care Plan for Resident #1, dated 1/6/2026, revealed the addition of hospice services starting on 12/26/25, with Hospice A identified as the provider. Heart failure listed as the admitting diagnosis. A review of the facility contract with Hospice A, dated 5/11/2023, revealed the agreement signed by a hospice representative but lacked a signature of a facility representative. During an interview on 7/16/2026 at 1:00 PM, the Administrator reported he could not find a copy of the contract with Hospice A and had to request a copy from the provider. The Administrator explained that while the hospice had signed the contract, the facility had not. The Administrator stated the facility will work with Hospice A to get an updated contract completed. 2. Review of the Care Plan for Resident #2, dated 6/7/2026, revealed that hospice services started with Hospice B on 5/18/2026. Combined systolic and diastolic heart failure listed as the admitting diagnosis.3. Review of the Care Plan for Resident #3, dated 5/6/2026, revealed that hospice services started with Hospice B on 5/7/2026. Brain mass listed as the admitting diagnosis. 4. Review of the Care Plan for Resident #5, dated 6/22/26, revealed that hospice services started with Hospice B on 6/15/2026. Congestive heart failure listed as the admitting diagnosis.Review of the facility contract with Hospice B, dated 12/16/2021, revealed, in part: .Incident reporting. Any of the following alleged incidents involving a Hospice Patient residing at a Facility: mistreatment or neglect; verbal, mental, sexual or physical abuse; injuries of an unknown source; or misappropriation of patient property.The contract language failed to specify facility staff must report alleged incidents of abuse, mistreatment, neglect or misappropriation of resident property by hospice staff to the hospice administrator immediately when the facility becomes aware.During an interview on 7/21/2026 at 3:44 PM, the Administrator reported that they did not have an updated contract with the Hospice B that included the required language that was missing from the 12/16/21 contract.

Based on clinical record review, facility policy review, resident representative interview and staff interview, the facility failed to ensure residents and/or their representatives were fully informed of the risks and benefits of taking psychotropic (medications that affect thought processes or behaviors) before the resident started taking the medication and when changes occurred for 2 of 5 residents (Residents #3 and Resident #47) reviewed for unnecessary medications. The facility reported a census of 117 residents.Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS identified the resident did not display any behaviors and had signs and symptoms of minimal depression. The list of diagnoses included depression, anxiety, bipolar disorder and an intellectual disability. The MDS indicated the resident medications prescribed in the high-risk classes of antipsychotic, antidepressant and antianxiety. Review of the electronic health record (EHR) Clinical Resident Profile section, dated 2/11/26, revealed the resident had a durable power of attorney (POA) for health care and financial decisions. Review of the EHR revealed the following Physician Orders: a. Clonazepam (an anti-anxiety medication) 0.5 milligrams (mg), 1 tablet by mouth 2x daily for generalized anxiety disorder. Start date: 1/03/25. Review of the February 2026 Medication Administration Record (MAR) revealed this order continued with no changes. b. Trazadone (an antidepressant) 25 mg one-half tablet (12.5 mg) 2x daily as needed (PRN) for agitation. Start date: 11/24/25. Discontinue date: 1/27/26. c. Lamictal (a mood stabilizer): 1. 25 mg - 1 tablet daily for behaviors for 2 weeks from 12/17/25 to 12/21/25, and renewed on 12/21/25 until discontinue date of 2/5/26. 2. 50 mg -1 tablet daily for behaviors from 12/17/25 to 12/21/25, and renewed 12/31/25 with discontinue date of 2/5/26. d. Buspirone 10 mg – 1 tablet three times a day, started on 10/28/25 changed to 15 mg – 1 tablet three times a day on 12/16/25. Review of the clinical record revealed a lack of documentation that facility staff had explained the risks and benefits of taking the above medications to the resident and/or the resident's representative in advance of the medications starting or being changed. During an interview on 2/9/26 at 9:47 AM, the POA for Resident #3 reported facility staff called frequently to notify of medication changes, but did not tell her what the medications were being used for, or the risks and benefits of the medications. During an interview on 2/11/2026 at 10:25 AM, Resident #3 reported he took medications to treat diabetes. The resident was able to confirm he took medications to treat mood, but denied having any problems with his mood. Resident #3 did not know what medications he took, or the risks and benefits of taking his medications. During an interview on 2/11/2026 at 10:28 AM, Staff D, Licensed Practical Nurse (LPN), stated if the physician ordered a new psychotropic medication, or if there was a change made to a psychotropic medication, the nurse notified the resident and family, did teaching with both the resident and family on the new or changed medication and documented this information on a psychotropic medication consent form. During an interview on 2/11/2026 at 10:33 AM, Staff C, Assistant Director of Nursing (ADON) explained nursing staff made sure the family was aware of new and changed psychotropic medication orders. Staff C reported they completed a consent form with the POA, and that they could obtain the consent over the phone, but they needed two nurses to hear the consent. Staff C reported nursing staff notified the POA for Resident #3 when he had medication changes and staff completed the medication consent form with the POA. During an interview on 2/11/2026 at 11:41 AM, the Director of Nursing (DON) explained that Lamictal was a mood stabilizer, and she did not consider Lamictal a psychotropic medication. The DON explained that nursing staff should be doing a consent form for any new medication that was classified as an antidepressant, antianxiety or antipsychotic. The DON explained they just recently found out nursing staff needed to obtain a new consent for any dose or medication change. 2. Review of the MDS assessment, dated 11/25/25 for Resident #47 identified an admission date of 11/17/25. A BIMS score of 15 out of 15 indicated Resident #47 cognition intact. The list of diagnoses included depression and diabetes mellitus. The MDS indicated Resident #47 prescribed medications in the high-risk classes of antipsychotic, antianxiety, and antidepressant medications. Review of Resident #47's Care Plan, revised on 1/6/26, revealed a Focus area to address the use of high-risk medications which included the resident's psychotropic medications. Interventions included, in part Review medication for potential side effects with resident and/or person in charge of healthcare decisions for informed consents. Review of Physician Orders revealed the following medications with a start date of 11/17/25, and discontinuation date of 12/22/25. a. Aripiprazole (atypical antipsychotic) 2 mg tablet, give 1 tablet by mouth in the morning. b. Buspirone (anti-anxiety)7.5 mg tablet, give 1 tablet by mouth three times a day c. Escitalopram (antidepressant) Oxalate 20 mg tablet, give 1 tablet by mouth in the morning. Review of the EHR revealed a consent form for the use of psychotropic medications dated 9/9/25. The EHR lacked a consent form the above medications prescribed on 11/17/25. During an interview on 2/11/26 at 12:04 PM, the Director of Nursing (DON) acknowledged the consent dated 9/9/25 is a previous admission for the resident. The DON stated a new consent from the current psychotropics prescribed should have been reviewed with the resident/and or representative upon her readmission in November. The facility policy, titled Unnecessary Medications, last revised May 2025, directed in part.Follow the requirement of residents' right to be fully informed of, participate in, or decline treatment before initiating or increasing a psychotropic medication. The informed consent must include information related to the benefits, risks, and alternatives for medications, including any black boxed warnings.

Based on observations, clinical record review, facility policy review, family, resident and staff interviews, the failed to make repairs of damaged flooring and walls in a timely manner for 2 of 4 (Resident #53 and Resident #81) resident rooms sampled; and failed to dispose of an empty cleaning spray bottle from 1 of 4 (Resident #81) resident rooms. The facility reported a census of 117 residents.Findings include:1. Review of the Minimum Data Set assessment for Resident #53, dated 1/28/26, revealed the resident admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicated a moderate cognitive impairment. The list of diagnoses included dementia. The MDS indicated Resident #53 required substantial/maximal assistance for transfers, and repositioning. Review of the electronic health record (EHR) revealed Resident #53 resided in their current room since 12/19/24. During an observation on 2/5/26 at 8:42 AM, a fist sized area with a dent and crack noted on the wall above the head of the resident's bed. An area on the wall behind the resident's recliner appeared to be have previously patched. A family member of Resident #53 present in the room. The family member stated the area on the wall above the resident's bed had been dented and cracked since the resident moved in to the room over a year ago. The family member stated they did request a repair be made to a larger hole which had been behind the resident's recliner. They stated the facility did make that repair. 2. Review of the MDS assessment for Resident #81, dated 1/28/26, revealed a BIMS score of 15 out of 15 which indicated intact cognition. The MDS indicated Resident #81 had clear speech, could make self-understood to others and understood others. The MDS indicated Resident #81 dependent for transfers and positioning. Review of Resident #81's Care Plan, last revised 1/23/26, revealed the resident dependent on staff for transfers with a Hoyer lift (type of mechanical lift), bed mobility, lower body dressing, showering and toilet hygiene. During an observation on 2/4/26 at 2:45 PM, a gouge noted on the floor of the residents room, located on the right side of the bed and measured approximately a quarter of an inch deep and 2 to 3 feet long; a piece of trim noted missing from the wall near the entrance of the bathroom; black marks noted on the lower part of the wall by the entrance to the bathroom; and a board approximately 2 feet by 6 inches by 1 and a half inches noted lying flat on the floor between the head of the residents bed and the wall on the left side. During an interview, Resident #81 stated the board had been laying on the floor for about 2 months and had been attached to the wall by his bed. Resident #81 stated the floor in the room had been tore up for about the same amount of time. The resident stated the facility staff were aware of the board on the floor, and he thought maintenance was waiting for the approval to fix the floor. During an observation on 2/9/26 at 12:54 PM, Resident #81 in his room working with the Restorative Aide. A spray bottle labeled Cleaner noted to be on the floor under the bed frame near the head of the bed. The spray bottle noted to be in the same location during observations on 2/10/26 at 11:40 AM. At 11:40 AM, the resident stated the housekeeping staff had yet to clean his room, and usually do so around noon. During an interview on 2/10/2026 at 10:30 AM, the Maintenance Director stated he received repair needs for resident rooms submitted by staff through an electronic system, or by a phone call. He stated not all requests were entered into the electronic system. The Administrator stated all staff have access to the electronic system, and are to utilize this system to turn in repair requests to maintenance. The Maintenance Director reported he walked the halls, but did not go into the resident room unless he was aware that a repair was needed. The Maintenance Director reported the only pending repair he had for a resident's room was to add a handle bar to assist a resident getting in and out of bed. During an interview on 2/10/2026 at 12:45 PM, Staff G, Certified Medication Assistant/Certified Nursing Assistant stated if she noticed that something needed repaired in a resident's room, she would enter a request in the computer for maintenance to repair it.During an interview on 2/10/2026 at 12:46 PM, Staff I, Licensed Practical Nurse (LPN), stated she puts the need for repairs in resident rooms or equipment needs in the computer or calls Maintenance to notify them of the needs. During an interview on 2/10/26 at 12:55 PM, Resident #81 stated housekeeping staff cleaned his room a short while ago. The empty spray bottom remained in the same location on the floor near the head of the resident's bed. During an interview on 2/10/2026 at 1:00 PM, Staff J, Housekeeping, stated she cleaned the floors and picked up trash in each of the resident's rooms as part of her daily housekeeping duties. Staff J confirmed she had already cleaned Resident #81's room.Review of the undated facility policy, titled Housekeeping and Cleaning Policy, revealed, in part, Repairs: Promptly fix cracks, peeling paint, or broken fixtures .daily cleaning of .Resident rooms: Dust surfaces, empty trash, clean bathrooms (toilets, sinks, showers), mop floors, disinfect high-touch areas.

Based on observations, clinical record review, facility policy review and staff interview, the facility failed to ensure staff completed hand hygiene and utilized Enhanced Barrier Precautions in an attempt to prevent the transmission of infections during resident care for 3 of 8 (Resident #2, Resident #3, and Resident #91) residents reviewed for infection control. The facility reported a census of 117. Findings include:1. Review of the Minimum Data Set (MDS) assessment for Resident #2, dated 12/10/25, revealed a list of diagnoses which included traumatic brain injury, seizure disorder and quadriplegia. The MDS indicated Resident #2 utilized a feeding tube (a surgical opening in the abdominal wall for the delivery of nutrition, hydration and medications) and a tracheostomy (a surgical opening in the throat to provide an alternate airway for breathing). Review of the Care Plan for Resident #2, revised 2/8/26, revealed a Focus area to address Enhanced Barrier Precautions (EBP) for trach and PEG tube (a type of feeding tube). The Intervention directed Enhanced Barrier Precautions are to be used with the following care activities (specify): - Dressing - Bathing/showering - Transferring - Providing hygiene Changing linens - Changing briefs or assistance with toileting - Caring for devices Trach, PEG Tube. Review of Physician Orders revealed an order, start date 11/20/25 to Cleanse G-tube site with normal saline. Cover with split gauze and secure with paper tape. Daily and PRN (as needed). During an observation on 2/5/26 at 9:24 AM, Staff K, Licensed Practical Nurse (LPN) provided feeding tube care to Resident #2. Staff K explained she could not get the feeding machine flow to work and needed to disconnect the lines to the machine and start over. Staff K performed hand hygiene with an alcohol-based hand rub and donned gloves. Staff K did not don a gown. Staff K disconnected the feeding tubing, feeding formula container and the flush bag, and emptied contents of bags into the bathroom sink. Staff K then removed her gloves, obtained a new container of feeding formula, wrote the date on the container and hung the bag on the IV pole. Without completing hand hygiene, Staff K donned gloves, filled the flush bag with water, and reconnected all tubing to the feeding pump. Without wearing a gown, Staff K sanitized her hands, applied gloves, primed the lines, and opened the port to the residents PEG tube and connected the feeding tube to the port. During an observation on 2/5/26 at 3:06 PM, while wearing a gown and gloves, Staff L, Certified Nursing Assistant (CNA) transported Resident #2 on a shower bed from the shower room to his room. Staff M, CNA, donned a gown and gloves, and took a mechanical lift into the resident's room. Staff M closed the residents door. At 3:19 PM, Staff L, CNA and Staff M, CNA both wearing gowns, exited the resident's room and moved the mechanical lift and shower bed out of the resident's room. Staff M, CNA, removed her gown in the hallway. Staff L, CNA, wore the gown down the hallway, through the common/TV area to the soiled utility room. During an observation on 2/05/2026 at 3:26 PM, Staff K, LPN, sanitized her hands with an alcohol-based rub, unlocked the medication cart, removed a carton of liquid protein and poured it into a cup. Staff K then punched out a Metoclopramide 10 milligram (mg) tablet and prepared to crush the tablet. After crushing the tablet, Staff K mixed the medication in with the liquid protein. Staff K then obtained a vial of Duoneb (Ipratropium/Albuterol 0.5-2.5 mg/milliliters (ml) nebulizer treatment), and took . Staff K locked the medication cart and took the cup with the liquid protein, medication and vial of Duoneb to Resident #2's room. Staff K entered Resident #2's room and placed a pair of gloves, a graduated cylinder, syringe and placed them on the bedside table. Without performing hand hygiene, Staff K then donned gloves. Without wearing a gown, Staff K used an electronic vitals machine to take the residents blood pressure, pulse and oxygen saturation vitas. She also used a stethoscope to listen to Resident #2's lungs. During cares, Resident #2 periodically coughed through the trach opening. Without completing hand hygiene, Staff K changed gloves and moved the trach humidifier machine and the nebulizer cart closer to Resident #2. Without donning a gown, Staff K prepared and started the Duoneb treatment. Staff K reported the resident had a history of coughing out sputum from trach. Staff K then leaned over the resident to reposition him and his pillow. Staff K raised the head of his bed up, removed her gloves, sanitized her hands with an alcohol-based rub, and re-gloved. Staff K then added tap water to the graduated cylinder, and positioned the resident to administer the medication and liquid protein. Without donning a gown, Staff K completed hand hygiene, re-applied new gloves, checked for stomach content residual and then delivered the 30 mL flush. Staff K then administered the medication/liquid protein via the feeding tube, and completed another 30 mL flush. Staff K then removed her gloves and completed hand hygiene During an interview on 2/10/26 at 3:15 PM, the Infection Preventionist stated staff providing cares to residents on EBP should wear a gown and gloves. She explained personal cares, wound care, and care for medical devices such as a feeding tube and trach required EBP. The Infection Preventionist stated hand hygiene should be done before entering a resident's room, before gloving, in between glove changes and after removing gloves. The Regional Nurse and Director of Nursing (DON) stated staff received infection control education during initial orientation, quarterly for handwashing, as needed and during annual competency skills. 2. Review of the MDS for Resident #4, dated 12/19/25 revealed a list of diagnoses which included amputation, end-stage renal disease, diabetes mellitus, morbid obesity, and non-pressure chronic ulcer of other part of right foot with fat layer exposed and identified an open lesion on the foot related to a surgical wound with wound care and application of dressings. Review of the Care Plan, updated 6/23/25 revealed the following Focus areas and associated Interventions: a. Enhanced Barrier Precautions, date initiated 10/8/25. Enhanced Barrier Precautions are to be used with the following care activities (specify): - Dressing - Bathing/showering - Transferring - Providing hygiene Changing linens - Changing briefs or assistance with toileting -Caring for wounds. b. Skin Integrity.I have a surgical wound to my right foot where I had 3-4-5th toes amputated, dated initiated 6/23/25. Ensure medications and treatments are completed as ordered. Review of Physician Orders revealed the following: a. Betadine solution dampen gauze wring out so not soaking wet, apply betadine dampened gauze to wound cover with dry gauze secured with roll gauze and tape wrap with ace loosely. Start date: 2/5/26. During an observation on 2/10/26 at 10:36 AM, Staff K, LPN gathered supplies for wound care and entered Resident #4's room. An orange sign for Enhanced Barrier Precautions noted to be posted on the resident's door. A yellow multipocketed holder stocked with Personal Protective Equipment (PPE) which included gloves, gowns, masks and alcohol-based hand rub (ABHR) hung over the door of the resident's room. Without wearing a gown, Staff K put on a pair of gloves and placed a pillow under Resident #4 right knee and calf. She then removed the dressing applied to the resident's foot. Staff K then removed gloves and put on clean gloves without completing hand hygiene. Staff K then used clean gauze and spray wound cleanser to cleanse the wound. Staff K removed gloves and applied ABHR prior to putting on clean gloves. Staff K applied a betadine solution-soaked gauze pad to the wound, removed gloves and put on clean gloves without first completing hand hygiene. Staff K then covered the betadine-soaked pad with a dry gauze pad and wrapped the residents wound with a roll of gauze, followed by wrapping the area with an ace wrap. Staff K disposed of waste in the trash, washer her hands and left the residents room with the trash. During an interview on 2/10/26 after the wound care observation, Staff K, LPN stated she was not aware of EBP for Resident #4 and stated she did not wear a gown during wound care. Staff K also stated she did not complete hand hygiene between glove changes for two of the three times she changed her gloves. During an interview on 2/11/26 at 12:04 PM, the DON stated Resident #4 had EBP in place due to his wound. She stated her expectation is for staff to follow EBP protocol of wearing a gown and gloves during wound care, and to complete hand hygiene between glove changes. The Enhanced Barrier Precautions signage posted on Resident #4's door provided the following instructions: Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. The EBP signage contained the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) logo on the bottom left of the sign. 3. Review of the MDS for Resident #91, dated 11/29/25 revealed diagnoses of stroke, diabetes mellitus, and morbid obesity. The MDS identified the risk for developing pressure injuries but did not identify a pressure ulcer. Review of the Physician Orders revealed an order, dated 1/26/26 for coccyx wound. Cleanse the area apply triad cream, and cover with Mepilex (a brand name) foam dressing every day shift and PRN (as needed) when soiled. During an observation on 2/10/2026 at 11:10 AM, Staff A, Registered Nurse (RN) donned a gown, washed her hands and applied gloves. Staff A then placed the foam dressing package, cotton swabs, multiple clean 4x4 gauze, a tube of Triad cream and a spray bottle of wound cleaner onto a chair which had appeared dirty and had a white substance scattered onto the seat cushion. Staff A cleaned Resident #91with wet wipes and as she disposed of the gloves and wipes, the wound cleaner bottle got knocked on the floor. Staff A washed her hands, re-gloved and tucked the clean depend under Resident #91, touching the resident's buttocks with her gloved hands. Staff A then picked up the wound cleanser bottle off the floor and sprayed the contents directly onto the wound and a 4x4 gauze that was used to cleanse the wound. Without completing hand hygiene and changing gloves, Staff A picked up a cotton swab from the chair, opened the Triad ointment tube and applied the ointment onto the swab, and then applied the ointment to the open wound. Staff A opened the foam dressing package and attempted to put her gloved hand into her pocket to find a marker. Staff A then placed the opened foam dressing onto the chair, removed a glove, retrieved the marker from her pocket. Staff a then wrote the date and her initials onto the foam dressing and then applied the dressing to the wound. Staff A then washed her hands and removed the trash. During an interview on 2/10/2026 at 12:30 pm, Staff B, Assistant Director of Nursing (ADON) stated she had worked at this facility for 20 years and the expectation was for the nurse to follow doctor orders and complete the treatment properly. Staff B stated her expectation was for a nurse to use a barrier on a clean surface when completing wound treatments and follow infection control protocols. Staff B stated the staff used clean towels as barriers. Review of the facility's policy, titled Handwashing, reviewed April 2025, revealed Policy statement which declared, in part The facility requires staff to wash their hands after each direct resident contact, for which Handwashing is indicated by accepted professional practice . As per recommendations from the CDC guidelines. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning hands in most clinical situations. The Procedure section directed, in part .Alcohol based hand sanitizer should be used: Immediately before touching a patient; Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; Before moving from work on a soiled body site to a clean body site on the same patient; After touching a patient or the patient's immediate environment; After contact with blood, body fluids, or contaminated surfaces; Immediately after glove removal. Review of the facility's policy, titled Enhanced Barrier Precautions, reviewed 10/25/25, revealed, in part .Use of Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities .Precautions, including use of gown and gloves, will be used during any high contact resident care activities to include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy/ventilator) or use and wound care. Face protection may also be included when performing activity with risk of splash or spray.

Based on observation, facility record review, staff interview, and facility policy review, the facility failed to ensure the Daily Staffing posting contained required information and posted daily/seven days a week. The facility reported a census of 117 residents. Findings include: An observation on 2/9/26 at 1:20 PM, revealed the facility posted the Daily Staffing information at the receptionist desk inside the main entrance. The current posting, dated 2/9/26 did not identify the resident census or indicate the actual hours required for each nursing staff type (Registered Nurse (RN), Licensed Practical Nurse (LPN), or Certified Nursing Assistant (CNA)).During an interview on 2/9/26 at 3:00 PM, the Director of Nursing (DON) stated the resident census and the actual hours worked for the RN, LPN, and CNA were not completed on the form for 2/9/26.A review of the Daily Staffing postings for the last 30 days (1/10/26 through 2/826) revealed the data to indicate the daily resident census and actual hours worked by each nursing category left blank.During an interview on 2/9/26 at 4:25 PM, Staff O, Scheduling and Staffing Manager, stated she is responsible to complete and post the Daily Staffing information. She explained she started her position in March 2025 and worked Monday through Friday. Staff O stated on Monday's she completes the Daily Staffing information for Saturdays and Sundays. Staff O stated she does not post the information on the weekends, and is unsure who is responsible to post the form. During an interview on 2/10/26 at 11:08 AM, the Director of Human Resources stated he started his position in April 2025. The Director stated the Daily Staffing forms did not include the actual hours worked by nurses and they were not posted on Saturday and Sunday. During an interview on 2/10/26 at 11:30 AM, the Administrator stated the Daily Staffing forms were not completed with the resident census and the actual hours worked for nurses, and the information had not been posted over the weekend. The undated facility policy titled Posting of Nurse Staffing Hours directed staff to post daily up-to-date nurse staffing information for residents, families, visitors, and staff to review that included: current date, resident census and total number of nursing staff and actual hours worked.

Based on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, staff and family interviews, and facility policy review, the facility failed to recognize and address potential statements and behaviors that indicated Resident #1's self harm risk after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. In the days leading up to his discharge, multiple staff members stated they observed Resident #1's potential signs of worsening depression or heard him verbalize comments of potential self-harm but did not report these concerns to facility management. During the early morning hours of [DATE], without 1:1 supervision in place, Resident #1 used items within reach and committed suicide hours before his scheduled discharge from the facility. The facility reported a census of 124 residents. On [DATE] at 5:00 pm, the State Survey Agency informed the facility the staff failure to recognize, address and report potential statements and behaviors of self-harm following the notification of an involuntary discharge created an Immediate Jeopardy situation, which resulted in the suicide of a resident. The Immediate Jeopardy began on [DATE] The facility removed the immediacy on [DATE] at 12:00 pm when the facility staff implemented the following Corrective Actions: Audits of all residents for Psychosocial History compliance Audits of all residents for a history of suicidal ideation or attemptsCreation and Implementation of a Suicide Prevention PolicyCreation and Implementation of a Phone Answering PolicyEducation to all employees of Suicide in Older AdultsEducation to all employees of Recognizing Behavioral Symptoms in Residents at Risk for Self HarmEducation to all employees for Clinical Procedure for Care of Residents with Depression and Assessing and Screening for Suicide RiskEducation to all employees of Resident RightsAudits of all residents behavior documentation for suicidal ideationsDiagnosis report for impulsivenessEducation to managerial staff of Behavior Interventions may only be changed/modified/discontinued by the Executive Director or the Director of NursingThe scope and severity lowered from a J to a G (harm that is not immediate) at the time of the survey after ensuring the facility implemented their policy and procedures, audits, and staff education.Findings include:The Minimum Data Set (MDS) of Resident #1 dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless on one day of the lookback period. The MDS recorded the resident dependent upon staff assistance for chair/bed-to-chair transfers. The MDS documented diagnoses that included: paraplegia, anxiety, depression, and alcohol abuse with alcohol-induced mood disorder. The Care Plan of Resident #1 identified a Focus Area of Mood Behavior, stating Resident #1 had a diagnosis of Major Depressive Disorder. It directed staff to perform BIMS and PHQ-9 (an assessment used to screen for and measure the severity of depression) upon admission, quarterly, annually and as needed and to notify the physician as needed with concerns. The Care Plan additionally directed staff to keep the resident's routine the same as much as able and to offer opportunities for the resident to express feelings. The Care Plan additionally directed for social services to intervene as needed. The Care Plan identified an additional Focus Area of Abuse Vulnerability, history of suicide attempts. The Care Plan directed Staff to observe and provide a safe environment, staff to receive annual training and for Notifications to be made to Immediate Supervisor. The Facility Reported Incident (FRI) dated [DATE] documented that, on [DATE], Resident #3 reported to the facility chaplain that she had been physically assaulted by Resident #1 on [DATE]. According to the FRI, Resident #1 had grabbed and squeezed the upper leg of Resident #3 while he was passing by her in his electric wheelchair. The facility immediately ensured separation of the two residents, assigning a 1:1 Certified Nursing Assistant (CNA) to supervise Resident #1 to maintain that separation. A skin assessment of Resident #3 revealed black and blue bruises consistent with her account of the incident. The Sheriff's Office was contacted and a police report was filed. In a discussion between Resident #1 and the Administrator, Resident #1 displayed an unprompted awareness of the identity of Resident #1. The facility initiated an emergency discharge of Resident #1, and an Emergency Notice of Involuntary Discharge was hand delivered to Resident #1 on [DATE]. With the assistance of the facility's Social Services Director, Resident #1 filed an appeal to the discharge and a hearing took place on [DATE]. On [DATE], the Director of Nursing (DON) stated that she and the Administrator together notified Resident #1 on [DATE] that the discharge had been upheld in the hearing and offered him assistance to file a second appeal. She stated Resident #1 declined her assistance, stating he was resigned to it that he was discharging, and asked for some boxes to pack his belongings. She stated he also requested the facility continue to work on finding alternate placement as another facility that had accepted him was not his first choice of places to transfer to. The DON clarified the resident had received this notice earlier but had failed to open the envelope which contained the findings of the hearing. The Facility Reported Incident (FRI) dated [DATE] documented that at approximately 5:30 am on [DATE], facility staff discovered Resident #1 deceased in his room following a successful suicide attempt. The FRI detailed Staff B, Registered Nurse (RN) was the night shift supervisor on duty. Staff A, Licensed Practical Nurse (LPN), MDS Coordinator, was on call for any staffing issues. On [DATE], two CNAs failed to report for their scheduled shift. Staff A notified Staff B per protocol. The FRI further stated that the two staff members developed a coverage plan to ensure sufficient staffing, which included removing the 1:1 supervision of Resident #1 so the assigned CNA could perform general floor duties. Resident #1 was checked on at least every two hours with no noted concerns during these checks until approximately 5:30 am. On this check, Resident #1 was found on the floor of his room, surrounded by blood. The attending nurse assessed and determined Resident #1 had used a piece of glass from a broken picture frame and a set of scissors to cut himself, severing an artery of his left arm, resulting in death. Staff immediately called 911 and required persons were notified of the incident. In the follow up investigation of the incident, the facility stated during the investigation, it was discovered a voicemail had been left on an unattended facility phone. To ensure emergency response protocols, the facility implemented a new policy to address that issue. The follow up further stated the decision to reassign the 1:1 CNA was made by Staff A and Staff B without reporting to or obtaining permission from the DON, as required by facility policy. Using the facility's Just Culture Algorithm, it was determined that this constituted a change due to failure to report and request approval from their supervisor for the staffing change. Both staff members received a suspension. On [DATE] at 12:29 pm, Staff A, LPN, MDS Coordinator stated she was on call the night of [DATE]. She reported she was asleep when Staff B, RN, texted to inform her that two CNAs had not reported for work. Staff A stated she instructed Staff B to call both absent staff members, providing her with phone numbers, and advised her to ask 2pm-10pm shift staff if anyone could stay late to assist. Staff A stated Staff B asked if the 1:1 supervision of Resident #1 could be removed, and she responded that it was acceptable as long as the resident was asleep. She added that a second CNA from the Memory Care Unit (MCU) were also reassigned so that each unit had a CNA on duty. Staff A further stated that there were two additional nurses on duty that night, both in orientation, and therefore she believed there was adequate staffing in the building. Staff A verbalized she felt Staff B would move the available staff around to accommodate the staffing needs. She also added the 1:1 supervision was intended to keep Resident #1 separated from other residents, and noted that on the night shift the 1:1 often sat outside the door while he slept rather than remaining in his room. She added that if the supervision had been for suicide watch, the approach would have been different.On [DATE] at 1:10 pm, Staff G, Certified Nurse Aide (CNA) stated she acted as the 1:1 on the 2:00 pm to 10:00 pm shift on [DATE]. She stated Resident #1 was making a lot of phone calls. She stated she was in the room with him for part of the shift and sitting in the hallway for part of the shift. She stated she thought one of the phone calls he had made had been to a bank. She overheard him stating he wanted money to go to his nephew if anything were to happen to him. She stated otherwise he was acting normal and she did not think anything of the statement. She said she had only been employed at the facility for a month or so and this was her first job as a CNA and she did not know Resident #1 well. She stated after she was sitting in the hallway, she overheard him talking and initially thought he was speaking to her. She stepped into the room and heard him on the phone so she stepped back into the hallway and was relieved by another staff member at 10:00 pm. On [DATE] at 1:55 pm, Staff H, CNA stated she worked with Resident #1 for a short time on [DATE] on the 2-10 shift, when Staff G was on break. She stated Resident #1 asked her to take him outside to smoke, so they went to the far end of the building outdoors and he smoked and then she assisted him back to his room. She stated Resident #1 had been acting depressed for several days. She said once the judgement came back that he had to move out, she knew there was nothing anyone could do about it. She stated she did not bring any concerns of his depression forward to any management or the social worker. She stated everyone knew how depressed he was, all the nurses on the floor, etc. She stated anybody who worked that hallway knew he was depressed. Staff H said she had worked at the facility for several years and knew Resident #1 pretty well. She stated he was very quiet and seemed down, but she had no idea he was contemplating suicide. She stated if she had any idea, she would have reported it and felt any other staff member would have as well. On [DATE] at 5:15 pm, Staff B, RN stated her shift began at 6:00 pm on [DATE]. She reported that, although her position was the night shift supervisor, she initially did not perform supervisory duties because she was covering for a nurse at 6:00 pm. Around 8:00 pm, a staffing agency nurse arrived, and from that time until approximately 10:00 pm, she resumed supervisory duties. At 10:00 pm, two CNAs failed to report for their shifts. After unsuccessfully attempting to contact them and asking on-duty staff to stay, she had contacted Staff A, the manager on call, and after informing her of the situation, requested the removal of the 1:1 supervision of Resident #1 as well as moving a second CNA from the MCU. Staff B stated she was aware Resident #1 was paralyzed, unable to get out of bed, and typically asleep by that time of night, which was why she requested the removal of the 1:1. She stated she returned to working the floor at 10:00 pm, and described the shift as busy. Staff B said that at approximately 5:30 am, she heard screaming from another area of the building. Following the sound, she heard staff calling her name regarding Resident #1. Upon entering his room, she observed the resident lying on the floor in a pool of blood. She directed another staff member to call 911, and she assessed the resident for a pulse and breathing, neither being present. Paramedics arrived quickly, and it was confirmed that Resident #1 had a do not resuscitate order; no CPR was performed. On [DATE] at 11:28 am, Staff I, CNA stated she was working the overnight shift on Resident #1's hallway on [DATE]. She stated she was the one who found him deceased . She stated that around 10:30 or maybe 11:00 pm, the 1:1 was pulled from Resident #1. She stated she was working the floor, following her normal routine. She thought it was around 1:00 am when she checked on him and asked him how he was doing. She stated she completed some charting and then around 2:00 am began her rounding again. She stated she checked on him again during that set of rounds and he was watching TV at that time. She stated at approximately 4:00 am, there was another resident on the same hall who needed to be woken up and gotten ready to go to dialysis. She made a light breakfast for that resident and made sure she ate. She said that around 4:15 she got the resident dressed and then about 4:30 she transported that resident to the front of the building to be picked up for dialysis and then went to do rounds again. She stated she checked on Resident #1 again during these rounds. Following the completion of her rounds, she stated she then needed to empty catheters for the applicable residents. Resident #1 had a catheter. She stated it was around 5:15 or 5:30 when she entered his room to empty his catheter and found him on the floor in a pool of blood and called for help. Staff I stated she knew Resident #1 pretty well. She added that when they found out he had to move out, many staff were upset about it. She said she didn't think he had done it (the assault). She explained that night, when she asked him how he was doing, he replied he was saying his good-byes. She expressed she should have known, when he said that, that something was wrong. She said she just keeps thinking about it. But he was moving to another facility. She stated she was not aware that anyone had reported any concerns to management of his depression. On [DATE] at 4:30 pm, the Social Services Director (SSD) stated she had helped Resident #1 file his appeal of the involuntary discharge. She stated she did not participate in the hearing regarding the discharge. The SSD stated she was on vacation from the 19th until the 23rd of July, returning to work on the 24th of July. Upon her return to work, she was informed the discharge was upheld and Resident #1 chose not to file a second appeal. She stated she went to his room to speak with him and told him she was sorry to hear about him losing his appeal and mentioned he would be transferring to another facility. She described Resident #1 would not make eye contact with her, although they normally had a good relationship. She stated she joked with him that at least at the other facility, he would be able to smoke and not get in trouble for it. When Resident #1 did not respond, she turned to leave, and Resident #1 stopped her and told her he did not want her to feel guilty about anything that happened, and that she had done all she could to help him. The SSD voiced that in hindsight, she felt this was a suicidal statement, but at the time he said it, she did not take it that way. The SSD also reported she had experience working a suicide hotline. The SSD stated the hearing regarding the involuntary discharge had taken place on [DATE] and when she had asked facility management if she was to participate in the hearing, she was told no. She explained after assisting him in filing the appeal, she had no further contact with Resident #1 until [DATE]. She stated she works more with the skilled residents in the facility while the other social service representative worked more with the long term care residents. She added his PHQ-9 scores were always zero, indicating no depression, saying he never gave any inclination he was thinking of suicide. She added that while nobody anticipated suicide, more follow up probably should have been provided. She stated there were no protocols in place of daily check ins but reiterated Resident #1 was offered psychiatric services but he declined them. She explained these services were offered after the appeal hearing had taken place, after the ruling was given. She explained the services offered were virtual and the Assistant Director of Nursing (ADON) for his hallway with a computer, attempting to get him to participate in the therapy session but was unaware of why therapy sessions had been set up. Another ADON in the facility explained to the resident the reason for the services and the resident then declined the services. On [DATE] at 4:47 pm, the DON stated that Staff F, LPN, who was in orientation that night, could have been pulled to be the 1:1 as she had worked as a CNA prior to becoming a nurse. She stated she didn't receive a phone call that night and that would have been her directive if anyone had called her. In regards to the referenced voicemail, she stated each hall of the facility has it's own cell phone that connects to the land lines. She stated after hours, there are prompts to be connected to the hall a person is trying to reach. She said on the night shift, the nurses generally only carry one phone, although they are covering more than one hall as a nurse. She said for instance, on night shift, there is one nurse who covers both the 300 hall and the 500 hall, but may only carry one of those two phones. She stated they found the voicemail on the phone of the hall where Resident #1 resided. She said the family member who left the voicemail also had her own personal cell phone number but she didn't call her, or the police or anyone else that she was aware of. She said when she called the family member the following morning to inform her of Resident #1's death, the family member stated she had left a voicemail the night before. In a second interview on [DATE] at 10:59 am, Staff A, LPN, MDS Coordinator clarified she did not give Staff B specific direction for staffing needs in regards to the two nurses who were orientating on the night shift of [DATE]. She stated once she ok'd the removal of the 1:1 and the second CNA from the memory care unit, she assumed Staff B was taking care of the situation. She added she had worked the day shift on Wednesday [DATE] and then had to work the overnight shift as well. She got home around 7:00 am on [DATE]. She stated she received copies of the schedule for [DATE] via text from the facility, looked at the schedule and felt they were fully staffed. She stated in her mind, due to the extra two nurses, they had enough staff. She verified no assessment was completed on Resident #1 prior to removing the 1:1. She stated the reason for this was he was in bed, and she knew staff often sat outside of the room. She felt if he was sleeping, there was no reason for a staff member to be sitting there. She clarified she is the MDS Coordinator, and not an ADON. She was aware the facility required staffing changes could only be made at the direction of the DON or an ADON. She stated she normally would call the DON but did not call her that night due to having extra nurses in orientation on duty. She reiterated if they had not been there, she would have come in. On [DATE] at 11:17 am, Staff J, RN stated she had worked at the facility for several months. She stated she did not notice a big mood change in Resident #1, but noted he was more quiet. She said right after the allegations of the assault were made against him, she specifically asked him if he had thoughts of suicide. She stated she asked him this because he seemed especially down that day. She said he denied it and laughed and said he would never do that. She said she did not work with him the week of [DATE]. On [DATE] at 11:37 am, Staff K, CNA stated she had been currently working at the facility for about one and a half years, but had also worked her prior and left. She stated she knew Resident #1 well and used to take care of him when he previously lived on another hall of the facility. She said she worked with him nearly every day she was scheduled to work. She described him as being down in the dumps over the last few weeks. She said he was very quiet. She said she occasionally acted as the 1:1 CNA and escorted him on a shopping trip on the local bus. She said recently, he was using his tablet more, and was not as talkative. She said prior to this, he would come to eat in the dining room and roam all over the facility. She said some mornings, she noticed the night shift 1:1 were sitting outside in the hallway with his door shut when she came on shift. She said in her opinion, they needed to be in the room with him but understood he also liked his privacy. She said she often assisted a second staff member to use the full body mechanical lift to transfer from his bed to his chair in the mornings, and he just seemed down. He used to visit with other male residents at meals before he was notified of needing to move out. She said she had noticed recently when it was time for his insulin, he would just park his chair near the medication cart, and sit with his head down and wait for the insulin then go back to his room. She said the nurses were aware of his behaviors, everybody could see it. On [DATE] at 11:45 am, Staff L, Certified Medication Aide (CMA) stated Resident #1 seemed a bit depressed. She said she didn't work his area of the building too often, and in his last week, she maybe only saw him once. She said he just seemed different. He used to be more bubbly, talking to everyone. Then he started staying in his room, not talking as much. She said it was out of the ordinary but she hadn't felt it was alarming. On [DATE] at 11:47 am, Staff M, CNA stated she had sat with him 1:1 a couple of days earlier in the week before the incident. She said he was very quiet. After he was dressed and out of bed, he asked her to just sit in the room and watch TV. She said they left the room once, he wanted to speak with the DON about his leaving. He was telling her he didn't want to go to the facility that had accepted him. There was another facility he wanted to go to instead. She said she asked him if he was nervous and he stated no, he just wanted to go to an alternate facility. She stated he was back in his room at the end of her shift, and just seemed quieter than usual.On [DATE] at 1:57 pm, Staff N, CNA stated she was scheduled to be the 1:1 on the 10:00 pm to 6:00 am shift on 724/25. She stated she was with him for approximately 45 minutes to an hour when she was pulled to work the floor in another area of the facility. She stated she looked in on him and he was watching TV and she sat in the hallway and had no interaction with him. She was not aware of any changes in him. On [DATE] at 3:05 pm, Staff D, Social Services designee, stated she had only worked at the facility for a few months. She stated she and Resident #1 had gotten off on the wrong foot when she started due to her needing to speak to him about him driving his electric wheelchair too fast through the halls. She stated once during the appeal process, she checked in with Resident #1 but he had been speaking with someone from Medicaid. She described him as being very closed off when she checked in and that was the only time she made contact with him other than saying hello in the hallways. On [DATE] at 9:04 am, Staff E, LPN stated she was the nurse assigned to Resident #1's hallway on [DATE] for the overnight shift. She stated she had been a nurse for over 20 years but had worked at the facility for a short time. She explained she was assigned to that hallway, as well as the MCU, and additionally needed to help in the Assisted Living part of the facility to administer insulin and cover meal breaks. She was also orienting Staff F, LPN who was a new nurse. She explained it was a very busy shift, and a new resident in the MCU was upset and exit seeking and setting off alarms much of the shift. She stated she did not see Resident #1 that shift until the morning. She stated she works throughout the building and did not know Resident #1 well. She added with the staffing pattern of most employees working in multiple areas of the building, she is unable to get to know the residents well or build rapport with them. She felt if she had known Resident #1 better, perhaps he would have confided in her as she had worked with other suicidal patients in the past and had been able to assist. She stated staff F, LPN administered insulin for Resident #1 that shift, and the Medication Aide administered his oral medications. She was aware that Resident #1 was under 1:1 supervision and the reason for the supervision. She stated no staff had informed her the 1:1 person had been removed from his room. She said that to her knowledge, Resident #1 had no prior suicidal ideations. When Staff E was told prior suicide attempt was included on the Resident Care Plan, she stated she is not familiar with the software program the facility uses for the resident's Electronic Health Records and did not know how to retrieve or read a resident care plan. Staff E Stated that Staff I, CMA had the phones prior to 10:00 pm as she was passing medications. She said at 10:00 pm, she thought that Staff F had the phones but she did not remember for sure. She said she had difficulty with the phones on prior shifts, she would find a Missed Call notification without the phone ever ringing. She said she would find the ringer volume was turned off but felt it could have been accidental that it got turned off based on the style of the phone and where the ringer switch is. She also stated she was not aware of how to listen to voicemails on the phones as the phones require a code to get into them and she doesn't know the codes. She said one phone in the facility has the code written on the back of the phone but the other ones do not. She said the normal routine for her was to carry both phones, but she did not have them that night as she was orienting another nurse.On [DATE] at 10:18 am, Staff F, LPN stated she worked at the facility earlier in the summer as a CNA. She had recently passed the State Boards and obtained her LPN license, and was then training as an LPN. She stated she trained with Staff E on her shift on [DATE]. She stated the only interaction she had with Resident #1 during that shift was approximately 9:30 or 9:45 pm when she administered his night time insulin. She stated the Medication Aide had administered his oral medication. She had been told Resident #1 often refused his nightly scheduled catheter flush, and he did refuse it that night. She stated she attempted to make some small talk with the resident when she was in the room with him, but he only responded with one word answers. She stated she was aware that there had been a CNA removed from the MCU unit to cover staffing needs but was not aware the 1:1 supervision had been removed from Resident #1. She said some staff sat in his room with him at night and others sat in the hallway. She verified after 10:00 pm, she had not been back in Resident #1's room. Staff F stated after 10:00 pm, she had both sets of keys (to the medication carts) and was given the phone to the MCU. She stated she did not have the phone for the hallway Resident #1 was on. She voiced she did know how to listen to voicemails on the facility phones but she didn't have that phone. On [DATE] at 1:18 pm, a family member of Resident #1 stated their family members all had apps on their phones they used to communicate with each other. She stated on the night of [DATE], Resident #1 had sent a message on the app It's check out time. She stated she did not think anything of it but another family member contacted her and stated she felt that meant he was thinking of suicide. She stated she called the facility but the phone rang to voicemail. She left a voicemail asking staff to keep an eye on him. She stated she had not had direct contact with Resident #1 for some time as he had asked her to sign some paperwork for him regarding something to do with his wheelchair. She had refused to sign the paperwork and he had been angry with her. She said after she called the facility and left the voicemail, she went to sleep. She received a phone call the next morning telling her he had committed suicide. She said he was supposed to be under 24 hour surveillance. She said from what she had heard, the facility was short staffed and they had nobody to watch him. She said she didn't know if Resident #1 knew they were short staffed when he killed himself. She stated maybe if he had surveillance, they could have saved his life. She added if they had just listened to his voicemail, that could have saved his life. On [DATE] at 1:42 pm, Staff O, CNA stated she had worked at the facility for a couple of years. She stated she most often worked on the skilled unit, but Resident #1 came down to visit that part of the building almost daily. She said she last saw him the day before the incident and told him that he looked nice. She said he replied to her that looking nice was only on the outside, not the inside. She stated she asked him if he was ok and he replied he was fine but the whole situation was off. She said she asked him again if he was ok and told him she would talk to him more the next day and he replied ok. She told him she would see him tomorrow and he replied the same. On [DATE] at 2:10 pm, Staff D, Social Services designee, stated her normal routine is to complete the PHQ-9 on residents and the BIMS assessment. She stated there is also a trauma assessment available that is specific to residents who have a history of trauma, but she had never used that assessment. She said the normal routine is only to do these assessments during the MDS period. On [DATE] at 2:55 pm, Staff P, ADON for the hall Resident #1 resided on, stated she had been the ADON for a few months. Prior to that, she worked at the facility for several years but didn't know Resident #1 well. She said she would see him around as he was very mobile through the facility. She said she had not had any conversations with him regarding his discharge and that no staff had brought any concerns to her regarding him. She said if staff had any concerns they should report it to the charge nurse and the charge nurse should report it to her. She said she had attempted to assist him in the virtual therapy sessions but he refused to participate. The Fire Department Patient Care record dated [DATE] recording the following: Squad 3** responded. Crew was met at the front door by nursing home staff. Staff reported patient was on the *** hallway. Staff reported the patient was a Do Not Resuscitate but this was an unusual instance so they called 911. On arrival to the room, the patient was found on the floor in a large pool of blood. It was noted blood was found all over the room also. Night shift lead nurse was in the room crying. She reported they came into the room and found the patient like this. Staff was not able to provide a last known well time for the crew. It was noted that there was obvious death. The patient was not breathing and had no pulse. Noted that there was a small pair of scissors (with blood on them) on a table and broken glass on the bed. The patient was not disturbed by the EMS crew, no EMS interventions were taken. Crew was able to see multiple cuts to the left wrist from the doorway with a large pool of blood coming from cut site. Nursing home staff reported that the notes taped on the window and refrigerator door appear to be new. They state Thank you Railroad (female name). Crew removed all staff from the room at this time. The Medical Examiner and sheriff's office were called to the scene. While getting information from the staff, it was reported the patient was leaving the facility that day. Staff was able to provide a current DNR status and a face sheet. On arrival of the Sheriff's Office, crew explained the circumstances they walked into. No further actions were taken. The scene was turned over to the Sheriff's [TRUNCATED]

Based on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, and staff interviews, the facility failed to perform behavioral health assessments for Resident #1 after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. On [DATE] the 1:1 supervision was discontinued to address a staffing shortage without Resident #1 being assessed. During the early morning hours of [DATE], with no 1:1 supervision, Resident #1 used items within reach and committed suicide hours before his scheduled discharge from the facility. The facility reported a census of 124 residents. On [DATE] at 5:00 pm, the State Survey Agency informed the facility of the failure to perform behavioral health assessments following notification of an involuntary discharge created an Immediate Jeopardy situation, which resulted in the suicide of a resident. The Immediate Jeopardy began on [DATE]. The facility removed the immediacy on [DATE] at 12:00 pm when the facility staff implemented the following Corrective Actions: Audits of all residents for Psychosocial History compliance Audits of all residents for a history of suicidal ideation or attemptsCreation and Implementation of a Suicide Prevention PolicyCreation and Implementation of a Phone Answering PolicyEducation to all employees of Suicide in Older AdultsEducation to all employees of Recognizing Behavioral Symptoms in Residents at Risk for Self HarmEducation to all employees for Clinical Procedure for Care of Residents with Depression and Assessing and Screening for Suicide RiskEducation to all employees of Resident RightsAudits of all residents behavior documentation for suicidal ideationsDiagnosis report for impulsivenessEducation to managerial staff of Behavior Interventions may only be changed/modified/discontinued by the Executive Director or the Director of NursingThe scope and severity lowered from a J to a G (harm that is not immediate) at the time of the survey after ensuring the facility implemented their policy andprocedures, audits, and staff education.Findings include:The Minimum Data Set (MDS) of Resident #1 dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless on one day of the lookback period. The MDS recorded the resident dependent upon staff assistance for chair/bed-to-chair transfers. The MDS documented diagnoses that included: paraplegia, anxiety, depression, and alcohol abuse with alcohol-induced mood disorder. The Care Plan of Resident #1 identified a Focus Area of Mood Behavior, stating Resident #1 had a diagnosis of Major Depressive Disorder. It directed staff to perform BIMS and PHQ-9 (an assessment used to screen for and measure the severity of depression) upon admission, quarterly, annually and as needed and to notify the physician as needed with concerns. The Care Plan additionally directed staff to keep the resident's routine the same as much as able and to offer opportunities for the resident to express feelings. The Care Plan additionally directed for social services to intervene as needed. The Care Plan identified an additional Focus Area of Abuse Vulnerability, history of suicide attempts. The Care Plan directed Staff to observe and provide a safe environment, staff to receive annual training and for Notifications to be made to Immediate Supervisor. The Facility Reported Incident (FRI) dated [DATE] documented that, on [DATE], Resident #3 reported to the facility chaplain that she had been physically assaulted by Resident #1 on [DATE]. According to the FRI, Resident #1 had grabbed and squeezed the upper leg of Resident #3 while he was passing by her in his electric wheelchair. The facility immediately ensured separation of the two residents, assigning a 1:1 Certified Nursing Assistant (CNA) to supervise Resident #1 to maintain that separation. A skin assessment of Resident #3 revealed black and blue bruises consistent with her account of the incident. The Sheriff's Office was contacted and a police report was filed. In a discussion between Resident #1 and the Administrator, Resident #1 displayed an unprompted awareness of the identity of Resident #1. The facility initiated an emergency discharge of Resident #1, and an Emergency Notice of Involuntary Discharge was hand delivered to Resident #1 on [DATE]. With the assistance of the facility's Social Services Director, Resident #1 filed an appeal to the discharge and a hearing took place on [DATE]. On [DATE], the Director of Nursing (DON) stated that she and the Administrator together notified Resident #1 on [DATE] that the discharge had been upheld in the hearing and offered him assistance to file a second appeal. She stated Resident #1 declined her assistance, stating he was resigned to it that he was discharging, and asked for some boxes to pack his belongings. She stated he also requested the facility continue to work on finding alternate placement as another facility that had accepted him was not his first choice of places to transfer to. The DON clarified the resident had received this notice earlier but had failed to open the envelope which contained the findings of the hearing. The Facility Reported Incident (FRI) dated [DATE] documented that at approximately 5:30 am on [DATE], facility staff discovered Resident #1 deceased in his room following a successful suicide attempt. The FRI detailed Staff B, Registered Nurse (RN) was the night shift supervisor on duty. Staff A, Licensed Practical Nurse (LPN), MDS Coordinator, was on call for any staffing issues. On [DATE], two CNAs failed to report for their scheduled shift. Staff A notified Staff B per protocol. The FRI further stated that the two staff members developed a coverage plan to ensure sufficient staffing, which included removing the 1:1 supervision of Resident #1 so the assigned CNA could perform general floor duties. Resident #1 was checked on at least every two hours with no noted concerns during these checks until approximately 5:30 am. On this check, Resident #1 was found on the floor of his room, surrounded by blood. The attending nurse assessed and determined Resident #1 had used a piece of glass from a broken picture frame and a set of scissors to cut himself, severing an artery of his left arm, resulting in death. Staff immediately called 911 and required persons were notified of the incident. During a chart review on [DATE], the Care Plan of Resident #1 failed to reflect any status updates regarding the assault, the involuntary discharge, or the 1:1 supervision. The Progress Notes portion of the resident's Electronic Health Record (EHR) failed to reflect any progress notes that had been entered by either of the facility social services representatives. The EHR additionally failed to document any psychosocial assessments having been completed following the notice of involuntary discharge on [DATE]. On [DATE] at 12:29 pm, Staff A, LPN, MDS Coordinator, stated she was on call the night of [DATE]. She reported she was asleep when Staff B, RN, texted to inform her that two CNAs had not reported for work. Staff A stated she instructed Staff B to call both absent staff members, providing her with phone numbers, and advised her to ask 2pm-10pm shift staff if anyone could stay late to assist. Staff A stated Staff B asked if the 1:1 supervision of Resident #1 could be removed, and she responded that it was acceptable as long as the resident was asleep. She added that a second CNA from the Memory Care Unit (MCU) were also reassigned so that each unit had a CNA on duty. Staff A further stated that there were two additional nurses on duty that night, both in orientation, and therefore she believed there was adequate staffing in the building. Staff A verbalized she felt Staff B would move the available staff around to accommodate the staffing needs. She also added the 1:1 supervision was intended to keep Resident #1 separated from other residents, and noted that on the night shift the 1:1 often sat outside the door while he slept rather than remaining in his room. She added that if the supervision had been for suicide watch, the approach would have been different. On [DATE] at 5:15 pm, Staff B, RN stated her shift began at 6:00 pm on [DATE]. She reported that, although her position was the night shift supervisor, she initially did not perform supervisory duties because she was covering for a nurse at 6:00 pm. Around 8:00 pm, a staffing agency nurse arrived, and from that time until approximately 10:00 pm, she resumed supervisory duties. At 10:00 pm, two CNAs failed to report for their shifts. After unsuccessfully attempting to contact them and asking on-duty staff to stay, she had contacted Staff A, the manager on call, and after informing her of the situation, requested the removal of the 1:1 supervision of Resident #1 as well as moving a second CNA from the MCU. Staff B stated she was aware Resident #1 was paralyzed, unable to get out of bed, and typically asleep by that time of night, which was why she requested the removal of the 1:1. She stated she returned to working the floor at 10:00 pm, and described the shift as busy. Staff B said that at approximately 5:30 am, she heard screaming from another area of the building. Following the sound, she heard staff calling her name regarding Resident #1. Upon entering his room, she observed the resident lying on the floor in a pool of blood. She directed another staff member to call 911, and she assessed the resident for a pulse and breathing, neither being present. Paramedics arrived quickly, and it was confirmed that Resident #1 had a do not resuscitate order; no CPR was performed. On [DATE] at 4:30 pm, the Social Services Director (SSD) stated she had helped Resident #1 file his appeal of the involuntary discharge. She stated she did not participate in the hearing regarding the discharge. The SSD stated she was on vacation from the 19th until the 23rd of July, returning to work on the 24th of July. Upon her return to work, she was informed the discharge was upheld and Resident #1 chose not to file a second appeal. She stated she went to his room to speak with him and told him she was sorry to hear about him losing his appeal and mentioned he would be transferring to another facility. She described Resident #1 would not make eye contact with her, although they normally had a good relationship. She stated she joked with him that at least at the other facility, he would be able to smoke and not get in trouble for it. When Resident #1 did not respond, she turned to leave, and Resident #1 stopped her and told her he did not want her to feel guilty about anything that happened, and that she had done all she could to help him. The SSD voiced that in hindsight, she felt this was a suicidal statement, but at the time he said it, she did not take it that way. The SSD also reported she had experience working a suicide hotline. The SSD stated the hearing regarding the involuntary discharge had taken place on [DATE] and when she had asked facility management if she was to participate in the hearing, she was told no. She explained after assisting him in filing the appeal, she had no further contact with Resident #1 until [DATE]. She stated she works more with the skilled residents in the facility while the other social service representative worked more with the long term care residents. She added his PHQ-9 scores were always zero, indicating no depression, saying he never gave any inclination he was thinking of suicide. She added that while nobody anticipated suicide, more follow up probably should have been provided. She stated there were no protocols in place of daily check ins but reiterated Resident #1 was offered psychiatric services but he declined them. She explained these services were offered after the appeal hearing had taken place, after the ruling was given. She explained the services offered were virtual and the Assistant Director of Nursing (ADON) for his hallway had acomputer, and attempted to get him to participate in the therapy session but the ADON was unaware of why therapy sessions had been set up. Another ADON in the facility explained to the resident the reason for the services and the resident then declined the services. In a second interview on [DATE] at 10:59 am, Staff A clarified she did not give Staff B specific direction for staffing needs in regards to the two nurses who were orientating on the night shift of [DATE]. She stated once she ok'd the removal of the 1:1 and the second CNA from the memory care unit, she assumed Staff B was taking care of the situation. She added she had worked the day shift on Wednesday [DATE] and then had to work the overnight shift as well. She got home around 7:00 am on [DATE]. She stated she received copies of the schedule for [DATE] via text from the facility, looked at the schedule and felt they were fully staffed. She stated in her mind, due to the extra two nurses, they had enough staff. She verified no assessment was completed on Resident #1 prior to removing the 1:1. She stated the reason for this was he was in bed, and she knew staff often sat outside of the room. She felt if he was sleeping, there was no reason for a staff member to be sitting there. She clarified she is the MDS Coordinator, and not an ADON. She was aware the facility required that any staffing changes could only be made at the direction of the DON or an ADON. She stated she normally would call the DON but did not call her that night due to having extra nurses in orientation on duty. She reiterated if they had not been there, she would have come in. On [DATE] at 3:05 pm, Staff D, Social Services designee, stated she had only worked at the facility for a few months. She stated she and Resident #1 had gotten off on the wrong foot when she started due to her needing to speak to him about him driving his electric wheelchair too fast through the halls. She stated once during the appeal process, she checked in with Resident #1 but he had been speaking with someone from Medicaid. She described him as being very closed off when she checked in on him and state that was the only time she had any contact with him after the involuntary discharge notice was given other than briefly saying hello in passing. On [DATE] at 9:04 am, Staff E, LPN stated she was the nurse assigned to Resident #1's hallway on [DATE] for the overnight shift. She stated she had been a nurse for over 20 years but had worked at the facility for a short time. She explained she was assigned to that hallway, as well as the MCU, and additionally needed to help in the Assisted Living part of the facility to administer insulin and cover meal breaks. She was also orienting Staff F, LPN who was a new nurse. She explained it was a very busy shift, and a new resident in the MCU unit was upset and exit seeking and setting off alarms much of the shift. She stated she did not see Resident #1 that shift until the morning. She stated she works throughout the building and did not know Resident #1 well. She added with the staffing pattern of most employees working in multiple areas of the building, she is unable to get to know the residents well or build rapport with them. She felt if she had known Resident #1 better, perhaps he would have confided in her as she had worked with other suicidal patients in the past and had been able to assist. She stated staff F, LPN administered insulin for Resident #1 that shift, and the Medication Aide administered his oral medications. She was aware that Resident #1 was under 1:1 supervision and the reason for the supervision. She stated no staff had informed her the 1:1 person had been removed from his room. She said that to her knowledge, Resident #1 had no prior suicidal ideations. When Staff E was told prior suicide attempt was included on the Resident Care Plan, she stated she is not familiar with the software program the facility uses for the resident's Electronic Health Records and did not know how to retrieve or read a resident care plan. On [DATE] at 10:18 am. Staff F, LPN stated she worked at the facility earlier in the summer as a CNA. She had recently passed the State Boards and obtained her LPN license, and was then training as an LPN. She stated she trained with Staff E on her shift on [DATE]. She stated the only interaction she had with Resident #1 during that shift was approximately 9:30 or 9:45 pm when she administered his night time insulin. She stated the Medication Aide had administered his oral medication. She had been told Resident #1 often refused his nightly scheduled catheter flush, and he did refuse it that night. She stated she attempted to make some small talk with the resident when she was in the room with him, but he only responded with one word answers. She stated she was aware that there had been a CNA removed from the MCU to cover staffing needs but was not aware the 1:1 supervision had been removed from Resident #1. She said some staff sat in his room with him at night and others sat in the hallway. She verified after 10:00 pm, she had not been back in Resident #1's room. The Fire Department Patient Care record dated [DATE] recording the following: Squad 3** responded. Crew was met at the front door by nursing home staff. Staff reported patient was on the *** hallway. Staff reported the patient was a Do Not Resuscitate but this was an unusual instance so they called 911. On arrival to the room, the patient was found on the floor in a large pool of blood. It was noted blood was found all over the room also. Night shift lead nurse was in the room crying. She reported they came into the room and found the patient like this. Staff was not able to provide a last known well time for the crew. It was noted that there was obvious death. The patient was not breathing and had no pulse. Noted that there was a small pair of scissors (with blood on them) on a table and broken glass on the bed. The patient was not disturbed by the EMS crew, no EMS interventions were taken. Crew was able to see multiple cuts to the left wrist from the doorway with a large pool of blood coming from cut site. Nursing home staff reported that the notes taped on the window and refrigerator door appear to be new. They state Thank you Railroad (female name). Crew removed all staff from the room at this time. The Medical Examiner and sheriff's office were called to the scene. While getting information from the staff, it was reported the patient was leaving the facility that day. Staff was able to provide a current DNR status and a face sheet. On arrival of the Sheriff's Office, crew explained the circumstances they walked into. No further actions were taken. The scene was turned over to the Sheriff's Office.On [DATE], the DON stated no staff called her the night of [DATE]. She stated that Staff F, LPN had been a CNA prior to becoming an LPN and she could have been pulled to sit with Resident #1 that night. She stated if staff had called her, that would have been her directive, to not remove the 1:1 but to have Staff F act as the 1:1. In an email dated [DATE] at 1:24 PM, the Administrator indicated the facility follows the nursing standards of practice related to assessments.

Based on clinical record review, family and staff interviews, the facility failed to provide timely interventions for 1 of 3 residents who experienced a newly documented open wound (#4). The facility reported a census of 124 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 3/26/25 did not include a Brief Interview for Mental Status (BIMS) score; however, an MDS assessment dated [DATE] revealed a BIMS score of 06 out of 15, which indicated severely impaired cognition. The MDS dated [DATE] included diagnoses of coronary artery disease (CAD), congestive heart failure (CHF), Alzheimer's Disease, non-Alzheimer's dementia, venous insufficiency, and seborrheic dermatitis (a common skin condition that causes a scaly, flaky, itchy rash, often on the scalp, face, and body folds). It also revealed the resident was independent with rolling left-to-right, sit-to-lying, and lying-to-sitting on the side of the bed, and required supervision with all other mobility. It further revealed, based on clinical assessment, the resident did not have any unhealed pressure ulcers or injuries and did not have any venous or arterial ulcers. It indicated the resident received dressings to his legs and feet.The Care Plan dated 8/29/23 indicated the resident had potential for complications with impaired skin integrity including skin tears, bruising AND/OR pressure related to current medical and physical status and had lower extremity (LE) edema. It directed staff to observe skin with AM/PM cares and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader and review skin concerns with medical doctor (MD).The electronic health record (EHR) included a physician's order dated 10/15/24 that directed staff to notify provider if any increase in swelling, scratching or new lesions.The Weekly Skin assessment dated [DATE] included a redness to bilateral lower extremities (BLE), left shin has small open area approximately 1.5 in in length x 0.5 in width that was not previously identified. Treatments as ordered. The assessment tool lacked a documented intervention.The Nurse Progress Notes for 4/15/25 did not include a documented intervention for the new BLE open area.On 8/06/25 at 12:33 PM, Staff C, Licensed Practical Nurse (LPN) stated the MD, family, and Assistant Director of Nursing (ADON) or Administrator On-Call (AOC) should be notified of newly identified resident skin wounds and get orders from the doctor. She also stated she didn't recall whether or not she contacted the MD or resident's family.On 8/07/25 at 12:21 PM, the Director of Nursing (DON) stated staff should have called the physician, gotten an order, started the order, documented it, and notified the family of the new order.In an email dated 8/07/25 at 1:24 PM, the Administrator indicated the facility follows the nursing standards of practice related to assessments.

Based on clinical record review, family and staff interviews, and policy review, the facility failed to conduct quarterly Care Conferences (CC) for 1 of 3 residents reviewed (#4). The facility reported a census of 124 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 3/26/25 did not include a Brief Interview for Mental Status (BIMS) score; however, an MDS assessment dated [DATE] revealed a BIMS score of 06 out of 15, which indicated severely impaired cognition. The MDS dated [DATE] included diagnoses of coronary artery disease (CAD), congestive heart failure (CHF), Alzheimer's Disease, non-Alzheimer's dementia, venous insufficiency, and seborrheic dermatitis (a common skin condition that causes a scaly, flaky, itchy rash, often on the scalp, face, and body folds). The Care Plan dated 2/24/23 indicated the resident had potential for complications with impaired skin integrity including skin tears, bruising AND/OR pressure related to current medical and physical status and had lower extremity (LE) edema. There were four (4) modifications made to the Care Plan's skin integrity focus.During an interview on8/04/25 at 12:27 PM, a family member stated Care Conferences were never completed.On 8/05/25 at 5:12 PM, Staff D, Social Services designee (SS) stated Care Conferences (CC) are scheduled 1 -2 weeks after MDS assessments are completed quarterly to ensure the resident's information is current. She also stated the resident and resident's representative are notified by mail and are contacted the day before the scheduled Care Conference if no confirmation is received. She added she has been the SS designee since 5/07/25 and documents CC in the resident's electronic health record (EHR) so she was not aware if previous CC summaries were stored on paper. The EHR indicated MDS assessments were completed 7/23/24, 10/15/24, 12/27/24, 3/26/25, and 6/17/25. The Assessments tab revealed Care Conference Summaries were documented on 7/31/24 and 6/17/25. There were no documented summaries for 10/24, 12/24, or 3/25.During an interview on 8/07/25 at 12:21 PM, the Director of Nursing (DON) stated a Care Plan conference should have occurred every quarter or upon a change of condition.A policy titled Care Plan - Reviews/Conferences reviewed 8/07/25 indicated the community will conduct a care plan review/conference at least quarterly, and as needed, that is interdisciplinary, provides an in-depth review of the resident's plan of care, and provides an opportunity for resident and resident representative and/or family discussion/input.

Based on clinical record review, family and staff interviews, and policy review, the facility failed to provide timely physician and family notification for 1 of 3 residents (Resident #4) who experienced a newly documented open wound. The facility reported a census of 124 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 3/26/25 did not include a Brief Interview for Mental Status (BIMS) score; however, an MDS assessment dated [DATE] revealed a BIMS score of 06 out of 15, which indicated severely impaired cognition. The MDS dated [DATE] included diagnoses of coronary artery disease (CAD), congestive heart failure (CHF), Alzheimer's Disease, non-Alzheimer's dementia, venous insufficiency, and seborrheic dermatitis (a common skin condition that causes a scaly, flaky, itchy rash, often on the scalp, face, and body folds). It also revealed the resident was independent with rolling left-to-right, sit-to-lying, and lying-to-sitting on the side of the bed, and required supervision with all other mobility. It further revealed, based on clinical assessment, the resident did not have any unhealed pressure ulcers or injuries and did not have any venous or arterial ulcers. It indicated the resident received dressings to his legs and feet.The Care Plan dated 8/29/23 indicated the resident had potential for complications with impaired skin integrity including skin tears, bruising AND/OR pressure related to current medical and physical status and had lower extremity (LE) edema. It directed staff to observe skin with AM/PM cares and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader and review skin concerns with medical doctor (MD).The electronic health record (EHR) included the following physician's order dated 2/06/24: Skin Management: Weekly Body Observation and Form to be completed 1x Week. Open Weekly Skin Check Tool in assessments and complete every evening shift every Tuesday for Prevention. If impairments present, measure and document a skin/wound progress note. Another physician's order dated 10/15/24 directed staff to notify provider if any increase in swelling, scratching or new lesions.A Physician Progress Note dated 4/14/25 indicated an increase in the resident's LEs (lower extremities) and included an order to increase the resident's furosemide (diuretic - medication that increases urination to remove excess water) to 60 milligrams (mg) by mouth twice daily.The Weekly Skin assessment dated [DATE] included additional information of redness to bilateral lower extremities (BLE), left shin has small open area approximately 1.5 in in length x 0.5 in width. Treatments as ordered. It did not include documented MD or family notification.The Weekly Skin Assessment Question History did not include previously measured BLE open areas.Review of the Nurse Progress Notes for 4/15/25 did not include MD (medical doctor) or family notification for the new BLE open area.On 8/06/25 at 12:33 PM, Staff C, Licensed Practical Nurse (LPN) stated the MD, family, and Assistant Director of Nursing (ADON) or Administrator On-Call (AOC) should be notified of newly identified resident skin wounds and notifications are documented in the Nurse Progress Notes. She also stated she didn't recall whether or not she contacted the MD or resident's family.On 8/07/25 at 12:21 PM, the Director of Nursing (DON) stated staff should have called the family and physician. They should have initiated any standing orders and continued attempts to contact the physician and document the call.A policy titled Notification of Change reviewed 8/07/25 indicated the community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is:a. An accident (including falls) which results in injury and has the potential for requiring physician-intervention.b. Acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).c. A need to alter treatment significantly (i.e. a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment).d. A decision to transfer of discharge the resident from the community.e. A change in resident rights.f. Changes in skin integrity, abnormal labs, changes in cognition, signs/symptoms of infection/virus, etc.any change that would constitute the need to alter the resident's orders and care for the resident.

Based on clinical record review, long term care ombudsman interview, and staff interview, the facility failed to cite the correct chapter of the Iowa Legislature State Regulations when issuing an involuntary discharge notice to 1 of 1 residents (Resident #1) reviewed. The facility reported a census of 124 residents.Findings include:The Minimum Data Set (MDS) of Resident #1 dated 6/4/25 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless on one day of the lookback period. The MDS recorded the resident dependent upon staff assistance for chair/bed-to-chair transfers. The MDS documented diagnoses that included: paraplegia, anxiety, depression, and alcohol abuse with alcohol-induced mood disorder.On 6/30/25, the facility addressed and hand delivered an involuntary discharge notice to Resident #1. The document, dated 6/30/25, titled Emergency Notice of Involuntary Discharge referenced Iowa Administrative Code 481-57.14(2) as state rule and regulation governing involuntary transfer. The document advised Resident #1 of being discharged to an appropriate facility or placement that can meet his needs and that he was being discharged due to his behavior posing a threat to the health and safety of other residents. During an interview on 7/31/25, the Long-Term Care Ombudsman stated the facility cited the wrong Iowa Administrative Code on the discharge notice. The LTCO stated Chapter 57 documented on the notice applies to Resident Care Facilities. The LTCO explained the facility should have referenced Chapter 58 for Long Term Care Facilities. She stated this error would normally have made the notice not be applicable and it should have been rewritten and the discharge process started over when this was completed. She added she was out of town during the proceedings, and when Resident #1 appealed the decision, the Administrative Law Judge upheld the discharge due to the facility having substantially complied with the notice requirement and the resident did not argue with the manner of the notice. During an interview on 8/6/25 the Administrator stated he had corrected the verbiage to Chapter 58 for any future involuntary discharges.

Based on clinical record review, legal guardian interview, and staff interviews, the facility failed to notify the resident's guardian in a timely manner after a fall resulting in injury and transfer to the hospital for 1 of 3 residents reviewed. (Resident #1). The facility reported census was 120. Findings include: According to the Minimum Data Set, dated dated dated [DATE], Resident #1 had a Brief Interview for Mental Status score of 3, indicating a severely impaired cognitive status. Resident #3 was independently mobile with using her wheel walker and required moderate assistance with dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included Alzheimer's, age related osteoporosis w/o (without) current pathological fracture, and chronic obstructive pulmonary disease, malnutrition. According to an Incident Report dated 2/13/25 at 6:10 p.m., written by Staff H, Resident #1 was in her bedroom with Staff F, Certified Nursing Assistant, preparing for bed, when Resident #1 tripped and fell on to her right knee and face striking her bed board. The injury resulted in Resident #1 being sent to the hospital, where x-rays discovered a facial fracture and knee fracture. A review of the electronic health record Face sheet revealed Resident #1 had a non-family legally appointed guardian. The Face Sheet indicated the phone number with an extension number to use when the guardian needed to be contacted. During an interview on 3/6/25 at 12:19 p.m. Staff H, Registered Nurse (RN) stated she called the guardian after Resident #1 fell on [DATE]. Staff H stated she could not recall the number she called or if she used an extension number, but remembers leaving a message. During an interview on 3/6/25 at 9:41 a.m. the Legal Guardian stated the facility called her office phone and left a message regarding the fall Resident #1 had on 2/13/25. The Legal Guardian stated she was not aware of the incident and transfer to the hospital until the following day. She indicated this has been an on-going concern. The Legal Guardian stated an after hours on-call number has been provided to the facility. She stated it is essential the legal guardian be notified promptly when a resident under their care is sent to the hospital. The Legal Guardian stated she had spoken with the Assistant Director of Nursing (ADON) who had told her that the nurse was given direction to call the on-call number that evening. During an interview on 3/6/25 at 11:00 a.m. the ADON stated she is responsible for the Memory Care Unit, 400 and 500 halls. On the evening of 2/13/25 she received a call from Staff H informing her Resident #1 had fallen with injuries and was being sent out to the hospital. The ADON stated she informed Staff H to contact Resident #1's guardian. She stated there was a number at the 400-hall nurse's station, noting there is an on-call number and process posted for after hours. The ADON stated after hearing that the on-call number was not used, she posted bright yellow cards with the number and process at each nurse's station.

Based on observation, resident and staff interviews, and temperature testing, the facility failed to serve food at a palatable temperature for one dinner meal observed and for several residents served room trays on the evening meal in the rooms on the 600 Hall. The facility reported a census of 124 residents. Findings include: During an interview on 12/10/24 at 12:26 PM, Staff D, Dietary Aid stated food temperatures are taken once the food has been placed in the steam table and before the first resident is served. Staff D was asked how they keep the room trays hot when taking meal trays to the resident rooms. She advised the plates and food covers are not heated prior to plating. She reported they typically try to get the meals to the resident rooms as soon as possible after they have been plated. When queried Staff D, stated she has heard a few random complaints that sometimes the food is not hot enough. Once the food is delivered to her it is placed in the steam table and temperature taken and logged into a log book prior to starting meal service. The log book was observed and temperatures were documented. On 12/10/24 at 4:10 PM an observation of evening meal temperatures was conducted in the kitchen prior to the food going out to the individual kitchenettes. The temperatures of the food going to Dining Room D were as follows prior to leaving the main kitchen. a. Turkey burgers-178 degrees F (Fahrenheit) b. Sweet potato mashed-166 degrees F c. Baked potatoes-202 degrees F d. Sweet potatoes-172 degrees F e. Pureed turkey burger - 178 degrees F f. Ground turkey burger-166 degrees F g. Mashed potatoes-193 degrees F h. Gravy-204 degrees F i. Alternate vegetable-tomato soup-186 degrees F On 12/10/24 at 5:50 PM the last meal tray was delivered to the residents and the meal items on the test tray were temperature checked by the Culinary Director. The following were the temperature results on the test tray food items. The items were tested with the Culinary Director's thermometer: a. Pea salad - 48 degrees F b. Turkey burger-118 degrees F c. Sweet potato fries-116 degrees F When queried, the Culinary Director advised the above food temperatures were not good. On/10/24 at approximately 6:00 PM Staff C, Certified Nursing Assistant (CNA) stated that she knows that the food temperatures are checked prior to serving but she is unsure what the food temperatures should be. She advised she is a CNA so she just helps out when needed and doesn't know the specifics. During an interview on 12/12/24 at 11:22 AM, the Culinary Director stated the temperatures weren't good, I was expecting the pea salad citation. It did not maintain a cold enough temperature. She stated since the turkey burgers were in juice she was surprised the temperature was as low as it was. The Culinary Director stated she thinks part of the problem was we were running behind. Fries are pretty hard to keep warm. I will meet with management and we will develop an effective system to serve meals at the appropriate temperatures. A review of an undated facility policy, titled The Dining Experience: Staff Responsibilities Policy statement declared The dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional, and/or special dietary needs and food preferences and are served at a safe and appetizing temperature. Individuals will be provided restorative dining services as needed to maintain or improve eating skills. The Procedure section, #14 directed food will be at the proper temperature, texture and/or consistency to meet each individual's needs and desires.

Based on record review, interviews, and the facility policy, the facility failed to report an alleged abuse incident for 1 of 1 residents reviewed for abuse (Resident #52). The facility reported a census of 124 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed the resident required partial/moderate assistance with toileting hygiene, upper and lower body dressing; sit to lying; lying to sitting; sit to standing; chair/bed to chair transfer; and toilet transfer. The MDS revealed the resident frequently incontinent of urine and occasionally incontinent of bowel. The MDS revealed medical diagnoses of anxiety disorder and depression. The Care Plan revealed a focus area dated 4/15/19 for risk of side effects of psychotropic medications related to anxiolytic and antidepressant medication therapy. Resident had a diagnosis of major depressive disorder and anxiety disorder and can become tearful at times. Resident had a history of making false statements. The interventions dated 4/15/19 revealed allowing resident to talk about her feelings, or cry/vent. The EMR (Electronic Medical Record) revealed the following Medical Diagnoses: a. unspecified intellectual disabilities b. anxiety disorder, unspecified c. other symptoms and signs involving cognitive functions and awareness d. major depressive disorder, single episode, full remission e. nocturnal enuresis The Incident Progress Note (late entry) dated 12/6/24 at 7:56 AM, revealed this writer was notified via phone by 3rd shift nurse that was on 600 hall of incident, she stated the following: The resident had propelled herself in her WC (wheelchair) to the [skilled unit] side of the building, the CNA (Certified Nurse Aide) over in [skilled unit] reported that Resident #52 was crying and when she asked Resident #52 what was wrong , Resident #52 stated that colored girl made me get up, she hit me and called me a B****.The CNA then told her nurse and the both of them took Resident #52 to their dining room, got her a hot chocolate and a snack to try and calm Resident #52 down. During this time Resident #52 was c/o (complains) her pants being too tight, so the [skilled unit] CNA went to Resident #52 room on 600 hall to get her a more comfortable pair of pants,while over there she told the 600 hall nurse what was going on, she then brought the pants to [skilled unit] and took Resident #52 to the bathroom, helped her change her pants, While assisting the resident in changing her pants she looked over the residents skin/body (as she was instructed to by her nurse) to check for any areas of concern, no areas of concern were noted. [skilled unit] CNA then took her back to the dining room to finish her snack and [NAME]. 600 hall nurse told this writer she had questioned the accused CNA about the situation the CNA [name redacted] stated the following: when she was trying to get the resident the resident wasn't happy about getting up but she needed to d/t (due to) her bedding being completely saturated with urine. She got her cleaned up and put in WC, did the residents hair in a ponytail, gave the resident her glasses and then the resident proceeded down the hall, the resident was not crying at that time. This writer was the nurse on call at the time, I called the DON (Director of Nursing) and Administrator right after I was informed and the DON instructed me to go to the facility and investigate the situation. I did, I got statements from everyone who talk/interacted with the resident that night/morning. I also did a head-to-toe assessment on the resident when I got to the facility, no areas of concern were seen. I then called the administrator and went over all information I had gathered from my investigation. We decided to implement the following as precaution, the accused CNA will no longer be assigned to 600 hall, and I will instruct staff to do cares for this resident in pairs just as precaution. After informing the residents sister of the situation, she requested Resident #52 not be on the 3rd shift get up list, I will take her off that list. The resident's sister [name redacted] is also in agreement to the other two precautions we put in place. We do not think the accusations are true, d/t the resident having a history of making false accusations and the head-to-toe assessment being completed, no issues found. The Incident Report revealed the following information a. Date of Incident: December 6, 2024 b. Time of Incident: Approximately 5:00 AM c. Incident Overview: On December 6, 2024, at approximately 5:00 AM, [name redacted], ADON was notified of a potential incident involving a resident, Resident #52, and [name redacted], CNA. [name redacted] promptly escalated the matter to [name redacted], Administrator, who then notified [name redacted], Director of Nursing (DON). A full investigation into the incident was immediately conducted .Following the initial report, [name redacted] (CNA) was immediately sent home pending the outcome of the investigation to ensure resident safety and to allow for an impartial review. Interviews were conducted with all employees involved, and their statements were documented as part of the investigation. During an observation on 12/11/24 at Resident #52 self propelled herself in her wheelchair in the hallway near the front entrance. She was dressed in clean clothes and her hair combed. During an interview on 12/11/24 at 2:50 PM, Staff A, ADON stated she was notified of the incident at 5:15 AM with Resident #52 and a the CNA that got her up that morning and then Staff A called the DON and Administrator was instructed to come to the facility and get statements on the incident. She stated she got to the facility around 5:50 AM and got statements from everyone involved in the incident. During an interview on 12/12/24 11:58 AM, the Administrator queried on the reason why they did not report the incident on 12/6/24 and he stated the requirements of abuse did not occur and so they did not think they needed to report it. During an interview on 12/12/24 at 12:07 PM, the Administrator stated it seemed to be a pattern with Resident #52 and after we investigated it, it seemed more of a behavior, and that was why we didn't report it. The Facility Abuse Prevention, Reporting, and Investigation Policy (no dated indicated) revealed the following reporting abuse: a. Mandatory Reporting: All abuse allegations must be reported immediately to the Abuse 1. Coordinators: Administrator and DON 2. Timeframe: Within 2 hours if the allegation involves serious harm; Within 24 hours for all other allegations. b. Notification: 1. The Abuse Coordinators will notify the following parties as required: Iowa Department of Inspections, Appeals, and Licensing (DIAL)

Based on record review, interviews, and the facility policy, the facility failed obtain a lab for a hemoglobin A1c per the provider's order for 1 of 25 residents reviewed for professional standards (Resident #35). The facility reported a census of 124 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed a diagnoses for diabetes mellitus (DM). The MDS revealed the resident received insulin injections 7 out of 7 days. The Care Plan revealed a focus area for potential for complication of diabetes with concern of hypoglycemia/hyperglycemia dated 3/30/23. The interventions dated 3/30/23 indicated medications, labs, and treatments as ordered/accepted. The EMR (Electronic Medical Record) revealed a diagnosis for Type II DM with diabetic peripheral angiopathy without gangrene. The Progress Note dated 9/25/24 at 6:29 PM, revealed new orders per [name redacted]: 1) Hgb A1c dx (diagnosis) of dm2 (Type II diabetes mellitus). The EMR revealed an order for an Hgb A1c with a start date of 9/26/24, end date of 9/26/24, and a completed status for the order. The facility lacked documentation of the results of the Hgb A1c completed on 9/26/24. During an interview on 12/11/24 at 2:46 PM, Staff A, ADON (Assistant Director of Nursing) stated she found the Hgb A1c completed in May and she looked everywhere for the Hgb A1c ordered in September. Staff A stated she saw the order for the Hgb A1c in September and doesn't know how it was missed. During an interview on 12/11/24 at 4:55 PM, the Director of Nursing (DON) stated the order placed by an agency nurse and all she could say was they missed it and the lab didn't get completed. The DON stated her expectation was when they got an order we will do 3 checks in place that were not in place prior to the survey. The first check was the nurse noted the order and put the order in and then the next nurse noted the order for the lab, and the last check was the ADON or DON reviewed the ordered and make sure the family knew and the lab knew about the order. The Facility Physician's Order- Recording dated 5/2020 revealed the following: a. If laboratory is involved (or according to facility process): 1. Make out lab slip 2. Notify lab. 3. Enter notation on calendar for any future labs to be drawn. Indicate any special instructions 4. document in nurse's notes

Based on observation, interview, and facility policy review the facility failed to ensure a medication cart remained locked when not in use for 1 of 7 medication carts. The facility reported a census of 124 residents. Findings include: On 12/9/24, observation of the medication cart for 400 hall present across from the nursing station revealed the following: a. On 12/9/24 at approximately 2:12 PM, a staff member walked past the medication cart and the medication cart lock was not depressed. Another staff member then passed by the medication cart and the medication cart lock was not depressed. The cart was unlocked, able to be opened without a staff member present, and medications were observed to be accessible inside the medication cart. b. On 12/9/24 at 2:13 PM, notified Staff B, Registered Nurse (RN) of the medication cart, who was present in the office off of the nursing station. Staff B queried about when medication cart was normally locked, and explained when not here. On 12/12/24 at approximately 11:00 AM, the Director of Nursing (DON) queried when staff should be locking the cart, and responded when not by it, using it, and acknowledged needed to be in their sight. The Facility Policy titled Medications Labeling and Storage, dated April 2008 revised November 2024, revealed the following: 4. All medications will be stored appropriately, either in the locked medication cart or medication room.

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure the Ombudsman notified of resident transfers to the hospital for 2 of 2 residents reviewed for hospitalization (Resident #37, Resident #110). The facility reported a census of 124 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #110 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of the Progress Note dated 9/20/24 at 11:12 AM revealed, in part, The ambulance was called, and the resident left the facility via non-emergency ambulance at 2022. Review of Ombudsman Notification provided by the facility did not include notification of Resident #110's transfer to the hospital on 9/20/24. 47336 2. The MDS assessment dated [DATE] revealed Resident #37 scored a 13 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed medical diagnoses of neurogenic bladder, diabetes mellitus, and heart failure. The MDS revealed the resident used an indwelling catheter. The Care Plan revealed a focus area dated 3/15/23 for suprapubic catheter related to neurogenic bladder. The interventions dated 3/15/23 revealed observation/monitored/documented any signs and symptoms of complications for pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns with notification to the MD (Medical Doctor) as needed with concerns. A review of Progress Notes revealed: a. On 9/5/24 at 6:30 AM, Resident #37 went to the emergency room via ambulance on at 7:14 AM. on 9/5/24. The resident returned to the facility at 1:56 PM. b. On 10/11/24 at 3:20 PM, Resident #37 went to the emergency room via ambulance. The facility lacked documentation of the ombudsman notification for Resident #37 for the months of September and October. During an observation on 12/09/24 at 12:31 PM, Resident #37 sat in his electric wheelchair in his room and watched television and dressed in clean clothes. During an interview on 12/12/24 at 11:53 AM, the DON (Director of Nursing) queried on when they notified the ombudsman and she stated when they had a discharge, a transfer to the hospital if they were gone over 24 hours, or a death. The DON informed of Resident #37 two transfer/discharge to the hospital and Resident #110 transfer to the hospital and no documentation found for the ombudsman notification and she stated they would check again. During an interview on 12/12/24 at 12:21 PM, the Administrator stated he looked through records again and he didn't see any documentation the ombudsman notified for Resident #37 or Resident #110. The Administrator stated he expected the notification to be sent. The Facility Ombudsman Notification for Discharges and Transfers (no date indicated) revealed the following: a. The Social Services Director or designee is responsible for notifying the Iowa Long-Term Care Ombudsman within 24 hours of issuing the written notice to the resident. b. Notification will include: 1. Resident name 2. Reason for discharge/transfer 3. Location and date of the planned move 4. A copy of the discharge/transfer notice c. Notification may be sent via secure email, fax, or other approved methods as required by the Ombudsman office.

Based on clinical record review, observations, facility video and staff interviews, the facility failed to ensure a resident with exit seeking behavior did not exit the facility without staff knowledge. (Resident #4) The facility reported census was 125. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 9/17/24 at 3:30 pm. The IJ began on August 4, 2024. Facility staff removed the Immediate Jeopardy on 9/24/24 through the following actions: - Resident placed on 1:1 observation on 8/4/24 until he was moved to the locked Memory Care Unit on 8/5/24. - Neuro checks initiated, witness statement obtained, and notifications made on 8/4/24. - Elopement assessment and care plan updated 8/5/24. - Staff education on elopement and documentation began 8/4/24. - Residents wander guard immediately checked for functionality on 8/4/24. - Staffing was reviewed for time of incident and determined not to be a contributing factor. How will you identify other residents who are at risk for being affected by this alleged deficient practice: All residents at risk for elopement have potential to be affected by this alleged deficient practice. What measures will you put into place or what system changes will you make to ensure that the deficient practice does not recur. - Staff education for elopement began 8/4/24. - All residents with wander guards were reviewed, tested and ensured orders were put in place for monitoring on 8/4/24 and 9/19/24. - Elopement drills were conducted 7/31/24 and 8/5/24. - Elopement Risk Assessments were reviewed on all residents and revised, if necessary, on 8/4/24. - All elopement care plans were reviewed and revised as necessary on 8/4/24. - Elopement Book at front desk was reviewed and updated as necessary on 8/4/24. - All Maintenance logs were reviewed and found in compliance with alarm monitoring on 8/4/24. - TARS reviewed and physician orders updated to include what functionality of the alarm looks like on 9/19/24. - Ideacom, our wander guard service vendor, sent a technician to Lutheran Living on 9/19/24 at approximately 7:30 PM and recalibrated the Wanderguard after the system passed all tests. The technician was unable to duplicate the issue and felt it was a technology glitch. Technician increased the sensitivity of the wander guard zones for optimal coverage. - Main entrance was monitored by staff, until Ideacom technician arrived to evaluate system and increase sensitivity. - Implementation of a Weekend Manager on Duty to ensure we have coverage at the front entrance every day of the week. - Wanderguard alarm on doors will continue to be monitored ongoing. - Wanderguard bracelets on residents will continue to be monitored ongoing. How the corrective action will be monitored to ensure that the deficient practice does not recur. - Negative findings will be corrected immediately and reported at Quality Assurance and Performance Improvement Meeting and conduct education training as needed. - Ongoing random reviews of this system will be incorporated into the monthly - Quality Assurance Performance Improvement Program. The scope lowered from J to D at the time of the survey after ensuring the facility implemented the education, audits and their policy and procedures. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score of 5, indicating a severely impaired cognitive status. Resident #4 required maximal to dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and he was frequently incontinent of bladder and bowel. Resident #4's diagnosis included cerebrovascular accident (stroke) with hemiplegia, Non-Alzheimer ' s dementia and atrial fibrillation. According to the facilities Elopement Risk Screen Tool dated 7/8/24, Resident #4 scored 30 and was determined at high risk for elopement. Resident #4's Care Plan indicated he was at risk for elopement with goal to keep resident safe and secure during his stay and interventions to: 1. Complete quarterly and as needed Elopement Assessments. 2. Observe, monitor, document behaviors, and mood exit seeking concerns and notify supervisor, social worker and physician as needed. 3. Notify supervisor if wanderguard (Accutech LC1200) is missing or not functioning properly. 4. Wanderguard bracelet placement-wanderguard is placed on wheelchair. Monitor per facility protocol. According to the August Treatment Administration Record (TAR), staff are to ensure Wanderguards are checked for proper placement and functioning each shift. August TAR indicates Resident #4's wanderguard was recorded as functioning and placed properly on his wheelchair throughout August. In an interview on 9/22/24 at 6:12 p.m. a visitor/witness (MB) stated on the morning of 8/4/24 she was visiting a friend and another resident outside the front entrance. She saw Resident #4 outside in his wheelchair talking on the phone. Resident #4 then began propelling himself down the sidewalk. The visitor (MB) stood and started towards Resident #4 as he began to gain speed down the slope, then tipped over onto his right side, onto the grass. The visitor (MB) turned back to the facility and ran inside to get help. The visitor (MB) stated the staff responded immediately. The visitor (MB) stated there was no alarm sounding or staff present outside during the time Resident #4 was outside. The visitor (MB) stated the alarm sounded when Resident #4 was propelled by staff back into the facility. In an interview on 9/22/24 at 5:56 p.m. Staff G, Certified Nurse Aide, stated she was working the day shift on 600 hall 8/4/24. Staff G stated she was on 300 hall that morning, talking to a resident when a family member ran in stating Resident #4 had tipped his wheelchair over, outside. Staff G stated she hollered for Staff H on 300 hall as they ran to the front entrance to help Resident #4. Staff G stated several staff arrived and took care of Resident #4 and got him back inside. Staff G stated there was no alarm sounding when she got to the front entrance. According to a statement written by Staff H on 8/5/24, Staff H, Certified Nurse Aide, stated she was working on 300 hall on 8/4/24 when she was asked by another staff (Staff G) for help. Staff H stated she ran behind Staff G with her nurse (Staff B) behind her. Staff H stated they all went outside where they found Resident #4 on the ground. They made sure he was okay and helped him back into his wheelchair. Once back inside the nurse took his vital signs and she went back to her hall. In an interview on 9/18/24 at 6:05 p.m. Staff B, Certified Medication Aide, stated after returning to 300 hall following her lunch break, she was informed by Staff H, that Resident #4 was outside on the ground near the tree. Staff B stated she started out, then was directed back in to get the nurse, before returning outside to assist. Staff B stated Resident #4 had tipped his wheelchair onto his right side onto the grass, near a tree along the sidewalk. Staff B stated she helped get Resident #4 back into his wheelchair. Staff B stated there was no alarms sounding when she initially went outside, but upon returning the wanderguard alarm did sound. Staff B stated wander guard tags are checked each shift for functioning and placement and when a wanderguard door alarm sounds it must be coded to disarm. According to a statement written by Staff M, Licensed Practical Nurse, Staff M stated she was alerted by staff to go outside the building as Resident #4 was on the ground with his wheelchair tipped over. Family members explained that Resident #4 was outside sitting area using his phone and the next thing they noticed, he began propelling his wheelchair on the sidewalk and the wheelchair tipped over onto the grass. Staff M stated she immediately instructed one staff to call the assigned nurse (Staff F) to make sure she was aware of the fall incident. Staff M sated Resident #4 was assessed, alert with no facial grimacing or voicing of pain or discomfort. Resident #4 was turned onto his back and active and passive range of motion performed. Resident #4 was then placed in a sitting position with gait belt applied and assisted up with assistance of 4 staff and transferred into his wheelchair. Resident #4 had a wander guard tag attached to his wheelchair and upon entering back into the facility the alarm sounded. Further assessment was conducted in the facility and noted pulse was 49. Verbal report given to staff and the nurse and Resident #4 was propelled to the dining room for lunch. The Assistant Director of Nursing was notified of the incident by text. In an interview on 9/18/24 at 6:42 p.m. Staff J, Certified Nurse Aide, stated she recalls the day before (8/3/24) Resident #4 eloped, she questioned whether the wanderguard was working properly. That day Resident #4 was near the elevator near the memory care unit next to wanderguard door units and the alarm did not sound. Staff J stated normally the elevator wanderguard alarm would sound when residents with Wanderguards get too close. Staff J stated she reported her observation to the nurse. In an interview on 9/18/24 at 6:32 p.m. Staff L, Certified Nurse Aide, stated on the morning of 8/4/24 she was assigned on 400 hall and Resident #4 was already actively trying to exit and stating he was leaving. Staff L stated this behavior had intensified over the last week. Staff L stated she had redirected him several times that morning and propelled him back to 400 hall lounge around 9:30 a.m. Then, while caring for another resident, she was informed Resident #4 had gotten outside. Staff L stated she came up front and several staff were outside with Resident #4. Staff L stated there was no wanderguard alarm sounding. Staff L stated the wanderguard alarm is loud and can easily be heard in the 400 hall. In an interview on 9/19/24 at 9:15 a.m. Staff E, Certified Medication Aide, stated she was working day shift on 400 hall 8/4/24. That morning Resident #4 was adamant about leaving and was exit seeking all morning, requiring redirection and propelling him back to 400 hall several times. During staff break times, the nurse (Staff F) stated she was going to give the resident some medication and that she would keep an eye on him. Staff E stated she went on break and returned 30 minutes later and began helping another aide, when a 300 hall aide came and stated Resident #4 had gotten outside. Staff E stated she got to the front door and by then several staff were already outdoors. Staff E stated there was no wanderguard alarm sounding, however it did sound as Resident #4 was brought back inside. Staff E stated the wanderguard alarm can be heard throughout the facility and requires a code to disarm it. In an interview on 9/19/24 at 11:14 a.m. Staff K, Certified Nurse Aide, stated she was working 400 hall on Saturday, 8/3/24 and noted Resident #4 was insistent on leaving and exit seeking all day. Staff K stated she shared this with the Sunday, 8/4/24 staff. Staff K stated she was working on the 500 hall on Sunday, 8/4/24 and had redirected Resident #4 more than once that morning. Staff K stated on the morning Resident #4 eloped, the alarm sounded briefly, then turned off. Staff K explained that the wander guard will alarm on the phones and display a code. In Resident #4's case, the phone alerted and displayed WG Hall 400, indicating it was a wander guard from someone on 400 hall. Staff K states she remembers that code at the time Resident #4 exited the building and it only lasted a few seconds. Staff K stated she was at the front entrance when Resident #4 was brought back in. Observation of facility video of the front entrance on 8/4/24, noted at 10:51:51 a.m. Resident #4 is observed exiting the front entrance in his wheelchair behind a visitor who had just coded the door open. At 10:57:30 a.m. a visitor is observed coding the front door and exiting. The video shows Resident #4 outside and visitors looking towards Resident #4. One visitor (MB) stands and starts towards Resident #4, then turns and runs into the facility at 11:02:50 to alert staff. At 11:03 a.m., nearly 11 minutes after Resident #4 exited the facility unsupervised and undetected, staff exit to assist Resident #4. Through testing the alarms, interviewing staff and watching the video, it was confirmed the wanderguard alarm never activated when Resident #4 exited the facility. During an observation on 9/19/24 at 10:57 a.m. Staff P, maintenance, was asked to test the wanderguard alarm system at the facilities front entrance. Staff P brought the wanderguard tag in close proximity to the wanderguard monitors and the alarm failed to sound. Minutes later a second attempt activated the wanderguard alarm requiring a code at the front door to disarm the alarm.

; Based on observations, clinical record review, resident and staff interviews, the facility failed to ensure residents are provided incontinence care in accordance with professional standards of practice. (Resident #19, #20) The facility reported census was 125. Findings include: During observations on 10/1/24 at 1:00 a.m. upon entering the lounge area between 600 and 700 halls, there were three staff visiting. Two were sitting in recliners (Staff AA) with their feet elevated and one standing between them talking. The TV was on and there were no residents in the proximity of the lounge area. There was a bowl on an end table which appeared to have been recently eaten from. The three aides including Staff AA, Certified Nursing Aide, quickly got up, folded a sheet, picked up the bowl and proceeded to the nurse's station. At 1:30 a.m. Staff AA walked onto 700 hall and returned within two minutes and then 600 hall, again returning in less than 5 minutes. She remained at the nurse's station until 2:24 a.m. at which time she answered a call light accompanied by another aide on 700 hall, both returning within 5 minutes. At 3:00 a.m. Staff AA and another aide entered the 700 hall together, doing what appeared as rounds, but failed to check in every room. The two returned to the nurse's station within 15 minutes where they remained as the surveyor departed at 4:00 a.m. In an interview on 10/1/24 at 2:15 a.m. Staff Z, Registered Nurse, stated most aides do okay, but some have been known to take naps. Staff Z stated she will wake aides up when she sees them sleeping. Staff Z did not provide any names, noting she is an agency nurse and not familiar with everyone's name. According to a Kardex, there were 15 residents on 700 hall and of those 5, including Resident #19 and #20 that were identified as being incontinent and needing assistance with checking and changing. According to the Minimum Data Set (MDS) dated [DATE], Resident #19 had a Brief Interview for Mental Status (BIMS) score of 10, indicating a moderately impaired cognitive status. Resident #9 required moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and he was frequently incontinent of bladder and occasional incontinent of bowel. Resident #19's diagnosis included Non-Alzheimer ' s dementia, cerebrovascular accident (stroke), atrial fibrillation, benign prostatic hypertrophy. In an interview on 10/1/24 at 11:20 a.m. Resident #19 was sitting in his recliner holding a great grand child and visiting with family. Resident #19 queried regarding care at night. Resident #19 stated they don't check him at night until about 4:00 a.m. Resident #19 voiced dissatisfaction with overnight staff. According to the Minimum Data Set (MDS) dated [DATE], Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #20 required independent to moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was occasionally incontinent of bladder and bowel. Resident #20's diagnosis included congestive heart failure, renal insufficiency, respiratory failure, diabetes mellitus, arthritis. In an interview on 10/1/24 at 11:30 a.m. Resident #20 was sitting in her recliner with her TV on. Resident #20 queried regarding care at night. Resident #20 stated they don't check her at night, noting she is often saturated in the morning.

Based on clinical record review, personnel records, medical examiner interview and staff interviews, the facility failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner for 1 of 5 residents (Resident #1) reviewed for safety. Per staff interview, Resident #1 called out for help on [DATE] at approximately 4:30 AM, and staff were unable to respond for up to 10 minutes. The resident subsequently found face down in bed, feet on the floor, unresponsive. The facility reported a census of 129 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 5:35 p.m. The IJ began on February 11, 2024, when Resident #1 found unresponsive. Facility staff removed the Immediate Jeopardy on [DATE] through the following actions: a. The Director of Nursing (DON) or designee will educate On-Call Clinical Staff on responsiveness to staffing calls. b. The DON or designee will educate direct care Licensed Nurses prior to working their next shift on escalation of unanswered attempts related to staffing to contact on call Nurse. c. Labor meeting daily Monday through Friday to review previous days staffing requirements and anticipate staffing needs with Executive Director, DON, Staffing Coordinator and other applicable staff. d. Resident interviews (10) regarding satisfaction with staffing ratios will be conducted by the Executive Director or designee weekly. e. Staff interviews (10) regarding satisfaction with staffing ratios will be conducted by the Executive Director or designee weekly. f. Nursing staff will be educated on responding to resident ' s needs prior to working next shift. (Calling out for assistance). The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 diagnoses included: arthritis, osteoporosis, Alzheimer's disease, anxiety, and depression. A score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicated a severe cognitive impairment. The assessment revealed Resident #1 required substantial/maximal assistance (meaning staff provided more than half of the effort to complete a task) for transfers to and from bed and chair, and to roll from lying on back to left and right side, and to return to lying on back on the bed. The MDS assesses Resident #1 as having clear speech with distinct intelligible words, and sometimes understood, and usually understood others. The Care Plan, created on [DATE], and initiated on [DATE], included a Focus Area for Safety and Falls R/T (related to) current medical and physical status. Poor safety awareness r/t dementia. Interventions included: 1. Body pillow to be placed when I am in bed, initiated [DATE]. 2. Med [NAME] (similar to a mattress) placed next to my bed, initiated on [DATE]. 3. Staff education to ensure placement of medmizer when in bed, initiated on [DATE]. 4. Bed in low position, no initiation date indicated. 5. Call light positioned for easy access, no initiation date indicated 6. Check for unmet needs: pain, toileting, hunger, thirst, temperature, no initiation date indicated A Care Plan Focus Area, initiated on [DATE], for ADL (Activities of Daily Living) Complications with Deficit's with ADL R/T current medical and physical status. Has meds and dx (diagnosis) that can affect ADL's. I have decreased mobility and depend on others to assist me with ADL's. Interventions included Bed Mobility x1 (one staff) extensive assist. I am not consistent with being able to turn side to side. I am dependent with laying to sitting. A Nursing Progress Note transcribed on [DATE] at 4:56 AM. by Staff K, Licensed Practical Nurse (LPN) stated: Resident was found by CNA (Certified Nursing Assistant) at 4:35 a.m. on the mat unresponsive. CNA notified Staff L, LPN about resident. No vitals noted. This nurse and Staff L verified resident's death at 4:35 a.m. This nurse called 911 to notify and speak with the Medical Examiner (ME) about resident. Waiting call back. During an interview on [DATE] at 7:41 AM, Staff H, Certified Nursing Assistant (CNA) stated she worked the night shift on [DATE], assigned to the 600 Hall. She stated she worked on a different hall then where Resident #1 resided. Staff H stated when Staff M, CNA left at 2:00 AM she also covered the 500 hall. She stated while on the 600 Hall, on her way to the 500 Hall around 4:30 AM heard the resident [Resident #1] yell out but didn't think it was anything serious. Staff H stated she headed into a different room a few doors down to provide care and answer the call light. While in this room, Staff I, CNA, came in the room and said Resident #1 was crying. Staff H stated it was about 5 to 10 minutes before they went to Resident #1's room and found her face down, the front part of her lower part of her body was on the fall mattress next to the bed, and the upper part of her body was on the upper part of the bed, chest down with her head face down, between the mattress and the side rail attached to the bed, the bed was in low position, and she was certain that was how the resident was positioned. Staff H stated she thought the resident must have reached for something and how she ended up on her stomach, and thought the resident yelled because her head was stuck there and she couldn't get up. The resident was pale, she didn't think she was breathing and sent Staff I to get the nurse. Staff L, LPN came to the room and directed them to turn the resident over, put her on the fall mattress and to get Staff K, LPN as that was the nurse assigned to the resident. When Staff K got to the room, the resident was on her back on the fall mattress. Staff H reported she had last seen the resident about an hour and a half prior, when provided incontinence care to the resident. At that time, the resident was in her bed, she thought positioned on her side and covered with a blanket. During an interview on [DATE] at 12:57 PM, Staff I, CNA, stated she worked the night shift on [DATE] on the 700 Hall. She stated another staff had left, and she was told by a nurse to cover both halls (assigned 700 Hall, and pick up 600 Hall). Staff I stated she told the nurse she couldn't cover both halls and they came to some sort of agreement to split one of the halls. She needed help for rounds, tried to find Staff H, CNA and as she looked for her saw the resident had slid partway out of the bed and onto a fall mat, her upper body was on the bed and her head was face down. The resident wasn't saying anything. Staff I stated she went to find Staff H, but found Staff L, LPN. Staff I stated Staff L told her it wasn't her hall and she needed to find Staff H. She found Staff H in another room and they went into Resident #1 room together, it didn't look like the resident was breathing so she went to get the nurse (Staff L). Staff L came, said to flip the resident over, they lifted the resident onto the fall mat on the floor and laid her on her back. Then she had to go to the locked unit so Staff K, the other nurse [LPN], could come over, Staff K was in the CCDI Unit because that CNA had also left in the middle of the shift that night. During an interview on [DATE] at 8:18 AM, Staff K, LPN, stated she worked the night shift on [DATE]. She stated she was in the CCDI unit when a CNA got her, told her the resident [Resident #1] had passed and Staff L needed help. When she got to the resident's room the resident was on the fall mattress positioned on her back, they had already moved her. Staff L said the resident was face down when they found her and turned her over, and they both confirmed the resident's death at that time. Staff K called 911 to notify the Medical Examiner (ME), and spoke to the ME when he came to the facility that morning. Staff K stated they were too short staffed that night, the aides that were there had to cover multiple halls so she called the manager on call, Staff S, Assistant Director of Nursing (ADON), to report they were very short staffed and needed help, Staff S refused to come to the facility and directed her to figure it out. During an interview on [DATE] at 4:29 PM, Staff L, LPN, stated she worked on the night shift on [DATE], and couldn't recall the details associated to the resident's death. She stated one of the CNA's came to her for help, the resident [Resident #1] was on the fall mattress and the bed, they had to turn her so she could assess her, but the other nurse, Staff K, had the resident that night, she came and took over, called the ME, notified family and charted it all, and really didn't remember much about it. During another interview on [DATE] at 9:24 AM, Staff L stated she remembered more about the night of [DATE]. She stated one of the aides came and told her the resident [Resident #1] was on a mat and a low bed, she [Staff L] told her it wasn't a fall because they were the same height and directed her to get the other aide to help her get the resident back in bed. Then both aides came and said she needed to come. Staff L stated when she got to the room the resident was face down on the bed, her lower body on the fall mat and her chest was sort of leaned onto the bed. Staff L turned her over onto her back, onto the mat, the resident wasn't breathing. Staff K arrived, and she told Staff K she was face down, and Staff K took over from there and why Staff K charted it. During an interview on [DATE] at 1:51 PM, Staff J, CNA, stated she worked at the facility through agency, a lot of double shifts and cared for the resident several times. On the night of [DATE] she was assigned to a different hall with the nurse, Staff L, and was there when Staff L came back from the resident's room, said the resident was found dead, face down. Staff J stated they were very short staffed that night. She stated she had taken care of the resident the day before and there were no concerns during the shift. During an interview on [DATE] at 9:11 AM, Staff M, CNA, stated she was scheduled to work the night shift on [DATE]. Staff M stated she told the Staff R, Scheduler that she couldn't work due to a family situation, but Staff R begged her to work until 2 a.m., and she agreed. Staff M thought there would be a someone scheduled to relieve her at 2:00 AM, but there was not. Staff M stated she reported off to one of the other aides from another hall before she left. Staff M reported she had last seen the resident [Resident #1] around 12:30 a.m. to check and change her, the resident was in her bed and okay at that time. She stated Staff K, LPN had just been in the room and administered medication to the resident. During an interview on [DATE] at 11:06 AM, Staff O, CNA, stated she had worked on all of the resident halls at the facility, usually on the night shift. When they are short staffed the CNA's have to take two halls, they can't hear call lights from the other Nurse's Station for the other hall they are also assigned to. On the night of [DATE] she was assigned to the CCDI Unit, by herself. She had a medical emergency that night and had to go to the emergency room , she thought it was around 3:30 AM. Staff K, LPN had to relieve her because they were so short staffed, the aides were already doubled up on halls that night. During an interview on [DATE] at 12:41 PM, the Investigator from the Medical Examiner office stated he went to the facility on the night of the residents death on [DATE]. He stated the resident was on her back, on a mattress on the floor, with a pillow under her head. The resident was dressed in a blue shirt and covered with a blanket. The Investigator stated staff reported to him the resident was found dead, and did not tell him she was found face down or had been moved. The payroll report and staff interview indicated night shift that started at 10 PM on [DATE] and ended at 6 a.m. on [DATE]. The Daily Night Shift Staffing Assignment Sheet for the 10 p.m. on [DATE] to 6 a.m. on [DATE] night shift revealed: Staff L, LPN, assigned to the 300, 600 and 700 Halls. Staff K, LPN, assigned to the 400 and 500 Halls, and the facility's locked CCDI Unit (Chronic Confusing or Dementing Illness). Staff J, CNA (Certified Nursing Assistant) assigned to the 300 Hall Staff P, CNA assigned to the 400 Hall. Staff M, CNA assigned to the 500 hall with notation went home at 2 a.m. Staff H, CNA assigned to the 600 Hall, with notation went to 500 at 2 a.m. Staff I, CNA, assigned to the 700 Hall, with notation covered 7 and 6 at 2 a.m. Staff O, CNA, assigned to the CCDI Unit. A payroll report for the staff that worked on the night shift on that night revealed Staff M clocked out at 1:57 AM, Staff O clocked out at 3:48 AM, with additional clock ins indicated for the shift. During an interview on [DATE] at 6:29 PM, with the DON and Staff S, ADON, and informed that Staff O clocked out at 3:48 a.m. on [DATE], the DON stated Staff O was a smoker, she probably clocked out for her break and forgot to clock in when she came back. When informed that Staff K reported she contacted Staff S on the [DATE] to [DATE] night shift with requests for assistance due to short staffing, the DON stated there was no proof that Staff K called for assistance, then Staff S stated they called her to notify her of the resident's death, but never asked for assistance. A Written Reprimand in Staff S's personnel file dated [DATE] stated on [DATE] - [DATE] the employee was called two times with concerns over lack of staff on the night shift. Staff S directed the CNA's to split hallways. The immediate supervisor had directed multiple times that the CNA's were not to split halls on the night shift. The employee failed to fulfill their on-call responsibilities and this potentially puts resident care at risk.

Based on clinical record review, staff interview, Facility Investigation Review and facility policy review the facility failed to thoroughly and timely investigate a resident's allegations of mean/aggressive treatment and involuntary seclusion by a facility staff member, failed to separate residents from an alleged perpetrator after staff had become aware of allegations, and failed to maintain thorough documentation regarding investigation into the resident's allegations for one of four residents reviewed for abuse (Resident #385). This deficient practice resulted in an Immediate Jeopardy to the health and safety of a resident who resided at the facility. The Facility had a census of 140. Findings Include: On 10/4/23 at 3:55 PM, the Iowa Department of Inspections, Appeals, and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The Immediate Jeopardy had a start date of 5/16/23. The facility staff removed the immediacy on 10/5/23 at 2:55 PM, and decreased the scope J to D level after the facility staff completed the following: 1. Staff member was immediately suspended, and terminated after investigation 2. All staff have been in-serviced on the abuse policies on the following dates: June 23, 2023, August 9, 2023, September 6, 2023 3. I have attached sign in sheets 4. All new hires are required to complete Iowa Dependent Adult Abuse training prior to working on the floor 5. HR audits employee files to ensure all staff are compliant with renewing adult dependent abuse training. 6. All resident admitted prior to 5/16/23 will be interviewed to determine if they have any concerns about abuse, and any negative findings will be investigated thoroughly. 7. All staff the that worked with employee will be interviewed to determine if they ever witnessed any abuse towards a resident from this employee. 8. Staff will be re-inserviced on abuse, abuse reporting, identifying abuse, beginning 10/4/23. 9. Staff will be in-serviced on actions to take until administrator/designee arrives including ensuring resident ' s safety, separate staff/residents, collect any evidence, calling 9-1-1 if appropriate. 10. The nurse is responsible for ensuring safety until administrator/designee can arrive. 11. The executive Director/Administrator, or designee conducts a thorough investigation which includes interviewing the resident, alleged perpetrator, any witnesses, residents that may have also been affected or witnessed, and staff that may have witnessed. 12. The Executive Director/Administrator is on-call 24/7 for any allegations of abuse. If the Executive Director is unable to be available a designee is responsible for any allegations of abuse. 13. All reports will be submitted within the timeframes outlined in the regulations regardless of time of day. 14. Please see attached training, on September 6, 2023, all staff were trained on grievances and abuse. The Quarterly Minimum Data Set (MDS) assessment for Resident #385 dated 07/05/2023 revealed the resident scored 8 out of 15 on a Brief Interview for Mental Status exam, which indicated the resident was severally cognitively impaired. The Investigation Summary, undated, and unsigned, revealed the following allegation: [Resident #385] filed a grievance with Social Services stating CNA (Certified Nursing Assistant) [Staff V] was mean to her. Stated she put her in room and told her not to come out. Stated she pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. She stated the CNA was very mean and unfriendly. The Section of the Investigation Summary dated 5/17/23 documented, Went to meet with resident. She states that yesterday a CNA got on my case. She states she threw me in my room. She states she was not hurt and has no injures. She does not remember the name of the CNA. When asked if she feels safe here she says she does, but she just hopes it doesn't happen again Encouraged R (resident) to let me know if there are any other concerns. She agreed. On 09/28/2023 a document titled, [Facility Name Redacted] Grievance was reviewed. It provided the following information: Resident # 385 Today's date 5/16/2023 Grievance heard by the Director of Social Services. Voiced by individual resident, therapy and activities. The grievance advised: Staff V, CNA, was very mean to resident. Put her in her room and told her not to come out. Pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. Resident stated the CNA was very mean and unfriendly. Review of the investigation provided by the facility lacked the schedule of employees who worked the same date and or shift as the alleged event, interview with other residents regarding Staff V interview with the resident's roommate, and information regarding availability of cameras in the area. The Investigation file lacked time cards to verify when Staff V had worked, as staff interviews conducted by the State Agency revealed conflicting dates of incident and when further action was taken. Interviews conducted by the State Agency regarding the alleged incident revealed staff members were aware of the resident's allegations prior to the DSS becoming aware (Staff X, Activities Assistant, Staff II, Activities Assistant at time of incident, Staff HH, Director of People and Culture). The Investigation Summary provided by the facility lacked interviews with Staff X, Staff II, and Staff HH who had been aware of the allegations prior to the Director of Social Services. On 09/28/2023 7:35 AM, the Executive Director, (ED), was interviewed. The resident had talked with the Director of Social Services,(DSS), about her concerns with CNA Staff V. The ED advised the resident had approached the DSS and told her she was afraid of the CNA. Resident reported she felt safe at the facility but not around that specific staff member. The Resident reported the CNA had abruptly pushed her wheelchair into her room and told her she couldn't come out of her room. A Facility Investigation was completed by the Executive Director. On 09/28/2023 at 8:00 AM an undated facility report titled Investigation Summary provided and narrated by the Executive Director/Administrator (ED), was reviewed. On 5/17/2023 Social Services gave grievance to the Executive Director. The report summarized an alleged incident with Resident #385 and Staff member V Certified Nursing Assistant (CNA), pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. R states CNA is mean and unfriendly. Corrective Action by facility: Staff V CNA, date of hire is 12/29/2022. The alleged perpetrator is currently suspended pending investigation. The report also advised the ED met with the Resident. The Resident reported yesterday a CNA got on my case. The Resident advised she threw me in my room The Resident reported she was not hurt and she does not have any injuries. She does not remember the name of the staff person. She advised she feels safe here and says she hopes it doesn't happen again. Conclusion-Per recommendation of the Executive Director, employee will be terminated. On 10/02/2023 11:58 AM, the ED reported there is not a time specified on the grievance filed by the resident as the facility felt the incident rose to the level of an abuse allegation and was treated it as such. On 10/02/23 05:55 PM.,the Director of Social Services (DSS), stated she was given the information for the grievance from another staff member. The DSS did not directly speak with or observe the Resident on the day of the incident. The DSS advised she wrote the information on a grievance form and put it in one of the Assistant Director of Nursing's (ADON) mailbox. The ADON brought the grievance and concern up the following morning in their daily meeting. On 10/03/2023 8:45 AM, the ED reported there are cameras near the lobby and front door but she is not aware if there are any cameras in the area where the incident occurred. The ED will follow up with this and get back with this Surveyor. The ED reported no cameras were reviewed during the facility investigation. The ED reviewed the resident's records and was unable to locate any documentation regarding any nursing assessment completed. The ED advised she talked to the resident the following day and asked the resident about the incident and she reported she was not in pain. The ED advised she does not believe she documented this anywhere. The Facility investigation also lacked interviews with other residents and other staff members. The Facility Assessment also lacked nursing assessment or documentation regarding the incident. There was no documentation that the Power of Attorney, family, or medical staff were notified of the incident. On 10/03/2023 at 10:08 AM., Staff X Activities Assistant stated she and a co-worker were gathering residents for an activity and went to the resident's room where they found the resident in her wheelchair. The resident looked confused and almost teary eyed, like a kid who got in trouble. The resident advised she needed to use the restroom and the CNA just pushed her into her room and left. That day and the next day the resident seemed to be looking over her shoulder. Staff X interpreted this as she was watching for the CNA that had put her in her room. That same day the resident stated she is mean to me, she told me I needed to stay in my room. On 10/03/23 at 10:56 AM., Staff HH Director of People and Culture (previously the Activities Director ) reported, what she could remember was the resident told one of my staff, either Staff X or Staff II and one of them came to me and reported that the resident shared she was pushed into her room and told her she couldn't leave. The resident was not coming out her room. 10/03/23 11:20 AM Email documentation was received from The Director of People and Culture and formerly the Activities Director. That email correspondence reads as follows: a. 5/17/2023 11:16 AM Email from the Director of Life and Community Enrichment sent to the Director of Social Services-Did you write a grievance up for Resident #385? Staff X mentioned she thought you did. She is still very upset about Staff V (CNA) being mean to her. The resident literally never complains or anything so it seem legit. b. 5/17/2023 1:21 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-I have not. I will today though. Unfortunately this seems like a very common occurrence. c. 5/17/2023 1:22 PM Email from the Director of Life and Community Enrichment to the Director of Social Services-With the staff member or Resident #385? d. 5/17/2023 1:22 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Staff member e. 5/17/2023 Email from the Director of Life and Community Enrichment to the Director of Social Services-That is a shame. When she was Agency working here she seemed great, but I have definitely seen a change. f. 5/17/2023 1:24 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Did the resident mention to you what Staff V did/said? I'm trying to recall what she told me yesterday. Something about she put her in her room and told her not to come out. Then something else. g. 5/17/2023 2:26 PM Director of Life and Community Enrichment sent to the Director of Social Services- Staff II and Staff X said she mentioned that she was bullying her and being mean to her and that this wasn't this first instance and that it happens every time she works. She mentioned she pushed her into her room and told her she couldn't come out. During an interview on 10/03/23 at 2:05 PM., with Staff II the current Activities Director reported she was involved with this incident with the resident. It was right before an activity event so it was between 1:00 and 1:30 pm. She was getting the residents from their rooms before the activity and Resident #385 was in her room and she wasn't acting normal. She appeared to be upset and when asked the resident said she had to stay in her room. When Staff II inquired about this the resident said the staff member got mad at her and said she had to stay in her room. The resident was able to point out the staff member the following day that reportedly told her she had to stay in her room. Staff II reported this information to her supervisor at the time. The Facility Policy titled Abuse, Neglect, and Exploitation dated April 2008 with the most current revised version dated January 2023 advised the following: It is policy of this community to take appropriate steps to prevent the occurrence of Abuse, Neglect and Misappropriation of resident property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately. 5. Investigation: a. Any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the administrator. b. The administrator, director of nursing, or designee will notify the appropriate regulatory. investigative, or law enforcement agencies immediately, in accordance with state regulations. c. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process. d. The investigation can include, but is not limited to: i. The name(s) of the resident(s) involved ii. The date and time the incident occurred i. The circumstances surrounding the incident iv. Where the incident took place V The names of any witnesses vi. The name of the person(s) alleged with committing the act

Based on interviews, clinical record review, facility policy review and facility investigation review, the facility failed to ensure a resident was not subjected to involuntary seclusion when a staff member had used verbal threats to impose the understanding to a resident that she was not allowed to leave her room. This deficient practice resulted in Resident #385 displaying behaviors of anxiety, tearfulness, and fear of the staff member that imposed the involuntary seclusion to the residents room for one of four residents reviewed for abuse (Resident #385). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of a resident who resided at the facility. The facility reported a census of 140 residents. Findings Include: On 10/4/23, the Iowa Department of Inspections and Appeals staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The Immediate Jeopardy had a start date of 5/16/23. The facility staff removed the immediacy on 10/5/23 at 2:55 PM, and decreased the scope from a J to a D level after the facility staff completed the following; a. All staff have been trained on June 23, 2023, August 9, 2023 and September 6, 2023 about how to report abuse b. Building administrator has her personal cell phone number listed on PCC to alert any staff working in the building to call Administrator immediately with any concern of abuse c. Grievances are reviewed in a timely manner, and any resident concerns are immediately followed up on, to prevent any abuse from occurring d. Involuntary seclusion is identified in the abuse policy, and staff have been trained. If a resident is crying, or told they should stay in their room by a staff person, another staff member should immediately intervene, ensure the resident's safety and notify the Executive Director or designee immediately. The Quarterly Minimum Data Set (MDS) assessment for Resident #385 dated 07/05/2023 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status exam, which indicated the resident was cognitively intact. The Investigation Summary, undated, and unsigned, revealed the following allegation: [Resident #385] filed a grievance with Social Services stating Certified Nursing Assistant (CNA) [Staff V] was mean to her. Stated she put her in room and told her not to come out. Stated she pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. She stated the CNA was very mean and unfriendly. The Section of the Investigation Summary dated 5/17/23 documented as follows; Went to meet with Resident#385. She states that yesterday a CNA got on my case. She states she threw me in my room. She states she was not hurt and has no injures. She does not remember the name of the CNA. When asked if she feels safe here she says she does, but she just hopes it doesn't happen again Encouraged Resident (R) to let me know if there are any other concerns. She agreed. Grievance Form dated 5/16/23 documented a grievance reported to the Director of Social Services was voiced from Resident#385, therapy and activities as follows; Staff V, CNA, was very mean to resident. Put her in her room and told her not to come out. Pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. Resident stated the CNA was very mean and unfriendly. The action plan resolution and date of resolution were left blank. On 09/28/2023 at 7:35 AM, the Executive Director, (ED), stated the resident had talked with the Director of Social Services,(DSS), about her concerns with CNA Staff V. The ED reported the resident had approached the DSS and told her she was afraid of the CNA. Resident#385 reported she felt safe at the facility but not around that specific staff member. The Resident stated the CNA had abruptly pushed her wheelchair into her room and told her she couldn't come out of her room. On 10/02/2023 at 11:58 AM, the ED advised there is not a time specified on the grievance filed by the resident as the facility felt the incident rose to the level of an abuse allegation and was treated it as such. On 10/02/23 5:55 PM, the Director of Social Services (DSS), reported she was given the information for the grievance from another staff member. The DSS did not directly speak with or observe the Resident on the day of the incident. The DSS advised she wrote the information on a grievance form and put it in one of the ADON's mailbox. The ADON brought the grievance and concern up the following morning in their daily meeting. On 10/03/2023 8:45 AM, ED reported there were cameras near the lobby and the front door but she was not aware if there were any cameras in the area where the incident occurred. The ED would follow up with this and get back. The ED reported no cameras were reviewed during the facility investigation. The ED reviewed the resident's records and was unable to locate any documentation regarding any nursing assessment completed. The ED advised she talked to the resident the following day and asked the resident about the incident and she reported she was not in pain. The ED stated she did not believe she documented this anywhere. There was no documentation that the Power of Attorney, family, or medical staff were notified of the incident. During an interview on 10/03/2023 at 10:08 AM., Staff X, Activities Assistant stated she and a co-worker were gathering residents for an activity and went to the Resident #385's room where they found the resident in her wheelchair. The resident looked confused and almost teary eyed, like a kid who got in trouble. The resident advised she needed to use the restroom and the CNA just pushed her into her room and left. That day and the next day the resident seemed to be looking over her shoulder. Staff K interpreted this as she was watching for the CNA that had put her in her room. That same day the resident stated she is mean to me-she told me I needed to stay in my room. During an interview on 10/03/23 at 10:56 AM., Staff HH Director of People and Culture (previously the Activities Director ) reported, the resident told one of my staff, either Staff X or Staff II and one of them came to me and reported that the resident shared she was pushed into her room and told her she couldn't leave. The resident was not coming out her room. On 10/03/23, review of Email documentation received from The Director of People and Culture and formerly the Activities Director revealed the following: a. 5/17/2023 11:16 AM Email from the Director of Life and Community Enrichment sent to the Director of Social Services-Did you write a grievance up for Resident #385? Staff X mentioned she thought you did. She is still very upset about Staff V (CNA) being mean to her. The resident literally never complains or anything so it seem legit. b. 5/17/2023 1:21 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-I have not. I will today though. Unfortunately this seems like a very common occurrence. c. 5/17/2023 1:22 PM Email from the Director of Life and Community Enrichment to the Director of Social Services-With the staff member or Resident #385? d. 5/17/2023 1:22 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Staff member e .5/17/2023 Email from the Director of Life and Community Enrichment to the Director of Social Services-That is a shame. When she was Agency working here she seemed great, but I have definitely seen a change. f. 5/17/2023 1:24 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Did the resident mention to you what Staff V did/said? I'm trying to recall what she told me yesterday. Something about she put her in her room and told her not to come out. Then something else. g. 5/17/2023 2:26 PM Director of Life and Community Enrichment sent to the Director of Social Services- Staff II and Staff X said she mentioned that she was bullying her and being mean to her and that this wasn't this first instance and that it happens every time she works. She mentioned she pushed her into her room and told her she couldn't come out. During an interview on 10/03/23 at 2:05 PM., Staff II the current Activities Director advised she was involved with this incident with the resident. It was right before an activity event so it was between one and 1:00 and 1:30 pm. She was getting the residents from their rooms before the activity and Resident #385 was in her room and she wasn't acting normal. She appeared to be upset and when asked the resident said she had to stay in her room. When Staff II inquired about this the resident said the staff member got mad at her and said she had to stay in her room. The resident was able to point out the staff member that reportedly told her she had to stay in her room. Staff II reported this information to her supervisor at the time. The Facility Policy titled Abuse, Neglect, and Exploitation dated April 2008 with the most current revised version dated January 2023 advised the following: It is policy of this community to take appropriate steps to prevent the occurrence of Abuse, Neglect and Misappropriation of resident property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in a serious bodily injuring, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term are facilities), in accordance with State law through established procedures. Further, The Community investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator or his or her designated representative, and to other officials in accordance with State law, including to the State Survey Agency. The facility policy documented under the sub title Definitions as follows; Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 45338 On 10/4/23 at 2:25 PM, when queried whether Resident #385 could self propel in her wheelchair, Staff BB, Certified Nursing Assistant (CNA) responded she did not think so, and further explained she had never seen the resident do it. Staff BB explained she would always push her back to her room when she came in. 47336 During an interview on 10/4/23 at 2:46 PM, Staff DD, CNA (Certified Nurse Aide) queried if she knew Resident #385 and she stated yes. Staff DD asked if the resident self propelled or if she needed push in her wheelchair throughout the building and she stated they always pushed her everywhere. During an interview on 10/4/23 at 3:09 PM, Staff EE, CNA queried if she knew Resident #385 and she stated yes, the resident was really nice and didn't really talk much. Staff EE asked if they resident moved around herself and she stated the resident was heavy and really weak and she had trouble when she rolled her. Staff EE asked if the resident self propelled herself in the wheelchair and she stated she didn't recall the resident ever moving her feet by herself and never self propelled. Staff EE asked if the resident ever stated issues with other CNAs and how they treated her and she stated no, she didn't remember that, she stated the resident quiet and didn't talk much, and mainly smiled. During an interview on 10/4/23 3:43 PM, Staff FF, CNA queried if she knew Resident #385 and she stated yes. Staff FF asked if the resident ever self propelled in her wheelchair and she stated she couldn't remember but they always took her to supper in her wheelchair. Staff FF stated the resident used a stand lift and she assumed she didn't move herself around too much. During an interview on 10/04/23 at 07:30 PM, Staff E, CNA queried if she knew Resident #385 and she stated yes. Staff E asked if she propelled herself in the wheelchair and she stated Resident #385 used a stand lift and they always pushed her in the wheelchair.

Based on observation, interview, and record review the facility failed to ensure adequate supervision for residents with a known history of falls, failed to ensure residents were safely transported and transferred via wheelchair and/or Hoyer lift for five of nine residents reviewed for accidents (Resident #26, Resident #48, Resident #60, Resident #84, Resident #99). This deficient practice resulted in increased pain, hospital transfer, staples to the back of the head, surgical repair of a hip, a new wound, and bruising. The facility reported a census of 140 residents. Findings include 1. The Admission Data Set (MDS) assessment for Resident #26 dated 7/26/23 revealed the resident scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Per this assessment, Resident #26 had falls in the last month prior to admission, entry, or reentry, unable to determine was selected for falls in the last two to six months prior to admission, entry, or reentry, and the resident did have a fracture related to a fall in the six months prior to admission, entry, or reentry. The Care Plan dated 7/31/23 documented, SAFETY/FALLS: I am at risk for falls AEB (as evidenced by) personal history of a fall resulting in left radial and ulnar fractures. Interventions per the Care Plan documented the following: a. (Intervention dated 8/8/23): 8/04/23 fall intervention: pillow to be placed along my side when I am in bed. b. (Intervention created 8/14/23): 8/11/23 fall intervention: Do not bring to meals unless food is ready or family is present. c. (Dated 7/31/23):Ensure floor mat is next to my bed when I am in bed. d. (Date 8/15/23):Floor mat to be placed by my bed when in bed. e. (Created date 7/31/23): Bed in low position. f. (Created date 7/31/23): Check for unmet needs: pain, toileting, hunger, thirst, temperature g. (Created date 7/21/23): Do not leave unattended in the Bathroom. h. (Created date 7/31/23): Encourage / Assist with non-skid shoes / socks i. (Created date 7/31/23): Ensure environment is free of clutter. j. (Created date 7/31/23): Fall review per facility protocol. k. (Created date 7/21/23): Have commonly used articles within easy reach. The resident's After Visit Summary dated 8/9/23 from the orthopedics department of [Hospital Name Redacted] documented the following, noted to occur prior to the resident's admission to the facility: [Resident #26] is an [age redacted] year old female with a medical history significant for diabetes and dementia who sustained a ground level fall in the bathroom on 07/08/2023. She sustained a traumatic subarachnoid hemorrhage, radius/ulna fracture, and T10 anterior vertebral body compression fracture. The Fall Risk Screening Tool dated 7/21/23 revealed Resident #26 had 1-3 falls in the past 3 months, had diabetes, took narcotic, psychotropic, and antihistamine medication, and documented the following narrative per the Functional Status section: Pt is not steady without help, not able to use call light, is cognitively impaired. The Narrative Summary on the Fall Risk Screening Tool documented, Resident gets up without calling, does not use call light, is not steady without assistance. The resident's Admit/Readmit Tool dated 7/21/23 documented Resident #26 alert to person only, and included the following narrative: Pt is confused will make weird comments about going home or babies being taken care of. The Baseline Care Plan dated 7/21/23 locked 7/30/23 identified Resident #26 as a fall risk. The Comprehensive Nursing Note dated 7/23/23 at 12:05 PM documented, in part, Ability to Express Ideas and Wants / Needs - Rarely / Never Understood Up and down trying to get up out of the chair and than the bed this AM. Back pain so pain medication for pain and anxiety given. Calling out the husband's name multiple time and trying to go search for him multiple time before he arrived. The Comprehensive Nursing Note dated 7/26/23 at 10:11 AM documented, in part, Ability to Express Ideas and Wants / Needs - Rarely / Never Understood Resident speech unclear and has difficulty communicating wants and needs at this time. The eMAR-Administration Note dated 7/27/23 at 10:14 PM documented, Anxious all shift, out of bed several times per self and walking in hallway. 1:1 (one to one) most of the evening after her husband left. The Comprehensive Nursing Note dated 7/29/23 at 4:39 PM documented, Ability to Express Ideas and Wants / Needs - Rarely / Never Understood Does not follow instructions or cues. Frequent cueing and assistance provided. The Late Entry Nurse Progress Note dated 8/4/23 at 11:08 AM documented, CNA (Certified Nurse Assistant) doing rounds around 0740 to get everybody up for breakfast, and found Pt on her knees with RUA (right upper extremity) on the mat as well in Pt's room. Nurse was next door by that time, CNA called nurse says she's on the mat. Pt transferred to wheelchair, ROM (range of motion) and VS (vital signs) assessed right away. ROM intact on BLE (bilateral lower extremities), RUA intact as well. VS WNL (within normal limits). ADON (Assistant Director of Nursing) notified, POA (Power of Attorney) notified, PCP (Primary Care Provider) faxed to make aware. Pt then taken to nurse's station after getting dress and uses the restroom. Pt continued to be monitored and offered 1:1 for fall intervention. The Incident Report dated 8/4/23 at 7:50 AM revealed the resident's fall was not witnessed. The IDT (interdisciplinary team) Post Fall Review dated 8/8/23, locked 8/13/23 for a fall which occurred on 8/4/23 at 7:50 AM documented the following per the new preventative intervention section: Fall discussed with members of IDT. Pillow to be placed along my side while in bed. The Incident Progress Note dated 8/8/23 at 11:54 PM documented, CNA [Name Redacted] observed Resident on floor in bedroom at 2240 (10:40 PM), laying supine on fall mat next to bed. [Name Redacted] left room and came to Nurse's station and requested assistance from Nurse. Both staff members returned to [Room Number Redacted] immediately. Nurse able to complete frontal body assessment with no new injuries noted. Resident denied pain initially, however once Resident attempted to sit up, voiced pain 'really bad in my back.' Resident laid back down and with support of staff, cautioned to remain in supine position. Resident frequently moving arms and legs, Nurse notes physical s/s (signs/symptoms) of spasms/pain in back during movement. V/S (vital signs) 98.0 - 179/82 - 92 - 95% RA - 98.0. Nurse notified POA (Power of Attorney) at 2250 (10:50 PM) of fall with possible injury, who requested Resident be seen by the ER(emergency room ) to see if any further injury occurred since initial fracture. 911 called by Nurse at 2258. Unit CNA sent to front to ensure ambulance is able to enter facility. Nurse in room with Resident and unable to leave room due to there being no other staff in unit. Nurse unable treat initial pain due to lack of staff/Resident not safe to leave alone while still on floor and moving her limbs in ways that are obviously causing her pain. EMTs (Emergency Medical Technicians) arrived to facility at 2210 (10:10 PM). Resident blackboarded at this time. Resident left facilityvia EMTs at 2230. Nurse called report to [Name Redacted Emergency Department] at this time. POA called facility at 2345 and notified that Resident was OOF (out of facility) and en route to hospital. Again Nurse explained that once Resident is out to hospital all updates should come from [Name Redacted] as they will be providing care for Resident. The Incident Report dated 8/8/23 at 10:40 PM revealed the resident's fall was not witnessed. The IDT Post Fall Review dated 8/9/23, locked 8/13/23 for a fall which occurred on 8/8/23 at 10:40 PM documented, Pt incontinent of bladder. Needs assistance with transfers. Unable to use call light independently. The preventative intervention section documented, Fall discussed with members of IDT. Pt sent to ER (emergency room ) for evaluation. Contour mattress will be placed on bed. The Nurse Progress Note dated 8/9/23 at 2:24 AM documented, Resident returned to the facility at this time via EMTs (Emergency Medical Technicians). No new orders noted. Resident resting in bed without s/s (signs/symptoms) of pain at this time. CT of Head completed in ED (emergency department) with clear results, no s/s or concern of head injury from unwitnessed fall on 8/8/23. POA called at this time and notified of return to facility. The Order Progress Note dated 8/11/23 at 11:58 AM documented, Sustained witnessed fall loc at the dining room. Following order received via verbal order following post fall assessment. POA , Spouse, Assistant Director of Nursing (ADON), PCP aware. Order: Send to ER for further evaluation. And skin laceration. The Nurse Progress Note dated 8/11/23 at 12:01 PM documented by Staff Z, Registered Nurse (RN), revealed the following: Pt fell on the floor, witnessed by fell ow Patients nearby @approx. 1050AM. According to witnessed, pt stood up and tried to make a step when immediately leaned sideway to the right and fall. When CNA came around, Pt already on the floor. Pt assisted on her back slowly, with neck sensitively being moved slowly. Some drainage of blood noted on back of head, pressure in placed, VS (vital signs), ROM (range of motion) assessed. No significant findings on ROM, VS BP (blood pressure) 176/91, T 97.7, P 97, R 20, O2 98% RA (room air). Pt alert to self (baseline). Order obtained, 911 then was called. Pt then picked up via emergency medical vehicle on a stretcher. Report given to ER nurse. The ED Provider Note, date of service 8/11/23 at 1:00 PM, HPI (History of Present Illness) patient is an [age redacted]-year-old female who is a poor historian secondary to her dementia. Patient comes in with a fall neck collar and body brace in her left arm in a cast complaining of a fall that happened when she was trying to get up she fell backwards hitting her head. Patient's other injuries had occurred 2 days prior. She had been transferred to the [Hospital Name Redacted] in [City Name] at that time. Patient does have a small parenchymal hemmhorage to her brain. The ED Note Addendum dated 8/11/23 at 1:04 PM documented, Three staples placed in laceration in the back of the head by provider. The Nurse Progress Note dated 8/11/23 at 10:08 PM documented, in part, Pt (patient) returned from ED about 1600 (4:00 PM). Pt alert to self and vitals are stable. Pt had some signs of discomfort this shift and scheduled medication given. The Health Status Note dated 8/11/23 at 11:10 AM documented, Phoned POA regarding fall incident this AM. POA voiced concerns of brain bleed of Pt that happened in the past, stated She had front brain bleed last July, we need to watch it. When called [Hospital Name] emergency room , Nurse at the ER are aware of the head bleed history in the past, ER nurse stated, her head bleed has not increased in size, it is still there but it has not affected with this fall and that no head injury noted other than laceration in the back of head, 3 staples in placed. Phoned POA to f/up (follow up) w (with) any head injury that according to ER report, there is no brain/head injury other than the small laceration on the back of head, and that three staples in placed and that staples will come with an order to be removed in 10 days.POA voiced understanding. The IDT Post Fall Review dated 8/11/23, locked 8/15/23, for a fall which occurred 8/11/23 at 10:50 AM documented the resident had a fall in the dining room, was sitting in her wheelchair prior to the fall, and sustained a laceration to the back of the head. The Post Fall Findings section documented, Pt was out in dining room sitting in wheelchair. She was witnessed to stand up tried to make step when she immediately leaned sideways to the right and fell . The fall prevention interventions section documented, Fall discussed with members of IDT. Do not bring to dining room unless meal is ready or family member present. The Nurse Progress Note dated 8/13/23 at 11:24 AM documented, F/up (follow up) fall 8/11/23- VSS 98.6-98-20-142/85. No changes in LOC (level of conciousness) or signs/symptoms of pain. Resident alert to self and family only as per baseline. Staples to posterior scalp laceration intact. No signs of pain. Cast LUE (left upper extremity) dry and in place. CMS intact. On 10/3/23 at 10: 27 AM, Staff X, Activities Assistant, explained Resident #26 had dementia really bad. Per Staff X, the resident was in the wheelchair and she looked lost. Staff X also explained the resident would lay in her bed and would be squirming. On 10/3/23 at approximately 10:50 AM, when queried about Resident #26's cognition, Staff Y explained the resident was not cognitively intact. Per Staff Y, the resident used a wheelchair. When queried if the resident tried to get up independently, Staff Y explained she did not remember over here (certain part of facility), and explained in a different part of the facility the resident would roll out of bed. On 10/03/23 at 1:31 PM, Staff Z Registered Nurse (RN), who had authored the resident's note on 8/11/23, explained the following for Resident #26: Staff Z explained the resident could not verbalize needs but could sometimes say she was in pain. Staff Q explained the resident could verbalize needs to use the restroom and could answer questions not accurately. Per Staff Z, the resident had Alzheimer's. Staff Z explained she did remember frequent falls, and did a lot of interventions, did a thick mattress on floor, and resident crawled and wanted to go home. Per Staff Z the resident was very restless when her husband was not around, and always looked for him when not around. Staff Z explained that was when the resident wanted to get out/go home. When queried if she was present when the resident fell , Staff Z explained the resident had falls in [certain section of building], and when had a fall she (Staff Z) was working the resident was gotten up a little late and had fallen the night before. Staff Z explained they had the resident up at the nursing station, it was time for lunch, the resident was taken for lunch and stood up and fell . Per Staff Z, she stood up and fell , and all of a sudden happened very very quickly. Per Staff Z, even when staff were around couldn't get to her fast when she stood up, she fell . Staff Z explained she had to send the ER because of a laceration to the back of the skull. Staff Z explained the resident had a skin tar when she had fallen and hit her head. Staff Z explained the resident had stitches done, and returned pretty much back to baseline, very restless. When queried if she saw the resident fall when she got the head laceration, Staff Z responded yes, she stood up and fell ,and she didn't even make a step. Per Staff Z, the resident stood up, lost her balance, and fell . When queried if she was ever on a 1:1, Staff explained yes. Per Staff Z, when she was a 1:1 someone needed to be with her next to her. Per Staff Z, a lot of the time when there was a 1:1 they had that person supervise 100%, and in Resident #26's case Staff Z explained someone needed to be sitting next to her. When queried if the resident had been on 1:1 before the head laceration, Staff Z responded yes. When queried if the resident was on 1:1 the day she got the head laceration, Staff Z responded yes. Per Staff Z, when the resident was taken to the dining room, everybody needed to be brought in the room, and that is when it happened. Staff Z explained nobody was there next to her (Resident #26), and Staff Z explained the facility was so short staffed that day. Per Staff Z, two aides took turns keeping an eye on her, and for that moment when needed to bring everyone down, the resident got left out for seconds, stood up, and fell . Staff Z explained she was even there as well as she needed to give medication to somebody, and was a little far to get to the resident to prevent her from falling. Staff Z explained it would be ideal if enough staff to be a 1:1 with her to be with her the time she was up. On 10/03/23 at 1:45 PM, Staff Z explained explained it seemed like CNA staff were burnt out, something like that, due to short staffing. Staff Z explained in that situation where she had fallen Staff Z did voice needed another person to be with her. Staff Z explained she was thankful the resident was asleep and wasn't restless. Staff Z explained the resident did not get up until 10. Staff Z explained she needed another staff here to work with her so that she could accommodate restless residents. Per Staff Z, prior to report the aide said the resident had not slept and was up all night until 3 in the morning. Staff Z explained most of the time she worked the resident hadn't slept and was very restless. On 10/4/23 at 2:52 PM, Staff DD, CNA explained the following about Resident #26: Per Staff DD, the resident always wanted to try to get up our of bed or stand up out of wheelchair. Staff DD explained there were times when herself and [redacted] would visit, and there were times the resident would be put in the dining room unsupervised. Staff DD explained one time the need to hurry up to her side and tell her to sit down as no one was around the resident. On 10/4/23 at 3:50 PM, Staff FF, CNA explained the following about Resident #26: Per Staff FF, when the resident first moved in she was pretty restless, and was pretty quiet. Staff FF explained towards the end the resident was kind of restless again. On 10/5/23 at 12:48 PM when queried about one to one supervision, the DON explained mostly in [dementia area] the facility tried to staff three and an activity aide. Per the DON, if having behaviors, up and down, they tried to get that person with them. The DON explained she had only seen it twice since she started. The DON also explained hospitality aides were utilized sometimes. Per the DON, the hospitality aids were only at the facility certain hours. The DON explained they knew Resident #26 started in a [certain part of the facility], and ended up long term care. Per the DON, Resident #26 had full blown dementia and should have been in the [dementia area]. When queried about stopping 1:1, the DON explained it would not be stopped if they were still a fall risk, unless behaviors adjusted, or a cause was determined. 2. The MDS for Resident #99 dated 4/17/23 revealed the resident scored 4 out of 15 on a BIMS exam, which indicated severe cognitive impairment. Per this assessment, the resident had not had falls since admission, entry, reentry, or the prior assessment. The Care Plan created 3/31/23 initiated 4/12/23 for Resident #99 documented SAFETY/FALLS: I am at risk for falls AEB (as evidenced by) personal history of a fall resulting in right hip fracture. Interventions per the Care Plan documented the following: a. 10/3/23- 10/2/23 fall intervention: implement standing order for bowel regime. b. 4/02/23 fall intervention: floor mat placed next to bed. c. 4/04/23 fall intervention: keep in common area when restless. d. 5/10/23 0015 fall intervention: Offer to bring me to the common area when I am restless. e. 5/10/23 0645 fall intervention: request UA. f. 5/14/23 fall intervention: Third shift staff to offer AM cares in the morning. g. 6/06/23 fall intervention: request order for UA. h. 7/18/23 fall intervention: staff will redirect me after family visits. i. 7/22/23 fall intervention: Contour mattress placed j. 9/22/23 fall intervention: med review completed. k. Fall intervention for 7/13/23: Dysem to WC. l. 3/31/23: Assistive Device (grabber, toilet seat riser, bathroom bars) m. 3/31/23: Bed in low position. n. 4/4/23: Call light positioned for easy access. o. 3/31/21: Check for unmet needs: pain, toileting, hunger, thirst, temperature p.3/31/23: Do not leave unattended in the Bathroom. q. 4/4/23: Ensure environment is free of clutter r. 4/4/23: Fall review per facility protocol s. 4/4/23: Have commonly used articles within easy reach. The Admission Summary/Move In Note for Resident #99 dated 3/30/23 at 5:32 PM documented, admitted from [Hospital Name Redacted] at 1330 (1:30 PM), transferred via ambulance, accompanied by EMT's (Emergency Medical Technicians] Admitting dx:: Right hip fx (fracture) Assessment overview:: See assessment tab. The Fall Risk Screen for Resident #99 dated 3/30/23 documented the resident had three or more falls in the last 6 months, was at risk for falls, and documented, Pt is a 1:1, family at bedside at this time. The Behavior Progress Note dated 4/1/23 at 10:33 PM documented, [Resident #99] having increase agitation and restlessness this PM, was noted to be up in room transferring self from bed to chair. Repeatedly stating she wants to go home. 1:1 most of the evening. Currently sitting in lounge area looking at magazines. The Nurse Progress Note dated 4/2/23 at 9:38 AM documented, approx. 0905 (9:05 AM) pt was found on floor next to bed, cna (certified nurse assistant) came and got this nurse, upon arrival, pt was sitting on her buttocks leaned back on bed. Pt R (right) leg was rotated inwards, pt was in extreme pain, pt was two person lifted while supporting leg into bed, bed was in the lowest position. VS (vital signs) were obtained by CNA, nurse immediately called 911 for EMT (emergency medical technician) services. Pt son [Name Redacted] arrived while ems (emergency medical services) was assessing pt, he also notified pt husband, they had verbalized that they would not hold room, due to pt possibly having to be readmitted to HOSPITAL for reFX of Rt hip. Ems took pt to [Hospital Name Redacted] left building approx. 0925 (9:25 AM) . Son took pt belongings upon leaving facility. Ed nurse was given full report approx0934 (9:34 AM). The Incident Report dated 4/2/23 at 9:05 A documented per the Notes section, Pt injury was related to hip fx (fracture), dislocation was a possibility send to ed for further evaluation. The Other Information section documented, pt has dementia is a fall risk. The Nurse Progress Note 4/2/23 at 9:51 AM documented, ADON (Assistant Director of Nursing) on call notified. Notified, that this nurse does not suspect pt (patient) rolled out of bed, but possibly attempted to stand up and fell on bottom, due to bed being so low to ground and in locked position. Pt had been restless prior to this nurse arriving for shift. Pt was also attempting to toilet self. Pt has dementia and does not make safe decision, pt is often a one on one due to this. The Nurse Progress Note dated 4/2/23 at 12:38 PM documented, Called ED (Emergency Department) to check on pt, ed nurse stated that they were able to reduce pt hip and pt will be coming back to facility sometime, Pt is being monitored as she was sedated at hospital. Ed nurse will call when pt is ready for DC (discharge). [Name Redacted] van driver notified that she will need picked up The Nurse Progress Note dated 4/2/23 at 4:06 PM documented, Pt returned to facility via medical emergency transport, on a stretcher assisted by two EMT guys. Pt's today's visit to ER (emergency room ) was d/t (due to) fall that resulted to closed dislocation of right hip. Hematoma of right hip noted .CT hip wo contrast of R hip unilat 2/3 views wo (without) contrast on R pelvis were performed. ED Dr. (doctor) dislocated lower extremity, profolol and zofran given prior. Pt is w family ATM resting in bed. Nurse manager notified of the return of Pt. The Nurse Progress Note dated 4/2/23 at 9:24 PM documented, [Resident #99] has been very restless and agitated this PM. Noted she did not return from ED (emergency department) with Abductor pillow and right foot appears externally rotated. Increased pain noted with repositioning, PRN (as needed) APAP (Tylenol) administered. Floor mat obtained and placed next to bed. Bed in lowest position and frequent checks completed. IV remains in right antecubital area. Attempted to remove and she became irritated and started hitting. Will try again when she calms down. The Nurse Progress Note dated 4/4/23 at 11:45 PM documented, At 1910 (7:10 PM) CNA informed this nurse patient was on floor. Patient was sitting on floor end of bed. Bed in low position. Medmizer pushed away from bed. Call light within reach. Gripper socks on. Patient unable to give clear description. Alert and oriented x1 per baseline. Was able to communicate she was hot. This nurse asked patient if she needed to use bathroom and patient stated yes. Patient last toileted at 1730 (5:30 PM). Right leg rotating in per normal. Dr. [Name Redacted] aware of this and getting further x-rays tomorrow. Neuro's WNL (within normal limits) and started per facility protocol. Patient denied hitting head. No bumps or bruises noted. Vital B/P (blood pressure) 170/76, pulse 124, respirations 20, temp 97.1. Vitals retaken at 1925 B/P 141/88, P (pulse) 122, resp 18, temp 98.1. Patient denied pain time of fall.Leg immobilizer placed on right leg. Patient was assist x3 with gait belt into wheelchair and then toileted. Patient was brought out to common area for closer monitoring. [Name Redacted] PA-C notified at 1920 (7:20 PM). Family member [Name Redacted] notified at 1925 (7:25PM). The Incident Report dated 4/4/23 at 7:10 PM documented the following Description of Action Taken: Patient assisted to toilet where she urinated. She was then brought out to common area to be monitored. The Notes section documented, Patient denied pain time of fall. Patient then started moaning due to discomfort in right leg. PRN (as needed) Tylenol given with relief. Review of Hospital Records History and Physical (H and P) for an admitted and time documented as 4/6/23 at 1:00 PM documented, Impression: Persistent dislocated right hip arthroplasty. Review of Hospital Records, preliminary results dated 4/6/23 at 3:03 PM, at revealed the resident had an xray of the hip unilateral 2/3 view revealed examination: right hip for indication of right hip pain. The Findings documented, There is a right hip hemiarthroplasty with dislocation. The Plan section documented, Dislocation of right hip arthroplasty-failed reduction in the emergency room .Plan is for right hip revision most likely Saturday afternoon. Review of H and P-Encounter Notes from Hospital Records for date of service 4/7/23 at 7:26 PM documented, This is an [age redacted]-year-old female with past medical history of dementia, atrial fibrillation on Eliquis, CVA, osteoporosis, hypertension who presented to the ED from [Name Redacted] skilled nursing facility with fall found to have dislocated right hip prosthesis. Patient recently underwent right hip hemiarthroplasty on 3/27 with Dr. [Name Redacted] for displaced right femoral neck fracture following a fall. She then represented on 4/2 after a fall and found to have dislocation of prosthesis which was successfully reduced in the ED and she was discharged back to [Facility Name Redacted]. Reportedly, patient sustained another fall on 4/4 and was again found to have dislocation of right hip prosthesis, reduction in the ED was unsuccessful. Case was discussed with Dr. [Name Redacted] who recommended transfer to [City Name] for revision. Review of the Orthopedic Consult present in Hospital Records, filed 4/8/23 at 9:47 PM, documented, in part, the following: She sustained a displaced right femoral neck fracture approximately 2 weeks ago and had an uncomplicated hemiarthroplasty. This was then complicated by dislocation several days later, which was reduced in the emergency department and then complicated by a secondary dislocation which could not be reduced in the emergency department .After waiting 48 hours from her last Eliquis dose, I recommended to the family that the patient return to the operating room and have a revision arthroplasty and conversion to total hip arthroplasty in order to try achieve pain relief as the patient does have significant crying out in pain with any attempt of motion or movement. The Nurse Progress Note dated 5/10/23 at 12:15 AM documented, CNA's went to do rounds and found patient lying on the floor on her left side next to her bed. Bed in low position, gripper socks on. Resident unable to tell this nurse what happened. This nurse asked patient what happened and if she was ok and she replied I'm in heaven. Patient lying next to bed with head by the foot of the bed on her left side. No signs of injury to head, no bumps, redness or bleeding noted to body. Patient denies any pain. Speech is clear. Able to move all extremities without pain. Vitals obtained. Patient assisted back in bed. Notified on call ADON (Assistant Director of Nursing) and faxed Dr. [Name Redacted] to notify. Will have dayshift nurse notify family. The Nurse Progress Note dated 5/10/23 at 6:44 AM documented, CNA alerted the nurse to come to her room. She was sitting on the bathroom floor taking off her brief. Nurse asked her if she was hurt and did she loose her balance and she stated she did not fall. Nurse and CNA assisted her to use the bathroom. She hadno bruising and no injury noted. Vitals were obtained. Nurse will contact MD regarding her falls this am and monitor her neuro. The Incident Report dated 5/10/23 at 6:45 AM documented the following Incident Description: She was on the bathroom floor trying to take off her brief. The Resident Description section documented, She remarked I did not fall I am just changing this as she was holding a brief. The Description of Action Taken ecion documented, Assisted her to use the bathroom, assessed for injury and checked vitals. The Incident Report dated 5/10/23 at 12:15 AM documented, Nursing Description: CNA's went to do rounds and found patient lying on the floor on her left side next to he bed. Bed in low position, gripper socks on. The Resident Description section documented, Resident unable to tell this nurse what happened. This nurse asked patient what happened and if she was ok and she replied Im in heaven. The Description of Incident documented, Patient lying next to bed with head by the foot of the bed on her left side. No signs of injury to head, no bumps, redness or bleeding noted to body. Patient denies any pain. Speech is clear. Able to move all extremities without pain. Vitals obtained. Patient assisted back in bed. The Incident Report dated 5/14/23 at 5:05 AM documented the following Nursing Description: Resident slide off her bed onto floor mat and on to floor. Resident scooted herself toward her bedroom entry door. Nurse found resident sitting on floor at 0505 (5:05 AM). The Resident Description section documented, I wanted to go to the restroom. The Late Entry Nurse Progress Note dated 5/14/23 at 5:50 AM documented, Resident was found sitting on the floor next to her bedroom door at 0505 by this nurse. Nurse asked resident what she was trying to do. Resident stated she wanted to go to the restroom. Nurse assessed resident, able to move all extremities well, no injuries, no complain of pain. Nueros intact, vitals as follow:117/51, 96.4, 98, 20, 96%. Grips equal and strong. Nurse and CNA assisted resident to w/c (wheelchair) and then toileted and changed resident and placed in a recliner on the lounge. Nurse faxed Dr. [Name Redacted] and texted ADON [Name Redacted] to inform of incident. Nurse notified oncoming nurse that family needs to be notified. The Nurse Progress Note dated 6/6/23 at 1:55 PM documented, Staff heard a noise, this Nurse notified Res was on floor of bathroom in another Res room. Noted Res on right side in fetal position grabbing back of her head. Res tearful at this time et reports pain to back of her head. Upon assessment noted small area of swelling et (and) redness to back of head. Also redness noted to tailbone area. Res had a previous rt (right) hip fx (fracture), gait appears to be the same, no increased pain noted upon standing Res. Neuro's initiated et wnl (within normal limits) at this time. This Nurse notified [Name Redacted Provider] of fall et injuries. Per CNA after getting Res off toilet she did buckle but this is not unusual for Res-reported this to [Name Redacted] also. Per [Name [NAME] [TRUNCATED]

Based on observation, record review, staff interview, and facility policy guidelines, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 1 of 26 residents reviewed (Resident #33). The facility identified a census of 132 residents. Findings include: 1. According to the annual Minimum Data Set (MDS) assessment tool dated 9/27/17, Resident #33 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assist of 1 staff for bed mobility, transfers, toilet use, and personal hygiene, and was occasionally incontinent of bowel. The resident demonstrated no mobility impairments or falls for this assessment period. A significant change MDS dated [DATE] revealed Resident # 33 had a BIMS Score of 1 (severe memory issues) and assistance with cares remained at extensive assistance of 1 staff. The MDS documented the resident experienced frequent bowel and bladder incontinence and one upper extremity impairment. The resident's [DIAGNOSES REDACTED]. The plan of care dated 10/07/15 and revised with a target date of 05/27/18, directed facility staff to assist with transfers and ambulation (walking) using a gait belt and a wheeled walker, ensure functionality of the bed alarm and chair alarm, anticipate resident needs, ensure visual appliances in place and shoes on when up. The care plan also directed staff to keep environment clutter free, and educate staff to assist the resident with ambulation and toilet use (08/17/16). A review of the (MONTH) (YEAR) MAR (Medication Review Record) revealed Resident # 33 received [MEDICATION NAME] (an antidepressant) 20 milligrams everyday and [MEDICATION NAME] 50 milligrams twice a day for hypertension. Both of these medications had the ability to have an effect on balance and ambulation. During cares on 04/24/18 at 09:54 A.M., an observation of Resident # 33's extremities revealed the resident's right arm displayed a partial contracture of the elbow. Resident # 33 could straighten the right arm three-fourths of the way. The right hand curled into the resident's palm, but could be straightened and each digit could be flexed. The resident ambulated with a side to side gait when assisted by 2 staff, a gait belt, and a wheeled walker. Staff A and Staff B (both Certified Nursing Assistants, or CNAs) assisted Resident # 33 into the bathroom, provided incontinence cares, and assisted the resident to the dining room table. Staff B sat down and supervised Resident # 33's breakfast meal. 04/24/18 10:27 AM , Resident # 33 sat in a recliner in front of the television with several other residents. Resident # 33 made no attempt to try to get out of the chair. A nursing progress note dated 11/8/17 11:25 P.M., documented a nursing assistant notified the nurse on duty Resident # 33 was found on the floor. The nurse documented the resident lay on the floor outside another resident's room with her legs extended and the right arm holding onto the left arm. The note described the area as uncluttered and the floor dry. Resident # 33 wore shoes and the walker remained within reach. The nurse assessed the resident and completed neurology checks. Resident #33 reported pain in the upper left extremity when touched or raised. Staff assisted the resident to stand with a gait belt and assist of 2. A range of motion assessment revealed all extremities within normal limits. Resident # 33 went to the emergency room and upon return, staff placed the resident in bed with a shoulder immobilizer in place and the left arm propped on a pillow. According to the summary submitted to the Department by the facility dated 11/9/17 at 11:29 a.m., Resident #33 fractured her left clavicle when she fell . On 04/23/18 at 02:16 PM, Staff D (Certified Nursing Assistant), verified she worked the shift Resident #33 fell and broke her clavicle. She stated she was getting linens and towels for showers. The nurse told her to go and check on Resident # 33. She found the resident on the floor by room [ROOM NUMBER] surrounded by Staff E and F (both Certified Nursing Assistants). Staff D did not see the resident get up and ambulate by herself. During an interview on 04/24/18 at 06:47 AM Staff I (Licensed Practical Nurse) stated working days on the unit and did not work when Resident # 33 fell and fractured her clavicle. Staff I stated this resident did not try to get up by herself often. The staffing pattern on the unit included a nurse and 3 aides for days and evenings, and 1 less on nights. Staff I reported 14 residents lived on the unit that day. During a telephone interview on 04/25/18 at 03:46 PM Staff E (Certified Nursing Assistant) stated she attended to Resident # 33 the day of the fall and fracture. She stated several residents were restless that evening. One of the residents wandered around trying to find her shoes. Staff E went to assist Resident # 33 with a transfer, and Resident # 33 seemed determined to help the other resident to find her shoes. Staff E placed a wheeled walker in front of the resident just as another resident (in the half circle of recliners) tried to transfer from a wheel chair to a recliner by herself. Staff E told Resident #33 to sit back down while she went to assist the other resident who she thought might be in danger of falling. Staff E could not recall seeing any other aides in the area at that time. When she finished with the other resident, she went looking for Resident # 33 and found her on the floor by room [ROOM NUMBER]. Staff E reported Resident # 33 complained of shoulder pain. A review of the incident report for 11/8.2017 at 2:50 PM revealed staff found Resident # 33 on the floor by another resident's room with the legs extended and the right arm holding onto the left arm and no alarm sounding at the time of the accident. An assessment of the resident revealed pain in the resident's upper left extremity when raised, and staff transferred Resident # 33 to the emergency room for further assessment. A review of the staffing pattern and resident census on the day of Resident # 33's fall and fracture revealed the unit was staffed by 3 aides, and 1 nurse. In an interview on 04/23/2018 at 03:10 P.M., the DON (Director of Nursing) reported holding inservices for staff on gait belt use and use of alarms. The facility policy for Accidents/Falls with a revision date of 02/2014 directed staff to provide emergency care, neurological observations if needed, and record a factual account of what occurred, with each incident investigated to determine the cause and prevent further injuries. ·

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent falls for one resident (Resident #1). The sample consisted of 4 residents and the facility reported a census of 133 residents. Findings include: 1. Resident #1 had a quarterly Minimum Data Set (MDS) assessment with a reference date of 4/12/17. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 8 out of 15. (A score of 8 indicated the resident cognitive moderately impaired.) The MDS noted the resident required extensive assistance of one staff members for bed mobility, and transfers, and limited assist of one staff members for dressing, ambulation, toilet use and personal hygiene. The resident's [DIAGNOSES REDACTED]. The resident's Care Plan identified a focus area with an initiated date of 1/17/14. The focus area identified the resident at risk for falls related to history of falls, receives diuretic and [DIAGNOSES REDACTED] (low blood sugar) medication. The interventions included and directed staff to provide contact guard assist (CGA) of 1 staff member with gait belt and front wheeled walker (FWW) for ambulation and transfers. Staff were to encourage the resident to use grab bars in hallways and bathroom, ensure call light in reach, and encourage him/her to wait for assistance. The care plan directed staff to ensure resident is wearing shoes or slippers with nonskid soles when up, ensure resident was wearing visual appliance when up and keep environment free of clutter. The care plan indicated the resident used bed and chair alarms to alert staff of the need to rise. The care plan identified the resident used a floor mat alarm and directed staff to place this next to the bed (to alert staff of the resident's need to rise). Review of a form titled Fall dated 05/19/17 at 10:20 a.m. indicated nurse called to Resident #1's room due to resident found on bathroom floor. Upon entering several staffs in room, observed resident on the floor lying on left side of body and head facing outside of bathroom door. Resident alert and no distress but complains of pain when moved to his/her back. Resident able to move all extremities per self but when gotten up from the floor with gait belt and assist of 3 resident complained of pain of left hip. Resident transferred to bed and vital signs taken and recorded. Observed no outward rotation but some shortening present of left leg, bulging of left upper anterior thigh noted and resident complains of pain with movement of left leg. Certified Nurse Aide (CNA) staff member reported resident gotten up unassisted and to the bathroom and scattered stool on floor, toilet seat, and in toilet bowl. Resident not wearing shoes or socks and alarms did not sound. No head injury noted and no skin tears found. Resident alert and usual, speech is clear and respirations noted to be easy. The Progress Nurses Notes dated 5/19/17 at 5:04 pm indicated Resident #1 admitted to the hospital with [REDACTED]. Review of the Operative/Procedure Report dated 5/19/17 indicated Resident #1 sustained injury and diagnosed with [REDACTED]. The x-rays identified extensive vascular calcifications. The left hip had intertrochanteric hip fracture with mild displacement with slight avulsion of the lesser trochanter and lateral apex angulation. The surgery consisted of open reduction, internal fixation of left hip with nail fixation. Review of Progress Notes dated 5/23/17 revealed Resident #1 readmitted to facility status [REDACTED]. Further review of Progress Notes dated 5/28/17 at 11:21 am indicated around 11 am Resident #1's vital signs have ceased and at 11:04 am resident pronounced dead. Interview on 7/19/17 at 10:49 am with Staff B, Certified Nurse Aide (CNA) stated she came into work at 6 am on 5/19/17 and the off going shift reported they did incontinence cares for Resident #1 on last rounds around 4 am. Staff B stated she was assigned to care for the resident that day. Staff B reported on her 6 am rounds she went into resident's room and resident in bed, did not want to get up and resident checked and was not incontinent at that time. Staff B stated the next time she seen the resident was 8-8:30 am when she brought in the resident's breakfast room tray. Staff B indicated the resident still did not want to get up so she turned off the floor mat alarm and the bed alarm to set the resident up in bed with bed side table. Staff B indicated she placed the meal tray over the resident's lap. Staff B indicated she then left the resident's room without turning the alarms back on, that it was an honest mistake. Staff B indicated she then got busy answering call lights of other residents until 10 am when she went on ½ lunch break. Staff B stated she never went back and checked the resident after she delivered the meal tray. Staff B indicated she returned from break at 10:30 am and learned the resident had fallen. Staff B states staff are to ensure alarms are in place and on before leaving a resident and that is what she normally does. An interview on 7/19/17 at 10:28 am with Staff A, housekeeper stated she was in Resident #1's hallway passing out clean linens to residents the morning of 5/19/17. Staff A stated she passed the resident's room going up the hallway but did not see resident at that time. Staff A indicated a few minutes later she came back down the hallway and passed the resident's room and noted resident to on the bathroom floor. Staff A stated the resident's alarms did not sound. Staff A stated her supervisor in the hallway and she told her resident was on the floor and she went to get nursing staff. Staff A reported she was not in the resident's room that morning until she noted resident on floor. Interview on 7/19/17 at 9:55 am with Staff C, Certified Nurse Aide (CNA) stated she was returning from her break around 10:30 am and walking down Resident #1's hallway when housekeeping staff notified her resident is on the floor. Staff C stated she immediately went to resident's room and observed resident on bathroom floor siting on floor leaning to his/her left side. Staff C indicated the resident's bed alarm was on the bed and on the floor mat alarm was on the floor at the time of fall. Staff C reported no alarms were sounding. Staff C indicated the resident had gown on, no shoes or socks on and had removed his/he incontinent brief and it was placed in the trash can in the bathroom. Staff C stated stool on toilet seat, in toilet, and on the backside of resident. Staff C stated another staff member assisted her in cleaning the resident up while the nurse was summoned. Staff C stated the resident is non complaint with using call light for staff assist and will attempt to self-transfer. Staff C indicated after the nurse assessed the resident she assisted with transferring resident to bed. Interview on 7/19/17 at 9:09 am with Staff D, Licensed Practical Nurse, stated she was on break at time of Resident #1's fall in the break room when she was called to the floor due to the fall. Staff D indicated upon entering the resident's room she observed resident on the bathroom floor and stool noted on toilet bowl, toilet seat, and on floor. Resident had no shoes or socks on, gown on, and had no brief on. Staff D stated resident lying on left side and when positioned resident onto back complained of pain. Staff D indicated she assessed the resident while on the floor and resident able to move all extremities. Staff D reported with assist of 3 staff members and using a gait belt stood resident up and transferred resident to bed. Staff D reported the resident complained of pain and with further assessment she noted left leg shortening with bulging noted to upper left anterior thigh. Staff D reported she notified the Nurse Practitioner (NP) who is in the facility at the time and she came to the room and examined resident. Staff D stated the NP gave order to send the resident to the emergency room for further evaluation and treatment. Staff D resident transferred to emergency room via ambulance and admitted for treatment for [REDACTED]. Review of a Performance Management Form of Staff B dated 5/19/17 revealed Staff B was caring for Resident #1, she unplugged the alarms to set the resident up for breakfast and forgot to plug the alarms back in. Resident got up unassisted and fell .

Based on observation, record review, staff interviews and review of the facility policy and procedures, the facility failed to reposition and adequately off load pressure from bony prominences (sacrum, coccyx, ischial tuberosity's, heels, shoulders etc.) while seated in a wheelchair or lying supine in bed (Resident #4). The facility reported a census of 143 residents and the sample consisted of 10 residents with pressure ulcers. Findings include: 1. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 1/4/17. The MDS identified a BIMS (Brief Interview for Mental Status) score of 12. A score of 12 out of 15 reflected the resident had moderate impairment with cognitive functioning. Resident #4 included and required extensive assistance of 1 staff person for transfers, bed mobility and toilet use. The [DIAGNOSES REDACTED]. The MDS reflected the resident experienced bowel and bladder incontinency and required assistance with personal hygiene. The MDS identified the following definitions of pressure ulcers: Stage I is intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow stringy substance). May also present as an intact or open/ruptured blister. Stage III is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling. Stage IV is a full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The care plan identified a problem on 6/6/16 with the resident at risk for impaired skin integrity in regards to decreased mobility and incontinence. The interventions directed the staff to assist and remind the resident to reposition before and after meals, at the hour of sleep, and as needed. The resident is to have a blue heel suspension boot on the left lower extremity and on at all times except in the shower or therapy. The resident's skin should be inspected during cares. The resident will have a pressure reduction mattress and a pressure reduction wheel chair seat cushion. The licensed nursing staff should watch for infections and provide treatments as ordered. The February Physician's order sheet documented an order for [REDACTED]. The quarterly Braden Scale completed on 01/04/2017 with a score of 13 found the resident to be at a moderate risk for skin breakdown risks. The February 2017 Treatment Administration Record (TAR) documented the order for the treatment to the left ischium (Stage IV pressure ulcer), the left blue heel suspension boot at all times along with frequent repositioning of the left foot, and repositioning every 2 hours with minimal time in the wheel chair. Licensed nursing staff initialed the orders as being completed. The Weekly Akin Assessment sheet of 01/18/2017 documented a Stage IV pressure ulcer on the left ischium measured 0.5 centimeters (cm) by 0.5 centimeters by 1.4 cm in depth. The assessment of 02/08/2017 documented the Stage IV pressure area as 0.5 cm by 0.5 cm by 1.6 cm in depth. On 02/14/2017 at 9:23 A.M., Staff I (Licensed Practical Nurse) prepared to perform a treatment to the pressure ulcer. The resident laid supine on the bed. After repositioning the resident onto his/her side, Staff I removed the old dressing. The inner middle area of both buttocks displayed 0.5 centimeter abrasions with scant clear drainage. The left ischium displayed a clean, free of drainage and had a 0.5 centimeter tunnel opening. Staff I completed the treatment. Staff G and Staff H (both Certified Nursing Assistants) dressed the resident and used the mechanical lift to place her/him in a wheel chair. The chair had a pressure reducing cushion in the seat of the chair. Observations of positioning: On 02/14/2017 at 1:30 P.M., Resident # 4 laid in bed supine. On 02/14/2017 at 3:00 P.M., Resident # 4 still in bed in the supine position. On 02/14/2017 at 4:00 P.M., Resident #4 sat up in a wheel chair (cushion in seat) in the dining room. On 02/15/2017 at 7:30 A.M., Resident # 4 sat at the breakfast table in a wheel chair (cushion in seat). On 02/15/2017 at 8:45 A.M., Resident # 4 still up in the wheel chair (cushion in seat). On 02/15/2017 at 10:15 A.M., Resident # 4 coming down the 700 hall in a wheel chair. When asked, the resident stated not being out of the wheel chair since gotten up that morning. On 02/15/2017 at 11:15 A.M., Resident # 4 was observed in a wheel chair and stated had remained in the wheel chair all morning. The resident demonstrated how to lift up using the arms of the wheel chair to ease pressure every so often and lean to one side or the other. Resident #4 verbalized none of the staff ever showed or assisted him/her to do that. On 02/15/2017 at 2:35 P.M., Resident # 4 laid in bed in a supine position. When asked if staff ever placed him/her on side, the resident verbalized no--not really. On 02/15/2017 at 12:40 P.M., the Interim Assistant Director of Nursing (ADON) verbalized it would be her expectation that staff would follow the care plan for repositioning residents at least every 2 hours, especially the residents with pressure ulcers. Staff should be off loading pressure for Resident #4 when in the wheel chair and not wanting to lie down. The interim ADON stated Resident # 4 did not like to lie down all the time. The resident required instruction and reminders when to redistribute pressure of the buttocks while seated in the wheelchair. Many residents may not tolerate sitting in a chair in the same position for an hour at a time and may require a more frequent position change. The facility policy and procedures titled Pressure Ulcers/Skin Integrity/Wound Management dated as last revised on 9/13/11, directed the staff to do the following: Wound assessment upon admission: a head to toe skin assessment will be conducted by a licensed nurse. It is recommended that this assessment is completed within the shift that the resident was admitted ; however, it must be completed within 24 hours of admission. A tissue tolerance test (both lying and sitting) must be completed per state requirements and/or facility policy within 24 hours of admission. Assessment information should identify specific factors that might increase risk of pressure ulcer development or affect healing of a pressure ulcer. A Norton or Braden skin assessment will also be completed upon admission. All residents are preventatively placed on pressure reduction mattresses and cushions in wheelchairs based on the skin assessments. Those residents who represent a high risk will have further preventative interventions put in place. Appropriate turning and repositioning schedules will also be put in place per assessment. An initial/immediate care plan will be initiated. Assessment and treatments differentiate the type of ulcer and describe and monitor the ulcers characteristics. Care planning - the care plan should address prevention of any skin breakdown, including sheering or friction, repositioning or off-loading pressure relief equipment and the care and treatment to be provided to the resident for a pressure ulcer or non-pressure wound behaviors and preferences. Routine/ongoing documentation, measurements of all pressure ulcers and non-pressure wounds will be completed at least weekly and with any noticeable change by a licensed nurse.

Based on record review, resident and staff interviews and review of facility policy and procedures, the facility failed to provide adequate supervision and ensure a resident remained free from accident hazards (Resident #1). Resident #1 received an ice pack filled with hot water from a coffee maker. The ice bag with hot water burst and burned the resident. The policy and procedure directed the staff to not apply this type of pack to the skin of residents. The sample consisted of 22 residents and the facility reported a census of 139 residents. Findings include: 1. Resident #1 had a MDS (Minimum data set) assessment with a reference date of 11/30/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had no long or short term memory problem or an impairment of cognitive skills for daily decision making. The MDS identified Resident #1 as requiring extensive assistance of two staff member for bed mobility, transfer, and toilet use, and limited assist of two staff members for ambulation, and dressing. The MDS documented the resident with an admission date of [DATE] to the facility. The Care Plan dated 11/28/2016, identified the resident had recent back surgery. The Care Plan directed staff that the resident required assist of one staff member for dressing, transfers, ambulation, repositioning, bed mobility, and staff are to monitor for sign and symptoms of back pain, use pain scale as applicable. The Care Plan identified the resident as alert and orientated to person, time and place. The Incident Report dated 11/30/16 at 7:15 p.m. indicated a Certified Nurse Aide (CNA) notified the nurse that Resident #1 requested something for bladder spasms other than pain medication. The nurse went to the resident ' s room to ask what the resident wanted. Resident #1 requested a hot bottle for the lower pelvic area. The nurse told the resident the facility did not have water bottles. The resident told the nurse They have been using bags like in the hospital and putting hot water from the coffee machine in it . The nurse picked up bag that the resident acknowledged had been used. The nurse did what the resident requested and checked the bag for leaks and held it upside down to make sure it did not leak. The nurse then laid the bag on the resident ' s lower pelvic area below the abdominal fold. The nurse turned away and the resident grabbed the bag and the bag burst open. The nurse quickly grabbed cold washcloths from the bathroom and applied them to the resident ' s burned areas. The nurse than assisted the resident to the bed and had the resident lie on the non-affected side and continued to apply cold washcloths to the affected areas. The resident had pain so the nurse rushed to get pain medication and then called 911 to send the resident to the emergency room for treatment. Review of the Progress Notes, Nurses Notes, dated 11/30/16 at 8:57 p.m. identified at around 7:15 p.m. a CNA notified Staff F, Registered Nurse (RN) that Resident #1 requested something for bladder spasms other than a pain medication. Staff F went to the resident ' s room to ask the resident what they wanted. The resident told Staff F he/she wanted a hot water bottle for the lower pelvic area. Staff F told the resident the facility does not have hot water bottles and the resident responded They have been using bags like this in the hospital and putting hot water from the coffee machine in it . Staff F picked up the bag that the resident acknowledged and that is what is being used. The nurse did what the resident requested and checked the bag for leaks and held it upside down to make sure it did not leak. Staff F then laid the bag on the resident ' s lower pelvic area, below the abdominal fold. Staff F turned away and the resident grabbed the bag and it burst open. Staff F quickly grabbed cold washcloths from the bathroom and applied them to the resident ' s burned areas. Staff F than assisted the resident to the bed and had the resident lie on the non-affected side and continued to apply cold washcloths to the affected areas. The resident in pain so Staff F rushed to get pain medication and then called 911 to send resident to emergency room for treatment. Staff F notified the resident ' s family of incident and resident being transported to the emergency room . An emergency transport report dated 11/30/16 indicated a call was received from the facility at 7:27 p.m. The call identified Resident #1 had signs and symptoms of second degree burns to the left lower quadrant, left lower back and upper groin area. The resident stated was burned by hot water used for bladder spasms. The resident reported the hot water was placed in a Ziploc type of bag with a commercial type of sleeve that goes over the bag. The resident voiced extreme pain. The facility nurse reported the resident had been at facility 2 to 3 days to recover from back surgery. The nurse reported using hot water from a commercial coffee maker into a bag to apply heat to the resident. The nurse stated she administered pain medication and the resident needed transported to the emergency room . Emergency transport personnel further documented they found resident lying in bed on the right side wearing a hospital gown with second degree burns to the left lower quadrant, left upper pelvic/genital area, left upper thigh/buttock area, and left lower back buttock area. An emergency transport personnel was advised to bypass the local emergency room and transport to the nearest out of city burn unit. Review of Resident #1 hospital records with admission date of [DATE] and discharged on [DATE] revealed the resident was admitted with 7% of body burns to the abdomen and left thigh. This injury occurred on 11/30/16 around 7:00 p.m. when a heated water/bag broke and spilled hot water across back, lower abdomen and left thigh. The resident was admitted to the burn unit during the early morning of 12/1/16. Hospital course consisted of portions of the burns were full thickness and skin grafting performed on 12/9/16 and the grafts appeared to have good graft take. Resident was distressed about the circumstances of the burn and psych nursing visited throughout his/her stay. Resident did not to return to facility and choose another facility to be discharged to. Review of a facsimile sent from the facility to Resident #1 physician dated 12/1/16 indicated an incident happened last night with resident that resulted in burns to abdomen and upper thigh due to improper use of applying heat, using hot water in a disposable pack. Immediate education has been initiated with all nursing staff on proper use of heat packs and proper equipment. Review of the policy and procedures for Aqua K pad heating application, with a revision date of 4/2009, directed the staff to use with a physician's order [REDACTED]. The only heat treatment to be used by the Nursing Department is the Aqua K pad; other sources, such as hot water bottle, heating pad, or microwave hot, may not be used. Staff are to document in the Nurse ' s Notes the date, time, procedure, observations, and resident reactions. Staff are to sign off treatment on the treatment sheet. Review of Resident #1 clinical record lacked a physician's order [REDACTED]. On 12/16/16 at 3:15 p.m. Resident #1 was interviewed and stated she/he lived at home independently prior to going to the facility for rehabilitation following back surgery. Resident #1 stated he/she expected to receive therapy and return back home and back to his/her job. The resident stated he/she had bladder spasms at the hospital and they used warm washcloths that resulted in relief. The resident stated he/she came to the facility on [DATE] and on 11/29/16 he/she had bladder spasms and asked staff to get him/her a heating application for it. The resident stated the staff got a disposable ice bag from the facility and filled it with warm tap water one time and on another time staff filled half full with hot water from the coffee machine and ½ full with ice cubes. The resident stated the bag seemed to be a little hot but did not hurt him/her. The resident stated on the evening of 11/30/16, he/she asked staff to get him/her a warm application and told staff they have been using the disposable ice bags that were in his/her room. The resident stated a staff member took the bag from his/her room and filled it with hot water from the coffee maker and the staff member handed it to him/her as he/she set in recliner in her/his room. The staff person told resident to not squeeze the bag. The resident stated the bag was too hot to handle and before he/she could say anything, the bag exploded onto his/her gown and underwear and went around to the back area. The resident stated he/she had immediate severe pain, causing him/her to scream out and cry out in pain. The resident stated the staff member immediately applied cold wash clothes to the area of groin, abdomen, left thigh and back area and assister him/her to bed and had him/her lay on right side and continued to apply the wash clothes. Resident #1 stated the pain to be unbelievable. The resident stated the ambulance arrived and administered a IV (Intravenously) fluids and administered him/her pain medication two times and after the second time he/she received the pain medication he/she did get some relief. The resident stated he/she transferred to the closest burn unit and admitted . The resident stated he/she underwent daily baths and scrubbing of the burn area that were very painful and described the pain as unbelievable. The resident stated he/she required a skin graft on 12/9/16 to treat the burn areas; the skin graft was taken from the abdominal area. The resident continued to need pain medication every day and would wake up daily with nightmares of the burn incident. The resident stated he/she will have to return to the burn clinic frequently and continue with the baths and scrubbing treatment to his/her burn areas. The resident stated he/she did not feel the staff did this on purpose but did think the staff member appeared to be in a rush. On 12/16/16 at 5:05 p.m. Staff G, Certified Nurse Aide (CNA) was interviewed and stated on 11/29/16 she was assigned to care for Resident #1. Staff G stated the resident asked her for hot wash clothes or a hot water bottle for bladder spasms. Staff G stated she went to the storage unit of the facility and retrieved a disposable ice pack bag and filled it half full of hot water from the coffee machine and half full of ice. Staff G stated the bag to be warm but not too hot to touch. Staff G reported she placed this bag onto the resident ' s skin of the lower abdomen and checked on resident 10 minutes later and the resident had removed the bag. Staff G stated prior to using and applying the bag, she asked Staff H, Registered Nurse (RN) if this would be alright. Staff G stated Staff H was shown the disposable ice bag and ok to use for the resident and make sure not to hot. Staff G stated she did this application for the resident 2 times during her second shift. Staff G stated another staff member attempted to heat water in the disposable ice pack bag in the microwave and the bag exploded in the microwave. Staff G stated she then went and got a second bag from the facility ' s storage supplies and filled ½ full with hot water from the coffee machine and ½ full of ice cubes on the second time she applied the heating application on 11/29/16. Staff G stated she had never used a disposable ice bag for heat before but have used them with ice. Staff G stated she has seen and used the Aqua-K heating application at the facility before. On 12/14/16 at 4:10 p.m. Staff H, Registered Nurse (RN) was interviewed and stated Staff G, CNA, asked her on 11/29/16 if she could get another heat pack for Resident #1. Staff H stated she told Staff G yes and to get it from supplies. Staff H stated she did not see the heat pack that Staff G got from supplies or what she put in the bag. Staff H stated she did not realize it was a disposable ice bag that was being used. Staff H stated she did not know if resident had an order for [REDACTED]. Staff H stated she was in the resident ' s room before and after the application of the heating bag that was used twice on 11/29/16. Staff H stated the resident requested the heating pack for complaints of bladder spasms. Staff H stated she has never seen these disposable ice bags used for heating application. On 12/9/16 at 1:23 p.m. Staff I, CNA was interviewed and stated Resident #1 asked her for a hot water bottle during the day of 11/30/16. Staff I stated this is the first time the resident asked for that and the resident pointed to disposable ice bag on his/her bed side table. The resident informed her staff had used that to put hot water in it. Staff I stated she checked with Staff D, RN, and she said it would be ok to use the disposable ice bag and put hot water in it for the resident. Staff I stated she filled the plastic bag with warm water from the sink, checked for leaks, and handed it to the resident who placed the bag with sleeve on it to his/her pelvic area and said he/she reported having bladder spasms. Staff I stated she told Staff D that the resident had bladder spasms. Staff I stated she checked on the resident after a little while and removed the heat pack. The resident had no further complaints. On 12/9/16 at 2:26 p.m. Staff D, RN was interviewed and stated she and Staff I (CNA) were in the resident ' s room. The resident informed them the staff used a disposable ice pack for a hot pack with hot tap water. Staff D stated she Ok ' d this for Staff I to do for the resident. Staff D stated the resident did not have a physician order [REDACTED]. Staff D stated she just returned from a long trip and she just listened to what Staff I told her about staff using the disposable ice bag and putting hot water in it. Staff D stated she should have first checked the physician's order [REDACTED]. Staff D stated the resident did not have an order for [REDACTED]. Staff D stated she never used a disposable ice bag for heat application nor had she seen it used. Staff D stated the facility used an Aqua K pad (device) for heat application and she had used this before for residents. Staff D stated the resident reported having bladder spasms and requested the hot pack. Staff D indicated she went back to check on resident and resident had removed the heat pack and stated he/she got relief from it like she usually does. On 12/16/16 at 4:06 p.m. Staff F, RN was interviewed and stated on 11/30/16, she came into work at 2 p.m. and did a new admission until 6 p.m. after receiving report. Staff F stated she then went to the floor and was assigned to care for Resident #1. Staff F stated around 7 p.m. a CNA reported to her that the resident requested something other than pain medication for bladder spasms. Staff F stated she went to the resident ' s room and talked with the resident. The resident sat in a recliner chair and wore a gown and underwear. Staff F stated the resident voiced she/he wanted a hot water bottle for her bladder spasms and informed Staff F the staff had used the disposable ice bag and obtaining hot water from the coffee maker machine. Staff F stated she took the ice bag to the coffee machine and filled it up half full of hot water, applied the sleeve to the bag and closed the two zip like plastic closures. Staff F stated she checked the bag for leaks. Staff F reported she then took the bag to the resident ' s room. The resident lifted up the gown and abdominal fold so Staff F could apply the heated bag to the area. Staff F stated she placed the bag with the opening of the bag towards the left side and used no towel between the bag and the skin, just the sleeve of the disposable ice pack. Staff F stated she started to walk away from the resident when she saw the resident moving, heard resident yell out and saw the hot water bag burst open. Staff F stated she immediately got cold wet wash clothes and applied them to the area of burns. Staff F stated she assisted resident to lay on the unaffected (right) side in bed, continued to apply cold wet wash clothes, and removed the wet grown. Staff F stated the resident cried and yelled out in pain. Staff F stated she called 911 and administered pain medication to the resident. Staff F stated the groin, thigh, abdomen area appeared red and the skin peeled. Staff F stated the ambulance arrived 10-15 minutes after the hot water bag broke, and transferred the resident to the emergency room . Staff F stated she did not check for an order for [REDACTED]. Staff F stated the resident told me what to do and I did what he/she wanted. Staff F stated she should have checked the physician orders [REDACTED]. Staff F stated she had used an Aqua K heating application in the facility after receiving the physician order. Staff F stated she did not intentionally mean for this to happen but was just following the resident ' s instruction. Staff F stated there was a label on the sleeve of the bag but she did not pay attention to it. The label identified the bag as disposable and for ice. On 12/9/16 at 11:08 a.m. and on 12/13/16 at 1:44 p.m. the Director of Nursing (DON) was interviewed and stated she received a call from Staff F about the incident. The DON stated she immediately went to the hospital and upon her arrival, the resident laid on an ambulance stretcher and exiting the facility. Staff A stated she immediately began an investigation of events. Staff A stated the staff had used inappropriate heating application for Resident at least 24 hours before this. Staff A stated staff did not have an order for [REDACTED]. The DON stated she immediately removed all disposable ice packs from central supply and the floor (supply closet). Review of the facility coffee/water machine NG-300 specifications, identified hot water temperature of 180 degrees. The Disposable Ice Pack label identified it to be ready to fill, latex-free, and measured 7 inches by 10 inches. Note: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. On 11/30/16 the Director of Nursing began in-services to all nursing staff about the application of heat or cold and the need for a current physician order [REDACTED]. As of the January 13, 2017 exit conference, the facility needed to : · continue to monitor nursing staff to assure the facility policy and procedures for the use of hot and cold therapy/treatment are followed.

Based on observation, record review, and staff interview, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #4). Resident #4 fell out of the shower chair on 2/10/16 and again on 4/13/16 sustaining a left hip fracture. Interviews revealed only one staff transferred Resident #4 to the shower chair on 4/13/16 and failed to use the seat strap. The facility reported a census of 142 residents. Findings include: According to the Admission Record Resident #4 had paralysis on one side of the body. The Minimum Data Set assessment dated [DATE] revealed Resident #4 had severe cognitive impairments. The MDS revealed Resident #4 required extensive assistance of one staff with bed mobility, transfers, toilet use and personal hygiene. The Care Plan updated 6/20/14 directed the staff to use the purple shower chair. The Care Plan updated 10/21/15 directed the staff to provide assist of two staff with the total mechanical lift for transfers and toileting. The Care Plan directed the staff to provide total assist of one with bathing and may need two assist at times. The Care Plan updated 2/11/16 directed the staff to use the seat strap on the shower chair when in the shower chair. The Fall report dated 2/10/16 at 2:53 p.m. revealed Resident #4 fell forward out of the shower chair during a shower. The facility provided education to the staff to always use the safety strap for Resident #4 when in the shower chair. The Fall report dated 4/13/16 at 12:14 p.m. revealed Resident #4 fell forward out of the shower chair. The Hospital Records dated 4/13/16 revealed Resident #4 had a left femur fracture. Resident #4 and family decided on non-operative management. An interview on 4/19/16 at 12:39 p.m. Staff A (Agency Aide) reported Staff E oriented Staff A to the building, the assignments, task sheets and assignment sheets. The staff wrote on the assignment sheet what order to get the residents out of bed. Staff E told Staff A that the facility lifts can be operated by one staff. However, after this incident Staff A learned Resident #4 required two staff to operate the total mechanical lift. Staff A reported he/she transferred Resident #4 to the shower chair with the total mechanical lift alone. Staff A pushed Resident #4 to the shower room in the shower chair. Resident #4 kept leaning forward. Staff A reported he/she pivoted to get a washcloth during the shower and Resident #4 fell forward out of the chair. Resident #4 hit his/her head on Staff A's left shin. Staff A reported she did not use the purple shower chair. Staff A reported the chair did not have a safety strap. Staff A reported he/she did not look at the task sheet prior to caring for Resident #4. An interview on 4//19/16 at 11:07 a.m. and 2:45 p.m. the Director of Nurses (DON) reported the agency staff completes a checklist on their first day at the facility. A facility nurse aide mentor reviews the checklist with the agency staff. The DON reported the facility implemented a checklist on 4/1/4/16. Observation on 4/20/16 at 10:42 a.m. to 11:34 a.m. revealed the facility had 13 shower chairs and 11 of the 13 chairs failed to contain safety straps. An interview on 4/20/16 at 12:33 p.m. the DON reported Resident #4 is the only resident care planned to use a safety strap. The facility policy is not to step away from a resident in the shower chair. The DON reported central supply ordered safety straps attach to all shower chairs in the building. The Education sheet dated 4/15/16 directed the nurse aide to carry a task sheet with them at all times. The sheet educated the staff to ensure they follow the task sheet including transfers, toileting, showers, activities of daily living and all other pertinent information on the task sheet. All nurses and nurse aides must review the task sheet daily for any changes prior to caring for the residents. Any questions on the task sheets should be addressed prior to caring for the residents.

Based on record review and interviews, the facility failed to promote care in an environment that maintained or enhances each resident's dignity and respect in full recognition of his or her individuality for 2 of 3 residents reviewed. Staff G failed to treat Resident #8 and #11 with respect and dignity. Concerns were identified for Resident #8 and #11. The facility reported a census of 142 residents. Findings include: The Minimum Data Set assessment dated [DATE] revealed Resident #8 had severe cognitive impairments, long and short term memory problems. The MDS revealed Resident #8 required extensive assistance of two staff with bed mobility, transfers, toilet use; and the resident totally dependent on staff for personal hygiene. During an interview on 4/27/16 at 10:10 p.m. Staff F, Certified Nurse Aide (CNA) reported while standing outside Resident #8's room, Staff G, CNA, told Staff F that Resident #8 was like trying to fight an f-ing (expletive) horse. Staff F and Staff G entered Resident #8's room to assist with bedtime cares. Staff F reported during the cares Staff G was not gentle. Staff F had to tell Staff G that Resident #8's head was against the wall. Staff F told the charge nurse what happened. Later that evening, according to Staff F, Staff G exited Resident #11's room and referred to Resident #11 as psycho. During an interview with Staff G, on 4/28/16 at 12:50 p.m., she denied being rough with Resident #8 on 4/17/16 or calling Resident #11 a pyscho or swearing around residents. In an interview on 4/28/16 at 11:49 a.m., the DON reported the staff informed him/her that Staff G pushed Resident #8's head against the wall. Staff F reported he/she informed the Staff I, charge nurse, the evening of 4/21/16. The charge nurse reported Staff F reported Staff G was rough and rushed the residents but did not specify which resident. The Abuse Prevention/Resident Treatment policy revised 3/2014 revealed the staff is supervised to identify inappropriate behaviors, such as using derogatory language, rough handling and ignoring residents while giving care. A reasonable person would expect staff to treat them with dignity, respect and full recognition of his or her individuality.

Based on record review and interviews, the facility failed to provide adequate supervision related to resident to resident altercations. Staff interviews revealed Resident #1 showed aggressive behaviors towards other residents. Record review identified Resident #1's care plan lacked provisions to adequately address his/her aggressive behaviors towards other residents until another resident sustained [REDACTED].#1 became agitated at Resident #2, and continued to kick his/her legs until Resident #2 fell to the floor, and sustained a pelvic fracture. The facility reported a census of 131 residents with four (4) residents reviewed during the investigation. Findings Include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) which revealed his/her cognitive status as moderately impairment. The MDS reflected Resident #1 independent with bed mobility, transfers and ambulation. The MDS documented Resident #1 used a walker for mobility. The MDS [DIAGNOSES REDACTED]. The MDS documented Resident #1 had no physical behaviors (no hitting, kicking or pushing.) The Care Plan with a initiated date of 1/27/15, identified he/she had alternation in psychosocial well-being related to cognitive deficits, dependent on staff for activities, cognitive stimulation and social interaction related to dementia. The interventions included: 1) staff to provide verbal reminders and cues as needed. 2) encourage out of the room activity, meals in dining room, group activities and lounge areas. 3) monitor mental status/mood/behavioral changes. Report changes to nurse. 4) education done with staff to keep other residents out of the resident ' s room. 2). The MDS assessment dated [DATE] for Resident #2 revealed he/she had short & long term memory problems and severe cognitive impairments for daily decision making skills. The MDS reflected Resident #2 independent with bed mobility, transfers, and ambulation. The MDS documented Resident #2 had no falls since admission/entry or reentry or prior assessment. The MDS documented the balance assessment indicated Resident #2 as steady at all times. The MDS indicated the resident had no functional limitations in both upper and lower extremities and in range of motion. Resident #2' s Fall assessment dated [DATE], indicated Resident #2 at risk for falls. The fall risk assessment documented the resident can be unsteady at times and when bending over to pick up imaginary items off floor. According to the Plan of Care, dated 7/21/14, Resident #2 had a risk for injury (falls) due to [DIAGNOSES REDACTED]. a). Anticipate needs or safety. b). Ensure resident is wearing proper footwear with transfers/ambulation. c). On 8/15/14, redirect when attempting to walk between recliner/chairs that are close together. d). On 9/19/14, continue to observe while up ambulating per self. e). On 9/19/14, monitor what he/she is trying to pick up off the floor and assist as able. f). On 10/30/14, lounge rearrange to provide more space for resident to walk in between chairs without tripping on them, resident's gait is steady. g).On 11/1/14, know that resident's peripheral vision is limited and may miss judge objects, assist as able and monitor walking around things. h). On 12/19/14, know that resident likes to sit/lay down on the floor, monitor whereabouts and encourage resident to sit or lay in chair/bed. i). On 4/17/15, If resident noted to be picking things up off unleveled ground, redirect resident to level ground. j). On 4/17/15, know that resident likes to sit /lay down on the floor, monitor whereabouts and encourage/redirect resident into bed/chair when resident shows signs of fatigue. Resident #2's care plan documented an update on 5/1/15, redirect resident when trying to take things or moves others belongings or trying to touch them (inadvertently), monitor whereabouts when wandering, chair, bed and floor alarms. The care plan noted the resident sustained [REDACTED]. Review of Resident's #2's Progress Notes dated 5/01/15 at 1:55 p.m. revealed the nurse heard a noise, and observed Resident #2 on the floor in main lobby/TV area, lying on his/her right side. The CNA (Certified Nurse Aide) who witnessed the fall reported Resident #2 had been picking things up, when Resident #1 put his/her legs between Resident #2's legs. Resident #2 attempted to move around Resident#1's legs/feet when Resident #1 lifted his/her legs up higher causing Resident #2 to trip and fall. Resident assisted to turn onto back on the floor and immediately assessed for injuries. Resident #2 complained of significant right hip pain, and could not straighten his/her legs for further assessment. Resident #2 reported pain with palpitation of area and the nurse completed an assessment and obtained orders to transfer the resident to the emergency room (ER). The Fall report (#3409) dated 5/1/15 at 1:55 p.m., revealed the nurse heard a noise and observed Resident #2 on floor in main lobby/TV area, turned on his/her right side. The fall report documented the same information as documented in the 5/1/15 progress notes. Review of Emergency Department Notes dated 5/1/15 indicated Resident # 2 arrived to the ER following a fall at the facility. The emergency room findings revealed there is a fracture of the right pubic bone and medial aspect of the superior pubic (pelvis fracture). The proximal right femur appears to be intact. There is an intertrochanteric nail in the proximal left femur. The pubic symphysis and sacroiliac joints are intact. Impression: fracture of the right pubic bone and aspect of the superior pubic ramus. Resident discharged back to facility with orders that included pain medication and non-ambulation until physical therapy evaluation and treatment. Review of the Progress Notes dated 5/4/15 at 9:46 p.m., revealed Resident #2 returned to the facility from the ER department. Interview on 5/28/15 at 1:15 a.m., Staff B Certified Nurse Aide/(CNA), stated on 5/1/15 before 2:00 p.m. she went back to the unit to collect her belongings and talk with staff. Staff B stated she first looked over in the lounge area and noticed Resident #1 sitting in a recliner with the recliner in the upright position; with his/her feet on the floor. Staff B also noticed Resident #2 picking at Resident #1's recliner. Staff B stated the residents seemed fine at that time. Staff B stated she turned her head away and continued talking to the staff behind the counter. Staff B stated then she turned her head around when she/he heard Resident #1 yelling get away get away. Staff B reported no one went over to Resident #1 or Resident #2 after Resident #1 yelled. Staff B stated she told Resident #1 not to say that and to stop kicking up his/her legs. Staff B indicated she went towards the residents and Resident #1 had been kicking his/her legs up and down and got them between Resident 2's legs. Resident #1 scooted down in recliner and started to kick higher. Resident #1 reached out and touched Resident #2's left hip and Resident #2 fell to the floor. Staff B stated it happened very fast, from the time Resident #1 yelled out and the time she got to the residents', about 20-25 feet away. Staff B stated she could have prevented the fall if she would have first separated the residents when she saw Resident #2 picking at Resident #1's chair. Interview on 5/28/15 at 1:50 p.m., Staff C, CNA (Certified Nurse Aide) stated Resident #1 had behaviors prior to 5/1/15 of being aggressive towards other residents. Resident #1 slapped and yelled at residents to shut up. Staff C stated staff will intervene and redirect the residents. Staff C stated if she had seen another resident messing/touching the recliner that Resident #1 had been sitting in, she would immediately separate them as she know this will upset Resident #1. Interview with Staff A, CNA on 5/28/15 at 2:10 a.m., revealed Resident #1 revealed he/she had been aggressive towards other residents. Staff A reported Resident #1 gets crabby and hits other residents. Staff A reported Resident #1 gets upset when others (residents) enter his/her personal space. Staff A reported she did not see the incident happen between Resident #1 and Resident #2 and did not hear Resident #1 yelling. Resident #1's care plan lacked any updates to address his/her behavior(s) or aggression towards other residents. Interview on 5/28/15 at 8:30 a.m., Staff D, Director of Nursing (DON), stated Resident #1 had a history of [REDACTED]. Staff D stated staff should immediately intervene and separate if another resident comes in close personal space or starts to mess with Resident's #1 stuff. The DON stated Resident #1 will get angry and possibly aggressive towards other resident at these times.

Based on observation, clinical record review and staff interviews, the facility failed to assess and implement interventions for a resident who had an onset of adverse symptoms which represented a physical condition (Resident #1). The emergency room Report identified Resident #1 had a severe case of yeast infection on the vulva area and the physician documented the area seemed as though the area had not been cleansed for several days to weeks. The facility identified a census of 144 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 3/21/13 which reflected the resident had a BIMS (Brief Interview for Mental Status score of 3 out of 15. A score of 3 identified the resident had a severely impaired cognitive status. The MDS indicated the resident required extensive assist from staff for all activities of daily living (ADLs) except eating and ambulation. The MDS identified the resident's [DIAGNOSES REDACTED]. The MDS indicated the resident experienced frequent urinary and bowel incontinent episodes. The resident's Care Plan identified a problem on 10/14/2012, with self- care deficit related to eating/ bathing/dressing/grooming/ toileting/ and personal hygiene. The care plan included and directed staff to: May need assistance of 1 for getting in or out of bed as needed, transfers with 1 person assistance, assist with ambulation, check and assist with incontinence cares and assist with reposition before and after meals, hour of sleep and as needed. Assist of one staff member for bathing, give showers twice weekly and as needed. On 3/31/2013, the care plan directed staff to use wash cloths and soap for all pericare (cleansing of perineal area) and to know (the resident) is having loose stools and excoriated. Apply creams as ordered. The Progress Notes dated 3/13/13 at 1:37 p.m., reflected Resident #1 had several loose stools this morning. Resident noted to be excoriated, raw open areas with minor bleeding of the buttock area. Staff applied barrier cream and PA (Physician Assistant) notified. At 8:09 p.m. staff documented that new orders obtained from the PA that included [MEDICATION NAME] ointment to be applied three times a day and after each incontinent episode to peri (perineal) area until healed. The Progress Notes dated 3/25/13 at 10:10 p.m. revealed Resident #1 given first dose of antibiotic for an upper respiratory infection. The Resident's Shower Sheet dated 3/29/13 revealed documentation the resident had big red bumps and itching. The shower sheet signed by the CNA (Certified Nurse Aide) Staff B and by the nurse Staff D. The record lacked an indication that an assessment had been completed to Resident's #1 ' s area of concerns noted on the shower sheet. On 5/7/13 at 3:51 p.m., Staff B was interviewed and stated on 3/29/13 she worked on the second shift and it had been reported by the day shift staff that Resident #1 groin/pubic area was red and itchy and staff applied barrier cream to the area.. Staff B stated he/she gave the resident a shower the evening of 3/29/13 and noted resident's groin/pubic area to be red, hard and the resident scratched at area. Staff B reported she had documented the area on the resident's bath sheet and also verbally reported it to the nurse, Staff D. On 5/8/13 at 10:42 a.m., Staff D was interviewed and stated she had not known about the resident ' s condition until a few days after the resident returned from the emergency room (ER). Staff D stated she did receive the Resident's #1 shower sheet from Staff B on 3/29/13. Staff D stated she did not review the shower sheet but just signed off on it (signed her signature). Staff D reported she should have reviewed the shower sheet, assessed the resident of any noted concerns, documented it (the assessment) and notified the physician and family. Staff D stated she did none of this. Staff D stated that no report given to her from prior shift or from staff of resident's noted groin area concern nor did Staff D report it to the oncoming shift. On 5/8/13 at 2:50 p.m., Staff J, CMA (Certified Medication Aide) was interviewed and reported she worked the second shift and took care of Resident #1 until 5 p.m. Staff J had received report from the nursing assistants that Resident #1 experienced tenderness when urinating and with perineal care. The CNA ' s requested a treatment cream. Staff J stated Staff D arrived to work at 5:00 p.m. and she informed Staff D of the resident ' s perineal tenderness. On 5/8/13 at 10:59 a.m., Staff E, CNA, was interviewed and reported she had been asked to come into Resident #1's room by another CNA. The CNA asked Staff E to look at the resident's groin area because the area appeared red and swollen. Staff E believes it had been on Friday (3/29/13) during the day shift. Staff E stated she then reported the concern to the nurse (Staff H). Staff E stated Staff H went to the resident's room after she had reported the red and swollen area. On 5/8/13 at 11:58 a.m., Staff H (Licensed Practical Nurse) was interviewed and stated on 3/29/13, she received a concern from Staff E that Resident #1 ' s groin area appeared red and swollen. Staff H stated she went to the resident ' s room and examined the resident while the resident sat on the toilet. Staff H stated she touched the front of the groin area and identified no redness, no hard area and no pain. Staff H stated she did not examine the folds (vulva area) or the vaginal area. The resident had no discharge present. Staff H stated the area looked swollen but thought it was [MEDICAL CONDITION] from the resident ' s pants being too tight. Staff H stated she should have documented the examination. Staff H stated this was the extent of her assessment of the resident ' s perineal area. Prior to leaving work, she reported this to the CMA (Certified Medical Assistant). On 5/7/13 at 4:08 p.m., Staff C (Certified Nursing Assistant) was interviewed and stated on 3/30/13 she had been assigned to care for Resident #1 on the 2nd shift. Staff C stated she toileted the resident twice before performing bed time cares. Staff C reported she did not notice the resident's groin area when performing perineal cares. Staff C stated she could not see the resident ' s pubic area when giving perineal cares as she would wipe the resident from behind. Staff C stated she gave bed times cares that evening and while washing the resident, she noted the pubic area to be red, swollen and a green vaginal discharge. Staff C stated the resident said "ouch" and flinched when Staff C wiped the perineal area. Staff C stated it had been very noticeable at that time doing anterior peri cares. Staff C stated she notified the nurse and she examined the resident. Staff C stated Staff B had reported the resident's groin condition to the nurse prior to 3/30/13. The Progress Notes dated 3/30/13 at 7:33 p.m. revealed the CNA (Staff C) requested the nurse come the resident ' s room. The resident complained of pain while doing perineal care. The nurse documented the resident's pubic area as red, swollen and appeared to be one large extremely hard blister. In the groin area it appeared red, swollen and dimpled almost as if it was a bad case of acne. On the outside of the resident's labia it was almost a purple color and the labia itself as white, inside the vaginal area is very hard to describe. It does not appear to be real moist and appears to be layers and layers of fungus or pus. The nurse notified the physician and obtained an order to send the resident to the ER for possible ' bad ' fungal infection that turned to [MEDICAL CONDITION]. The Emergency Department Visit Documentation identified a History of Present Illness report dated 3/30/13. The history of the present illness revealed the nursing home staff was concerned about the growth in the resident ' s vulva, white gray discharge and red skin. The assessment of the resident revealed a very severe case of yeast infection around the vulva area and it appears the resident has not had her vulva cleaned in several days to weeks. The resident does not complain of pain or discomfort however the physical exam shows a very bright red vulva with gray yellow discharge that is copious. When the ER nurse went to catheter (catheterize-insert catheter into urethra and into bladder) there was a lot of bleeding which shows there are friable tissues that have been inflamed and infected for a long time. The resident received the first dose of [MEDICATION NAME] (antifungal medication) and also had her vulva cleaned thoroughly by the ER nurses. [MEDICATION NAME] cream placed on the vulva. The nurse and I (physician) both feel that this is a possibility of negligence on behalf of the caregivers at the facility of this elderly resident with cognitive disabilities. The hospital obtained photographs of the perineal area. Review of the Progress Notes dated 3/30/13 at 9:43 p.m. revealed Resident #1 returned to the facility from the ER with new orders to give the resident [MEDICATION NAME] 150 mg (milligrams) in 72 hours from now, wash vulva thoroughly with soap and water every 12 hours then place [MEDICATION NAME] cream on vulva every 12 hours, and to follow-up with the gynecologist physician next available appointment.

Based on record review, interviews and observation, the facility failed to implement interventions and provide adequate supervision designed to prevent accidents for Resident #22 and Resident #12. The facility identified a census of 147 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference assessment date of 10/09/12 for Resident #22, which indicated the resident functional status was limited assistance of one person to ambulate in the room and in the corridor. The balance during transitions and walking per MDS indicated the resident was not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and transferring from bed and chair or wheelchair). The resident required a walker for locomotion per the assessment. The assessment identified Resident #22 had [DIAGNOSES REDACTED]. Record review identified a Physical Therapist had last seen Resident #22 on 10/29/09 and discontinued services. The care plan with a goal date of 1/23/13 indicated for fall risk the approaches/interventions were the following: - monitor for medication side effects - occupational/physical therapy as necessary - maintain a clutter free room - call light within reach - remind resident to use call - remind resident to call on staff to pick up articles from the floor. - remind resident to keep walker with him/her at all times. - alarm to bed at all times to alert staff of need to use. - 6/01/12 alarm in chair, when sitting in coves in specialty care center, keep in site when ambulating. - 6/25/12 alarm at all times to chair to alert staff that resident is up walking. - 8/20/12 Stand by assistance at all times. - 10/08/12 Respond to alarm promptly when up ambulating. Care plan indicated for self - care deficit the approaches were: - independent with repositioning in bed - transfers independently as of 3/1/12 - 6/30/12 remind resident to use walker, when up ambulating. - ambulates with stand by assistance - 8/20/12 - assist to bathroom for toileting - assistance of one for dressing Care plan indicated for vision (glaucoma) the approaches were to ensure resident was wearing his/her glasses daily, use large print for reading material and administer eye medications. Care plan indicated the resident at risk for fluid volume deficit due to hypertension (high blood pressure) and being on diuretics. The approaches were: - encourage fluids, watch for signs & symptoms of dehydration ( muscle weakness, change in mental status, dizziness from position change as lying to sitting/sitting to standing); and give medication as ordered. A review of the clinical record and nursing notes reflected the resident had falls on the following dates: a. On 6/01/12 - observed sitting on floor at the end of the hall; 6/24/12 - noise at end of hallway and staff saw resident sitting on the floor in front the window. b. On 8/20/12 resident mistaken walker for recliner at the end of the hallway, went to sit and slid to the floor landing on resident's bottom (fall witnessed by staff). The incident report for the fall on 8/20/12 indicated the resident was independent with walker under close supervision in common area. The resident's gait was steady. The intervention was for the resident to ambulate with stand by assistance. On 9/21/12 resident was prescribed Augmentin for a Urinary tract infection. A review of the physician progress notes [REDACTED]. On 10/07/12 at 9:57 p.m. the resident took a drink of water and stated to choke, on assessment the lung had faint crackles on right side. The physician order [REDACTED]. c. On 10/08/12 at 1:49 p.m. the resident alarm sounding and a loud crash heard. The residents fall occurred between the doors opened to kitchenette area. resident sustained [REDACTED]. The resident was able to move all extremities. The resident uncooperative. The physician notified. Nursing notes of 10/08/12 at 2:25 p.m. indicated the chest x-ray results were received and were okay. The incident report for fall on 10/08/12 indicated the resident's alarm sounded and resident found on floor in dining area with walker. The resident had a recent white count, which was elevated and the resident was on an antibiotic. The intervention was to respond to the alarm promptly and keep kitchenette doors closed at all times, when not in kitchenette. On 10/09/12 the nursing notes indicate the resident started on an antibiotic for an upper respiratory infection. Social services indicated in a note of 10/12/12 alert and oriented to self, had both short and long term memory deficit with impaired decision making. He/She refused cares and medications at times. d. On 11/21/12 at 11:25 p.m. The CNA had the resident in the bathroom and resident fell sustaining a fractured right hip. The incident report for a fall on 11/21/12 indicated the resident toileted with assistance of staff ambulated away from the toilet with walker, lost balance, fell backwards. The resident sustained [REDACTED]. An interview done on 11/28/12 at 2:40 p.m. with Staff T regarding the fall on 11/21/12 of Resident #22. Staff T indicated she had toileted the resident in the bathroom in the resident's room. The resident stood up and was standing with his/her walker. Staff T turned to open the bathroom door and the resident fell backwards. Staff T indicated that her ADON (assistant director of nursing) stated the CNA did not need to use a gaitbelt on the resident, when the resident ambulated with stand by assist. Alarms used in chair and the bed, because the resident would get up by self. Staff T indicated the resident had not been unsteady that day (11/21/12) when walking to bathroom. On 11/28/12 at 3:25 p.m. Staff S, ADON, indicated that staff is not expected to use a gaitbelt, when a resident was stand by assist to ambulate. Resident #22 would get up and ambulate without the walker. Staff U (the nurse on duty on 11/21/12) interviewed on 11/28/12 at 3:50 p.m. Prior to the fall 11/21/12, the resident ambulated with a walker and stand by assistance and had alarms, so the staff knew when the resident got up from the bed or chair. The resident would sit at the end of the halls, so the resident alarmed to let the staff know when she/he got up. The resident's gait was not unsteady. The resident would stop and be distracted, if you walked close beside him/her. Staff U indicated the resident was okay, if staff was 1/2 step behind her/him. On 11/21/12 at about 6:00 p.m. Staff U heard a noise and went to the resident's room. Resident #22 was on the floor in the bathroom, and Staff T was kneeling beside the resident. During the incontinence care of Resident #22 on 11/28/12 at 10:00 a.m. provided by Staff V and Staff W. The resident had a dressing on right hip/thigh. Staff V and Staff W indicated prior to the resident's fall and sustaining a fracture of the right hip, they ambulated the resident with a walker. The resident had an alarm to indicate when the resident got up to ambulated. On 11/28/12 at 10:55 a.m. Staff X indicated the resident was unsteady at times. Resident #22 would sit in chairs at the windows. Alarms were used in chairs and bed. The resident was stand by assist to ambulate. On 11/29/12 at 1:30 p.m. Staff S, Staff Y (MDS & care plan Staff), and Director of Nursing (DON) reported to this surveyor that the resident was coded on the 10/09/12 MDS as unable to stabilize without staff due to an urinary tract infection. A urinary tract infection made a resident more of a risk for a fall. The DON indicated the staff can increase assistance/care as needed for residents. She indicated Resident #22 would become agitated; if staff was beside her/him to ambulate, therefore the fall risk would increase. 2. The Minimum (MDS) data set [DATE] identified Resident #12 with the following Diagnoses: [REDACTED]. The assessment identified the resident required staff assistance with most activities of daily living. The care plan dated 11/11/12 identified the resident with the potential for falls and directed staff to transfer and ambulate the resident with the assist of one staff member utilizing the gait belt and wheeled walker. The physician's orders [REDACTED]. The initial handwritten care plan dated 11/11/12, under the heading of ambulation, directed staff to use the gait belt and walker as aides for mobility. On 11/29/12 at 10:30 a.m., Staff C, RN, Assistant Director of Nursing (ADON) verified that care plan to be the current plan that the staff should be following. The incident reports revealed the resident fell on : a. 11/24/12 at 11:30 a.m. the alarm sounded after the resident stood up unassisted and fell before the CNA could stop the resident from falling which resulted in a bruise to the right hand. b. 11/24/12 at 2:22 p.m., the resident stood up from the toilet and ran and lowered to the floor. The fall risk assessments dated 9/28/12, the second page did not have any documentation to show the resident was assessed as at risk for falls. The fall risk assessment dated [DATE] identified the resident at risk for falls due to increased weakness and shortness of breath. The progress notes in the electronic medical record revealed the following entries: a. 11/24/12 at 11:55 a.m. the resident got up unassistedand fell and had an oxygen saturation rate of 73% on room air. (normal should be above 90%). b. 11/26/12 at 2:16 p.m. the resident got up off the toilet, ran and fell to his/her knees. During an observation on 11/27/12 at 7:50 a.m., Staff A, CNA, assisted the resident to sit at the edge of the bed then stated she could not find her gait belt and assisted the resident to stand and pulled up the resident's pants while holding the resident under his/her left arm then assisted the resident back in bed. At 7:57 a.m., Staff A left the room and stated she would find her gait belt. At 8:03 a.m., an observation revealed Staff A stood by the resident who sat in the wheelchair. Staff A stated "I still can't find my gait belt" and reported she helped the resident up holding the resident under his/her left arm. In an interview on 11/27/12 at 12:58 p.m., Staff B, CNA, reported Resident #12 should be transferred using the gait belt and wheeled walker. In an interview on 11/27/12 at 1:00 p.m., Staff A, CNA, reported Resident #12 should be transferred using a gait belt and that the observation earlier "I could not find the gait belt at first, but I did find it to transfer him/her from the wheelchair to the toilet." Then Staff A reported that she did not have the gait belt on the resident when she transferred him/her from the toilet to the wheelchair, that she left the gait belt in another resident's room and all CNAs should have their own gait belt. In an interview on 11/29/12 at 7:55 a.m., the Director of Nursing (DON) reported her expectation of staff if ready to transfer a resident and did not have a gait belt, to turn on the call light and get assistance to bring the aide a gait belt. If the resident was calm and sitting, would expect the aide to ask the resident to stay in the room until the aide returned with a gait belt. All staff are trained to wear gait belts. In the attempt to reduce the number of resident falls, the DON and ADONs discuss falls with the department heads in the interdisciplinary team meeting for interventions. In an interview on 11/29/12 at 8:15 a.m., Staff C, RN, ADON, reported Resident #12 should be transferred with the assist of one staff member with the gait belt and walker or grab bar in the bathroom. If the CNA did not have a gait belt with her, would expect her to leave the resident in a safe place with the pressure alarm on and call for someone to get her a gait belt. The aides are to have their gait belt on at all times as it is a part of their uniform. A review of the CNA orientation checklist dated 11/12/12, revealed Staff A, CNA, received training on the proper procedure for one and two person assist transfers. II. Based on observation, record review and staff interview, the facility failed to maintain a safe environment for residents with high water temperatures in the bathroom sinks in resident rooms. The facility identified a census of 147 residents. Findings include: 1. During the initial tour of residents on 11/26/12 at 10:30 a.m. with Staff C, RN, ADON, the following high water temperatures were observed: a. Room 708: 140 degrees Fahrenheit (F), the resident reported "the water gets too hot very quickly" b. Room 709: 138.8 degrees F c. Room 715: 133.2 degrees F d. Room 716: 132.6 degrees F In an interview on 11/28/12 at 2:10 p.m., the maintenance director reported that the expected temperature range of water in the resident's bathroom sinks should be 110 to 120 degrees F, could not explain why the water temperatures were so high in the 700 hall on 11/26/12 and reported he did routine checks of water temperatures and provided a copy. In an interview on 11/28/12 at 2:23 p.m. , the maintenance director provided a copy of temperature logs for the past year, none which showed temperatures above 120 and if there were readings that high, we would adjust it immediately. He also reported none of the residents or staff had complained about high water temperatures and that the facility did not have specific policies and followed state rules.