Every finding on record at Oakview Nursing Home

Based on record review, policy review and staff interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine for 5 of 5 residents reviewed (Residents #3, #21, #29, #39, and #45). The facility reported a census of 43 residents. Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS indicated Resident #3 didn't receive an updated COVID-19 vaccine and lacked up-to-date status. Resident #3's Electronic Health Record (EHR) lacked documentation of vaccine receipt or a vaccine offer. On 7/15/26 at 9:55 AM, the Director of Nursing (DON) reported the facility should offer the vaccine at least annually. She reported she couldn't prove the facility offered the vaccine. The Influenza, COVID-19 and Pneumococcal Vaccination policy dated 2021 instructed the facility to offer the COVID-19 vaccination as recommended by the Centers for Disease Control (CDC) or the Iowa Department of Public Health. The CDC recommends updated vaccines for individuals vaccinated prior to the 2025-2026 vaccine to receive one or more doses. The guidelines further recommend everyone over the age of 6 months receive an updated COVID-19 vaccine. The Iowa Department of Health and Human Services (Public Health) recommends following the CDC guidelines. 2. Resident #21's MDS assessment dated [DATE] documented a BIMS score of 12, indicating moderately impaired cognition. The MDS indicated Resident #21 didn't receive an updated COVID-19 vaccine and lacked up-to-date status. Resident #21's EHR lacked documentation of vaccine receipt or a vaccine offer. 3. Resident #29's MDS assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #29 didn't receive an updated COVID-19 vaccine and lacked up-to-date status. Resident #29's EHR lacked documentation of vaccine receipt or a vaccine offer. 4. Resident #39's MDS assessment dated [DATE] documented a BIMS score of 3, indicating severe cognitive impairment. The MDS indicated Resident #39 didn't receive an updated COVID-19 vaccine and lacked up-to-date status. Resident #39's EHR lacked documentation of vaccine receipt or a vaccine offer. 5. Resident #45's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. The MDS indicated Resident #45 didn't receive an updated COVID-19 vaccine and lacked up-to-date status. Resident #45's EHR lacked documentation of vaccine receipt or a vaccine offer.

Based on record review, staff interviews and the Resident Assessment Instrument (RAI) manual the facility failed to complete the quarterly Minimum Data Set (MDS) assessment in the required timeframe for 1 of 1 residents reviewed (Resident #34). The facility reported a census of 43 residents. Findings include:Resident #34's Minimum Data Set (MDS) assessment report in the Electronic Health Record (EHR) documented completion of the last MDS assessment on 3/4/26. The MDS report showed the facility didn't complete the current quarterly MDS assessment. On 7/13/26 at 10:20 AM, the MDS Coordinator reported the tracking system in the EHR didn't exist, causing the facility to miss the quarterly MDS. On 7/13/26 at 10:24 AM, the Administrator reported staff should complete the MDS within the required timeframe. She reported the facility didn't have a policy for MDS assessments and followed the Resident Assessment Instrument (RAI) Manual. The RAI Manual dated October 2025 on page 2-17 instructed to complete the quarterly MDS every 3 months.

Based on clinical record review, policy review and staff interview, the facility failed to identify a weight loss resulting in a failure to offer nutritional interventions, notify the Physician, Dietitian, or their family related to weight loss and poor intakes at meals for 1 of 1 resident reviewed (Resident #11). The facility reported a census of 43 residents. Findings include:Resident #11's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS revealed Resident #11 ate independently. The MDS included diagnoses of Heart Failure (weakened heart), renal failure (kidney failure), and fatigue (extreme tiredness). Resident #11's Care Plan dated 1/6/26 documented a nutritional problem or potential nutritional problem related to a new environment, advancing age, and comorbidities (multiple medical conditions). The Care Plan documented the following interventions:Provide and serve diet as ordered. Monitor intake and record every meal.Registered Dietitian to evaluate and make diet change recommendations as needed.Weigh at the same time of day and record per facility policy. Resident #11's Care Plan lacked interventions related to low food intake identified on the current Care Plan since admission on [DATE]. The Weights and Vitals Summary obtained 7/16/26 showed the following weights since admission: [DATE]: 176.5 pounds (lbs.)1/9/26: 175.0 lbs.2/20/26: 183.5 lbs.3/7/26: 173 lbs.4/5/26: 175 lbs.5/7/26: 176 lbs.6/5/26: 174 lbs.7/8/26: 161 lbs.7/10/26: 160.5 lbs. Resident #11's Progress Notes lacked an assessment or communication with the physician, dietitian, or family regarding the weight loss noted in July 2026. Resident #11's current Order Summary Report didn't list the use of oral nutrition supplements or fortified foods. Resident #11's Meal Intakes from breakfast on 6/16/26 through breakfast on 7/15/26 documented Resident #11 ate 0-25% for 26 meals, 26-50% of 11 meals, refused 8 meals, and lacked documentation for 4 meals out of 88 total meals. On 7/15/26 at 10:20 AM, the MDS Coordinator reported any assessment or notification to the physician regarding a weight loss belonged in the progress notes. The MDS Coordinator reported finding no entries for Resident #11. On 7/15/26 at 10:50 AM, the Director of Nursing (DON) reported nurses should assess and notify the physician and family immediately when residents experience significant weight loss. The Assessment of Change of Condition dated 2023 instructed the 24-hour report serves as the major communication tool for reporting on residents, including weight changes. The policy further directed Licensed Nurses to complete a head-to-toe assessment, including full vital signs, and notify the attending physician, family, and DON.

Based on observations, staff interviews and policy review, the facility failed to prevent cross-contamination during peri cares for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 43 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #2's impairment to both sides of the upper and lower extremities and total dependence on staff for toileting hygiene and dressing. The MDS included diagnoses of dementia (chronic memory loss) and stroke (blood clot or bleed in the brain). On 7/14/26 at 12:55 PM Staff B, Certified Nurses' Aide (CNA) and Staff C, CNA performed perineal care (cleaning of the private areas) on Resident #2. Staff B and Staff C completed hand hygiene and applied a gown and gloves. Both staff members gathered supplies and placed a barrier underneath Resident #2. Staff B and Staff C removed Resident #2's pants and incontinence brief. Staff B began cleaning Resident #2 from front to back. Staff B rolled Resident #2 onto the right side and used the same wipe multiple times. Staff B and Staff C rolled Resident #2 to the left side. During the turn, Staff B touched Resident #2's right hand with dirty gloves while adjusting the hand. Staff C began wiping Resident #2 from front to back using the same wipe multiple times. Staff C set the wipe down on the bed pad, folded it over, and used it again. Staff C repeated this action twice. Staff B then handed a clean brief to Staff C using the same dirty gloves used during the cleaning. Staff C, wearing the same dirty gloves from the care, placed the clean brief under Resident #2 on top of the bed pad where Staff C previously placed the dirty wipes. Staff B and Staff C rolled Resident #2 onto her back. Staff B began cleaning the front perineal area, wiping from front to back using the wipes multiple times. Staff B pulled the new brief up with the same dirty gloves, and both staff members secured it. Using the same dirty gloves, Staff B and Staff C pulled up Resident #2's pants. Staff B grabbed Resident #2's left hand with dirty gloves to adjust the arm onto the bed. Both staff members lifted Resident #2 up in bed, touched the bedsheet with dirty gloves, grabbed the blanket, and covered Resident #2. Staff B and Staff C removed the dirty gloves and completed hand hygiene. On 7/14/26 at 1:10 PM Staff B and Staff C acknowledged they didn't change their gloves between clean and dirty tasks. Both staff members confirmed touching multiple surfaces and Resident #2 with dirty gloves during the care. On 7/14/26 at 1:20 PM the Director of Nursing (DON) stated staff must change gloves between clean and dirty tasks. The Nurse Consultant (NC) stated staff must use wipes only one time. The Incontinent Care policy undated instructed staff to remove gloves after providing perineal care. The policy lacked directions instructing staff to use a wipe only once and change gloves between dirty and clean tasks.

Based on record review, staff interviews, facility investigation, and policy review, the facility failed to follow the transfer technique to safely transfer a resident for 1 of 3 residents reviewed (Resident #1). On 12/10/25, Resident #1 complained of severe pain with the inability to move her ankle free in all movements. Resident #1 reported that she got her legs tangled when she got transferred. In reviewing Resident #1's clinical record her Kardex (a pocket Care Plan) instructed the staff to transfer her with the assistance of 2 staff and a full-body mechanical lift. The staff interviews determined the staff transferred Resident #1 at times without the full-body mechanical lift. The physician documented Resident #1 received her ankle fracture during a transfer. The facility reported a census of 43 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS included diagnoses of heart failure, chronic kidney disease, muscle weakness, and difficulty walking. The Care Plan Task revised 8/21/25, documented Resident #1 required the use of a full-body mechanical lift with the assistance of 2 staff for transfers. The Kardex Report as of 12/1/25 indicated Resident #1 required assistance from 2 staff and the full-body mechanical lift.The Nurses Note documented 12/11/25 at 10:47 AM reflected the facility notified the physician about Resident #1's complaint of increased pain, swelling, and the inability to bare weight on her right ankle. The physician gave an order to get x-rays on the right ankle. An X-ray Report dated 12/11/25 at 1:33 PM, identified Resident #1 had a questionable right ankle fracture without dislocation.Review of Physician Progress Noted dated 12/15/25, indicated Resident #1 sustained an ankle fracture during a transfer. An interview on 2/5/26 at 11:49 AM, Staff A, Certified Nursing Assistant (CNA), stated at shift change Resident #1 sat on the commode. Resident #1 used her call light for assistance off the commode and transfer to the recliner. Staff A and Staff B, CNA, attempted to place the mechanical lift sling under Resident #1 to transfer her but couldn't. Instead of using the mechanical lift Staff A and Staff B attempted to manually transfer Resident #1 to the recliner. Staff A reported the transfer as very hard and awkward, adding it was a struggle. Staff A said they got tangled with Resident #1's legs. Staff A stated they (Staff A and Staff B) did get Resident #1 to the recliner. Staff A denied Resident #1 having a fall or complained of pain or discomfort. In an interview on 2/5/26 at 12:00 PM Staff B couldn't recall a time or incident transferring Resident #1 prior to finding the ankle injury. Staff B didn't believe she had been involved when Resident #1 may have received the injury. Staff B stated she knew of times other CNAs transferred Resident #1 without the use of the mechanical lift. In an interview on 2/5/26 at 12:50 PM Staff C, CNA, stated on 12/6/25 shortly before shift change (2:00 PM), Resident #1 told her she needed transferred to the commode quickly to avoid an accident. Staff C and Staff D, CNA, transferred Resident #1 with a two man transfer to the commode. An interview on 2/5/26 at 1:16 PM, Staff D, CNA, stated she was not sure if the injury happened when she had assisted with Resident #1's transfer on 12/6/25. Staff D, CNA, stated almost every single one of us (CNAs) were doing a two-man pivot transfer, on that day (12/6/25) Resident #1 was fine when she was transferred to the commode, when Staff D, CNA, had returned to check on Resident #1, she had found Resident #1 had already been transferred from the commode to her recliner. A short time later, Resident #1 needed assistance with her pants, Staff D, CNA stated she helped stand Resident #1 pulling up her pants and adjusting her for comfort.Review of the facility's Investigation Summary dated 12/11/25 documented Resident #1 required the assistance of two staff and a mechanical lift for all transfers. On the morning of 12/11/25 Resident #1 reported having significant pain to her right ankle related to the transfer to her recliner after supper the previous night. Resident #1 her feet got tangled up when she went to her chair the night before. When questioning Resident #1 about her ankle, she responded she didn't want to hurt her feelings. On assessment Resident #1 could wiggle her toes and move her leg but couldn't flex her ankle joint. The facility's Investigation included a review of the staffing schedules, staff interviews, and statements that determined incidences of the CNAs assisting Resident #1 with a two-person transfer.Review of Facility Provided Safe Resident Handling/Transfers Policy and Procedure dated 2025 instructed the following:It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. Resident's lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, staff and resident interview, record review, and policy review, the facility failed to ensure the medical record of one (Resident (R) 39) of 13 residents reviewed in the sample was complete and accurately documented. The inaccurate documentation of use of a left-hand edema glove had the potential to cause a delay in receipt of a new glove or inaccurate assessment of edema and effectiveness of the intervention for R39. Findings include: Review of R39's Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including flaccid hemiplegia on the left side, muscle weakness, history of stroke, and lymphedema. Review of R39's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/31/23, located in the MDS tab of the EMR, revealed he scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. He had impaired range of motion in his upper extremity on one side. Review of R39's 06/21/23 physical therapy Discharge Summary, located in the Miscellaneous tab of the EMR, revealed a recommendation for, Glove on left hand during the day, off at bedtime. Review of R39's EMR under the Orders tab revealed an order, which originated on 05/10/23, for, Left arm edema glove, on AM, off PM every day shift related to flaccid hemiplegia affecting left nondominant side. Review of R39's 06/07/23 Care Plan, located in the Care Plan tab of the EMR, revealed documented, I need assistance with ADL's [activities of daily living], I have had a flaccid hemiplegia affecting left nondominant side. The resident's goal was, I will maintain current level of function through the review date. The interventions included: see task for assistance required. Review of R39's Tasks tab of the EMR revealed, Special Equipment: left hand edema glove on in AM [morning] and off at HS [bedtime] - lotion hand upon removal. Review of R39's POC [Point of Care] Response History for 07/04/23 to 08/03/23 addressing use of a left-hand edema glove daily, located in the Tasks tab of the EMR, revealed an answer of Yes to the question Is the resident wearing the device? on: -07/04/23 at 1:38 PM and 3:23 PM; -07/06/23 at 6:23 PM; -07/07/23 at 9:43 AM and 7:09 PM; -07/08/23 at 10:41 AM and 4:40 PM; -07/09/23 at 2:29 PM; -07/12/23 at 10:19 AM and 3:15 PM; -07/14/23 at 3:16 PM; -07/16/23 at 2:52 PM; -07/21/23 at 1:49 PM and 6:23 PM; -07/22/23 at 2:14 PM; -07/23/23 at 3:53 PM; -07/24/23 at 1:55 PM and 7:00 PM; -07/26/23 at 3:07 PM; -07/27/23 at 3:55 PM; -08/01/23 at 4:00 PM; and -08/03/23 at 7:26 PM. Review of R39's Notes tab in the EMR revealed the Orders - Administration Notes from 08/03/23 to 07/04/23 revealed the resident's left hand edema glove was not available. In an observation of R39 in his room on 08/01/23 at 1:03 PM, he was seated in his recliner with no glove on his left hand. R39's left hand was curled into a loose fist. R39 stated he was unable to move his left arm or hand. He stated he did not have a glove to wear. In observations on 08/02/23 at 10:12 AM and 2:20 PM, 08/03/23 at 9:41 AM and 3:30 PM, and 08/04/23 at 10:10 AM in R39's room, he was observed seated in his recliner without a glove on his left hand. In an interview on 08/04/23 at 10:22 AM, Certified Nurse Aide (CNA) 1 stated the resident's glove had been lost and a new one had been ordered; there was no glove to apply for R39 at the moment. In an interview on 08/04/23 at 10:32 AM, CNA2 stated R39 did not have a glove, and stated she believed it had not been available for over a month. She stated she did not know why Yes would be checked on the POC Response History as the glove was not available. In an interview on 08/04/23 at 10:37 AM, the Director of Nursing (DON) stated R39 was on his third glove, as the first glove was torn and the second glove did not fit properly. She stated a new glove was currently on order but had not been delivered yet. The DON stated the CNA's documentation on the POC Response History should not reflect yes to the question whether the glove was on, as it was not available. In an interview on 08/04/23 11:37 AM, the DON stated the CNAs on the evening shift were documenting, Yes on POC Response History; however, the Yes meant the glove was not on, even though the question was Is the resident wearing the device? She stated the question in the task should be changed to reflect accurately that he did not have the glove on. Review of the ADL Documentation policy, dated 2023, revealed, Accuracy in documentation is critical to highlight changes [and] generate the appropriate referrals . Code for actual elder performance [and] actual support provided.

Based on observations and interviews, the facility failed to ensure staff used gloves when breaking up medication for one resident (Resident (R) 39) and when transferring medication from one cup to another for R3 to prevent possible cross contamination, from a sample of four residents observed during medication pass. Findings include: During medication observation for R39 on 08/02/23 at 9:10 AM with Certified Medication Aide (CMA) 1, revealed that CMA 1 obtained one pill of calcium antacid 500 milligrams (mg) from the over the counter (OTC) medication drawer on the medication cart. CMA 1 placed the calcium antacid in her bare hands and broke into four pieces, then placed it into the medication cup with other medications for R39. During medication observation for R3 on 08/02/23 at 9:16 AM with CMA 1, revealed while preparing R3's medications, CMA 1 said that R3 likes all of her larger pills (one dull yellowish/orangish round thick pill of potassium chloride 10 milliequivalent (meq), one thick oblong while pill of Gabapentin 600 mg, one thick white oblong pill of Metformin 1000 mg, and one thick white oblong pill of oyster shell 500 mg) in one cup and the other pills into a separate cup. CMA 1 was observed attempting to pour the larger pills from one medication cup to another; however, the pills were not transferring. Then CMA 1 picked up all five of the pills and placed them into the second medication cup with her bare hands. During this transfer, CMA 1 said I know I'm not to do this, but and continued to transfer pills with her bare hands. Interview with the Infection Preventionist (IP) on 08/03/23 at 1:35 PM, she confirmed that at no time should a nurse or CMA be touching medications with their bare hands.

Based on clinical record review, staff interviews, and facility policy, the facility failed to issue an SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice - Form ) to 1 out of 3 residents reviewed (Resident #17). The facility reported a census of 42. Findings include: A request was made for copies of the SNFABN form that was issued to three residents. Of the three residents, Resident #17 remained in the facility. Upon request the facility was unable to provide the correct form given to the resident. On 1/11/22 at 3:20 p.m., the Social Services Director (SSD), stated he did not fill out the correct form (Form ) for Resident #17. The SSD explained he did not know why he didn't use the correct form, but he didn't. The SSD reported that he filled out the form for Part B (not skilled level of care) instead and concurred that it was the wrong form. The undated form titled the Decision Matrix For Using Discharge Letters protocol, directed staff to give a SNFABN Form # to a resident when they stayed in the building, two days before discharge from skilled level of care.

Based on record review, staff interviews, and policy review the facility failed to ensure residents on hospice services had a care plan in place that integrated with the facilities care plan for 2 of 2 residents reviewed (Resident #2 & #46). The facility reported a census of 42 residents. Findings include 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident received Hospice services. The Care Plan Focus 5/25/21 documented that the resident had a nutritional problem or potential nutritional problem related to poor dentition making it difficult for her to chew some meats, hard fruits, or hard vegetables. The resident did not want an alteration to her diet texture. Hospice Care. The Kardex printed on 1/10/22 for Resident #2 lacked hospice services, needs, and interventions. During an interview on 1/10/22 at 2:17 PM with Staff B, Registered Nurse (RN), responded as she was providing Resident #2's Care Plan that it was the complete Care Plan. When asked if the Care Plan included Hospice, Staff B stated no it would be a separate one online. Staff B responded that the Certified Nurse Aides (CNA) didn't have access to the Care Plan, as the CNA's used the facilities Kardex system. An observation on 1/10/22 at 4:03 PM revealed Staff B putting multiple Hospice care plans in a binder with the Hospice residents' kardex. During an interview on 1/11/22 at 12:53 PM Staff C, Hospice employee, revealed Staff D, Hospice employee, emailed Staff A, RN, on 1/10/22 all seven Hospice residents' Care Plans. Staff C revealed that Staff A could no longer login to see the residents' Care Plans due to being inactive for too long. During an interview on 1/12/22 at 1:20 PM Staff D, revealed Hospice admitted Resident #2 for senile degeneration of the brain. During an interview on 1/12/22 at 2:08 PM Staff A revealed she did request that Staff D email her the most current Hospice Care Plans on 1/10/22 to update the old ones in the Kardex. 2. Resident #6's MDS assessment dated [DATE], documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required set up help only for bed mobility, transfer, and toileting. A care plan focus documented that this resident needed assistance with his activities of daily living and was admitted to Hospice on 7/23/21. No other mention of hospice care or hospice interventions was in this resident's care plan. A kardex (electronic form with care plan guidleines for Certified Nurse Aides) printed on 1/10/22, did not include hospice interventions or mention hospice care. A Hospice POC (Plan of Care) Report with interventions dated on 7/24/21, documented interventions for hospice care. An undated Care Plan protocol form, directed staff to follow the Resident Assessment Instrument (RAI) manual and critical elements pathways to provide a guide to complete a comprehensive individualized care plan to meet each resident's needs.

Based on observation and staff interviews, the facility failed to store and serve food under sanitary conditions in order to prevent the risk of food borne illness. The facility reported census was 44 residents. Findings include: 1. During observation of the outdoor cooler on 01/27/20, at 07:49 a.m., pork chops were stored on the second shelf from the bottom, in a baking pan covered with plastic wrap labeled 1/27/19 lunch. Beverages in individual beverage cups, containing juices and milk, were stored on the bottom shelf, below the pan containing pork chops. 2. During observation in the East dining room on 1/27/20, at 11:26 p.m., Staff [NAME] wore gloves as they dished food from the steam table. Without changing gloves, Staff [NAME] picked up a tenderloin sandwich and placed the sandwich on a plate. Staff [NAME] handed the plate to Staff F, who delivered it a resident. Staff [NAME] picked up a patty melt sandwich, with gloved hands, from the steam table and placed it on a plate. Staff [NAME] placed their gloved hand on the sandwich while they cut the sandwich in half. Staff [NAME] handed the plate to Staff F who delivered it to a resident. Staff [NAME] failed to change gloves after touching contaminated surfaces. Oakview Dietary Meal Service Policy, dated (YEAR), failed to address safe food handling. 3. On 1/28/20 at 9:54, a.m., Staff G, Cook failed to wear a beard in kitchen food prep area. On 1/28/20 at 11:25 a.m., Staff G failed to wear a beard net while dishing and serving salads at the steam table. During interview on 1/28/20 at 12:41 p.m., the Dietary Manager (DM) acknowledged meat should not be stored above other foods where contamination was possible. DM further stated staff should change gloves after touching contaminated surfaces before handling food and staff did not wear beard nets if the beard was 1/4 inch length or less.

Based on observation, clinical record review and staff interview, the facility failed to revise the comprehensive plan of care for one of 12 residents reviewed. (Resident #32) The facility census was 44 residents. Findings include: A Minimum Data Set ((MDS) dated [DATE], documented Resident #32 had [DIAGNOSES REDACTED]. The MDS did not identify the use of oxygen. During observation on 1/27/20 at 2:43 p.m., the resident had an oxygen concentrator in their room on 2 liters per nasal cannula. The monthly medication records revealed the use of oxygen was not listed on the (MONTH) Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. [MEDICATION NAME] 1 mg. was administered every Tuesday. Review of the resident's care plan did not reveal problem/focus areas or interventions related to the use of oxygen or anticoagulant medication. During interview on 1/28/20 at 3:30 p.m., the Director of Nursing (DON), stated she did not know why the oxygen order was not on the (MONTH) and (MONTH) Physicians Orders. During interview on 1/29/20 at 1:20 p.m., the DON expected [MEDICATION NAME] use and oxygen use to be addressed on the plan of care.

Based on observation, clinical record review, staff interview and policy review, the facility failed to ensure proper dosage administration of insulin for one resident. (Resident #22) The facility census was 44 residents. Findings include: 1. The Admission Record face sheet for Resident #22 listed a [DIAGNOSES REDACTED]. During medication administration on 1/28/20 at 4:15 p.m., Staff B, Registered Nurse (RN) prepared to administer Basaglar insulin 45 units via insulin pen to the resident. Staff B failed to prime the insulin pen with 2 units of insulin and waste those units prior to dialing up the prescribed doses in the pen. The surveyor stopped her and questioned her about the need to perform one more step before giving the insulin. Staff B then wasted 2 units and redialed the pen to the prescribed 45 units. A review of the manufacturer's directions regarding the quick pen directed the following: Step 5: Priming your pen-prime before each injection. Priming ensures the pen is ready to use and removes air that may collect in the cartridge during normal use. If you do no prime the pen before each injection, you may get too much or too little insulin. Step 6: Turn the dose knob to select 2 units. Step 7: Hold pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with needle pointing up. Push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin repeat the priming steps but not more than 4 times. If you still do not see insulin, change the needle and repeat the priming steps. Small air bubbles are normal and will not affect your dose. During interview on 1/28/20 at 4:20 p.m., Staff B stated she had no idea she needed to prime the insulin pen before dialing up the prescribed dose. During interview on 1/29/20 at 2:15 p.m., the Director of Nursing (DON) stated it was an expectation that insulin pens be primed with 2 units of insulin, which are then wasted, before the actual dose was dialed up on the pens. The DON stated this is done to assure a correct dosage due to changing of the needles on the insulin pens.

Based on observation, dietary menu review, dietary policy review and staff interview, the facility failed to prepare pureed foods in a manner that meets the nutritional needs of three residents on a pureed diet. The facility census was 44 residents. Findings include: 1. During kitchen observation on 01/28/20 09:54 a.m. Staff [NAME] prepared 6 servings of pureed foods, processing 3 servings at a time. Staff [NAME] placed 3-3 ounce pork chops and 3 slices of bread in the food processor. Staff added milk to the food processor and blended to desired consistency. Staff [NAME] then placed 3- 4 ounce servings of green beans in the food processor. Staff [NAME] processed the green beans, adding warm milk and food thickener, to desired consistency. Staff [NAME] processed 3 brownies in the food processor adding warm milk and food thickener and processed to the desired consistency. Staff [NAME] did not prepare food in a manner that assured nutritional needs of residents. Oakview Week 5 menu stated noon puree menu on Tuesday was as follows: #8 scoop pureed marinated chicken #12 scoop pureed fruit salsa #8 scoop mashed potatoes #12 scoop pureed green beans #20 scoop bread/margarine #12 pureed brownie 8 fluid ounces milk Review of facility provided, undated, West dining room diet orders revealed 3 Residents received pureed diets. Oakview Pureed Diets Policy, dated 8/97, stated Volume may be increased due to the addition of liquid. The policy further provided a chart policy that showed types and amounts of food and liquid to combine to produce the correct pureed serving size. During interview on 1/28/20 at 10:20 a.m. Staff [NAME] stated she referred to the menu to determine the serving size for pureed foods. Staff [NAME] acknowledged they altered the consistency and added addition milk and thickener during the pureeing process. Staff further stated they did not measure food or follow a recipe when they pureed the food. Staff [NAME] stated she served prepared 6 puree servings and served 3. Staff [NAME] confirmed Resident's received 8 ounces of milk with meals in addition to milk added during the pureeing process. During interview on 1/28/20 at 10:20 a.m., the Dietary Manager acknowledged Staff [NAME] did not measure or follow a recipe when pureeing and acknowledged pureed foods should be measured to determine proper serving size.

Based on clinical record review and staff interview, the facility failed to notify the State Ombudsman's office of the hospitalization of one of one resident reviewed (Resident #38). The facility census was 44 residents. Findings include: 1. The Admission Record face sheet dated 7/9/19 for Resident #38 identified [DIAGNOSES REDACTED]. A review of the resident census report the resident was transferred to the hospital on [DATE] and returned on 1/2/2020. During interview on 1/29/20 at 2:00 p.m., the Director of Clinical Services acknowledged the resident's name was not on the (MONTH) 2019 notification list. During interview on 1/29/20 at 2:20 p.m., the Administrator expected the Ombudsman would have been notified of the resident's transfer out in (MONTH) on the monthly list.

Based on observation and staff interview, the facility failed to ensure dietary staff utilized proper gloving during one meal service to prevent food-borne illness. The facility census was 40 residents. Findings include: 1. During lunch preparation on 12/11/18 at 11:15 a.m., Staff E, Cook, donned gloves and grabbed a roll out of a container. Staff E went on to touch a variety of surfaces with their gloved hands that included the outside of a potato chip bag, pans, foil wraps, handles of spoons and scoops, the surface of the counter and her apron and repeatedly handled ready to eat rolls without out changing gloves. During interview on 12/12/18 at 11:19 a.m., the Administrator reported dietary staff was trained to safely handle food to prevent food-borne illness. The administrator stated staff should wash hands with each glove change and would not expect staff to touch ready to eat food with bare hands or contaminated gloves. A document titled Oakview Inc Glove Use Gloves in Dietary dated (YEAR) stated since gloves can become contaminated very easily, they must be changed often. They may only be used for one task and must be discarded if damaged or if the worker is interrupted during their task. 2. During the lunch meal service on 12/10/18 at 11:38 a.m., Staff B wearing gloves utilized serving utensils, plates and the steam table to serve 13 of 15 residents in dining room. Staff returned Resident #4's plate to the steam table to have the meat cut into pieces. Staff B utilized the same contaminated glove to hold the resident's meat in place while cutting it into pieces and the plate was returned to the resident. During interview on 12/10/18 at 11:40 a.m., Staff B stated she should have changed gloves prior to touching the residents meat.

Based on clinical record review and staff interview, the facility failed to resubmit residents with a [DIAGNOSES REDACTED]. (Resident #40) The facility census was 40 residents. Findings include: 1. The PASARR dated 1/18/18, identified Resident #40 had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], listed mental health [DIAGNOSES REDACTED]. A mental health note dated 8/10/18, identified [DIAGNOSES REDACTED]. During interview on 12/12/18 at 10:30 a.m., the Director of Nursing (DON) revealed the initial PASARR was submitted prior to admission to the nursing home. The DON confirmed residents admitted with [DIAGNOSES REDACTED]. The DON confirmed the facility failed to resubmit a PASARR that included a comprehensive list of mental illness [DIAGNOSES REDACTED].

Based on observation, clinical record review and staff interview, the facility failed to ensure staff provided complete incontinence care for one of three residents observed. (Resident #26) The facility census was 40 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #26 had [DIAGNOSES REDACTED]. The Interdisciplinary Care Plan initiated on 8/15/18, directed staff to assist with toileting due to incontinent of bladder and bowel with goal to be clean and odor free. Observation on 12/11/18 at 8:45 a.m., revealed Staff C, certified nurse aide, CNA and Staff D, CNA assisted the resident with incontinence care. Staff C provided incontinence care while Staff D held the resident in a standing position. Staff C cleansed the resident from front to back but failed to cleanse both hips that had contact with the urine residue. During interview on 12/11/18 at 9:30 a.m., Staff C acknowledged the resident's brief was wet. During interview on 12/12/18 at 10:30 a.m., the Director of Nursing, (DON) stated when a resident was wet it would be an expected to cleanse the resident's hips.

Based on observation, clinical record review and staff interviews, the facility failed to provide ongoing interventions to prevent healing of a pressure ulcers for one of four residents reviewed (Resident #5) The facility census was 40 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. Observation on 12/10/18 at 11:26 a.m., the resident was transferred to the toilet by Staff G, Certified Nurse Aide, CNA and Staff H, Registered Nurse, RN. Observation revealed an open area on the residents left side of the sacrum (bony prominence of buttocks). Staff H identified the open areas as Stage II pressure ulcers and stated she would need to come back and measure the areas and start the treatment of [REDACTED]. Staff H stated it looked like the areas had been open for a day or so. Staff H stated the resident was at high risk for developing pressure ulcers. At 2:01 p.m., Staff H measured the areas and stated she had obtained an order from the physician to apply Z guard, which she applied to both areas. Staff H stated the area was identified on 12/4/18. Staff H confirmed the areas had advanced from Stage I to Stage II pressure ulcers. Staff H stated a Roho cushion (pressure relieving device) was placed in the resident's wheelchair on the day the pressure ulcers were identified. Wound/Skin Record documented two Stage I pressure ulcers with an onset date of 12/4/18. Barrier cream was applied and record showed a Roho cushion (pressure relieving cushion) was applied. A physician order [REDACTED]. During interview on 12/13/18 at 9:55 a.m., the Director of Nursing (DON), confirmed an intervention of a low air loss mattress should have been put into place.

Based on observation, clinical record review and staff interviews, the facility failed to ensure safe transfers for two of five residents observed. (Residents #1 & #26) The facility census was 40 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had [DIAGNOSES REDACTED]. The Care Plan revised on 9/5/18, revealed the resident at risk for falls and a directive to transfer with the assistance of two staff. During observation on 12/11/18 at 7:40 a.m., Staff A parked the wheelchair next to the bed with the right arm rest off of the wheelchair. Staff A encouraged the resident to slide from the bed into the wheelchair. Staff A put the arm rest back on the wheelchair after the resident transferred. The resident was slow with movement and had a difficult time during the transfer. During the transfer no gait belt was utilized and there was only one staff present for the transfer. During interview on 12/11/18 at 8:12 a.m., the Associate Director of Nursing she stated the care plan was current and the resident required two staff for transfers. During interview on 12/11/18 at 10:09 a.m., Staff A acknowledged the resident required two staff for transfers. 2. The MDS assessment dated [DATE], revealed Resident #26 had [DIAGNOSES REDACTED]. The Care Plan dated 8/22/18, revealed the resident was at risk for falls with a directive to transfer with the assistance of two staff. During observation on 12/11/18 at 8:45 a.m., Staff D placed a gait belt around the resident, placed an arm around each side of the resident and using the gait belt lifted the resident to a standing position. Staff C moved the wheelchair and Staff D pivoted and placed resident on the toilet. Staff D stood the resident, with the same technique while Staff C provided incontinent care. Staff D transferred the resident to the wheelchair and wheeled the resident to the recliner in the room and transferred the resident with the use of a gait belt. During interview on 12/11/18 at 9:30 a.m., Staff D acknowledged the resident required two staff for transfers. During interview on 12/11/18 at 9:30 a.m., Staff C acknowledged the resident required two staff for transfers. During interview on 12/11/18 at 10:00 a.m., the Assistant Director of Nursing stated the resident required two staff for transfers and would expect staff to follow the plan of care.

Based on observation and staff interview, the facility failed to ensure dietary staff served food under sanitary conditions and failed to properly date and label food in the refrigerator. The facility census was 38 residents. Findings include: 1. During the initial dietary tour on 10/2/17 at 8:00 a.m., the Amana refrigerator had the following food items without an open date: a . One pound package of margarine was opened and wrapped with plastic with no opened date or used by date on package. b. A 10 inch plate of cheese slices wrapped in plastic that was dated 9/25/17 and stated that it was to be thrown out by 9/30/17. Dietary manager was present during initial tour and acknowledged the cheese plate should have been thrown out and all food should be dated and labeled. 2. Observation on 10/02/17 at 11:30 a.m., revealed Staff F, Dietary Aide/Cook was assigned to serve the lunch meal in East dining room. At 11:30 a.m., Staff F was observed buttering bread and went on to touch a variety of surfaces with their gloved hands including bread wrappers, the steam table and plates. Staff F proceeded to wear the same gloves during lunch service without changing the gloves and continued to butter three other pieces of bread and served them to 3 other residents. During interview on 10/03/17 at 1:40 p.m., the dietary supervisor stated ready to eat foods should not be handled with gloves and staff should be utilizing utensils.

Based on record review and staff interview, the facility failed to provide adequate supervision and implement interventions to prevent injury for one (1) of three (3) residents reviewed who sustained a fall with a fracture (Resident #1). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1 dated [DATE], documented the resident required total assistance of two for bed mobility and transfer. The MDS documented the resident scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment. The assessment identified Resident #1's balance as not steady and only able to stabilized with staff assistance when walking, when moving from seated to standing position, when turning around, when moving on and off the toilet, and during surface to surface transfer. The plan of care dated [DATE], documented [DIAGNOSES REDACTED]. The plan included a problem of risk for falls due to dementia related to safety awareness. The plan of care documented, strengths as has good eyesight and is able to comprehend the importance of safety issues. The care plan directed the following interventions: a. Keep room free of clutter in the doorways to the bathroom and hall. b. Encourage resident to go to exercises and ambulate to all activities. Have encouraged resident along with family to walk outside as resident used to love to walk and did so daily. Currently thinks is going home at some point and will walk at that time. c. Added on [DATE]- fall -PT to evaluate and treat. Will do exercises with restorative nurse to maintain strength and endurance. d. Added on [DATE]- pull-away alarm on at all times. An incident report dated [DATE] at 5:15 p.m., documented the resident had been found on the floor in their room. An additional comment or step taken to prevent re-occurrence had been to encourage the resident to stand up slowly. A fall evaluation dated [DATE] at 5:15 p.m., documented the resident had been yelling help, found on floor in room. The form documented the interventions to encourage the resident to stand up slowly, ordered Physical Therapy, restorative program evaluated. On [DATE], an intervention had been added to the same form for a pull-away alarm on at all times. A fall risk assessment dated [DATE], documented the resident had scored a 14, which indicated a high risk for falling. A unsigned facility document called West addition Certified Nurse Aide (CNA) information sheet updated [DATE], included a directive for the resident to have a pull-away alarm. The document instructed the CNAs that if/(when) pull away alarms are placed correctly the residents could not take them off. An entry in the nurses notes dated [DATE] (no time), documented the resident up to bathroom by self. An entry in the nurses notes dated [DATE] at 4:00 p.m., documented the resident had been up and walked to the restroom by him/her(self), and reported to the CNA "I can do this by myself". An entry in the nurses notes dated [DATE] at 7:00 a.m., documented the resident had been found sitting on the side of the bed, had unclipped alarm from gown. An entry in the nurses notes dated [DATE] at 9:00 p.m., documented staff heard someone calling for help, found resident on floor at the foot of bed with a pool of blood under the resident. Resident had been on left side facing door, had apparently removed Provo boots which were still in the bed, and had unclipped the pull-away alarm from their nightgown. The clip of the alarm had been dangling at the side of the bed. Could see the resident hit the left side of their forehead on the floor and had formed a golf ball sized hematoma with a ,[DATE] inch red abrasion area to the center of it. Attempted to move resident and discovered blood coming from a skin tear about four inches long on left arm just below the elbow. Resident stated back hurt. Order received to transfer to local emergency room . It should be noted that resident did not activate call light for help prior to incident though it had been in reach. Resident had been noted to have some mild confusion that day during evening and had also attempted to transfer self to toilet that afternoon with no request for help or activation of bathroom call light. An incident/accident report dated [DATE] at 9:00 p.m., documented the resident had been found on the floor of their room. The reported noted the resident had apparently removed their Provo boots and unclipped their pull-away alarm. The resident attempted to get out of bed to go to bathroom and fell . Resident did not use call light. He/She sustained a skin tear to left arm just under elbow, hematoma to left side of forehead, complained of back pain and left knee not fully mobile. An order had been obtained to transport the resident to a local hospital. An additional comment and/or steps taken to prevent re-occurrence had been to remind the resident they must not try to get up on their own. Advised CNAs to clip alarm where it is hard to reach. A history and physical dated [DATE], documented the resident presented to the hospital. The report documented the patient unhooked him/her (self) from bed alarm and attempted to go to the bathroom and had been found on the floor. The following [DIAGNOSES REDACTED]. Clinical record review revealed a major injury determination form had been completed and signed by the physician on [DATE]. The form documented the resident had a fall on [DATE] at 9:00 p.m., sustained a hematoma to the forehead, left elbow skin tear, left femoral neck fracture and right pubic ramus fracture. The form documented the physician had reviewed the circumstances, injury and prognosis of the patient and they believed the injury sustained had not been a major injury, and to the best of the physicians knowledge, barring any complications, they believed the patient would return to his/her previous functional status. An entry in the nurses notes dated [DATE] at 6:00 p.m., documented the resident had returned to the nursing home. An entry in the nurses notes dated [DATE] at 12:00 a.m., documented cessation of all vital signs. A death record documented the resident had expired on [DATE] at 12:00 a.m., with the principle cause of death having been pneumonia. Staff A (Licensed Practical Nurse, LPN) stated during interview on [DATE] at 12:59 p.m., the resident had removed their clip alarm the morning of the incident at about 7:00 a.m. Staff A stated she had entered the resident's room to do eye drops and found the resident sitting at the side of the bed. Staff A stated she had only thought to get the resident cleaned up but to be honest did not think about adding a pressure alarm or any other interventions at that time to prevent a fall. Staff B (LPN) stated during interview at 1:10 p.m., she had seen the resident remove their clip alarm occasionally for about a month prior to the fall. Staff B stated she had not seen the resident unclip it and stand up, but instead had seen the resident in bed and turn over and set the alarm off, and the resident would then unclip it. Staff B stated she had been sure she had reported this to someone but did not know who. Staff B verified she had put the resident to bed and placed a clip alarm on the resident the night of the fall but did not remember where the alarm had been clipped. Staff B stated she usually tried to place it out of the resident's reach but the resident had still been able to remove it at times. Staff C (Certified Medication Aide, CMA) stated during interview at 1:15 p.m., she had been aware of the resident removing their clip alarm prior to the resident falling. At 1:32 p.m., Staff C returned to the surveyor and stated she had not actually seen the resident remove the alarm but had heard other staff stating the resident had removed the alarm on occasions prior to the resident's fall. Staff D (CMA) stated during interview at 1:35 p.m., she had seen the resident remove the pull-away alarm. Staff D stated usually (staff) tried to clip it to the resident's back where he/she could not reach it. Staff D stated she had seen the resident taking off the alarm for about six weeks prior to the fall. Staff D reported sometimes she took it upon herself to add a pressure alarm because the resident could still remove the pull-away alarm. Staff D stated she thought she had reported this to someone but did not recall which staff she had informed. The facility Director of Nursing (DON) stated during interview on [DATE] at 1:40 p.m., she had not been aware the resident had ever removed the clip alarm and no staff had reported this. The DON stated she had not been aware the resident could remove the alarm until they came in and reviewed the nurses notes after the resident sustained [REDACTED]. The DON stated she would expect staff to place a pressure alarm on the resident if the resident had been removing the clip alarm and that this could have been added per nursing judgment.

Based on record review and interviews, the facility failed to implement intervention(s) to ensure Resident #9 received adequate supervision to prevent accidents for 1 of 4 residents reviewed. Resident #9 sustained falls on 7/2/12, 7/8/12, 7/10/12, and on 7/19/12 fell and sustained a hip fracture. The resident's clinical record lacked any reassessment or modification necessary to address the resident's needs from 7/2/12 to 7/19/12. The facility reported a census of 43 residents. Findings included: A quarterly Minimum Data Set (MDS) assessment tool, with an Assessment Reference Date (ARD) of 5/2/12 identified Resident #9 had severe cognitive impairments. The assessment indicated Resident #9 scored three (3) out of fifteen (15) on his/her Brief Interview for Mental Status (BIMS) test. The BIMS score established the resident had no difficulty with repeating words, however he/she was not orientated to the year, month or day; or he/she could not recall words previously asked to repeat. The MDS documented the resident independent with bed mobility, transfers, ambulation in room and corridor, and for toilet use. The MDS documented the resident's balance steady at all times during transitions and walking except when turning around to face the opposite direction (the resident was not steady but able to stabilize his/her balance without staff). The MDS identified the resident had no range of motion impairments, and no falls during the previous assessment period. The MDS documented the resident's [DIAGNOSES REDACTED]. On 6/5/13 at 12:30 p.m., Staff F (MDS and Care Plan Registered Nurse) stated she had been employed at the facility approximately 9 months and planned to attempt to find the electronic or printed care plan in effect after the 5/2/12 MDS. On 6/5/13 at 1:10 p.m., Staff F presented a care plan she believed covered the time after the 5/2/12 MDS, stated there was no way to know for sure if the care plan covered the time, and no other paper care plan found. The resident Plan Of Care, presented by Staff F 6/5/13 at 1:10 p.m., identified the resident a fall risk, original date 11/15/11, related to a recent fracture of femoral neck and confusion at times, and a goal not to fall during the quarter, estimated date 5/1/12. Interventions included: a). Call light to remain in place at all times when the resident remained in the room. b). Use walker in and out of the room for stability. c). The resident required reminders when without walker and must sit down and wait for staff to find the walker, therapy had evaluated the resident and documented the resident safe to ambulate with walker. d). Keep room clutter free at all times. A Fall Risk Assessment And Interventions sheet dated 5/2/12 documented Resident #9 at high risk for falls. A score of seven or higher indicated the resident at a higher fall risk, and directed staff to consider environmental risk factors for interventions. The instructions on the Fall Risk Assessment form recommend the form be completed after a fall or based on facility policy. The resident record lacked any other fall risk assessments until the resident fall with injury (on 7/19/12). Incident/Accident Report sheets and Nurse's Notes documented the following falls: a). A Nurse's Notes entry dated 7/2/12 at 12:12 a.m. documented staff heard the resident yell for help, a CNA (Certified Nursing Assistant) found the resident on the floor without injury, the resident stated he/she walked over to close the room door and turn off the bedroom lights, turned around, fell backwards into the door, and slid to the floor. The nurse's notes documented the nurses encourage use of walker in his/her room and turning night light on, and leaving the bathroom light on with door open a little. The Accident/Incident Report documented encouraged the resident to use the walker in room and use of night light. The resident's care plan lacked documentation of any of these interventions, or any changes or modifications. b. A Nurse's Notes entry dated 7/8/12 at 7:50 p.m. documented another resident reported the Resident #9 had fallen. A nurse and CNA went to the resident's room, found the resident on knees in front of recliner, the resident stated he/she slid out of the recliner to knees and unable to get up. Staff used a gait belt and assisted the resident to the recliner. The resident had a 2 centimeter (cm) by 2 cm abrasion to the left knee. The notes documented the resident's call light not "on" and not within reach at the time of the fall. The nurse documented she encouraged the resident to use the call light to request assistance and placed the call light in the resident's recliner. The Incident/Accident Report with the same date and time documented the resident confused per normal. The report documented the resident's call light not "on" and not in reach. The report revealed staff should encourage the resident to ask for help and place the call light within reach of resident in recliner. The resident's care plan lacked documentation of any of these interventions, any changes or modifications. c. A Nurse's Notes entry dated 7/10/12 at 6:00 p.m. documented the resident stood from the dining room table, stepped back and fell over his/her own feet, without injury. The Incident/Accident Report with the same date and time documented the resident's condition before the fall normal and confused. The report documented the resident fell on his/her buttocks and steps taken to prevent further falls included to remind the resident to let the CNAs assist him/her up from the table and get (obtain) walker after supper. The resident's care plan lacked documentation of any of these interventions, any changes or modifications. The facility did not have Fall Investigation Worksheets for falls on 7/2/12, 7/8/12 and 7/10/12 falls as requested by the Department. d. A Nurse's Notes entry dated 7/19/12 at 4:15 a.m., documented staff found the resident on the floor on the right side between the bed and bathroom. The resident complained of pain in left hip and unsure what had happened. The assessment revealed the resident unable to perform range of motion to left lower extremity, left hip area tender to touch, and pain increased when he/she log rolled to back. The notes documented staff called an ambulance and the resident sent to the emergency room . An Incident/Accident Report with the same date and time documented staff found the resident on the floor during rounds. Light not on and the resident not hollering out. The resident had left hip pain with movement. The report identified the resident barefooted without a walker nearby and his/her condition before the fall confused per normal. Additional comments noted steps taken to prevent recurrence documented the resident's history reviewed, interventions reviewed, noted resident used wheel chair on and off for three weeks, re-direction with walker used, and right leg weak. A Falls Investigation Worksheet for the 7/19/12 at 4:15 a.m. fall documented the resident had not used an assistive device and the call light had been within reach at the time of the fall. The medical considerations section revealed the resident declined in ambulation, and needed cueing and using wheelchair. The environmental section revealed the safety interventions (call light and walker) were in use at the time of the fall. (The Incident/Accident Report form revealed the call light was not "on", and the walker was not nearby.) The interventions/recommendations after the fall now included the following: alarms during the night, pressure mattress alarms, more frequent night checks, continues to toilet before bedtime and monitor for pull up use. Monitor for hypotensive episodes. Physical Therapy (PT) & speech evaluations for cognitive changes or assistance needed. Assist of 1 staff during ambulation during the night and as needed throughout the day. Document and implement interventions. A Nurse's Notes entry dated 7/19/12 at 7:10 a.m. documented the resident admitted to the hospital for a left hip fracture. A hospital Discharge Summary, dated 7/23/12, documented the resident had a closed reduction and internal fixation of the left hip intertrochanteric/subtrochanteric femur fracture performed 7/19/12. During an interview with Staff P on 6/6/13 at 10:30 a.m., she reported she could not remember the resident, and if the resident had been unsteady prior to the fall in July 2012. During interview 6/6/13 at 10:20 a.m. Staff F stated she was unable to identify when floor mat by bed started, unable to locate any information in the electronic care plan system or any paper care plans with documentation of interventions added to the care plans after the resident's falls from 7/2/12 to 7/19/12. Staff F stated she had added fall interventions to the electronic care plan since she began employment nine months ago, sometimes interventions changed, and unable to locate any intervention history in the electronic record or when new interventions hand written on printed electronic care plans. During interview 6/6/13 at 10:20 a.m. Staff K stated she was unable to locate any additional information with interventions and dates related to falls from 7/2/12 to 7/19/12 in addition to the interventions documented in the Nurse's Notes and Incident/Accident Report sheets. A Nurse's Notes entry dated 7/23/12 at 2:30 p.m. documented the resident returned to the facility on skilled services. admission orders [REDACTED]. The resident touch toe weight bearing only for 6 to 8 weeks, and required two staff assistance with transfers. The resident's record documented Physical Therapy (PT) services provided from 7/23/12 through 8/23/12 for gait, therapeutic exercises, and transfers, the resident allowed touch toe weight bearing only to the left leg, and the resident to receive restorative services until a change in weight bearing status ordered. A 5 day MDS assessment, dated 7/27/12 documented the resident with a BIMS score of 3, required extensive staff assistance with bed mobility, transfers, toilet use, and bathing, had not ambulated, required staff assistance to stabilize for balance when moved from a seated to standing position, on and off the toilet, and for surface to surface transfers, and had one sided lower extremity range of motion impairment. The MDS documented the resident had one fall without injury since admission or reentry to the facility. Nurse's Notes and or Incident/Accident Report identified Resident #9 sustained 17 falls without injury on the following dates and times: 7/25/12 at 2:05 a.m.; 8/16/12 at 2:20 p.m.; 8/24/12 at 7:45 p.m. ; 8/27/12 at 3:00 p.m.; 8/27/12 at 3:00 p.m.; 8/31/12 at 7:30 p.m.; 9/4/12 at 7:50 a.m.; 9/16/12 at 6:15 p.m.; 9/22/12 at 8:30 p.m. ; 9/23/12 at 7:25 p.m.; 9/27/12 at 7:30 p.m.; 10/21/12 at 4:00 p.m.; 1/13/13 at 1:10 p.m. ; 1/27/13 at 7:15 p.m.; 2/10/13 at 3:30 p.m.; 3/11/13 at 8:00 p.m.; 5/20/13 at 9:15 p.m.; The record revealed PT resumed services 9/12/12 for gait, strength, range of motion, transfers, and balance. A Therapy Progress Documentation sheet, dated 9/12/12, documented the resident allowed weight bearing as tolerated, resident confused why legs felt weak, quickly forgot when told leg broken. A PT Weekly Progress Note from 9/26/12 to 10/21/12, and dated 10/21/12, documented the resident ambulated approximately 150 feet with contact guard assist, the resident required verbal cues for walker manipulation during transfers, and verbal cues to decrease forward trunk lean during gait. A PT Updated Plan Of treatment for [REDACTED]. An MDS's dated 12/23/12 and 3/25/13 documented the resident's BIMS remained a 3, indicated severely impaired cognition, the resident required limited assistance with transfers and toilet use, and the resident had not ambulated during the previous seven day period. The MDS documented the resident required staff assistance to stabilize for balance when moved from seated to standing position, moved on and off the toilet, and for surface to surface transfers, had one sided lower extremity impaired range of motion, and used a wheel chair for mobility. In addition the 12/23/12 MDS documented the resident had one fall without injury during the previous assessment period and the 3/25/13 MDS documented the resident had two falls without injury during the previous assessment period. The Plan of Care, identified by Staff F as the resident's current care plan, identified the resident a fall risk, original date 11/15/11. Interventions included the following: call light will be in place at all times when the resident remained in the room. A pull away alarm required at all times, half side rails for positioning & a floor mat next by the bed at bed time. The resident required reminders when without walker and must sit down and wait for staff to find walker. Therapy had evaluated the resident as safe to ambulate with walker, and keep room clutter free at all times. The care plan lacked dates when any of the interventions were implemented. During interview 6/6/13 at 10:20 a.m. Staff K verified the two care plans found by facility documented therapy evaluated the resident and stated the resident safe to ambulate with a walker. Staff K presented physician's orders [REDACTED]. The care plan and or physician orders [REDACTED]. During the same interview, Staff K stated she was unable to find any PT screens or evaluations completed since 10/23/12. During interview 6/6/13 at 10:15 a.m. Staff K (Assistant Director of Nursing) stated the only documentation she found related to a restorative program prior to the resident's fall/fracture 7/19/12 was a physician order, dated 8/23/11, to discontinue physical therapy and begin a restorative aide program. Staff K found one Restorative Care Flow Record dated October 2011 and staff documented the resident received restorative aide services 8 times that month. The form lacked any information at the top of page in the Restorative Nursing Program area to identify the resident's program. Staff K stated she had no information to document whether or not the resident remained on a restorative program at the time of the fall/fracture and had no information to document the restorative program the resident received.

Based on observation, clinical record review and interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision against hazards. On 11/3/12 Resident #1 left the nursing home without being noticed by staff. Another resident observed Resident #1 exit the east hall door to the parking area and alerted staff. The east hall was under construction and the outside door alarm was not active at this time. Staff attempted to locate the resident and called for assistance from the local fire department. Resident #1 was found approximately 3 hours later asleep in a nearby residence's garage. The facility and or director of nursing failed to plan for resident safety knowing the door alarm was not active. This constituted an immediate jeopardy to the health and safety of the resident. The facility reported a census of 41 residents with seven (7) with exit seeking attributes. Findings include: According to the Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had an admitted to the facility of 3/30/12. The assessment revealed the resident had [DIAGNOSES REDACTED]. The resident had severe cognitive ability and could not participate in their 9/26/12 assessment. Resident #1 ambulated about independently and could perform their activities of daily living with cues and supervision. According to the Care Plan dated 10/12/12 identified Resident #1 as a flight risk if they were overly anxious and exhibiting behaviors. The care plan directed the staff to apply a Wanderguard bracelet on the resident and check daily for proper functioning. Resident #1's Nurse's Notes from 3/30/12 to 11/3/12 identified the following elopement attempts from the facility on: 4/17/12, 5/23/12, 6/9/12, 6/20/12, 6/21/12 (twice), 7/25/12, 7/31/12 (twice), 9/8/12, 9/18/12, 10/5/12, 10/12/12, 11/3/12. Resident #1 attempted a total of 14 elopements from the facility and the staff responded to the door alarm(s) appropriately with the resident unharmed. Review of an Incident/Accident Report form dated 11/3/12 indicated Resident #1 eloped from the building via the East door at 5:05 a.m. The facility nurse became aware of the elopement from another resident sitting by the exit door. According to the county Sheriff's narrative, on 11/3/12 Resident #1 was reported missing from the nursing home. The report identified another resident observed Resident #1 walk down the east hall and out the door to the parking area. This hall was under construction and the outside door alarm was not active at this time. The narrative revealed the resident left a few minutes after 5 a.m., wearing a vest and pants. Staff attempted to locate him/her and then called for assistance from the local fire department. The Sheriff noted responders were being called to help with the search. The Sheriff checked all vehicles in the parking lot and conducted a search to the east of the nursing home which included the interior of garages and outbuildings. The Sheriff noted arrangements were made for aircraft from the State Patrol and a K9 unit from another county. When the Sheriff started his search west of the nursing home with the intent of knocking on doors of residences and checking their property he located Resident #1 asleep in a lawn chair inside a garage directly across the street from the nursing home. According to the narrative, the resident did not know where he/she was found (at) or how he/she got to the location. Review of a local Sheriff Dispatch report dated 11/3/12 revealed the facility placed a call to 911 at 5:31 a.m. and emergency personnel dispatched. An interview with the Sheriff on 11/7/12 at 7:44 a.m., revealed when he located Resident #1 (on 11/3/12) he/she was wearing a long sleeve blouse with a vest and, no coat. The resident did not complaint of being cold until they went outside, returning back to the nursing home. According the State Climatologist the local weather conditions on 11/3/12 were as follows: the temperature at 4:53 a.m. noted to be 37 degrees Fahrenheit (F) with a wind chill of 32 degrees (F). The wind from North West at 6 miles per hour and skies cloudy. On 11/7/12 at 12:00 p.m., the surveyor obtained exterior photographs of where Resident #1 had exited and was located. A written statement by Staff A (undated) revealed on Saturday (November 3, 2012) around 5 a.m., another resident informed her and the DON of Resident #1 ' s had gone out the east door. The resident told her he/she went out to get Resident #1 but could not find him/her so he/she came back in to tell staff. Staff A documented the DON went out the east door to look for Resident #1 and she went out the north and west side of the building to find the resident. As Staff A returned to the building, the DON had left in her car to look for Resident #1 and she started a room to room search. During an interview with Staff A on 11/6/12 at 1:50 p.m., Staff A stated she worked 11/2/12 to 11/3/12 on the West/South Hall with the D.O.N. and another staff member assigned to the new East Hall. Staff A stated when she arrived to work she did not know the doors were not alarmed. Staff A indicated the facility did not have a plan to keep someone at the nurse ' s station by the East Hall. Staff A stated the day of the incident the facility had 8 residents who require the assistance of 2 staff for cares/transfers and could see how staff would be able to sit at the nurse ' s station. During an interview with Staff B on 11/7/12 at 4:45 a.m., the staff stated the East Hall code alarm door has been gone for a while. Staff B stated she received no directions on how to monitor the East Hall after the alarms were removed and stated they leave the nurse ' s station unattended at times. Staff B stated they have a wondering resident who resides close to the East Hall exit door and wears a Wanderguard bracelet. During an interview with Staff C on 11/7/12 at 7:00 a.m. revealed October 31, 2012 or November 1st, 2012, the East Hall alarmed door was removed and the staff were not given any direction on how to monitor the East Hall to assure resident safety. During an interview with Staff D on 11/7/12 at 7:10 a.m., Staff D stated he worked 11/2/12 to 11/3/12 a.m. Staff D stated he last saw Resident #1 around 5:00 a.m. when he went into their room and shut the door. Staff D went down the hall, responding to another resident's sounding alarm. Staff D did not see Resident #1 again until he/she was escorted back into the building shortly after 8:00 a.m. Staff D stated Resident #1 had a history of [REDACTED]. According to a written statement dated 11/6/12 signed by Staff E, the door with the alarm to the outside had been removed on 10/30/12. The statement noted after the incident, the east door had an alarm placed by 9:30 a.m., on 11/3/12. (The facility did not have an alarm system on the East hall door from 10/30/12 to 11/3/12.) During an interview with the Director of Nurses (D.O.N.) on 11/6/12 at 11:00 a.m. revealed she worked the night shift on 11/2/12-11/3/12 morning with 2 other staff members. The D.O.N. stated she was working the East/South Hall and knew when arrived to work the East Hall did not have a working alarm system and did not know how long it had been like that as they were in the middle of a large remodel/building project. The D.O.N. stated the facility did not have a plan on how to monitor the door to assure the safety of the residents. The D.O.N. stated at about 5:00 a.m. on 11/3/12 she got called away from the desk which left the desk unattended and Resident #1 walked out the East door. The D.O.N. stated another resident alerted her that Resident #1 had walked out the door and the search for Resident #1 started. A local deputy Sheriff found Resident #1 at 8:10 a.m. in a garage across the street from the facility, asleep in a lawn chair. During an interview with the Maintenance Supervisor on 11/6/12 at 9:56 a.m. and again on 11/7/12 at 6:30 a.m. he stated when they left the building on 11/2/12 at approximately 2:00 p.m. they planned to come back to the facility on Saturday 11/3/12 a.m. and install an alarm to the East Hall fire doors as the construction company replaced the fire doors by the nurse ' s station on 11/2/12. During the 11/7/12 interview, he stated he could not remember for sure when the construction company removed the exterior East door which had an alarm on the door. The Supervisor acknowledged the East Hall did not have an alarm system on either door and no yellow caution tape on either door. The facility removed the East Hall exit door alarm on 10/30/12 and failed to have a safety plan to monitor the East Hall to assure resident safety. The facility had 7 residents identified as elopement risks. The above circumstances were coded at a "J" Immediate and Serious Jeopardy level. The facility responded to the situation and on 11/3/12 they alarmed the east exit door. The facility also provided close monitoring of Resident #1 after the incident. The facility initiated a Wanderguard and took pictures of all residents with Wanderguard. Removal of the immediate jeopardy was on 11/3/12 as a result of alarming the exit door and closer monitoring of Resident #1. These actions lowered the deficiency from a scope and severity level of J to E, with the need for ongoing monitoring of alarms and education to staff.