Every finding on record at Parkview Care Center

Based on record review, and resident and staff interviews, the facility failed to ensure residents maintained the right to communicate with and have access to persons outside the facility for 1 of 2 residents reviewed (Resident #21) for resident rights. The facility reported a census of 48 residents. Findings include:Resident #21's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS documented active diagnoses of dementia (brain disorder causing memory loss) and stroke (loss of blood flow to the brain). The Care Plan dated 8/13/26 revealed focus areas related to psychosocial wellbeing and an absence of personal contact with family or friends due to residence on the Special Care Unit (SCU). The Care Plan included an intervention directing staff to arrange a method of contact between Resident #21 and family or friends. A Care Conference Note dated 11/13/25 revealed Resident #21's wife passed away on 9/30/25. A Social Worker progress note dated 6/2/26 at 1:03 PM revealed a family member who did not hold Power of Attorney (POA) for healthcare decisions referred Resident #21 to a hospice (end-of-life care) agency. The Social Worker documented Resident #21 Representative requested facility staff remove the non-POA family member from the emergency contact list and withhold all information. A Social Worker progress note dated 6/3/26 at 11:02 AM revealed the non-POA family member contacted another hospice agency with a referral for Resident #21. A Social Worker progress note dated 6/4/26 revealed Resident #21 Representative instructed staff to block the non-POA family member from calling the facility to speak with Resident #21 due to overstepping boundaries. Staff called the non-POA family member to inform him he could no longer communicate with Resident #21. On 8/18/26 at 9:21 AM the non-POA family member reported last speaking with Resident #21 two months prior. The non-POA family member explained prior to Resident #21's wife's death, the wife called him during visits so he could speak with Resident #21. The non-POA family member described a shared love of music, explaining he tried to send a self-made compact disc (CD) to Resident #21. The non-POA family member stated the Social Worker called to inform him he could no longer talk with Resident #21. On 8/18/26 at 12:21 PM Staff E, Certified Nursing Assistant (CNA), reported Resident #21 didn't mention family members beyond his wife. Staff E explained Resident #21 didn't speak often. On 8/18/26 at 2:55 PM Staff C, Licensed Practical Nurse (LPN), reported Resident #21 never asked to call family. Staff C knew of past issues regarding the non-POA family member, who called random hospice companies to make referrals for Resident #21. Following Resident #21 Representative instructions, staff denied phone communication between the non-POA family member and Resident #21. Staff C didn't know if Resident #21 wanted to speak with the non-POA family member and never heard Resident #21 discuss him. On 8/18/26 at 3:52 PM Resident #21 reported he wanted to talk with the non-POA family member if he called. Resident #21 discussed their shared interest in music, noted the non-POA family member sang jazz well, and stated the non-POA family member tried to send him a music CD. On 8/19/26 at 2:28 PM the Social Worker reported Resident #21 Representative didn't want the non-POA family member contacting Resident #21 due to overstepping by making hospice referrals. The Social Worker stated Resident #21 and the non-POA family member maintained a good relationship. The Social Worker acknowledged cutting off contact based on Resident #21 Representative's directive. When asked if anyone consulted Resident #21 regarding contact, the Social Worker stated, she didn't think they discussed with Resident #21 if was something he wanted. On 8/19/26 at 2:45 PM the Director of Nursing (DON) reported receiving calls from outside hospice agencies based on referrals from the non-POA family member. The DON explained the attending physician deemed hospice inappropriate because Resident #21 wasn't at end of life. The DON stated after staff thought they handled the issue, the non-POA family member contacted additional hospices, totaling 3 or 4 agencies. The DON stated the Social Worker spoke with Resident #21 Representative, who requested restricting contact. The DON indicated the Social Worker should've asked Resident #21 whether he wanted contact with the non-POA family member. The Resident's [NAME] of Rights policy dated 1/26/15 instructed the resident maintains a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The Visitation Rights of Residents Policy and Procedure policy dated 1/5/24 instructed the facility provide immediate access to the resident by immediate family and other relatives, subject to the resident's right to deny or withdraw consent at any time.

Based on observations, resident and staff interviews, the facility failed to maintain an environment that was free from pests (houseflies) in resident rooms and the dining area. The facility reported a census of 48 residents. Findings include: 1. Review of the Minimum Data Set (MDS) Assessment, dated Aug. 15, 2025, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition.During an interview on Oct. 8, 2025 at 10:36 AM, Resident #15's door was observed to be shut with a bed pad placed under the crack of the door, when queried why bed pad was placed under door, Resident #15 stated it was to keep the flies out of his room. Resident #15 reported having trouble with flies in his room through the summer months. 2. Review of the MDS Assessment, dated July 18, 2025, revealed Resident #16 had a BIMS score of 13 out of 15, which indicated intact cognition.During an interview on Oct. 8, 2025 at 10:55 AM, Resident #16 reported that she would see a fly every once and a while in her room, when asked about fly swatter observed on Resident #16's television stand, and said that it (the fly) usually goes away. 3. Review of the MDS Assessment, dated Sept. 4, 2025, revealed Resident #13 had a BIMS score of 15 out of 15, which indicated intact cognition. During an interview on Oct. 9, 2025, Resident #13, observed with fly swatter in hand, stated, they (the flies) are pecking my eyes out. When queried how often Resident #13 saw flies in his room, he stated every day. Resident #13 stated they know about it, when asked if the facility was aware of flies in his room. 4. During an observation of the noon meal in the main dining room on Oct. 8, 2025 at 11:54 AM, a large trash can placed in the corner of the dining room, containing trash and food items, lacked a lid/cover. At 11:54 AM, a table of 3 residents sat together, one of the residents stated there's a fly on me, it drives me crazy. During an observation of the morning meal in the main dining room on Oct. 9, 2025 at 9:12 AM, at least one fly sat on top of 3 of the 6 round dining room tables. Review of the facility provided pest control company receipts revealed services provided, in part: a. On July 16, 2025, insecticide spray and rodenticide bait were utilized for target pests listed as spiders, ants, and mice. b. On Aug. 13, 2025, insecticide spray and rodenticide bait were utilized for target pests listed as spiders and mice.c, On Sept. 17, 2025, insecticide spray and rodenticide bait were utilized for target pests listed as spiders, ants, and mice. During an interview on Oct. 8, 2025 at 2:45 PM, the Housekeeping Supervisor confirmed hearing from residents about flies in the facility and reported that the facility has a pest control company visit monthly to set up traps and monitor. The supervisor reported having knowledge that a resident likes to open a window at night and believed this may be an entry for flies but denied knowledge of any other open or unsealed doors or windows. During an interview on Oct. 9, 2025, Staff A, Certified Nursing Assistant (CNA) reported that the facility had at least 3 fluorescent light bug traps: one near each nursing station and one in the dining room. Staff A stated that the bug trap in the dining room needed the light bulb replaced. When queried how staff should know that a bulb would need to be replaced, Staff A stated that the light bulb color would change from blue to orange when it was no longer effective.During an interview on Oct. 9, 2025 at 12:50 PM, Staff C, Licensed Practical Nurse (LPN), confirmed seeing flies in resident rooms and common areas. Staff C reported that if staff see flies swarming around anyone, or if staff know that flies are bugging a resident, they would try to take care of it using a fly swatter. During an interview on Oct. 9, 2025 at 2:30 PM, Facility Administrator, reported that the facility had a pest control company visit monthly to replace fluorescent light bug trap bulbs. When queried how staff should know that a bulb would need to be replaced, Administrator stated that the light bulb color would change from blue to orange when it was no longer effective. The administrator reported having knowledge that at least one trap required a new bulb and that the facility planned to have more traps installed at outside exit doors.Review of the facility policy titled, Pest Control, dated May 2008, revealed the Policy statement which declared, our facility shall maintain an effective pest control program. Section A. Policy Interpretation and Implementation directed, in part: This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. a. Pest services provided by (redacted). b. Windows are screened at all times. c. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. d. Garbage and trash are not permitted to accumulate and are removed from the facility daily. e. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, facility policy review and staff interviews, the facility failed to maintain a sanitary kitchen which included safe refrigerator temperatures, consist daily refrigerator temperature check documentation, target sanitization levels in the dishwasher, staff hand hygiene practices, and clean deep freeze equipment. The facility reported the census of 49 residents. Findings include:Review of the June 2025 Refrigerator Logs revealed temperatures logged during the evening shift on 6/25/25; 6/27/25; 6/28/25; 6/29/25; and 6/30/25. Review of the June 2025 Refrigerator Log for Refrigerator #2 revealed the following temperature documented during the evening shift: a. 6/25/25: 48 degrees Fahrenheit (F).b. 6/27/25: 48 degrees F.c. 6/28/25: 48 degrees F.d. 6/29/25: 48 degrees F.e. 6/30/25: 47 degrees F.During the initial kitchen observation on 6/30/25 at 10:18 a.m., the white deep freeze had a large amount of ice buildup along the inside of the freezer walls. During the initial kitchen observation on 6/30/25 at 10:38 a.m., the temperature logs on the refrigerator had a total of 5 entries for June. The Dietary Manager queried where the dishwasher logs were located and the Dietary Manager stated he didn't have them at the moment. The thermometers for two refrigerators in the main kitchen registered a temperature of 45 degrees F. The thermometer for the refrigerator on the counter by the handwashing sink log registered a temperature of 48 degrees F. During an observation on 7/1/25 at 8:52 a.m., Staff E, Dietary Aide/Cook queried where the test strips were located for the dishwasher and she stated she didn't know where they were. During an observation on 7/1/25 at 8:58 a.m., the Dietary Manager found the test strips for the dishwasher and after a cycle run for testing the strip read 25 parts per million (ppm). The color on the strip was light purple. The Dietary Manager stated [name redacted] was in a couple months ago and did some adjustments. The Dietary Manager asked about the dishwashing logs and he provided them. The Dietary Manager confirmed the refrigerator and freezers temperatures were not being completed even though he told his staff to do them. The Dietary Manager queried on providing the manufacture instructions for the dishwasher and he stated he couldn't because the dishwasher had been here longer than he was. The Dietary Manager asked if he would talk with someone about providing the manufacturer instructions and he stated yes, he would. During an observation on 7/1/25 at 11:10 a.m., Staff E temped the alternate main dish of smashed burgers. Staff E cleaned the thermometer and lifted the trash lid with her bare hands and placed the wipes in the trash can and then the lifted the trash can lid again to place another wipe in it and the side of the thermometer touched the top of the trash lid. Staff E continued to temp the smashed burgers and did not wash her hands or the clean the thermometer after it touched the trash lid. During an interview on 7/1/25 at 11:34 a.m., the Dietary Manager queried on the plan for the dishwasher and the Dietary Manager stated he placed a call to the company who fixed it and the staff would need to hand sanitize the dishes until the sanitizing up to a target 50 PPM. The Dietary Manager queried on problems with the dishwasher and he stated no, not until now. During an observation on 7/1/25 at 11:37 a.m., the thermometer for refrigerator on the corner by the handwashing sink temperature read 52 degrees F. During an observation on 7/1/25 at 11:45 a.m., the Dietary Manager used a different test strip roll and ran a dishwasher cycle and retested the sanitizer and the Dietary Manager stated the strips got darker. The color on the strip was between the 25 PPM and the 50 PPM. The Dietary Manager confirmed the test strip not dark enough and the staff would not use the dishwasher until it was fixed. During an observation on 7/1/25 at 12:10 p.m., the thermometer for the refrigerator on the counter of the kitchen by the handwashing sink temperature read 55 degrees F. During an interview on 7/1/25 12:41 p.m., Dietary Manager queried on the temperature of the refrigerator next to the handwashing sink and he stated the refrigerator settled down after meal services and he had the coils cleaned a few weeks ago. The Dietary Manager stated he instructed staff to limit their use of the refrigerator and keep the doors closed. The Dietary Manager stated he would keep an eye on it and would shuffle items to the other refrigerator. During an interview on 7/1/25 at 1:05 p.m., the Administrator notified of the dishwasher sanitizer strips not meeting the required level and the Administrator stated she would speak to the Dietary Manager and see what was going on.During an interview on 7/1/25 at 1:32 p.m., the Administrator stated the dishwasher strip was at 50 PPM and showed a picture on her phone that was close to 50 PPM on the strip. The Administrator stated the facility would use paper plates until [name redacted] came to the facility and looked at the dishwasher. During an interview on 7/1/25 at 1:45 p.m., the Dietary Manager stated he fixed the problem and the dishwasher was working, because he adjusted the tubing. During an interview on 7/1/25 at 1:53 p.m., the Dietary Manager tested a test strip on the dishwasher and the strip read under 50 PPM. The Dietary Manager checked the sanitizer again and the strip still did not read at least 50 PPM. The color of the strip continued to look light purple/lilac. While the Dietary Manager checked the dishwasher, staff put dishes away that were placed on the dishwasher racks. The Dietary Manager stated the facility would use paper plates and he instructed the staff to clean the dishes and put them away and they would rewash the dishes when the dishwasher was fixed. During an observation on 7/1/25 at 1:53 p.m., the thermometer for refrigerator by the handwashing sink temperature read 55 degrees F. The Dietary Manager confirmed the refrigerator not cooling down and they needed to move items out of it. The refrigerator door opened and observed the thermometer on the inside of the refrigerator, which registered a of 60 degrees F. During an observation on 7/1/25 at 2:56 p.m., no staff present in the kitchen. The refrigerator temperature by the handwashing sink read 56 degrees F. Opened the door to the refrigerator and the refrigerator still had cups and pitches with beverages in them. On 7/1/25 at 2:58 p.m., the Director of Nursing notified and observed the temperature of the refrigerator by the handwashing sink in the kitchen at 56 degrees F and beverages still in the refrigerator. On 7/1/25 at 3:03 p.m., the Dietary Manager stated the drinks in the refrigerator had been warm for too long and would be dumped and all the other items in the refrigerator had been moved to another refrigerator. On 7/2/25 at 8:22 a.m., the Dietary Manager stated [name redacted] came in last night and fixed the dishwasher and [name redacted] was also coming in today to check the dishwasher again. The sanitizer on the dishwasher checked and the strip read 50 PPM. The Dietary Manager stated he cleaned the coils on the refrigerator this morning and the temperature held steady at 38 degrees F. Upon observation, the refrigerator temperature 41 degrees F. The Dietary Manager stated he would watch the temperature and make sure it didn't go up before placing anything in it. During an interview on 7/2/25 at 8:28 a.m., Staff E, Dietary Aide/Cook queried on how the dishwasher sanitizer is checked and she stated she didn't know who checked it and Staff E never had checked it. Staff E asked what she did when she needed to lift the lid to the trash can and Staff E stated she would wash her hands. Staff E informed of the observation of her touching the trash lid with her hands and the thermometer touching the trash lid and Staff E did not deny she didn't wash her hands before temping the smashed burgers. Staff E queried on how completed the temperature logs on the refrigerators and Staff E stated the cooks did them. Staff E asked about the refrigerator by the handwashing sink and Staff E stated they moved everything out of it. and since the weather has been hot outside the temperature fluctuated. Staff E stated she didn't know exactly when the refrigerator temperatures started fluctuating. Staff E stated the staff informed the Dietary Manager when the temperature in the refrigerator went up. Staff E asked who did the deep cleaning the deep freeze and Staff E stated Staff F usually done it. During an interview on 7/2/25 at 9:54 a.m., Staff G, Dietary Aide queried on how the temperatures for the refrigerators are checked and logged and she stated usually the cooks do the checks. Staff G queried on the higher temperature of the refrigerator by the handwashing sink and she stated she noticed it in the last few weeks and in the cooler months they don't have issues. Staff G asked if she checked the sanitizer in the dishwasher and Staff G stated no, she never had and didn't know who did. Review of the invoice for the dishwasher repair dated 7/2/25 at 10:02 a.m. revealed the following: e-call sanitizer not hitting 50 ppm, came in found drain solenoid had dropped down not draining as it should, adjusted solenoid. Titration levels look good now, showed state 75 ppm.During an interview on 7/2/25 at 10:08 AM, Staff F, Dietary [NAME] queried on how checked and logged the temperatures on the refrigerators and she stated the temperatures needed done in the morning and the evening and she was not good at doing it. Staff F stated the temperature on the refrigerator always looked good in the morning and as the progressed the temperatures plummeted with the heat outside. Staff E stated the temperatures of the refrigerators should be at 34 degrees F. Staff F queried on who defrosted the freezer and Staff F stated it usually fell on the Dietary Manager. Staff F stated when she was the Dietary Manager, Staff F did it once a month. Staff F stated it had been at least 3 months since the last time the deep freeze was cleaned and it needed done. During an interview on 7/3/25 at 12:28 PM, the Dietary Manager asked about the temperature logs for the refrigerator and he confirmed they were not getting done. The Dietary Manager queried on the dishwasher log and he stated he didn't know if someone was color blind, but he explained to staff where the strip color should be. The Dietary Manager confirmed problems with the sanitizer in the dishwasher at the beginning of the week, but now everything worked properly. The Dietary Manager asked about the deep freeze cleaning schedule and the Dietary Manager stated it is cleaned once a month by him or one of the cooks. The Dietary Manager stated he believed they cleaned the freezer within the last month on a Wednesday but he didn't know the date or who cleaned it. The Dietary Manager informed of the cook touching the trash can lid with their hands and the thermometer touching it and the Dietary Manager stated staff need to wash their hands after touching the lid and he needed to reeducate the staff. The Dietary Manager asked about the refrigerator logs and one of the logs documented 48 degrees and the Dietary Manager stated the cooks were supposed to check and log the temperatures in the morning before they started using them and, in the evening, before they leave for the night. The Dietary Manager stated he instructed staff if a temperature is out of range not to write it down, but to come to him so the appliance could be looked at. Review of the facility policy titled Sanitization Policy, revised October 2008 revealed a Policy Statement which declared The food service area shall be maintained in a clean and sanitary manner. The Policy Interpretation and Implementation section directed the following, in part: 8. Dishwashing machines must be operated using the following specifications:Low-Temperature Dishwasher (Chemical Sanitization)a. Wash temperature (120 degrees F)b. Final rinse with 50 ppm hypochlorite (chlorine) for at least 10 seconds.17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the facility policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revised on October 2017 revealed a Policy Statement which declared Food and nutrition service employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The Policy Interpretation and Implementation section directed the following, in part: 6. Employees must wash their hands:f. After handling soiled equipment or utensilsh. After engaging in other activities that contaminate the handsReview of the facility policy titled Refrigerator and Freezers Policy revised December 2014 revealed a Policy Statement which declared This facility safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The Policy Interpretation and Implementation section directed the following, in part: 1. Acceptable temperatures ranges are 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers. 2. monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted.

Based on observation, record review, resident and staff interviews, and the facility policy, the facility failed to provide a palatable vegetable for 1 of 1 meal observed. The facility reported a census of 49 residents. Findings include:1. The Facility Spring/Summer 2025 Menu Week 1 revealed the following menu for Tuesday, July 1, 2025::a. Lemon chicken b. Garlic parmesan pastac. Roasted caesar vegetable [a substitute of California mix (generally a mixture of broccoli, cauliflower and carrots) made]d. Garlic toaste. Sugar cookie [NAME] 7/1/25 at 12:52 p.m., the State Agency received and tasted a lunch tray with the above menu items. The California mix sampled contained mostly broccoli pieces. The broccoli pieces were soft and mushy, and tasted and smelled like black pepper. During an interview on 7/2/25 at 8:28 a.m., Staff E, Dietary Aide/Cook queried if she followed a recipe for the menus stated she followed the recipes. Staff E stated the vegetable was a California mix. Staff E queried if the California mix had a recipe for how much seasoning to add and Staff E stated no, she didn't measure the seasoning, Staff E sprinkled the seasoning and tasted it and thought it tasted fine. Staff E stated some people said it was too spicy, but Staff E made sure she stirred it pretty good. Staff E stated she used a salt free seasoning blend in the California mix and might have had a big clump in it. During an interview on 7/3/25 at 8:43 a.m., the Dietician queried on using a salt free seasoning blend with the vegetables and she stated the cooks added the seasoning for taste. The Dietician stated if residents complained, it was a different story. She stated she wouldn't put spices on broccoli. The Dietician asked about the texture of the broccoli and she stated the broccoli should be tender and the spices withheld unless the vegetables were supposed to be spiced. During an interview on 7/3/25 at 12:28 p.m., the Dietary Manager queried on the broccoli served on 7/1/25 and he stated broccoli was difficult to hold and constantly wanted to turn pale. The Dietary Manager stated he would prefer they undercook the broccoli and let the steam table finishing cooking it, but there was no way to keep the broccoli from getting mushy. The Dietary Manager asked about the salt free seasoning blend to the vegetable dish and the Dietary Manager stated it was very possible the cook added too much. 2. During an observation on 07/01/25 at 12:04 PM, dietary staff brought Resident 36's food out. The resident received mechanically ground lemon chicken with sauce/gravy, pasta, and broccoli casserole. Staff A, Certified Nurses Aide (CNA), and Staff C, CNA, assisted the resident with sitting at the table. The resident started to eat and talk with his tablemates. At 12:12 PM, Staff A, CNA, sat at the resident's table. Resident #36 requested salt for his food. Staff A helped to apply salt to the resident's food and then offered to pepper the resident's food. Resident #36 responded that someone had already peppered it. Resident #36 told one of his tablemates that the food had too much pepper. 3. On 6/30/25 at 2:01 PM, Resident #21 reported the food was not good. She explained that it was either undercooked or overcooked.On 7/01/25 at 12:07 PM, dietary staff served Resident #21 her lunch which included lemon chicken with a sauce, pasta and a broccoli casserole. The broccoli casserole was mushy and overcooked in appearance. The resident ate 50 percent of the meal, and did not eat the broccoli casserole. The facility policy, titled Food and Nutrition Services, dated October 2017, identified the facility provided each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs.

Based on observation, record review, staff interviews, and the facility policy, the facility failed to follow the menu for 1 of 1 meals observed and 2 of 2 residents sampled for a therapeutic diet (Resident #21 and Resident #36). The facility reported a census of 49 residents.Findings include: 1. Review of the facility Spring/Summer 2025 Menu Week 1 revealed the following menu for Tuesday, July 1, 2025: a. Lemon chicken b. Garlic parmesan pastac. Roasted caesar vegetable [a substitute of California mix (generally a mixture of broccoli, cauliflower and carrots) made]d. Garlic toast e. Sugar cookie barsDuring an observation of the puree process on 7/1/25 at 10:47 a.m., Staff E, Dietary Cook/Aide did not prepare the puree garlic toast menu item. During an observation 7/1/25 at 11:50 a.m., the lunch meal service started. Staff E prepared plates for the residents. No garlic toast served with the prepared plates throughout the lunch meal service. During an interview on 7/1/25 12:41 a.m., Dietary Manager confirmed no bread served and stated garlic bread was supposed to have been served. During an interview on 7/2/25 at 9:54 a.m., Staff G, Dietary Aide queried if bread was served for lunch yesterday and Staff G stated no, she thought they were supposed to have garlic toast. Staff G stated she guessed they didn't have enough, but no one told her that directly. During an interview on 7/3/25 at 12:28 p.m., the Dietary Manager queried on not having the garlic toast and the Dietary Manager stated [name redacted] hadn't been getting them supplies because sometimes they run out. The Dietary Manager asked about substitutes and the Dietary Manager stated he usually tried to come up one, but didn't always. 2. The Minimum Data Set (MDS) assessment for Resident #36, dated 3/28/25, identified the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (indicative of severe cognitive impairment) and diagnoses of dementia and diabetes.The Care Plan for Resident #36, last revised 4/3/25, identified the resident was at risk for weight loss due to cognitive status.On 07/01/25 at 12:04 PM, dietary staff brought Resident 36's food out. The resident received mechanically ground lemon chicken with sauce, pasta, broccoli casserole. The resident ate 100 percent. The resident did not receive a piece of garlic bread per the facility menu and was not offered a bread substitute. 3. The MDS assessment for Resident #21, dated 5/2/25, identified the resident had a BIMS of 11 out of 15 (indicative of a moderate cognitive impairment) and diagnosis of cerebral vascular accident (stroke) and diabetes.The Care Plan for Resident #21, last revised 5/8/25, identified the resident received a therapeutic diet related to a diagnosis of diabetes. On 7/01/25 at 12:07 PM, dietary staff served Resident #21 her lunch which included lemon chicken with a sauce, pasta and a broccoli casserole. Resident #21 did not receive a piece of garlic bread per the facility menu and was not offered a bread substitute.The facility policy, titled Food and Nutrition Services, dated October 2017, identified the facility provided each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs.

Based on clinical record review, facility policy review, and staff interview, the facility failed to notify the physician of a weight gain for 1 of 3 residents reviewed for nutrition (Resident #24). The facility reported a census of 49 residents.Findings include: The Minimum Data Set (MDS) assessment tool, dated 5/30/25, listed diagnoses for Resident #24 which included edema (swelling), non-Alzheimer's dementia, and major depressive disorder. The MDS listed the resident's cognition as severely impaired. A 9/4/24 Care Plan entry stated the resident would maintain a healthy weight. Review of Resident #24's Weight Report listed the following weights:a. 5/1/25 a weight of 158 lbs. (pounds)b. 6/26/25 180 lbs., a gain of 22 lbs. or 13.92 percent.A 5/26/25 Quarterly Nutritional Assessment stated the resident had a weight gain and recommended a reduction of the resident's supplement to 60 milliliters (ml) once daily. The facility lacked documentation of provider notification of the resident's additional weight gain from 5/26/25 until 6/26/25. On 7/3/25 at 9:27 a.m. Staff D Registered Nurse (RN) stated if a resident had a 22 lbs. weight gain in two months she would check the resident for swelling and make sure the weight was correct. She stated she would notify the provider. On 7/3/25 at 9:30 a.m., the Director of Nursing (DON) stated if a resident gained 22 lbs. in two months, she would notify the Registered Dietician and the provider. She stated she expected staff to address a weight gain.Review of the undated facility policy Change in Condition revealed the facility would consult with the resident's physician when there was a significant change in condition or a need to alter treatment.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure medications and chemicals were secured and not accessible to 10 of 10 (which included Resident #11) cognitively impaired and independently mobile residents on the memory care unit. The facility reported a census of 49 residents. Findings include:1. The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #11 which included obesity, prediabetes, and a moderate intellectual disability The MDS stated the resident was independent with walking and listed her cognition as severely impaired. Review of the Care Plan, dated 10/24/24, revealed Resident #11 had cognitive loss and dementia and impaired decision making. The Care Plan directed staff to determine if her decisions would endanger her or others. The Care Plan documented the resident felt the need to touch different things and directed staff to allow this when safe to do so. During an observation on 6/30/25 at 1:47 p.m., while in the day room of the Memory Care Unit, Resident #11 pulled back the curtain covering the right-hand cubby and looked in. Other residents sat in the room but no staff were present. 2. Review of an untitled facility document revealed a list of 10 cognitively impaired, independently mobile residents in the locked Memory Care Unit. Observations on 7/2/25 revealed residents from the above list were unattended in the day room without staff at the following times: 8:52 a.m. to 8:55 a.m.; 9:02 a.m. to 9:08 a.m.; and 9:13 a.m. to 9:15 a.m.During an observation on 7/2/25 at 9:54 a.m., the right-hand cubby in the day room found to have contained the following:a. Staff B Certified Nursing Assistant's (CNAs) bag which contained an almost full bottle of ibuprofen 200 milligrams (mg)b. A spray bottle of Old English furniture polish in which the label stated it could cause eye irritationDuring an interview On 7/2/25 at 10:06 p.m., the Director of Nursing (DON) stated the resident environment should be free from medications and chemicals. She stated staff should lock up their personal items. The undated facility Hazard Communication Program stated the facility was committed to preventing chemical exposures.The undated facility policy [Facility Name Redacted] Medication Pass and Treatments directed staff to keep medications locked at all times.

Based on clinical record review, policy review, and staff interview, the facility failed to offer an annual influenza vaccine for 2 of 5 residents (Residents #11 and #24) reviewed for immunization. The facility reported a census of 49 residents.Findings include:1. The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #11 which included obesity, prediabetes, and moderate intellectual disabilities and listed her cognition as severely impaired. An untitled document, dated 3/13/24, documented that the Resident #24's resident representative consented to an influenza vaccine. The facility lacked documentation the resident received an influenza vaccine during the 2024-2025 flu season. 2. The MDS assessment tool, dated 5/30/25, listed diagnoses for Resident #24 which included edema (swelling), non-Alzheimer's dementia, and major depressive disorder. The MDS listed the resident's cognition as severely impaired. An untitled document, dated 3/13/24, documented that the Resident #24's resident representative consented to an influenza vaccine. The facility lacked documentation the resident received an influenza vaccine during the 2024-2025 flu season. The undated facility Policy for Provision of Influenza and Pneumococcal Vaccines, stated the facility would screen residents to determine if they were current on their immunizations. The policy stated the facility would offer all residents the influenza vaccines. On 7/3/25 at 9:39 a.m., the Director of Nursing(DON) stated she was not sure how the facility missed the above resident's annual influenza shots.

Based on clinical record review, facility policy review, and staff interview, the facility failed to ensure resident code status were clear and consistent in the electronic health record as compared to the documentation kept in binder at the nurses desk for 1 of 24 residents (Resident #33) reviewed for advance directives. The facility reported a census of 49 residents. Findings include:The Minimum Data Set (MDS) assessment tool, dated 5/2/25, listed diagnoses for Resident #33 which included non-Alzheimer's dementia, anxiety disorder, and depression and listed her Brief Interview for Mental Status (BIMS) score as 0 out of 15, indicating severely impaired cognition. The facility Resuscitation Policy, effective 8/17/17, stated the facility would maintain each resident's resuscitation status in the clinical record. On 7/1/25 at 12:50 p.m., a review of Resident #33's Iowa Physician Order for Scope of Treatment, dated 1/20/23 and scanned in the electronic health record (EHR), revealed the resident was a Full Code. The resident's IPOST, dated 9/24/24, located in a book at the nursing station, stated the resident was a Do Not Resuscitate (DNR). On 7/1/25 at 12:52 p.m., Staff C Licensed Practical Nurse (LPN) stated if he needed to determine a resident's code status, he would either look in the EHR or the book at the nursing station, whichever was the fastest. On 7/1/24 at approximately 1:00 p.m., the Director of Nursing (DON) stated that code statuses should match and she would remedy the situation.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide an ongoing program of activities for 1 of 1 residents reviewed for activities (Resident #24). The facility reported a census of 49 residents.Findings include:The annual Minimum Data Set(MDS) assessment tool, dated 11/29/25, listed diagnoses for Resident #24 which included edema (swelling), non-Alzheimer's dementia, and major depressive disorder. The MDS listed the resident's cognition as severely impaired and stated the resident preferred the following activities: listening to music and spending time outdoors. Review of the Care Plan, dated 3/3/22, revealed the resident was at ease in joining other residents in activities. The Care Plan identified the resident enjoyed Jewish singing and visiting with friends from the meditating community. The facility Activity Services Policy, revised 7/13/23, stated the facility would plan activities based on resident interests, abilities, and needs. The facility designed activities to promote physical, mental, and social well-being. The untitled monthly activity logs revealed the resident participated in the following activities:a. April 2025: exercise - participated 22 times, refused once; one-on-one visits - participated 23 times.b. May 2025: exercise - participated 17 times, refused 5 times; one-on-one visits - participated 22 times; games -refused 1 time; pretty nails - refused 1 time; bible study - participated 1 time.c. June 2025: exercise - ball toss, walking, target toss, bean bag toss - participated 16 times, refused 2 times; one-on-one visits -participated 19 times; games - participated 1 time; church - participated 1 time; party - refused 1 timeReview of the activity calendars revealed other activity offerings included: outing, bingo, movie, cooking, crafting, coffee club, help with cleaning/folding. The facility lacked documentation these activities were offered to Resident #24. The activity calendar lacked documentation of further activities offered to the resident. Observations of Resident #24 revealed the following:a. On 6/30/25 at 1:32 p.m., the resident sat on the edge of his bed.b. On 7/1/25 at 8:51 a.m., the resident laid in bed.c. On 7/1/25 at 11:37 a.m. and 12:10 p.m., the resident sat at the dining room table.d. On 7/2/25 from 8:44 a.m. until 9:48 a.m., the resident sat on the couch in the day room and watched a TV game show. e. On 7/2/25 at 11:09 a.m. and 11:46 a.m., the resident sat at the dining room table. f. On 7/2/25 at 1:38 p.m., the resident laid in bed. g. On 7/2/25 at 3:10 p.m., the resident sat in a recliner in the day room and watched a TV game show.h. On 7/3/25 at 8:59 a.m., the resident sat in a recliner in the day room. During an interview on 7/3/25 at 9:42 a.m., the Director of Nursing (DON) agreed that resident should be kept busy and stimulated with activities. During an interview on 7/3/25 at 9:03 a.m., the Life Enrichment Coordinator stated she completed an hour of activities in the memory care unit. She stated she was responsible for transportation also so when she was doing that, she could not spend time on activities. During an interview on 7/3/25 at 9:18 a.m., the Director of Activities stated she was new at the facility but stated in her old facility she conducted activities every hour to 2 hours, around 5 activities per day. She stated she would like to carry out that schedule at this facility eventually. She stated staff could complete an activity with the residents before lunch.

Based on observation, clinical record review, resident and staff interviews the facility failed to ensure a residents clothing fit properly and in good repair as to provide personal privacy while in common areas of the facility for 1 of 12 (Resident #6) residents reviewed. The facility reported a census of 47 residents. Findings include: The Minimum Data Sample (MDS), dated [DATE], for Resident # 6 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. The MDS listed diagnoses included: non-Alzheimer's dementia, anxiety disorder, and depression. During an observation on 8/13/24 at 12:21 PM, Resident # 6 used his wheelchair to propel the hallway near his room. Resident #6 had a tear in his pants from his groin to his knee, with an adult incontinence brief visible through the tear. During an interview on 08/15/24 at 09:39 AM, Resident # 6 stated his clothes do not fit properly, most of them are torn, and need to be thrown out. During an interview on 08/15/24 at 10:16 AM, Staff F, Certified Medication Aide (CMS), stated CMA's and Certified Nursing Assistants (CNA's) are look at a residents clothing when they are assisting with dressing , and report any clothing needs to nursing or Social Services. She acknowledged Resident # 6 required new clothing, and stated he is on the the list of people they look for clothes for when they get clothing donations from staff or the community. Staff F stated if the resident were to come out of his room undressed or with holes in his clothing staff are directed to assist the resident back to his room and help him dress appropriately. If the resident were to refuse, they are to tell the charge nurse and have them document the episode in the electronic health record's progress notes. She acknowledged that if there was no charting done, she believes that an episode of refusal did not occur. During an interview on 08/15/24 at 10:21 AM . Staff G, CNA acknowledged Resident # 6 needs new clothes. She stated he had very few pairs of pants. She stated the expectation is for staff to assist a resident back to their room if they are not wearing clothes, wearing clothes improperly, or wearing clothes with revealing rips, holes, or tears. If the resident refused assistance they are to tell the nurse and have them document the behavior. During an interview on 08/14/24 at 02:31 PM, Staff E, Social Services acknowledged Resident # 6 is in need of new clothing. She stated he is on their donations list, having received a donation of clothing and shoes earlier in the year. She stated the facility is responsible for contacting Resident # 6's Power of Attorney to inform them that he is in need of new clothes. She indicated she did not know when the last time a request for new clothing had been made. She stated there is no formal system to assess clothing needs for cognitively impaired residents. She noted housekeeping does an initial inventory of resident clothing and CNAs are then responsible for informing social services or nursing staff of a residents needs. During an interview on 08/14/24 at 08:52 AM , the Administrator stated it is her expectation if a resident was moving around the facility with significant holes in their pants or shirts the CNAs or nursing staff would direct the resident to their room and assist them in dressing more appropriately. If the resident refuses, the expectation is that the CNAs or nursing staff document this refusal. She acknowledged the resident is on a clothing donation list. A review of Nursing Progress Notes revealed a note, dated 6/12/23, documenting contact with Resident #6 Power of Attorney. No further documentation of contact with the Power of Attorney found in the clinical record. The facility provided documentation indicating Resident #6 last received a clothing donation on 02/02/24.

Based on document review, and staff interviews the facility failed to employ a Certified Dietary Manager to carry out the functions of the food and nutrition service. The facility reported a census of 47 residents. Findings include: During an interview on 08/13/24 at 11:00 AM, the Dietary Supervisor stated she did not have education and training completed to be a Certified Dietary Manager. She stated she enrolled and began the class to be certified over a year ago but had not completeted the course work. A review of the Dietary schedule for July 21, 2024 to August 3, 2024 revealed the Dietary Supervisor scheduled to work: 7/21/24, 7/23/24, 7/24/24, 7/28/24, 7/29/24, 7/30/24, and 8/3/24. During an interview on 08/13/24 at 3:30 PM, the Administrator confirmed the facility did not employ a Certified Dietary Manager but had her enrolled in the program to become a Certified Dietary Manager.

Based on facility record review, staff interviews, and hospital record review, the facility failed to ensure residents were appropriately assessed and provided interventions to maintain their optimal health and well being for 1 of 3 residents reviewed (Resident #1). The facility reported census was 44 residents. Findings include: According to a Minimum Data Set (MDS) with a reference date of 2/16/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognitive status. Resident #1 had been independent with ADL's, but following a fall with fracture, was dependent on staff with transfers (Hoyer), mobility (W/C), dressing, toilet use, and personal hygiene needs. Resident #1's diagnoses included fracture right femur, myopia. A Progress Note dated 3/29/24 found Resident #1 returned from the hospital following a fall and fractured right femur. Resident #1 was placed on an opioid for pain control, and according to the VS.weight.BM document, had no recorded bowel movements since her return through 4/2/24. A Progress Note written by Staff A, Registered Nurse, on 3/29/24, indicated Resident #1 had very active bowel sounds in all 4 quadrants upon re-admission. A Progress Note written by Staff B, Registered Nurse, on 4/3/24 at 12:34 p.m. indicated Resident #1 refused to eat lunch and received a new standing order for constipation, Senna S 2 tabs twice daily and Bisacodyl suppository 10 mg rectally as needed daily. In an interview on 4/16/24 at 1:15 p.m. Staff B, Registered Nurse, stated she usually works from 6:00 a.m. to 2:00 p.m. Staff B stated she recalls on 4/3/24, Resident #1 complaining of stomach discomfort, abdominal distention and constipation. Staff B stated she updated the physician of the resident's condition and wrote a standing order for Senna and a Bisacodyl suppository. Staff B stated the Senna and Bisacodyl suppository was not in stock, so they would have to wait for the pharmacy delivery that evening. Staff B stated she informed Staff C at shift change report. Staff B stated the next day (4/4/24), Resident #1 continued to have stomach discomfort and abdominal distention. Staff recalled being informed that the suppository administered was not effective, which prompted her to obtain an order for a fleets enema, which was again not in stock and was not administered during her shift. Staff B stated she did not attempt another suppository or assess Resident #1 for impaction. A Progress Note written by Staff C, Licensed Practical Nurse, on 4/3/24 at 5:01 p.m. indicated Resident #1's abdomen was hardened, Resident #1 had an emesis and was complaining of stomach pain. Staff C indicated Resident #1 was found to be impacted and Staff C digitally removed the impaction, noting a large amount of hardened, dark stool was removed. A Progress Note written by Staff C, Licensed Practical Nurse, on 4/3/24 at 5:54 p.m. indicated Resident #1 was delivered a room tray and Resident #1 only wanted drinks. Orange juice and prune juice were provided. A Progress Note written by Staff D, Licensed Practical Nurse, on 4/4/24 5:30 a.m. indicated Resident #1 had a large liquid brown emesis last evening and her abdomen remained distended. Staff D administered a suppository (8:00 p.m. on Medication Administration Record (MAR)) indicating only a smear resulted. In an interview on 4/16/24 at 1:00 p.m. Staff C, Licensed Practical Nurse, stated he generally works 6:00 a.m. to 6:00 p.m. and recalls Resident #1 having trouble with her bowels, stomach pain, and distention. On the evening of 4/4/24, Staff C checked Resident #1 for impaction and removed a large amount of hard stool. Staff C stated he remembered hearing in report that there was an order for Senna, but did not recall being informed of the order for a suppository. Staff C stated he had Resident #1 remain in bed during his shift. A Progress Note written by Staff B, Registered Nurse, on 4/4/24 at 8:22 a.m. indicated Resident #1 was still complaining of discomfort to abdomen and abdomen remained distended. No emesis noted at breakfast. Staff B indicated she contacted the physician's office to update on Resident #1's condition. Resident #1 was encouraged to drink fluids. A Progress Note written by Staff B, Registered Nurse, on 4/4/24 at 11:06 a.m. indicated Resident #1 had a small greenish emesis after lunch. A Progress Note written by Staff B, Registered Nurse, on 4/4/24 at 1:18 p.m. indicated new orders received for Zofran ODT 4 milligrams every six hours as needed (nausea), Miralax twice daily (laxative), and a one time order for a fleets enema. Pharmacy notified to ensure Miralax and fleets enema would be delivered on evening run. In an interview on 4/16/24 at 3:30 p.m. Staff F, Certified Medication Aide, stated she was working the evening shift on 4/4/24. Staff F stated Resident #1 was not feeling well and had reportedly vomited a couple of times that morning. Resident was complaining of her neck brace. Staff F recalls Resident #1 getting an enema, but she was not in the room. In an interview on 4/16/24 at 3:19 p.m. Staff E, Certified Nurse Aide, stated she recalls Resident #1 having bowel discomfort on 4/3/24 and 4/4/24. Resident #1 was stating she needed to have a bowel movement. Staff E stated Resident #1 was questioning things as she always does. Resident #1's abdomen was hard and distended. Staff E stated they tried pushing fluids to help her out. A Progress Note written by Staff H, Licensed Practical Nurse, on 4/4/24 at 9:15 p.m. indicated fleets enema delivered by pharmacy and administered with a moderate amount of soft stool expelled. In an interview on 4/16/24 at 4:38 p.m. Staff H, Licensed Practical Nurse, stated she was working a 6:00 p.m. to 6:00 a.m. shift on 4/4/24. Resident #1 had been sick earlier with bowel issues. Staff H indicated Resident #1 had gotten up for supper, but didn't eat much. They were able to get her to drink some prune juice. Staff H stated she received the fleets enema from pharmacy and administered it, feeling like she had good results. Resident #1 had a medium amount of soft stool expelled and her abdomen was less rigid afterwards and stated she was feeling better. Staff H stated Resident #1's bowel issues was a high priority. Staff I, Registered Nurse, stated Resident #1 had no further bowel movements that evening and seemed to sleep ok. Staff I stated she did not assess Resident #1 before leaving that morning. In an interview on 4/17/24 at 11:35 a.m. Staff G, Certified Nurse Aide, stated she worked 6:00 a.m. to 2:00 p.m. on 4/5/24 and provided care for Resident #1. Staff G stated that morning her and another aide changed and dressed Resident #1. Resident #1 had a small bowel movement. Resident #1 was awake and talkative, but mumbling and not speaking in full sentences. Staff G stated Resident #1 was not complaining of pain, but may have gotten a pain medication earlier. Resident #1 was transferred per Hoyer lift into her wheelchair and propelled to the dining room. Resident #1 took a few bites of food and drank all of her fluids. Resident #1 was having difficulties staying upright in her chair and was falling asleep, all of which was unusual. After breakfast at around 8:30 a.m. they laid Resident #1 back into bed. Staff G stated Resident #1's abdomen was very distended and hard. Staff G stated she informed the nurse, Staff A, of Resident #1's inability to stay upright and her mumbling. Staff G stated she thought Resident #1 had an enema that morning, but wasn't sure. At around 9:15 a.m. Resident #1 was playing with her call light and noticeably groggy and not making sense. Staff G stated she again reported this to their nurse, Staff A. At 10:30 a.m. Staff G checked on Resident #1, noting she remained dry, but was very warm and sweating. Staff G stated she removed Resident #1's long sleeve shirt and placed her in a gown. Staff G stated she also removed her socks and noticed her feet were slightly mottling. Staff G stated she reported Resident #1's condition to their nurse, Staff A, who agreed with Resident #1 remaining in bed for lunch. At around 11:30 a.m. Staff G stated she passed room trays. She stated she was able to get Resident #1 to eat a few bites of yogurt and dessert and a few sips of water. It was around this time the DON came in and asked how Resident #1 was doing. Staff G stated she reported her observations. At around 12:00 p.m. Staff G stated she checked on Resident #1 and she was dry and a tiny bit responsive. Her head of bed was at 45 degrees. From 12:30 p.m. to 1:30 p.m. Resident #1 remained in bed and unresponsive. A Progress Note written by Staff A, Registered Nurse, on 4/5/24 at 1:30 p.m. indicated Staff A checked on Resident #1 after she had not come to the dining room for lunch. Resident #1' s vital signs were temperature 93.9, pulse 44, respirations 26, blood pressure 111/28 and unable to get an oxygen saturation level. In an interview on 4/17/24 at 2:00 p.m. Staff A, Registered Nurse, stated she was working the day shift on 4/5/24 after being off a few days prior. Staff A stated it was reported to her that Resident #1 was having bowel issues and they had administered an enema to try and resolve the issue. Staff A stated that morning after breakfast she completed an assessment, including vital signs on Resident #1. Resident #1's abdomen was distended and hard, but not sore. Staff A stated she had no concerns and no further contact with Resident #1 until after lunch at about 11:30 a.m. It was at that time Staff A went to Resident #1's room because she did not come out for lunch. Staff A stated she checked her vital signs which were concerning and initiated oxygen, but noted Resident #1 was talkative and alert. Staff A stated the DON and Staff I also came into the room and together they dealt with Resident #1. At 2:10 p.m. the physician was notified and gave an order to send Resident #1 out for evaluation. When asked why there was a delay over a 2 hours before sending Resident #1 to the hospital, Staff A provided no explanation. A Progress Note written by Staff I, Registered Nurse, on 4/5/24 at 1:36 p.m. indicated Staff I was called to Resident #1's room by the Director of Nursing (DON). Blood pressure again checked and was 80/20. Unable to obtain an oxygen saturation level. Oxygen administered at 2 liters per minute per nasal canula with head of bed elevated. Resident #1 had audible gurgling. Physician notified and updated and family notified of Resident #1's condition. A Progress Note written by Staff A, Registered Nurse, on 4/5/24 at 2:30 p.m. indicated Resident #1's physician was updated on her condition and Resident #1 was requesting to go to the hospital. At 2:10 p.m. Staff A was given orders to send Resident #1 to the hospital. A Progress Note written by Staff A, Registered Nurse, on 4/5/24 at 2:34 p.m. indicated the ambulance arrived at 2:30 p.m. Resident #1 vital signs were obtained and Resident #1 was placed on a gurney and left just prior to 3:00 p.m. In an interview on 4/17/24 at 1:30 p.m. the Director of Nursing (DON), stated Resident #1 was not the same after her fall and fractured right femur. Resident #1 seemed more anxious and needy. The DON stated she met with Resident #1 in an attempt to relieve her anxiety. The DON stated Resident #1 had always had a pot belly, as if she was pregnant. On 4/3/24, Staff B, reported Resident #1 was constipated and having episodes of emesis. Resident #1 was encouraged to stay active, eat and drink plenty of fluids. Nothing seemed to be helping and on 4/4/24 they got an order for an enema. That evening Resident #1 was up for supper and ate a few bites. The enema was given with seemingly good results. The next morning the DON stated she spoke with Resident #1 and she seemed to be fine. The DON stated Resident #1 was having difficulties keeping her head up with her c-collar on, so she was searching for a high back wheelchair around lunch time. The DON stated Staff A reported Resident #1 was placed on oxygen and her vital signs were not good. The DON stated she got Staff I and together they checked Resident #1's blood pressure. Resident #1's feet were mottled and Staff I contacted Resident #1's son to report her condition. The son then spoke with the social worker and DON and decided he wanted his mother sent to the hospital. The DON stated when she observed the feet mottling, she felt death was imminent. In an interview on 4/17/24 at 12:30 p.m. Staff K, Certified Medication Aide, stated on the morning of 4/5/24, she passed Resident #1's morning medications. Staff K stated the medications were crushed due to Resident having difficulties swallowing. Staff K stated Resident #1 stated she was in pain and ready to go. Staff K stated she did not recall anything else about that morning. In an interview on 4/17/24 at 11:20 a.m. Staff J, Certified Nurse Aide, stated on 4/3/24 and 4/4/24 Resident #1 seemed her normal self. Resident #1 was talkative and stated her stomach felt hard and bigger. Staff J stated Resident #1's abdomen was very distended. Staff J stated Resident #1 had a medium bowel movement noted in her brief on the morning of 4/3/24 and a small bowel movement during a transfer on the morning of 4/4/24. According to the Prehospital Care Report (Emergency Medical Services (EMS) dated 4/5/24, EMS was on scene at 2:22 p.m. They were dispatched on report of a resident (Resident #1) being cold and clammy with depressed oxygen and blood pressure levels. Resident #1 was lying in bed, supine with a c-collar on. Staff report resident was alert and oriented and acting her normal self at breakfast this morning. Staff reports placing Resident #1 on oxygen at 2 liters per minute per nasal canula. Resident #1 is unresponsive, breathing normally, but oxygen saturation is at 67% when removed from oxygen. Resident #1 is cool and clammy. Hands and feet are purple in color. Resident #1 is hypotensive, eyes fixed and not responsive. Placed on a gurney and oxygen added at 10 liters per minute. According to the hospital Emergency Department (ED) Provider Note dated 4/5/24, Resident #1 was brought in for evaluation and was unresponsive and showing signs of mottling in her extremities. Resident #1 was felt to be in the dying process. Resident #1 was dramatically hypotensive, possible septic and mildly hypoxic. ED Course: It was decided given her current picture that comfort measures would be most appropriate, and these were initiated, but she ended up passing away in the ER.

Based on resident and staff interviews, the facility failed to provide an effective rodent control program within the facility. The facility reported census was 44 residents. Findings include: In an interview on 4/18/24 at 10:40 a.m. Staff N, Housekeeper, stated she has worked at the facility for three months and during that time mouse infestation has been an on-going issue. Staff N stated she had observed multiple mice in resident rooms and frequently sees droppings when sweeping. Staff N stated just today she swept up mouse droppings in room [ROOM NUMBER] on B-hall. Staff N stated they are to check the glue traps daily, but noted it had been so bad the mice are chewing on the traps and don't seem to be sticking to the glue. Staff N stated the residents in room [ROOM NUMBER] and 113 on B-hall have both complained about seeing mice in their room. Staff N stated she heard an aide, Staff M, witnessed seeing a mouse on the lap of a resident in room [ROOM NUMBER] on B-hall. In an interview on 4/18/24 at 1:30 p.m. Staff M, Certified Nurse Aide, stated a couple of weeks ago, she witnessed a mouse on the lap of a resident sitting in his room. In an interview on 4/18/24 at 11:00 a.m. Staff O, Housekeeping Supervisor, stated she had worked at the facility for several years and recently returned and had never seen the mice like they have seen this year. Staff O stated in early February they began seeing mice and contacted their pest control provider. The provider placed poison on the exterior of the building and glue traps were provided for the interior. Staff O stated initially they were catching 5-7 mice a day, mostly on B-hall. It has since slowed down. Staff O stated some of the issue is related to room [ROOM NUMBER]. The resident has food brought in, trash on his floor, and will not allow housekeeping in to clean his room routinely. In an interview on 4/18/24 at 10:20 a.m. Staff P, Dietary Supervisor, stated in the last month she had a couple of dietary staff see mice in the kitchen area. Staff P stated she had also seen mouse droppings near the storage shelves and kitchen. Staff P stated about six weeks ago she saw a mouse in the break room and reported her concerns to their maintenance and housekeeping supervisor and was provided glue traps. Staff P stated she removed the food from the bottom shelf and has placed several glue traps in the kitchen area. During an observation and interview on 4/18/24 at 10:50 a.m. Resident #4 (room [ROOM NUMBER]) was sitting up in his recliner with the TV on. Resident #4 stated he sees mice in his room all of the time and the staff does nothing about it. Resident #4 was agitated. A Minimum Data Set (MDS) completed 3/8/24 noted Resident #4 with a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognitive status. During an observation and interview on 4/18/24 at 10:40 a.m. Resident #5 (room [ROOM NUMBER]) was lying on his bed. There was a noticeable odor in the room and the door was covered with trash, boxes, and belongings. Resident #5 stated he often hears and sees mice in his room. A Minimum Data Set completed 3/8/24 noted Resident #5 with a Brief Interview for Mental Status score of 13 out of 15, indicating an intact cognitive status.

Based on the clinical record review, staff interviews, and facility policy review, the facility failed to implement a Legion Water Management Program. The facility reported a census of 47 residents. Findings include: During an interview on 2/13/24 at 10:24 AM, Staff Q, Maintenance queried on documentation for water temperatures and he stated the water heaters only went up to 110 degrees. Staff Q stated he only visualized the temperatures and never documented them. When asked Staff Q what he did for Legion, he stated no one spoke to him about Legion. Staff Q stated he received a policy from another facility a couple of days ago. When asked Staff Q what he did when rooms vacant, he stated he checked them out before someone moved into them. The Legion Map Surveillance (no date identified) revealed the following information: a. where the water located b. the direction of the water flow c. where the water heaters located The Legion Map Surveillance lacked documentation of where showerheads, hoses, fountains, and filters located. The facility lacked documentation for locations of possible water stagnation and inadequate disinfection. The facility lacked documentation for water temperature fluctuations or water temperature changes. The facility lacked documentation on specific measures to control the introduction or the spread of Legion. During an interview on 2/13/24 at 10:24 AM, when asked Staff Q for a map of the water system and areas for possible stagnation of water, he stated they didn't have a map that he was aware of and the recirculation pumps worked. Staff Q stated they didn't have a diagram of the pipes they just went down the halls and the water heaters set at a certain temperature so they only went so high. During an interview on 2/14/24 at 2:10 PM, the Director of Nursing (DON) queried on how they assessed for Legion and she stated she knew she was supposed to. When asked the DON if they did anything for Legion, she stated not they didn't. When asked the DON if they tested the water for Legion or other water-borne pathogens and she stated the maintenance man would know if they did, but she didn't know. The Facility Legion Water Management Program Policy dated 7/2017 revealed the following information: a. The water management team consist of at least the following personnel: 1. The Infection Preventionist 2. The Administrator 3. The Medical Director 4. The Director of Maintenance 5. The Director of Environmental Services b. The purpose of the water management program were to identify areas in the water system where Legion bacteria could grow and spread, and to reduce the risk of Legionnaire's disease. c. The water management program included the following elements: 1. An interdisciplinary water management team 2. A detailed description and diagram of the water system in the facility, including the following: aa. receiving; bb. cold water distribution; cc. heating; dd. hot water distribution; and ee. waste 3. The identification of area in the water system that could encourage the growth and spread of Legion or other waterborne bacteria, including: aa. storage tanks; bb. water heaters; cc. filters; dd. aerators; ee. showerheads and hoses: ff. misters, atomizers, air washers and humidifiers; gg. hot tubs hh. water fountains; and ii. medical devices such as CPAP (continuous positive airway pressure) machines, hydrotherapy equipment, etc. 4. The identification of situations that can lead to Legion growth such as: aa. construction; bb. water main breaks; cc. changes in municipal water quality dd. the presence of biofilm, scale or sediment; ee. water temperature fluctuations; ff. water pressure changes; gg. water stagnation; hh. inadequate disinfectant 5. Specific measures used to control the introduction and/or spread of Legion (example: temperature, disinfectants) 6. Control limits or parameters acceptable and monitored 7. A diagram of where control measures applied; 8. A system to monitor control limits and the effectiveness of control measures; 9. A plan for when control limits not met and/or control measure not effective; and 10. documentation of the program.

Based on observations, policy review, and staff interviews the facility failed to prepare foods under sanitary conditions for 1 of 2 days of kitchen observation. The facility reported a census of 47 residents. Findings include: On 2/13/24 at 11:15 AM observed Staff F, Dietary, put her hand in her left pocket and take out a pen and a marker while wearing a serving glove. She wrote on the foil covering a pan of hot food. Still wearing the glove, Staff F placed the marker back in her left pocket. She then picked up a pan of rice with her gloved hand and her bare right hand. She opened the oven with her bare right hand and placed the pan in the oven. She picked up another pan her gloved hand and opened a drawer with her her right hand. Staff F then picked up cooked chicken pieces with the same glove and put them in another pan. She covered the pan with foil and carried it to the stove. Staff F then threw the glove away and used hand sanitizer. She then put her hand back in her pocket and took out a marker which she used to label more tinfoil. She put her left hand back in her pocket with the marker. Staff F picked up a piece of paper and 3 pans and the paper rested against the lip of one pan. She held the bottom of another pan against her clothing while carrying it to the sanitized counter. She failed to use soap and water hand hygiene during this observation. At 11:48 AM Staff F collected a package of spaghetti from dry storage and carried it to the counter by holding it against the front left side of her shirt. On 2/13/24 at 11:25 AM observed Staff G, Dietary, picked up the lid to the garbage can with her left hand to dispose of a piece of plastic wrap. She then reached over to pick up a bowl of pureed food to place it in the microwave. She picked up the thermometer with her left hand to temp the pureed food. She failed to use soap and water hand hygiene between touching the garbage can lid, the bowl of food, and the thermometer. On 2/13/24 at 11:57 AM observed Staff H, Dietary, leaned against a sanitized surface drinks were being served from. She labeled drinks with a black marker while she leaned forward with the front of her clothing touching the edge and the top surface of the island counter. The length of her bare left forearm also rested on the surface. Her right shoe rested on the surface of the lower shelf next to a box labeled potatoes. When Staff H moved on to the next task, the surface of the counter was not sanitized. 02/15/24 at 9:51 AM the Dietary Supervisor stated staff are trained at orientation on sanitation and cleaning expectations. It included proper procedure for dishes, clearing tables, hand hygiene, and charting. She provided an example of washing hands timed to the length it takes to sing happy birthday and stated she expected staff to wash their hands this way between kitchen tasks. She indicated they do not usually have the lid on the garbage. A policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised October 2017, documented employees must wash their hands before coming in contact with any food surfaces, during food preparation as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and after engaging in other activities that contaminate hands. The policy noted hand gel cannot be used in place of handwashing in the food service area. Gloves were considered single-use items that must be discarded after completing the task for which they were used and the use of disposable gloves did not substitute for proper handwashing.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to offer the influenza vaccine annually to 2 out of 5 residents reviewed; and failed to offer the pneumococcal vaccine at recommended times to 4 out of 5 residents reviewed for influenza and pneumococcal vaccinations (Resident #1, #2, #4, #24). The facility reported a census of 47 residents. Findings include: 1. The Preventative Health Care Report revealed the following information for Resident #4: a. pneumococcal vaccine administered 9/4/20 from an outside source. The Iowa Registry Immunization Record revealed resident received the Pneumococcal 23 on 9/4/20. The IRIS revealed 1 of 2 dose series. The facility lacked documentation of consent or declination forms for Resident #4 for the pneumococcal vaccine. 2. The Preventative Health Care Report revealed the following information for Resident #2: a. Influenza administered on 11/8/22 The facility consent form for influenza and pneumococcal signed on 11/8/22 by Resident #2 revealed resident consented for influenza and pneumococcal vaccinations. The facility lacked documentation for a pneumococcal vaccine offered or administered to the resident. 3. The Preventative Health Care Report revealed the following information for Resident #24: a. pneumococcal vaccine administered on 12/2/18 from an unknown source The facility consent form for influenza and the pneumococcal vaccine signed on 11/1/22 for Resident #24 revealed consent for both the pneumococcal influenza vaccine. The facility lacked documentation the pneumococcal vaccine offered or administered to Resident #24 in 2023. 4. The Preventative Health Care Report revealed the following information for Resident #1: a. influenza vaccine administered on 12/15/22 b. pneumococcal vaccine refused on 11/10/21 The facility consent/declination form revealed Resident #1 refused the pneumococcal vaccine on 11/1/22. The facility lacked documentation the influenza or the pneumococcal vaccinations offered to Resident #1 in 2023. During an interview on 2/14/24 at 2:10 PM, the Director of Nursing (DON) queried on how they track vaccines and she stated they received a report from IRIS. When asked the DON how often they offer the pneumococcal vaccine, she stated they didn't do the pneumococcal vaccines at the facility. She stated the clinic kept track of them and when someone received a vaccine it was uploaded to IRIS. She stated the pharmacy let them know who needed the vaccine. During an interview on 2/14/24 at 2:10 PM, when asked the DON how often influenza vaccines offered, she stated over time the pharmacy comes in and did the flu vaccine clinic. When asked the DON about consent and declinations for the flu vaccines, she stated the pharmacy kept the consents for them. The Facility Influenza and Pneumococcal Vaccine Policy reviewed on 6/8/22 revealed the following information: a. All residents admitted to the facility screened to determine if they current on adult immunizations. Documentation of the resident's immunization status maintained in the medical record. Consent for annual vaccination obtained from resident or family member at the time of admission or anytime afterwards. b. Any resident admitted to our facility after medical clinics have done influenza vaccinations will be offered the influenza vaccine unless documented they already received vaccine for that year or documented contraindication. c. Pneumococcal immunization status will be determined on admission regardless of date. Vaccination provided by medical clinics.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to notify a resident's responsible party and hospice provider in a timely manner when an injury occurred for 1 of 3 residents reviewed (Resident #46) for notification. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) for Resident #46 dated 1/5/24 indicated a significant change related to a decline in health and the start of hospice care. It included diagnoses of heart failure, post traumatic stress disorder, and chronic obstructive pulmonary disease. The Brief Interview for Mental Status documented a score of 7 which indicated severe cognitive impairment. The Care Plan with a care conference date of 12/7/23 documented impaired decision making and a history of falling related to dementia with a hospice consult on 12/28/23. On 2/12/24 at 1:07 PM observed the resident finished meeting with a hospice provider and laying in bed. Resident #46 stated his knee hurt. He pulled up the bottom of his covers and pant leg to show an open wound about the size of a dime on his knee. The wound appeared moist and there was dried blood on 3 separate sections of the sheet similar in size to the wound. The resident also had a wound to his right eye near his eyebrow. On 2/12/24 at 1:11 PM Staff I, RN, stated she was not aware of the injury to the resident's knee and didn't know if it was related to the eye injury. A hospice document titled Hospice IDG Comprehensive Assessment and Plan of Care Update Report faxed on 2/9/24 indicated symptoms being managed for the resident included pain and falls, and safety concerns included risk for falls. The Progress Note dated 2/12/24 at 3:00 AM documented Resident #46 attempting to get out of bed when the nurse entered the room. He went to the bathroom alone and staff observed him using the toilet. The nurse noted the resident had blood in the bed, all over face and hands, and a small amount on the floor. A 2 cm x .2 cm laceration was noted on the resident's right eyebrow with mild purple bruising. The resident was unable to state the cause. Care provided and the provider notified. The note failed to indicate notification of family or hospice. The Progress Note dated 2/12/24 at 3:34 PM noted blood on the resident's sheets. The resident had a skinned knee. When he pulled the sheets back it caused the sore to bleed. Care provided and the provider notified. The note failed to indicate notification of family or hospice. An untitled document used to track wound treatment, dated 2/12/24, documented communication to the Director of Nursing (DON) regarding the eye injury. It failed to include notification of the family or hospice. The facility failed to create a skin document for the knee injury. On 2/15/24 at 11:31 AM the DON stated staff should initiate neurological assessments for unwitnessed incidents. Staff should contact a responsible party, the provider, and in this case hospice. On 2/19/24 at 12:26 PM the DON confirmed by email that she was unable to find anything that documented the resident's wife was notified of the incident(s) leading to injury on 2/12/24. An undated policy titled Falls documented the charge nurse, DON, and Administrator are responsible for falls. The policy ensured a thorough assessment was completed and appropriately documented with interventions to prevent future falls. Procedure #6 specified to notify the physician and family.

Based on clinical record review, policy review, facility document review, and staff interviews, the facility failed to ensure a resident was free from physical abuse for 1 of 2 residents reviewed for abuse (Resident #38). The facility reported a census of 47 residents. Findings include: The facility policy Abuse, revised 8/31/16, stated the facility would not permit residents to be subjected to abuse by any person and defined abuse to include willful infliction of injury. The Minimum Data Set (MDS) assessment tool, dated 12/1/23, listed diagnoses for Resident #38 which included hypertension, depression, and hyperlipidemia (a high level of fat in the blood). The MDS stated the resident required partial to moderate assistance for bathing, dressing, and personal hygiene. The MDS stated the resident had physical behavioral symptoms directed toward others such as hitting and kicking 4-6 days during the 7 day review period and displayed rejection of care daily. The MDS listed the resident's cognition as severely impaired. Care Plan entries, dated 12/7/23, documented the resident often became aggressive during cares and directed staff to use a calm voice and reassure her staff was taking care of her. A 12/27/23 written statement by Staff M Certified Nursing Assistant(CNA) stated she and Staff N CNA walked Resident #38 into the shower room and asked her to start getting undressed. The resident started fighting and hit Staff N and attempted to bite both Staff N and Staff M. Staff N told the resident that was not nice and smacked the resident on the head. Staff N immediately apologized to the resident. Staff M then assisted the resident with showering while Staff N left the immediate area. On 2/12/24 at 2:00 p.m., Staff M CNA stated on the day of the incident the resident tried to bite Staff N and Staff N hit her with an open hand and after Staff N said oh my God, I am so sorry. Staff M stated the hit was on the upper forehead and hair and made a smack sound when it happened. Staff M did not see any redness to the area and stated she reported this to the Director of Nursing (DON) and Staff N was subsequently fired. On 2/13/24 at 10:00 a.m., Staff N CNA stated that she and Staff M CNA tried to get the resident's clothes off prior to a shower and the resident hit her on the arm multiple times. Staff N stated she hit the resident on the top of her head and described it as between a tap and a hit. She stated this was an immediate reaction and she felt frustrated. She stated the hit did not make a noise and did not cause any redness or bruising. She stated the hit was on the top of the resident's head on her hair. Staff N stated she never hit her before and she was very sorry this all happened. On 2/19/24 at 2:08 p.m., the DON stated on the day of the incident a CNA reported that the resident bit Staff N and Staff N bopped her on the head. The DON stated she and the Administrator then assessed the resident and pulled Staff N off the floor. The DON stated she expected staff to treat residents with kindness, respect, and patience. On 2/19/24 at 3:27 p.m., the Administrator stated regarding the incident that Staff N did not deny that she hit Resident #38. She stated they removed Staff N from the unit. An undated written statement by the DON stated Staff N was immediately relieved of her duties at the time of the incident.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to honor a resident's food and beverage preferences for 1 of 16 residents reviewed during dining services (Resident #1). The facility reported a census of 47 residents. Findings include: The facility policy Resident Food Preferences, revised July 2017, stated individual food preferences would be assessed upon admission and communicated to the interdisciplinary team and the Food Services Department would offer a variety of foods at each scheduled meal. The Care Plan approach dated 1/27/22 directed staff to encourage fluids throughout the day. The Minimum Data Set (MDS) assessment tool, dated 11/24/23, listed diagnoses for Resident #1 which included cerebrovascular accident(stroke), schizophrenia, and hypertension(high blood pressure). The MDS stated the resident was independent with eating and listed her Brief Interview for Mental Status(BIMS) score as 5 out of 15, indicating severely impaired cognition. On 2/13/24 at 8:30 a.m., observed the resident sitting at the breakfast table and she asked Staff E Certified Nursing Assistant(CNA) what was in one of her bowls and Staff E stated it was oatmeal. The resident stated she did not like oatmeal and Staff E told the resident she also had eggs. Staff E did not offer to bring the resident another breakfast item. At 8:34 a.m. observed Staff J CNA sit down at the table and the resident stated that she wanted a cup of coffee. Staff J smiled at the resident but did not provide her with a cup of coffee. The resident then took a bite of her eggs but said it was too hot and Staff J told the resident she also had oatmeal. The resident stated she did not like oatmeal. Staff J did not offer the resident an alternative to the oatmeal and the resident ate only eggs for her breakfast meal. On 2/14/24 at 9:54 a.m., observed the resident sitting in an activity and drinking coffee. On 2/19/24 at 2:08 p.m., the Director of Nursing(DON) stated if a resident did not like her meal, staff would offer them something different.

Based on record review and interview, the facility failed to provide an intervention of an advance directive for 1 resident who requested CPR (Cardiopulmonary Resuscitation)(Resident # 12). and failed to clearly identify the code status for 3 of 13 residents reviewed (Residents# 1, 4 and, 13). The findings constitute an immediate jeopardy to residents health and safety. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated [DATE], listed [DIAGNOSES REDACTED]. The MDS stated the resident required limited assistance of 1 staff for dressing, extensive assistance of 1 staff for bed mobility, extensive assistance of 2 staff for bathing, depended totally on 1 staff for personal hygiene, and depended totally on 2 staff for toilet use. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A [DATE] Advance Directives/Medical Treatment Decisions form revealed the resident checked the box stating, I do not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and I want life-sustaining treatment to be provided. The resident's physician order [REDACTED]. The resident's care plan, last dated [DATE], stated the resident was a Full Code. Nursing notes, dated [DATE], stated the nurse entered the resident's room at 9:55 p.m., found the resident expired, and contacted the physician to obtain an order to release the body. The notes lacked documentation of a resident assessment and lacked documentation of CPR initiation. An undated facility document entitled Death directed staff to verify the resident's code status on the door/chart and if no sticker present, check the advance directive tab in the chart. The facility Resuscitation Policy, dated [DATE], stated: 1. Upon determination that a resident is in cardiopulmonary or respiratory arrest(note the time), CPR will be immediately initiated by nursing staff and 911 called for advanced cardiac life support unless one of the exceptions applies: a. When the resident or surrogate has indicated that resuscitation is not desired and the attending physician has issued a written do not resuscitate(DNR) order that is maintained in the facility's clinical record ; or b. When there is the presence of obviously clinical signs of irreversible death(defined as rigor mortis or dependent lividity); or c. When attempts to perform CPR would place the rescuer at risk of personal injury. Staff D's employee file lacked any documentation specific to education related to how staff determined the code status of residents. During an interview on [DATE] at 8:39 a.m., Staff E CNA(Certified Nursing Assistant) stated on the night the resident passed away, she helped him/her change his/her gown around 6 or 7 in the evening. She was not sure of the time but stated later in the evening Staff F found the resident expired. When Staff E entered the resident's room, the resident was sitting in his/her wheelchair slumped over with his/her face on the bed. There was a brownie on the floor and the resident had some brownie on his/her lips. Staff E stated the resident was still kind of warm but his/her lips were purple. She stated another staff member had given the resident a brownie for snacks earlier that evening but she did not know who the staff member was. She stated after finding the resident expired, she informed Staff D LPN(Licensed Practical Nurse). Staff D came to the resident's room and checked his/her vitals and determined he/she was gone. Staff D then instructed Staff E to begin post-mortem cares. Staff E stated she did not observe Staff D initiate the [MEDICATION NAME] maneuver, chest compressions, or rescue breathing. During an interview on [DATE] at 10:54 a.m., Staff F CNA stated she did not remember if she was the person who found the resident expired and stated she didn't remember anything about the event. During an interview on [DATE] at 11:54 a.m., Staff E stated when she helped transfer the resident from the wheelchair to bed after the resident expired, the resident did not feel cold and felt limp, not stiff. She stated the resident still had color in the arms and legs and stated she didn't remember Staff D stating anything about initiating CPR. During an interview on [DATE] at 10:45 a.m., Staff D LPN stated on the night of the resident's death, Staff F informed her the resident passed away. When she went into the room the resident was obviously deceased . She stated he/she was not moving or breathing and was pale and cool to the touch. She stated she did not specifically remember if she listened to heart sounds but stated this was her usual practice. She stated she thought the resident was a DNR(Do Not Resuscitate) and information regarding code status was located in the chart. During an interview on [DATE] at 11:30 a.m., Staff D stated on the night the resident expired she did not remember looking at any documents to determine the resident's code status. She stated after she checked the resident's vitals, she called the ADON(Assistant Director of Nursing). She couldn't remember but thought the ADON told her the resident was a DNR and to begin paperwork. She stated when she assessed the resident she didn't believe he was stiff yet. During an interview on [DATE] at 9:15 a.m., Staff I LPN stated doors have red and green dots to indicate DNR and Full Code status. He stated he did not know how he would determine a resident's code status if he were not near the resident's room but stated he would call for help and begin chest compressions if they were a Full Code. During an interview on [DATE] at 9:30 a.m., the Administrator stated the facility had stickers on the charts to indicate code status. She stated if not near the chart, staff would run to the chart to view the status. She stated with regard to Resident # 12, she feels the nurse should have had better documentation. She stated if a resident was blue but warm to the touch, she would expect staff to start CPR because one wouldn't know if the resident was blue due to choking or not. 2. The MDS assessment tool, dated [DATE], listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for walking in the room and bathing, extensive assistance of 2 staff for bed mobility, transfers, walking in the hall, and toilet use, and depended totally on 1 staff for personal hygiene. The MDS listed the resident's cognition as severely impaired. The resident's [DATE] Advance Directives/Medical Treatment Decisions form stated the resident chose DNR status. The resident's current physician's orders [REDACTED]. 3. The MDS, dated [DATE], listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for bathing, extensive assistance of 2 staff for dressing, depended totally on 1 staff for personal hygiene, and depended totally on 2 staff for bed mobility, transfers, and toilet use. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The resident's [DATE] Advance Directives/Medical Treatment Decisions form stated the resident chose DNR status. The resident's current physician's orders [REDACTED]. 4. The Quarterly MDS with an assessment reference date of [DATE] documented both long and short term memory loss issues with severely impaired decision-making for Resident #13. [DIAGNOSES REDACTED]. The plan of care updated last on [DATE] documented the resident as a Full Code at the top of each page. The Resident Face Sheet documented Resident # 13 as a Full Code under Advanced Directives. The Face Sheet noted the admitted as [DATE]. The latest physician's orders [REDACTED]. Under General flow sheet at the bottom of the first page of the POS, code status is No Code as of [DATE]. An observation of the nameplate on the wall outside of Resident # 13's room on [DATE] at 1:50 P.M., displayed a red dot by the resident's name. The Administrator verbalized a red dot signified Do Not Resuscitate, while a green dot signified a Full Code. Facility documentation revealed 21 residents with a Full Code status. The facility abated the IJ on [DATE] when they completed the following: The DON reviewed the discrepancies notes and all those found incorrect, were corrected to reflect the residents' wishes as outlined in their Advance Directive. The Advance Directive are discussed upon admission and then quarterly at care plan conferences to maintain the current and correct wishes of the resident, resident family and or resident's representatives. Upon admission, the advance directive will be discussed with the resident, the resident's family and or the resident's representative by the admitting nurse. The wishes noted on the Advance Directive will be noted with a red or green sticker, respective to those wishes, on the chart and also on the name plate by the same admitting nurse. The same admitting nurse will also review the physician's orders [REDACTED]. The Director or Nursing, social Worker and QA nurse were educated to this change on [DATE]. Upon any changes after admission, the Social Worker will have the resident's advance Directive update with signatures and will place new stickers on the chart and name plate to alert staff of the changes in the resident's in the wishes of the resident, resident's family and or resident representatives. The physician's orders [REDACTED]. This will be monitored by the QA nurse for consistency within 24 hours of the change. The Social Worker, Director of Nursing and QA nurse were educated to this on [DATE]. A Resuscitation Policy was written on [DATE] by the DON and Administrator. The DON and Administrator also reviewed the Policy with all nursing staff and obtained signed acknowledgements for staff present; and staff not present were counseled via telephone and verbalized an understanding. These actions lowered the scoped and severity from a K to a D level with the need for ongoing monitoring of all the prior.

Based on record review, facility policy, and interviews the facility failed to ensure one (1) of five (5) residents remained free of abuse. Concerns identified for Resident #5. The facility reported a census of 56 residents. Findings include: The Abuse Prevention, Identification, Investigation and Reporting Policy dated 12-21-16 identified all residents had the right to be free from abuse by anyone, including, but not limited to, facility staff. The policy indicated Abuse is defined under Federal regulations as the willful intimation or punishment with resulting mental anguish. The policy revealed instances of abuse (pertained to) all residents, irrespective of any mental or physical condition, causing physical pain or mental anguish. The policy defined mental abuse as not limited to humiliation, harassment, threats of punishment; and mistreatment meant inappropriate treatment of [REDACTED]. Examples of verbal abuse included threats of harm and saying things to frighten a resident. According to the Face Sheet Resident #5 had [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment dated [DATE] Resident #5 had severe cognitive impairments. Resident #5 had fluctuating inattention and disorganized thinking behaviors. Resident #5 had physical, verbal and other behaviors. The MDS dated [DATE] revealed Resident #5 required extensive assistance with bed mobility and transfers. The Plan of Care revealed Resident #5 enjoyed playing with baby dolls. The Plan of Care directed the staff to assess whether behaviors endanger Resident #5 or others, intervene if necessary, avoid over stimulation, maintain calm environment, maintain a slow, calm and understandable approach. The care plan directed staff to place Resident #5 in specially designated therapeutic unit, give anxiety medication 1 hour before shower, when socially inappropriate/disruptive, move to a quiet, calm environment, away from other residents, when socially inappropriate. The care plan directed staff to assess Resident #5 for pain and transfer with assist of one to two staff with a gait belt. The facility timely self- reported an allegation of abuse that occurred on 2/27/17 at 7:30 a.m. between Staff D and Resident #5. Staff D, Certified Nurse Aide (CNA) reportedly threatened to hit a combative resident if they didn't stop. An interview on 3/2/17 at 10:25 a.m. Staff B reported she heard Staff D yelling at Resident #5 from the dining room. Staff D stepped to the edge of the dining room. Staff B reported Staff D was in Resident #5's room. Staff B heard Staff D state, I swear to god if you hit me, I will (expletive) punch you back. An interview on 3/2/17 at 11:30 a.m. Staff C reported he/she delivered laundry to Resident #5's room and Staff D was assisting Resident #5 when he/she entered the room. Resident #5 was hitting and swatting Staff D. Staff D told Resident #5 to knock it off and to quit hitting her. Staff D threw Resident #5's baby doll to the opposite side of the room. Staff C reported Resident #5 had a scared look on his/her face when Staff D threw his/her baby doll. Staff C reported after Staff D threw the doll, Resident #5 cooperated with cares. Staff C reported Staff D walked over to the closet and told Staff C he/she hated old people. An interview on 3/1/17 at 1:30 p.m. Staff A reported the door to Resident #5's room was open. Staff A observed Staff D attempting to dress Resident #5 and Resident #5 was resistive. Staff A heard Staff D state to Resident #5, I swear to god if you claw me, I will (expletive) hit you and I will take your (expletive) babies. Staff A reported Resident #5 thinks the baby dolls are real and cares for them. During an interview with Staff D, on 3/2/17 at 1:00 p.m., she reported Resident #5 had been combative during cares. Staff D admitted she got frustrated and told the resident she would take his/her doll if the resident continued to hit her again. Staff D acknowledged she did throw the resident's doll and it slid to the roommate's side of the room. Staff D denied saying she would hit the resident or cursing at the resident. During an interview with Staff E, CNA on 3/2/17 at 1:50 p.m., she reported Resident #5 gets combative with staff and they should call another staff for help or re-approach later ensuring the resident is safe first. Staff E reported Staff D can be rude to residents. Staff E reported examples as follows: Staff D checked a resident and reported out loud, she's full of (expletive). Staff E reported another incident when Staff D did not want to assist with feeding a resident from the B dining room, and stated she was not here to baby people. An interview on 3/2/17 at 4:31 p.m. the Administrator reported the facility has a zero tolerance for abuse. The Administrator reported the staff immediately reported the allegation and terminated Staff D. The Administrator reported Staff D had abuse training on hire, dignity training on 1/20/17, 6 hour dementia training on 2/16/17 and resident's rights training on 2/18/16. A reasonable person would likely feel verbal/mental abused, feel humiliated and or fearful, if a person threated to harm them; and threw their personal possession across the room.

Based on record review, hospital records, and interviews, the facility failed to provide the goods and services necessary to avoid physical harm for 1 of 8 residents. Resident #1 did not receive safe transfers on two occasions which resulted in a fractured elbow and bumping his/her head. The facility reported a census of 60 residents. Findings include: The facility Abuse dated 11/5/99 documented the facility will investigate all allegation of resident abuse including neglect. The procedure documented residents will not be subjected to abuse by any person including staff members and defined abuse by care taker of the good and services that are necessary to attain or maintain physical well-being. The identification section to prevent an abuse situation included the following: repeated injuries & injury incompatible with explanation. 1. The annual Minimum Data Set Assessment ((MDS) dated [DATE] identified Resident # 1 with a BIMS (Brief Interview for Mental Status) which indicated moderately compromised cognitive function related to daily decision making skills. The MDS indicated the resident required limited assistance of staff all activities of daily living (ADL) including transfers, toileting, dressing, eating, personal hygiene and bathing. The MDS indicated the resident required a wheelchair propelled by staff for mobility. The MDS indicated the resident [DIAGNOSES REDACTED]. The resident's Care Plan with a goal date of 05/26/16 noted the resident limited in wheelchair related to weakness and impaired mobility. The staff were instructed to provide assistance of one to two staff with a gait belt for toileting and transfers. A fall risk assessment dated [DATE] indicated a score of 15 that indicated the resident to be a high fall risk. Nursing Notes dated 3/2/16 at 10:15 p.m., documented Resident #1 fell to the floor when a CNA (Staff F) had been transferring the resident to bed when the resident ' s feet got tangled up. Resident #1 fell to the floor and hit his/her head on the TV stand. The notes documented no injuries noted. The incident report noted steps to prevent reoccurrence was to provide education to Staff F on transfers and resident foot placement. The Nursing notes dated 04/03/16 at 8:30 a.m. Staff E, License Practical Nurse (LPN) stated she had been walking by the resident's room and heard the resident hollering, went into the room. Staff E observed the resident sitting on the floor next to the toilet in the bathroom with a CNA (Staff F) standing behind the resident. The CAN (Staff F) stated she was transferring the resident from the toilet to wheelchair, resident had not been standing well and lowered to the floor. An Incident report dated 04/03/16 at 8:30 a.m. noted a CNA (Staff F) assisted Resident #1 from toilet to wheelchair. The CNA (Staff F) stated the resident not standing well and lowered to the floor. The resident denied hitting head, complained upper arm pain. The incident report noted steps to prevent reoccurrence was to provide two assistance with gait belt with transfers. The Nursing Home To Hospital Transfer form dated 4/3/16 revealed the reason for the transferred as follows: lowered to the floor; complaint of right increasing arm pain. The nursing home documented the resident ' s mental status as alert, oriented and follows instructions. The resident's usual functional status listed Resident #1 as non-ambulatory with a fall risk. The resident had been transferred from Hospital A to Hospital B for distal humerus fracture after a mechanical fall on 4/3/16. The resident reported at Hospital A the staff weren ' t holding him/her while he/she was going to the bathroom and fell . The Hospital B Demographics Summary documented the following: the x-ray of the elbow revealed a distal humerus fracture. The location of the fracture with the history provided, as well as the resident's initial statement of they weren't holding me was concerning for possible elder neglect by the current (nursing home) facility. The report documented the type of dependent adult abuse as denial of critical care by caretaker, failure to provide adequate medical care and proper supervision. The hospital report documented the nursing home LPN Staff E reported Resident #1 had been transferred from toilet to wheelchair and the resident's legs gave out or became weak at which time the resident began to fall. During the fall, Staff E reported the staff had a hold of Resident #1 the entire time underneath his/her arms, and lowered the resident to the ground to sit on his/her bottom with legs in front. The physician summary documented the physician felt this is abuse because: the facility description of the incident does not included any information regarding how the right humerus fracture may have been obtained. The physicians do not feel that the injury is in line with the description regarding the incident. The report identified two physicians were involved in the decision. On 04/18/16 at 10:00 a.m. Staff E stated when she heard the resident's room she noted the resident did not have a gait belt on. She stated Staff F, CNA told her she had been transferring the resident from the toilet to wheelchair when the resident got weak and couldn't stand so she had to lower the resident to the floor. On 04/19/16 at 3:30 p.m. Staff F, Certified Nurse Aide, CNA stated she assisted Resident #1 to stand by placing his/her left arm under the resident's left arm and proceeded to complete peri-care with her right hand. She stated the resident became weak and started to go down. She stated she placed her right arm under the resident's right arm to control the fall. She stated she did not see the resident strike his/her arm when going down. She stated the resident landed on his/her bottom with feet toward the sink, and leaning against the CNA. When asked why she had not used a gait belt on the resident per the care plan, Staff F stated she had forgotten her gait belt at home, and had no reason to think the resident would not be steady so decided to transfer the resident without. On 04/19/16 at 4:00 p.m. the Director of Nursing stated she would have expected the staff to use a gait belt if the resident had been care planned for staff to use one. She stated she would have expected the staff to obtain another gait belt if she did not have her own. The facility updated the resident' s care plan on 4/3/16 for two (2) staff to transfer the resident with gait belt; however this intervention had been discontinued on 4/5/16. On 4/5/16, staff would transfer the resident with 2 assist with a Hoyer (mechanical lift) at all times. During an interview with Resident #1 on 4/14/16 at 9:30 a.m., he/she stated on the day he/she fell , staff had taken him/her to the bathroom and she tried to stand up by pulling him/her self up holding on the sink. Resident #1 reported he/she stuck his/her elbow and did not recall how it occurred. Resident #1 reported someone (staff) had been with him/her. Resident #1 reported she did not recall if staff had used a gait belt and reported staff seldom used a gait belt when helping him/her to walk or for taking him/her to the bathroom. Resident #1 reported he/she did not want to get someone in trouble and stated staff do help him/her when he/she needs it.

Based on record review, hospital records, and interviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #1). The facility reported a census of 60 residents. Findings include: The annual Minimum Data Set Assessment ((MDS) dated [DATE] identified Resident # 1 with a BIMS (Brief Interview for Mental Status) which indicated moderately compromised cognitive function related to daily decision making skills. The MDS indicated the resident required limited assistance of staff all activities of daily living (ADL) including transfers, toileting, dressing, eating, personal hygiene and bathing. The MDS indicated the resident required a wheelchair propelled by staff for mobility. The MDS indicated the resident [DIAGNOSES REDACTED]. The resident's Care Plan with a goal date of 05/26/16 noted the resident limited in wheelchair related to weakness and impaired mobility. The staff were instructed to provide assistance of one to two staff with a gait belt for toileting and transfers. The staff were instructed to provide a wheelchair for mobility with assistance of one, to keep call light in reach at all times and provide a clutter free environment. A fall risk assessment dated [DATE] indicated a score of 15 that indicated the resident to be a high fall risk. Nursing Notes dated 3/2/16 at 10:15 p.m., documented Resident #1 fell to the floor when a CNA (Staff F) had been transferring the resident to bed when the resident ' s feet got tangled up. Resident #1 fell to the floor and hit his/her head on the TV stand. The notes documented no injuries noted. The incident report noted steps to prevent reoccurrence was to provide education to Staff F on transfers. An Incident report dated 04/03/16 at 8:30 a.m. identified a CNA (Staff F) assisted the resident from toilet to wheelchair. The CNA stated the resident not standing well and lowered to the floor. The resident denied hitting head, complained upper arm pain. The incident report noted steps to prevent reoccurrence was to provide two staff assistance with gait belt with transfers. According to the Nursing Notes dated 04/03/16 at 8:30 a.m. Staff E, LPN noted had been walking by the resident's room and heard the resident hollering, went into the room and observed the resident sitting on the floor next to the toilet in the bathroom with a CAN (Staff F) standing behind the resident. The CNA stated she was transferring the resident from the toilet to wheelchair, resident had not been standing well and lowered to the floor. Vital signs obtained and the resident complained of arm pain and refused to allow the nurse to assess the arm, and denied any other pain. The resident transferred to a wheelchair. The Radiology report noted an oblique fracture of the distal humeral metaphysis with mild apex anterolateral angulation, additional a 3 centimeter fracture fragment along the medial metaphysis, extensive soft tissue swelling. The facility policy for transferring a resident dated 12/20/1999 instructed the staff to: apply transfer belt to waist over clothing with enough looseness to insert two fingers under the belt. The staff were instructed to stand in front of the resident, grasp the gait belt on both sides, gently lift the resident and guide toward the goal. The policy instructed the staff when destination had been reached, gently lower and encourage the resident to use arms to reach toward destination and bear weight. Remove gait belt. On 04/18/16 at 10:00 a.m. Staff E stated when she heard the resident's room she noted the resident did not have a gait belt on. She stated Staff F, CNA told her she had been transferring the resident from the toilet to wheelchair when the resident got weak and couldn't stand so she had to lower the resident to the floor. Staff E stated the CNA did not tell her why she had not used a gait belt to transfer the resident. On 04/19/16 at 3:30 p.m. Staff F, CNA stated they were taking residents back to their rooms from breakfast. She stated another staff had taken Resident #1 back to his/her bedroom and placed the resident on the toilet. She stated the resident had pulled the call light string so she went into help the resident. She stated she assisted the resident to stand by placing his/her left arm under the resident's left arm and proceeded to complete peri-care with her right hand. She stated the resident became weak and started to go down. She stated she placed her right arm under the resident's right arm to control the fall. She stated she did not see the resident strike his/her arm when going down. She stated the resident landed on his/her bottom with feet toward the sink, and leaning against the CNA. When asked why she had not used a gait belt on the resident per the care plan, Staff F stated she had forgotten her gait belt at home, and had no reason to think the resident would not be steady so decided to transfer the resident without. Staff F stated in retrospect she should not have attempted the transfer without the gait belt. On 04/19/16 at 4:00 p.m. the facility Director of Nursing stated she would have expected the staff to use a gait belt if the resident had been care planned for staff to use one. She stated she would have expected the staff to obtain another gait belt if she did not have her own. During an interview with Staff I, CNA on 4/19/16, at 9:08 a.m., she reported Staff F is a tiny staff person and based on Resident #1 ' s size, she would not have tried to transfer the resident alone. Staff I stated Staff F should have asked for assistance, however they were so busy. During an interview with Resident #1 on 4/14/16 at 9:30 a.m., he/she stated on the day he/she fell , staff had taken him/her to the bathroom and she tried to stand up by pulling him/her self up holding on the sink. Resident #1 reported he/she stuck his/her elbow and did not recall how it occurred. Resident #1 reported someone (staff) had been with him/her. Resident #1 reported she did not recall if staff had used a gait belt and reported staff seldom used a gait belt when helping him/her to walk or for taking him/her to the bathroom. Resident #1 reported he/she did not want to get someone in trouble and stated staff do help him/her when he/she needs it.

Based on record review, facility policy, and staff interviews and review of the facility abuse policy/procedures, the facility staff failed to report resident to resident sexual exploitation by Resident #1 to the Iowa Department of Inspections and Appeals within 24 hours and immediately separate Resident #1 from all residents in the facility until investigated and determined abuse. The sample consisted of 4 residents involved (Resident #2, #3, #4). The facility reported a census of 63 residents. Findings included: 1. Resident #1 had an annual Minimum Data Set (MDS) assessment with a reference date of 01/01/16. The MDS identified the resident had a BIMs (Brief Interview for Mental Status) score of 12. A score of 12 identified the resident to be moderately cognitively impaired. The MDS indicated the resident required limited staff assistance bed mobility, transfers, toileting, personal hygiene and bathing. The MDS indicated the resident's [DIAGNOSES REDACTED]. The MDS indicated the resident utilized a wheelchair or walker for mobility. The resident's Care Plan with a target date of 04/01/16 documented the resident received antianxiety medications for anxiety and to monitor mood and response to the medication. A handwritten note dated 12/15/15 noted the resident had overt sexual behaviors and instructed staff that the resident would not have contact with another resident who is unable to consent, resident to notify nursing staff when required privacy for sexual relations, encourage the resident to discuss frustrations with nursing or primary care provider. On 03/01/16 a handwritten noted the resident had been transferred to another wing in the facility. On 03/02/16 the staff were instructed to proved fifteen minutes checks for location and that the resident had signed an education form that the resident understood consequences of adverse behaviors. The facility Resident Abuse Procedure, Investigating and Reporting policy noted that all personnel must promptly report any incident or suspected incident of abuse. The staff were instructed follow the following procedures: 1. Immediate removal of resident or employee from a harmful environment and initiate medical treatment as necessary. 2. Upon receiving reports of physical or sexual abuse, the charge nurse shall examine the resident and report finding to his/her supervisor. Findings of the examination must be recorded in the resident's medical record. If sexual abuse is suspected, do not bath the resident or wash clothing or linen. Call the police immediately. 3. Notify (via the phone if not present) immediate supervisor-department head-administrator, along with the completion of an incident report. The following information should be reported to the charge nurse: a) the name of residents involved b) the date and time the incident occurred c) where the incident occurred d) the names of the persons committing the incident, if known e) the name of any witnesses to the incident f) the type of abuse that was committed(i.e., verbal, physical, sexual, neglect, sect) g) other information tat may be requested by the charge nurse 4. Notify the primary care physician, or on call physician if after hours, of incident Review of nurse's notes dated on 10/04/15 Staff A, Licensed Practical Nurse (LPN) documented Resident #1 had been sitting in the hallway by the nurses station when a certified nursing assistant (CAN) observed the the resident placing hand on another(unnamed) resident's thigh and began rubbing that resident's inner thigh. The CNA asked Resident #1 to stop the activity related to inappropriate behavior. Resident #1 then moved away from the unnamed resident. When interviewed on 3/22/16 at 11:10 a.m., Staff A, LPN, stated during the incident in December with Resident #2 she had been working but the incident had not been reported to her, but to the Assistant Director of Nursing (ADON). Staff A stated she did not know of any other incidents when Resident #1 had touched other residents inappropriately. On 12/15/15 another resident reported to Staff I, LPN that Resident #1 had been touching Resident #2 inappropriately in the groin area. The nurse noted she and the facility social worker immediately went and spoke with Resident #1 who did not deny touching Resident #2. Resident #1 stated that Resident #2 had made hand gestures suggesting that Resident #2 wanted to be touched. The nurse explained to Resident #1 the inappropriateness of this, that Resident #2 was unable to give consent, that Resident #2 had involuntary arm and leg movements. Resident #1 told nurse and social worker that, they had partners and able to have their needs taken care of and that he/she can't leave here The nurse noted they informed the Administrator of the incident. On 03/01/16 at 4:30 p.m. a staff person had documented Staff B, Registered Nurse (RN) had been sitting at the nurses station when another resident informed her Resident #3 was being touched by Resident #1. When Staff B turned around Resident #1 removed his/her hand from under Resident #3's pant leg at right the thigh. Staff B noted Resident #1 had been removed immediately from the situation. Resident #3 told the staff thank you as they moved him/her to the dining room. During an interview with Staff H, CNA, on 03/22/16 at 3:30 p.m. he stated on 03/01/16 he had been assisting Resident #1 transfer from his/her recliner when the resident touched his (Staff H) crouch. He stated he told the resident not to do that and continued with the transfer. He stated he then propelled the resident to the nurse's station and parked him/her by Resident #3. He stated a few minutes later one of the nurses stated Resident #1 had his/her hand up the pant leg of Resident #3. Staff H stated they removed Resident #1 from the area. Staff H stated that Resident #1 had made sexually based comments to him on several occasions and he blew it off because he just thought sometimes residents would make inappropriate comments. He stated when Resident #1 had made comments about Resident #4 being his/her boyfriend/girlfriend he did tell the nurse. An incident report dated 12/15/15 at 8:30 a.m. indicated un unknown resident reported that another resident (Resident #1) had been observed inappropriately touching Resident #2 in the groin area. On 12/15/15 another resident reported to the ADON that Resident #1 had been touching Resident #2 inappropriately in the groin area. The nurse noted she and the Social Worker immediately went and spoke with Resident #1 who did not deny touching Resident #2. Resident #1 stated that Resident #2 had made hand gestures suggesting that Resident #2 wanted to be touched. The nurse explained to Resident #1 the inappropriateness of this, that Resident #2 was unable to give consent, that Resident #2 had involuntary arm and leg movements. Resident #1 told nurse and social worker that, they had partners and able to have their needs taken care of and that he/she can't leave here. The nurse noted they informed the Administrator of the incident. On 03/22/16 at 9:50 a.m. Staff E, Social Worker, stated another resident had brought to the ADON's attention that Resident #1 had touched Resident #2's genitals. She stated she and the ADON went to Resident #1 to talk about inappropriate behaviors. She stated that Resident #1 gave them the impression that he/she thought Resident #2 wanted touched. She stated that Resident #1 tried to justify his/her actions by saying that the staff did not know what it is like not to be able to have outlet for sexual expression. Staff E stated that after the incident with Resident #3 they again talked with Resident #1 regarding the inappropriate touching of other residents. She stated the resident did not deny the incidents had happened. She stated the Administrator had also talked with Resident #1 regarding the incidents and the police were called. Staff E stated they had moved Resident #1 to the other wing in the building and are conducting fifteen minutes checks on the resident for location. An Incident report dated 03/01/16 at 4:30 p.m. indicated the Resident #3 observed sitting in chair at nurses station when another resident (Resident #1) raised the resident's pant leg, placed hand under Resident #3's clothing on his/her inner thigh. The staff who observed the incident removed Resident #3 from the area and instructed Resident #1 to return to his/her bedroom. During an interview on 3/22/16, Staff B, LPN, she stated she had been getting a chart off the B wing when another resident called out to her and pointed to Resident #1 who had his/her hand up Resident #3 pants. She stated Resident #3's pants were pulled up to his/her knees and Resident #1 had pushed the pants up to the other resident's thigh. She stated she could tell Resident #1 had his hand in Resident #3's lap area and pulled the hand from the inside of the thigh area. She stated Resident #3 had been sitting in a recliner and Resident #1 backed his/her wheelchair away from Resident #3. Staff B stated she then told the charge nurse Staff D, LPN. During an interview on 3/22/16 at 1:30 p.m., Staff D, LPN, stated when the incident between Resident #1 and Resident #3 occurred she had been back in the CCDI unit. She stated Staff B, LPN, told her what she had observed between the two residents. Staff D stated she informed Staff B they needed to tell the Administrator and ADON about the incident especially since the same thing had happened with Resident #2. Staff D stated that Resident #1 had also made inappropriate sexual comments to one of the younger CNA. Staff D stated she encouraged the CNA to talk with the Administrator regarding the comments. Staff D stated she had heard about the incident with Resident #4 from another staff nurse. During an interview on 3/22/16 at 9:35 a.m., Staff C, CNA, stated he did work on 12/15/15, but had not observed Resident #1 touching Resident #2 inappropriately but stated he had seen Resident #1 go into Resident #4's bedroom. Staff C stated he did observe Resident #1 rubbing his/her genital while playing footsie with Resident #4. Staff C stated Resident #1 had invited Resident #4 to his/her bedroom to watch television and since Resident #4 did not go, Resident #1 went to the other resident's room. Staff C stated he believed it only happened the one time. Staff C stated that he saw the incident with Resident #3, but other staff also had been there and took care of the situation. When asked if he had notified anyone of the incident with Resident #4, Staff C he did notify the nurse. During an interview, Staff G, RN, stated she had been giving end of shift report sometime near the end of February, to the on coming nurse when Staff C, CNA, came up and told her that Resident #1 had been trying to be inappropriate with Resident #4. She stated Resident #1 had been trying to get Resident #4 to come into his/her room to watch TV since Resident #1 had a large TV and Resident #4 had just a small one. Staff G stated all Staff C said was Resident #1 had been playing footsie with Resident #4. She stated she did not know Resident #1 had been telling the staff that Resident #4 was his/her boyfriend/girlfriend. Staff G stated she only worked weekends so did not hear anything else. Staff G stated she did not chart the incident because it had been told to her at the end of her shift so did not give it another thought. On 03/16/16 at 10:30 a.m. the Administrator stated they had not reported the incident with Resident #2 when it happened in December 2015 because they had educated Resident #1 regarding inappropriate behaviors with other residents and felt it to be an isolated incident. She stated when the incident with Resident #3 occurred then they did report it and called the police. On 03/22/16 at 2:30 p.m., when informed of the other two incidents of inappropriate sexual contact with Resident #4 and the unknown resident, the Administrator stated she had not been made aware of those. She acknowledged that they were not reported and that they were not fully investigated. The Administrator noted she had only interviewed the witnesses to the incidents regarding Residents #2 and #3 so did not know about the others. She stated they did move Resident #1 to the other side of the building away from the cognitively impaired residents and placed Resident #1 on fifteen minutes checks for location.

Based on observation, record review, staff and resident interviews and review of the facility abuse policy/procedures, the facility failed to ensure four residents (Resident #2, #3, #4) were free from sexual exploitation from Resident #1. The facility reported a census of 63 residents. Findings included: 1. An annual MDS ( Minimum Data Set Assessment Tool ) dated 01/01/16 identified Resident # 1 with BIMS (Brief Interview for Mental Status) of 12 which indicated intact cognition for daily decision making. The MDS indicated the resident required limited staff assistance bed mobility, transfers, toileting,personal hygiene and bathing. The MDS indicated the resident [DIAGNOSES REDACTED]. The MDS indicated the resident utilized a wheelchair or walker for mobility. The resident's Care Plan with a target date of 04/01/16 documented the resident received antianxiety medications for anxiety and to monitor mood and response to the medication. A handwritten note dated 12/15/15 noted the resident had overt sexual behaviors and instructed staff that the resident would not have contact with another resident who is unable to consent, resident to notify nursing staff when required privacy for sexual relations, encourage the resident to discuss frustrations with nursing or primary care provider. On 03/01/16 a handwritten noted the resident had been transferred to another wing in the facility. On 03/02/16 the staff were instructed to proved fifteen minutes checks for location and that the resident had signed an education form that the resident understood consequences of adverse behaviors. The facility resident abuse procedure, investigating and reporting policy noted that all personnel must promptly report any incident or suspected incident of abuse. The staff were instructed follow the following procedures: 1. Immediate removal of resident or employee from a harmful environment and initiate medical treatment as necessary. 2. Upon receiving reports of physical or sexual abuse, the charge nurse shall examine the resident and report finding to his/her supervisor. Findings of the examination must be recorded in the resident's medical record. If sexual abuse is suspected, do not bath the resident or wash clothing or linen. Call the police immediately. 3. Notify (via the phone if not present) immediate supervisor-department head-administrator, along with the completion of an incident report. The following information should be reported to the charge nurse: a) the name of residents involved b) the date and time the incident occurred c) where the incident occurred d) the names of the persons committing the incident, if known e) the name of any witnesses to the incident f) the type of abuse that was committed(i.e., verbal, physical, sexual, neglect, sect) g) other information tat may be requested by the charge nurse 4. Notify the primary care physician, or on call physician if after hours, of incident Review of nurse's notes dated on 10/04/15 Staff A, LPN had documented Resident #1 had been sitting in the hallway by the nurses station when a certified nursing assistant (CNA) observed the the resident pacing hand on another(unnamed) resident's thigh and began rubbing that resident's inner thigh. The CNA asked Resident #1 to stop the activity related to inappropriate behavior. Resident #1 then moved away from the unnamed resident. During an interview with Staff A, LPN on 03/22/16 at 11:10 a.m. she stated during the incident in December with Resident #2 she had been working but the incident had not been reported to her, but to the ADON. Staff a stated she did not know of any other incidents when Resident #1 had touched other residents inappropriately. On 12/15/15 another resident reported to Staff I, LPN that Resident #1 had been touching Resident #2 inappropriately in the groin area. The nurse noted she and the facility social worker immediately went and spoke with Resident #1 who did not deny touching Resident #2. Resident #1 stated that Resident #2 had made hand gestures suggesting that Resident #2 wanted to be touched. The nurse explained to Resident #1 the inappropriateness of this, that Resident #2 was unable to give consent, that Resident #2 had involuntary arm and leg movements. Resident #1 told nurse and social worker that they had partners and able to have their needs taken care of and that he/she can't leave here The nurse noted they informed the facility administrator of the incident. On 03/01/16 at 4:30 p.m. a staff had documented Staff B, RN had been sitting at the nurses station when another resident informed her Resident #3 was being touched by Resident #1. When Staff B turned around Resident #1 removed his/her hand from under resident #3's pant leg at right thigh. Staff B noted Resident #1 had been removed immediately from the situation. Resident #3 told the staff thank you as they moved him/her to the dining room. On 03/03/16 The facility notified the Resident #1's physician due to recent sexual behaviors toward other residents, need to find alternate placement for the resident. The staff asked for examination to rule out [MEDICAL CONDITION], or admission for acute care and/or transfer to psych due to behaviors and targeting, for counseling in regard to recent reveal ed sexual orientation. The staff also asked if the resident would benefit from hormone therapy. During an interview with Resident #1 on 03/23/16 at 11:30 a.m. he/she stated that nothing went on except touching the body of Resident #2, Resident #3 and Resident #4 and that he/she did not do anything that the other residents did not want them to do. Resident #1 stated the other residents gave him/her sexual signals with their body movement to indicate their willingness to participate in the activity. Resident #1 stated when that happened and he/she touched them it got into a big mess. Resident #1 stated he did not know why every one got so upset, he/she was not doing anything wrong. When attempted to explain that none of the other residents were mentally capable of making those kind of decisions, Resident #1 became agitated and stated Oh hell, they can to, they wanted sex and they were enticing me When again informed that the other resident could not make those decisions, the resident stated well, that's your interpretation, and it won't happen again because I have to stay down here on this side. Resident #1 then stated bet you didn't know there are a bunch of gay people working here. When asked what he/she meant the resident stated well, they touch peoples genitals all the time. When explained that when staff touch resident's private areas it is during times they are providing personal cares. The resident replied that's just what they want you to think. When explained to resident that most people that reside in the facility are there because they could not provide self care, the resident stated well, I think they get more from it than that. During an interview with Staff H, CNA on 03/22/16 at 3:30 p.m. he stated on 03/01/16 he had been assisting Resident #1 transfer from his/her recliner when the resident touched his (Staff H) crouch. He stated he told the resident not to do that and continued with the transfer. He stated he then propelled the resident to the nurse's station and parked him/her by Resident #3. He stated a few minutes later one of the nurses stated Resident #1 had his/her hand up the pant leg of Resident #3. Staff H stated they removed Resident #1 from the area. Staff H stated that Resident #1 had made sexually based comments to him on several occasions and he blew it off because he just thought sometimes residents would make inappropriate comments. He stated when Resident #1 had made comments about Resident #4 being his/her boyfriend/girlfriend he did tell the nurse. 2. The annual MDS ( Minimum Data Set Assessment Tool ) dated 12/25/15 identified Resident # 2 with severely compromised cognitive function related to daily decision making skills. The MDS indicated the resident to be dependent on two or more staff for all activities of daily living (ADL) including transfers, toileting,dressing, eating, personal hygiene and bathing. The MDS indicated the resident required a wheelchair propelled by staff for mobility. The MDS indicated the resident [DIAGNOSES REDACTED]. The resident's Care Plan with a goal date of 03/25/16 noted the resident demonstrated the inability to meet own ADL care needs. The staff were instructed to utilize a lifting device; Hoyer lift with two staff assistance for all transfers. The staff were instructed to provide a gerichair for mobility, to turn and reposition every two hours, and when in the wheeled chair keep in high traffic areas. An incident report dated 12/15/15 at 8:30 a.m. indicated un unknown resident reported that another resident (Resident #1) had been observed inappropriately touching Resident #2 in the groin area. On 12/15/15 another resident reported to the assistant director of nursing (ADON) that Resident #1 had been touching Resident #2 inappropriately in the groin area. The nurse noted she and the facility social worker immediately went and spoke with Resident #1 who did not deny touching Resident #2. Resident #1 stated that Resident #2 had made hand gestures suggesting that Resident #2 wanted to be touched. The nurse explained to Resident #1 the inappropriateness of this, that Resident #2 was unable to give consent, that Resident #2 had involuntary arm and leg movements. Resident #1 told nurse and social worker that they had partners and able to have their needs taken care of and that he/she can't leave here The nurse noted they informed the facility administrator of the incident. On 03/22/16 at 9:50 a.m. Staff E, Social Worker, stated another resident had brought to the ADON attention that Resident #1 had touched Resident #2's genitals. She stated she and the ADON went to Resident #1 to talk about inappropriate behaviors. She stated that Resident #1 gave them the impression that he/she thought Resident #2 wanted it. She stated that Resident #1 tried to justify his/her actions by saying that the staff did not know what it is like not to be able to have outlet for sexual expression. Staff E stated that after the incident with Resident #3 they again talked with Resident #1 regarding the inappropriate touching of other residents. She stated the resident did not deny the incidents had happened. She stated the facility administrator had also talked with Resident #1 regarding the incidents and the police were called. Staff E stated they had moved Resident # to the other wing in the building and are conducting fifteen minutes checks on the resident for location. 3. The annual MDS ( Minimum Data Set Assessment Tool ) dated 02/12/16 identified Resident # 3 a BIMS (Brief interview for Mental Status) which indicated severely compromised cognitive function related to daily decision making skills. The MDS indicated the resident to be dependent on staff for all activities of daily living (ADL) including transfers, toileting,dressing, eating, personal hygiene and bathing. The MDS indicated the resident required a wheelchair propelled by staff for mobility. The MDS indicated the resident [DIAGNOSES REDACTED]. The resident's care plan with a goal date of 05/19/16 noted the resident to have delusions related to dementia and [MEDICAL CONDITION]. The care plan instructed staff to keep distance between the resident and others during delusional periods, provide safe, quiet, low-stimuli environment, respect resident's need for privacy and space and avoid unnecessary touching. The care plan instructed staff to to provide a gerichair for mobility and to keep the resident in high traffic areas during times of hallucinations. An Incident report dated 03/01/16 at 4:30 p.m. indicated the resident had been observed sitting in chair at nurses station when another resident (Resident #1) raised the resident's pant leg, placed hand under Resident #3's clothing on his/her inner thigh. The staff who observed the incident removed Resident #3 from the area and instructed Resident #1 to return to his/her bedroom. On 03/01/16 at 4:30 p.m. a staff had documented Staff B, RN had been sitting at the nurses station when another resident informed her Resident #3 was being touched by Resident #1. When Staff B turned around Resident #1 removed his/her hand from under resident #3's pant leg at right thigh. Staff B noted Resident #1 had been removed immediately from the situation. Resident #3 told the staff thank you as they moved him/her to the dining room. During an interview with Staff B, LPN on 03/22/16 she stated she had been getting a chart off the B wing when another resident called out to her and pointed to Resident #1 who had his/her hand up Resident #3 pants. She stated Resident #3's pants were pulled up to his/her knees and Resident #1 had pushed the pants up to the other resident's thigh. She stated she could tell Resident #1 had his hand in Resident #3's lap area and pulled the hand from the inside of the thigh area. She stated Resident #3 had been sitting in a recliner and Resident #1 backed his/her wheelchair away from Resident #3. Staff B stated she then told the charge nurse Staff D, LPN. During an interview with Staff D, LPN on 03/22/16 at 1:30 p.m. she stated stated when the incident between Resident #1 and Resident #3 occurred she had been back in the CCDI unit. She stated Staff B, LPN told her what she had observed between the two residents. Staff D stated she informed Staff B they needed to tell the Administrator and assistant director of nursing about the incident especially since the same thing had happened with Resident #2. Staff D stated that Resident #1 had also made inappropriate sexual comments to one of the younger CNA. Staff D stated she encouraged the CNA to talk with the administrator regarding the comments. Staff d stated she had heard about the incident with Resident #4 from another staff nurse. 4. The annual MDS ( Minimum Data Set Assessment Tool ) dated 02/26/16 identified Resident # 4 with a BIMS of 3 (Brief interview for Mental Status) which indicated severely compromised cognitive function related to daily decision making skills. The MDS indicated the resident required staff supervision all activities of daily living (ADL) including transfers, toileting,dressing, personal hygiene and bathing. The MDS indicated the resident required a walker for mobility. The MDS indicated the resident [DIAGNOSES REDACTED]. The resident's care plan with a goal date of 05/26/16 indicated the resident exhibited behavioral symptoms and instructed staff to use a calm approach and reassurance when resident upset, sees a psychiatric care and medications, monitor the resident's mood and response to medications. During an interview with Staff C, CNA on 03/22/16 at 9:35 a.m. he stated he did work on 12/15/15, but had not observed Resident #1 touching Resident #2 inappropriately but stated he had seen Resident #1 go into Resident #4's bedroom. Staff C stated he did observe Resident #1 rubbing his/her genital while playing footsie with Resident #4. Staff C stated Resident #1 had invited Resident #4 to his/her bedroom to watch television and since Resident #4 did not go, Resident #1 went to the other resident's room. Staff C stated he believed it only happened the one time. Staff C stated that he saw the incident with Resident #3, but other staff also had been there and took care of the situation. When asked if he had notified anyone of the incident with Resident #4, Staff C he did notify the charge nurse Staff--RN. During an interview with Staff F, CNA on 03/23/16 at 12:30 p.m. he stated he had been in the hallway waiting for a resident when he observed Resident #1 following Resident #4 into his/her room. He stated he just thought that Resident #1 had forgotten his/her room number. He stated he saw Resident #1 park the wheelchair catty cornered to Resident #4's recliner. Staff F stated Resident #1 had his hand inside his/her own pants while rubbing Resident #4's thigh. Staff F stated he thought Resident #4 looked uncomfortable with the situation. He stated as he walked in the room Resident #1 pulled his/her hand out of his/her pants and away from Resident #4. Staff F stated he then called Staff C into the room, and Staff C went to tell the charge nurse. He stated this had happened around 02/27/16 after breakfast or lunch. Staff F stated he removed Resident #1 from the area. Staff F stated he had not seen Resident #1 do any other appropriate actions but would not place Resident #1 near other residents because he would call out to them or reach toward them. Staff F stated he had heard ion staff to staff reports that Resident #1 had acted inappropriate toward other residents. During an interview with Staff G, RN stated she had been giving end of shift report to the on coming nurse when Staff C, CNA came up and told her that Resident #1 had been trying to be inappropriate with Resident #4, sometime near the end of February. She stated Resident #1 had been trying to get Resident #4 to come into his/her room to watch TV since Resident #1 had a large TV and Resident #4 had just a small one. Staff G stated all Staff C said was Resident #1 had been playing footsie with Resident #4. She stated she did not know Resident #1 had been telling the staff that Resident #4 was his/her boyfriend/girlfriend. Staff G stated she only worked weekends so did not hear anything else. Staff G stated she did not chart the incident because it had been told to her at the end of her shift so did not give it another thought.

Based on observation, clinical record review, staff and family interviews, the facility failed to adequately assess a resident with complaints of pain and increased [MEDICAL CONDITION] for 1 of 6 residents reviewed (Resident #4). The facility reported a census of 53 residents. Findings include: 1. According to the Minimum Data Set (MDS) with a reference date of 6/20/14 revealed Resident #4 had [DIAGNOSES REDACTED]. to pump enough blood to the rest of the body), [MEDICAL CONDITION] (condition in which the kidneys do not function efficiently), and anxiety disorder. Resident #4 had a cognitive score of 9 which indicated the resident had moderately impaired cognitive ability. The MDS indicated the resident required the assistance of 2 staff for bed mobility, transfers, toilet use and the assistance of 1 staff for personal hygiene. According to the Comprehensive Care Plan dated 5/15/12 directed the staff to transfer the resident with assist of 2 staff with a gait belt and to use a wheelchair for long distances and use a walker for short distances. The Care Plan indicated the resident will report onset of pain and directed the staff to assess the pain and administer pain medications. Review of a Fax communication form dated 6/13/14 indicated a facility nurse reported to Resident #4's physician that the resident had 2 plus [MEDICAL CONDITION] in both lower legs and had swelling on and off for the past couple of days. The Physician responded back on 6/13/14 with orders to change the resident's diuretic. Review of a Fax communication form dated 6/24/14 indicated a facility nurse reported to Resident #4's physician that the resident continued to have [MEDICAL CONDITION] in their lower extremities and had been uncomfortable. The Physician respond back on 6/24/14 with orders for lab work, and questioned if the resident had on support stockings and if the resident's leg elevated when sitting. Review of Resident #4's Nurses Notes revealed the following information: a. On 7/17/14 a facility nurse noted the resident had [MEDICAL CONDITION] in both legs. The nurse obtained the resident ' s temperature and vitals. b. On 7/18/14 at 12:00 p.m. that they had pain in both legs and back. c. On 7/18/14 at 8:30 a.m. the physician directed the staff to elevate the resident's legs. d. On 7/21/14, no new orders after a physician completed her rounds. The nursing staff sent a FAX requesting the dietician stop the resident's house supplement as the resident had a 20 pound weight gain in 4 months. A fax was sent to primary care physician requesting to discontinue the house supplement due to the weight gain. The house supplement was discontinued on 7/22/14. e. On 7/24/14 at 2:00 p.m. the resident requested pain medication for their leg pain. f. On 7/25/14 at 11:15 a.m. Resident #4 found tearful and complaining of leg and back pain. g. On 7/27/14 a C.N.A. reported to the nurse the resident had a skin tear on their left lower leg. The resident stated they were resting their leg on a waste basket. h. on 7/27/14 at 8 p.m., the nurse reported Resident #4 had SOB ( shortness of breath) & she completed vitals and gave the resident a PRN (as needed) nebulizer treatment. The document identified the resident settled down. i. On 7/28/14 at 9:00 a.m., staff documented the resident had weeping from his/her lower extremity with 4 plus [MEDICAL CONDITION]. The resident ' s lungs were assessed and staff noted Rhonchi through all fields and a productive cough. (Rhonchi is a low pitched snore like sound, that can be caused by airway secretion and airway narrowing). The nursing staff placed a call to the primary physician to make him/her aware. The report was given to the primary care physician ' s nurse who would alert the physician. The nurse prepared a FAX and informed the family member. At noon on 7/28/14, the nurse documented the resident still had a cough, but no SOB. The nurse resent the fax at this time. At 2:15 p.m. on 7/28/14, the nurse called and spoke with the physician ' s nurse about the earlier faxes and correspondence from day the shift nurse. The family member was there and very concerned. At 2:30 p.m., on 7/28/14, the aide approached the nurse and stated the resident wanted a pain pill for his/her legs & back. The nurse documented she assessed the resident ' s legs and they were real hard on the backs of his/her thighs and ankles, and had 4 plus [MEDICAL CONDITION]. On 7/28/14 (no time) Resident #4's son-in-law re-approached the nurse ' s station and wanted to know if they would send the resident to the hospital. On 7/28/14 at 2:45 (p.m.) the nursing note reported they called ambulance and gave them a report on the resident. At 2:50 (p.m.) the nurses notes identified the order had been received from the physician to send the resident to the emergency room . At 2:45 P.M. on 7/28/14 the surveyor observations included Resident #4 in a recliner in the resident's room moaning. Resident #4's lower extremities noted to be reddened, [MEDICAL CONDITION] and not elevated. The resident did not have TED hose on. At this time, Resident #4 family member asked the surveyor if they could help get their family member to the hospital. The family member stated they have told the facility staff repeatedly about the increase in swelling and extreme pain and the facility staff won't do anything about it. The family member again stated their family member is in a great deal of pain and it hurts them to see the resident cry with pain. Observation at this time revealed Resident #4 sitting in their recliner, feet down and slippers on without stockings. The resident's lower extremities are swollen and reddened, the resident had been moaning out in pain. Observation on 7/28/14 at 3:10 p.m. revealed Resident #4 lying on an ambulance cart, the resident's left lower pant leg was wet with clear fluid, a [MEDICATION NAME] pad was noted on the resident ' s left lower leg. The facility failed to assess the resident's lower extremities for [MEDICAL CONDITION] and redness. The PRN Medication Administration Record [REDACTED]. On 7/28/14 at 8 P.M. Facility nurse contacted hospital for a status report and Resident admitted with [MEDICAL CONDITION]. Review of the Communication Form to Resident #4's physician dated 7/28/14 indicated the resident had abnormal lung sound, coughing and swelling in both of their lower legs with weeping. The Nurse informed the physician the symptoms started on 7/27/14 and that the resident had a hospitalization from ,[DATE]-[DATE] for [MEDICAL CONDITION] and [MEDICAL CONDITION]. The physician gave an order to send the resident to the emergency room . During an interview with Staff C-C.N.A. on 7/29/14 at 8:30 a.m. revealed the C.N.A. stated they worked with Resident #4 the past week and the resident complained of aching all over and had swelling of their lower legs. During an interview with Staff D-RN on 7/29/14 at 8:50 a.m. revealed they worked with Resident #4 yesterday day (7/28/14) shift and the resident experienced more shortness of breath between 8-9 a.m. and their legs were swollen and weeping. Staff D reported she kept monitoring the resident and the resident was not having discomfort. Staff D reported the resident ' s vitals were normal. Staff D reported the resident ' s legs weeping was new yesterday (7/28/14). The staff stated they faxed the resident's physician several times yesterday but no response on their shift. Staff D stated Resident #4 kept telling them he/she felt sick. Staff D reported she did not know why the resident had been recently hospitalized . During an interview with the Director of Nurses on 7/29/14 at 11:35 a.m. revealed Resident #4 had a hospital admission yesterday with [DIAGNOSES REDACTED]. During review of an Assessment Policy dated 8/15/1998 directed the staff to maintain a comprehensive and accurate assessment of each resident's functional capacity.

Based on record review and interviews, the facility failed to provide adequate supervision for Resident # 1. On 5/21/14 Resident #1 attempted to self-transfer and fell sustaining a close head injury. Staff interviewed and record review revealed Resident #1 would often attempt to self-transfer as soon as staff left the room. Staff acknowledged at the time of the fall, Resident #1's 15 minute checks had not been completed. A total of 5 residents were sampled. The facility reported a census of 53 residents. Findings include: 1. The Initial MDS (Minimum Data Set) with an assessment reference date of 05/13/2014 revealed Resident # 1 demonstrated moderate cognitive impairments with a score of 8 on the Brief Interview of Mental Status (BIMS) cognitive test. The assessment noted observations of disorganized thinking or inattention (unclear or illogical flow of ideas; easily distracted or difficulty following what was said). The assessment revealed Resident #1 needed one (1) staff person to assist with bed mobility, transfers, ambulation in room/corridor , dressing, personal hygiene, and toilet use. The test for balance detected Resident #1 unsteady and only able to stabilize with staff assistance during the following times: when walking, when moving from seated to standing position, when turning around, moving on and off the toilet and during surface to surface transfers (transfers between bed and chair or wheelchair). The assessment revealed Resident #1 had range of motion limitations to use his/her lower extremity. The resident used a walker and /or a wheelchair for mobility and had sustained a hip fracture prior to admission. The resident had [DIAGNOSES REDACTED]. The care plan with a start date of 05/06/2014 referred to Resident # 1's poor balance and risk of sustaining a fall due to not waiting for staff to assist. A hand written intervention on the care plan dated 04/29/2014, directed staff to complete checks on the resident every 15 minutes and added additional direction on 05/06/2014 to stay with the resident when toileted, check frequently for safety, provide one (1) staff assistance with a gait belt and a walker for ambulation, and to recline the resident's recliner when seated. Staff were directed to remind Resident # 1 how unsafe it was to be up alone and to assist back to her/his chair when found up alone. The May 2014 MAR (Medication Administration Record) documented the use of Benazepril (a hypertensive for blood pressure) 20 milligrams every day and Hydrochlorothiazide (a diuretic) 12.5 milligram every day. Both medications can cause dizziness or feelings of faintness when rising or changing positions and increased the chances of falling. Resident # 1 also required the antibiotics Bactrim (Sulfa) every day for 10 days and Cipro 500 milligrams twice a day for 10 days for a urinary tract infection which can contribute to increased confusion especially in the elderly. A review of the Skilled Daily Nursing Notes for Resident # 1 revealed that as early as 05/09/2014, the facility documented the resident's non-compliant episodes of being confused and up without calling for assistance. Interventions consisted of the 15 minute checks and trying to educate the confused resident on the use of the call light. Documented episodes of being up without assist were 05/09/2014 , 05/11/2014 (multiple attempts), 05/13/2014 at 4:00 P.M., 05/14/2014 at 5:00 A.M., 05/16/2014 (multiple attempts) at 10:40 P.M.. On 05/18/2014 Resident ate lunch with his/her hands due to not understanding how to use silverware. On May 5, 2014, the facility transferred Resident #1 to the local hospital after nursing and therapy staff noted periods of garbled speech. Resident #1 returned to the facility with a [DIAGNOSES REDACTED]. An incident report dated 5/21/14 at 10:45 a.m., identified Resident #1 had been on the floor. The resident stated he/she was going to hem the curtains. The report noted the resident did hit his/her head with a small abrasion and had no pain. According to the incident report, his/her blood pressure and pulse after the fall were 180/90 and 90 with equal pupils. The report documented the current treatment for [REDACTED]. The Physician and family received notification and post fall neurological checks with assessments started. On 5/21/2014 at 10:45 a.m., Staff A (Registered Nurse) documented Resident # 1 was found on the floor of her/his room. During an assessment of the resident, Staff A found a small abrasion on the back of the resident's head, but no other injuries. A nursing note on 05/21/2014 at 1:30 p.m. documented Resident # 1's speech was garbled and documented therapy noted the garbled speech a few days prior to the fall. On 05/22/2014 at 6:00 A.M., Staff B documented being unable to awaken Resident # 1 even after initiating a sternal rub to the chest. The blood pressure was 170/90 at that time with slightly reactive pin point pupils. Resident # 1 was sent to the emergency room at the local hospital and all parties notified. The emergency room report of 05/22/2014 found Resident #1 exhibited very poor responses overall, had swelling and bruising at the occipital lobe (upper back of the head), and equal pupils. The physician record revealed a non-displaced left occipital skull fracture was present. The [DIAGNOSES REDACTED]. The neurological examamination revealed Resident #1 did not respond when checking his/her orientation, cranial nerves, no response to cerebellar function testing, or no response when checking the resident ' s sensory functioning. The resident ' s eye remained closed. The resident ' s family requested observation only and to not transfer the resident to a higher level of care. On 5/23/2014, the admitting Physician documented Resident # 1 as unresponsvie and with multiple intracranial hemorrhages, a subarachnoid hemorrhage, and a interventricular hemorrhage after a computerized axial tomography scan (CAT scan) was performed. On 06/20/2014 at 11:55 A.M., one of the attending physician reported the 05/21/2014 fall occurring at the nursing facility did contribute to the resident's death. The Funeral Home File Copy of the death certificate, the physician listed the medical cause of death as a fall. When interviewed on 06/17/2014 at 1:30 p.m., Staff A verbalized passing Resident #1's room around 10:45 a.m. on 05/21/2014 and saw the resident on the floor. Resident # 1 made the statement he/she was going to hem the curtains as she/he sat on the floor with both feet out in front. Staff A commented Resident # 1 usually needed redirection at least once a shift about not getting up unassisted. According to Staff A, interventions consisted of reading a newspaper or magazine, or going to an activity if not in therapy. Prior to the fall, the resident was seated in the recliner in her/his room. After the fall, nursing placed the resident out at the nursing station for observation. Staff A identified she was the first one in the room after the incident and did not recall which other staff came to help her with the resident. In an interview on 06/17/2014 at 2:20 P.M., Staff C (Certified Nursing assistant) identified during her written statement the following: Resident # 1 was in a recliner in her/his room with the call light attached to the recliner when she left the floor on the morning of 05/21/2014 around 9:45 A.M. Upon return to the floor around 10:40 A.M., Staff C checked the resident and noted the resident was still in the recliner. At 10: 45 A.M., she checked on the resident again and found her/him seated on the floor by a dresser close to the bathroom with both legs out in front of him/her. Resident # 1 was very anxious and wanted to get up and fix the curtains. A small amount of blood was on the floor. The recliner still had the footrest up. Staff A came to the resident's room and started her assessment of the resident. Staff C reported working with the resident probably 8 times since her/his admission 22 days prior to the fall and verbalized Resident # 1 always appeared anxious. During her shifts, Staff C verbalized always needing to redirect the resident and sometimes Resident # 1 would get up as soon as she left the room. When asked what interventions were tried, Staff C stated interventions were conversation, bathroom, reading a book, or laying on the bed. During an earlier interview (at 12:15 p.m.) with this aide on the same dated, she (Staff C) reported coming back to the floor after being gone to find the 15 minute checks were not done from 9:45 AM until the resident fell at 10:45 A.M. This admission came after Staff C verbalized the resident was in the recliner prior to her leaving the floor. When asked why the 15 minute checks (Saftety Checks list for 5/22/2014) identified the resident as being in the wheel chair, she admitted filling in the 15 minute check gap from 9:45 A.M. to 10:45 A.M. because she hated to see blanks and her partner (Staff E, Certified Nursing Assistant) on the shift that day had not filled in the 15 minute checks. When asked how she knew what to fill in, she stated she asked Staff E where the resident was during that time. Staff C stated the 15 minute checks were incorrect about the resident being in the wheel chair before the fall, Resident # 1 was in the recliner. No one actually knew where the resident was from 9:45 A.M. to 10:45 A.M. on 05/22/2014. During an interview on 06/18/2014 at 10:20 a.m., Staff E stated she was busy assisting other resident's at the time of Resident #1's fall. She was aware the resident was on 15 minute checks, but had no further information on this. Staff E remembered Resident # 1 as always wanting to go somewhere and being anxious. Redirection was given many times during a shift and Resident # 1 spent a lot of time at the nursing station so she/he could be observed. Staff E recalled therapy made the resident tired and she/he preferred to spend time in her/his room instead of going to activities. In an interview with Staff D (Certified Nursing Assistant) on 06/17/2014 at 12:45 p.m., the aide verbalized working with Resident # 1 frequently. Resident # 1 was always happy, but confused and required 15 minute checks to try to keep her/him from getting up alone. Staff D related the resident went to rehabilitation therapy and spent quite a lot of time in bed from being tired. He always tried to place the resident up at the nursing station because she/he would forget to use the call light and get up without assistance. If the resident was in the recliner, she/he would forget to lower the foot rest when getting out of the chair. Resident # 1did not like activities and spent a lot of time in her/his room. Staff would have to redirect the resident several times a shift. An interview with Staff F (Certified Nursing Assistant) on 06/17/2014 at 3:25 p.m., confirmed Resident # 1 had difficulty remembering not to get up by her/him(self), remembering to use the wheeled walker, and could not recall how to use the call light for assistance. She verbalized needing to redirect Resident # 1 multiple times in an 8 hour shift and even then, the resident would get up alone in-between the 15 minute checks. Interventions included seating the resident at the nursing station to talk to other residents. Staff F verbalized Resident # 1 was always nice, but wanting to get up and go somewhere, and did not really like to go to any activities (especially exercises), so was in her/his room a lot. Resident # 1 was unsteady during ambulation and always busy doing something with her/his hands. During an interview on 06/17/2014 at 4:00 p.m., Staff G (Registered Nurse) for the evening shift verbalized spending time with Resident # 1 in her/his room or at the nursing station. She did not feel Resident # 1 needed redirection much on the evening shift. On 06/20/2014 at 12:21 p.m., Resident # 1's POA (Power of Attorney/daughter) stated she felt the facility had done everything they could have done to keep the resident from falling. She stated Resident # 1 was one who was always on the go and with the dementia could not remember to call for assistance. The facility provided the Department a letter which noted that Staff C was on duty the day of the fall and had changed her story numerous of times when talking with the surveyor.

Based on observation, record review, and staff interviews, the facility failed to ensure Resident #5 received nursing services for the prevention of pressure areas and implement timely interventions to promote and reevaluate properly fitting shoes. The facility failed to demonstrate safe infection control techniques when performing wound care for Resident #1. The facility reported a census of 66 residents. The sample consisted of fifteen residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment with a reference date of 11/30/12 reflected Resident #5 had a BIMS (Brief Interview for Mental Status) score of 13 which identified the resident with no cognitive impairment (the BIMS scale for cognitive impairment identified a score of 0-7 indicates severe impairment, 8-12 indicated moderate impairment, and 13-15 indicated the impaired). The MDS identified the resident required limited assistance from staff for bed mobility and ambulation. The MDS assessment noted the resident did not have a risk for pressure ulcer development and did not have pressure sores at the time of the assessment. Resident #2's had [DIAGNOSES REDACTED]. The MDS reflected the resident did not have behaviors of resisting cares. The January 2013 behavioral symptoms identified the resident had anxiety but did not identify the resident to be resistive to cares. Resident #5 had a Care Plan initiated at admission to the facility on [DATE]. On 6/7/12 a revision was made and a skin integrity problem identified. The Care Plan directed staff to encourage the resident to drink fluids, monitor healing progress or lack thereof of skin issues, and contact MD (Medical Doctor) for condition update PRN (as needed) and treatment change as needed. No other interventions were listed on the care plan. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Weekly Follow-up Forms (which identify skin issues for residents and track the progression and treatment of [REDACTED]. The physician was notified and treatment initiated. Weekly evaluations of the wound were documented and recorded measurements of the wound from first observation on 5/22/12 through the present time. The MDS assessment with a reference date of 11/30/12 noted the resident did not have any pressure areas at the time of assessment. The seven day evaluation period for the MDS reflected on 11/24/12 and ended 11/30/12. The Weekly Follow-up Form dated 11/21/12 revealed the resident still had an open area on the right heel measuring skin measuring 1.3 cm by 2 cm with a superficial depth of 0.1 cm. The next weekly measurement on 11/28/12 noted measurements of the area as 1 cm by 2 cm with a depth of 0.1 cm. The Weekly Follow-up Forms revealed a blister was identified on the resident ' s right heel on 1/30/13. The physician was notified and skin treatment initiated. The blister was 7.2 centimeters (cm) by 4.2 cm and was fluid filled. On 2/21/13 at 6:30 a.m. Staff F (Wound Nurse) was interviewed and stated the initial wound on the resident ' s right heel was proving to be chronic with fluctuating periods of improvement and worsening. Staff F stated the resident was non-compliant with attempts to treat the wound, as evidenced by the resident ' s refusal to see the physician as documented on the 1/30/13 weekly Follow-up Form. She stated the resident was cautioned about wearing hard shoes on his/her feet and self-propelling the wheelchair while wearing shoes, but agreed this was not documented on the resident ' s care plan. She stated a second intervention for the resident, also not documented on the care plan, was to wear padded blue boots at night on both feet. She stated the resident often preferred not to wear socks with his/her shoes despite education from staff encouraging the resident to wear socks. She stated the resident's feet were frequently moist. The Wound Nurse stated she did not consider the blister on the resident ' s left heel as pressure related. She stated the blister was caused by the resident ' s frequently moist feet and the resident ' s continued self-propelling of a wheelchair. Observation of the wound care by Staff F on 2/20/13 at 8:30 a.m. revealed the right heel wound measured 3 cm by 1.5 cm and was superficial in depth. The treatment consisted of removing the old dressing, applying [MEDICATION NAME] (antibiotic) ointment on the wound with a Q-tip, and covering the wound with [MEDICATION NAME] and gauze twice daily. (Didn ' t cleanse wound) The wound on the left heel measured 4.2 cm by 2.1 cm and was superficial in depth. Treatment consisted of removing the old dressing, applying Triple Antibiotic ointment on the wound with a Q-tip, and covering the wound with [MEDICATION NAME] and gauze ounce daily. The resident stated he/she wears the moon boots at night and self- propels self in the wheelchair when up most of the day. Review of the resident ' s Treatment Administration Records (TARs) revealed the wound treatments for the right chronic wound were not done consistently by staff during the months of October/November/December of 2012. Documentation revealed: October- 16 treatments were not documented as completed. November- 9 treatments were not documented as completed. December- 7 treatments were not documented as completed. Review of Resident #5 ' s shower skin checks revealed there were no skin issues documented by the shower aide on 1/29/13. The blister on the resident ' s left heel was identified by staff on 1/30/13. Review of the facility Skin Care Policy, revision date 10/5/10, documented it is the policy of this facility that a resident with any kind of a skin issue (i.e. Any red area, skin tear, pressure ulcers) shall receive treatment to promote healing, prevent infection, and prevent new conditions from developing. Pressure area classifications included: Stage 2: A partial thickness loss of skin layers that presents clinically as an abrasion, a blister, or shallow crater. All assessed skin conditions will be charted on daily for seven days and then weekly. Preventative routine care includes but is not limited to the following: -turning and proper positioning. -application of pressure reduction or relief devices. -providing good skin care (i.e. keeping skin clean, instituting measures to reduce excessive Moisture). -maintaining adequate nutrition and hydration. The DON sent a note to the physician on 2/22/2013. The DON expressed that in June 2012, the resident would only allow not wearing a shoe to the right foot. The staff attempted off-loading with pillows while the resident rested in bed. The resident would kick the pillows away. The physician documented the resident had a long history of poor compliance with treatment including diabetes and ulcers. The plan of care did not identify poor compliance by the resident and therefore did not direct staff with interventions to use to enhance prevention of pressure ulcers and promote healing of the current heel ulcers. 2. The Minimum Data Set (MDS) assessment with a reference date of 11/2/12, documented Resident #1 had an intact cognition as evidenced by a BIMS (Brief Interview for Mental Status) score of 14 (the BIMS scale for cognitive impairment states a score of 0-7 indicated severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates the resident is not cognitively impaired). The MDS noted the resident was admitted to the facility on [DATE] with a stage three pressure ulcer, but identified the resident as not at risk for developing pressure ulcers. The MDS noted skin and ulcer treatments for Resident #1 included pressure ulcer care and application of dressings to the feet. [DIAGNOSES REDACTED]. The plan of care, revised on 12/8/12, documented the resident had impaired skin integrity and instructed staff to insure relief of pressure when sitting through change in position by toileting, boosting, shifting of weight, ambulating or return to bed for rest every 2 hours and to provide wound care as outlined by the physician every day. The current Weekly Follow-up Forms (which identify skin issues for residents and track the progression and treatment of [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation on the MAR indicated [REDACTED]. On 2/19/13 at 10:00 a.m., observation revealed Staff H (Licensed Practical Nurse- LPN)) lifted the resident ' s right foot onto a towel barrier on the bed surface. The nurse placed her supplies for the wound care directly on the resident ' s bedspread (considered contaminated) (two unwrapped rolls of gauze, unwrapped 4 by 4 pads, and a roll of tape). The LPN washed her hands and applied gloves to both hands. The LPN did not wash the wound with normal saline as instructed on the MAR. The LPN used a Q-tip to apply [MEDICATION NAME] ointment onto the edges of the wound which measured approximately 3 cm (centimeter) by 3 cm. She placed a [MEDICATION NAME] pad onto the wound and covered the pad with a 4 by 4 dressing pad and wrapped it with roller gauze. She removed her scissors from her pocket (considered contaminated) and cut the gauze wrap and taped it on to the dressing. She replaced the scissors into her pocket. On 2/20/13 at 8:00 a.m. Staff F, Wound Nurse was interviewed and stated the facility policy for wound care does not require nurses to cleanse a wound with normal saline prior to the application of ointments/medications unless the physician orders [REDACTED]. Review of the facility Skin Care Policy ( revision date 10/5/10) documented it is the policy of this facility that a resident with any kind of a skin issue (i.e. Any red area, skin tear, pressure ulcers) shall receive treatment to promote healing, prevent infection, and prevent new conditions from developing. Preventative routine care includes the provision of good skin care (i.e. keeping skin clean). Wound Care, A collaborative Practice Manual for Health Professionals, third edition by Carrie Sussman-Lippincott, page 223 provided the following information: Recommended Guidelines for Pressure Ulcer Cleansing: 1. Cleanse wounds initially and at each dressing change, 2. Use minimal mechanical force when cleansing ulcer with gauze, cloth or sponges, 3. Do not clean wounds with skin cleansers or antiseptic agents ([MEDICATION NAME]-iodine, sodium hypochlorite solutions, hydrogen peroxide, and acetic acid), 4. Use normal saline for cleansing most ulcers. 5. Use enough irrigation pressure to enhance wound cleansing without causing trauma to the wound bed. Safe and effective ulcer irrigation pressures range from 4 to 15 psi. 6. Consider whirlpool treatment for [REDACTED]. Discontinue whirlpool when ulcer is clean.

Based on record review and staff interview, the facility failed to plan for and direct services to ensure one (1) of six (6) residents received adequate supervision from hazards. Record review identified Resident #5 had a physician's orders [REDACTED]. Staff interviews identified the facility staff became aware the resident would self transfer and failed to plan for and direct services to alert staff of the resident's supervision needs with transfers. The resident sustained [REDACTED]. The facility reported a census of 57 residents. Findings include: The Significant Change Minimum Data Set (MDS) with an assessment reference date of 9/14/2012 revealed Resident #5 had a Brief Interview of Mental Status (BIMS) test score of 6. A score of six identified the resident had severe long and short term memory impairments. Facility staff provided limited assistance for bed mobility, transfers, ambulation, toilet use, and personal hygiene. The assessment identified the Resident # 5 had functional range of motion impairments of both the upper and lower extremities. The test for balance identified the resident unable to stabilize his/her balance without staff assistance when walking, making surface to surface transfers, and when moving from a seated position to standing position. The Admission face sheet for Resident # 5 documented a subdural hematoma brain bleed, dementia, [DIAGNOSES REDACTED], GERD, and incontinence for diagnoses. A Fall Risk Assessment completed on 09/12/2012 with a score of 11 placed Resident # 5 in the high risk category. The Nursing Home physician readmission order's dated 11/09/2012 called for transfers to be completed with the assistance of 1 (one) staff when the resident was up and during transfers. A review of the medical record nursing notes revealed the following entries: * Resident # 5 returned to the facility on [DATE] after a hospitalization on [DATE] for cellulitis of both lower extremities. *The 11/16/2012 (12:00) nursing note documented the physician's orders [REDACTED]. *11/22/2012 at 2:20 P.M., Resident # 5 found seated on the floor next to a recliner. No mention of any alarms or new interventions. A fax communication to the Physician, dated 11/23/2012, informed the Physician staff found Resident # 5 on the floor in his/her room. The fax failed to contain any new interventions at that time. *The nursing notes dated 11/25/2012 at 10:00 A.M., documented Resident # 5 up ambulating in the hall with a walker. No mention of any assistance being given. The nursing notes dated 11/30/2012 at 12:20 P.M., staff documented the resident fell in the lobby. No witness except another resident. The Incident/Accident Report dated 11/30/2012 at 12:20 P.M. documented Resident # 7 told staff Resident # 5 had been up ambulating in the lobby and just fell to his/her left side. The incident report documented the resident complained of pain to the left hip area. The form documented a bed and chair alarm placed on the resident after the incident but none on before the accident. The Resident Fall and Injury Monitoring form completed at that time documented Resident #5's last seen observation by staff to be 45 minutes prior to the incident. Nursing notes dated 11/30/12 at 12:20 a.m., documented the resident fell in lobby area. The resident reported having left hip pain. The notes documented the mobile medical results received, and all normal. The notes documented at 6:30 p.m., the resident continued to complain of left hip discomfort, and had difficulty raising his/her leg when staff applied cream to his/her lower extremity. Nursing Notes dated 12/1/12 (no time) identified the resident continued to complain of pain and unable to raise his/her left leg more than a foot off the ground. The resident refused anything for pain. The nursing notes dated 12/1/12 at 1 p.m. the resident still complained of pain to left hip and refused to take pain medication. The nursing noted dated 12/2/12 identified the resident could not bear weight to left ankle and hip. The nursing notes dated 12/3/12 identified the resident's left hip had been assessed, with no bruising, however the resident continued to experience discomfort with elevating it when bearing weight. The nursing notes dated 12/4/12 documented the resident continued to complain of pain. The facility notified the physician for a second X-ray. The notes identified a second X-ray completed on 12/6/12, and identified no injuries to the resident's left hip. The nursing notes dated 12/7/12 identified the resident continued to complain of pain and asking for stronger pain medication. The nursing notes dated 12/7/12 to 12/13/12 identified the resident continue to complain of pain. The nursing notes dated 12/14/12 documented the resident would have a CT (Computerized Tomograpy). A mobile hip Xray found no fracture at the time of the accident, however on 12/14/2012 a CT scan revealed a fracture of the (L) hip. The plan of care with a problem date of 5/16/2011 (impaired physical mobility) and an initial approach date of 9/29/2011 directed facility staff to provide the resident with stand by assist of 1 staff for long distances; and to use a walker with ambulation in the room. The plan indicated the facility discontinued a body alarm on 10/23/2012; and then on 11/30/2012 (the day of the resident's fall and fracture) placed a bed and chair alarm on the resident. An update on 12/07/2012 directed 1 to 2 staff to assist the resident with the walker and ambulation. In an interview on 01/02/2013 at 2:30 P.M., Staff L (Registered Nurse) verbalized being the nurse on duty at the time of Resident # 5's fall on 11/30/2013. The only person in the lobby at the time of the incident was Resident # 7. Staff L verbalized Resident # 5's care plan called for 1 assist when the resident ambulated. The resident used no body alarm prior to the fall due to being non-compliant about leaving it on. The facility started a pressure alarm after the fall. During an interview on 01/02/2013 at 4:45 P.M., Resident # 7 verbalized being in the lobby with Resident # 5 on 11/30/2012. Resident # 7's BIMS (Brief Interview of Mental Status) score of 14 on the 10/26/2012 MDS (Minimum Data Set) indicated no issues with long and short term memory. Resident # 7 verbalized Resident # 5 sat in a wheel chair and just got up and fell over. In an interview on 01/03/2013 at 8:35 A.M., Staff C (Registered Nurse) remembered Resident # 5 as non-compliant with using the call light or remembering not to get up without assistance. One night on the night shift, while walking past Resident # 5's room, Staff C found the resident up and on the way to the bathroom without assistance. Staff C verbalized Resident # 5 did not have any alarm until after the 11/30/2012 fall even though staff would find him/her up without assistance. Resident # 5 did fall prior to the 11/30/2012 fall, but Staff C could not recall dates. During an interview on 01/03/2013 at 9:37 A.M., Staff J (Certified Nursing Assistant) verbalized Resident # 5 needed to have the assistance of 1 staff and a walker to ambulate prior to the 11/30/2012 fall. Staff J admitted finding Resident # 5 up in his/her room multiple times alone and without the walker. In an interview on 01/03/2013 at 9:50 A.M., Staff F (Registered Nurse) verbalized Resident # 5 did not use the call light for assistance and would take the body alarm off before the facility discontinued it. During an interview on 01/03/2013 at 8:45 A.M., Staff I (Certified Nursing Assistant) verbalized Resident # 5 fell in October 2012. Remembered finding the resident on the floor by the recliner. Did not recall hearing an alarm or not, but knew the resident had a habit of taking the alarm off and never used the call light for help. On 01/02/2013 at 1:15 P.M., Staff A (Registered Nurse) verbalized finding Resident # 5 on the floor on 11/30/2012 after falling earlier that day and having the portable Xray. ** No documentation of this could be found in the resident's chart. Staff A could not remember if the resident had a pressure alarm at that time. Staff A verbalized getting moved from section to section to work and being new to the facility. During an interview on 01/03/2012 at 10:40 A.M., The Director of Nursing verbalized the body alarm did get discontinued sometime prior to the 11/30/2012 fall because of not leaving the alarm on and the facility put no other intervention in place. After the 11/30/2012 fall, the facility placed a pressure alarm on the resident. The Director of Nursing admitted being aware Resident # 5 continued to get up without assistance after the removal of the body alarm, but should be up with the assistance of 1 staff person.