Every finding on record at Oakwood Specialty Care

Based on observation, clinical record review, staff interview, and facility policy review the facility failed to perform appropriate hand hygiene during personal cares for one of two residents observed for toileting hygiene (Res #3). The facility reported a census of 50 residents.Findings include:The Minimum Data Set of Resident #3 dated 8/20/25 coded the resident dependent for toileting hygiene. The MDS reflected the resident always incontinent of urine and bowel. The MDS documented diagnoses that included non Alzheimer's dementia and Parkinson's Disease. The Care Plan of Resident #3 documented the resident to always have urinary incontinence and frequent bowel incontinence, dated 5/5/25. On 9/3/25 at 8:51 am, Resident #3 was in the dining room finishing breakfast. A puddle of urine was noted to be on the floor underneath his wheelchair.On 9/3/25 at 9:06 am, Staff A, Certified Nurse Aide (CNA) cued Resident #3 to put his feet up on his wheelchair foot pedals to take him to his room. When she noted the urine, she notified another staff member for it to be cleaned. Observation of incontinence cares began on 9/3/25 at 9:07 am. Staff A stated Staff B, CNA would also be assisting her as Resident #3 was a heavy assist to stand and transfer to bed. After pushing Resident #3 in his wheelchair into his room and closing the door, Staff A and Staff B both washed their hands and donned isolation gowns and disposable gloves. Staff A stated the resident required isolation gowns due to wounds on his legs. Staff A, wearing gloves, repositioned the wheelchair for a safe transfer as Staff B turned down the bedding on the bed. Staff B then removed the foot pedals from the wheelchair as Staff A locked the brakes on the wheelchair. Staff B then placed a gait belt (a belt worn around a patient's waist to assist with walking and transfers) around the resident's waist. Staff gave step by step instructions as his walker was placed in front of him. Staff stood on either side of Resident #3, holding the gait belt and guiding him safely to a standing position and transferring him to the bed. The wheelchair cushion was soiled with urine. The resident was positioned on the bed on top of a disposable bed pad. Staff A opened the closet and obtained a clean incontinence brief, wipes and clean clothing. With no glove changes or hand washing, Staff A assisted Res #3 to turn to his left side, and lowered his pants and pull up style incontinence brief, turned him to his right side to continue to lower his clothing. Staff B opened a plastic bag and Staff A placed his soiled clothing in the bag and tore the side of the incontinent brief to fully open the brief. Staff A then used disposable wipes to cleanse his abdomen and then groin area with separate wipes. On 9/3/25 at 9:18 am, staff assisted the resident to turn to his right side and then cleansed his buttocks and disposed of the soiled brief. Staff tucked the soiled under pad underneath the resident and placed a clean under pad in it's place. Staff turned the resident to assist in getting the pad in place. Staff B placed a clean pull up style brief over Res #3's feet and positioned it in place. Staff B then placed clean shorts on him and repeated the process until he was dressed. Staff B placed boundary identifying wedges on the bed near the resident and placed his sheets and blanket over him. She then used the remote control of the bed to place the bed in a safe position. Staff A then removed her gown and gloves and washed her hands. Staff B obtained the call light for the resident and placed it in his reach and then removed her gown and gloves and washed her hands.On 9/3/25 at 9:24 am Staff A placed clean gloves on her hands. She gathered the soiled clothing from the room and Staff B placed the soiled wheelchair in the bathroom and shut the bathroom door. She folded his walker and placed it near the bedside table. Staff A placed the garbage in the biohazard trash box in the room and placed a clean trash liner in the can. She then turned off the room light and exited the room. On 9/3/25 at 9:32 am, the Director of Nursing (DON) stated the resident's wheelchair should have been cleaned and staff should change gloves and wash hands between dirty and clean tasks. The facility policy Handwashing/Hand Hygiene, revision date August 2019 documented the following:Point 7: Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:a. Before and after coming on duty;b. Before and after direct contact with residents;c. Before preparing or handling medications;d. Before performing any non-surgical invasive procedures;e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites);f. Before donning sterile gloves;g. Before handling clean or soiled dressings, gauze pads, etc.;h. Before moving from a contaminated body site to a clean body site during resident care;i. After contact with a resident's intact skin;j. After contact with blood or bodily fluids;k. After handling used dressings, contaminated equipment, etc.;l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;m. After removing gloves;n. Before and after entering isolation precaution settings;o. Before and after eating or handling food;p. Before and after assisting a resident with meals; andq. After personal use of the toilet or conducting your personal hygiene.

Based on record review, Facility Assessment and staff interviews, the facility failed to maintain an adequate number of staff for the facility's census. The facility reported a census of 50 residents. Findings include: The Payroll Based Journal (PBJ) Staffing Data Report for the fiscal year's Quarter 2 (1/1/24 to 3/31/24) revealed the category for an excessively low weekend staffing triggered and the facility had a one-star staffing rating triggered. The Facility Assessment for 2024 provided by the Administrator to the survey team on 9/3/24 had a review date 7/26/24. The assessment revealed the following daily staffing pattern and total number of staff needed per day: Licensed Nurse providing direct care: 6-7 Certified Nursing Assistants ((CNA/ Restorative): 11-13 Certified Medication Aide (CMA): 0-2 The facility had an average daily census of 50.6 residents. The facility assessment revealed staffing based on the resident's acuity and staffing strengths. The assessment also revealed the facility provided a wide range of services and used a team approach to support and care for the residents. A Facility Assessment revised 5/5/22 provided by the survey team on 9/5/24 revealed an average daily census of 43 resident. The assessment documented the types of residents and the top 5 diagnoses as coded on the MDS (Minimum Data Set Assessment) as well as the facility's services and resources such as equipment. The facility assessment documented the facility had a total of 43 employees, but lacked a daily staffing pattern or the total number of staff needed to care for the residents each day. The facility's Nursing Schedules dated 1/1/24 - 3/31/24 had a total of 26 days on the weekend (Saturday/Sunday). The schedules revealed the following: a. Weekend staffing for Nursing: 26 of 26 day nursing shifts and 23 of 26 evening nursing shifts were insufficiently staffed. b. Weekend staffing for CNA's: 24 of 26 day shifts, 16 of 26 evening shifts, and 24 of 26 night shifts were insufficiently staffed. During an interview 9/4/24 at 9:45 AM, the DON confirmed the schedules dated 1/1/24 to 3/31/24 provided to the surveyor had the most up-to-date information and consistent with the staff who worked on those dates. During an interview 9/04/24 at 3:37 PM, Staff A, Certified Nursing Assistant (CNA) reported she worked the 2-10 PM shift. Staff A reported staffing could be better. The number of residents and what needed to be done for the residents was a lot to get done during her shift. Staff A reported only 1 CNA and 1 nurse assigned on each hall, but on the 6 AM - 2 PM shift there were 3 nurses and 6 CNA's assigned. There were 5 residents on Hall B and 5-8 residents on Hall C who required a mechanical lift and two staff assistance on transfers, and four to five residents required feeding assistance. During an interview 9/04/24 at 3:45 PM, Staff B, CNA, reported not enough CNA's are assigned to work on the 2-10 PM shift. Only 2 CNA's and 2 nurses assigned on the 2-10 PM shift typically. Staff B reported residents often got mad because they thought they had waited too long for someone to assist them. She tried to get to the residents as soon as she could but there was just one CNA on each hall (Hall B and Hall C). Staff B reported 25 residents on Hall C, and 3 residents required a mechanical lift and 2 staff for transfers, During an interview 9/05/24 at 7:55 AM, the Director of Nursing (DON) reported the number of staff scheduled each shift on Saturday and Sunday as follows: 6 AM - 2 PM: 4 nurses and 5 CNA's. Sometimes 1 nurse worked as a CNA when they didn't have enough CNA's 2 PM -10 PM: 3-4 nurses and 4 CNA's 10 PM -6 AM: 1 nurse and 3 CNA's The DON reported agency staff, the DON, Assistant DON, and the MDS nurse sometimes covered shifts whenever short-staffed. She took the resident's acuity into account for staffing when needed. The DON reported staffing numbers entered into Data Force, and Corporate entered the PBJ data. During an interview 9/05/24 at 12:27 PM, the DON reported the previous Administrator had worked on the facility assessment and the DON adjusted staffing numbers based on the PPD (per patient day). The staffing numbers in 1/2024 were different than the current staffing numbers needed. The average census 1/2024 to 3/2024 at 42, but the census currently at 50 and the resident acuity now higher. The DON and ADON worked the floor a lot during and had a high staff turnover during that time. The DON reported she took over updates on the facility assessment in 4/2024 after the prior administrator left. The facility assessment is a working document on her computer and unsure if she had prior versions of the facility assessment. On 9/05/24 at 12:49 PM, the DON provided a Facility assessment dated [DATE] from the Regional Nurse's computer. This assessment revealed the facility had an average census of 43 residents but had no daily staffing pattern listed. During an interview 9/05/24 at 1:15 PM, the Regional Nurse reported she did not have a copy of a Facility Assessment from 2023 but the prior survey team should have one because they requested this during the facility's survey last year. The Regional Nurse reported she planned to check through the survey folder from last year to see if the facility assessment was sent electronically. During an interview 9/05/24 at 1:50 PM, the Regional Nurse reported she would check to see if the prior administrator had a copy of the previous facility assessment but at this time the only facility assessments found are from 5/2022 and 2/2024.

Based on observations, staff interviews, and policy review the facility failed to maintain clean and sanitary conditions in the kitchen, failed to label and store food items and discard leftovers after 3 days in order to maintain food quality and reduce the risk of food-borne illness in the kitchen and the designated resident's refrigerator for one of one nursing units observed. Facility staff also failed to wash hands to prevent food borne illness. The facility reported a census of 50 residents. Findings include: 1. Initial kitchen observations on [DATE] starting at 9:40 AM revealed the following: a. The microwave had dried yellow debris splattered over the interior glass door and the glass plate inside the microwave, and splatters of food on the top and sides inside the microwave. b. A large frying pan had multiple scratches and the interior surface had peeled and missing Teflon coating. c. The [NAME] Cold Refrigerator had food particles on shelving, and a red liquid spillage on the bottom. The outside of the refrigerator and Victory freezer had splatters of dried liquid debris. d. Gray, fuzzy particles hung from the ceiling above the steam cart. e. The Arctic Air refrigerator had the following items: A box of prune juice without a lid, and dated ,d+[DATE]. One quart of half & half had no open date. One open gallon of white whole milk had no open date. f. The [NAME] Cold refrigerator had containers of food not labeled or dated: A container of apple sauce A container of blue berries A container labeled saltine crackers had sliced tomatoes inside. A container with a green lid labeled pickles had what appeared to be cooked hamburger patties with broth and white particles floating inside. A large package of hot dogs with the top of the package open to air and undated when opened. Three cans of crescent rolls had a use by date [DATE]. Two bags of chicken breasts and two rolls of uncooked hamburger not labeled or dated. The bags of chicken breasts were lying on top of the uncooked hamburger thawing on the bottom shelf of the refrigerator. g. The Victory Freezer had several bags of unlabeled and undated food including a bag of French fries, a bag of sausage links, and two bags of diced chicken. h. The dry storage area had a container labeled dry milk and a use by date ,d+[DATE]. Observations during a follow-up visit to the kitchen on [DATE] revealed the following: a. At 11:33 AM, the garbage can located by the handwashing sink had trash heaped over the top and the garbage can lid propped open from the trash inside. b. At 12:02 PM Staff C, Dietary, placed an item into the overflowing trash, then proceeded to place utensils on the steam table. At 12:03 PM Staff C took dirty dishes to the dishwashing area after she prepared pureed rice and broccoli casserole in a robot coupe. At 12:08 PM Staff C blended chicken breasts in a robot container then poured the ground chicken into a metal pan. Staff C did not wash her hands. At 12:16 PM Staff C, prepared pureed chicken. At 12:22 PM Staff C washed her hands. c. At 12:34 PM, a staff member in the kitchen removed the bag of overflowing trash and placed the bag on the floor by the large mixer. A follow-up visit to the kitchen on [DATE] at 09:45 AM revealed the following: a. The ceiling above the steam table still had gray, fuzzy debris. b. Several items in the [NAME] Cold refrigerator remained unlabeled and undated including 1 quart half and half, 1 gallon of white milk, hot dogs in a Ziploc bag, and a roll of hamburger thawing on the bottom shelf. c. Three cans of outdated Crescent rolls (use by date [DATE]). d. A large frying pan still scratched and had peeled up and missing protective coating. e. The Victory freezer continued to have items unlabeled and undated including the bag of French fries, sausage links, and two bags of diced chicken. The top of a box of uncooked hamburger patties was open and had food exposed to air. f. A container of dry milk remained on the shelf in the dry storage area and had a use by date ,d+[DATE]. During an interview on [DATE] at 9:40 AM, the Activities Director (AD) reported the dietary manager (DM) quit that morning so other departments worked in the kitchen. In an interview on [DATE] at 10:25 AM, the Administrator reported the DM just quit on [DATE] AM. During an interview [DATE] at 1:37 PM, the Dietician reported staff had a daily cleaning checklist and items marked off on the checklist whenever the cleaning task completed. She expected staff labeled and dated food whenever food came into the facility, whenever food opened, as well as any left overs. The surveyor showed the dietician the unlabeled and undated food in the refrigerator. The dietician reported she was uncertain what some of the food were in the containers. During an interview [DATE] at 10:05 AM the Dietician reported she threw the containers of applesauce and hamburger patties away after the surveyor pointed it out to her. On [DATE] at 10:54 AM, the Regional Clinical Director reported the facility had no policy on maintenance of equipment or supplies such as pots and pans in the kitchen. On [DATE] at 7:25 AM, the Administrator showed the surveyor documents that were laminated and posted in the kitchen on [DATE] for staff to reference regarding proper food storage and safe food service. During an interview on [DATE] at 7:40 AM, and a tour of the kitchen with Staff C and the surveyor, Staff C reported the frying pan as not sanitizable and she planned to discard the pan. Staff C stated she would not use the pan in her kitchen. Staff C stated all food should be labeled and dated, including leftovers. The leftovers should be discarded after 3 days. Staff C confirmed the refrigerators had lots of spillage and food particles in them and the doors on the outside needed cleaned. At the time, Staff C stated she found some cleaning checklists dated 2023, but planned to look for cleaning checklists from 2024. On [DATE] at 9:20 AM, Staff C reported no cleaning schedules found except from 2023. She posted a Proper Food Storage policy and put together a log book with a cleaning schedule effective [DATE] for staff to complete and sign off tasks when completed. 2. On [DATE] at 10:35 AM, Staff D, Licensed Practical Nurse (LPN) reported the refrigerator for resident food and pop located in a locked room on Hall B. Observations of the residents' refrigerator with Staff D revealed the following: a. Brown, sticky spillage on the interior door shelf. b. A package of honey ham had a use by date of [DATE]. c. Eight containers of Activia yogurt had a date of [DATE]. d. A box had a resident's name wrote on it but no date listed. The box contained dried up pizza slices inside. e. A fast food bag labeled with a resident's name had a sandwich inside. The bag had a date [DATE]. f. Fourteen mighty shakes had a use by [DATE]. No thaw date listed on the shakes. g. A clear bowl had what appeared to be beef and noodles not dated or labeled. During an interview [DATE] at 10:35 AM, Staff D, LPN, reported she was unsure who cleaned the residents' refrigerator. She had only worked at the facility for a few months. During an interview [DATE] at 10:49 AM, Staff E, Housekeeper, reported she had never cleaned the residents' refrigerator but would have done it if someone told her it needed cleaned. During an interview [DATE] at 10:51 AM, Staff F, Certified Nursing Assistant (CNA) reported she was not sure who cleaned the residents' refrigerator. Staff F thought the night shift staff cleaned the refrigerator because they cleaned the staff breakroom refrigerator. During an interview [DATE] at 10:55 AM, the Director of Nursing (DON) reported the AD took care of the resident snack room and residents' refrigerator. The DON reported she thought pop mostly kept in the refrigerator. The DON confirmed no record of who cleaned the refrigerator or when the refrigerator had been cleaned out. At the time, the surveyor showed the DON the expired items, thawed mighty shakes, and unlabeled and undated food. During an interview [DATE] at 11:31 AM, the Regional Dietary Manager reported mighty shakes discarded after 7 days if thawed and not used. A Preventing Foodborne Illness- Food Handling policy revised ,d+[DATE] revealed food stored, prepared, handled and served to minimize the risk of foodborne illness. The critical factors implicated in foodborne illness are poor personal hygiene of food service employees and contaminated equipment. All food service equipment and utensils sanitized according to current guidelines and manufacturers' recommendations. A Food Receiving and Storage policy revised ,d+[DATE] revealed the following: a. Foods received and stored in a manner that complies with safe food handling practices. A clean food storage area maintained at all times. b. All foods stored in the refrigerator or freezer needed covered, labeled and dated. c. Refrigerated food must be stored below 41 degrees F and labeled with a use by date. d. Beverages dated when opened and discarded after 24 hours. e. Wrappers of frozen foods must stay intact until thawing. f. Uncooked and raw animal products needed stored separately in a drip-proof container and below fruits, vegetables and other ready-to-eat foods. g. Dry foods stored in bins removed from original packaging, labeled and dated (use by date). An undated Proper Food Storage Policy revealed the refrigerator and freezer should always be organized and clean and the bottoms and outside of them wiped clean daily. All food items labeled and dated, and food disposed of after 3 days of the marked date.

Based on observation, menu review, record review, and staff interviews, the facility failed to serve the appropriate portions for 4 of 4 residents who received pureed diets (Resident #9, #12, #27, and #31) and 10 of 10 residents on a mechanical soft diet (Resident #4, #7, #18, #19, #25, #28, #30, #35, #37, and #47). The facility reported a census of 50 residents. Findings include: The facility's Week 3 menu for Tuesday lunch identified barbeque (BBQ) chicken to be served as part of the planned pureed textured diet for the lunch meal served on 09/03/24. The facility's Week 3 menu for Tuesday lunch identified a #8 scoop of BBQ chicken to be served as part of the planned mechanical soft textured diet for the lunch meal served on 09/03/24. The facility's Census Order -All Special Diet Report identified four (4) residents on a pureed texture diet, and ten (10) residents on a mechanical soft textured diet. During observation on 09/03/24 at 12:08 PM, Staff C, Dietary Manager, placed six (6) chicken breasts into a robot coupe container and blended the contents. Staff C took tongs and removed a large portion of chicken breast from the container, and placed it into a small metal pan. Staff C blended the remaining contents in the robot container, then poured the ground chicken into a different metal pan. At 12:12 PM, Staff C placed 4 more chicken breasts into the robot container, and blended the contents together. Staff C poured all of the ground meat into a measuring cup and reported a total of 6 cups. Staff C checked the serving chart on the wall and reported a #10 scoop and a #20 scoop would be used whenever the entree served for residents on a ground/mechanical soft diet. The serving chart revealed a #10 scoop the equivalent of 3 1/4 ounces (oz.), and a #20 scoop the equivalent of 1 5/8 oz. At 12:16 PM, Staff C reported she planned to prepare five (5) pureed servings. Staff C placed 5 chicken breasts into a robot coupe container, added some BBQ sauce, and blended the contents together. Staff C poured the contents into a measuring cup and reported a total of 2 cups. Staff C checked the serving chart on the wall and reported a #8 scoop and a #20 scoop would be used when the entree served to the residents on a pureed diet. The serving chart revealed a #8 scoop the equivalent of 4 oz., and a #20 scoop the equivalent of 1 5/8 oz. During the lunch meal service on 09/03/24, the Activities Director (AD) plated food for the residents on a pureed diet (Resident #9, #12, #27, and #31) and for the residents on a mechanical soft diet (Resident #4, #7, #18, #19, #25, #28, #30, #35, #37, and #47). During meal service a gray and yellow scoop fell on to the floor but the scoops were not replaced. The AD continued to plate the food. At 1:29 PM, the AD reported the last resident's food plated. The AD reported she used the following serving sizes: a. One #8 (gray) scoop of ground chicken, the equivalent of 4 oz. Residents on a mechanical soft diet were supposed to get a total of 4 7/8 oz. of ground chicken. b. One #16 (blue) scoop of pureed chicken, the equivalent of 2 oz. Residents on a pureed diet were supposed to get a total of 5 5/8 oz. of pureed chicken. During an interview on 09/04/24 at 10:05 AM, the consulting dietician reported she expected staff to follow the menu and serve the proper serving sizes. During an interview 09/04/24 at 10:10 AM, Staff C reported not enough serving utensils in the kitchen. She told the Administrator on 9/3/24 to order 4 of each serving utensil. During an interview 09/04/24 at 3:30 PM, the AD reported she looked at the menu book to know what serving size to serve on each entree, then she looked at the colored chart to see which numbered scoop to use. The AD stated she didn't know she needed to use two different scoops when she served the pureed chicken and ground chicken, but confirmed a couple of scoops fell on to the floor during the lunch meal service on 09/03/24. On 09/05/24 at 7:25 AM, the Administrator showed the surveyor the documents that were laminated and posted in the kitchen on 09/04/24 for staff to reference regarding equivalent measurements and serving food.

Based on observation, staff interview, and facility policy review the facility failed to prepare and serve all foods at a safe and palatable temperature in order to prevent foodborne illness for 1 of 1 meals observed. The facility reported a census of 50 residents. Findings include: During observation on 09/03/24 at 12:17 PM, four plates of lettuce salad with cut up pieces of ham, turkey, and boiled eggs, and twelve bowls of cottage cheese sat on the counter next to the stove. The plates of salad and the bowls of cottage cheese were not on ice or a cooling mechanism. During observation on 09/03/24 at 12:43 PM, the Activities Director (AD) checked and reported the food temperatures on the following entrees: a. Ground chicken at 162 degrees Fahrenheit (F) b. Pureed rice/broccoli casserole at 184 (F) c. Pureed chicken at 173.5 (F) At 12:53 PM, the AD began to plate food for the residents. At 12:59 PM, the Director of Nursing (DON) checked the temperatures on the following entrees: a. Lettuce salad at 54.1 (F) b. Cottage cheese at 49.6 (F) At 1:04 PM, a container of cheese slices sat on the counter and not on ice or a cooling mechanism. At 1:29 PM, the AD reported the last food plated for the residents. The AD checked the food temperatures of the remaining food which revealed the following: a. Ground chicken at 134 (F) b. Pureed rice/broccoli casserole at 136.8 (F) c. Pureed chicken at 163 (F) During meal service, the surveyor observed: A cheese slice placed on a hamburger patty for Resident #15, #17, and #39. Lettuce salads served to Resident #21, #41, and #50. Cottage cheese served to Resident #5 and #19. During an interview on 09/04/24 at 10:05 AM, the dietician consultant reported she expected the rice casserole at least 145 degrees (F), and chicken at least 165 degrees (F) whenever the entrees served. On 09/05/24 at 7:25 AM, the Administrator showed the surveyor documents that were laminated and posted in the kitchen on 09/04/24 for staff to reference regarding food temperatures and safe food service. A Preventing Foodborne Illness- Food Handling policy revised 7/2014 revealed food prepared and served to minimize the risk of foodborne illness. The critical factors implicated in foodborne illness are improper temperatures. An undated Food Temperature Chart revealed the minimum cooking temperature for poultry at 166 degrees (F) and casseroles at 165 degrees (F). A County Health Department Food Safety Program for Proper Food Storage revealed cold foods kept at 41 degrees (F) or below.

Based on clinical record review, staff interview and facility policy review, the facility failed to maintain accurate medical records for 1 of 18 residents (Res #26) reviewed. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) Assessment of Resident #26 dated 9/20/23 identified a Brief Interview of Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. The MDS documented the resident to have experienced hallucinations during the look back period. The MDS documented the resident exhibited verbal behaviors directed towards others during 4-6 days of the 7-day look back period and exhibited wandering behavior during 1-3 days of the 7-day look back period. The MDS documented diagnoses that included Non-Alzheimer's Dementia, seizure disorder, depression and bipolar disorder. The MDS failed to document the resident having a diagnosis of schizophrenia. The Medical Diagnosis section of the Electronic Health Record (EHR) of Resident #26 documented schizophrenia became an active diagnosis on 9/8/23 but was not added to the EHR until 5/2/24. The Note To Attending Physician documented the pharmacy requested to change the residents order for Olanzapine (also known as Zyprexa), an antipsychotic medication from 2.5 mg twice a day to 5 mg once a day due to insurance regulations. The physician signed agreement with this request on 9/5/23. The note failed to reveal a diagnosis related to this medication. The Medication Administration Record (MAR) for Resident #26 for Sept of 2023 revealed the order for Zyprexa/Olanzapine 2.5 mg twice daily was ordered as related to unspecified dementia, and bipolar disorder. This order was discontinued on 9/7/23. The MAR recorded the new order for Olanzapine, 5 mg once a day, start date of 9/8/23 was ordered as related to schizophrenia. The Order Details for the Olanzapine dated 9/7/23 was documented as being entered into the EHR by Staff H, Licensed Practical Nurse. The Nurses Note dated 9/7/23 at 2:37 pm documented a new order was received from the physician to change Olanzapine 2.5 mg twice daily to 5 mg daily. The Note documented this was related to insurance change. The Note failed to document the physician giving a diagnosis of schizophrenia related to this medication. The encounter note dated 10/6/23 by the Mental Health Nurse Practitioner (NP) documented this visit was the initial evaluation by the provider to begin services for Resident #26. The note documented the visit was for an initial psychiatric review of diagnostics and evaluation of current medications. The note documented the resident was receiving Olanzapine for the treatment of schizophrenia. The note additionally documented behaviors of combativeness, yelling out, pulling fire alarms, increased agitation, elopement attempts, and throwing furniture. Additional behaviors were documented including making repetitive statements, cursing, agitation and wanting to return to his home. The note recorded multiple diagnoses of past medical history, which did not include schizophrenia. The note listed the resident's medications, dosage and frequency was taken from the facility where the patient resided, and reflected the best information available at the time of the encounter. Each medication listed was linked to a diagnosis and an ICD-10 code (International Classification of Diseases, a global system for coding and classifying medical diagnoses, symptoms and procedures) except for the Olanzapine which only stated schizophrenia with no ICD-10 code. On 9/5/24 at 8:35 am, the Director of Nursing (DON) stated Staff H, LPN no longer worked for the facility. She stated Staff H had moved to a different state and the phone number the facility had on file for her was no longer active and they were unable to reach her. She stated the facility was unable to determine why Staff H had used the diagnosis of schizophrenia for the medication and was unable to locate any earlier record of Resident #26 having the diagnosis. She stated the diagnosis was free typed into the medication order and not linked to an active order in the resident's EHR. She stated the medication was for bipolar disorder on prior orders. The DON further stated that the pharmacy did request clarification from the Mental Health Nurse Practitioner (NP) recently on 6/11/24 and the NP did feel the diagnosis was accurate. On 9/5/24 at 11:23 am, the DON stated she would be speaking to her psychiatric provider and asking her to look at the diagnosis and address it formally. She stated her expectation is for a nurse to type a diagnosis if a physician gives a verbal order which includes that diagnosis, and a progress note should be made to link that diagnosis with the verbal order. She stated if a physician does not add a new diagnosis, the medication should be linked to an active diagnosis currently on the resident's record. The facility policy Electronic Medical Records, revised March 2014 failed to reflect an expectation of Medical Records to be accurate and complete.

Based on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination of invasive medical equipment for 1 of 1 resident reviewed (#12). The facility reported a census of 50 residents. Findings include: On 9/03/24 at 10:54 AM, Resident #12 was observed with a urinary catheter hung on the left side of the recliner with dependent loop. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was not able to complete the interview. It included diagnoses of neurogenic bladder (lack of bladder control due to nerve damage), cerebral palsy, bipolar disorder, and need for assistance with personal cares. It also revealed the resident had an indwelling catheter and was dependent in all activities of daily living (ADLs). A Physician's Order included Enhanced Barrier Precautions (EBP) due to colostomy & suprapubic catheter every shift for infection control. A Progress Note dated 7/24/24 indicated the resident had a catheter and care was provided by staff. The Care Plan dated 1/03/22 indicated the resident was at risk for potential infection related to the catheter and directed staff to perform catheter care per facility protocol. It also included EBP when performing high-contact care activities. On 9/05/24 at 10:35 AM, Staff G, Certified Nurse Aide (CNA) emptied Resident #12's urinary catheter collection bag. During the procedure, Staff G performed hand hygiene with soap and water. She stated she was going to lay a clear, plastic trash bag on the floor to set the dirty container in. She donned gloves and grabbed the plastic bag and urine container. She placed the urine container in the plastic bag on the floor, obtained an alcohol swab off the bedside table, opened the package, removed the swab, and cleaned the catheter bag drain. She emptied the urine into the container, obtained another alcohol swab off the bedside table, opened it, removed the swab, and cleaned the catheter bag drain. She tucked the drain into the drain holder and emptied the urine into the toilet. At 10:05 am, Staff G stated that she forgot to put on the Personal Protective Equipment (PPE) gown for Enhanced Barrier Precautions (EBP). She also stated she should have performed hand hygiene between emptying the urine into the container and cleaning the drain. On 9/05/24 at 11:56 AM, the Director of Nursing (DON) stated staff should gown appropriately for resident care and should have had sanitizer set up and ready for a glove change between the two steps. A policy titled Enhanced Barrier Precautions dated 3/28/24 defined Enhanced Barrier Precautions as an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. It indicated PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact care included device care or use of urinary catheters. A policy titled Handwashing/Hand Hygiene revised 8/2019, directed staff to perform hand hygiene before and after handling an invasive device (e.g. urinary catheters), after handling contaminated equipment, and before moving from a contaminated body site to a clean body site during resident care.

Based on observations, staff interview and resident interviews, the facility failed to serve room trays at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care, by delaying room tray delivery for the lunch meal past 1:00 p.m. The facility reported a census of 48. Findings include: In an interview on 5/28/24 at 1:30 p.m. the Director of Nursing stated meal times are scheduled at 8:00 a.m., 12:00 p.m. and 5:45 p.m. During observations on 5/23/24 at 12:15 p.m. staff began serving individual meal plates to residents in the dining room at 12:15 p.m. and completed the serving in the dining room at 12:37 p.m. Room trays observed being prepared at 12:40 p.m. At 12:50 p.m. through 12:52 p.m. room trays delivered to hall 1. Room trays for hall 2 left the kitchen at 1:00 p.m. and the last tray served on hall 2 was at 1:11 p.m. Interviews of residents receiving food trays found some who expressed dissatisfaction with the late serving time. During observations on 5/28/24, staff began serving individual meal plates to residents in the dining room at 12:15 p.m. Room trays were observed being prepared and left the kitchen for hall 1 at 1:00 p.m. Room trays for hall 2 left the kitchen at 1:10 p.m. and the last tray served on hall 2 was at 1:18 p.m.

Based on observations, clinical record review, resident and staff interviews, the facility failed to ensure residents are provided bathing opportunities for 2 of 3 residents dependent on staff. (Residents #2, #6) The facility reported resident census of 48. Findings include: 1. The Admission Minimum Data Set (MDS) with a reference date of 9/26/23, Resident #2 had a Brief Mental Status (BIMS) score of 15 out of 15 which indicated an intact cognitive status. Resident #2 required limited assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included chronic obstructive pulmonary disease, diabetes mellitus and bipolar disorder. According to Resident #2's Care Plan dated 9/28/23, Resident #2 requires limited physical assistance with bathing. Review of Resident #2's bathing records for September and October 2023, found three occasions in which there was an excess of five days in between bathing opportunities (9/7-9/14/23, 9/15-9/21/23, and 9/25-10/2/23). According to Resident #2's Care Plan dated 9/28/23, the care plan lacked interventions related to the use and care of her catheter. During observations on 10/19/23, Resident #2 remained in her gown until 10:20 a.m. and indicated staff only dressed and groomed her and did not provide peri care or change her brief. Resident #2 stated staff had emptied her catheter bag, but did not clean the tubing. At 2:00 p.m. Resident #2 stated the day shift had not provided any catheter care or changed her brief throughout the day. On 10/19/23 at 2:39 p.m. Staff J, Certified Nurse Aide, stated she was working a double shift today and stated there was only her and another aide for both halls today until 11:00 a.m. Staff J stated she did not think resident needs could be met with only two staff and nearly 50 residents during the day. Staff J reported that two aides per hall is more reasonable. When asked Staff J what is expected with catheters she stated they are expected to empty the bag and clean the catheter tubing each shift. Staff J stated she did not clean Resident #2's catheter during the day shift. On 10/19/23 at 2:55 p.m. the Director of Nursing (DON) reported aides are expected to clean catheter tubing when they provide peri cares and empty the catheter bag each shift. She stated they are also expected to ensure the tubing is not kinked and report any concerns with the catheter and urine to the nurse. 2. The Admission MDS with a reference date of 9/4/23, documented Resident #6 had a BIMS score of 15 out of 15 which indicated an intact cognitive status. Resident #6 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #6's diagnosis included coronary artery disease, congestive heart failure, renal failure, diabetes mellitus and bipolar arthritis. According to Resident #6's Care Plan dated 10/2/23, Resident #6 requires extensive physical assistance with bathing. Review of Resident #6's bathing records for September and October 2023, revealed two dates in which bathing was not offered (9/2, and 10/14/23) and three occasions in which there was an excess of five days in between bathing opportunities (9/20-9/28, 9/28-10/4, and 10/7-10/14/23).

Based on observation, clinical record review, resident and staff interviews, the facility failed to answer call lights within a reasonable amount of time. (Residents #2, #6, #7, #8) The facility reported resident census of 48. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 9/26/23, Resident #2 had a Brief Mental Status (BIMS) score of 15 out of 15 indicating an intact cognitive status. Resident #2 required limited assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included chronic obstructive pulmonary disease, diabetes mellitus and bipolar disorder. In an interview on 10/18/23 at 12:00 p.m. Resident #2 stated her only concern with the facility was not having enough staff, noting long call light wait times. 2. According to a MDS with a reference date of 9/26/23, Resident #6 had a BIMS score of 15 out of 15 indicating an intact cognitive status. Resident #6 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #6's diagnosis included congestive heart failure, diabetes mellitus, renal failure and arthritis. In an interview on 10/18/23 at 8:15 a.m. Resident #6 stated the facility did not have enough help noting she has waited two hours before getting removed from the dining room and an hour for call lights to get answered. 3. According to a MDS with a reference date of 10/9/23, Resident #7 had a Brief Mental Status BIMS score of 15 out of 15 indicating an intact cognitive status. Resident #8 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #7 was coded as frequently incontinent of bladder. Resident #7's diagnosis included cerebrovascular accident (stroke), aphasia and hemiplegia. During an observation on 10/18/23 at 8:30 a.m. Resident #7 observed sitting in her wheelchair. The resident asked this surveyor if he could hand her the call light, and stated she was sitting in urine. Observed the call light not accessible as it was draped over her recliner. 4. According to a MDS with a reference date of 7/13/23, Resident #8 had a BIMS score of 14 out of 15 indicating an intact cognitive status. Resident #8 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #8 is coded as frequently incontinent of bladder. Resident #8's diagnosis included cerebrovascular accident (stroke), aphasia and hemiplegia. During an observation on 10/19/23, at 11:50 a.m. observed Resident #8's call light activated. At 12:05 p.m. observed the call light turned off. This surveyor entered the resident's room and asked her what she needed. Resident #8 stated she needed to go to the bathroom and requested the call light be turned on again. At 12:07 p.m. staff responded to and provided assistance to the toilet. In an interview on 10/19/23 at 2:39 p.m. Staff J, Certified Nurse Aide, stated she was working a double shift today and stated there was only her and another aide for both halls today until 11:00 a.m. Staff J stated she doesn't think resident needs can be met with only two staff and nearly 50 residents during the day. Staff J thinks two aides per hall is more reasonable.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to administer medications as ordered for 4 of 11 residents reviewed for medication administration (Residents #1, #14, #16, #23) and failed to administer the correct nutritional feeding for 1 of 1 residents reviewed with a Gastrostomy Tube(g-tube-a tube inserted into the stomach through the abdomen) (Resident #38). The facility reported a census of 34 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 2/9/23, listed diagnoses for Resident #14 which included non-Alzheimer's dementia, anxiety, and bipolar disorder. The MDS listed the resident's Brief Interview for Mental Health (BIMS) score as 5 out of 15, which indicated severely impaired cognition. A 9/4/18 Care Plan entry stated the resident received Clonazepam (a medication used to treat anxiety) for anxiety. A 3/11/23 Incident, Accident, Unusual Occurrence Note stated the resident received 1 milligram (milligram) instead of 0.5 mg. The note did not include the name of the medication. A 3/29/22 Order Entry listed an order for Clonazepam 1 mg, give 0.5 mg by mouth two times a day and 1 tablet 1 time per day. The March 2023 Medication Administration Record (MAR) directed staff to administer Clonazepam 1 mg 0.5 tablets in the morning and midday and 1 tablet of clonazepam in the evening. On 6/15/23 at 9:05 a.m., the Director of Nursing (DON) stated she could not find any clarification in the record regarding which medication the error involved but deduced from the MAR it was the Clonazepam. She stated nurses should check the MAR and compare the dose with the medication card and stated the facility directed nurses to triple check medications. 46873 2. The Quarterly MDS of Resident #1 dated 3/30/23 identified a (BIMS) score of 14 which indicated cognition intact. On 6/13/23 at 8:24 am Resident #1 received two morning medications. Staff A, Certified Medication Aide (CMA) stated the other medications she pulled from the drawer were not scheduled at that time. The MAR for June 2023 failed to reveal documentation of medications scheduled for 5:00 am on 6/13/23 being given. On 6/13/23 at 8:41 am, the (DON) stated Resident #1 normally took his 5:00 am medications anytime between 5:00 and 5:30 am. She stated the night shift had a busy night and may have failed to document the medications. She stated she would call the nurse and ask her if they were given. On 6/13/23 at 8:50 am, Resident #1 stated he had not received any medications that morning prior to the 2 medications given at 8:24 am. He stated the staff crush the medications and place them on his bedside table but he did not received them that morning. He stated he didn't know what happened why he didn't get them. Observation 6/13/23 at 8:55 am medications Sucralfate and Pantoprazole for the 13th of June were noted to still be in the medication blister packs. Both medications were scheduled to be given at 5:00 am on the MAR. Communication with Physician note dated 6/13/2023 at 9:03 am documented the Primary Care Physician for Resident #1 was informed of Resident #1 not receiving his 5:00 am medications on 6/13/23 and orders were received. On 6/13/23 at 4:50 pm the DON stated she spoke to the night shift nurse who verified the 5:00 am medications were not administered to Resident #1 on 6/13/23. She further stated the physician was notified of the error and gave an order to give the medications late. 3. The Entry MDS of Resident #38 dated 6/4/23 identified a (BIMS) score of 14 which indicated cognition intact. The MDS documented diagnoses that included severe protein calorie malnutrition and cerebral palsy. The MDS documented the presence of a feeding tube. The MDS recorded the resident received 50% or more of total calories through tube feeding and 501 cc/day (cubic centimeters per day) or more fluid in take per tube feeding. The Care Plan for Resident #38 revised 6/8/23 identified the resident required a percutaneous endoscopic gastrostomy (PEG) tube for adequate nutritional intake. The Care Plan also identified Resident #38 had orders for Jevity 1.2 cal tube feeding formula. On 6/12/23 at 11:50 am, Resident #38 was observed resting in bed with continuous tube feeding running through his PEG tube. The tube feeding formula being administered was observed to be Jevity 1.5 cal rather than the ordered formula of Jevity 1.2 cal. On 6/13/23 at 1:11 pm, Resident #38 was observed resting in bed with continuous tube feeding of Jevity 1.2 running through his PEG tube. On 6/13/23 at 4:55 pm, the Director of Nursing (DON) stated tube feeding supplies are kept in the closet of the resident's room and a new box had been opened on 6/12/23. She stated she was not aware of any Jevity 1.5 cal anywhere in the building and did not know where that would have come from. She also stated she would check other store rooms to see if she could discover how the incorrect feeding could have been hung. On 6/14/23 at 3:48 pm the DON stated she spoke to the nurse who had administered the incorrect tube feeding. The DON stated education had been provided to the nurse regarding double checking the formula bottle to verify it is the ordered formula prior to administration. The DON also stated she had notified the physician and the family of Resident #38 of the error. The Incident, Accident, Unusual Occurence Note dated 6/13/23 at 5:40 pm documented the Advanced Registered Nurse Practioner was notified of and received no new orders. The Note documented the Power of Attorney for Resident #38 was updated and Resident #38 was assessed and had no gastrointestinal upset. 47336 4. The Quarterly MDS assessment dated [DATE] revealed Resident #23 scored 4 out of 15 on a BIMS exam, which indicated severely impaired. The MDS revealed medical diagnosis of a thyroid disorder. The Care Plan dated 4/20/23 revealed a focus problem of hypothyroidism related to thyroiditis (swelling of the thyroid). The interventions dated 2/7/23 included administering thyroid replacement therapy as ordered. The EMR (Electronic Medical Record) revealed a diagnosis of hypothyroidism, unspecified. The Physician Orders dated 2/8/23 for Levothyroxine Sodium oral tablet 25 mcg (microgram)- give 25 mcg by mouth one time a day. The MAR (Medication Administration Record) for March 2023 revealed a number 9 marked on the 7th, 8th, 9th, 10th. The number 9 charted meant other, see progress notes. The Progress notes dated 3/7/2023 at 11:20 AM revealed medication not available at this time for Levothyroxine 25 mcg tablet. The Progress notes dated 3/8/2023 at 9:16 AM revealed medication not available at this time for Levothyroxine 25 mcg tablet. The Progress notes dated 3/9/2023 at 9:46 AM revealed medication not available for Levothyroxine 25 mcg tablet. The Progress notes dated 3/10/2023 at 6:30 AM revealed the nurse called the pharmacy and the pharmacy stated the medication sent on the 3rd however they would send more to the facility. The Progress notes dated 3/10/2023 at 9:05 AM revealed medication not available at this time for Levothyroxine 25 mcg tablet. 5. The Annual MDS assessment dated [DATE] revealed the Resident #16 scored 15 out of 15 on a BIMS exam, which indicated cognitively intact. The MDS revealed Medical Diagnosis of Atrial Fibrillation (A-fib). The MDS revealed the resident received an anticoagulant 0 out of 7 days. The Electronic Medical Record (EMR) revealed Resident #16 medical diagnosis of unspecified A-fib and the presence of a cardiac pacemaker. The Physician Orders ordered on 4/21/22 Rivaroxaban tablet 20 mg (milligram) give 1 tablet by mouth one time a day. The Care Plan dated 5/3/23 revealed a focus problem of Resident #16 being at risk for deep vein thrombosis and prescribed Rivaroxaban. Interventions dated 5/1/23 revealed administration of anticoagulant (blood thinner) as ordered. The Care Plan revealed a focus problem of anticoagulant/blood thinning therapy Rivaroxaban related to A-Fib. The interventions dated 4/21/22 indicated to monitor for side effects such as usual bruising, bleeding gums, purpura (a rash of purple spots), and changes in mental status which indicated hyper-coagulation and effectiveness. The Progress Notes dated 2/28/2023 at 4:41 PM revealed medication unavailable for Rivaroxaban 20 mg tablet. The Progress Notes dated 3/1/2023 at 3:27 PM revealed medication unavailable for Rivaroxaban 20 mg tablet. The Progress Notes dated 3/16/2023 at 3:16 PM revealed medication unavailable and ordered from pharmacy for Rivaroxaban 20 mg tablet. The Progress Notes dated 3/17/2023 at 5:04 PM revealed medication unavailable and ordered from pharmacy for Rivaroxaban 20 mg tablet. During an interview on 6/12/23 at 12:48 PM, Resident #16 stated instances he didn't have the right medications. The resident stated about every month he went without his blood thinner for 2 or 3 days because they didn't have it. During an interview on 6/14/23 at 11:41 AM, Staff B, RN (Registered Nurse) queried why a resident's medication would not be available and she stated it was possible staff didn't order the medication. During an interview on 6/15/23 at 8:04 AM, Staff G, LPN (Licensed Practical Nurse), queried why a medication would not be available and she stated she wasn't sure and would assume if the medication wasn't located in the drawer they needed to check the emergency kit and if they didn't have it, they needed to call pharmacy. She stated pharmacy came every evening and they delivered STAT (immediately) orders too. Staff G stated the agency nurses might not known how to reorder medication on the computer. She stated Rivaroxaban came in short cycles and on day 5 the numbers changed on the card reminding them for reorder. During an interview on 6/15/23 at 10:07 AM, the DON queried on the expectations of medications being stocked and available for residents and she stated the medications should be available and when the medication is ordered before 5 PM the medication arrived that evening. She stated if the pharmacy couldn't fill it, the doctor was notified for new orders and the family notified if the medication wasn't given. The facility policy Administering Medications, revised April 2019, directed staff to administer medications in a timely manner as prescribed. The policy directed staff to administer medications in accordance with prescriber orders within the required time frame and to check the medication label 3 times to verify the right medication, dosage, and time.

Based on observation, policy review, and staff interview, the facility failed to follow proper sanitation and food handling practices during the initial pool and for 1 of 1 meal observed. The facility reported a census of 34 residents. Findings include: Observations during the initial tour on 6/12/23 at 9:45 a.m. revealed the following concerns: a. The hand washing sink had no paper towels and was located directly in front of a table which had a package of bread and other food items on top of it. The bread was less than 2 feet from the freezer. b. The fire prevention spigots had dust particles hanging down from them directly over the stove top. c. A fan with heavy dust particles clinging to the grill blew directly into the dish washing area. d. The [NAME] refrigerator contained 12 various type of juices which were not labeled with dates. e. A bag of corned beef hash was on the bottom shelf undated. f. A bag of ham was dated 6/2/23. g. A bag of lettuce was dated 6/4/23. h. There were multiple red splatters on the outside of the [NAME] refrigerator. i. The overhead fire prevention system had dust particles hanging down. j. A fan with dust particles on the grate blew into the dish washing room. During the lunch meal service/preparation on 6/13/23 at 11:30 a.m. the following concerns were identified: a. The paper towel dispenser near the hand washing sink near the dishwashing room was broken. During hand washing all of the paper towels fell out. The Administrator was in the kitchen and stated he would leave the kitchen to retrieve paper towels. b. A cart containing blue insulated cups was covered with brown splatters. c. The inside 6 walls of the microwave were covered with brown and yellow drips. The glass plate at the bottom was covered with dried, crusty, food. The outside of the microwave was covered with greasy looking smudges. d. The ceiling vent in front of the main kitchen door to the side of the milk cooler contained heavy string-like dust particles. e. The dust particles on the fire suppression system remained. f. Dust remained in the grates of the fan in the dish washing room. g. Staff C Cook wore gloves and touched the refrigerator door with his right hand and a bag of frozen chicken with his left hand. He then touched the insides of metal pan liners with his right hand. He later placed food he served to residents in the pans. h. At 6/13/23 at 11:44 a.m., Staff C left the kitchen and stated he was going to the restroom. Staff C returned shortly and touched his hair while putting his hair net on. He then donned gloves without washing his hands and with his gloved fingers, he touched his beard. Without changing gloves, he reached into a blue water bucket and retrieved a cloth which he used to wipe off a thermometer. He then used the thermometer to obtain a temperature on a hamburger. The blue bucket contained another cloth which was soiled with a brown substance. Staff C chewed gum during this time. i. At 11:53 a.m. Staff E Dietary Manager of a sister facility arrived in the kitchen and began to wash his hands at the sink near the break room door. There were no paper towels at that sink so Staff E shut off the water with his bare hands. There were still no paper towels near the hand washing sink near the dish washing room. j. The wall behind the stove was covered with brown splatters. k. Staff C wore gloves and touched the handle of the thermometer with his right hand. He then used the same gloved hand to touch baked fish he then placed in the steam table to serve to a resident. l. Staff C continued to chew gum as he obtained food temperatures and stood over the steam table. m. Staff C wore gloves and touched salad bowls, the pantry door knob, and his watch and then with the same gloves he touched multiple pieces of bread he then served to the residents. The facility policy Handwashing, dated February 2016, directed staff to wash hands in accordance with established procedures in order to prevent contagion and to protect residents from infections. The policy directed staff to wash hands in situations including the following: when leaving and returning to the kitchen area, after handling hair, after hand contact with unclean equipment and work surfaces. The policy Cleaning Instructions, dated February 2016, stated all kitchen areas and equipment would be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility policy Storage, dated February 2016, stated the facility would store food under sanitary conditions and stated staff would date food items. On 6/14/23 at 1:05 p.m., Staff D Dietary Manager of a sister facility stated there should be daily, weekly, and monthly cleaning lists which staff should sign off every day. She stated the microwave and walls needed to be cleaned daily and staff should check food dates. She stated staff should complete hand washing: between tasks, after using the restroom, after eating, if they dropped anything, and right before meals. She stated for ready-to-eat food, staff should use a utensil to serve and stated Staff C will complete additional training. During an interview on 6/15/23 at 11:04 a.m., the Corporate Nurse stated that the facility did not have a specific policy for glove use in the kitchen but she would look into this.

Based on clinical record review, observations, staff interview and facility policy, the facility failed to provide clean bed linens for 1 of 16 residents reviewed for homelike environment (Resident #7). Findings include: The Significant Change Minimum Data Set (MDS) for Resident#7 dated 1/3/23 identified a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS revealed the resident required extensive physical assistance of 1 person for bed mobility and personal hygiene and extensive physical assistance of 2 persons for transfers. The Care Plan revised on 5/17/23 identified the resident required assistance for all activities of daily living. The Care Plan directed staff to transfer the resident with assistance of 2 using a Hoyer lift and needing assistance of 1 staff member for personal hygiene. On 6/12/23 at 2:14 pm, Resident #7 was observed lying in his bed. An odor was noted in the room. The fitted sheet was visibly soiled and was noted to only be partially on the mattress with one corner of the fitted sheet not under the mattress. Bathing documentation reflected Resident #7 received a bath on 6/13/23, documented at 11:25 am. On 6/13/23 at 11:44 am, Resident #7 was in the dining room being assisted by staff to lunch. No body odor was noted. On 6/13/23 at 12:57 pm, Resident #7 remained in his wheelchair in the common area of the facility. The soiled sheets were still on the bed and the room had a strong odor. On 6/13/23 at 1:07 pm, the Director of Nursing stated her expectation is for bed linens to be changed on the first shower day of the week for the resident. On 6/13/23 at 5:00 pm Resident #7 was in the dining room. The soiled sheets remained on his bed. On 6/14/23 at 9:24 am Staff A, Certified Medication Aide (CMA) stated there is an assignment book which has the assigned shower days. She stated bed linens are normally stripped before the shower and housekeeping wipes down the mattress while the resident is in the shower. She stated new sheets are provided after the shower. She also said that if sheets are stained or obviously dirty those are changed immediately regardless of whether or not it is a shower day. On 6/14/23 at 1:40 pm, Staff F, Certified Medication Aide (CMA) stated she assisted that morning in the Hoyer lift transfer of Resident #7 and she completed a full linen change that morning. She stated Resident #7 spits a lot and his flat sheet near the head of his bed was soiled with sputum. The Policy titled Laundry and Bedding, Soiled, with a revision date of October 2018 directed staff as follows: soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control.

Based on record review, Resident Assessment Instrument (RAI) manual v1.17.1_October 2019, and staff interview, the facility failed to complete a comprehensive assessment of a resident's needs within 14 days of admission for 1 of 15 residents (Resident #38) for Minimum Data Set (MDS) requirements. Findings Include: The Entry Minimum Data Set (MDS) of Resident #38 dated 5/30/23 identified the resident had an admitted to the facility of 5/20/23. Section 2.5 of the RAI manual, dated October 2019, defines admission as the date a person enters the facility and is admitted as a resident. The RAI documented an Admission assessment must occur in any of the following admission situations: when the resident has never been admitted to this facility before; OR when the resident has been in this facility previously and was discharged return not anticipated; OR when the resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge. Section 2.6 of the RAI manual documented an Admission Assessment must be completed no later than the 14th calendar day of the resident's admission (admitted plus 13 calendar days). On 6/14/23, admitted plus 25 calendar days, the Admission Assessment of Resident #38 remained incomplete. On 6/15/23 at 8:24 am, the MDS Coordinator stated an admission assessment is to be completed within two weeks of a resident's admission. She stated she would complete the Admission MDS for Resident #38 immediately. The Policy MDS Completion and Submission Timeframes, revision date July 2017, documented the Policy Statement of Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The Policy documented : The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submittedto CMS ' QIES Assessment Submission and Processing (ASAP) system in accordance with current federaland state guidelines Timeframes for completion and submission of assessments is based on the current requirements publishedin the Resident Assessment Instrument Manual.

Based on interview and record review the facility failed to accurately document the functional status and the anticoagulant medications on the MDS (Minimum Data Set) assessment for 2 of 15 residents reviewed (R# 16, R#23). The facility reported a census of 34. Findings Include: 1. The Annual MDS assessment dated [DATE] revealed Resident #23 scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired. The MDS revealed medical diagnosis of non-traumatic brain dysfunction; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and unspecified lack of coordination. The MDS revealed the resident did not transfer between surfaces including to or from the bed, chair or wheelchair during the 7 day look back period. The Care Plan dated 4/20/23 revealed a focus problem of history of falling. Interventions dated 1/25/23 revealed using a one way slide to wheelchair. The Care Plan revealed a focus problem of required staff assistance for all ADLs (Activities of Daily Living). The interventions dated 1/25/23 included required assistance of two for transfers and the use of an EZ stand lift for transfers or the Hoyer lift when resident felt fatigued or uncooperative. During an observation on 6/12/23 at 3:18 PM, Resident #23 laid on his bed with the bed in the lowest position and the call light within reach. During an observation on 6/13/23 at 10:36 AM, Resident #23 sat in his wheelchair in dining room area engaging in an activity. 2. The Annual MDS assessment dated [DATE] revealed Resident #16 scored 15 out of 15 on a BIMS exam, which indicated cognitively intact. The MDS revealed medical diagnosis of Atrial Fibrillation (A-fib). The MDS lacked documentation the resident received an anticoagulant (blood thinner) in the 7 day look back period. The Electronic Medical Record (EMR) revealed Resident #16 medical diagnosis of unspecified A-fib and the presence of a cardiac pacemaker. The Physician Orders ordered on 4/21/22 revealed Resident #16 took Rivaroxaban (blood thinner) tablet 20 mg- give 1 tablet by mouth one time a day. The Care Plan dated 5/3/23 revealed a focus problem of Resident #16 being at risk for deep vein thrombosis and prescribed Rivaroxaban. Interventions dated 5/1/23 revealed administration of anticoagulant as ordered. The Care Plan revealed a focus problem of anticoagulant/blood thinning therapy rivaroxaban related to A-Fib. The interventions dated 4/21/22 indicated to monitor for side effects such as usual bruising, bleeding gums, purpura (a rash of purple spots), and changes in mental status which indicated hyper-coagulation and effectiveness. During an interview on 6/15/23 at 9:35 AM, Staff H, MDS coordinator queried if Resident #16 took an anticoagulant would it be addressed on the MDS and she stated yes and looked at the resident's file and stated yes it should have been there. Staff H asked why a transfer under the functional status revealed the activity didn't occur for Resident #23 and she stated he definitely transferred and reviewed his file and stated the MDS needed updated and coded as extensive assistance. During an interview on 6/15/23 at 10:07 AM, the DON (Director of Nursing) queried on the expectation of the MDS being coded correctly and she stated she expected the MDS to be coded correctly and to the RAI (Resident Assessment Instrument) guidelines. During an interview on 6/15/23 at 2:50 PM, the Nurse Consultant stated there wasn't a policy for MDS, they follow the RAI guidelines.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for weight loss (Resident #24). The facility reported a census of 34 residents. Findings Include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/31/23, listed diagnoses for Resident #24 which included non-Alzheimer's dementia, seizure disorder, and moderate intellectual disabilities. The MDS stated the resident required extensive assistance of 1 staff for eating and listed the resident's Brief Interview for Mental Status(BIMS) as 0 out of 15, which indicated severely impaired cognition. During an observation on 6/14/23 at 8:09 a.m., the resident sat at breakfast and had a glass of red liquid and a water. The resident did not appear to have a nutritional supplement. The Weights and Vitals report revealed the following: The resident's weights of 124 lbs on 9/5/22 and 111.2 lbs on 3/1/23 calculated as a 10.32% loss. The report listed the following subsequent weights: 4/3/23 110.9 lbs 5/1/23 110.6 lbs 6/1/23 107.6 lbs A 1/11/23 Fax Notification of Risk Malnutrition to the physician stated the resident had weight loss and met the criteria for at risk for malnutrition. The Care Plan included the following entries: 2/23/21 The resident was at increased risk for impaired nutrition and would consume more than 50% of meals and staff would review her diet and weigh regularly. 3/31/21 The resident required the assistance of 1 staff for eating. 4/9/21 The resident used a lip plate while eating. 6/29/21 The resident received a pureed diet. 6/13/22 Staff to provide meals within diet and will monitor her diet tolerance and will provide a (Nutritional Intervention Program(NIP) program. 3/28/23 Staff to encourage resident to come to dining room for meals. The Care Plan lacked documentation of the resident's weight loss and lacked further interventions attempted. A 3/9/23 Dietary Note stated the resident's most recent weight was 111.2 lbs and stated the resident had a significant weight loss x 6 months. The note included a recommendation for a 4 ounce house supplement twice daily. The resident's June 2023 Medication Administration Record(MAR) lacked documentation of the administration of a house supplement twice daily. The facility lacked notification of a more recent physician notification of the resident's weight loss. The Diet Type Report, dated 6/12/23, stated the resident was on a Regular/No added salt(NAS) diet pureed consistency. The list lacked documentation of additional dietary interventions or supplements. The facility policy Resident Assessment Instrument, dated February 2016, stated the facility would calculate the resident's weight loss and the resident may potentially benefit from various nutritional approaches. On 6/14/23 at 10:10 a.m., the Director or Nursing(DON) stated the family and provider should be aware of a resident's weight loss and the facility should complete care planning. She stated the facility should complete more interventions and stated the nursing department administered the supplements and the documentation was located on the MAR. She stated weight losses should definitely be included on the care plan and they would send this information to the provider. She stated she would look for additional documentation related to the resident's weight loss. On 6/14/23 at 10:30 a.m. the DON stated she could not find anything additional after the January 2023 physician's notification related to the resident's weight loss.

Based on observation, record review, and interviews, the facility failed to assess pain or carry out interventions to relieve pain for 1 of 2 residents reviewed for pain (Resident #11). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 5/24/23, listed diagnoses for Resident #11 which included chronic pain, other neurologic conditions, and spondylosis (degeneration of the spine) in the lumbar region. The MDS revealed the resident required extensive assistance of 1 for room mobility and toileting; limited assistance of 1 for transfers and corridor mobility; supervision for bed mobility and personal hygiene; and ate independently with set up. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an observation on 06/12/23 at 11:09 am, Resident #11 propelled her wheelchair from the dining room to her room. The resident emitted groans, sighs, and grunts as she moved her chair forward. The resident displayed facial grimacing as she traveled down the hallway. During an observation on 06/14/23 at 09:04 am, Resident #11 groaned and moaned as she repositioned herself in her wheelchair. The resident frowned, grimaced, and sighed. The resident's June Medication Administration Record (MAR) listed an order for the following medications; 1. Acetaminophen (a non-narcotic pain reliever) 650 milligrams (mg) two times per day for chronic pain, documented ' E ' as effective for 15 of 27 administrations. Documentation did not list 'E' for 12 out of 27 administrations. 2. The MAR listed an order for Orphenadrine citrate extended release (skeletal muscle relaxant) 100 mg two times per day for chronic pain, indicated by 'E' as effective for 9 of 27 administrations. Documentation did not list 'E' for 18 out of 27 administrations. 3. The MAR listed an order for Duloxetine capsule delayed release particles (used for nerve pain) 60 mg one time per day for pain, documented 'E' as effective 8 of 14 administrations. Documentation did not list 'E' for 6 out of 14 administrations. 4. The MAR listed an order for Meloxicam (nonsteroidal anti-inflammatory drug) 15 mg one time per day for chronic pain, indicated 'E' as effective 8 of 14 administrations. Documentation did not list 'E' for 6 out of 14 administrations. The resident's June MAR indicated pain level scores of 5 or higher twice on 6/1/23, once on 6/2/23, once on 6/4/23, once on 6/6/23, once on 6/8/23, once on 6/9/23, once on 6/10/23, once on 6/13/23, and once on 6/14/23. Progress Notes on 6/1/23, 6/2/23, 6/4/23, 6/8/23, 6/9/23, 6/10/23, and 6/13/23 lacked documentation of follow-up interventions related to the resident's complaints of pain. A Progress Note dated 6/6/2023 listed orders for Hydrocodone-Acetaminophen (narcotic with non-narcotic pain reliever) 10-325 mg four times a day related to chronic pain, low back pain, and spondylosis (a type of arthritis). A Care Conference Note dated 6/8/23 lacked a review of therapy and chronic pain. The resident's Care Plan, intervention dated 4/4/18, specified that staff monitor, document, and report to nurse as needed any signs or symptoms of nonverbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing), and notify physician if interventions are unsuccessful or if current complaint is a significant change. The resident's care plan, intervention dated 9/27/19, indicated repositioning, pain medication, and sleeping as interventions. The resident's care plan, intervention dated 3/31/23, indicated repositioning and ability to bear weight. The resident's care plan intervention, dated 5/5/23, identified therapy as an intervention. The care plan lacked more individualized interventions. During an interview on 06/12/23 at 11:09 am, Resident #11 reported that she had pain even with medication use and she had not seen a doctor yet. During an interview on 6/14/23 at 9:04 am, Resident #11 indicated she had pain in her lower back. During an interview on 06/14/23 at 09:16 am Staff B, Registered Nurse (RN), acknowledged the resident will sleep in her wheelchair with her head back and has chronic pain. Staff B stated they told the resident to reposition but she slid forward in the wheelchair. Staff B stated that nothing works so far and staff try the best they can. During an interview on 06/14/23 at 09:26 am, the Director of Nursing (DON) indicated the facility discussed pain management during weekly meetings. The DON reported the resident stated her pain was 10 to avoid being asked to do something, saying it hurts too much. The DON reported the resident does not have as needed (PRN) medication. During an interview on 6/14/23 at 2:30 pm, the DON confirmed the facility documents pain based on individual baselines. A pain level of 4 or 5 was flagged for someone without regular pain, and an individual with chronic pain had a baseline documented in the vitals section of the Electronic Health Record (EHR). The DON said current documentation lacked the location of the resident's pain and interventions provided at the time of disclosure. The DON stated when she reviewed pain, she looked for interventions like medication and time of delivery, non-medication diversion and interventions, repositioning, and therapy. She stated she planned an in-service for 6/27/23 to address missing information.

Based on facility records, staff interview and policy review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met on a quarterly basis. Findings include: Per sign in sheets provided by the facility, the facility held QAPI meetings on 7/14/22, 10/27/22 and 5/17/23. There was no meeting between October of 2022 and May of 2023. On 6/15/23 at 10:15 am, the Administrator stated no meeting was held in 2023 prior to May 17. The Administrator stated Past Non Compliance Education was provided to facility staff due to the missed meeting. The facility was in transition of change of leadership during the time the meeting was missed. One administrator served the building from March through October of 2022 and another from November of 2022 through March of 2023, with the current Administrator beginning in March of 2023. There were also four different Director of Nurses during this time frame. The Policy Quality Assurance and Performance Improvement - Governance and Leadership, revised March 2020, documented 'The Committee meets at least quarterly, or more often if necessary'.

Based on clinical record review, family and staff interviews and facility policy review, the facility failed to assure that staff provided appropriate tracheostomy care to include the assessment of respiratory failure and failed to provide appropriate training to nursing staff on procedures during an accidental extubation (tracheostomy tube fall out), tracheostomy care and suctioning for 1 of 1 resident (Resident #12). This failure resulted in the transport by MedAir to a hospital and placed on mechanical ventilation therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The facility identified a census of 36 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 27, 2022 on January 26, 2023 at 10:45 A.M. The facility staff removed the Immediate Jeopardy on January 26, 2023 through the following actions: a. Staff education provided regarding the location of the crash cart (stored behind the nurse's station in the CNA room. b. Staff education provided regarding on the equipment available to them on the crash cart for suctioning. c. Staff education will be completed prior to admitting residents with a tracheostomy tube regarding a tracheostomy course assigned in Relias with a course posttest, tracheal suctioning competency, tracheostomy cleaning, supplies readily available at bedside, humidification systems, tracheostomy assessments, how to handle extubation, and suctioning procedures for future emergency situations. d. Staff education regarding contacting the on-call nurse with any questions on equipment that cannot be located. e. Night nurse will review crash cart supply checklist and complete nightly. Measures or systemic changes made to ensure this will not recur and affect others: Nursing staff and Agency nursing staff will be educated regarding above plan of correction during orientation process. Facility will continue with current plan of correction to complete orientation checklists upon hire. Binder including above listed education will be placed at nurses' station with education sign off to assure that new nursing staff (Facility and agency) are educated appropriately. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident#12 had the diagnoses including diagnosis of heart failure, respiratory failure, tracheostomy, obesity and obstructive sleep apnea. The MDS documented that the resident required extensive assist with bed mobility, dressing and toilet use from 2 persons. Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which suggested an intact cognition. The Care Plan dated 10/25/22 directed staff to administer oxygen as ordered, change the tubing as the protocol directs, provide humidification and suction as needed and monitor for changes that may indicate worsening respiratory status and report it to the physician. The care plan did not address the tracheostomy or care for tracheostomy. The physician order received by phone on 7/24/22, may suction trach every 4 hours and as needed every 4 hours. The physician order received on 7/27/22 directed staff to clean tracheostomy 1 time a week and prn, resident will clean tracheostomy other days, and change oxygen tubing weekly. The physician order received 10/21/22 directed staff to fill humidification chamber with distilled water every evening and as needed. On 11/19/22 Situation, Background, Assessment, Recommendation (SBAR) documentation at 8:20 AM, Staff B, Director of Nursing (DON) revealed a change of condition for Resident #12, shortness of breath, generalized weakness, skin discoloration, and an altered level of consciousness and reported vital signs of Blood pressure 128/88, pulse 75, respiration 20, temperature 98.9 and oxygen saturation 89% with recommendation of emergency room . On 11/19/22 Focused Evaluation documentation at 5 PM Staff C, Registered Nurse (RN) revealed Resident #12 refused medication, experienced nausea, finger tips cyanotic (white color) and unable to obtain oxygen saturation, vital signs blood pressure 97/73, pulse 92, respiration 20, temperature 97.6, resident refused to have lung sound and abdomen assessed, notified physician, no new order, Resident #12 refused offer to go to the hospital during day shift 3 times. Document titled Mercy Medical Center Final Report dated 11/29/22 revealed Resident #12 with a chronic tracheostomy was treated in the [NAME] County emergency room for acute hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), was suctioned and a large amount of tan secretions returned, WBC count 21.1 (normal 4.5 - 11), chest x-ray revealed pulmonary (lung) congestion with bilateral pleural effusions (buildup of fluid in the tissues that line the lungs). Resident #12 was transported by AirMed to Mercy Hospital for diagnosis of severe hypoxic respiratory failure where they removed the tracheostomy tube and replaced it, performed a bronchoscopy (a procedure that lets the doctor look at the lungs and air passages) which revealed thick secretions in both lungs that were removed with suctioning. Resident #12 was placed on mechanical ventilation and intravenous (IV) antibiotic. On 1/24/23 at 11:32 AM, a family of Resident #12 stated the resident was in the intensive care unit on a ventilator due to pneumonia that she acquired at the nursing facility and the nursing facility would not take her back unless Resident #12 signed a do not resuscitate (DNR) form, and Resident #12 was not going to sign a DNR form, she is still young and a fighter. During an interview on 1/25/23 at 3:08 PM Staff E, Licensed Practical Nurse (LPN), stated she worked the evening of 11/19/22 and did not receive information in report that Resident #12 was sick, a CNA reported Resident #12 was short of breath. Staff E stated found Resident #12's skin color to be ashen (gray), hypoxic and Resident #12 told Staff E she was afraid to go to the hospital. Staff E stated she looked for a nebulizer order and machine, could not find one and could not find suction catheters that were to be at bedside. Staff E stated, That was the #1 problem, it was a disaster. Staff E stated Staff H notified 911 and the physician while she brought the crash cart to the room for fear that the resident would code. Staff E stated, I'm an ER nurse and I had nothing to help her. During an interview on 1/25/23 at 4:25 PM Staff H, RN, stated she convinced Resident #12 to go to the hospital and called 911 on the evening of 11/19/22. Staff H stated she had knowledge of trach care before working at this facility and passed on several times in report that the trach needed to be plugged during the day time and open during the evening or more trach care would need to be done, and Resident #12 told her the day staff wouldn't plug it and the staff told her that Resident #12 refused to plug it. Staff H stated the obturator and tracheostomy cannula (tube) were not at bedside, as Staff M, Director of Nursing (DON) directed to have them kept in the crash cart which is in a closed room at the nurse's station. Staff H stated when the new DON came, that was not re-addressed. Staff H stated The other nurses were nervous to take care of the trach, they did not know enough about it. Staff H stated the inner cannula of the tracheostomy tube was to be cleansed every day and she was aware that the resident was not doing it. Staff H stated, She didn't have a mirror to suction or take it out, she wasn't doing it. Staff H stated she did not know who would place a new tracheostomy tube if it came but she had to do it one time for Resident #12 and the humidification container was empty several times when she came in to work. During an interview on 1/25/23 at 1:26 PM Staff N, LPN stated she did suction Resident #12's tracheostomy 1 time, because someone else didn't know how to. Staff N stated Resident #12 was to perform her own tracheostomy care and had not actually seen Resident #12 do her own tracheostomy care, I wasn't in her room much. During an interview on 1/25/23 at 12:30 PM, Staff B, (Interim DON #1), stated she had not performed tracheostomy care for Resident #12 while she was the DON at this facility and had not observed other nursing staff provide care for Resident #12. Staff B did not know what was at Resident #12's bedside for the tracheostomy care. During an interview on 1/24/23 at 2:55 PM Staff L, (interim DON) stated she started work at the facility a week after Resident #12 was transported to the hospital, had conversation with the hospital respiratory therapy department and Resident #12 was barley maintaining at 10 liters of oxygen and a full code status and had asked if Resident #12 could be weaned down to 7 or 8 liters of oxygen and was told it was not possible at that time. The DON stated a conversation with a female physician who asked if the facility would take Resident #12 if on a no code status, and the DON stated they would if a Do Not Resuscitate (DNR) status was obtained. The DON stated she had not spoken with family about the DNR status and it was not a mandate from her or corporate to make the resident a DNR. During an interview on 1/26/23 at 1:16 PM Staff O, LPN stated there was a lady who came in with the supplies the day before Resident #12 was admitted and she didn't get the training. Staff O stated Resident #12 would instruct how to do the care that she wanted, I had no idea how to do it. Oxygen Policy dated October 2010 revealed: Oxygen equipment #3. humidification bottle Assessment #2 signs and symptoms of hypoxia (lack of oxygen) Steps in procedure #9 check mask, tank and humidifying jar to be sure there is water in the humidifying jar and water level is high enough that the water bubbles as oxygen flows through #11 periodically re-check water level in the humidifying jar and document oxygen flow rate. Tracheostomy care dated 2013 revealed: General guidelines #2 gloves are to be clean and sterile #6 a replacement tracheostomy tube must be available at the bedside at all times #7 Suction machine and a supply of suction catheters, sterile gloves and flush solution must be at bed side at all times Procedure guidelines #7 listen to lung sounds with a stethoscope Site and Stoma Care #2 clean stoma site with peroxide-soaked solution, rinse with saline soaked gauze, and disinfect stoma with antiseptic gauze, single sweep for each side, air dry, apply gauze around stoma site. During an interview on 1/26/23 at 12:55 PM, Staff P, LPN stated she had been assigned to the Relias training for tracheostomy care, visualized the binder with the training, oriented to the crash cart and its contents and is aware of the on-call nurse schedule to call for assistance if needed. During an interview on 1/26/23 at 12:58 PM Staff E, LPN stated she has completed an orientation training, reviewed the tracheostomy training, visualized the binder with the training and was oriented to the crash cart and its content. During an interview on 1/26/23 at 12:50 PM the Regional Director of Clinical Services stated that the care plans for tracheostomy residents will include detailed directions for the nurses. Observation on 1/26/23 at 12:50 PM the training book for tracheostomy care, oxygen humidification set up and suction set up was complete and had descriptive pictures was located at the nurse station. The crash cart located in the room connected to the nurse station was stocked with tracheostomy and suction supplies and the crash cart check off list located on the top of the crash cart. During an interview on 1/26/23 at 1:46 PM the Administrator stated evaluation of nursing staff will be completed and was confident the staff will be capable to care for future residents with a tracheostomy as there will be a follow up with staff and resident to be sure. 35434 During an interview/observation on 1/25/23 at 3:20 p.m., Staff D Corporate Nurse pointed out a suction machine in room [ROOM NUMBER] which had Resident #12's name on it. The suction machine had a canister and tubing coming out of the canister but lacked a suction catheter.

Based on observation, clinical record review, policy review, staff interview, and resident interview, the the facility failed to ensure 1 of 4 residents was free from abuse(Resident #4). The facility reported a census of 36 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 12/30/22, listed diagnoses for Resident #4 which included diabetes, pain in the right knee, and chronic pain syndrome. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene, extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use, and depended completely on 1 staff for bathing. The MDS listed the resident's BIMS(Brief Interview for Mental Status) score as 12 out of 15, which indicated moderately intact cognition. A Care Plan entry, dated 5/5/22, stated the resident utilized a Hoyer lift (a type of mechanical lift) with the assistance of 2 staff for transfers. Staff I's Employee Punch Report for January 2023 documented she worked 6:30 a.m. -12:00 p.m. on 1/9/23. The undated, untitled facility investigation stated the resident reported that staff dropped her in the Hoyer by pulling the emergency release and one staff laughed. During an interview on 1/24/23 at 9:03 a.m., Resident #4 stated 2 Certified Nursing Assistants(CNAs) had her up in the Hoyer lift and one of the aides pulled the emergency release and she landed in the recliner and it hurt her. During the interview, Resident #4's husband was present(Resident #5). Resident #5 stated that he observed this event and after it happened the aide threatened to do it again during subsequent transfers and placed her hand on the emergency release. Resident #5 stated that the aide thought it was funny. During an observation on 1/24/23 at 9:43 a.m., Staff L interim Director of Nursing(DON) and Staff K CNA transferred Resident #4 from her electric wheelchair into her bed using the EZ Lift(a type of mechanical lift). Staff F CNA then arrived and assisted with personal cares and then Staff K and Staff F transferred the resident back to the electric wheelchair using the lift. During an interview immediately after cares on 1/24/23 at 10:12 a.m., Staff F stated that the emergency release was located at the bottom of the center bar of the lift and in order to utilize it, one would pull it up. She stated when pulled, the resident would descend and it depended on the weight of the resident as to how fast this would happen. She stated this feature was not used a lot but staff may need to use it for example if the battery did not work. During an interview on 1/25/23 at 9:35 a.m., Staff F CNA stated she was getting ready to transfer Resident #4 out of bed and Staff I CNA went by the room and stated she would help with the transfer. After Staff I left the area, the resident stated to Staff F that she did not care for Staff I because during a transfer she pulled the emergency release on the mechanical lift and she fell into bed and it hurt her. Staff F stated the resident reported that after this incident during subsequent transfers, Staff I acted like she was going to pull the emergency release. After the resident reported this to Staff F, Staff I returned to the room to assist with the transfer. Staff F stated as they were pulling the resident in the mechanical lift from the bed over to the recliner, Staff I reached down and put her hand on the emergency release and before Staff F could say anything the resident told Staff I not to touch that. Staff F stated Staff I then said she wasn't going to and was kind of laughing. Staff F stated Staff I stated that she utilized the emergency release once with the resident and ever since then she(Staff I) acted like she was going to do it again to get a rise out of her. Staff F stated she told Staff I that the resident disliked her because of this. Staff F stated it did not cross her mind that this was abuse and she did not report it but stated about a half an hour later Staff J Assistant Director of Nursing(ADON) came and asked her about the incident. During an interview on 1/25/23 at 10:14 a.m., Staff G CNA stated Resident #4 told her she did not like Staff I. During an interview on 1/25/23 at 2:30 p.m., Resident #5 confirmed that it was Staff I who used the emergency release with Resident #4. He stated he did not feel like this act was mean spirited but stated it hurt Resident #4. Resident #4 arrived during the interview and stated when Staff I utilized the emergency release it made her mad and really upset her. Staff #4 stated it made her really mad because Staff I thought it was so funny. During an interview on 1/26/23 at 2:04 p.m., Staff I stated Resident #4 told her 2 months ago that another staff member utilized the emergency release on the lift and dropped her into bed. Staff I stated she(Staff I) joked around with everyone and told the resident that she was going to tease her about it. She stated after the resident told her that, every time she would go in there, she would move her hand down to the emergency release button but would not push it. Staff I stated she never used the emergency release button. She stated when she teased the resident and did this the resident would say don't you do that and they would both laugh(Staff I and the resident). Staff I stated she thought the resident mistakenly thought is was her(Staff I) who used the emergency release but it was not. Staff I stated Resident #4 and #5 were some of her favorite residents in the facility and that her father used to work for Resident #5. Staff I stated she thought maybe she just caught Resident #4 on a bad day and stated she would be scared if someone dropped her(Staff I) in the lift. She stated she would not go out of her way to make someone feel uncomfortable. The facility policy Lifting Machine, Using a Mechanical revised July of 2017, stated the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lift. The policy directed staff to slowly lower the resident to the receiving surface. The facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, stated residents had the right to be free from abuse which included corporal punishment, verbal abuse, mental abuse, and physical abuse. The policy stated if the alleged perpetrator was an employee or staff member, the individual was immediately reassigned to duties that did not involve residents. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. During an interview on 1/31/23 at 1:04 p.m., the Administrator stated he expected staff to treat residents with respect and dignity and stated staff was there for the residents. He stated Staff I admitted to him that she used the emergency release with Resident #4. The Administrator stated Staff I stated that she and the resident laughed about it and it was a running joke that she would put her hand by the emergency release button.

Based on clinical record review, policy review, resident, family and staff interviews, the facility failed to appropriately provided assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the nursing staff did not provide thorough follow-up assessments, update the resident's physician with the significant changes or provide treatment for 3 of 3 residents reviewed (Resident #9, #11, #23). The facility reported a census of 41. Findings Include 1. The Significant Change Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that the resident required extensive assistance of 2 staff for bed mobility, dressing, toileting and transfers. Resident #11's Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. The Care Plan identified a focus area for Resident #11 with revision date 10/13/21 as follows; the resident had been at risk for falls because of dementia and becoming restless, and the resident would get up without assistance. The Care Plan directed staff to provide the assistance of 2 persons with the use of a gait belt for pivot transfers. The Care Plan also directed that when the resident had been siting in a wheelchair the resident should be in the common area. The Care Plan identified a focus area for Resident#11 with initated date of 3/16/22 as follows; the resident had chosen to receive hospice care. The Care Plan directed the staff to coordinate the residents care with the hospice team. The Care Plan documented three different phone numbers to contact the hospice staff 24 hours a day. The Care Plan directed nurses to coordinate with the Hospice team and staff to report any non-verbal signs or symptoms of pain to the nurses. The residents Care Plan documented a focus area with initated date of 3/30/20 related to the residents Alzheimer's disease. The Care Plan directed staff to allow time for questions when confused and frustrated. The Care Plan also directed staff to speak to the resident slowly in a low stimulus environment especially during times of confusion. The incident report dated 6/26/22 at 3PM revealed Staff R, Temporary Nursing Assistant (TNA) transferred Resident #11 from wheelchair to bed. Resident #11 lowered to the floor after TNA was hit several times by Resident #11. Staff R put on the blue call light for assistance, and the nurse found the resident on the floor on the her right side. Mobile x-ray revealed a fracture of Right Femur. Resident #11 was receiving Hospice level of care therefore was not transferred to the hospital. Resident #11's primary physician came to the facility to evaluate, immobilizer placed on right leg. TNA suspended pending investigation. Staff educated on transfers. Daughter notified. Nurses Note (Late Entry) dated 6/26/22 at 11:30 AM for Resident #11 documented that the X-ray resulted concluded that the resident had a displaced femur fracture. Nurses Note (Late Entry) dated 6/26/22 at 3:30 PM documented that a physician examined the resident, and reviewed the x-ray results. The physician reported that the resident had not been a surgical candidate. The resident would remain on hospice services and will continued to be monitored. Nurses Note dated 6/26/22 at 6:35 PM documented the following; the nurse had been called to the residents room by a Certified Nurses Aide (CNA). Upon entering the room this nurse observed the resident on the floor on her right side next to the bed. The Temporary Nurse Assistant (TNA) reported that he had been transferring the resident, and the resident pushed him and so he had to lower the resident to the floor on to the residents knees. The residents vitals had been within normal limits, the resident did not hit her head, but she complained of right knee pain. The nurse called the doctor and and order had been obtained for a right knee X-ray. The family had also been notified. Nurses Note dated 6/26/22 at 6:37 PM documented that Resident#11's primary physician examined the resident and ordered the following; 1. No weight bearing to the right leg 2. Straight leg immobilizer right leg on 6/27/22 3. Physical therapy and or/ occupational therapy 4. Splint application on 6/27/11 5. Wheelchair with straight leg immobilizer 6. Right hip xray 2 views 6/27/22 7. Bedrest today and until right straight leg immobilizer applied on 6/27/22 8. [MEDICATION(S)] 50 milligrams (mgs) by mouth three times a day 9. Will need assist with meals in bed 10 Reposition every two hours while in bed The review of Resident #11's progress notes revealed no assessment of pain or follow-up assessment of resident condition to include pain assessment post fall. The Progress Notes post fall on 6/26/22 lacked documentation of pain assessment or pain medication given. The Progress Notes documented on 6/26/22 that the resident did not get pain medication until two hours after the fall at 8:07pm on 6/26/22 The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/28/22 at 3:33PM, Staff R, Temporary Nurse Assistant (TNA) stated he was trained to pick Resident #11 up and put her to bed. Staff R stated, That's what everyone did for her without a gait belt. Staff R stated the incident happened at 6:30 AM, 6/26/22 after working 16 hours, was instructed to get Resident #11 up for breakfast. Staff R stated he attempted to transfer Resident #11 to the wheelchair and Resident #11 became combative and was lowered to the floor. Staff R stated, I heard a pop noise when I lowered her and her right knee looked inverted but the nurse and the DON refused to call to have someone come to look at it. During an interview on 9/28/22 at 10:01 AM Staff A, Certified Nursing Assistant (CNA) stated she worked on 6/26/22 with just 1 other CNA and Staff R, TNA was instructed to stay to assist. Staff A stated the blue light was activated, Staff R, TNA was in hall and stated that Resident #11 was on the floor. Staff A stated she notified Staff S, Licensed Practical Nurse (LPN), Staff U, LPN and Staff M, Business Office Manager (BOM) and all responded. Resident #11 was sitting on the floor with her back up against the bed leaning to the right. Staff A stated she sat on the floor to support Resident #11 and was directed to get Resident #11 off the floor with a gait belt. Staff A stated that Resident #11 could not bear weight. Staff A stated, She yelled and her leg was inverted inward, her knee was swinging. Staff A stated she was instructed by the nurses to put Resident #11 into a wheelchair and take her to breakfast. Staff A stated Resident #11 groaned and grimaced in pain with the transfers. Staff A stated, There is no way the nurses didn't know, I reported it 3 times. Staff A stated the mobile x-ray came when it was at the end of her shift, and the next day Resident #11 was on bed rest and comfort care. Follow up interview on 10/7/22 at 1:28 PM Staff A, CNA stated that Staff U, LPN helped put Resident #11 back to bed after the fall and instructed Staff H, CNA and Staff A, CNA to get Resident #11 up for breakfast. Staff A stated after returning Resident #11 to bed, she reported to Staff U, LPN that she was not going to get Resident #11 up again due to complaints of pain and her leg was not right. 2. The MDS dated [DATE] for Resident #9 revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 had a BIMS of 15 out of 15 suggesting intact cognition. The care plan dated 4/19/22 for Resident #9 revealed instruction for staff to assist with 2 staff and use of a mechanical lift as needed for transfers, as resident #9 used a rope to transfer himself to and from the bed to wheelchair that has a seatbelt. Resident #9 experienced occasional pain and the care plan instructed staff to monitor for pain, worsening of symptoms and report to the physician. An incident report dated 6/27/22 revealed Resident #9 fell on [DATE], the DON assessed the resident who complained of pain in both legs, right arm and right hip and a Tylenol was offered, and order received for x-rays. The corrective action was for anti-tips to be applied to the front of the wheelchair. Progress notes dated 6/22/22 documented by the DON time of fall 11:15 AM, notified physician at 11:20 AM, Resident #9 requested hospital at 11:45 AM and the ambulance service called at 11:50 AM. Progress note dated 6/22/22 at 2:30 PM documented by Staff G, LPN revealed Resident #9 had tipped over forward while still in wheelchair, left shoulder against bed, and resident stated both ankles, hip and arm were fractured, notified physician office, received order for x-ray, and notified Biotech for x-ray. A document phone order dated 6/22/22 at 11:03 AM physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication sheet dated June 2022 revealed Resident #9 received daily [MEDICATION(S)] 30 mg with morning medications documented at 7 AM, it was given, and pain level was documented as 0 indicating no complaints of pain at that time. Acetaminophen (Tylenol) 325mg 2 tablets ordered for every 4 hours when needed for pain was not documented as given on 6/22/22 and pain level was not documented. Hospital record titled [NAME] County Hospital and Clinics dated 6/23/22 revealed fractures of right femur (leg), Left hip, left ankle and left elbow and transferred Resident to the University of Iowa. Hospital records titled University of Iowa Health Care revealed Resident #9 was admitted on [DATE] and discharged [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/30/22 at 12:49 PM Resident #9 stated he experienced a serious fall after he reached for something and the wheel chair flipped over on top of him. Resident #9 stated, I told them right away I wanted to go to the hospital because I knew my bones were broken. Resident #9 stated the DON wanted to get x-rays in the facility, he reluctantly agreed, then after waiting and in pain, he changed his mind, requested to the nurse for a transfer to the hospital, and was told the DON denied the transfer. Resident #9 stated a CNA took him to the DON office and he asked to go to the hospital, the DON said no, the x ray was on its way. Resident #9 stated he told the DON he was in pain and the DON continued to deny the request to transfer to the hospital. Resident #9 stated a CNA told him he had a right to decide to go and went to his room and he called an ambulance for the transfer. Resident #9 stated he asked the nurse for pain medication and received a Tylenol. Resident #9 stated he has a stronger pain medication but it was not time for that and he called the ambulance due to serious pain. During an interview on 9/28/22 at 10:01 AM Staff A, CNA stated she worked on 6/22/22, the blue light was on in Resident #9's room, he was flipped over onto floor, wheelchair on top of him. Staff G, LPN Staff Q, CNA and the DON turned him upright in the chair and Resident #9 said he broke his legs and arms, and asked to go to the hospital. Staff A stated the DON told Resident #9 she could order x-rays and he agreed but 1 hour later Resident #9 turned on his call light, complained of pain and Staff Q, CNA took him to the front desk to ask the nurse to send him to the hospital. Staff A stated Resident #9 said he was not going to wait anymore and the DON yelled from her office we are not sending him to the hospital. During an interview on 9/28/22 at 8:24 am Staff B, CNA stated she worked on 6/22/22 and witnessed Resident #9 complaints of pain and asked to be transported to the hospital and the DON said no, the portable x-ray was on the way from Des Moines. Staff B stated she reported the pain to the nurses. During an interview on 9/30/22 at 3:15 PM, Staff Q, CNA stated on 6/22/22 when she entered Resident #9's room, the LPN and DON had put already the wheelchair upright, heard Resident #9 state he heard 3 pops, he broke something and he needed to be transferred to the hospital, the LPN said I'll be making some phone calls and the DON told her Resident #9 will be treated in the facility and ordered a mobile x-ray. Staff Q stated 2 hours later, Resident #9 saw me walk past his room, hollered, he was crying and said he was in excruciating pain and wanted to go to the hospital. Staff Q stated she wheeled Resident #9 to the front nursing desk, Staff G, LPN said she wanted to send Resident #9 to the hospital 2 hours ago but the DON won't let her. Staff Q stated she pushed him over to the DON's office, told the administrator that Resident #9 wanted to go to the hospital, the administrator shut the door, and the DON opened the door and told me go do my job so she could do hers. Staff Q stated Resident #9 asked again to go to the hospital, the DON said no she ordered the x-rays, and Resident #9 asked how much longer and the DON didn't know. Staff Q stated she told Resident #9 that he had a right to call for an ambulance and the DON heard this and told Staff Q to leave the building. Staff Q stated she was terminated for advocating for Resident #9. During an interview on 9/28/22 at 11:06 AM, Staff E, LPN stated on 6/22/22 she heard someone yelling for help, Staff G, LPN and the DON responded and found Resident #9 under the wheelchair, turned it over, and he was assessed by the DON. Staff E stated Resident #9 said he was in pain and was sure he broke his ankles and elbow and requested to go to the hospital, the DON said we would do in house x-rays. Staff E stated with Biotech it could be 6-8 hours or the next day before they would come to do x-rays. Staff E stated Biotech called within the hour of ordering the x-rays, stated they could not x-ray Resident #9 because of the way his body was. Staff E stated Resident #9 was in pain for that 2 hours and was not her patient and could not say if he received anything for pain. Staff E stated the DON spoke aggressively to Resident #9 when Staff Q, CNA took him to the DON's office and the DON cussed at the staff. Staff E stated, She was angry with us, we were just trying to get him help. Staff E stated Resident #9 called for an ambulance. During an interview on 9/30/22 at 2:30 PM, Staff G, LPN stated she was Resident #9's nurse when he fell on [DATE], he was still buckled into his wheelchair so the chair was on top of him. Staff G stated Resident #9 requested to go to the hospital because he broke bones, the DON wanted to have x-ray come here. Staff G stated Resident #9 was in pain and the Tylenol was not affective, and when reported to the DON, she was yelling at everyone right in front of the residents. Staff G stated Resident #9 was out of pain control, asked to go to the hospital, the DON would not let staff call the hospital and Resident #9 called for the ambulance. Review of a Document titled Falls - Clinical Protocol reveals the nurse will assess document and report musculoskeletal function and pain, and the staff, with physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. During an interview on 9/29/22 at 2:32, the DON stated the criteria after a fall was for the nurse to do an assessment. The DON stated, If immediate care is needed we will send them out, the nurse decides if the resident goes to hospital or not or gets x-rays here. The DON stated, When we are expecting a fracture, we keep them comfortable and keep them in bed, I would not expect them to go to the dining room for food, it would come to them. During an interview on 10/11/22 at 2:04 PM, the Administrator stated an expectation for a resident who had a fall was for the nurse to do an assessment, talk to the physician and the physician to decide if the resident will need an x ray, the mobile would be notified, or the resident would be sent to the hospital if the physician ordered for the hospital. The Administrator stated it would be a nursing judgment call if the resident got up for breakfast after a fall and the nurse would treat signs and symptoms of pain. Review of Fall Policy revealed after initial assessment, staff, with the physician's guidance, will follow up until the resident is stable and delayed complications ruled out and continue monitoring and document the individual's response to interventions. During an interview on 10/11/22 at 2:04 PM, the Administrator stated the expectation of the nursing staff was to do an assessment, talk to the physician and the physician would decide treatment options and follow up assessments charted in the progress notes. The Administrator stated it would be a nursing judgement call for further activity and pain treatment. During an interview on 10/25/22 at 1:30 PM the Interim DON stated the initial nursing assessments are put into the risk assessment in PCC. 3. A 5-Day Minimum Data Set (MDS) dated [DATE] documented that Resident#23 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident scored a 15 out of 15 for the Brief Interview for Mental Status, which indicated normal cognitive functioning. The MDS documented that the resident required extensive assistance of 2 staff members for bed mobility, transfers and toileting. The MDS documented that the resident required a walker or wheelchair for mobility. The MDS revealed that Resident #23 had a wedge compression fracture of Thoracic 5- Thoracic 6 (T5-T6) vertebra. The MDS documented that the resident had been admitted under Medicare for a Part A stay (skilled level of care), and had been discharged from an acute hospital on 6/10/22. The MDS documented that the resident's goal had been to return to the community. The Care Plan documented a focus area as follows; the resident had pain due to recent fall with fracture prior to admission with initiation date of 6/10/22. The Care Plan directed staff to observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. The Care Plan also identified a focus area with intiation date of 6/14/22 as follows; the resident had orders for therapy. The Care Plan directed physical therapy and occupational therapy to provide services. The Care Plan identified a focus area of transitional care planning with initiation date of 6/14/22 with the goal to transition back to the community, with the intention to return home Clinical Documentation reported the resident was admitted to skilled care level for Physical therapy (PT) and Occupational therapy (OT). The plan was for strengthening to go home. A Progress Note dated 6/11/22 at 2:45 p.m. documented as follows; Residents roommate notified this nurse of resident fall in the room. Resident had been observed laying on the floor on her left side, and rated her pain a 10 out of 10. The resident's vitals were within normal limits. No visible injury upon inspection, and the resident denied hitting her head. The resident requested to be transported to the hospital, and a physician ordered had been obtained for the request of transport. A Progress Note dated 6/11/22 at 6:27 p.m. documented as follows; Update from the hospital emergency room staff included that the head Computerized Tomography (CT) scan results indicated severe/worse changes to T6 fracture compared to previous injury CT from 5/29/22. Discharge orders are to administer no non-steroidal anti-[CONDITION(S)] drugs (NSAIDs) due to kidney function. Resident is to call orthopedics on 6/13/22 for evaluation and treatment due to recent changes. Occupational Therapy Treatment Encounter Note dated 6/10/22 documented that the resident complained of pain at rest at a 9 out of 10 with a heavy/deep ache, bloated feeling to the thoracic spine around to the abdomen. On 6/11/22 at 7:43 p.m. a Progress Note revealed the family discussed with staff the increase in weakness and legs buckling with standing. The staff recommended the resident stay in bed and be evaluated the next day. The family wanted the doctor notified of their concerns with pain control and medications due to poor kidney function. A Nurses Note dated 6/12/22 at 2:55 p.m. documented that the DON discussed status of the residents fall on 6/11/22, with Staff OO, Physician and Staff OO classified it as a minor incident. In a Progress Note entry dated on 6/12//22 at 7:36 p.m. there is the comment in the charting for continued numbness and lack of feeling to both legs. A Skilled Evaluation Note dated 6/12/22 at 10:39 p.m. documented that the resident complained of pain to T5-T6 area and scheduled pain medication had been given. A Phone Message/ Call dated 6/13/22 at 4:43PM the family had called the residents clinic in regards to the numbness from the waist down that the resident had experienced, and was unable to get out of bed and walk. A Phone Message/Call dated 6/14/22 at 7:52AM the residents family called and wanted the resident evaluated in Des Moines. The residents Physician ordered for the resident to be evaluated in the emergency room . A Nurses Note dated 6/14/22 at 9:21 a.m. documented that Staff OO, Physician ordered the resident to be sent to the emergency room for evaluation due to decreased sensation to both lower extremities. In an interview on 10/29/22 at 3:40 PM with Resident #23's family member reported that the resident had been admitted to the nursing home on 6/10/22 after a hospital stay due to a T6 compression fracture. At the time of admission to the nursing home the resident had been able to walk with staff assistance, and used a walker. When the resident returned to the facility she started to complain of numbness from her waist down. The family member reported that the facility called and told her about the numbness. The family remember reported she told the facility staff to call the doctor and let them know it was not normal for the resident. The family member stated she had been notified that day on 6/11/22 that the facility staff could not get a hold of the doctor, so she then left a message with the Assisted Director of Nursing (ADON). The family member reported that on 6/12/22 the resident was very upset, she still could not feel from the waist down, and the resident and family member had no idea if the doctor had been contacted. The resident and family member could not get any information. The family member reported that on 6/13/22 the facility therapy department would not work with the resident since the resident had changes in her status. The family member reported that she called the doctor's office on 6/14/22, and had been told that the resident would be seen by a doctor on 6/16/22, the family member requested that the resident been sent out for evaluation immediately. The family member reported that the resident had been then sent out for evaluation, and the resident had emergency neurological surgery. The family member reported that the neurosurgeon stated that the issue should have been taken care of right away when the loss of feeling happened. The family member reported that the resident is now paralyzed from the waist down, and currently resides in a long- term care facility. A Report created by Staff PP, Advanced Registered Nurse Practitioner (ARNP) dated 6/14/22 documented as follows; the resident had a known T6 compression fracture from 5/27/22, developed sharp and stabbing pain with movement, with location to the mid to lower back and traveled into bilateral buttocks, with associated symptoms of numbness to groin region and bilateral lower extremities, incontinent of bowel and bladder, unable to move legs, unable to stand or ambulate. The resident had a fall on 6/11/22 at the nursing home with immediate pain. The resident reported not being able to move legs, stand/walk since. The resident had been evaluated at an emergency room with noted worsening compression fractures at that time, and had been discharge back to the nursing home with pain management instructions. The residents family member report that the resident had been able to walking prior to the 6/11/22 fall, and since then the resident had complete loss of bladder and bowel, intractable pain with spasms, unable to move/lift both legs, and could only feel some touch from the knee to foot. Family member also reported abdominal distention since the fall. In a document titled Falls Clinical Protocol with the revised date of 2018 it stated that the staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or days after a fall. While signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. In an interview on 10/25/22 at 12:40 PM Staff LL, RN stated she remembered Resident #23 not being at the facility very long. She was notified by the resident's roommate that Resident #23 had fallen. She had tried getting up by herself from the recliner and fell . They did not try to move her since they knew they were going to need to send her out due to having a back injury already. The ambulance was called immediately and they transported her to the hospital. She didn't remember much of 6/12/22 with the resident other than she had a lot of pain. In an interview on 10/25/22 at 1:00 PM Staff MM, LPN stated she vaguely remembered Resident #23. She worked here the night shift after the resident had fallen, taken to the hospital and returned. She wasn't there very long. She was not here when Resident #23 fell . She did not remember anything about the assessments for the resident. In an interview on 10/25/22 at 1:30 PM Staff HH (Interim Director of Nursing) IDON stated she expected staff to do an assessment when the resident falls and then to determine if they need to go to the hospital and if neurological checks need done. If the fall is unwitnessed or witnessed and they hit their head a neurological assessment is triggered in point click care and it lists frequency for how often assessments are to be done. If there is a change in the assessment after the fall the doctor should be notified. In an interview on 10/26/22 at 9:50 AM the Administrator and Staff KK, Regional Director of Clinical Services stated they will look further into the facility assessments for Resident #23. The interim director of nursing has started working with nurses on what is needed for good charting.

Based on observation, clinical record review, and staff interviews, the facility failed to provide appropriate supervision to ensure each resident ' s individual safety for 2 of 2 residents reviewed (Resident #11 & # 21). The facility reported a census of 41 residents. Findings Include: 1. The Significant Change Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed the diagnoses of high blood pressure, Alzheimer's, anxiety and [CONDITION(S)] in both knees. The MDS indicated that the resident required extensive assistance of 2 staff for bed mobility, dressing, toileting and transfers. Resident #11's Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. The Care Plan identified a focus area for Resident #11 with revision date 10/13/21 as follows; the resident had been at risk for falls because of dementia and becoming restless, and the resident would get up without assistance. The Care Plan directed staff to provide the assistance of 2 persons with the use of a gait belt for pivot transfers. The Care Plan also directed that when the resident had been siting in a wheelchair the resident should be in the common area. The Care Plan identified a focus area for Resident#11 with initated date of 3/16/22 as follows; the resident had chosen to receive hospice care. The Care Plan directed the staff to coordinate the residents care with the hospice team. The Care Plan documented three different phone numbers to contact the hospice staff 24 hours a day. The Care Plan directed nurses to coordinate with the Hospice team and staff to report any non-verbal signs or symptoms of pain to the nurses. The residents Care Plan documented a focus area with initated date of 3/30/20 related to the residents Alzheimer's disease. The Care Plan directed staff to allow time for questions when confused and frustrated. The Care Plan also directed staff to speak to the resident slowly in a low stimulus environment especially during times of confusion The incident report dated 6/26/22 at 3PM revealed Staff R, Temporary Nursing Assistant (TNA) transferred Resident #11 from wheelchair to bed. Resident #11 lowered to the floor after TNA hit several times by Resident #11. Staff R put on the blue call light for assistance, and the nurse found the resident on the floor on the right side. Mobile x-ray revealed a fracture of Right Femur. Resident #11 had received Hospice level of care therefore was not transferred to the hospital. Resident #11's primary physician came to the facility to evaluate. Immobilizer placed on leg. TNA suspended pending investigation. Staff educated on transfers. Daughter notified. Incident report lacked assessment of pain. Review of employee file revealed Staff R was hired on 5/9/22 and the TNA had previously worked at McDonalds and Dollar General Store. The Administrator provided Relias training for Staff R to include safe transfers to be completed by 6/22/22 and safe transferring and repositioning, self paced to be completed by 9/30/22. During an interview on 9/28/22 at 3:33PM, Staff R, Temporary Nurse Assistant (TNA) stated he was trained to pick Resident #11 up and put her to bed. Staff R stated, that ' s what everyone did for her without a gait belt. Staff R stated the incident happened at 6:30 AM, 6/26/22 after working 16 hours, was instructed to get Resident #11 up for breakfast. Staff R stated he attempted to transfer Resident #11 to the wheelchair and Resident #11 became combative and was lowered to the floor. Staff R stated, I heard a pop noise when I lowered her and her right knee looked inverted but the nurse and DON refused to call to have someone come to look at it. Staff R stated he was instructed to go home, suspended during the investigation, and then terminated. Staff R stated he did not receive adequate training by Staff W, CNA. The Progress Notes dated 6/26/22 lacked documentation of post fall assessments or administration of pain medications after the 6:30 AM fall on 6/26/22. The Progress Note dated 626/22 at 8:07PM the documented that the resident received the first dose of [MEDICATION(S)]. The progress notes dated 6/26/22 at 11:30 AM for Resident #11 documented x-ray results as follows; the x-ray right knee to be a distal femur fracture. The progress notes dated 6/26/22 at 3:30 PM identified as a late entry revealed Resident #11 ' s primary physician was in the facility, reviewed the x-ray, the resident was not a surgical candidate and will remain in the facility on Hospice care. The progress notes dated 6/26/22 at 6:35 PM revealed TNA called for assistance and nurses found resident #11 on the floor laying on her right side. The progress notes dated 6/26/22 at 6:37 PM revealed that Resident #11 ' s primary physician was in the facility and new orders received to keep resident #11 in bed until the immobilizer is placed on 6/27/22 to the right leg and order given for pain medication [MEDICATION(S)] to be given 3 times a day. The Medication Administration Record (MAR) dated June 2022 for Resident #11 revealed an order for Acetaminophen 325 milligrams (mg) 2 tablets to be given every 4 hours as needed for pain, and no documentation of Acetaminophen given for the entire month of June, 2022. The MAR dated June 2022 for Resident #11 revealed an order for [MEDICATION(S)] 50 mg to be given 1 time for pain given on 6/26/22 at 8:07 PM. An order for [MEDICATION(S)] 50 mg to be given 3 times a day, started on 6/27/22 in AM. During an interview on 9/28/22 at 10:01 AM Staff A, Certified Nursing Assistant (CNA) stated she worked on 6/26/22 with just 1 other CNA and Staff R, TNA was instructed to stay to assist. Staff A stated the blue light was activated, Staff R, TNA was in hall and stated that Resident #11 was on the floor. Staff A stated she notified Staff S, Licensed Practical Nurse (LPN), Staff U, LPN and Staff M, Business Office Manager (BOM) and all responded. Resident #11 was sitting on the floor with her back up against the bed leaning to the right. Staff A stated she sat on the floor to support Resident #11 and was directed to get Resident #11 off the floor with a gait belt. Staff A stated that Resident #11 could not bear weight. Staff A stated, She yelled and her leg was inverted inward, her knee was swinging. Staff A stated she was instructed by the nurses to put Resident #11 into a wheelchair and take her to breakfast. Staff A stated Resident #11 groaned and grimaced in pain with the transfers. Staff A stated, There is no way the nurses didn ' t know, I reported it 3 times. Staff A stated the mobile x-ray came when it was at the end of her shift, and the next day Resident #11 was on bed rest and comfort care. Follow up interview on 10/7/22 at 1:28 PM Staff A, CNA stated that Staff U, LPN helped put Resident #11 back to bed after the fall and instructed Staff H, CNA and Staff A, CNA to get Resident #11 up for breakfast. Staff A stated she reported to Staff U, LPN that Resident #11 was in pain and her leg was not right. During an interview on 9/29/22 at 10:23 AM Staff V, CNA stated he had worked with Staff R, TNA and TNA ' s could not go into a room and transfer anyone without a CNA supervising them and TNA ' s were not certified so they can ' t do Hoyer lifts. Staff V stated, 2 CNA ' s to 40 high acuity people are not enough and I feel unsafe so I haven ' t been back to work there. The Administrator provided a document titled Staff In-Service dated 6/27/22 revealed instructions for all TNA's to be assisted by a CNA if you do not feel comfortable transferring a resident, ask for help. A signature sheet was attached with staff signatures. During an interview on 9/29/22 at 10:36 AM Staff J, CNA stated TNA ' s cannot provide care or transfer residents without a CNA. Staff J stated, I was just thrown out there to fend for myself. Staff J stated she did not receive orientation training and no training audits were done. During an interview on 9/29/22 at 11:01 AM Staff I, CNA stated she began work as a TNA on June 23, 2022 and just passed the CNA testing 9/21/22. Staff I stated, I was told I can do everything with a CNA so I was the 2nd person on the Hoyer, showers, pericare, empted catheters and transfers, I did whatever Staff W, CNA said to do. Staff I stated she did not have access to a care plan. Staff I stated, I didn ' t have the ability to chart on the computer. On 9/29/22 the Administrator provided a blank orientation checklist titled Nursing Assistant that revealed the following clinical skills performance: #19 Resident Transfer Lifting/moving resident in bed Pivot transfer from bed to chair Bed to chair - non-ambulatory Mechanical lift assistance During an interview on 9/29/22 at 2:03 PM Staff W, CNA, stated she worked with TNA's on 2-10 shift. Staff W stated, The facility does not provide instruction for the TNA's to follow since they can't get into Point Click Care for the care plan so they can't do any care without a CNA, to include transfers. Staff W explained everyone had computer training on the Relias program. Staff W stated, TNA' s can be the second person on a Hoyer and the second shift TNA's have been assisting with Hoyer transfers. Staff W stated Resident #11 was a 2 person assist and Staff R should not have completed the transfer by himself. Staff W stated staff followed the TNA paper guidelines. The Administrator provided a document titled Non-Certified Aide Duties dated 7/15/22. The bullet points revealed that the TNA can be the 2nd person for a transfer, can assist with resident care as long as another aid is in the room, while the aid is giving a shower, could pass ice & linens, and watch call lights then get a nurse or aide to assist the resident physically. During an interview on 9/29/22 at 2:32 the DON stated the staff CNA assignment follows the criteria set up by corporate, by census, not acuity. The DON stated the criteria after a fall was for the nurse to do an assessment. The DON stated, If immediate care is needed we will send them out, the nurse decides if the resident goes to hospital or not or gets x-rays here. The DON stated, When we are expecting a fracture, we keep them comfortable and keep them in bed, I would not expect them to go to the dining room for food, it would come to them. The DON stated Staff Q, CNA trained Staff R, CNA and did not complete a training paper and a past non compliance form was filled out in June, to be corrected by July 2022, and no further TNA ' s were hired. The DON stated that a TNA can run a hoyer but not assist on the resident side. During an interview on 10/11/22 at 2:04 PM, the Administrator stated an expectation for a resident who had a fall was for the nurse to do an assessment, talk to the physician and the physician to decide if the resident will need an x ray, the mobile would be notified, or the resident would be sent to the hospital if the physician ordered for the hospital. The Administrator stated it would be a nursing judgment call if the resident got up for breakfast after a fall and the nurse would treat signs and symptoms of pain. 2. The Quarterly Material Data Set (MDS) dated [DATE] for Resident #21 revealed diagnosis of high blood pressure, post traumatic stress disorder ([CONDITION(S)]), [CONDITION(S)] with manic episodes and right hip pain. The MDS documented that Resident #21 transferred to the toilet and ambulated with a walker with supervision, and had occasionally incontinent of urine. Resident #21 ' s Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated an intact cognition. The Care plan dated 8/16/22 for Resident #21 identified the need for specialized services to include psychiatric medication management and had impaired thought processes related to [CONDITION(S)] disorder when in a manic episode and would forget conversations with others. During an interview on 10/12/22 at 9:18 AM a family member stated on 9/29/22 around noon Resident #21 called and stated he came to Des Moines for an audiology appointment and the nurses had it all screwed up and he was waiting for the driver to pick him up. The family stated he was still at work around 4:20 PM when the Director of Nursing (DON) from the facility called and asked him to pick up Resident #21 at a mental health center across from Methodist Hospital and the DON would meet to return Resident #21 back to the facility. The family member stated, I live and work in Des Moines so I have met him several times when he got on the veterans bus and came in for an appointment. The family member stated it is not ideal for Resident #21 to be by himself on the ride to and from Des Moines and was concerned for him and found him in front of the [NAME] Ball mental health clinic with a worker from that clinic who stated the clinic had closed at 4 PM. The family member stated, It was almost 5 PM and he had no food, no medications, was manic, very hungry and mad. The family member stated he took the Resident immediately to a fast food restaurant and drove to Southridge Mall and met the DON. The family member stated there was no appointment scheduled for Resident #21 on 9/29/22. Medication Administration Record (MAR) dated September 2022 revealed that on 9/29/22 Resident #21 did not receive the following medications: extra strength Tylenol 500mg 2 tablets for pain, [MEDICATION(S)] 0.5mg for anxiety and [MEDICATION(S)] 10mg for [CONDITION(S)] manic episodes which were scheduled to be administered at noon. During an interview on 10/12/22 at 9:58 AM Staff G, Licensed Practical Nurse (LPN) stated that Resident #21 left the facility at 9 AM for an audiology appointment in Des Moines and the facility received a call at 4:30 PM from Resident #21, who was confused and stated he was in front of a mental health building. Staff G stated the DON took the call, a lady assisted Resident #21 with the call and the DON asked her to stay with him until someone came to get him. Staff G stated, It was not our typical transport, it was a 4 door car, a Uber driver and we did not know this guy. Staff G stated Resident #21 would make his own appointments and staff would have to make sure there really was an appointment. Staff G stated, I don ' t know why that didn ' t happen this time. During an interview on 10/12/22 at 12:15 PM, Staff N, Social Worker stated she was present at the nurses station on 9/29/22 at 4:30 PM when Resident #21 called, he was confused and yelling into the phone. Staff N stated she asked the resident to calm down and look around to see if anyone was there, and the resident gave his phone to a lady who assisted to locate him. During an interview on 10/12/22 at 12:35 PM, Staff E, LPN stated an Uber driver transported Resident #21 at 9AM, his English was not good, and the staff did not know this man. Staff E stated the driver called around 12 PM due to Resident #21 refused to return to the facility, asked about a different location, and was told no. Staff E stated Resident #21 called the facility at 4PM, yelled then hung up, caller ID utilized to call him back and Resident #21 said he was at a mental health clinic by himself. Staff E stated, I asked why we were not calling the police or an ambulance and the DON didn ' t say anything. Staff E stated she didn ' t document the calls, didn ' t know the protocol and didn ' t ' t want the DON to strike it out. Staff E stated the DON left at 5:30 PM. Staff E stated she was concerned as Resident #21 had an altercation with the DON a week before. Staff E stated, I have never experienced it as bad as he has been lately. Staff E stated the DON was looking for other living arrangements for Resident #21. During an interview on 10/12/22 at 11:56 AM the Director of Nursing (DON) stated the facility will transport a resident to an appointment or set up the transportation and usually ask the family before setting the appointment up and if the resident ' s BIMS is below 12 the family goes with the resident. The DON stated the Uber driver never called but was aware that Resident #21 got out of the Uber car and was on his own in Des Moines. The DON stated Resident #21 was fine and safe on return to the center. A document titled UnityPoint Audiology, with date of service as 9/26/22, documented the appointment information for which the son was in attendance, and the recommendations included the next tentative appointment was scheduled for 10/19/22 for a fitting for hearing aids and strongly encouraged the son to accompany Resident #21 to the next appointment. An email document provided by the corporate nurse revealed a statement by the DON on 9/30/22 at 11:44 AM to this corporate nurse that Resident #21 was sent to an audiology appointment on 9/29/22 via transport car around 9:15 AM, the facility never received a missed call that he did not show up. Resident #21 was picked up by the driver, did not want to return, the resident asked the driver to take him to his wife ' s house, but the driver denied the request and Resident #21 got out. Facility received a call at 4:20 PM that Resident #21 was sitting at a clinic that closed at 4 PM, the DON called transit, asked to pick him up, they said the resident refused the transfer. The DON called the son so Resident #21 would not be sitting by himself, met Resident #21 and his son in Des Moines and transported resident back to the facility. During an interview on 10/18/22 at 10:30 AM Staff Z, LPN stated the DON did not want the State to know about Resident #21 being in Des Moines by himself, it was not charted and his behavior on return was not charted. Staff Z stated the facility usually sends lunch with a resident or money to get lunch, not this time, and it would depend on the resident if medications were sent with the resident, medications were not sent with Resident #21 as he was manic at the time and the DON was aware. A review of Resident #21 ' s progress notes for 9/29/22 revealed no charting of time of the resident exiting the building and no charting of phone conversations with the resident or family. Progress note dated 9/29/22 at 5:53 PM revealed Resident #21 returned to the facility from appointment. Progress note dated 9/30/22 at 5:08 AM revealed Resident #21 remained up all shift hollering, cussing and slamming things around in his room. During an interview on 10/18/22 at 11:03 AM, Staff GG, Certified Nursing Assistant (CNA) stated Resident #21 returned to the facility on [DATE] after 8PM, yelling, cussing and uncontrollable when the DON brought him in. Staff GG stated Resident #21 sat by the front door on his walker yelling at the DON to get away from him. Staff GG stated After she left, he tried to go out the front door and grabbed both my arms above my wrists, squeezed so hard I had fingerprint welts and he threatened to kill me and said if he had a gun he would shoot me in the face and he would not let go of me, I was scared and I was afraid he was going to break my wrists. Staff GG stated Staff FF, LPN attempted to assist and Staff O, Maintenance Supervisor was in the building and calmed him down and helped him to his room. Staff GG stated she didn ' t ' t go into Resident #21 ' s room as he was throwing things and acting crazy. During a follow-up interview on 10/14/22 at 9:23 AM Resident #21 ' s family member stated it was hard to talk with Resident #21 on the 9/29/22 as he was manic. The family member stated, Oakwood should understand that when he is manic, someone should be with him and no one told me or my mom he was going to an appointment on the 29th of September. The family member stated Resident #21 was treated at the hospital a week before going to the 9/26/22 appointment. The family member stated, We got him through that appointment but the physician wanted to be sure I would be with him on his last appointment and if he does not get his medication when scheduled, he would get worse and he didn ' t get his medication on the 29th. The family member stated the DON had been planning to send Resident #21 to Hope Harbor, and the DON had this conversation with the family member before sending Resident #21 on his own to Des Moines with a transit driver. The family member stated, It would have been a 50/50 chance of it working for him to travel by himself and this time it didn ' t happen, his [CONDITION(S)] took over. During an interview on 10/14/22 at 10:55 AM, the Administrator stated her expectation for staff was to assist residents with appointments and to make arrangements. The Administrator stated that the Social Worker will be making all future transportation arrangements and notification of families. During an interview on 10/19/22 at 7:53 AM, Staff FF, LPN stated she worked when Resident #21 returned from Des Moines on 9/29/22 around 7:53 PM and stated she may have documented it incorrectly in the chart. Staff FF stated Resident #21 was very agitated, attempted to leave the facility and left bruises on Staff GG. Staff FF stated they were thankful Staff O, maintenance supervisor, was in the facility and assisted. Staff FF stated, I can usually calm him down but not that night. Staff FF stated Resident #21 could not find his phone and was verbally aggressive about finding it and Staff FF called the DON who had it and stated she would bring it back the next day. Staff FF stated Resident #21 was very upset, manic, and the DON came in at midnight to return the phone. Staff FF stated Resident #21 was readmitted from Hope Harbor on 10/18/22, made threats about hurting Staff Z, LPN for messing up his appointments and ripped the alarm off the wall in his room.

Based on clinical record review, staff interview, and policy review, the facility failed to provide care and services for an insulin/[CONDITION(S)] dependent resident in accordance with professional standards of care for 1 of 1 insulin/[CONDITION(S)] dependents residents reviewed (Resident #21). The facility failed to thoroughly review the resident's hospital discharge summary and orders upon admission on 4/14/22, to meet the resident's needs. The resident failed to receive insulin for a day and a half and missed a [CONDITION(S)] treatment on 4/15/22 due to a lack of transportation. The resident experienced diabetic ketoascidosis (a serious diabetes complication) and transferred to the Emergency Department with a blood glucose reading in the 1000 range. The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses for Resident #21 which included diabetes, [CONDITION(S)], and heart failure. The MDS listed Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. The hospital Discharge Summary sheet dated 4/14/22 documented the resident had End Stage [CONDITION(S)] ([CONDITION(S)]) and Type 1 diabetes. The summary stated the resident received [CONDITION(S)] services and had very high blood glucose and received 15 units of insulin. The document stated the resident was stable on [MEDICATION(S)] (insulin) 15 units a day and received [CONDITION(S)] treatments on Mondays, Wednesdays, and Fridays. The sheet listed orders for lancets (device to finger-stick for blood glucose testing) and urine [MEDICATION(S)] test strips (to test urine for ketones). A Progress Note dated 4/14/22 documented the resident admitted to the facility and had a left upper arm fistula (port for [CONDITION(S)]). The facility lacked documentation of staff following up or clarifying with the physician regarding the resident's requirement of insulin. A [CONDITION(S)] Clinic Progress Report dated 4/15/22 at 5:57 p.m., documented the resident failed to show up for her scheduled [CONDITION(S)] treatment as the nursing home unable to provide transportation to the clinic. Review of the report lacked documentation that it was alright for the resident to miss the session. Review of the Progress Notes dated 4/15/22 lacked documentation of the efforts made by the facility to transport the resident to [CONDITION(S)]. A Progress Note dated 4/16/22 at 10:00 p.m., documented at 5:45 p.m. the resident had increased lethargy, confusion, and fruity breath. The resident reported she was diabetic and had a blood glucose level of 325 milligrams (mg) / deciliter (dl). A normal reading considered 70-120 mg/dl. The facility contacted the physician and obtained an order to send the resident to the Emergency Department. A Progress Note dated 4/16/22 at 6:15 p.m., documented the facility sent the resident to the Emergency Department. The April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital Encounter Note dated 4/17/22 documented the resident developed increased thirst, abdominal pain, and weakness at the nursing home and had diabetic ketoacidosis and [CONDITION(S)] (high potassium) due to a lack of insulin and a missed [CONDITION(S)] session. The note documented an outside Emergency Department evaluated the resident. The resident had a blood glucose reading in the 1000's and upon arrival at this hospital had a blood glucose reading of 747 mg/dl. A hospital Discharge Summary dated 4/26/22 stated the resident admitted to the hospital on 4/17/22 and discharged on [DATE]. The resident received [CONDITION(S)] treatments and insulin. The Care Plan failed to address the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The End-Stage [CONDITION(S)] ([CONDITION(S)]) Care of a Resident policy dated 2001, stated the facility would care for those with [CONDITION(S)] according to current standards of care. The policy stated the resident's Care Plan would reflect the resident's needs related to [CONDITION(S)]/[CONDITION(S)]. The policy failed to address how residents would transport to the [CONDITION(S)] clinic. During a phone interview on 5/2/22 at 11:42 a.m., Staff D, Registered Nurse, stated the resident admitted to the facility at 8:45 in the evening. She stated she believed the Director of Nurses entered the orders. With regard to the admission, she only completed the resident's skin assessment. She stated someone on the day shift received report from the hospital and documented it on a sheet of paper. The sheet noted the resident was diabetic. Staff A knew the resident received [CONDITION(S)] services because she had a fistula. During a phone interview on 5/4/22 at 9:36 a.m., Staff E, [CONDITION(S)] Administrator, stated the resident was in the hospital until 4/14/22. She stated she spoke with the hospital Social Worker who stated the nursing home would set up transportation for the resident to get to [CONDITION(S)] on 4/15/22. She stated when the resident did not come on 4/15/22, they called the nursing home and the nursing home stated they did not have a way to transport the resident to [CONDITION(S)]. She stated the [CONDITION(S)] facility informed the nursing home she was on insulin and did not tell the nursing home it was okay for the resident to miss the [CONDITION(S)] session. She asked the nursing home to bring the resident to [CONDITION(S)]. Staff E stated they educated the facility on fluid and medication. During a phone interview on 5/4/22 at 11:24 a.m., Staff F, Registered Nurse, stated she first took care of the resident on 4/15/22. She did not receive report from anyone regarding the resident and there were no diagnoses in the computer. She did not receive report on the resident until the morning of 4/16/22. On the morning of 4/16/22 the resident was really lethargic and had sweet breath. Staff F asked the resident if she was diabetic. The resident confirmed she was diabetic. Staff F checked the resident's blood glucose level and obtained a reading of 320 mg/dl. Staff F sent the resident to the Emergency Department and her blood glucose reading was 1100 mg/dl. Staff F stated she was very angry because there were no diagnoses entered in the electronic records and she did not know the resident was diabetic. She stated she should have been able to look in her profile the diagnoses list. She stated when she completed admissions she reviewed the entire discharge summary. During an interview on 5/3/22 at 1:30 p.m., the Director of Nursing (DON) stated she input the resident's orders upon admission. She stated the hospital discontinued the resident's insulin prior to discharge. She stated she received [CONDITION(S)] on Mondays, Wednesdays, and Fridays. She stated the hospital stated they would send someone to come and get her and they didn't. She stated the facility called [CONDITION(S)] and informed them the resident would not be there. She stated she talked to a nurse at the [CONDITION(S)] clinic but did not know her name and stated the nurse told her it would be ok for the resident to wait until Monday. During an interview on 5/3/22 at 2:22 p.m., the DON stated she messed up and upon looking at the top of the resident's Discharge Summary, she was a Type 1 diabetic. She stated the Social Worker at the hospital told her she would set up transportation for the resident's [CONDITION(S)] on 4/15/22. During an interview on 5/4/22 at 1:28 p.m., the DON provided the [CONDITION(S)] Clinic Progress Report dated 4/15/22 and stated the [CONDITION(S)] clinic stated it was ok for the resident not to go to [CONDITION(S)]. The surveyor stated it did not state that on the document and the DON stated the resident was allowed to refuse to go to [CONDITION(S)]. During a phone interview on 5/9/22 at 2:25 p.m., the Administrator stated she did not remember anyone saying anything to her about the resident needing to go to [CONDITION(S)]. The State Agency notified the facility of the Immediate Jeopardy on 5/4/22 at 12:45 p.m. The Immediate Jeopardy situation started on 4/14/22. The facility removed the Immediate Jeopardy on 5/4/22 by implementing staff education to all nurses on 5/4/22 that they must review the hospital discharge summary thoroughly including admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to treat, monitor, and manage residents pain with both pharmacological and non-pharmacological interventions to the extent possible for 2 of 3 residents reviewed for pain (Residents #2 and #19). The failure resulted in Resident #2 experiencing ongoing pain often rating the pain level at an 8 or higher on a 0 to 10 pain scale, with 10 indicating the worst pain imaginable. The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required extensive assistance of 1 staff for personal hygiene, extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use, and depended completely on 1 staff for bathing. Resident #2 had a Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating moderately impaired cognition. The Care Plan revised 3/16/22 documented Resident #2 experienced occasional generalized pain and pain to the lower legs and utilized [MEDICATION(S)] (an opioid), [MEDICATION(S)] (to treat nerve pain), Tylenol, and Bio freeze (muscle pain cream) and stated the resident's pain would be controlled. The Care Plan directed staff to monitor for side effects sedation, dizziness, nausea, vomiting, constipation, and respiratory depression, monitor for worsening of symptoms and report to physician, things that help when having pain are pain medication, repositioning, sleeping, or watching television. The Pain Level Summary for 3/3/22 listed the resident's pain level as 10 at 10:45 a.m. and 4:59 p.m. The Summary lacked a follow-up pain assessment until 3/4/22 at 9:41 a.m. which listed the pain level as 8. A 3/3/22 Progress Note stated the resident received Tums (for heartburn) 500 milligrams (mg) tablet for heartburn which was ineffective. The 3/3/22 notes lacked further assessments of the resident's pain. The Pain Level Summary for 3/4/22 listed the resident's pain level as 8 at 9:41 a.m. The Summary lacked a follow-up pain assessment until 12:06 p.m. which listed the pain level as 5. The resident's Progress Notes did not address the resident's pain on 3/4/22. A Progress Noted dated 3/5/22 at 8:16 p.m., documented Resident #2 complained of hip pain rated at an 8. The notes did not include a follow-up pain assessment. A Progress Noted dated 3/9/22 at 6:52 p.m., documented Resident #2 complained of pain and rated the pain a 5 to the right hip described as constant, aching, and sharp and it comes and goes. The note failed to include a follow-up pain assessment. The Pain Level Summary dated 3/18/22 listed the Resident #2's pain level a 10 at 8:17 a.m. and 8:19 a.m. The Summary lacked a follow up pain assessment until 10:54 a.m. which listed the pain level as 6. The Pain Level Summary for 3/23/22 listed the resident's pain level as 9 at 9:10 a.m. The Summary lacked a follow up pain assessment until 12:48 p.m. which listed the pain level as 7. The March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation staff administered the medication from 3/1/22-3/24/22. During an interview on 3/22/22 at 9:07 a.m., the resident stated his hip hurt. During an observation on 3/22/22 at 2:39 p.m. the resident was in his recliner and asked if someone would help him with the pain in his hip. Observations on 3/23/22 revealed the following: a. At 8:43 a.m., resident was in his room and stated his right hip hurt. b. At 8:46 a.m., Staff B, Certified Nursing Assistant, CNA, assisted the resident to reposition in bed. Staff A, CNA, entered the room. The resident stated his left hip and right foot ached several times. He stated he was in a lot of pain right now, I can tell you. As Staff B assisted the resident to put his shirt on, he stated oh, oh a couple of times and stated he ached and asked staff to please get him in the chair. c. At 9:07 a.m., Staff E, Licensed Practical Nurse (LPN), brought a medication cup into the resident. d. At 9:57 a.m., Staff A answered the resident's call light and he stated he was still in pain in his left hip. Staff A stated she would tell the nurse. e. At 12:12 p.m., Staff A, Staff C, and Staff D hooked the resident up to the mechanical lift to change his incontinent brief. During the cares, the resident stated (expletive) that hurts. A 3/24/22 Physician's Note stated the physician did not wish to order a different pain medication for the resident. During an interview on 3/23/22 at 3:07 p.m., Staff E, LPN, stated the resident stated he was in pain every day and she assumed more medication would help. She stated if a resident rated pain at a 10/10 staff should reassess in 30 minutes and if it did not subside, they should call the physician. During an interview on 3/24/22 at 8:12 a.m., Staff D, CNA, stated the resident was in pain 95% of the time in his bottom or hip. She stated she assisted the resident to his recliner and placed a wedge under him but this didn't relieve the pain all the time. She stated some days he did not stop hollering about pain. During an interview on 3/24/22 at 8:20 a.m., Staff G, CNA, stated the resident complained a lot about his hip. She stated repositioning helped him briefly but then he complained about it again. She stated he frequently complained of pain. During an interview on 3/24/22 at 8:28 a.m., Staff C, CNA, stated the resident stated he hurt every day. During an interview on 3/24/22 at 9:58 a.m., the Director of Nursing, DON, stated if a resident reported 10/10 pain multiple times per day, she would reach out to the physician. She stated regarding Resident #2, she would reach out to his physician to push for something stronger so he had something around the clock for pain. During an interview on 3/24/22 at 10:43 a.m., the DON provided documentation from the physician. She stated the physician did not want the resident on any stronger medication and he felt (the complaints of pain) were from his behaviors. She stated they would continue repositioning and non-pharmacological interventions as they had been. During an interview on 3/23/22 at 10:57 a.m., the DON stated she would follow up with the resident's psychiatric provider to see if they had any ideas for pain relief. 2. In a Minimum Data Set (MDS) dated [DATE] for Resident #19 the Brief Interview for Mental Status (BIMS) is scored at 12 or moderate cognitive impairment. The MDS revealed she required extensive assistance with one staff member for bed mobility, transferred and ambulated in the room with extensive assistance of one staff member. The MDS recorded Resident #19 reported they experienced pain on an occasional basis and rated the worst pain at a 10 on a 00 to 10 pain scale with 10 being the worst pain imaginable. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised on 2/3/21 identified a focus area for chronic pain. I have chronic pain related to [CONDITION(S)]. I am on opioid pain medication [MEDICATION(S)], Tylenol, and a [MEDICATION(S)] to left shoulder, and muscle rub to left ankle. I am able to tolerate a pain level 10/10 most of the time, but depends on the day, there are days I need something before that. In an interview on 3/22/22 at 9:09 AM, resident #19 stated she has pain in her left ankle and can't get up because of it. She stated she has medication for it. She stated she has pain in her neck, shoulder and her left ankle. In an interview on 3/23/22 at 8:00 AM, Resident #19 stated she has pain all the time. Her goal for where to be on a pain scale is a 1 (one is little to no pain). She is at a 9 now. She just received her morning medication. She repositioned with the assistance of staff for the pain by her request. She moaned when turned. She stated the muscle rub they put on only lasts a little while. In an interview on 3/23/22 at 1:00 PM, the DON stated they changed pharmacies and had medication change over on 2/19/22. That was when they found out that resident #19's insurance would no longer cover her [MEDICATION(S)] patches for her ankle. They used her prn medications for the pain until they could get an order from the doctor to replace the [MEDICATION(S)]. In an interview on 3/24/22 at 10:00 AM, the DON stated when dealing with a resident with chronic pain we start with pain monitoring seeing where they fall on the pain scale. We then work with the doctor giving them the information from monitoring. They will give us orders for the resident. We then start following the doctors' orders with giving medications and follow up with use of the pain scale. We monitor and see how the resident is doing after the medication is given. If they are needing more relief after medication, non-pharmacological techniques will be tried such as range of motion. If still not effective we would reach out to the doctor for something more. If the resident rates their pain at a 10 once we would use a prn (as needed) medication. If they rate a 10 more often we would contact the doctor after trying non-pharmacological techniques. On a document titled NSG: Pain Evaluation dated 1/5/22 Resident #19 was evaluated for pain. At that time, she rated her pain at an 8. The conclusion stated a pain management intervention is necessary. Progress Notes revealed the [MEDICATION(S)] 4% (pain patch) twice a day was not available starting on 2/19/22 through 2/22/22. A new order from Dr. [NAME] was obtained on 2/22/22 to replace the patch with a routine muscle rub. In a document titled Weights and Vitals summary dated the month of 2/2022 the resident's pain level was checked twice a day. It ranged from 0 to 7 from 2/19/22 through 2/22/22. A Pain Assessment and Management policy dated 3/2020 had a pain management defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Under monitoring and modifying approaches it stated to monitor the following factors to determine if the resident's pain is being adequately controlled: The resident's response to interventions and level of comfort over time.

Based on clinical record review, observations, staff interviews, and facility abuse policy, the facility failed ensure the resident's right to be free from abuse on two occasions for 1 of 3 sampled (Resident #9) for abuse. The facility reported a census of 45 residents. Findings included: The Minimum Data Set assessment dated [DATE], for Resident #9, revealed a BIMS score of 6, which indicated the resident's cognition severely impaired. The MDS revealed Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident experienced behaviors not directed towards others. The Care Plan revealed Resident #9 has major depressive disorder, generalized anxiety disorder, and a mood disorder and prescribed medications to treat those disorders. The Care Plan revealed the resident has impaired cognitive function and difficulty expressing her ideas or wants due to a traumatic [CONDITION(S)] and anxiety. Staff should allow resident plenty of time to respond. The Care Plan revealed the resident also has a history of behaviors and hit her previous roommate. The resident sometimes displays crying, pacing, yelling for her friend when her anxiety is worsening. The Care Plan revealed when the resident has increased anxiety staff can assist the resident by having her talk to her friend. An observation on 12/13/21 at 2:20 pm revealed the Resident #9 ambulating out of her room, crying and wailing. The resident followed the staff around while crying. Staff attempted to redirect the resident and console her. An observation on 12/21/21 at 10:23 am revealed Resident #9 by the nurse's station. Resident wailing in a repetitive speech. Staff tried to console the resident. A Progress Note dated 10/29/21 at 11:20 am, revealed the resident room changed due to behaviors and increased crying. Resident under one-on-one observation. A Progress Note dated 10/29/21 at 3:58 pm, revealed the social worker with the resident for one on one observations. A Progress Note dated 10/29/21 at 4:41 pm, revealed Social Worker reported to Staff B, Registered Nurse (RN) to continue with 15 minutes checks on Resident #9. A Progress Note dated 10/29/21 at 9:33 pm, revealed Resident #9 had behaviors earlier in the shift and on one on one observations. A Progress Note dated 11/10/21 at 9:59 pm, showed Resident #9 had behaviors of crying and yelling during the shift. An undated Investigative Report revealed on 11/23/21 the Social Worker reported on 10/29/21 while performing one-on-one observations for Resident #9, the resident became upset while sitting in the dining room and the Social Worker assisted the resident to her room. The report showed the resident began crying and staff B, RN came down the hall and administered medications to Resident #9. Resident #9 did not calm down and stood in the doorway refusing to enter her room. The Social Worker reported she attempted to coax the resident into her room but Staff B used her hand to put the resident in her room and held her in the room while she shut the door. An undated written statement from Social Worker, revealed on 10/29/21 around 4 pm, Staff B, RN took Resident #9 into her room and shut the door. The report from the Social Worker revealed the resident started screaming and saying no. The Social Worker reported the resident not combative at the time of the incident. A monthly schedule for October 2021 revealed Staff B, RN worked on 10/29/21 for a 2 pm to 10 pm shift. In an interview on 12/21/21 at 3:30 pm, the Regional Consultant reported during her investigation, the Social Worker reported to her Staff B, RN closed the door shut to Resident #9's room. The Regional Consultant reported the way the Social Worker explained it to her is the Social Worker felt Staff B was aggressive but no harm came to the resident. In an interview on 12/27/21 at 10:32 am the Social Worker, recalled on 10/29/21 being in Resident #9's room because the resident required one-on-one observation. The Social Worker reported the resident standing in the doorway crying when Staff B RN, approached the resident, put her hand on the resident's abdomen as to move her, and then shut the resident's door. The Social Worker reported Staff B did not hold the door closed. The Social Worker reported she stayed in the room with the resident, talked to her, calmed her down and then reopened the door for the resident. In an interview on 12/28/21 at 1:13 pm, Staff B, RN, reported she could not specifically remember the incident with Resident #9 regarding shutting the door. She reported many of the residents complained about Resident #9 being loud so she would shut Resident #9's door to appease the other residents. She reported the resident often-received one-on-one observation due to her behaviors so she could not recall one single event. She reported if the resident ever cried loudly and if she ever stood in the way of the doorway, she would make sure the resident cleared the area before she would shut the door to Resident #9's room. She reported she did not assault the resident or hold the resident in her room. An undated Investigative Report revealed further investigation of an allegation of confinement reported on 11/23/21. Staff F, Certified Nurse Aide (CNA) reported she saw Staff D, CNA hold Resident #9's door shut as instructed by Staff B, RN. Staff F unable to recall the date this occurred. An email from Staff B, RN, dated 11/30/21 time stamped at 8:14 am, Staff B reported on 11/10/21 she walked Resident #9 down the hallway with the resident toward Resident #9's room. Resident #9 began to escalate behaviors of crying and screaming. Staff B reported once at Resident #9's room, Resident #9 started screaming, Where's Billy? Staff B reported she used distractions, offered Resident #9 a snack, asking the resident to calm down, and asking if she wanted to use the restroom or to watch television. The e-mail revealed the resident screamed no, no, no, and flailed her arms out. Staff B's email revealed she thought Resident #9 failed to hit Staff B. Staff B reported the resident screamed and became aggressive and no staff were around to help. Staff B reported she shut the door between her and Resident #9 but did not hold the door shut to the resident's room. Staff B wrote she tried to protect herself and the resident by keeping a door between them. In the email, Staff B wrote she asked the resident to back away from the door and helped her. A schedule for November 2021 revealed Staff B, RN and Staff D, CNA scheduled to work 2 pm to 10 pm shift on 11/10/21. A Daily Assignment sheet revealed Staff B, RN and Staff D, CNA worked the evening shift on 11/10/21. In an interview on 12/27/21 at 9:23 am, Staff D, CNA reported around suppertime on 11/10/21, Resident #9 was emotional. Staff D witnessed Staff G, CNA place Resident #9 in her room and held the door so Resident #9 could not get out. The nurse down the hall took over and held the door shut for about 10 minutes. Staff D reported the nurse stopped her and told her to hold the door so the nurse could pass medications. Staff D reported she held the door for about two minutes but then asked another staff member who had come in early for her shift to assist the resident. Staff D reported she felt what Staff G and the nurse did to the resident is wrong. In an interview on 12/27/21 at 10:16 am, Staff F, CNA reported she worked night shift but came in to work at 6 pm to clean. She recalled she came out of a room and witnessed Staff D, CNA, standing outside Resident's #9 door. Staff F reported Staff D did not appear to hold the door shut. Staff F reported Staff D asked her to help because she would need to be getting the residents to bed soon. Staff F reported she went in and assisted the resident to the restroom, and then went back to cleaning. Staff F reported she recalled the resident crying. However, Staff F reported the resident cried often and not an unusual event. In an interview on 12/28/21 at 1:13 pm, Staff B, RN, could not recall the event very well, she reported the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff often would then take Resident #9 from the overly stimulated environments and assisted Resident #9 to her room to calm her down. Staff B recalled Resident #9 in her room crying and inconsolable. Staff B reported Resident #9's behaviors did not improve and only escalated. Staff B reported she closed the door between her and the resident and talked to her through the door. She reported when the resident started to calm down, she cracked the door open, talked to her through it, and told her when she had calmed down she could come out. Staff B reported she returned to her med cart and Resident #9 came out to the cart and seemed fine. Staff B reported she did not ask any other staff to hold the door shut for her so she could pass medications. In an interview at 12/28/21 at 12:16 pm, the previous Administrator reported when Resident #9 escalated in behaviors and over-stimulated, staff would try to remove the resident from the stimulated environment, as an intervention, and take her to her room but the process did not include holding the door shut. A Resident Abuse under Federal Certification Guidelines policy dated November 2019 revealed each resident has the right to be from abuse and involuntary seclusion. The interpretive guidelines revealed abuse is defined as a willful infliction of unreasonable confinement, intimidation or punishment resulting in pain or mental anguish.

Based on review of clinical records, staff interviews, and facility abuse policy, the facility failed to notify the State Agency within 24 hours of an allegation of abuse for 1 of 3 residents sampled (Resident #9) for abuse. The facility reported a census of 45 residents. Findings included: The Minimum Data Set assessment dated [DATE], for Resident #9, revealed a BIMS score of 6, which indicated Resident #9 ' s cognition severely impaired. The MDS revealed Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident experienced behaviors not directed towards others. The Care Plan revealed Resident #9 has major depressive disorder, generalized anxiety disorder, and a mood disorder and prescribed medications to treat those disorders. The Care Plan revealed the resident has impaired cognitive function and difficulty expressing her ideas or wants due to a traumatic [CONDITION(S)] and anxiety. Staff should allow resident plenty of time to respond. The Care Plan revealed the resident also has a history of behaviors and hit her previous roommate. The resident sometimes displays crying, pacing, yelling for her friend when her anxiety is worsening. The Care Plan revealed when the resident has increased anxiety staff can assist the resident by having her talk to her friend. An undated Investigative Report revealed on 11/23/21 the Social Worker reported on 10/29/21 while performing one on one cares for Resident #9, the resident became upset while sitting in the dining room and the social worker assisted the resident to her room. The report showed the resident began crying and staff B, Registered Nurse (RN) came down the hall and administered medications to Resident #9. Resident #9 did not calm down and stood in the doorway refusing to enter her room. Social worker reported she attempted to coax the resident into her room but Staff B used her hand to put the resident in her room and held her in the room while she shut the door. An undated written statement from Social Worker, revealed on 10/29/21 around 4 pm, Staff B, Registered Nurse (RN) took Resident #9 into her room and shut the door. The report from the Social Worker revealed the resident started screaming and saying no. The Social Worker reported the resident not combative at the time of the incident. In an interview on 12/21/21 at 3:30 pm, the Regional Consultant reported during her investigation, the Social Worker reported to her Staff B, RN closed the door shut to Resident #9's room. The Regional Consultant reported the way the Social Worker explained it to her is the Social Worker felt Staff B aggressive but no harm came to the resident. In an interview on 12/27/21 at 10:32 am the Social Worker, recalled on 10/29/21 being in Resident #9's room at the time the alleged confinement took place, because the resident required one on one observation. The social worker reported the Staff B, RN at med cart and came to the room, told the resident to be quiet, put her hand on Resident #9's abdomen to clear the resident from the doorway and shut the resident's door. The social worker reported she sent an email to the previous administrator and to the MDS Coordinator who was the interim Director of Nurses at the time. The Social Worker reported as far as she knows the event not investigated and not asked by management regarding the incident. Staff B continued to work at the facility. The social worker stated perhaps this is her fault should have followed up with management. A copy of a printed email dated 10/29/21 at 5:01 pm, revealed a Social Worker sent an e-mail to the previous Administrator and the MDS Coordinator to inform them of the event. The e-mail revealed the Social Worker witnessed resident standing in the doorway, crying, and Staff B used her hand to put Resident #9's room and hold her there while she shut the resident's room door. In the email, the Social Worker reported the resident started screaming and saying no and pushed against Staff B's hand. The e-mail documented Resident #9 not combative, but crying and inconsolable. In an interview on 12/21/21 at 3:30 pm, the Regional Consultant reported only being made aware of these events in late November. The Regional Consultant reported in an investigation, the Social Worker reported sending an e-mail to the previous Administrator. During the investigation with the previous Administrator, she reported to the Regional Consultant she did not receive an email. The Regional Consultant stated if there is an allegation of abuse, the Social Worker should have talked to someone before leaving the facility and leaving the resident in Staff B's care. An undated Investigative Report revealed, further investigation of an allegation of confinement reported on 11/23/21, revealed on a different date, Staff F, Certified Nurse Aide (CNA) reported she observed Staff D, CNA hold Resident #9's door shut per instruction of Staff B, RN. The investigative report revealed Staff F unable to recall the date this occurred. An email from Staff B, RN, dated 11/30/21 time stamped at 8:14 am, Staff B reported on 11/10/21 she walked Resident #9 down the hallway with the resident toward Resident #9's room. Resident #9 began to escalate behaviors of crying and screaming. Staff B reported once at Resident #9's room, Resident #9 started screaming, Where's Billy? Staff B reported she used distractions, offered Resident #9 a snack asking Resident #9 to calm down, to use the restroom or to watch television. The e-mail revealed the resident screamed no, no, no, and flailed her arms out. Staff B's email revealed she thought Resident #9 flailed to hit Staff B. Staff B reported the resident screamed and became aggressive and no staff were around to help. Staff B reported she shut the door between her and Resident #9 but did not hold the door shut to the resident's room. Staff B wrote she tried to protect herself and the resident by keeping a door between them. In the email, Staff B wrote she asked the resident to back away from the door and helped her. In an interview on 12/27/21 at 9:23 am, Staff D, Certified Nurse Aide (CNA) reported around suppertime on 11/10/21, Resident #9 emotional and a CNA had put #9 in her room and held the door so #9 could not get out. The nurse down the hall took over and held the door shut for about 10 minutes and then stopped Staff D and told her to hold the door so the nurse could pass medications. Staff D reported she held the door for about two minutes but then asked another staff member who had come in early for her shift to assist the resident. Staff D reported she felt what the CNA and the nurse did to the resident is wrong. In an interview on 12/27/21 at 10:16 am, Staff F, CNA reported she worked night shift but came in to work at 6 pm to clean. She recalled she came out of a room and saw a CNA standing outside Resident's #9 door. Staff F reported the staff member not holding the door shut but the CNA asked her to help because she would need to be getting the residents to bed soon. Staff F reported she went in and assisted the resident to the restroom, and then went back to cleaning. Staff F reported looking back at the event, she should have asked more questions. In an interview on 12/28/21 at 11:45 am, Staff H, CNA, reported her and Staff I, CNA, received a report, on the following morning of the event, from Staff F, CNA who witnessed the event. Staff H and Staff I brought it up in the 9 am daily morning meeting with the nursing staff, and were told to write statements from the administrator (previous administrator). Staff H reported she gave her written report to Staff J, previous administrator. She reported she believed Staff I gave her written report to Staff J, previous interim DON. Staff H reported there were other occurrences with Staff B doing unethical things previously to this event. Staff H reported when she asked the Staff J why Staff B still allowed to work, she reported Staff J said, I wish we weren't so desperate for help. In an interview on 12/28/21 at 12:16 pm, Staff K, previous Administrator, reported never being told about Resident #9 being confined to her room on either account. She reported her expectations of staff are for them to report directly to their supervisors for suspected abuse. She stated if the possible perpetrator is the direct supervisor then staff should have called her directly. She reported once an allegation of abuse has been made, they would start an investigation and notify the Department of Inspections and Appeals (DIA). A Timely Abuse Reporting policy dated 11/2019 revealed staff should report all allegations of abuse, neglect, exploitation, and mistreatment, to the charge nurse immediately. The charge nurse is responsible for immediately reporting the allegations of abuse to the administrator. All allegations of resident abuse should be reported to DIA no later than two hours after the allegation is made. In an interview on 12/30/21 at 8:59 am, Staff J, MDS Coordinator, reported if staff suspect abuse they should tell management immediately. If management is not is not available, they should report to their charge nurse. If the alleged perpetrator is one of the charge nurses then staff should inform the other charge nurse on duty. Once management is made aware of the abuse allegation, they should reported it to DIA within 2 hours.

Based on review of clinical records, staff interviews, and abuse policy review, the facility failed to separate the resident from the alleged perpetrator and failed to conduct two timely abuse investigations for 1 of 3 residents sampled (Resident #9) for abuse. The facility reported a census of 45 residents. Findings included: The Minimum Data Set assessment dated [DATE], for Resident #9, revealed a BIMS score of 6, which indicated Resident #9 ' s cognition severely impaired. The MDS revealed Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident experienced behaviors not directed towards others. The Care Plan revealed Resident #9 has major depressive disorder, generalized anxiety disorder, and a mood disorder and prescribed medications to treat those disorders. The Care Plan revealed the resident has impaired cognitive function and difficulty expressing her ideas or wants due to a traumatic [CONDITION(S)] and anxiety. Staff should allow resident plenty of time to respond. The Care Plan revealed the resident also has a history of behaviors and hit her previous roommate. The resident sometimes displays crying, pacing, yelling for her friend when her anxiety is worsening. The Care Plan revealed when the resident has increased anxiety staff can assist the resident by having her talk to her friend. An undated Written Statement from the Social Worker, revealed on 10/29/21 around 4 pm, Staff B, Registered Nurse (RN) took Resident #9 into her room and shut the door. The report from the Social Worker revealed the resident started screaming and saying no. The Social Worker reported the resident not combative at the time of the incident. An undated Investigative Report revealed on 11/23/21 the Social Worker reported on 10/29/21 while performing one on one cares for Resident #9, the resident became upset while sitting in the dining room and the Social Worker assisted the resident to her room. The report showed the resident began crying and Staff B, RN came down the hall and administered medications to Resident #9. Resident #9 did not calm down and stood in the doorway refusing to enter her room. Social worker reported she attempted to coax the resident into her room but Staff B used her hand to put the resident in her room and held her in the room while she shut the door. An undated Written Statement from Social Worker, revealed on 10/29/21 around 4 pm, Staff B, RN took Resident #9 into her room and shut the door. The report from the Social Worker revealed the resident started screaming and saying no. The Social Worker reported the resident not combative at the time of the incident. A copy of a printed email dated 10/29/21 at 5:01 pm revealed a Social Worker sent an e-mail to the previous administrator and the MDS coordinator to inform them of the event she witnessed. A monthly schedule between 10/29/21 - 11/30/21 revealed Staff B worked the following dates in the facility: 10/29/21 through 11/5/21, 11/7/21, and 11/9/21 through 11/19/21. Time punches for Staff B, RN revealed she worked the following days 10/29, 10/30, 10/31, 11/2, 11/3, 11/4, 11/5, 11/7, 11/9, 11/10, 11/11, 11/12, 11/13, 11/14, 11/16, 11/17, 11/18, 11/19, and 11/22. A monthly schedule between 11/10/21 - 11/30/21 revealed Staff D, CNA worked the following dates in the facility: 11/10/21. Time punches for Staff D, Certified Nurse Aide (CNA) revealed she worked 11/10/21 from 2 pm till 6 pm. In an interview on 12/27/21 at 10:32 am, the Social Worker reported she e-mailed the administrator and Staff J, MDS Coordinator, to inform them of what she witnessed. The Social Worker reported she never heard back from either of them and Staff B continued to work at the facility with Resident #9. The social worker stated I guess it is my fault. If I had a conversation with them then maybe this wouldn't have happened. In an interview on 12/21/21 at 3:30 pm, the Regional Consultant reported the current management team not made aware of the events which took place with Resident #9 and Staff B until late November. The Regional Consultant reported she interviewed Staff K, previous Administrator, who reported not knowing of the events or receiving an email from the social worker. In an interview on 12/27/21 at 9:45 am, Staff E, Certified Medication Aide (CMA), reported at a 9 am morning meeting Staff H, CNA and Staff I, CNA brought it to their attention that Staff B, RN had a CNA hold Resident #9's door closed. Staff K, the previous Administrator, had Staff H and Staff I write a written statement. Staff E reported Staff K said in the meeting stated, its just said we are this short that we gotta keep people. In an interview on 12/28/21 at 1:13 pm, Staff B, RN reported no one had talked to her previously or investigated anything as far as she knows. Staff B said on 11/22/21, the current Director of Nursing (DON) of the facility told her she could not return to the facility to work due to being under investigation. Staff B reported when Resident #9 acted out and she closed the door on the resident, if someone had seen her, she felt the staff who witnessed the event should have come down and offered to help her instead of just doing nothing and report her. In an interview on 12/28/21 at 11:44 am, Staff H, CNA, reported her and Staff I, CNA received a morning report from Staff F, CNA. Staff H reported in report, Staff F reported seeing a CNA hold a door shut to Resident #9's room. Staff H reported her and Staff I brought up what they heard in the 9 am morning meeting with the nursing staff. Staff H reported to Staff K, the previous Administrator told her and Staff I to give a written statement of what they heard. Staff H wrote a statement and gave it to Staff K. Staff H reported Staff B, RN, had done unethical things prior to this event and management fully aware, but asked why Staff B allowed to work. Staff H reported Staff K stated I wish we weren't so desperate for help. In an interview on 12/29/21 at 8:14 am, Staff I, CNA, reported she received a shift report from Staff F, CNA in the morning around 5:45 am. Staff I stated Staff F told her and Staff H, CNA on the evening shift, Staff F witnessed a CNA hold a door shut to Resident #9's room. She stated in the report, CNA said Staff B, RN told CNA to hold the door shut. Staff I reported unsure whether Staff F reported what she saw to anyone. Staff I reported she brought it up in the 9 am nurses meeting and told Staff K, previous Administrator what she received in report. Staff I reported Staff K told her and Staff H to write a statement. Staff I reported she wrote her statement and certain she gave it to Staff K. Staff I said if someone witnesses a staff member being mean to a resident, staff should separate and make sure the resident is safe. Then report to your supervisor, and if they don't do anything about it then call in the allegation yourself. In an interview on 12/28/21 at 12:16 pm, Staff K, previous Administrator, reported never being told about Resident #9 being confined to her room on either account. Staff K reported often Staff H would gossip about things which were hearsay. Staff K reported she would ask Staff H and other staff to give written statements anytime they had something to tell. Staff K reported she never received written statements regarding Resident #9 being confined. She reported her expectations of staff are for them to report directly to their supervisors any suspected abuse. She stated if the possible perpetrator is the direct supervisor then staff should have called her directly. She reported once an allegation of abuse has been made, they would start an investigation and notify the State Agency.

Based on record review and staff interviews, the facility failed to promptly assess and provide timely intervention for 1 of 4 sampled (Resident #1) who had severe pain. The staff repeatedly reported the pain to the charge nurse and the charge nurse failed to intervene in a timely manner. The facility reported a census of 33. Findings include: According to the Minimum Data Set (MDS) assessment dated of [DATE], Resident #1 had a Brief Interview for Mental Status score of 6 indicating a moderately impaired cognitive status. Resident #1 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. Resident #1 had also been confirmed positive for COVID-19 recovered. During an interview on [DATE] at 2:11 p.m. Staff A (Nurse Aide) stated on the evening of [DATE] she was working a 2:00 p.m. to 10:00 p.m. shift and assigned to Resident #1's hall. Sometime shortly after supper, Resident #1 was laid down and Staff C passed his evening medications. At 8:00 p.m., Resident #1 activated his call light and Staff A responded. Resident #1 stated he was having severe abdominal pain and refused to allow Staff A to touch his abdomen. Staff A stated she reported Resident #1's complaint to Staff C. Staff A stated Staff C did not check on Resident #1 at that time. At 8:20 p.m., Resident #1 again activated his call light and Staff A responded. Resident #1 was complaining of intense abdominal pain. Staff A stated she again told Staff C of Resident #1's complaint. Staff C responded, stating Resident #1 do not have anything (medication) for his stomach and she didn't think she needed to assess him. At 8:45 p.m. Resident #1 activated his call light and Staff A responded. Resident #1 stated he was still having severe abdominal pain. Staff A stated she again informed Staff C who made no comment and did not check on Resident #1. Between 9:00 p.m. and 9:10 p.m. Staff A was doing rounds and entered Resident #1's room. Resident #1 was still complaining of severe pain, to the point of crying in pain. Staff A again informed Staff C who did nothing at that time. At 9:30 p.m. Staff A was at the nurse's station and shortly later Staff C came up and stated Resident #1's abdomen was not distended and his bowel sounds were okay. Staff A stated she and Staff B (Licensed Practical Nurse) entered Resident #1's room. Resident #1 stated he was still having severe pain and when asked, stated Staff C had not been in his room. Both Staff A and Staff B returned to the nurse's station. Staff B stated she was not seeing the same thing which Staff C was reporting and suggested Staff C return to Resident #1's room or Staff B would do the assessment. Staff C then insisted she had assessed him. Staff A stated Resident #1 said he wasn't checked on and so is Resident #1 lying. Staff A stated she told Staff C Resident #1 was requesting to go to the hospital and Staff C responded, stating he couldn't go to the hospital because he is on hospice. Staff A stated that is not true. Shortly after that (9:45 p.m.), Staff C finally went to Resident #1's room and assessed him. Staff C came back to the nurse's station and called hospice. Staff A stated she was scheduled to work a double shift, but left the facility to go home for a bit, planning on returning a little later. While out of the facility Staff A received the call informing her Resident #1 had passed away. During an interview on [DATE] at 4:11 p.m., Staff B (Licensed Practical Nurse) stated on [DATE] she was working a double shift from 2:00 p.m. until 6:00 a.m. the following day. Staff B stated that evening Staff A (Nurse Aide) approached her expressing frustration with Staff C. Staff B stated she has repeatedly told Staff C that Resident #1 was complaining of stomach pain. Staff B stated she said something to Staff C, who responded, stating Resident #1 has nothing (medication) for his stomach and he has had a recent bowel movement. Staff B stated after her break at around 8:45 p.m. Staff A remained frustrated and Staff B suggested to Staff C that maybe she should assess Resident #1. See if his abdomen is distended, check bowel sounds and find out exactly where the pain is in his abdomen and what kind of pain he is feeling. Staff C stated she would. Staff C reluctantly walked down the hall as Staff B and Staff A remained at the nurse's station. Neither Staff B nor Staff A witnessed Staff C gown up (Resident #1 was in isolation) or enter Resident #1's room. When Staff C returned to the nurse's station, Staff B asked how Resident #1 was doing. Staff C stated Resident #1's abdomen was not distended, soft, his bowel sounds were normal and he seemed to be more comfortable. Staff B stated, she and Staff A then went down to Resident #1's room. Staff B stated Resident #1's abdomen was visibly distended and painful to the touch. It was obvious that Resident #1 was visibly experiencing severe pain. Resident #1 stated he felt like he needed to vomit. Staff B and Staff A attempted to reposition him for comfort. The staff asked Resident #1 if Staff C had entered his room and checked on him. Resident #1 stated she had not. Staff B and Staff A then returned to the nurse's station and reported Resident #1's condition to Staff C. Staff C insisted she had assessed Resident #1. Staff A then confronted Staff C stating Resident #1 was not assessed and that he was requesting to go to the hospital. Staff B stated she also didn't believe Staff C had went in his room because Staff C described the abdomen as soft and bowel sounds normal and her findings were totally different. Staff C didn't provide an answer. Staff C stated I don't know what you want me to do. Staff C told Staff A, Resident #1 was on hospice so he could not go to the hospital. Staff B suggested Staff C contact hospice, which she did and hospice agreed to come in. Staff B stated later on about 10:30 p.m. Staff D came to her stating Resident #1 was vomiting profusely and she needed help. Staff B stated she and Staff D attempted to reposition Resident #1 and she applied his oxygen. Resident #1 lungs were rattling and he was complaining of not being able to breathe. Staff B stated within minutes Resident #1 passed away. During an interview on [DATE] at 2:36 p.m. Staff C (Licensed Practical Nurse) stated she usually starts her evening medication pass between 6:30 p.m. and 7:00 p.m. On the evening of [DATE], Staff C stated she remembers passing Resident #1's evening medications around that time. Resident #1 had mentioned that his stomach was bothering him and he thought he may have eaten his potatoes too fast. Sometime between 8:00 p.m. and 9:00 p.m. Staff A had told her Resident #1 was wanting something for his stomach. Staff C stated Resident #1 does not have anything ordered for an upset stomach. Staff C stated she admits she should have went and checked on Resident #1, but noted she was busy. At 9:00 p.m., Staff A reported Resident #1's abdomen was hard and distended and he was in pain. Staff C stated she went and assessed Resident #1 at around 9:30 p.m. and his abdomen was soft, bowel sounds good and no complaints of pain. Staff C stated Resident #1 asked about going to the hospital and she stated she would need to call hospice which Resident #1 was okay with. Staff A was upset and Staff C stated if you want him to go, I'll send him. Staff A stated you won't because you don't want to do the paper work. Staff C stated she called hospice and they said they will come out and see him. Staff C stated she doesn't recall discussing Resident #1's condition with Staff B that evening. According to Progress Notes dated [DATE], at 9:45 p.m., Staff C documented Resident #1's skin warm and dry, color pale, no cough noted, lungs clear bilaterally, respirations even and unlabored, no complaints of dyspnea, abdomen distended, soft and not tender to touch, bowel sounds all quadrants, resident voiding ok, vital signs Temperature: 98.5, Pulse: 72, Respirations: 16, Blood Pressure: ,[DATE], Blood Oxygen Saturation : 94% on room air. Resident #1 wanted hospice called. Power of Attorney present and aware. According to Progress Notes dated [DATE], at 10:17 p.m. Staff C notified hospice and hospice returned call at 10:32 p.m. and will planned on visiting Resident #1. During an interview on [DATE] at 9:33 a.m. Staff F stated she was contacted by the facility nurse (Staff C) on the evening of [DATE]. Staff C indicated Resident #1 was complaining of abdominal pain and his abdomen was slightly distended. Resident #1 had good bowel sounds and had a bowel movement within the last 24 hours. Staff C stated Resident #1 had been asking about gong to the hospital and she told him he was on hospice and didn't need to go. Staff C stated Resident #1 then requested to see the Hospice Nurse. During an interview on [DATE] at 3:35 p.m., Staff E (Nurse Aide) stated she was working the evening shift on [DATE] and assigned Hall 1. Staff E stated she recalled Staff A being frustrated with Staff C for not checking on Resident #1. Staff A stated Resident #1 complained of stomach pain and she told Staff C several times. Staff E stated she recalled witnessing Staff A informing Staff C of Resident #1's stomach pain and Staff C stated she would get to it later. Staff E reported working at the facility for 6 weeks and noticed Staff C reacted slowly to concerns. During an interview on [DATE] at 10:12 a.m., the Medical Director stated he was not familiar with Resident #1. The Medical Director received a call from Hospice on the evening of [DATE] to inform him Resident #1 passed away. The medical Director was briefed on Resident #1's condition prior to death, noting Resident #1 had abdominal pain, distention, and emesis over a three hour period and then suddenly died . The Medical Director stated based on that information, it was likely something new like a ruptured abdominal aneurysm or intra-abdominal bleed. The Medical Director stated there may have been some aspiration related to the vomiting, but that would not account for the abdomen distention and pain. The Medical Director stated given the brief onset of symptoms to sudden death, it was unlikely earlier medical interventions would have changed anything.

Based on observation, interview, and record review, the facility failed to implement CMS and CDC recommended infection control practices in order to control and prevent the potential spread of COVID-19 amongst residents and staff. The facility allowed staff to work and provide care to residents after reporting signs and symptoms of COVID-19, who later tested positive for COVID-19. Furthermore, the facility failed to ensure staff providing care to residents and working in COVID-19 positive resident areas wore appropriate personal protective equipment (PPE) when entering the unit. These facility staff cared for residents who tested positive for COVID-19, and then assisted with the care of other residents in the facility. The facility failed to thoroughly investigate an outbreak of COVID-19, in which 30 residents contracted the disease, and six expired. Additionally, the facility failed to ensure that all staff were thoroughly screened before beginning their scheduled shifts. A determination was made that the facility's noncompliance with one or more requirements of participation placed all residents in the facility in immediate jeopardy. On [DATE] at 2:15pm, the Administrator was notified of the immediate jeopardy at F880, Infection Prevention and Control. It was determined that the immediate jeopardy began on [DATE]. The immediate jeopardy was removed on [DATE] after the surveyor verified implementation of a removal plan. The scope and severity was lowered to an F. Findings include: - Review of resident (R1's) admission history and census, located in R1's electronic health record, documented that R1 admitted to the facility on [DATE], to room C-29. Review of R2's admission history and census, located in R2's electronic health record, documented that at the time R1 admitted to the facility, R2 resided in room C-25, on the same hall. Review of an interdisciplinary team (IDT) note, dated [DATE], documented that R2 enjoys walking/wandering around the facility with walker. checks each and every door (thinks it is his job to take care of everyone, makes sure they are ok.) On [DATE] at 8:50am, the Administrator indicated that the facility experienced an outbreak of COVID-19. The Administrator indicated that the facility accepted R1 who tested negative while in the hospital, but that 12 days following her admission to the facility, the resident developed symptoms of COVID-19 and subsequently tested positive. The Administrator indicated that the facility also housed R2, who wandered, and that the facility believed this wandering resident may have gotten into biohazardous materials from the COVID-19 positive resident, and that was how the disease spread throughout the facility. The Administrator indicated that approximately 30 residents became ill, and that six died during the outbreak. The Administrator indicated that two residents who developed COVID-19 remained on the isolation unit, but that [DATE] was the day they both were expected to leave the isolation unit. When asked for a summary of the outbreak, the Administrator indicated that the facility failed to complete an investigation into the outbreak, and that a summary of the incident had not been completed. On [DATE] at 9:00am, Nurse Aide (NA1) indicated that the facility experienced an outbreak of COVID-19 after newly admitted R1 developed symptoms of the disease and tested positive. NA1 indicated that R1 experienced a nagging cough, which staff didn't notice the first couple of days R1 was at the facility. R1 then developed a fever, and was tested . NA1 indicated that R2 regularly wandered throughout the facility, and was difficult to redirect. NA1 indicated that R2 tested positive for COVID-19, and that keeping him on the isolation unit was difficult, and at times R2 would leave the isolation unit and access other areas of the facility. NA1 indicated that after the outbreak began, she developed shortness of breath, reported the symptom on the employee screening logs, but was allowed to continue working. NA1 indicated that she collapsed at work and required emergency transportation to the hospital, where she tested positive for COVID-19. On [DATE] at 10:10am, R2 sat in a wheelchair on the isolation unit. NA2 and another staff person, both wearing facemasks and face shields, entered the unit. The staff failed to don any further PPE prior to entering the unit. The staff approached R2 and stopped to speak with him, each standing within six feet of R2. The staff then walked down the hall and stopped in front of the other isolated resident's room, and then donned isolation gowns and disposable gloves. After approximately five minutes, the staff exited the room and removed their isolation gowns and gloves in front of the door in the hallway, disposing of the supplies in a bin. They then walked down the hallway and exited the isolation unit. On [DATE] at 10:17am, NA2 indicated that she was on what the facility called the COVID corner, where residents who tested positive for COVID-19 resided. NA2 indicated that staff did not have to don full PPE, consisting of isolation gowns, face masks, gloves, and eye protection, prior to entering the isolation unit. NA2 indicated that the PPE was donned only when entering the individual resident rooms. NA2 then indicated that the isolation unit had no dedicated staff to care for the two residents housed there, and that the staff would go assist other residents throughout the facility with cares. NA2 indicated that the outbreak of COVID-19 began after R1 was admitted and then became symptomatic. NA2 indicated that R2 wandered throughout the facility, and was difficult to keep in his room. R2 also would enter other resident rooms and go through other resident's belongings. NA2 indicated that R2 later developed signs and symptoms of COVID-19, and tested positive. On [DATE] at 11:54am, facility staff exited a resident room on the isolation unit. The staff person was wearing an isolation gown, disposable gloves, a face mask, and eye protection. The staff member removed the isolation gown and gloves while standing in the hallway at the entrance to the resident room, then walked the length of the hallway to the double doors leading off of the unit. The staff person then asked another staff person for assistance. Both of the staff then reentered the unit and walked down the hallway to the resident room, failing to don the appropriate PPE prior to entering the isolation unit. On [DATE] at 1:29pm, Licensed Practical Nurse (LPN1) indicated that the facility had an outbreak of COVID-19. R1 admitted from a nearby hospital, where she initially was negative. After admission, R1 developed a cough, was tested , and shown to be positive. R2, who liked to get up and wander, and had a history of [REDACTED]. On [DATE] at 2:30pm, the Administrator indicated that because the residents last day on the isolation unit was to be [DATE], facility staff would not be expected to don full PPE prior to entering the isolation unit. - Review of the facility's Prevent COVID-19 screening logs documented the following: On [DATE], a facility staff person documented that they recently traveled outside of Iowa, lived with someone with symptoms or a positive test, provided care to a patient with COVID-19, and had close contact to someone with respiratory symptoms. The staff person documented a normal body temperature. The staffing sheet for [DATE] documented that the staff person was present that day. This staff person later tested positive for COVID-19. On [DATE], two facility staff people had temperatures logged, but failed to answer any screening questions. One of these staff later tested positive for COVID-19. On [DATE], a staff person reported having a new onset of coughing. Review of the staffing sheet for [DATE] documented the staff person was present that day. This staff person later tested positive for COVID-19. On [DATE], a staff person reported a new onset of coughing. The log documented that the staff person was allowed to begin working. This staff person later tested positive for COVID-19. On [DATE], a staff person documented a temperature of 99.1F, and failed to answer any screening questions. This staff person later tested positive for COVID-19. On [DATE], a staff person documented a temperature of 99.1F at the beginning of their shift, then left the facility, documenting an exit temperature of 99.6F. When the staff person returned to the facility, they documented an increased temperature of 99.7F. This staff person later tested positive for COVID-19. On [DATE] at 1:00pm, during a confidential interview, a facility staff person indicated that they had answered yes to some of the screening questions on the aforementioned dates. The staff person indicated that the facility allowed them to work and did not question them about why the questions were answered yes. On [DATE] at 1:29pm, LPN1 indicated that a staff person had collapsed at work following the onset of the outbreak, and later tested positive as well. LPN1 indicated that she had also answered yes to some of the screening questions on the forms, but that no administration ever came to screen her further, and that she was allowed to work. On [DATE] at 2:13pm, the Administrator indicated that the expectation of staff would be to answer all screening questions, and if the answer to any screening questions was 'yes,' the staff person would not be allowed to work.

This deficiency relates to facility self reported incident -I. Based on record review, interviews, and facility policy, the facility failed to provide adequate supervision related to resident to resident abuse. Interviews identified Resident #1 had been seen in Resident #2's room prior to when he/she abused Resident #2 on 1/15/16. In addition, staff reported Resident #1 had been seen in another resident's room (Resident #6); and had access throughout the facility. Record review established Resident#1 as sex offender and his/her care plan did not address any approaches related to his/her risk of abusing residents or monitoring him/her. The findings constitute an immediate jeopardy to the residents health and safety. The facility identify a census of 70 residents with three residents identified as sex offenders on the Registry. Findings include: According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 1/20/16, Resident #2 had a brief interview for mental status (BIMS) score of 12 indicating moderately impaired cognitive skills for daily decision making. Resident #2 required extensive assistance with assist of one to two staff with bed mobility, ambulation, dressing, toilet use and personal hygiene. Resident #2's [DIAGNOSES REDACTED]. Resident #2's care plan with a goal date of 5/3/16 revealed he/she had short-term memory deficits in remembering information provided to him/her. Resident #2 required one staff assistance for all personal cares. According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 11/19/15, Resident #1 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #1 required supervision with transfers, dressing and personal hygiene. He/she utilized a wheelchair for mobility and had been assessed as independent for toilet use. Resident #1's [DIAGNOSES REDACTED]. Resident #1 had been admitted on [DATE]. Record review established a background screen conducted prior to Resident #1's admission on 10/2/15 and noted Resident #1 on the Iowa Sex Offender Registry. Resident #1's Care Plan with a problem onset of 10/22/15 indicated Resident #1 as a sex offender and may be at risk of mistreating or abusing minors. Resident #1's goal was to not have any sexual behaviors. Approaches included registering the resident change of address with the police department, contact the police if resident elopes, one on one supervision required for facility field trips (outings). The resident's care plan noted the facility is in compliance with the 2000 feet ruling of a public school or child care setting and Resident #1 will not participate in activities that involve children unless provided one on one supervision. Resident #1's care plan identified no employees under the age of 18 will be scheduled to provide Resident #1's care. The care plan did not address any approaches related to Resident #1's risk of abusing residents. The resident's care plan identified he/she had been independent throughout the facility with a wheelchair. An incident/accident occurrence form dated 1/15/16 documented at 2:00 p.m., staff reported Resident #1 had been in another resident's room. Staff observed Resident #1 pulling his/her hand out of another resident's (Resident #2) pants. The preventative measures implemented listed one on one with Resident #1. The facility's investigation of the incident regarding Resident #1 and Resident #2 revealed the police were notified immediately (around 2:20 p.m.,) and asked to investigate the incident. In an interview on 2/10/16 at 9:40 a.m. Resident #2, as he/she had been resting quietly in his/her bed. When questioned regarding a male/female resident coming into his/her room, Resident #2 seemed to recall the incident. Resident #2 stated he/she was half asleep and half awake when it happened. The resident came into his/her room uninvited. Resident #2 stated he/she could not recall what happened, but thought staff came in. Resident #2 stated she had earlier visited that resident in the hallway, but could not recall his/her name. In an interview on 2/4/16 at 2:12 p.m. Staff A, Certified Nurse Aide (CNA), indicated on the afternoon of 1/15/16 she had been assigned to watch call lights during a facility staff meeting. Resident #2 and #5's call light activated and Staff A responded. Upon entering the room Staff A saw Resident #1 pulled up in his/her wheelchair beside the bed of Resident #2. Resident #2 had been laying on his/her bed. Staff A asked what was going on, and Resident #1 immediately removed his/her right hand from under Resident #2's brief. Resident #1 then propelled him/herself out of the room as Staff A notified the nurse, Staff B. Upon returning to the room with Staff B, Staff A stated Resident #2's brief was pulled down and his/her dress was pulled up, but below his/her breasts. When staff asked Resident #2, he/she stated He/she did not do anything, and neither did I. Staff A spoke with Resident #5 who is Resident #2's roommate. Resident #5 stated he/she had activated the call light. Staff A stated Resident #5 reported a week before Resident #1 was in his/her room and Staff C instructed him/her to turn on his/her call light if it ever happened again. Staff A stated earlier that day Resident #1 and Resident #2 were in the hallway leading to the smoking area. Staff A did not notice any inappropriate contact, but when the Administrator was informed the Administrator instructed her to keep Resident #1 and #2 separated. Staff A stated Resident #1 was a social person and several female residents liked his/her attention. Staff A was aware of Resident #1's sex offender history and stated she voiced concern that he/she was allowed access to a personal computer given his/her history. Staff A stated she did not have any knowledge whether Resident #1 was accessing pornography on his/her computer. According to Resident #5's Minimum Data Set (MDS) assessment with assessment reference date of 12/2/15, Resident #5 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #5's [DIAGNOSES REDACTED]. In an interview on 2/10/16 at 9:30 a.m. Resident #5 stated on 1/15/16 Resident #1 entered his/her room uninvited. Resident #1 had been in his/her wheelchair and propelled him/herself over to Resident #5's roommate's (Resident #2) side of the room; and just stared at him/her. Resident #2 had been lying in bed. Resident #5 stated he/she turned on his/her call light and when staff arrived he/she asked that Resident #1 be removed from their room. Resident #5 stated Resident #1 didn't say anything nor did Resident #2. Resident #5 was not aware whether there was any physical contact between the residents. In an interview on 2/10/16 at 1:50 p.m. Staff C, certified nurse aide, stated she knew of an incident a week or so prior to the 1/15/16 incident in which Resident #1 went into Resident #2's room. Staff A stated it was around 7:00 p.m. to 8:00 p.m. and as she was walking down hall 3 and noticed some movement out the corner of her eye coming from the doorway of room 66. Staff C stated room 66 is empty, but across the hall from Resident #2's room. Staff C stood out of sight up the hall and within a few seconds, Resident #1 darted across the hall in his/her wheelchair into Resident #2's room. Staff C went immediately to the room and found Resident #1 pulled up beside Resident #2's wheelchair facing each other. Staff C stated there was no physical contact between the residents and she instructed Resident #1 to leave the room. Staff C stated she reported the incident, but could not recall specific date or who the nurse was that evening. Staff C stated she had not known Resident #1 to be sexually inappropriate with other residents, but noted he/she often cruised the hallways, which made her uncomfortable. A review of the residents rooms showed Resident #1 and Resident #2 room's located on opposite hallways. In an interview on 2/10/16 at 3:55 p.m. Staff D, Licensed Practical Nurse, stated she recalled an evening in which Resident #1 entered the room of Resident #6 at around 10:00 p.m. to 10:30 p.m. Staff D was sitting at the nurse's station and saw Resident #1 propel his/her wheelchair into Resident #6's room at the end of the hallway. Staff D stated she got up and walked down the hall and as she got to the doorway, Resident #1 had propelled him/her(self) out of the room. Staff D stated she peaked in the room and Resident #6 had been lying in bed asleep. Staff D informed Resident #1 that he/she was not to be in resident rooms. Staff D stated she did not inform anyone of the incident or document the incident in Resident #1's record. Staff D initially stated Resident #1 was in Resident #6's room for 5 minutes, but when questioned further, she adjusted her statement to say the resident had only been in the room for 2-3 minutes. In an interview on 2/10/16 at 10:35 a.m. Staff E, certified nurse aide, stated she was working on the day Resident #1 was found in Resident #2's room. Staff E stated at the time of the incident there was a staff meeting and her and Staff A were monitoring for call lights. Staff E stated she was aware of Resident #1's sex offender status and knew of times in which he/she would attempt to enter male/female rooms and was redirected. Staff E knew of no other incidents in which Resident #1 had been sexually inappropriate. In an interview on 2/10/16 at 3:05 p.m. the Administrator stated she was informed of Resident #1 touching Resident #2 inappropriately on 1/15/16. The Administrator immediately initiated an investigation, speaking to Resident #2 first. Resident #2 acknowledged Resident #1 was in his/her room and that she had invited him/her in. Resident #2 denied being touched stating they were just talking. The Administrator then spoke with Resident #5, roommate of Resident #2. Resident #5 stated Resident #1 entered their room and went over to the bedside of Resident #2. Resident #5 activated the call light. Resident #5 stated he/she was unable to see Resident #1 and Resident #2 and noted neither resident was talking. The Administrator then questioned Resident #1. Resident #1 stated he/she went into Resident #2's room to talk and visit. Resident #1 then stated he/she made love to him/her. Resident #1 admitted to rubbing and touching Resident #2's private area. Resident #1 stated Resident #2 wanted him/her to do it and never said no. The Administrator contacted the police and Resident #1's probation officer and Resident #1 was arrested and removed from the facility. The Administrator stated Resident #1 was not court ordered to the facility, but she was aware of his/her sexual offender history and that he/she was on probation. The Administrator stated Resident #1 was a very social and friendly resident with both male and female residents. He/she was known to be in doorways of residents and was typically redirected from the doorways. The Administrator stated she had never known Resident #1 to be in other resident rooms or to be sexually inappropriate. The Administrator stated there were no previous indications that Resident #1 would target adults. The Administrator stated, based on Resident #2's statement, Resident #2 consented to the encounter on 1/15/16. In an interview on 2/10/16 at 3:00 p.m. the Director of Nursing (DON), stated Resident #1 was a sexual offender related to children and was care planned based on this. The DON stated she knew of a few times Resident #1 was in the doorways of other residents, but was not aware of him/her ever being in a male/females room until the incident on 1/15/16. The DON reported Resident #1 had been redirected when at the doorways of others. The DON stated until the 1/15/16 incident, Resident #1 had not been sexually inappropriate. The DON stated there was an incident in which a male/female resident wanted to have a sexual relationship with Resident #1, but Resident #1 stated he/she did not want to pursue the relationship. In an interview on 2/11/16 at 8:30 a.m. the Probation Officer for Resident #1, stated he became Resident #1's probation officer in December 2015. The Probation Officer stated he received a call on 1/15/16 regarding Resident #1 touching another resident inappropriately at the facility. Resident #1 admitted to having sexually explicit contact with Resident #2. The Probation Officer stated Resident #1 violated his/her probation and was arrested. The Probation Officer stated in his experience with working with sex offenders, he has found sex offenders are opportunists and at risk of perpetrating on anyone. Facility Abuse Prevention and Sex Offender Registry policy/procedure dated December 2015 indicated the purpose is the nursing home to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents. The Policy identified every resident has the right to be free from mistreatment and neglect. The policy revealed this included the facility's identification of residents whose personal histories render them at risk for abusing other residents. The policy included guidelines which included the facility to check all existing and prospective residents on the Iowa's Sex Offender's Registry. The policy identify a resident on the sex offender registry will be analyzed for determining risk for abusing other residents; and addressing those risks with interventions on the care plan. On 1/1/5/16, the facility immediately separated Resident #1 and Resident # 2; and placed Resident #1 on 1:1 supervision until his/her emergency discharge. The facility contacted the Police and Resident #1's probation officer. The facility abated the IJ on 1/16/16 when they educated staff on the following: All staff were educated to report immediately if a sex offender resident is in another resident's room or coming out of a resident's room or loitering in the hallways. When any inappropriate touching or fondling is witnessed, staff need to report to the nurse (immediately) and the DON and Administrator; and the nurse will complete documentation of the incident. The facility will evaluate the risk the current sex offender residents present to determine the level of supervisor needed to monitor them; and if a new sex offender resident is admitted . Determine the resident's risk for abusing other residents and ensure adequate supervision is provided. If a resident with a history of sex offender is admitted , all staff will be educated regarding supervision, documentation of resident (to resident) interaction and assessment and care plan interventions will be completed.

Based on record review, interviews, and facility policy, the facility failed to protect 1 of 3 residents from resident to resident abuse. Record review and interviews identified the facility failed to develop interventions to protect Resident #2 from being abused by Resident #1. Interviews revealed staff had seen Resident #1 in Resident #2's room prior to the abuse incident on 1/15/16 and staff asked his/her roommate (Resident #5) to turn on the call light if Resident #1 returned to their room. Resident #1's record identified he/she as a Registered Sex Offender. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identify the census of 70 residents. Findings include: According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 1/20/16, Resident #2 had a brief interview for mental status (BIMS) score of 12 indicating moderately impaired cognitive skills for daily decision making. Resident #2 required extensive assistance with assist of one to two staff with bed mobility, ambulation, dressing, toilet use and personal hygiene. Resident #2's [DIAGNOSES REDACTED]. Resident #2's care plan with a goal date of 5/3/16 revealed he/she had short-term memory deficits in remembering information provided to him/her. Resident #2 required one staff assistance for all personal cares. According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 11/19/15, Resident #1 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #1 required supervision with transfers, dressing and personal hygiene. He/she utilized a wheelchair for mobility and had been assessed as independent for toilet use. Resident #1's [DIAGNOSES REDACTED]. Resident #1 had been admitted on [DATE]. Record review established a background screen conducted prior to Resident #1's admission on 10/2/15 and noted Resident #1 on the Iowa Sex Offender Registry. Resident #1's Care Plan with a problem onset of 10/22/15 indicated Resident #1 as a sex offender and may be at risk of mistreating or abusing minors. Resident #1's goal was to not have any sexual behaviors. Approaches included registering the resident change of address with the police department, contact the police if resident elopes, one on one supervision required for facility field trips (outings). The resident's care plan noted the facility is in compliance with the 2000 feet ruling of a public school or child care setting and Resident #1 will not participate in activities that involve children unless provided one on one supervision. Resident #1's care plan identified no employees under the age of 18 will be scheduled to provide Resident #1's care. The care plan did not address any approaches related to Resident #1's risk of abusing residents. The resident's care plan identified he/she had been independent throughout the facility with a wheelchair. An incident/accident occurrence form dated 1/15/16 documented at 2:00 p.m., staff reported Resident #1 had been in another resident's room. Staff observed Resident #1 pulling his/her hand out of another resident's (Resident #2) pants. The preventative measures implemented listed one on one with Resident #1. The facility's investigation of the incident regarding Resident #1 and Resident #2 revealed the police were notified immediately (around 2:20 p.m.,) and asked to investigate the incident. In an interview on 2/10/16 at 9:40 a.m. Resident #2, as he/she had been resting quietly in his/her bed. When questioned regarding a male/female resident coming into his/her room, Resident #2 seemed to recall the incident. Resident #2 stated he/she was half asleep and half awake when it happened. The resident came into his/her room uninvited. Resident #2 stated he/she could not recall what happened, but thought staff came in. Resident #2 stated she had earlier visited that resident in the hallway, but could not recall his/her name. In an interview on 2/4/16 at 2:12 p.m. Staff A, Certified Nurse Aide (CNA), indicated on the afternoon of 1/15/16 she had been assigned to watch call lights during a facility staff meeting. Resident #2 and #5's call light activated and Staff A responded. Upon entering the room Staff A saw Resident #1 pulled up in his/her wheelchair beside the bed of Resident #2. Resident #2 had been laying on his/her bed. Staff A asked what was going on, and Resident #1 immediately removed his/her right hand from under Resident #2's brief. Resident #1 then propelled him/herself out of the room as Staff A notified the nurse, Staff B. Upon returning to the room with Staff B, Staff A stated Resident #2's brief was pulled down and his/her dress was pulled up, but below his/her breasts. When staff asked Resident #2, he/she stated He/she did not do anything, and neither did I. Staff A spoke with Resident #5 who is Resident #2's roommate. Resident #5 stated he/she had activated the call light. Staff A stated Resident #5 reported a week before Resident #1 was in his/her room and Staff C instructed him/her to turn on his/her call light if it ever happened again. Staff A stated earlier that day Resident #1 and Resident #2 were in the hallway leading to the smoking area. Staff A did not notice any inappropriate contact, but when the Administrator was informed the Administrator instructed her to keep Resident #1 and #2 separated. Staff A stated Resident #1 was a social person and several female residents liked his/her attention. Staff A was aware of Resident #1's sex offender history and stated she voiced concern that he/she was allowed access to a personal computer given his/her history. Staff A stated she did not have any knowledge whether Resident #1 was accessing pornography on his/her computer. According to Resident #5's Minimum Data Set (MDS) assessment with assessment reference date of 12/2/15, Resident #5 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #5's [DIAGNOSES REDACTED]. In an interview on 2/10/16 at 9:30 a.m. Resident #5 stated on 1/15/16 Resident #1 entered his/her room uninvited. Resident #1 had been in his/her wheelchair and propelled him/herself over to Resident #5's roommate's (Resident #2) side of the room; and just stared at him/her. Resident #2 had been lying in bed. Resident #5 stated he/she turned on his/her call light and when staff arrived he/she asked that Resident #1 be removed from their room. Resident #5 stated Resident #1 didn't say anything nor did Resident #2. Resident #5 was not aware whether there was any physical contact between the residents. Resident #5 stated Resident #1 has never bothered him/her. In an interview on 2/10/16 at 1:50 p.m. Staff C, certified nurse aide, stated she knew of an incident a week or so prior to the 1/15/16 incident in which Resident #1 went into Resident #2's room. Staff A stated it was around 7:00 p.m. to 8:00 p.m. and as she was walking down hall 3 and noticed some movement out the corner of her eye coming from the doorway of room [ROOM NUMBER]. Staff C stated room [ROOM NUMBER] is empty, but across the hall from Resident #2's room. Staff C stood out of sight up the hall and within a few seconds, Resident #1 darted across the hall in his/her wheelchair into Resident #2's room. Staff C went immediately to the room and found Resident #1 pulled up beside Resident #2's wheelchair facing each other. Staff C stated there was no physical contact between the residents and she instructed Resident #1 to leave the room. Staff C stated she reported the incident, but could not recall specific date or who the nurse was that evening. Staff C stated she had not known Resident #1 to be sexually inappropriate with other residents, but noted he/she often cruised the hallways, which made her uncomfortable. In an interview on 2/10/16 at 3:55 p.m. Staff D, Licensed Practical Nurse, stated she recalled an evening in which Resident #1 entered the room of Resident #6 at around 10:00 p.m. to 10:30 p.m. Staff D was sitting at the nurse's station and saw Resident #1 propel his/her wheelchair into Resident #6's room at the end of the hallway. Staff D stated she got up and walked down the hall and as she got to the doorway, Resident #1 had propelled him/her(self) out of the room. Staff D stated she peaked in the room and Resident #6 had been lying in bed asleep. Staff D informed Resident #1 that he/she was not to be in resident rooms. Staff D stated she did not inform anyone of the incident or document the incident in Resident #1's record. Staff D initially stated Resident #1 was in Resident #6's room for 5 minutes, but when questioned further, she adjusted her statement to say the resident had only been in the room for 2-3 minutes. In an interview on 2/10/16 at 10:35 a.m. Staff E, certified nurse aide, stated she was working on the day Resident #1 was found in Resident #2's room. Staff E stated at the time of the incident there was a staff meeting and her and Staff A were monitoring for call lights. Staff E stated she was aware of Resident #1's sex offender status and knew of times in which he/she would attempt to enter male/female rooms and was redirected. Staff E knew of no other incidents in which Resident #1 had been sexually inappropriate. In an interview on 2/10/16 at 3:05 p.m. the Administrator stated she was informed of Resident #1 touching Resident #2 inappropriately on 1/15/16. The Administrator immediately initiated an investigation, speaking to Resident #2 first. Resident #2 acknowledged Resident #1 was in his/her room and that she had invited him/her in. Resident #2 denied being touched stating they were just talking. The Administrator then spoke with Resident #5, roommate of Resident #2. Resident #5 stated Resident #1 entered their room and went over to the bedside of Resident #2. Resident #5 activated the call light. Resident #5 stated he/she was unable to see Resident #1 and Resident #2 and noted neither resident was talking. The Administrator then questioned Resident #1. Resident #1 stated he/she went into Resident #2's room to talk and visit. Resident #1 then stated he/she made love to him/her. Resident #1 admitted to rubbing and touching Resident #2's private area. Resident #1 stated Resident #2 wanted him/her to do it and never said no. The Administrator contacted the police and Resident #1's probation officer and Resident #1 was arrested and removed from the facility. The Administrator stated Resident #1 was not court ordered to the facility, but she was aware of his/her sexual offender history and that he/she was on probation. The Administrator stated Resident #1 was a very social and friendly resident with both male and female residents. He/she was known to be in doorways of residents and was typically redirected from the doorways. The Administrator stated she had never known Resident #1 to be in other resident rooms or to be sexually inappropriate. The Administrator stated there were no previous indications that Resident #1 would target adults. The Administrator stated, based on Resident #2's statement, Resident #2 consented to the encounter on 1/15/16. In an interview on 2/10/16 at 3:00 p.m. the Director of Nursing (DON), stated Resident #1 was a sexual offender related to children and was care planned based on this. The DON stated she knew of a few times Resident #1 was in the doorways of other residents, but was not aware of him/her ever being in a male/females room until the incident on 1/15/16. The DON reported Resident #1 had been redirected when at the doorways of others. The DON stated until the 1/15/16 incident, Resident #1 had not been sexually inappropriate. The DON stated there was an incident in which a male/female resident wanted to have a sexual relationship with Resident #1, but Resident #1 stated he/she did not want to pursue the relationship. In an interview on 2/11/16 at 8:30 a.m. the Probation Officer for Resident #1, stated he became Resident #1's probation officer in December 2015. The Probation Officer stated he received a call on 1/15/16 regarding Resident #1 touching another resident inappropriately at the facility. Resident #1 admitted to having sexually explicit contact with Resident #2. The Probation Officer stated Resident #1 violated his/her probation and was arrested. The Probation Officer stated in his experience with working with sex offenders, he has found sex offenders are opportunists and at risk of perpetrating on anyone. Facility Abuse Prevention and Sex Offender Registry policy/procedure dated December 2015 indicated the purpose is the nursing home to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents. The Policy identified every resident has the right to be free from mistreatment and neglect. The policy revealed this included the facility's identification of residents whose personal histories render them at risk for abusing other residents. The policy included guidelines which included the facility to check all existing and prospective residents on the Iowa's Sex Offender's Registry. The policy identify a resident on the sex offender registry will be analyzed for determining risk for abusing other residents; and addressing those risks with interventions on the care plan. On 1/1/5/16, the facility immediately separated Resident #1 and Resident # 2; and placed Resident #1 on 1:1 supervision until his/her emergency discharge. The facility contacted the Police and Resident #1's probation officer. The facility abated the IJ on 1/16/16 when they educated staff on the following: All staff were educated to report immediately if a sex offender resident is in another resident's room or coming out of a resident's room or loitering in the hallways. When any inappropriate touching or fondling is witnessed, staff need to report to the nurse (immediately) and the DON and Administrator; and the nurse will complete documentation of the incident. The facility will evaluate the risk the current sex offender residents present to determine the level of supervisor needed to monitor them; and if a sex offender is admitted the staff were educated regarding supervision, documentation of resident to resident interactions, assessing and care planning. The facility will determine the resident's risk for abusing other residents and ensure adequate supervision is provided. Staff were also re-educated on the list of residents with a sex offender history and all new staff will be educated on the supervision, care plan, and documentation of resident (to resident) interaction/s during their orientation process.

Based on record review, interviews, and facility policy, the facility failed to implement strategies to prevent Resident #1 from abusing Resident #2. The facility policy established residents whose personal histories render them at risk of abusing other residents would be analyzed with care plan provisions to prevent abuse. Interviews revealed staff had seen Resident #1 in Resident #2's room prior to the abuse incident on 1/15/16. Record review identified Resident #1's care plan did not address any strategies to prevent resident abuse. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identify the census of 70 residents. Findings include: According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 1/20/16, Resident #2 had a brief interview for mental status (BIMS) score of 12 indicating moderately impaired cognitive skills for daily decision making. Resident #2 required extensive assistance with assist of one to two staff with bed mobility, ambulation, dressing, toilet use and personal hygiene. Resident #2's [DIAGNOSES REDACTED]. Resident #2's care plan with a goal date of 5/3/16 revealed he/she had short-term memory deficits in remembering information provided to him/her. Resident #2 required one staff assistance for all personal cares. According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 11/19/15, Resident #1 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #1 required supervision with transfers, dressing and personal hygiene. He/she utilized a wheelchair for mobility and had been assessed as independent for toilet use. Resident #1's [DIAGNOSES REDACTED]. Resident #1 had been admitted on [DATE]. Record review established a background screen conducted prior to Resident #1's admission on 10/2/15 and noted Resident #1 on the Iowa Sex Offender Registry. Resident #1's Care Plan with a problem onset of 10/22/15 indicated Resident #1 as a sex offender and may be at risk of mistreating or abusing minors. Resident #1's goal was to not have any sexual behaviors. Approaches included registering the resident change of address with the police department, contact the police if resident elopes, one on one supervision required for facility field trips (outings). The resident's care plan noted the facility is in compliance with the 2000 feet ruling of a public school or child care setting and Resident #1 will not participate in activities that involve children unless provided one on one supervision. Resident #1's care plan identified no employees under the age of 18 will be scheduled to provide Resident #1's care. The care plan did not address any approaches related to Resident #1's risk of abusing residents. The resident's care plan identified he/she had been independent throughout the facility with a wheelchair. An incident/accident occurrence form dated 1/15/16 documented at 2:00 p.m., staff reported Resident #1 had been in another resident's room. Staff observed Resident #1 pulling his/her hand out of another resident's (Resident #2) pants. The preventative measures implemented listed one on one with Resident #1. The facility's investigation of the incident regarding Resident #1 and Resident #2 revealed the police were notified immediately (around 2:20 p.m.,) and asked to investigate the incident. In an interview on 2/10/16 at 9:40 a.m. Resident #2, as he/she had been resting quietly in his/her bed. When questioned regarding a male/female resident coming into his/her room, Resident #2 seemed to recall the incident. Resident #2 stated he/she was half asleep and half awake when it happened. The resident came into his/her room uninvited. Resident #2 stated he/she could not recall what happened, but thought staff came in. Resident #2 stated she had earlier visited that resident in the hallway, but could not recall his/her name. In an interview on 2/4/16 at 2:12 p.m. Staff A, Certified Nurse Aide (CNA), indicated on the afternoon of 1/15/16 she had been assigned to watch call lights during a facility staff meeting. Resident #2 and #5's call light activated and Staff A responded. Upon entering the room Staff A saw Resident #1 pulled up in his/her wheelchair beside the bed of Resident #2. Resident #2 had been laying on his/her bed. Staff A asked what was going on, and Resident #1 immediately removed his/her right hand from under Resident #2's brief. Resident #1 then propelled him/herself out of the room as Staff A notified the nurse, Staff B. Upon returning to the room with Staff B, Staff A stated Resident #2's brief was pulled down and his/her dress was pulled up, but below his/her breasts. When staff asked Resident #2, he/she stated He/she did not do anything, and neither did I. Staff A spoke with Resident #5 who is Resident #2's roommate. Resident #5 stated he/she had activated the call light. Staff A stated Resident #5 reported a week before Resident #1 was in his/her room and Staff C instructed him/her to turn on his/her call light if it ever happened again. Staff A stated earlier that day Resident #1 and Resident #2 were in the hallway leading to the smoking area. Staff A did not notice any inappropriate contact, but when the Administrator was informed the Administrator instructed her to keep Resident #1 and #2 separated. Staff A stated Resident #1 was a social person and several female residents liked his/her attention. Staff A was aware of Resident #1's sex offender history and stated she voiced concern that he/she was allowed access to a personal computer given his/her history. Staff A stated she did not have any knowledge whether Resident #1 was accessing pornography on his/her computer. According to Resident #5's Minimum Data Set (MDS) assessment with assessment reference date of 12/2/15, Resident #5 had a brief interview for mental status (BIMS) score of 15 indicating intact cognitive skills for daily decision making. Resident #5's [DIAGNOSES REDACTED]. In an interview on 2/10/16 at 9:30 a.m. Resident #5 stated on 1/15/16 Resident #1 entered his/her room uninvited. Resident #1 had been in his/her wheelchair and propelled him/herself over to Resident #5's roommate's (Resident #2) side of the room; and just stared at him/her. Resident #2 had been lying in bed. Resident #5 stated he/she turned on his/her call light and when staff arrived he/she asked that Resident #1 be removed from their room. Resident #5 stated Resident #1 didn't say anything nor did Resident #2. Resident #5 was not aware whether there was any physical contact between the residents. Resident #5 stated Resident #1 has never bothered him/her. In an interview on 2/10/16 at 1:50 p.m. Staff C, certified nurse aide, stated she knew of an incident a week or so prior to the 1/15/16 incident in which Resident #1 went into Resident #2's room. Staff A stated it was around 7:00 p.m. to 8:00 p.m. and as she was walking down hall 3 and noticed some movement out the corner of her eye coming from the doorway of room [ROOM NUMBER]. Staff C stated room [ROOM NUMBER] is empty, but across the hall from Resident #2's room. Staff C stood out of sight up the hall and within a few seconds, Resident #1 darted across the hall in his/her wheelchair into Resident #2's room. Staff C went immediately to the room and found Resident #1 pulled up beside Resident #2's wheelchair facing each other. Staff C stated there was no physical contact between the residents and she instructed Resident #1 to leave the room. Staff C stated she reported the incident, but could not recall specific date or who the nurse was that evening. Staff C stated she had not known Resident #1 to be sexually inappropriate with other residents, but noted he/she often cruised the hallways, which made her uncomfortable. A review of the residents rooms showed Resident #1 and Resident #2 room's located on opposite hallways. In an interview on 2/10/16 at 3:55 p.m. Staff D, Licensed Practical Nurse, stated she recalled an evening in which Resident #1 entered the room of Resident #6 at around 10:00 p.m. to 10:30 p.m. Staff D was sitting at the nurse's station and saw Resident #1 propel his/her wheelchair into Resident #6's room at the end of the hallway. Staff D stated she got up and walked down the hall and as she got to the doorway, Resident #1 had propelled him/her(self) out of the room. Staff D stated she peaked in the room and Resident #6 had been lying in bed asleep. Staff D informed Resident #1 that he/she was not to be in resident rooms. Staff D stated she did not inform anyone of the incident or document the incident in Resident #1's record. Staff D initially stated Resident #1 was in Resident #6's room for 5 minutes, but when questioned further, she adjusted her statement to say the resident had only been in the room for 2-3 minutes. In an interview on 2/10/16 at 10:35 a.m. Staff E, certified nurse aide, stated she was working on the day Resident #1 was found in Resident #2's room. Staff E stated at the time of the incident there was a staff meeting and her and Staff A were monitoring for call lights. Staff E stated she was aware of Resident #1's sex offender status and knew of times in which he/she would attempt to enter male/female rooms and was redirected. Staff E knew of no other incidents in which Resident #1 had been sexually inappropriate. In an interview on 2/10/16 at 3:05 p.m. the Administrator stated she was informed of Resident #1 touching Resident #2 inappropriately on 1/15/16. The Administrator immediately initiated an investigation, speaking to Resident #2 first. Resident #2 acknowledged Resident #1 was in his/her room and that she had invited him/her in. Resident #2 denied being touched stating they were just talking. The Administrator then spoke with Resident #5, roommate of Resident #2. Resident #5 stated Resident #1 entered their room and went over to the bedside of Resident #2. Resident #5 activated the call light. Resident #5 stated he/she was unable to see Resident #1 and Resident #2 and noted neither resident was talking. The Administrator then questioned Resident #1. Resident #1 stated he/she went into Resident #2's room to talk and visit. Resident #1 then stated he/she made love to him/her. Resident #1 admitted to rubbing and touching Resident #2's private area. Resident #1 stated Resident #2 wanted him/her to do it and never said no. The Administrator contacted the police and Resident #1's probation officer and Resident #1 was arrested and removed from the facility. The Administrator stated Resident #1 was not court ordered to the facility, but she was aware of his/her sexual offender history and that he/she was on probation. The Administrator stated Resident #1 was a very social and friendly resident with both male and female residents. He/she was known to be in doorways of residents and was typically redirected from the doorways. The Administrator stated she had never known Resident #1 to be in other resident rooms or to be sexually inappropriate. The Administrator stated there were no previous indications that Resident #1 would target adults. The Administrator stated, based on Resident #2's statement, Resident #2 consented to the encounter on 1/15/16. In an interview on 2/10/16 at 3:00 p.m. the Director of Nursing (DON), stated Resident #1 was a sexual offender related to children and was care planned based on this. The DON stated she knew of a few times Resident #1 was in the doorways of other residents, but was not aware of him/her ever being in a male/females room until the incident on 1/15/16. The DON reported Resident #1 had been redirected when at the doorways of others. The DON stated until the 1/15/16 incident, Resident #1 had not been sexually inappropriate. The DON stated there was an incident in which a male/female resident wanted to have a sexual relationship with Resident #1, but Resident #1 stated he/she did not want to pursue the relationship. In an interview on 2/11/16 at 8:30 a.m. the Probation Officer for Resident #1, stated he became Resident #1's probation officer in December 2015. The Probation Officer stated he received a call on 1/15/16 regarding Resident #1 touching another resident inappropriately at the facility. Resident #1 admitted to having sexually explicit contact with Resident #2. The Probation Officer stated Resident #1 violated his/her probation and was arrested. The Probation Officer stated in his experience with working with sex offenders, he has found sex offenders are opportunists and at risk of perpetrating on anyone. Facility Abuse Prevention and Sex Offender Registry policy/procedure dated December 2015 indicated the purpose is the nursing home to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents. The Policy identified every resident has the right to be free from mistreatment and neglect. The policy revealed this included the facility ' s identification of residents whose personal histories render them at risk for abusing other residents. The policy included guidelines which included the facility to check all existing and prospective residents on the Iowa ' s Sex Offender ' s Registry. The policy identify a resident on the sex offender registry will be analyzed for determining risk for abusing other residents; and addressing those risks with interventions on the care plan. On 1/1/5/16, the facility immediately separated Resident #1 and Resident # 2; and placed Resident #1 on 1:1 supervision until his/her emergency discharge. The facility contacted the Police and Resident #1's probation officer. The facility abated the IJ on 1/16/16 when they educated staff on the following: All staff were educated to report immediately if a sex offender resident is in another resident's room or coming out of a resident's room or loitering in the hallways. When any inappropriate touching or fondling is witnessed, staff need to report to the nurse (immediately) and the DON and Administrator; and the nurse will complete documentation of the incident. The facility will evaluate the risk the current sex offender residents present to determine the level of supervisor needed to monitor them. The facility will determine the resident's risk for abusing other residents and ensure adequate supervision is provided. The facility will developed care plan with specific monitoring on the resident who are sex offenders or a newly admitted sex offender. Staff were also re-educated on the list of residents with a sex offender history and all new staff will be educated on the supervision, care plan, and documentation of resident (to resident) interaction/s during their orientation process.

Based on observation, record review and interviews, the facility failed to ensure a resident who entered the facility without pressure sore did not develop pressure sores and failed to ensure services promoted healing of the resident's heel ulcer. The concern was identified for one (1) of three (3) residents with pressure sores (Resident #9). The facility reported census was 57 residents. Findings include: An admission Minimum Data Set (MDS) with an assessment reference date of 12/21/13 indicated Resident #9 with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairments. The MDS assessment identified the resident required one staff to physical assist with bed mobility, transfers, and ambulation. Resident #9' s primary [DIAGNOSES REDACTED]. Skin assessment evaluation for the MDS noted the resident was not at high risk for developing pressure ulcers and did not have any pressure ulcers on admission. The MDS identified Resident #9 did not have any of the following skin conditions/ ulcers/ wounds/skin problems: no infection of the foot ([MEDICAL CONDITION]); no [MEDICAL CONDITION]; no open [MEDICAL CONDITION] on the foot; no open lesion/cuts, no surgical wounds, no burns, and no skin tears. The MDS identified Resident #9 did not reject activities of daily living (ADL) cares. Braden scale assessment on admission scored 19 indicating Resident #9 was not high risk for pressure sore development. The Care planned dated 12/20/13 for skin prevention on admission listed the following interventions: 1. Encourage the resident to shift weight while sitting up in a chair. 2. Encourage good nutritional intake. 3. Daily observation of skin with routine care. 4. Resident # 9 needed a full evaluation of skin weekly with bath or shower. 5. Resident #9 had a pressure reducing mattress on his/her bed. Record review of a radiology report dated 2/3/14 revealed the resident had a fall resulting in a [MEDICAL CONDITION]. The resident was admitted to the hospital and had surgical repair of the fracture. The re-admission MDS dated [DATE] revealed the resident returned to the facility on [DATE]. The MDS skin assessment revealed the resident was now at risk for development of pressure ulcers. The The resident required physical assistance of two staff for bed mobility, transfers, and ambulation. The MDS identified Resident #9 did not have an unhealed pressure ulcer. The resident had surgical wounds, skin tear(s) and open lesion(s) with treatment for [REDACTED].#9 did not reject ADL cares. Braden skin assessment dated [DATE] scored 19 indicating Resident #9 with a low risk of pressure sore development. The activity section scored the resident with a 2 on the chairfast and described chairfast as the ability to walk severely limited; and cannot bear own weight and or must be assisted into chair or wheelchair. The friction and shear section noted a potential for a problem. Review of the resident's care plan after return from the hospital on [DATE] revealed the care plan was updated to include the resident's [MEDICAL CONDITION] and revealed no new interventions were implemented for prevention of pressure ulcers. Review of the Pressure Ulcer Healing Record dated 4/9/14 revealed a pressure ulcer was identified on the resident's left outer heel. The ulcer measured 2 centimeters (cm) in diameter and was covered with black eschar (dead tissue that falls off from healthy skin- scab-like) and was unstageable. There was no drainage or odor noted from the site. The physician was notified by facsimile (fax) dated 4/9/14 and orders were received to treat the area with skin prep until healed. Review of a second Pressure Ulcer Healing Record dated 4/14/14 revealed a pressure ulcer was identified on the resident's right buttock. Measurements were 1.6 cm by 0.5 cm with a < (less then) 0.1 depth and the area was labeled stage 2. Scant serosanguineous (fluid consisting of serum and blood) was noted. A Fax dated 4/14/14 to the physician revealed a treatment of [REDACTED]. The Pressure Ulcer Healing Record dated 4/28/14 revealed the pressure ulcer on the resident's left outer heel measured at 1.1 cm by 0.8 cm, with black/brown eschar and was unstageable. There was no drainage or odor noted from the site. Observation on 4/29/14 at 8:40 a.m. revealed Staff A, Certified Nurse Aide (CNA), provided appropriate toileting cares for the resident. The resident's skin on both buttocks revealed no open areas. The Assistant Director of Nursing (ADON), present in the room, stated the wound had healed. Staff assisted the resident to bed and placed on his/her back. The resident's feet and heels rested directly on the surface of a blue bolster at the end of the bed, the resident ' s heels were not floating. Observation on 4/29/14 at 2:00 p.m. revealed Staff C, Registered Nurse (RN), washed her hands, gloved and provided wound care to the resident's heel appropriately. The wound was covered with brown eschar. The nurse speculated that the resident's shoe may have been rubbing on the site of the open area but was unsure. She stated the resident was no longer wearing the shoes while the area was being treated. The nurse then assisted the resident to turn onto the left side to provide cares for the open area on the resident's buttock. The area appeared healed and the nurse applied barrier cream to the area. She stated she would notify the physician the area was healed. The resident remained on the side lying position with a pillow between his/her knees and the feet resting sideways on the surface. The following updates were noted on the care plan: 1. 4/14/14- an air overlay on the resident's bed. 2. 4/15/14- a pressure relieving cushion was placed in the resident's chair. 3. 4/22/14- a wedge pillow was placed on the resident s bed for side lying positioning. 4. 4/23/14- heels up in bed. 5. An undated intervention of pressure relieving boots bilaterally was discontinued on 4/23/14. Further review of Nurse's Notes entries from 3/13/14 to the discovery date of the initial pressure ulcer on 4/9/14 revealed the resident was noted to be lying in bed frequently and attempts by the resident self transfer/ambulation were limited to two. Both times resulted in falls. During an interview with the Director of Nurses (DON) on 4/30/14 at 4:00 p.m. she reported the resident had a Braden score of 15 on admission. The DON reported the resident was up and down restless so there was no skin interventions except the standard skin prevention interventions were put into place. The DON reported due to the frequent change of positions by the resident and staff repositioning every two hours per facility protocol the resident was not considered high risk for pressure ulcer development upon returning from hospitalization after the hip repair surgery. She stated the resident was not in bed more at the end of March 2014 through April 2014 because of continued self transfers/ambulation episodes and staff repositioning. The DON stated she evaluated the occurrence of the ulcers and stated the areas developed by the resident were unexpected. The DON stated on 4/9/14 after the resident developed heel ulcer, they tried the blue boots. The DON reported the resident hated the blue boots and screamed until off. When the resident developed the coccyx ulcer on 4/14/14, they changed the wheelchair cushion to Roho and air overlay.

See first Revisit for F-323 findings. Based on record review and interviews, the facility failed to ensure each resident received adequate assistance and supervision to protect him/her from self or in the environment for one of five residents reviewed. Resident #7 informed the Administrator that he/she needed assistance to the bathroom. The Administrator did not utilize the call light and left the resident's room to alert staff of the resident's needs. Upon return, Resident #7 had fallen and sustained a fracture hip. The facility reported census of 59 residents. Findings include: Record review established Resident #7 had been hospitalized prior to admission to the nursing home. The hospital history and physical dated 9/2/11 documented Resident #7 had been admitted to a local hospital on [DATE] for a three week stay during which the resident was treated for [REDACTED]. A complete blood count performed on 9/3/11 revealed the resident's hemoglobin was noted to be 8 g/dL (normal range is 11.9-16.1 g/dL). Low hemoglobin levels can contribute to extreme fatigue, weakness, and dizziness. On 9/4/11 the resident's hemoglobin was still below normal range but had increased significantly to 10.8 g/dL. A metabolic screen completed on 9/3/11 revealed the resident had a blood potassium level of 3.4 mg/d (normal range is 3.7-5.3 mg/dL which reflected the resident was hypokalemic. This condition can lead to cardiac irregularities and symptoms of dizziness). The resident's potassium level reached within the normal range with intravenous potassium on 9/5/11. Copies of the resident's lab work and assessments were sent to the facility with the resident when he/she was admitted to the facility on [DATE] for rehabilitation and strengthening. The resident's medical history, as noted on the hospital admitting assessment form dated 9/2/11, revealed the resident had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment was not completed by facility staff during Resident #7's two day stay. Initial assessment status of the resident was determined by a facility nurse at the time of admit for the resident's initial temporary care plan. This information was placed on the resident's "Care Card," an orange instruction sheet taped on the inner door of the cupboard in the resident's bathroom. The "Care Card" directed staff to provide mobility, transfers, and ambulation with one staff member assisting the resident along with the use of a gaitbelt and wheeled walker. Additional instructions included two siderails were to be placed in upright position when the resident was in bed. Other assessments completed during the resident's two day stay at the facility included an undated fall assessment in which the resident scored 14 points placing him/her in the high risk category (a score above 10 indicated high risk for falls). Additional assessments included an undated siderail assessment which revealed the resident had a history of [REDACTED]. Record review revealed the social worker, Staff D, evaluated the resident at 12:35 p.m. on 9/6/11. She stated the resident was alert. The resident's family had been present at that time and expressed desire for Resident #7 to return home when stronger. Nurse's notes on 9/5/11 at 3:15 p.m. revealed a status report was called to the facility from the hospital regarding the resident's hospital stay. The report stated the resident was wheezing, was alert, and had two loose green stools before transfer. Nurse's notes at 3:45 p.m. stated the resident was admitted to the facility with stable vital signs. On 9/6/11 at 1:00 p.m. the nurse's notes revealed Resident #7 complained of dizziness and shortness of breath. The resident continued to complain of dizziness as documented in the nurse's notes at 2:20 p.m., and 7:00 p.m. that same day. At 2:20 p.m. staff documented the call light had been in reach and siderails up. The physician was notified of the resident's dizziness at 4:45 p.m. On 9/7/11 at 1:00 a.m. the nurse's notes revealed the resident complained again of previous dizzy spells but stated at that particular times she was not dizzy. The resident was instructed by the nurse to use the call light for assistance if he/she needed to go to the bathroom. The notes documented the resident verbalized an understanding. Staff assisted the resident to the bathroom and the resident did not complained of dizziness. The call light was within reach. At 6:10 a.m., the nurse's noted documented the Administrator returned to the resident's room and found Resident #7 on the floor sitting against the wall. The notes indicated the resident was confused and asked for his/her family member. The notes documented a trail of feces led from bed to door of room. Staff G completed the assessment after the fall and documented Resident #7 complained of right hip pain and being unable to move his/her right leg thus the nurse stopped the assessment. The physician and the resident's family were called and the resident was transported by ambulance to the local emergency room for evaluation. The notes documented Resident #7's family called the nursing home to inform them Resident #7 had fractured his/her right hip. The facility reported an X-ray confirmed Resident #7 had a fractured hip and required surgery. Review of the Incident/Accident/Unusual Occurrence Form dated 9/7/11 as documented by Staff H, Registered Nurse (RN), revealed the resident had been found at 6:10 a.m. by the Administrator, sitting on the floor with his/her back against the wall. The resident's vital signs were pulse-116, respirations-20, temperature 97.5, and blood pressure was 160/100. The incident report did not document any information on the siderails. An interview with the Administrator, on 9/8/11 at 10:00 a.m. revealed she had been in the hall by the resident's room at approximately 6:05 a.m. on 9/7/11 and was on her way to the MDS office which is located next door to the resident's room (approximately 11/5 feet away). She heard the resident calling for help and arrived at Resident #7's door entrance and asked if he/she needed help. The Administrator stated Resident #7 was sitting on the edge of the bed with his/her feet on the floor and wanted to go to the bathroom. The Administrator stated the lights in the room were off and the call light had not been activated. The Administrator stated she told the resident she would go get someone to assist him/her to the bathroom. She turned and went to the door of MDS office and told the MDS nurse (Staff B) that Resident #7 needed some assistance. A nurse at the nurse's station, down the hall from the MDS office, overheard the Administrator speaking to the MDS nurse and paged overheard for a Certified Nurse's Aide (CNA) to go help the resident. The Administrator returned to the resident's room and found the resident sitting on the floor up against the wall in the room. The Administrator stated she was gone form the resident's room approximately 10-20 seconds. The Administrator explained she did not help the resident to the bathroom when first asked for help because she was unaware of the resident's ambulation status and she did not have a gait belt with her at the time. She stated she did not look on the resident's Care Card to discern the resident's ambulation status. An interview with the MDS nurse, Staff B, on 9/8/11 at 2:40 p.m. revealed she was in her office at 6:00 a.m. on 9/7/11 but did not hear the resident calling for help. The Administrator came to her office and said the resident needed help to the bathroom. Staff B stated she picked up the phone to call the nurse's station to inform a staff there there that the resident needed help to go to the bathroom. Before she was able to call, she heard over the loudspeaker a page for a CNA to go assist the resident. The Administrator told Staff B she would return to the resident's room to help the resident ambulate to the bathroom because she thought a CNA was on the way due to the overheard page. She stated each CNA carried a gaitbelt and two extra gaitbelts were kept at the nurse's station. When interviewed on 9/8/11 at 1:00 p.m. Staff E, CNA, stated she and Staff F, CNA, were checking alarms at 6:00 a.m. on 9/7/11. She stated they walked down the hall and passed Resident#7's room where the open door revealed the resident appeared to be sleeping in a dark room. Staff E stated the call light was not on. She stated Resident #6, in the room next door to Resident #7, asked for assistance, and the two CNAs went into room and closed the hallway door to insure privacy for Resident #6. Staff E denied hearing Resident #7 calling for help. Approximately 15 minutes later Staff G, RN, knocked on the door and told Staff E and Staff F they were needed next door to assist with a resident. Staff E stated she went immediately to the room and saw Resident #7 sitting on the floor. Staff E stated the Administrator was next to the resident attempting to clean feces off of the resident's gown. Staff E stated she started to clean the trail of feces up off the floor. When interviewed on 9/8/11 at 2:00 p.m. Staff F confirmed Staff E's version of events that occurred the morning of 9/7/11. After assisting Resident #6 Staff F stated she entered Resident #7's bed room shortly after Staff E and assisted Staff E in cleaning up the floor. Staff F stated the CNAs carry walkie-talkies with them so they can notified when assistance is needed. She stated when in a room with the door closed it is difficult to hear call lights or overhead pages. She stated she did not hear Resident #7 calling for help or the overhead page for assistance. During an interview with Staff C, CNA, she stated she cared for the resident during the day shift on 9/6/11. She stated the resident was assessed to need help from one staff member to ambulate along with the use a gaitbelt and a wheeled walker. Staff C stated the resident used his/her call light twice during the shift for assistance with ambulating to the bathroom. The resident told Staff C she was dizzy and weak so the CNA called a second CNA to assist with transferring the resident the resident to the bathroom both times. Staff C stated Resident #7 did not attempt to get up without help of staff during the shift. During an interview with the family member of Resident #7 on 9/8/11 at 12:30 p.m. she stated the facility called her early in the morning on 9/7/11 and informed her that Resident #7 had fallen and was going to be transported to the emergency room . She stated she was not given any details about the fall at that time. The family member stated she called the facility on 9/8/11 and spoke with the Administrator about the circumstances concerning the resident's fall. The family member stated she was told the resident got out of bed on his/her own and tripped over his/her walker. The family member stated that she had told the facility at the time of admission about two falls the resident had at home., one occurring the week before the resident was admitted to the facility. She stated the resident told her the morning of 9/7/11 no one would answer his/her call light and when she saw two "girls" walking down the hall she got out of bed and walked to the doorway to get their attention. The resident told his/her family member he/she was not clear on what happened besides the fall and recalled calling out for his/her family member after the incident. The family member revealed the resident was now at a Des Moines hospital and was not stable to have surgery at this time due to abnormal blood work however the physician anticipated surgery would occur soon.

Based on observations, staff interviews, and clinical record review the facility failed to ensure a safe environment free of accidents/hazards for one of 10 sampled residents (Resident #19) when the facility staff neglected to follow the resident's care plan to apply a seat pressure alarm under the resident while seated in the dining room chair for fall prevention. The facility reported a census of 65 residents. Findings include: 1. A review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 9/22/11 identified Resident #19 with a short term memory problem and moderately impaired daily decision-making skills. MDS assessment revealed the resident required limited assistance of one staff member for transfers, ambulation, and activities of daily living. The MDS indicated the resident's balance capabilities were impaired and the resident required assistance when walking, turning, and transferring from surface to surface. A fall risk assessment dated [DATE] revealed the resident to be at high risk for falls as determined by his/her score of 17 (a score of 10 or above indicates high risk. The resident's care plan, dated 9/15/11 (the resident's admitted ), indicated the resident was at high risk for falls due to a poor safety awareness and attempted transfers without staff assistance due to forgetfulness. Interventions implemented for the resident at that time included pressure alarms for the resident's bed and chair, give verbal reminders not to ambulate or transfer without staff assistance, ensure Resident #19 wears proper footwear for ambulation, maintain resident environment free of clutter and safety hazards, and a hall box to alert staff if the resident gets out of bed by his/herself. Added interventions included on 9/24/11 a motion sensor alarm was added to the resident's existing alarms, on 9/29/11 a floor mat was placed next to the resident's bed, and on 9/25/11 the resident was placed at an assisted table for dining for 1:1 supervision as needed. On 9/29/11 the resident was care planned to have a seatbelt restraint while sitting in a chair due to his/her history of falls and as a reminder not to get up without help and this was also documented the Interdisciplinary Progress Notes. This was discontinued from the care plan on an unknown date and there was no mention of this in the resident's subsequent nurse's notes entries. Nurse's notes dated from 9/19/11 through 10/6/11 revealed multiple entries noting the resident's non-compliance with instructions to call for assistance when wanting to get up (9/19, 9/20, 9/22, 9/23, 9/24, 9/27, 10/2, and 10/5/11). Nurse's notes entires revealed the resident was re-educated frequently at these times about the need to call for help with transfer or ambulation. The presence of alarms on the resident's chair and bed were noted in the entries. Further notations in the nurse's notes revealed the resident had falls on 9/25/11 and 9/29/11 due to this non-compliance. The resident did not have injuries from these falls and there was no documentation indicating the alarms were sounding at the time of these two incidents. Nurse's notes also documented behaviors exhibited by the resident including verbal abuse towards staff , striking out towards staff, and resistance to cares. Review of the facility incident report dated 10/6/11 noted the resident suffered a fall on that day, when he stood up from the dining table without assistance, and fell to the ground onto his/her right side. A staff member witnessed the fall and stated the resident did not strike his head. The report noted "no pressure alarm was under resident per care plan". During a telephone interview with Staff A, Certified nursing assistant (CNA) on 10/17/11 at 1:30 p.m. she stated she and another CNA, Staff B, had helped Resident #19 ambulate to the dining room for supper using a wheeled walker and a gaitbelt. The resident was seated at the table and Staff A then realized the resident needed to have a pressure alarm on the seat of the chair. Staff A stated the Director of Nurses (DON) was seated near by and she told the DON Resident #19 needed an alarm for the chair. Staff A stated the DON said "Who?" and the CNA repeated it was for Resident #19. Staff A stated the DON said "OK" and got up out of her chair. The CNA stated she thought the DON was going to get the chair alarm for the resident. She and Staff B went back down the hall to assist another resident into the dining room. Upon returning to the dining room she stated she did not check to see if the alarm was under Resident #19. She stated she did not see the resident fall when she returned to the dining room. Staff B sat down to assist a resident with eating. Staff B, was an agency-employed CNA, who worked occasionally upon request of the facility. The CNA was not on the upcoming schedule to work. Attempts by the surveyor to reach Staff B by phone were unsuccessful. An interview with the DON on 10/17/11 at 2:30 p.m. revealed she was orienting a new staff member at the time of the incident. She had gone to the nurse's station to check an order while the orientee remained down the hall at the medicine cart. While at the nurse's station, Staff A informed her that Resident #19 needed a chair alarm. She stated she asked Staff A where the alarm was and Staff A replied she did not know. The DON stated she told Staff A to go get an alarm to place it on the resident's chair. She saw Staff A and Staff B start down the resident's hall and she thought they were going to get the alarm. She returned to the medicine cart to continue with the new employee orientation. As she and the orientee took the medicine cart into the dining room, the DON saw Resident #19 on the floor. During an interview on 10/17/11 at 3:10 p.m. Staff C, Licensed Practical Nurse (LPN), stated she was administering medications in the dining room at the time of the incident. She did not see the resident fall, but she heard a noise and looked up to see the resident sitting on the floor on his buttocks. The LPN went to the resident and assessed him/her as per facility policy for falls. She obtained the resident's vital signs, tested hand grips, alignment, neuro status, and pain status. The resident appeared to be uninjured by the fall and was assisted to stand by staff. An interview with the Administrator on 10/17/11 at 1:00 p.m., she stated she was not in the dining room at the time of the resident's fall. While interviewing Staff A she stated she thought the DON was going to get the chair alarm for Resident #19. The Administrator also interviewed the DON who stated she instructed Staff A to get the alarm for the resident's chair. Staff A was suspended from duty by the Administrator while an investigation of the incident was conducted. On 10/13/11 Resident # 19 was admitted to a hospital psychiatric facility for evaluation of behaviors.

Based on record review and staff interviews, the facility staff failed to provide adequate supervision and implement care plan fall intervention's for one of three residents. Resident #2 had been transferred by two staff to his/her wheelchair and taken to the dining room, when approximately 15 minutes later he/she fell and sustained a fractured right hip. At the time of the fall no safety intervention was in place. The facility reported a census of 63 residents. Findings include: According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 4/20/11, identified Resident #2 with short and long term memory deficits with severely impaired cognitive skills for daily decision making. Resident #2 required extensive assistance with physical assist of two staff with bed mobility, transferring and locomotion and was totally dependent on staff for dressing, personal hygiene, toilet use and bathing. Resident #2's [DIAGNOSES REDACTED]. Incident Report dated 3/3/11 indicated Resident #2 was found squatting next to bed. No sustained injury. Alarm systems were not sounding. Care plan indicated pressure alarm to bed with a wireless sensor system at doorway and mat under chair was added on 1/4/11. Incident Report dated 3/13/11 indicated Resident #2 was found sitting on the floor in front of the recliner. No sustained injury. Alarm systems in place were not sounding. Incident Report dated 7/14/11 indicated dietary aide noted Resident #2 was out of his/her wheel chair in the independent dining room area and called out to nursing staff. Within seconds the aide indicated Resident #2 had fallen. Resident #2 complained of right hip pain and stated, "It's broke. It's broke, damn it". A summary of the incident (undated/unsigned) identified Resident #2 did not trip over anything and landed hard on his/her right side. During the nursing assessment the nurse attempted ROM (range of motion) to the resident's right lower extremity and the resident complained of pain. The resident was transferred to the local hospital by ambulance and it was determined he/she had fractured his/her right femur. Resident #2's plan of care dated 4/4/11 identified a problem with increased risk for falls with approaches which included: a. Assist of two and gait belt with transfers and ambulation. b. Motion sensor to be facing resident when in bed or chair in room. c. Pressure alarm to bed with wireless sensor system at doorway and mat under chair. d. Pressure alarm to all chairs when out of room. (5/22/11). In an interview on 7/27/11 at 12:50 p.m., Staff A indicated that on 7/14/11 at around 7:10 a.m. she was in the independent dining room passing out breakfast trays to residents when she heard several residents telling Resident #2 to sit down. Staff A turned to the direction of where Resident #2 was and found him/her standing next to his/her wheel chair. Staff A instructed Resident #2 to sit down and hollered out to Staff C and told her Resident #2 was standing. Within seconds and before Staff A, Staff B, or Staff C could respond, Resident #2 took another step or two and stumbled to the floor. Staff A indicated there was no alarm sounding. In an interview on 7/27/11 at 1:08 p.m., Staff B indicated that on 7/14/11 she was passing drinks in the independent dining room when she heard several residents telling Resident #2 to sit down. Staff B turned to the direction of where Resident #2 was and found him/her standing next to his/her wheel chair. Within seconds and before Staff B could respond, Resident #2 fell to the floor. In an interview on 7/27/11 at 3:23 p.m., Staff C indicated that on the morning of 7/14/11 she was standing at her medication cart when Staff A stated Resident #2 was up. Staff C immediately locked the medication cart and began walking to the dining room when Staff A then said, "Oh no, he/she just fell ." Staff C responded to Resident #2 who was lying on the floor near his/her wheel chair. Resident #2 complained of his/her right hip hurting, stating, "It's broke, damn it, it's broke." Staff C indicated there was no chair alarm on Resident #2's wheel chair. As Resident #2 was attended by another nurse, Staff C walked down the hallway to get a pillow. Staff C saw Staff D and asked who had gotten Resident #2 up that morning. Staff D responded that he and Staff E had. Staff C indicated that there was no alarm in the Resident #2's wheelchair and he/she had fallen. Staff D stated, "Oh no." Staff C indicated everything happened in a split second and she didn't believe Staff A or Staff B could have responded in time to prevent Resident #2 from falling. In a telephone interview on 7/27/11 at 3:23 p.m., Staff D indicated he was working the day shift on 7/14/11 and assigned to Resident #2. That morning he and Staff E got Resident #2 ready for breakfast and transferred him/her from his/her bed into his/her wheel chair and Staff E propelled Resident #2 to the dining room. About two minutes later, Staff C informed him Resident #2 had fallen and didn't have his/her chair alarm. Staff D indicated he was aware Resident #2 required a chair alarm and simply forgot to place the alarm in the wheel chair before transferring Resident #2. In a telephone interview on 7/26/11 at 3:21 p.m., Staff E indicated she was working the day shift on 7/14/11 and assigned to Resident #2. That morning Staff E prepared and dressed Resident #2 and Staff D assisted with transferring Resident #2 into his/her wheel chair. Staff E then propelled Resident #2 to the dining room. Ten to fifteen minutes later, Staff E learned that Resident #2 had fallen and did not have his/her chair alarm. Staff E indicated she was aware Resident #2 required a chair alarm and simply forgot that morning, noting they were a little behind with getting residents up and were rushing.

Based on record review and interviews, the facility failed to ensure each resident received adequate assistance and supervision to protect him/her from self or in the environment for one of five residents reviewed. Resident #7 informed the Administrator that he/she needed assistance to the bathroom. The Administrator did not utilize the call light and left the resident's room to alert staff of the resident's needs. Upon return, Resident #7 had fallen and sustained a fracture hip. The facility reported census of 59 residents. Findings include: Record review established Resident #7 had been hospitalized prior to admission to the nursing home. The hospital history and physical dated 9/2/11 documented Resident #7 had been admitted to a local hospital on [DATE] for a three week stay during which the resident was treated for [REDACTED]. A complete blood count performed on 9/3/11 revealed the resident's hemoglobin was noted to be 8 g/dL (normal range is 11.9-16.1 g/dL). Low hemoglobin levels can contribute to extreme fatigue, weakness, and dizziness. On 9/4/11 the resident's hemoglobin was still below normal range but had increased significantly to 10.8 g/dL. A metabolic screen completed on 9/3/11 revealed the resident had a blood potassium level of 3.4 mg/d (normal range is 3.7-5.3 mg/dL which reflected the resident was hypokalemic. This condition can lead to cardiac irregularities and symptoms of dizziness). The resident's potassium level reached within the normal range with intravenous potassium on 9/5/11. Copies of the resident's lab work and assessments were sent to the facility with the resident when he/she was admitted to the facility on [DATE] for rehabilitation and strengthening. The resident's medical history, as noted on the hospital admitting assessment form dated 9/2/11, revealed the resident had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment was not completed by facility staff during Resident #7's two day stay. Initial assessment status of the resident was determined by a facility nurse at the time of admit for the resident's initial temporary care plan. This information was placed on the resident's "Care Card," an orange instruction sheet taped on the inner door of the cupboard in the resident's bathroom. The "Care Card" directed staff to provide mobility, transfers, and ambulation with one staff member assisting the resident along with the use of a gaitbelt and wheeled walker. Additional instructions included two siderails were to be placed in upright position when the resident was in bed. Other assessments completed during the resident's two day stay at the facility included an undated fall assessment in which the resident scored 14 points placing him/her in the high risk category (a score above 10 indicated high risk for falls). Additional assessments included an undated siderail assessment which revealed the resident had a history of [REDACTED]. Record review revealed the social worker, Staff D, evaluated the resident at 12:35 p.m. on 9/6/11. She stated the resident was alert. The resident's family had been present at that time and expressed desire for Resident #7 to return home when stronger. Nurse's notes on 9/5/11 at 3:15 p.m. revealed a status report was called to the facility from the hospital regarding the resident's hospital stay. The report stated the resident was wheezing, was alert, and had two loose green stools before transfer. Nurse's notes at 3:45 p.m. stated the resident was admitted to the facility with stable vital signs. On 9/6/11 at 1:00 p.m. the nurse's notes revealed Resident #7 complained of dizziness and shortness of breath. The resident continued to complain of dizziness as documented in the nurse's notes at 2:20 p.m., and 7:00 p.m. that same day. At 2:20 p.m. staff documented the call light had been in reach and siderails up. The physician was notified of the resident's dizziness at 4:45 p.m. On 9/7/11 at 1:00 a.m. the nurse's notes revealed the resident complained again of previous dizzy spells but stated at that particular times she was not dizzy. The resident was instructed by the nurse to use the call light for assistance if he/she needed to go to the bathroom. The notes documented the resident verbalized an understanding. Staff assisted the resident to the bathroom and the resident did not complained of dizziness. The call light was within reach. At 6:10 a.m., the nurse's noted documented the Administrator returned to the resident's room and found Resident #7 on the floor sitting against the wall. The notes indicated the resident was confused and asked for his/her family member. The notes documented a trail of feces led from bed to door of room. Staff G completed the assessment after the fall and documented Resident #7 complained of right hip pain and being unable to move his/her right leg thus the nurse stopped the assessment. The physician and the resident's family were called and the resident was transported by ambulance to the local emergency room for evaluation. The notes documented Resident #7's family called the nursing home to inform them Resident #7 had fractured his/her right hip. The facility reported an X-ray confirmed Resident #7 had a fractured hip and required surgery. Review of the Incident/Accident/Unusual Occurrence Form dated 9/7/11 as documented by Staff H, Registered Nurse (RN), revealed the resident had been found at 6:10 a.m. by the Administrator, sitting on the floor with his/her back against the wall. The resident's vital signs were pulse-116, respirations-20, temperature 97.5, and blood pressure was 160/100. The incident report did not document any information on the siderails. An interview with the Administrator, on 9/8/11 at 10:00 a.m. revealed she had been in the hall by the resident's room at approximately 6:05 a.m. on 9/7/11 and was on her way to the MDS office which is located next door to the resident's room (approximately 11/5 feet away). She heard the resident calling for help and arrived at Resident #7's door entrance and asked if he/she needed help. The Administrator stated Resident #7 was sitting on the edge of the bed with his/her feet on the floor and wanted to go to the bathroom. The Administrator stated the lights in the room were off and the call light had not been activated. The Administrator stated she told the resident she would go get someone to assist him/her to the bathroom. She turned and went to the door of MDS office and told the MDS nurse (Staff B) that Resident #7 needed some assistance. A nurse at the nurse's station, down the hall from the MDS office, overheard the Administrator speaking to the MDS nurse and paged overheard for a Certified Nurse's Aide (CNA) to go help the resident. The Administrator returned to the resident's room and found the resident sitting on the floor up against the wall in the room. The Administrator stated she was gone form the resident's room approximately 10-20 seconds. The Administrator explained she did not help the resident to the bathroom when first asked for help because she was unaware of the resident's ambulation status and she did not have a gait belt with her at the time. She stated she did not look on the resident's Care Card to discern the resident's ambulation status. An interview with the MDS nurse, Staff B, on 9/8/11 at 2:40 p.m. revealed she was in her office at 6:00 a.m. on 9/7/11 but did not hear the resident calling for help. The Administrator came to her office and said the resident needed help to the bathroom. Staff B stated she picked up the phone to call the nurse's station to inform a staff there there that the resident needed help to go to the bathroom. Before she was able to call, she heard over the loudspeaker a page for a CNA to go assist the resident. The Administrator told Staff B she would return to the resident's room to help the resident ambulate to the bathroom because she thought a CNA was on the way due to the overheard page. She stated each CNA carried a gaitbelt and two extra gaitbelts were kept at the nurse's station. When interviewed on 9/8/11 at 1:00 p.m. Staff E, CNA, stated she and Staff F, CNA, were checking alarms at 6:00 a.m. on 9/7/11. She stated they walked down the hall and passed Resident#7's room where the open door revealed the resident appeared to be sleeping in a dark room. Staff E stated the call light was not on. She stated Resident #6, in the room next door to Resident #7, asked for assistance, and the two CNAs went into room and closed the hallway door to insure privacy for Resident #6. Staff E denied hearing Resident #7 calling for help. Approximately 15 minutes later Staff G, RN, knocked on the door and told Staff E and Staff F they were needed next door to assist with a resident. Staff E stated she went immediately to the room and saw Resident #7 sitting on the floor. Staff E stated the Administrator was next to the resident attempting to clean feces off of the resident's gown. Staff E stated she started to clean the trail of feces up off the floor. When interviewed on 9/8/11 at 2:00 p.m. Staff F confirmed Staff E's version of events that occurred the morning of 9/7/11. After assisting Resident #6 Staff F stated she entered Resident #7's bed room shortly after Staff E and assisted Staff E in cleaning up the floor. Staff F stated the CNAs carry walkie-talkies with them so they can notified when assistance is needed. She stated when in a room with the door closed it is difficult to hear call lights or overhead pages. She stated she did not hear Resident #7 calling for help or the overhead page for assistance. During an interview with Staff C, CNA, she stated she cared for the resident during the day shift on 9/6/11. She stated the resident was assessed to need help from one staff member to ambulate along with the use a gaitbelt and a wheeled walker. Staff C stated the resident used his/her call light twice during the shift for assistance with ambulating to the bathroom. The resident told Staff C she was dizzy and weak so the CNA called a second CNA to assist with transferring the resident the resident to the bathroom both times. Staff C stated Resident #7 did not attempt to get up without help of staff during the shift. During an interview with the family member of Resident #7 on 9/8/11 at 12:30 p.m. she stated the facility called her early in the morning on 9/7/11 and informed her that Resident #7 had fallen and was going to be transported to the emergency room . She stated she was not given any details about the fall at that time. The family member stated she called the facility on 9/8/11 and spoke with the Administrator about the circumstances concerning the resident's fall. The family member stated she was told the resident got out of bed on his/her own and tripped over his/her walker. The family member stated that she had told the facility at the time of admission about two falls the resident had at home., one occurring the week before the resident was admitted to the facility. She stated the resident told her the morning of 9/7/11 no one would answer his/her call light and when she saw two "girls" walking down the hall she got out of bed and walked to the doorway to get their attention. The resident told his/her family member he/she was not clear on what happened besides the fall and recalled calling out for his/her family member after the incident. The family member revealed the resident was now at a Des Moines hospital and was not stable to have surgery at this time due to abnormal blood work however the physician anticipated surgery would occur soon.

Based on observations, staff interviews, and clinical record review the facility failed to ensure a safe environment free of accidents/hazards for one of 10 sampled residents (Resident #19) when the facility staff neglected to follow the resident's care plan to apply a seat pressure alarm under the resident while seated in the dining room chair for fall prevention. The facility reported a census of 65 residents. Findings include: 1. A review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 9/22/11 identified Resident #19 with a short term memory problem and moderately impaired daily decision-making skills. MDS assessment revealed the resident required limited assistance of one staff member for transfers, ambulation, and activities of daily living. The MDS indicated the resident's balance capabilities were impaired and the resident required assistance when walking, turning, and transferring from surface to surface. A fall risk assessment dated [DATE] revealed the resident to be at high risk for falls as determined by his/her score of 17 (a score of 10 or above indicates high risk. The resident's care plan, dated 9/15/11 (the resident's admitted ), indicated the resident was at high risk for falls due to a poor safety awareness and attempted transfers without staff assistance due to forgetfulness. Interventions implemented for the resident at that time included pressure alarms for the resident's bed and chair, give verbal reminders not to ambulate or transfer without staff assistance, ensure Resident #19 wears proper footwear for ambulation, maintain resident environment free of clutter and safety hazards, and a hall box to alert staff if the resident gets out of bed by his/herself. Added interventions included on 9/24/11 a motion sensor alarm was added to the resident's existing alarms, on 9/29/11 a floor mat was placed next to the resident's bed, and on 9/25/11 the resident was placed at an assisted table for dining for 1:1 supervision as needed. On 9/29/11 the resident was care planned to have a seatbelt restraint while sitting in a chair due to his/her history of falls and as a reminder not to get up without help and this was also documented the Interdisciplinary Progress Notes. This was discontinued from the care plan on an unknown date and there was no mention of this in the resident's subsequent nurse's notes entries. Nurse's notes dated from 9/19/11 through 10/6/11 revealed multiple entries noting the resident's non-compliance with instructions to call for assistance when wanting to get up (9/19, 9/20, 9/22, 9/23, 9/24, 9/27, 10/2, and 10/5/11). Nurse's notes entires revealed the resident was re-educated frequently at these times about the need to call for help with transfer or ambulation. The presence of alarms on the resident's chair and bed were noted in the entries. Further notations in the nurse's notes revealed the resident had falls on 9/25/11 and 9/29/11 due to this non-compliance. The resident did not have injuries from these falls and there was no documentation indicating the alarms were sounding at the time of these two incidents. Nurse's notes also documented behaviors exhibited by the resident including verbal abuse towards staff , striking out towards staff, and resistance to cares. Review of the facility incident report dated 10/6/11 noted the resident suffered a fall on that day, when he stood up from the dining table without assistance, and fell to the ground onto his/her right side. A staff member witnessed the fall and stated the resident did not strike his head. The report noted "no pressure alarm was under resident per care plan". During a telephone interview with Staff A, Certified nursing assistant (CNA) on 10/17/11 at 1:30 p.m. she stated she and another CNA, Staff B, had helped Resident #19 ambulate to the dining room for supper using a wheeled walker and a gaitbelt. The resident was seated at the table and Staff A then realized the resident needed to have a pressure alarm on the seat of the chair. Staff A stated the Director of Nurses (DON) was seated near by and she told the DON Resident #19 needed an alarm for the chair. Staff A stated the DON said "Who?" and the CNA repeated it was for Resident #19. Staff A stated the DON said "OK" and got up out of her chair. The CNA stated she thought the DON was going to get the chair alarm for the resident. She and Staff B went back down the hall to assist another resident into the dining room. Upon returning to the dining room she stated she did not check to see if the alarm was under Resident #19. She stated she did not see the resident fall when she returned to the dining room. Staff B sat down to assist a resident with eating. Staff B, was an agency-employed CNA, who worked occasionally upon request of the facility. The CNA was not on the upcoming schedule to work. Attempts by the surveyor to reach Staff B by phone were unsuccessful. An interview with the DON on 10/17/11 at 2:30 p.m. revealed she was orienting a new staff member at the time of the incident. She had gone to the nurse's station to check an order while the orientee remained down the hall at the medicine cart. While at the nurse's station, Staff A informed her that Resident #19 needed a chair alarm. She stated she asked Staff A where the alarm was and Staff A replied she did not know. The DON stated she told Staff A to go get an alarm to place it on the resident's chair. She saw Staff A and Staff B start down the resident's hall and she thought they were going to get the alarm. She returned to the medicine cart to continue with the new employee orientation. As she and the orientee took the medicine cart into the dining room, the DON saw Resident #19 on the floor. During an interview on 10/17/11 at 3:10 p.m. Staff C, Licensed Practical Nurse (LPN), stated she was administering medications in the dining room at the time of the incident. She did not see the resident fall, but she heard a noise and looked up to see the resident sitting on the floor on his buttocks. The LPN went to the resident and assessed him/her as per facility policy for falls. She obtained the resident's vital signs, tested hand grips, alignment, neuro status, and pain status. The resident appeared to be uninjured by the fall and was assisted to stand by staff. An interview with the Administrator on 10/17/11 at 1:00 p.m., she stated she was not in the dining room at the time of the resident's fall. While interviewing Staff A she stated she thought the DON was going to get the chair alarm for Resident #19. The Administrator also interviewed the DON who stated she instructed Staff A to get the alarm for the resident's chair. Staff A was suspended from duty by the Administrator while an investigation of the incident was conducted. On 10/13/11 Resident # 19 was admitted to a hospital psychiatric facility for evaluation of behaviors.

This deficiency relates to Mandatory # -M, # -A and # -I. Based on record review and staff interviews, the facility failed to provide nursing provisions with adequate and timely interventions and or assessments in accordance with the plan of care for 3 of 3 residents with falls (Residents #3, #2 and #5). The facility failed to protect Resident #3 and Resident #2 from potential hazards when they transferred them from the floor to the bed without a complete assessment. The facility reported a census of 61 residents. Findings include: 1.The facility staff discovered Resident #3 on the floor of his/her room, complaining of neck pain and the staff failed to assess for signs of potential neck trauma. The nurse failed to provide adequate nursing provisions and instead instructed the staff to assist the resident back to bed without stabilizing the resident ' s neck. The X-rays later confirmed the resident sustained [REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 12/8/10, indicated Resident #3 short and long term memory and cognitive skills for daily decision making were not determined. The assessment indicated Resident #3 needed limited assistance with bed mobility and eating and extensive assistance with transfers, locomotion, dressing, toilet use and personal hygiene and total dependence with bathing. Resident #3's [DIAGNOSES REDACTED]. Resident #3's care plan onset date of 11/11/10 indicated resident at risk for falls and directed staff to: a. Assist with two (2) staff members during transfers and ambulation; and the use of a gait belt. b. Assist with walking to activities, dining, etc. c. Personal alarm while in bed. Nurse's notes dated 12/13/10 at 9:20 p.m. and written by Staff D indicated Resident #3 ' s alarm activated and Staff J and herself entered the resident ' s room to find the resident lying on the floor. Staff D documented Resident #3 was found lying on his/her left side complaining of neck pain and requesting to get up. Staff D documented Resident #3 had blood noted on the pillowcase that was placed under the resident ' s head. The resident had a large bump that measured 4 cm (centimeters) in diameter and raised 2 cm on the back of his/her head. Staff D documented three staff assisted the resident up using a gait belt and transferred the resident to the bed. Resident #3 continued to complain of neck pain. The resident ' s hand grips were both weak and he/she was unable to move his/her neck from side to side. Resident #3's speech was unclear and he/she continued to complain of neck pain. At 9:50 p.m. emergency medical services arrived, assessed Resident #3, stabilized Resident #3's neck with a c-collar and transported Resident #3 to the hospital. Hospital imaging record dated 12/13/10 at 11:01 p.m. indicated Resident #3 had acute fractures involving C2 and C3 vertebrae. Facility corrective action form dated 12/14/10 indicated Staff D should have stabilized Resident #3's neck prior to moving the resident from the floor onto the bed. Staff D failed to follow proper assessment and intervention protocols resulting in a potential for harm to the resident. In an interview on 12/23/10 at 12:55 p.m. Staff H indicated she responded to Resident #3's room per request from Staff D. Resident #3 was lying on the floor and Staff D had kneeled beside him/her. Staff H noticed a big knot on the back of Resident #3's head and Resident #3 was complaining of his/her neck hurting and the bottom half of his/her body being cold. Resident #3 asked staff to get him/her up. Staff D instructed Staff H and Staff I to assist Resident #3 back into bed. Staff H stated Resident #3's neck was not stabilized. Staff H and Staff I remained with the resident until emergency services arrived and transported the resident to the hospital. In an interview on 12/28/10 at 10:06 a.m. Staff I indicated she and Staff H were summoned to Resident #3's room and they observed Resident #3 on the floor with Staff D and Staff J at the resident's side. Staff I stated Staff D instructed him/her to assist the resident back into bed. Staff I indicated Resident #3 was not complaining of pain, but was complaining of being cold. Staff I indicated Resident #3 first began complaining of neck pain when the paramedics arrived. In an interview on 12/28/10 at 12:30 p.m. Staff J indicated she responded to Resident #3's room upon hearing an alarm sounding and found Resident #3 on the floor. Staff J immediately summoned Staff D. Staff J indicated from that time forward she was in and out of the room getting equipment and supplies. Staff J indicated Resident #3 never complained of having neck pain while she was in the room. In an interview on 12/23/10 at 12:16 p.m. Resident #3's physician stated his/her prognosis was poor and treatment options were limited. The physician stated there was no adverse effect related to Resident #3 being moved without his/her neck being stabilized, however he/she indicated doing so was poor judgment and could have resulted in paralyzation or death. 2. The facility staff discovered Resident #2 on the floor on 11/1/10 with an abrasion across the bride of his/her nose and possible head injury. The facility staff failed to properly assess the resident for injury and instead instructed staff to assist back into bed. The Minimum Data Set (MDS) with an assessment reference date of 12/1/10, indicated Resident #2 with short and long term memory deficit and severely impaired cognitive skills for daily decision making. The assessment indicated Resident #2 needed limited assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene and total dependence with bathing. Resident #2's [DIAGNOSES REDACTED]. Resident #2's care plan with an onset date of 9/10/10 indicated a potential for injury from falls with directives for staff to use the following interventions : a. Assist with transfers and ambulation with assist of 1 and use gait belt. Walk and dine. b. Pressure alarm to bed, wheelchair and chair. Nurse's notes written by Staff E dated 11/2/10 at 4:30 a.m. indicated a CNA had called Staff E to Resident #2 ' s room. The resident had a scratch on the bridge of his/her nose measuring 0.4 centimeters (cm) x 0.9 cm. with an unknown origin. The staff documented no drainage noted and staff cleaned with wound wash and left the area open to air. (The note had lines drawn through it and with the word "error" written next to it.) A facility fax form dated 11/2/10 at 4:30 a.m., signed by Staff E and sent at 4:45 a.m. addressed to Resident #2's physician revealed the resident had a scratch measuring 0.4cm x 0.9 cm scratch bridge of nose with no drainage noted and the origin unknown. The fax written by Staff E had also requested treatment. Nurse's notes written by Staff J dated 11/2/10 at 1535 (3:35 p.m.) indicated the resident had fallen last light on 11/2/10 around 4:40 a.m. The nurse noted several bruises note to the resident's right inner knee, left hip and right inner thigh. The nurse charted the resident did not complain of pain and the resident had range of motion (ROM) in all extremities. The nurse documented she started charting neuro ' s and recorded the resident ' s vitals. In an interview on 12/22/10 at 9:45 a.m. Staff G (CNA) indicated that in the early hours on 11/2/10, he discovered Resident #2 positioned on the floor at the end of his/her bed. Staff G notified the nurse, Staff E who responded immediately. Staff G stated that Staff E instructed him to help get the resident back into bed so we (Staff G and Staff E) did not have to do any paperwork. Following Resident #2 being moved back into bed Staff E stated Staff G made the comment, "This is our little secret". Staff G indicated he left work that morning without reporting the fall, but returned that afternoon and informed Staff A, DON (Director of Nursing). In an interview on 12/21/10 at 3:02 p.m. Staff A (DON) indicated on the afternoon of 11/2/10, Staff G informed her that Resident #2 had been found on the floor during the overnight shift and had an abrasion across the bridge of his/her nose. Staff A stated Staff G indicated Staff E told him, "Let's put him/her to bed and this can be our little secret". Staff A contacted Staff E and Staff E claimed she did do an assessment, including vital signs on Resident #2, but forgot to do the incident report. According to Staff A, Staff E denied asking Staff G to keep it a secret. Staff A, DON indicated her expectations for any resident found on the floor would be the nurse complete a thorough head to toe assessment, assess for any pain, deformities or potential, fractures or head injuries and if the resident indicated they hit their head or the fall was unwitnessed by staff or there was a physical indication the resident hit their head, the nurse should initiate neuro checks per facility policy. Staff A also noted residents are not to be moved until thoroughly assessed and the nurse had a reasonable belief that there are no fractures or injuries which may be exacerbated by moving the resident. Staff E documented a late entry in the Nurse ' s notes dated 11/3/10 indicated Resident #2 had fallen on 11/2/10 at 4:30 a.m. Staff E documented the following: CNA called this nurse to room. Resident #2 was noted on floor lying on right side, facing the end of bed. Active range of motion in all extremities without complaint of pain/discomfort. Resident denied hitting head, however noted 0.4 x 0.9 cm scrape on bridge of nose. Resident assisted back to bed with assist of two and gait belt. Area on nose cleaned and bandage applied. The facility Falls Protocol Quick Reference indicated the following: 2) Assessment and intervention process when fall occurs. a) Complete head to toe assessment by charge nurse. b) Administer first aide as resident's condition warrants. c) Complete investigation form. d) Interview witnesses. e) Notify resident's family and physician. f) Document the account of the fall and follow up in the nurse's notes. g) Continue observation/assessment of resident for at least 24 hours or resident's condition is stable. Facilities Neurological Assessment Protocol Purpose: 1. To observe the resident for development of focal or generalized deficits of function that could indicate pathologic events occurring as a result of head injury or suspected head injury; and 2. To provide documentation of neurological assessment for a resident who has fallen unwitnessed or has hit his/her head, or conditions warrant. Procedure: Neurological assessment will include: Date, time vitals signs, pupil reaction, extremity function, consciousness, speech, response to name/environment and pain, [MEDICAL CONDITION], headache and vomiting. Resident #2 ' s Neurological assessment form showed his/her first assessment initiated on 11/2/10 at 3:35 p.m. by Staff J. In an interview on 12/22/10 at 9:30 a.m. Staff E insists she properly assessed Resident #2 on the morning of 11/2/10 and initiated neuro checks, but got busy and forgot to document. The facility failed to protect Resident #3 and Resident #2 against potential hazards when they assisted them from the floor without complete assessments. 3. The facility failed to provide timely intervention for Resident #5 when the facility staff discovered Resident #5 on the floor (11/15/10) and the resident complained of severe pain in his/her left hip with a visible area over the left bony prominence of the hip, and the facility did not transport the resident to the hospital for further evaluation until 1:05 p.m. The facility failed Upon Resident #5's return to the facility on [DATE] the resident complained of pain most of the overnight hours and only received Tylenol for pain and not the stronger pain medication [MEDICATION NAME] ([MEDICATION NAME] APAP 5-325) for pain. The nurse responsible failed to administer the [MEDICATION NAME] because she believed the medication was not available, when in fact the medication was in the emergency kit supply and failed to resolve Resident #5's pain issues. The Minimum Data Set (MDS) with an assessment reference date of 11/25/10, indicated Resident #5's short and long term memory and cognitive skills for daily decision making were determined. The assessment indicated Resident #5 needed limited assistance for bed mobility, locomotion, eating, personal hygiene and bathing and extensive to total dependence with transfers, dressing and toilet use. Resident #5's [DIAGNOSES REDACTED]. Resident #5's care plan onset date 12/4/09 indicated resident at risk for falls with interventions which included: a. Assist with transfers and ambulation with assist of 2, gait belt and walker. Follow with wheelchair. b. Resident not to be left in wheelchair while in room. c. Low bed. d. Wide landing strip at bedside. Resident #5's care card indicated he/she used a wheelchair for mobility, and required a gait belt and two (2) staff when transferring. The care card indicated a landing strip was used beside bed, and the resident used a low bed. The card also indicated not to leave wheelchair or walker in the room. Nurse's notes dated 11/15/10 and written by Staff D indicated at 9:30 a.m, Resident #5 was found lying on the floor. The resident was assessed with [REDACTED]. The resident complained of left hip pain and staff did not observe any deformities. A small red area was noted over the bony prominence of left hip measuring 3 cm x 2 cm. Resident #5 indicated "It hurts like hell. " The staff notified the physician via fax. 10:10 a.m. [MEDICATION NAME] x1 was given for complaint of pain. Resident #5 continued to complain of hip pain stating, " It ' s broken. Give me a shot like they did in the hospital". 10:45 a.m. Resident #5 was yelling out for more pain medication and continued to complain of left hip pain. Resident #5 was assisted to bed and refused to allow the nurse to further assess the left hip stating, "Stop that and get out of there". Physician's office called with update regarding Resident #5's condition. 11:00 a.m. Physician's office returned call and Resident #5's physician requesting to see resident at the emergency room . 12:03 p.m. Fax received from physician's office to send Resident #5 to the emergency room . 12:30 p.m. Resident #5 was refusing to get out of bed and continued to complain of left hip pain. Room tray ordered. 1:05 p.m. Resident #5 was transported to emergency room with staff accompanying. Hospital diagnostic imaging record dated 11/15/10 at 1:53 p.m. indicated left hip x-ray impression: acute fracture involving the left femoral neck. November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview on 12/27/10 at 9:59 p.m. Staff F indicated she worked the overnight shift on 11/19/10. Staff F indicated Resident #5 complained of pain most of the shift and was only given Tylenol because according to the nurse, Staff E, stronger pain medication was not available. The facility submitted the Corrective Action Form for Staff E, dated 11/23/10 indicated she failed to document resident pain and administer pain medications as ordered.