Every finding on record at Perry Lutheran Home

Based on observation, staff interviews and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service. The facility reported a census of 50 residents.Findings include:On 4/1/26 at 11:20 AM an observation revealed Staff C, CNA assisted a resident seated at a lunch room table. Staff C walked to another resident who attempted to stand up. Staff C explained politely to the resident that he would assist the resident in eating lunch. Staff C sat down next to the resident, did not complete hand hygiene, used a fork and assisted the resident in taking some bites of food. On 4/1/26 at 1:48 PM Staff C explained that Resident #2 required assistance today with lunch. Staff C explained he washes his hands in the big bathroom usually. Staff C acknowledged he did not complete hand hygiene prior to assisting Resident #2 with the lunch meal today. On 4/2/26 at 11:30 AM the Administrator explained she expected that staff assisting a resident with any meal would have completed hand hygiene prior to and after the staff assisted the resident. Review of a policy provided by the facility dated 2/5/22 titled, Hand Washing Technique documented handwashing before and after physical contact with each resident is the single most important means of preventing the spread of infection. Staff should always wash hands before and after physical contact with each resident, after handling a source that was likely to be contaminated (equipment, dressings and secretions from the resident), before eating, drinking, or handling food.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices to ensure use of Enhanced Barrier Precautions (EBP) when required during catheter care for 1 (Resident #48) of 2 residents reviewed. The facility reported a census of 50 residents. Findings include:The Minimum Data Set (MDS) for Resident #48, dated 3/10/26, included diagnoses of cancer, urinary tract infection in the past 30 days, and retention of urine. The MDS revealed the resident had an indwelling urinary catheter (tube into the bladder to drain urine).The Care Plan with initiated date 3/10/26, revealed the resident required EBP related to indwelling catheter. Observation on 3/31/26 at 1:32 PM, Staff B, Certified Nurse Aide entered Resident #48's room, with an EBP sign on the door, washed her hands and applied gloves only. Staff B proceeded to cleanse the tip of the catheter bag drain tube, drain the urine from the catheter bag, and cleansed the catheter bag drain tube again. Staff B removed her gloves and washed hands. Interview on 3/31/26 at 1:40 PM - Staff B stated EBP is for residents with catheters and wounds and the personal protective equipment (PPE) required for any cares with residents on EBP was a gown, face mask, and gloves. Staff B stated she should have worn a gown to empty the resident's catheter bag. Facility Enhanced Barrier Precautions policy, dated 3/2026, revealed EBP is an approach of targeted gown and glove use during high contact resident care activities and EBP will be implemented for residents with urinary catheters. Interview on 4/01/26 at 1:50 PM, the Infection Preventionist stated expectation for staff to wear a gown and gloves when providing any high contact care for residents on EBP, which includes catheter care.

Based on clinical record review, staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents for 3 of 5 resident reviewed for vaccines (#2, #35, and #38). The facility reported a census of 50 residents.Findings include:1.Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of diabetes mellitus, non-Alzheimer's dementia, and hypertension. It revealed the resident was not up to date with the COVID-19 vaccination.A physician's order dated 10/09/25 docoumented the resident may have annual flu vaccine unless contraindicated with resident or responsible party permission. It did not include a COVID-19 vaccination order.The Electronic Health Record (EHR) included a document titled Flu, RSV, Pneumonia Vaccines and Covid Booster Consents dated 7/25/25 indicated the resident's Power-of-Attorney (POA) consented to receive the COVID-19 booster yearly.The Clinical Immunizations tab lacked a documented COVID-19 vaccination after 10/07/24.The Progress Notes did not include any documentation the resident received a COVID-19 vaccination.The Care Plan did not include any documented vaccinations.2. Resident #35's MDS assessment dated [DATE] identified a BIMS score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and hypertension. It revealed the resident was not up to date with the COVID-19 vaccination.A physician's order dated 10/09/25 documented the resident may have annual flu vaccine unless contraindicated with resident or responsible party permission. It did not include a COVID-19 vaccination order.The EHR included a document titled Influenza, Pneumonia, and Covid Vaccine Consent dated 8/18/25 did not indicate a verbal response from the resident's POA.The Clinical Immunizations tab lacked a documented COVID-19 vaccination after 10/07/24.The Progress Notes did not include any documentation the resident received a COVID-19 vaccination.The Care Plan did not include any documented vaccinations.3. Resident #38's MDS assessment dated [DATE] revealed a BIMS score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and hypertension. It revealed the resident was not up to date with the COVID-19 vaccination.A physician's order dated 10/09/25 documented the resident may have annual flu vaccine unless contraindicated with resident or responsible party permission. It did not include a COVID-19 vaccination order.The EHR included a document titled Flu, RSV, Pneumonia Vaccines and Covid Booster Consents dated 11/05/24 indicated the resident's POA consented to receive the COVID-19 booster yearly.The Clinical Immunizations tab lacked a documented COVID-19 vaccination after 10/07/24.The Progress Notes did not include any documentation the resident received a COVID-19 booster after 11/07/24.The Care Plan did not include any documented vaccinations.A CDC document titled Recommended Adult Immunization Schedule 2025 for Ages 19 Years or Older indicated the COVID-19 vaccination is based on individual-based decision-making-with an emphasis that the risk-benefit of vaccination is most favorable for individuals who are at an increased risk for severe COVID-19 disease and lowest for individuals who are not at an increased risk according to the CDC list of COVID-19 risk factors.On 4/01/26 at 12:59 PM, the Administrator stated the facility always contacts the POA for all resident immunizations. She also stated Staff A, Medical Records clerk provided the information to the POAs based on the CDC information sheet and completed the consent forms.On 4/01/26 at 1:05 PM, Staff A stated a check mark is placed beside the resident's or resident representative's decision for each vaccination offered.A policy titled Infection Control COVID-19 revised 10/24/24 indicated All residents/tenants and staff will be screened upon admission/hire for COVID-19 vaccination status. If the resident/tenant or staff is not up to date (as defined by the CDC and referenced under the definition section of this policy), the resident/tenant, their representative (as appropriate) or staff member will be provided education on the benefits, risks and potential adverse effects of the COVID-19 vaccines. Upon review of the educational items provided to the resident or staff, they will be given an opportunity to consent or decline COVID-19 vaccination, in coordination with the attending physician or medical director. Anytime the FDA authorizes, and CDC approves use of additional COVID-19 vaccines and/or doses, education will be provided to all residents/tenants (or their representatives as appropriate) and staff members who are not up to date on the COVID-19 vaccine(s), and an updated consent/declination will be completed. If available and able, COVID-19 vaccines will be administered by the provider. If the COVID-19 vaccines are not available/able to be administered by the provider: Resident/tenant's will be assisted with setting up an appointment and transportation to/from a vaccine provider for receipt of the vaccine. Staff members will be provided information on locations that are able to administer the vaccine and assisted as much as possible to obtain vaccination. All resident/tenant and staff vaccination status' will be documented either in the resident/tenant's medical record or in the staff's medical file.

Based on observations, staff interviews and the peri care audit review, the facility failed to provide proper hand hygiene while providing incontinence care with 1 of 1 residents (Resident #3) observed. The facility reported a total census of 56 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of Alzheimer's Disease, arthritis, hip fracture, and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.Observation on 1/5/25 at 3:45 pm with Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA performed hand hygiene prior to applying gloves, then proceeded to put on their enhanced barrier precautions (EBP). Staff A and Staff B proceeded to remove Resident #3's pants and soiled brief. Staff A cleansed the front perineal area and then Staff A and Staff B rolled Resident #3 towards Staff A and Staff B cleansed the back side of Resident #3. Staff B removed the soiled brief and bed pad, then placed the new brief and bed pad under Resident #3. Staff B then rolled Resident #3 towards herself and Staff A then finished putting on the new brief and bed pad. Both Staff A and Staff B proceeded to pull up Resident #3's pants, then applied a sling under Resident #3 for the mechanical lift still with soiled gloves. After the sling was placed on Resident #3, then, Staff A and Staff B changed their gloves, but failed to perform hand hygiene. Staff A and Staff B then applied new gloves and utilized the mechanical lift to transfer Resident #3 out of bed into her wheelchair. After Resident #3 was up in the wheelchair and leg pedals put on, they placed a blanket on Resident #3 and combed her hair. Both staff members failed to change their gloves and perform hand hygiene throughout the process of performing peri care.Interview on 1/7/26 at 1:03pm with Staff A, CNA stated that she should have changed her gloves and performed hand hygiene during the peri care process.Review of the facility provided undated Peri Care Audit revealed the following information:Wash hands and put on gloves. Remove any badly soiled pads, clothing, linens and place in container/bag per protocol. If pad is heavily soiled it can be turned on itself to expose dry surface area. If removal of soiled linen occurs, then change gloves.Clean the lower abdomen, anterior thighs and dry, as needed.Place soiled wash cloths on cloth towel or preferably in a plastic bagRemove gloves before turning resident to their side, unless using buddy systemWash buttocks and both sides of upper thighs - be sure to dry the skin.Wash anal area, front to back using facility choice of solution and cloths/wipes. 9. Bag soiled cloths/wipes per facility choice. Be sure to dry the skin. 10. Remove gloves, wash hands and roll resident to side onto a clean, dry surface. 11. Wash the opposite hip and dry. Remove gloves. 12. Remove gloves, wash hands and re-apply gloves. 13. Apply moisture barrier per facility protocol. Note: must use new gloves if additional barrier must be removed from container for further application. 14. Remove gloves and cleanse hands when application is complete.Interview on 1/7/26 at 12:45 pm with the DON stated she would expect the staff to change gloves and perform hand hygiene while performing peri care.

Based on clinical record review, family interview, staff interviews, police dispatch interview and policy review, the facility failed to appropriately assess and provide intervention to 1 of 3 residents reviewed (Resident #2) for hospitalization and further failed to follow physician orders and provide adequate intervention for low blood sugars (Resident #2). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia and respiratory failure. The MDS revealed the resident was on high risk drug classes to include insulin and had received insulin injections 7 days of the 7 day look back period. The Care Plan for Resident #2, with an initiation date of [DATE], included a focus area: resident had a diagnosis of diabetes and was at risk for frequent infections, alteration of skin, visual impairment, hyper/hypoglycemia, renal failure and cognitive/physical impairment. The Care Plan interventions instructed staff as follows: Administer medications and obtain labs as ordered. Observe blood glucose levels as ordered.Administer meds as ordered. Report noted signs of hypoglycemia: blood sugar 50 mg/dl, shakiness, sweating, chills, clamminess, change in mentation, abdominal discomfort. Report noted signs of hyperglycemia: high blood sugar, increased thirst, blurred vision, headache, frequent urination. Give HS (hour of sleep) snack to prevent hypoglycemia overnight. Observe skin for changes- redness, circulatory problems, breakdown, etc. Report noted signs of hyperglycemia thirst, excessive appetite or voiding, change in level of consciousness or mood, report to physician as indicated. Review of the Electronic Health Record (EHR) for Resident #2 revealed the following orders: Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/ml (insulin glargine), inject 24 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus with other diabetic kidney complication; Type 2 Diabetes Mellitus with diabetic nephropathy. Start date of [DATE]. Scheduled to be given in the AM- 7:00 AM. Tirzepatide Subcutaneous Solution Auto-Injector 5 mg/0.5ml (Tirzepatide), inject 0.5 ml subcutaneously one time a day every Monday related to Type 2 Diabetes Mellitus with other diabetic kidney complication; Type 2 Diabetes Mellitus with diabetic nephropathy. Start date of [DATE]. Scheduled to be given in the PM- 4:00 PM. Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro) inject 6 unit subcutaneously three times a day related to Type 2 Diabetes Mellitus with diabetic nephropathy, hold if BS (blood sugar) is less than 120. Start date of [DATE]. Scheduled to be given in the AM- 7:00 AM, at noon and in the PM- 4:00 PM. Check Blood Sugar three times a day related to Type 2 Diabetes Mellitus with other diabetic kidney complication. Start date of [DATE]. Scheduled to be checked in the AM-7:00 AM, at noon and in the PM- 4:00 PM. Review of the EHR for Resident #2 lacked an order for Glucagon Emergency Injection Kit and lacked an order for Glucose Oral Tablet prior to [DATE]. Review of the Treatment Administration Record (TAR) for Resident #2 for the month of [DATE], revealed on [DATE] the scheduled medication Tirzepatide Subcutaneous Solution Auto-Injector 5 mg/0.5ml was not given at the scheduled time of 4:00 PM. The scheduled blood sugar check for 4:00 PM was not completed and the scheduled Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-injector 100 unit/ml was not given to the resident at the scheduled time of 4:00 PM. The TAR documented a 9, which is a code for other/see nurse notes. Review of the EHR for Resident #2 revealed the following Progress Notes completed by Staff A, Registered Nurse (RN):Progress note dated [DATE] at 6:30 PM, titled EMAR-Administration Note, Note Text: Tirzepatide Subcutaneous Solution Auto-Injector 5 mg/0.5ml (Tizrapatide), inject 0.5 ml subcutaneously one time a day every Monday related to Type 2 Diabetes Mellitus with other diabetic kidney complication; Type 2 Diabetes Mellitus with diabetic nephropathy. Blood sugar 27 held. Progress note dated [DATE] at 6:30 PM, titled EMAR-Administration Note, Note Text: Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro) inject 6 unit subcutaneously three times a day related to Type 2 Diabetes Mellitus with diabetic nephropathy, hold if BS (blood sugar) is less than 120. Blood sugar 27 held. Progress note dated [DATE] at 6:50 PM, titled Nurses Note, Note Text: Called to resident room by family member, she stated the resident is unresponsive. Nurse went to the room to find resident to be responding to pain only. Blood sugar checked and results 27. Family asked nurse to call 911, nurse told her she had protocols to follow and that is not the first thing to do. Family requested that they lay resident on the floor, CNA (Certified Nursing Assistant) and family member laid her on the floor. Family member called 911 and the police department responded. Family member ordered the police officers to do CPR and they obliged and started CPR. Ambulance crew arrived and stopped CPR. IV (intravenous) was started Glucagon given per paramedics. Responsive after Glucagon given. Loaded on cot and taken to local hospital. Review of the hospital record for Resident #2 with an admit date of [DATE] revealed the resident was admitted to the hospital from the emergency department on [DATE] at 8:37 PM. The hospital record documented the resident presented to the emergency department for altered mental status and per EMS record and discussion with facility, resident was visited by family at 7:00 PM when resident was alert but not responding to commands, she gradually became less responsive and a family member called 911 and on arrival chest compressions were performed. The resident's blood glucose was found to be 27 and EMS gave IV glucagon, the resident was immediately more alert, responsive after, but reported nausea and shortness of breath. In total, the resident received 2 minutes of chest compressions without additional IV medications or shock. The Resident was treated in the emergency department with Bumex 1mg, Dextrose 50 W injection and initially placed on dextrose infusion. The hospital record documented under the assessment and plan section diagnoses of acute toxic metabolic encephalopathy and severe hypoglycemia (Severe hypoglycemia is a condition where blood glucose levels drop dangerously low, typically below 54. It is a medical emergency that requires immediate medical attention, severe hypoglycemia can be life-threatening and requires treatment with emergency glucagon and/or medical intervention.). The plan was glucose checks every two hours for uptrend and dextrose 10% 50ml/hr infusion. During an interview [DATE] at 1:45 PM, Staff A, RN, stated she recalled Resident #2 and recalled what happened on the 18th of August, 2025. Staff A stated on the 18th of August she worked the 6:00 PM to 6:00 AM shift. When she arrived for her shift, the 6:00 AM to 6:00 PM nurse, Staff B, Licensed Practical Nurse (LPN), gave her a shift change report and told her that she had not had time to go down to Resident #2's room to check her blood sugar (BS), scheduled for 4:00 PM, or give her the scheduled insulin (Lispro) or her scheduled Tirzepatide, both are scheduled for 4:00 pm, with a two hour window. Staff A stated at around 6:40 PM a family member arrived to see Resident #2 and then yelled down the hall for Staff A to come to the room, stating Resident #2 was unresponsive. Staff A stated she went down to the resident's room, this was around 6:40 PM, and the resident was in her reclining chair. She stated the resident did respond to painful stimuli, but was not responding to verbal commands or communicating verbally. Staff A took the resident's blood sugar and it was at 27 (A blood sugar level below 70 is low and can be harmful, a blood sugar level below 54 is a cause for immediate action; Medical Encyclopedia). Staff A stated she went back to her medication cart in the hallway to look for Glucagon (Emergency Injection Kit) and could not find Glucagon in the medication cart. Staff A stated she looked for an order for this resident for Glucagon and could not find an order. She looked for all residents in the facility for an order for Glucagon and could not find any orders. Staff A asked for assistance from other staff to look in the medication cart on the 2nd floor for Glucagon. There was not any Glucagon in the medication cart on the 2nd floor, or on the 1st floor. Staff A stated she looked for Glucagon for approximately 15 minutes and the family member called 911 at approximately 7:00 PM. Staff A stated she should have given the resident some sugar such as in the form of juice when she could not find the Glucagon, however she did not do this, nor did she call the resident's primary care physician (PCP). The Police Department arrived before the paramedics. Staff A stated the resident's pulse was normal and her oxygen saturation was normal. The family member asked the police to perform CPR, which they did. When the paramedics arrived, they stopped the CPR and they administered Glucagon. Staff A stated the resident's blood sugar should have been checked prior to 6:00 PM when Staff A arrived for her scheduled shift. The 4:00 PM scheduled blood sugar check and Insulin Lispro was not completed or administered, and the scheduled 4:00 PM Tirzepatide was not administered. Staff A stated she did not go down to the resident's room prior to the family member calling out for help, she had not had a chance to go down to the resident's room to check her blood sugar, or give her the two scheduled medications for diabetes mellitus. Staff A stated the window for these orders ended at 6:00 PM, however she had intended on getting to the resident's room as soon as she could after she arrived for her shift as she was informed by Staff B that these orders were not completed yet. Staff A stated she only checked the blood sugar for the resident after the family member told her the resident was unresponsive and said she thought it was due to low blood sugars. During an interview [DATE] at 2:20 PM, Staff B, LPN, stated she recalled Resident #2 and recalled working on [DATE], the 6:00 AM to 6:00 PM shift. Staff B stated the resident was tired that day, however she was normally tired. Staff B recalled checking the resident's blood sugar at 7:00 AM, this was under 120 and the Insulin Lispro was held, not given. At 12:00 PM, the resident had a blood sugar over 120 and the Insulin Lispro was given. Staff B stated she did not get back down to the resident's room for her 4:00 PM blood sugar check or to administer the 4:00 PM dose of Insulin Lispro if the resident's blood sugar would have been over 120. She also did not administer the 4:00 PM scheduled Tirzepatide. Staff B stated when the 6:00 PM nurse came on duty, she informed Staff A that she had not checked the resident's blood sugar yet or given the Insulin Lispro or the Tirzepatide. Staff B stated she last checked on the resident in the afternoon and the resident was resting. Staff B believed there was a two hour window to complete the scheduled 4:00 PM blood sugar and administer the Insulin Lispro if the blood sugar was over 120, and to administer the Tirzepatide. The window would have closed at 6:00 PM. Staff B stated she recalled the resident had a shower that afternoon, around 3:00 PM, and was doing well at that time. During an interview [DATE] at 2:30 PM, the Administrator stated the facility completed a Quality Assessment (QA) summary regarding the events on [DATE] with Resident #2. The Administrator stated Staff A was going back and forth between the medication cart to check vitals and find a glucometer and Glucagon. The Administrator stated the facility now has Glucagon in all of the carts, it was not in the carts that night. The Administrator acknowledged the resident did not have an order for Glucagon on or prior to [DATE]. The Administrator stated the facility now has orders for Glucagon for all residents who have a diagnosis of Diabetes Mellitus (DM). The Administrator stated an expectation Staff B would have given the resident her 4:00 PM scheduled medication related to DM, and checked the resident's blood sugar before 6:00 PM. Staff B was outside the scheduling window. The Administrator stated there was Glucagon in the E-kit. She acknowledged Staff A did not use the Glucagon in the E-kit and did not administer juice or a carbohydrate to the resident The Administrator stated Staff B was given corrective action related to the incident on [DATE] with Resident #2. Review the EHR for Resident #2 revealed blood sugar under 70 on three separate occasions in the month of August, 2025: On [DATE] the resident's blood sugar was 68 in the AM. On [DATE] the resident's blood sugar was 60 in the AM. On [DATE] the resident's blood sugar was 55 in the AM. Staff B, LPN, performed the blood sugar checks on the 10th and on the 11th. Review of the EHR lacked documentation of steps taken to bring the resident's blood sugar up past 70. During an interview [DATE] at 9:20 AM, Staff B, LPN, stated she could not recall what steps she took when Resident #2's blood sugars were under 70. Staff B stated the protocol is to give the resident a glass of juice or a carbohydrate, depending on the resident's full symptoms, inform the PCP and re-check the blood sugar within 15 to 30 minutes, and continue to check on the resident. Staff B could not recall what steps she took, if any, when Resident #2's blood sugars were under 70. She stated the steps taken should be documented in the EHR. During an interview [DATE] at 9:30 AM, the Director of Nursing (DON) stated the facility policy and standard of practice would be to offer juice, depending on full symptoms, to a resident who had a blood sugar under 70 and re-check the blood sugar within 20-30 minutes. The DON stated an expectation the steps taken to bring the blood sugar above 70 be documented in the EHR. The DON acknowledged a lack of documentation in the EHR for steps taken to raise the blood sugar of Resident #2 when it was below 70. During an interview [DATE] at 9:35 AM, a family member of Resident #2 stated she came to visit the resident on [DATE] a little before 7:00 PM. When the family member arrived at the resident's room, the resident was slumped over to the right in a reclining chair and would not respond. The family member lifted the resident's head and the resident did not respond, her eyes were glazed and fixed and she had drool coming out of her mouth. The family member yelled down the hallway for help, two staff members were in the hallway and did not respond initially. The family member continued to yell for help and Staff A, along with a Certified Nursing Assistant (CNA), came into the room, Staff C. The family member told Staff A that a blood sugar check should be completed, she told the nurse the resident was unresponsive. The family member stated the nurse did not check vital signs and walked out of the room to get the glucometer to check blood sugar. Staff A returned to the room and realized she did not have the strip for the glucometer and went back out into the hallway. Staff A returned to the room and checked the resident's blood sugar, which was at 27. The family member asked Staff A to call for an ambulance and Staff A said not yet. Staff A left the room and did not return. The family member said she followed Staff A and asked her again to call for an ambulance and Staff A told the family member to go ahead and do it herself. The family member called 911 and talked to dispatch. The family member said she was left alone in the room with Resident #2 and Resident #2 was still unresponsive and not able to talk or move on her own. The family member told dispatch what was happening and dispatch walked her through what to do, dispatch had her check the resident's pulse and breathing, her breathing was slow and shallow. Dispatch instructed the family member to lower the resident to the floor. The family member was unable to do this alone, she called out for help again. A CNA came into the room eventually and assisted the family member to lower the resident to the floor, Staff C. Dispatch asked if there was an Automated External Defibrillator (AED) and the family member asked the CNA if there was an AED, the CNA said she did not know. The police arrived then and an officer started doing CPR right away. The family member said she told the officer maybe CPR should not be done, the officer said once it was started it could not be stopped. The paramedics arrived shortly after and took over. The family member stated during all of this time, Staff A did not return to the room to assist. Staff A returned to the room after the paramedics arrived and said they did not have an order or any Glucagon in the facility. During an interview [DATE] at 10:00 AM, the local Police Department stated a call came in to dispatch on [DATE] at 7:10 PM for medical assistance for Resident #2. They do not have a police report or names of officers responding as this was a medical call. Dispatch would have stayed on the phone with the caller until assistance arrived. During an interview [DATE] at 12:10 PM, Staff C, CNA, stated she recalled working on [DATE], a 4:00 PM to 8:00 PM shift in a CNA role. Staff C stated she is also a CMA (Certified Medical Assistant). She might have stayed later that evening, to around 8:30 PM. Staff C stated she was working on the floor and hallway where Resident #2 resided when a family member yelled out for help. Staff C stated she went down to the resident's room and the family member stated she thought the resident's blood sugar was low. Staff C observed the resident in her reclining chair, she appeared to be sleeping. Staff C stated the resident was unresponsive, she did not respond when Staff C said her name, her eyes were closed. Staff C stated she ran to get Staff A, RN, and to get the blood pressure cuff to check the resident's vitals. Staff C told Staff A that the resident was unresponsive and they needed to check her blood sugar and do vitals. Staff C believed she grabbed the glucometer and she and Staff A returned to the resident's room. Staff C believed she took the blood sugar first, it was at 27. Staff A re-took the blood sugar and it continued to read at 27. Staff C took the resident's pulse and it was at 97 she believed. Staff C stated she did not take the resident's blood pressure, she cannot be sure if Staff A took the resident's blood pressure reading. Staff C stated it was a chaotic situation. Staff A left the room and the family member asked if Staff A was going to call for an ambulance. Staff A told the family member that she was not calling an ambulance yet, she needed to follow protocol. Staff C stated she is not sure what the protocol entailed, she believed Staff A was looking for an order for Glucagon and checking to see what the resident's code status was. The family member asked over and over for Staff A to call for an ambulance, Staff A eventually told the family member she could call for an ambulance if she wanted to call. Staff C stated she was running back and forth and then the family member asked for her help to move the resident from the chair to the floor. The family member was alone in the resident's room at this time. The family member was on the phone with dispatch at the time. The resident was still unresponsive. Staff C stated Staff A was looking for Glucagon and they did not have any in the facility that could be found. The police arrived before the paramedics. Review of the EHR for Resident #2 lacked documentation regarding the resident's blood pressure, temperature and pulse for [DATE] at the time of resident being reported as unresponsive. During an interview [DATE] at 2:50 PM, the DON stated the blood pressure, temperature and pulse readings should be in the EHR for the evening of [DATE] when the resident was reported as unresponsive and stated an expectation the resident's vitals were taken and documented in the EHR. Review of the facility policy Diabetic Management (Blood Glucose Monitoring), updated [DATE], documented the process if a resident had hypoglycemia and is responsive and able to swallow safely: 1. Test the blood glucose. If less than 70, recheck the blood glucose. 2. If blood glucose remains below 70, give 15 grams of carbohydrates. (give one of the following options) * 4-6 ounces Fruit Juice * 4-6 ounces of soda pop * 8 ounces of skim milk* 3-4 packets of table sugar in juice* 4 glucose tablets * One tube (15 ounces) glucose gel (if ordered)3. Monitor the resident closely. Re-check the blood glucose within 15 minutes, or sooner, if resident condition warrants.If the blood glucose remains low (<70), administer another 15-gram dose of carbohydrates and notify the physician. Follow any orders/instructions. Repeat until blood sugar is noted to be >70. 4. Once stabilized, the resident should receive a snack (such as, peanut butter sandwich and 8 ounces skim milk) or the next scheduled meal if within 30 minutes. 5. Update the physician and family of hypoglycemic episode and corrective measures unless otherwise directed by physician orders or as directed by family. If the resident is unresponsive and/or unable to swallow:1. Test the blood glucose. If below 70, recheck the blood glucose2. If the blood glucose remains below 70 and is unresponsive, give Glucagon 1mg. IM or SQ x1 dose, as ordered 3. Monitor the resident closely and assess level of consciousness and vital signs4. Repeat the blood glucose in 15 minutes 5. If blood glucose remains <70 and the resident is not able or willing to consume nutrition, call 911 and transfer to the hospital. 6. If the blood glucose is <70 and the resident is responsive and able to swallow follow the interventions in Process A. 7. Notify the physician and family of episode and interventions 8. Document series of events in the Progress Notes- Provide follow up documentation as deemed necessary. If at any time family/responsible party requests transfer to ER, call for ambulance and notify physician. Review of the facility policy Medication and Treatment Orders, dated 2024, documented orders need to be written completely and followed as ordered.

Based on observations, clinical record review, staff interview, and policy review, the facility failed to maintain infection control standards by staff not disinfecting a facility multi-resident use glucose machine (device to measure blood sugar) after use, failed to complete hand hygiene between administering medications for 4 of 5 residents, failed to change gloves and sanitize hands during cares and failed to apply personal protective equipment for catheter and incontinent care for 1 of 1 resident (Resident #23) reviewed. The facility reported a census of 60 residents. Findings include: 1. Observation showed on 3/11/25 from 11:10 AM - 12 PM, Staff C, Certified Medication Aide (CMA) administered medications to 4 different residents. Staff A did not wash or sanitize hands before or after administering medications to each of the 4 residents. Facility policy Medication Administration Procedures dated January 2025, revealed to cleanse hands before handling medication and before contact with resident. Interview on 3/12/25 at 4:31 PM, the Assistant Director of Nursing (ADON) stated expectation for staff to complete hand hygiene between residents when administering medication. 2. Observation and interview on 3/12/25 at 7:54 AM, Staff D, CMA completed a resident's blood sugar check with the glucose machine and then placed the glucose machine in the medication cart in an open box of lancets (device to puncture a person's skin for blood) without disinfecting the glucose machine. When asked about disinfecting the glucose machine, Staff D stated the glucose machine is a facility machine which is currently used for 2 other residents on the unit also. Staff D then wiped the glucose machine with an alcohol swab and placed the glucose machine back in the box and stated she always just wipes off the glucose machine with an alcohol swab. Facility policy Finger Stick Glucose Check Protocol, dated 6/2024 revealed if using a community wide glucose machine, disinfect after each use following the manufacturer's guidelines for drying time. Interview on 3/12/25 at 3:09 PM, the ADON stated expectation to disinfect the glucose machine after each use with a disinfecting wipe and the glucose machine must remain wet with the disinfectant for 3 minutes per instructions. 49056 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 documented diagnosis as peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain), benign prostatic hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal, potentially causing urinary difficulties), hip fracture and depression. The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. During an observation completed on 3/12/25 at 4:30 PM with Staff E, Certified Nursing Assistant (CNA), the aide failed to apply personal protective equipment per Enhanced Barrier Precautions (EBP) when providing catheter care on Resident #23. Observed the EBP's signage on the door of Resident #23. Interview on 3/12/25 at 4:50 PM with Staff E stated she had started back at the facility around three weeks ago and had been told that it depends when to wear it. Staff E stated she realized she should have worn a gown during the catheter care process. Interview on 3/13/25 at 2:05 PM with the Assistant Director of Nursing (ADON) stated that all staff need to utilize the Enhanced Barrier Precautions when needed. Review of the facility policy named Enhanced Barrier Precautions dated June 24, revealed EBP's are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP's are an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of CDC-targeted MDROs. EBP's should be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Chronic wounds (include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers) and indwelling medical devices, regardless of MDRO colonization status. (indwelling device examples include central/PICC lines, urinary catheters, feeding tubes and tracheotomies). 4. Observation completed on 3/12/25 at 4:30 PM with Staff E, CNA and Staff F, CNA. Staff E and Staff F performed hand hygiene prior to applying gloves then proceeded to perform pericare on Resident #23. Staff E and Staff F assisted pulling Resident #23's pants down, then proceeded to remove the dirty brief. Staff E with soiled gloves proceeded to utilize washcloths to perform perineal care. Staff E and Staff F rolled Resident #23 to his side then proceeded to utilize washcloths to perform perineal care. Staff E placed a clean brief, rolled Resident #23 to his back and fastened a new brief, then Staff E and Staff F proceeded to pull pants up. Staff F failed to change gloves and perform hand hygiene throughout the process of performing pericare. Interview on 3/12/25 at 4:50 PM with Staff F stated that she should have changed her gloves and performed hand hygiene more frequently than she did. Interview on 3/13/25 at 2:05 PM with the ADON stated that she expected staff to change gloves between cares and to sanitize/wash hands after cares are completed. Review of the facility provided Peri Care Audit revealed: 1. Assemble equipment: peri care items, bags, towel/blanket to cover for privacy. 2. Knock on door before entering. 3. Explain procedure to resident. 4. Provide privacy: i.e. room door/bathroom door, privacy & window curtains. 5. Wash hand & put on gloves. 6. Remove any badly soiled pads, clothing, linens & place in container/bag per protocol. If pad is not heavily soiled it can be turned on itself to expose dry surface area. 7. If removal of soiled linen occurs, then change gloves. 8. Clean the lower abdomen, anterior thighs and dry, as needed. 9. Place soiled wash cloths on a cloth towel or preferably in a plastic bag. 10. Remove gloves before turning resident to their side, unless using buddy system 11. Wash buttocks and both sides of upper thighs, be sure to dry the skin. 12. Wash anal area, front to back using facility choice of solution and cloths/wipes. 13. Remove gloves, wash hands and roll resident to side onto a clean, dry surface. 14. Wash the opposite hip and dry. Remove gloves. 15. Remove gloves, wash hands and re-apply gloves. a. Apply moisture barrier per facility protocol. Note: must use new gloves if additional barrier must be removed from container for further application. b. Remove gloves and cleanse hands when application is complete. 17. Pick up any soiled equipment used, place in plastic bag to remove to area to clean. 18. Wash hands.

Based on clinical record review, staff interviews, facility record review, and facility policy review the facility failed to implement specific fall interventions in a timely manner after 3 falls for 1 of 1 residents reviewed (Residents #3). The facility reported a total census of 60 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of non-Alzheimer's Dementia, anxiety, depression and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment cognition. Review of MDS dated [DATE] revealed Resident #3 was substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds the trunk or lungs and provides more than half the effort) with transfers and upper and lower body dressing. Review of the facility reported incident dated 2/14/25 at 7:05 AM revealed Resident #3 was walking with a staff member with her walker to the bathroom when she became weak. Resident #3 was lowered to the floor. Resident #3 assessed for injuries, and none found. The root cause analysis was performed and showed increased weakness which caused Resident #3's knees to buckle, the intervention will be to perform follow up labs to check infection status. The Care Plan has been updated with changes. Review of Resident #3's Care Plan with an initiated date of 2/17/25 revealed the intervention was to perform follow up labs to check infection status. Review of facility Progress Notes revealed lab work was obtained by staff on 2/18/25. Interview on 3/13/25 at 2:05 PM with he ADON and she stated she followed up with the nurse that filled out the incident report for the fall on 2/14/25 at 7:05 AM to encourage staff to utilize extra help if Resident #3 felt weak. The ADON confirmed and verified that this education was not documented. The ADON also confirmed that the lab work completed on 2/18/25 was the intervention for this fall and that no other intervention was put into place. Review of the facility reported incident dated 2/14/25 at 11:50 PM revealed Resident #3 was found on the floor lying on her left side, her knees were pulled up partway to her abdomen, resting on left arm and right arm over torso. Resident #3 was lying on top of her grabber, and had regular athletic socks on. Resident #3 was last seen at 11:15 PM. Resident #3 returned four days ago from the hospital due to pneumonia and on an antibiotic. Resident #3 has increased confusion. Resident #3 had no injuries observed at the time of the incident. The root cause analysis was performed and showed increased confusion. The intervention will be to update the physician of Resident #3 not being back to baseline and to follow his recommendations. The facility educated staff to utilize gripper socks during night time care. The Care Plan has been updated with changes. Review of the resident Care Plan with initiated date of 2/17/25 intervention revealed to update the physician regarding Resident #3 not being back to baseline and to follow physician recommendations. The facility failed to add documentation of utilizing the gripper socks with night time cares to the Care Plan. Review of facility Progress Notes on 2/15/25 at 4:02 AM revealed the immediate intervention was to put gripper socks on. Interview on 3/13/25 at 2:05 PM with the ADON and she stated she requested the floor nurse to update the physician on the condition of Resident #3 regarding the increased confusion and falls. The ADON acknowledged that the floor nurse faxed the results of the lab work with a note stating follow up CBC and CMP post hospital with pneumonia. Do you wish any changes, last dose of antibiotic given 2/17/25. The physician responded back with no changes on 2/20/25. The ADON acknowledged that there was not an intervention put into place for this fall. Review of the facility reported incident dated 2/16/25 at 10:45 PM revealed Resident #3 was found on the floor lying almost prone on the floor alongside her bed. Resident #3's right hip was resting on the base of her side table, left leg was lying partly on her right leg and her head was resting on the base of the side table. Resident #3's body was partially wrapped up in the bedding. Resident #3 had on athletic socks. Resident #3 stated I was trying to get out The basement, I was going to fall into the basement. I was hollering for my sister. Resident #3 received two new bruises, no other injuries noted. The immediate interventions were to place gripper socks on and the roll up blankets on the edges of the bed to remind Resident #3 of the mattress borders. The root cause analysis was performed and showed increased confusion, increased weakness, facility will request physical therapy to evaluate and treat orders and also educated staff to put on gripper socks during night time care. Review of resident Care Plan with initiated date of 2/17/25 revealed the intervention was to request physical therapy orders to evaluate and treat. The facility failed to add documentation of utilizing the gripper socks with night time cares to the Care Plan. Review of the facility Progress Notes dated 2/17/25 at 9:57 AM the son requested the bolster mattress be put back on Resident #3's bed. Review of the facility Progress Notes dated 2/21/25 at 9:34 AM the facility requested physical therapy orders and at 12:51 PM received orders for physical therapy. Review of the facility policy dated January 2025 and titled Falls and Fall Risk, Managing revealed: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. An interview on 3/13/25 at 2:05 PM with the ADON revealed that these falls happened on the weekend and she thinks they have 3 days to review them and put interventions in place. The ADON stated her expectation would be to have nursing implement timely interventions when the ADON is not available and they could put any simple interventions in place.

Based on observation, staff interview and policy review, the facility failed to store and maintain medications in a safe manner. The facility reported a census of 60 residents. Findings include: During an observation on 3/11/25 at 10:54 AM, the medication cart was located in the main hallway by the dining room on the CCDI (Chronic Confusion or Dementing Illness) unit, up against a wall, unlocked. On top of the medication cart was a bubble packet of prescription medication of Olanzapine (an Antipsychotic medication) with 2 pills left in the packet. The cart was left unattended. Approximately 3 minutes later Staff B, Licensed Practical Nurse (LPN), came out of the dining room to the cart. The cart was not observable from the dining room, there is a wall separating the cart from the dining room. Three residents were observed by the medication cart, two of the residents walking independently and one in a wheelchair. The cart was unattended upon arrival to the unit at 10:54 AM, with no nursing staff present, and was unattended for approximately 4 minutes of observation. During an interview on 3/11/25 at 11:05 AM, Staff B stated she does not normally leave the medication cart unlocked and unattended and stated she should never leave medications unattended on the cart. Staff B stated many of the residents on the CCDI unit, including one of them who walked past the medication cart several times, like to take items and carry them with them or into their rooms. Staff B stated one resident routinely takes the computer mouse off of the cart and takes it to her room (a resident who walked past the cart more than once). Staff B stated it is not safe to leave the medication cart unlocked and not safe to leave medications unattended on top of the cart. Staff B stated she was in the dining room attending to another resident. During an interview on 3/11/25 at 1:10 PM, the Administrator stated an expectation the medication cart is locked at all times when unattended and an expectation medications are stored and locked in the medication cart and not left unattended on the medication cart. Review of the facility policy, Medication Administration Procedures, dated January 2025, documented the medication cart is to be kept locked at all times unless in use and within nurse's sight.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 60 residents. Findings include: Observation on 3/11/25 at 11:25 AM Staff A, Cook, applied gloves after performing hand hygiene. Staff A with gloved hands grabbed the bread sack and untwisted the bread tie, then opened the bread sack and took out 4 pieces of bread and laid them on a sheet of parchment paper. Staff A then grabbed the peanut butter jar with her gloved hands along with the knife, proceeded to spread peanut butter on the bread. Staff A grabbed the bread and put it together to make the sandwich and cut the sandwich with the knife. Staff A placed the 2 sandwiches on a plate with her soiled gloves. Staff A, then took off the gloves and washed her hands Observation on 3/11/25 at 11:30 AM Staff A, applied a glove to her right hand then proceeded to open a baggie that had a hotdog package inside. Staff A reached into the baggie to open the hotdog package, then reached into the hotdog package with her gloved hand and pulled out a hotdog and placed it on a plate. Staff A, then took off the glove and washed her hands. Per the undated facility Policy name Proper Use of Single Use Gloves revealed staff must change disposable gloves between tasks and not wear them continuously. A glove must be limited to one task only- thus the term Single Use. Once a person dons (puts on) the glove(s) and leaves the task to open a refrigerator, oven, box, bag, etc, the glove(s) are contaminated and are to be removed/replaced before returning to handling the ready to eat food item(s) and It is preferred to use a utensil (e.g. tong) instead of gloves when handling ready to eat foods if at all possible. Interview on 3/11/25 at 11:55 AM with the Dietary Manager revealed her expectation would be for all staff to get their supplies ready, wash their hands and use tongs to take out the bread from the bread sack and hotdog's from the package.

Based on clinical record review, staff interview and policy review the facility failed to provide/obtain bed hold notifications for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 60. Findings include: Review of Resident #3's Electronic Healthcare Record (EHR) revealed Resident #3 was in the hospital from [DATE] to 2/10/25. Further review of the EHR page titles, Clinical Census confirmed the Resident was in the hospital on these dates. Review for bed hold notification for Resident #3 revealed there was no bed hold form to review for the dates of hospitalization. During an interview on 3/13/25 at 10:14 AM the Administrator acknowledged and verified that there was not a bed hold completed for this hospital stay. The Administrator stated she would expect this to be completed. Review of the undated facility provided policy titled, Bed Hold revealed: Prior to and upon transfer of a resident to a hospital or if the resident goes on therapeutic leave, the facility will provide written notice to the resident and/or representative of the bed-hold policy. Bed Hold notices will be given upon admission, the resident and/or representative will receive education on the bed hold notice policy within the admission packet. They must sign form acknowledging they were informed of the policy and at the time of transfer, or in case of an emergency, within 24 hrs resident and/or representative will be notified of bed hold notice. Initial notification may be via phone and followed up with written form. The written bed hold notice will specify the duration of the bed-hold policy during which the resident is permitted to return and resume residence in the facility. The reserve bed payment policy. The rate for holding a bed will be determined by the resident ' s payer source. The facility policy regarding bed-hold periods regarding permitting residents to return to facility in the event an advance notice is possible, the resident/representative will be given the notice two times, once at the onset of the discussion of transfer and again when the transfer takes place. The facility agrees to hold the bed of any resident upon the return of a signed bed hold agreement or the verbal confirmation obtained by the facility. Each time a resident goes out of the building overnight; a new bed hold agreement must be obtained.

Based on clinical record review, staff interview, and facility policy/procedure review at the time of the investigation, the facility failed to provide needed services in accordance with professional standards for one of three residents reviewed by not sending a resident to the nearest emergency room when their was a change in their assessment for which resulted in the resident being admitted to the hospital with hypoxemia, bronchopneumonia and dehydration. (Resident #2). The facility identified a census of 59 residents. Findings include: 1. A Admission Minimum Data Set (MDS) completed for Resident #2 with an assessment reference date of 8/5/24, documented diagnosis for which included hypertension, non-Alzheimer dementia, anxiety, depression, asthma and chronic obstructive pulmonary disease (COPD). The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe impaired cognitive decisions and no acute onset of mental changes. The resident required substantial assistance to maximal assistance for activity of daily living and was independent with ambulation with a walker. The Careplan with a focus area initiated 8/12/24, I have a diagnosis of Chronic Obstructive Pulmonary Disease and am at risk for shortness of breath and respiratory infections. Interventions include: *Allow for rest periods between tasks as needed. *Give bronchodilator as ordered. Document any side effects and effectiveness. Document adverse effects trembling, headaches, dry mouth, palpitations, muscle cramps, cough, nausea and vomiting, diarrhea. *Nebulizer Therapy: Change Tubing Weekly and PRN *Observe daily for signs of respiratory infections or distress, adventitious lung sounds, shortness of breath, elevated temperature and notify physician as indicated. *Observe for signs/symptoms of hypertension such as headache, visual changes, mental status changes, slurred speech, decreased alertness. report to physician as indicated. *10/11/24: resident was sent to emergency room and admitted for bronchitis related to COPD The Progress Notes documented on the following dates and times: *10/9/2024 at 1:02 p.m. Nurses Note Text: Resident is on follow up for being lowered to the floor. Resident short of breath this morning. Walked with staff and allowed this nurse to administer suppository for constipation. Effective. Resident walked without difficulty using walker and used inhaler. Appears more comfortable sitting upright. *10/9/2024 at 4:25 p.m., Nurses Note Text: Called to unit by staff, resident was sitting at a table in the dining area, stood up and moved with out his walker. Reached for the hand rail and lost his balance, falling to his left side. Hitting his head on the shower room door. Staff assist to standing, Sat resident in a straight chair. Neuro checks initiated. Neurological continue until resident became combative. Will reapproach . *10/9/2024 at 5:38 p.m., Nurses Note Text: Sitting at table with peers for supper, as needed Tylenol given to promote comfort as he stated his legs ache. Neurological continue as he will allow. *10/10/2024 at 11:36 p.m., Nurses Note Text: follow up on fall 10/09/24. No latent injuries noted. Ambulating with a fairly steady gait with front wheeled walker and assistance of one. *10/11/2024 at 3:21 p.m., Nurses Note Text: Staff called this nurse to assess resident with concern that resident was pale and slurring. Not at his regular baseline. Resident was very sleepy. Resident was slurring his words and wasn't cooperating with instructions. Resident woke up and ambulated using his walker to the dining room and had very little appetite. Resident remained alert the rest of this morning shift. Orthostatic Blood pressures are low. Completed twice this shift. 101/59 laying, Standing 99/68, Sitting 100/56. Resident denies pain. Slightly aggressive with cares. *10/11/2024 at 9:15 p.m., Nurses Note Text: Resident is on fall follow up. Observed resident in unit to be sitting at the table. Staff reports he did not eat this evening. Resident awake, mumbling, looking down at floor. Staff reported they attempted to get resident to stand and walk down the hallway to bed but he would not stand. Registered Nurse (RN) assisted staff to stand resident at this time and he continued to not want to put feet down and stand up. He eventually did and had one foot on top of the other while in upright position. Staff straightened his feet out and he began to walk but it was very staggered type of walking. Resident holding on to walker and would pull brakes up making it difficult to move forward. Resident needed numerous instructions to unlock brakes and keep walking. At point halfway down the hall, resident stopped and refused to go any further. He sank down to his knees, staff unable to hold him up. He was lowered to the floor on his knees without incident. Additional staff called to assist resident back to standing. He stood with maximum assist of 3 staff but would not walk. Resident put on seat of his walker and rolled to his room. Resident brought to side of his bed at which time he laid himself back with feet outstretched and became minimally unresponsive. Resident transferred to his bed. Residents eyes were open and staring. Pupils small and slowly reactive. He was not moving eyes or tracking to sound of staff voice. He would not grip hands and was not moving his extremities. He did not respond to verbal or tactile stimuli. Heart rate continued to erratic up into 130s. Blood Pressure initially unable to obtain, then finally able to get 68/48. Recheck 100/68. Oxygen placed at 2.5 liters and pulse ox came up to about 83-85%. Skin color to face grayish. Spoke with Dr. on call for who stated to send resident to ER. EMS called. Report called to ER. While other staff sat with resident while this nurse made phone calls etc, staff reported resident would intermittently yell out like he was in pain. Resident left facility. Resident was more alert at time of transfer but not at baseline. *10/12/2024 at 1:03 a.m., Nurses Note Text: Received call from nurse at hospital. Resident is being admitted at least through the weekend. Resident has bronchitis related to COPD exacerbation, hypoxemia, and dehydration. CT scan was negative for a brain bleed. He was given a half liter of fluid and perked up, and his color improved. He will be receiving antibiotics. *10/14/2024 at 8:39 a.m., Nurses Note Text: Received phone call from hospital that resident will be discharging today. Report given to this nurse and is as followed: Has been standing and pivoting, using nebs, antibiotic, and incentive spirometer for pneumonia, vitals have been stable, has had thick productive cough, had bowel movement yesterday (10-13). No combativeness in hospital. *10/14/2024 at 11:30 a.m., Nurses Note Text: Resident returned to facility via wheelchair this morning. He was discharged from the hospital. Resident was hospitalized secondary to mental status changes and profound weakness. Resident admitted to the hospital for acute COPD exacerbation and bronchopneumonia. He has poor dentition, pupils equal and reactive. He does have diminished breath sounds bilateral lower lobes. Heart rate regular, abdomen is soft and non-tender. Bowel Sounds are positive all 4 quadrants. He is slow to respond, not making much sense when speaking. He does answer easy yes/no questions appropriately. The Neurological Assessment Flow Sheet dated 10/9/24, documented: every 15 minutes times 4, every 30 minutes times 4, every 1 hour times 4 and every shift times 24 hours. 10/9/24 at 3:25 p.m., resident alert, with equal pupil response and hand grips, move all extremities and . appropriate response to pain 10/9/24 at 3:40 p.m., resident alert, with equal pupil response and hand grips, move all extremities and appropriate response to pain. 10/9/24 at 3:55 p.m., resident alert, with equal pupil response and hand grips, move all extremities and appropriate response to pain. 10/9/24 at 4:10 p.m., resident alert, with equal pupil response and hand grips, move all extremities and appropriate response to pain. 10/9/24 at 4:40 p.m., resident alert, with equal pupil response and hand grips, move all extremities and appropriate response to pain. 10/9/24 at 5:10 p.m., resident drowsy, sluggish pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/9/24 at 5:40 p.m., resident drowsy, sluggish pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/9/24 at 6:10 p.m., resident drowsy, sluggish pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/9/24 at 7:10 p.m., resident drowsy, equal pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/9/24 at 8:10 p.m., resident drowsy, equal pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/9/24 at 9:10 p.m., resident drowsy, equal pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/9/24 at 10:10 p.m., resident drowsy, equal pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/10/24, 6:00 a.m.,- 2:00 p.m., chart lacked documentation of neurological assessment being completed. 10/10/24, 2:00 p.m.,-10:00 p.m., resident drowsy, equal pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. 10/10/24, 10:00 p.m.,-6:00 a.m., resident drowsy, equal pupil response, unable to follow commands for hand grasps and movement of extremities, and absent with pain response. The Nursing Facility to Hospital Transfer Form dated 10/11/24 with no time, documented that the reason for transfer is due to change in mental status, status post fall on 10/9/24. Mental status as confused and forgetful. The County Hospital History and Physical dated 10/11/24 at 11:50 p.m., documented the chief complaint for this resident is altered mental status, profound weakness. The [AGE] year old male that lives at a local memory unit in a skilled nursing facility. fell 2 days ago with what appears to be a minor head injury but does take aspirin regularly. Today he was found to be weak, requiring assistance for ambulation where typically he does not. This evening he became increasingly more confused and less responsive, but because of his decreased responsiveness he was brought to the emergency room . Found to be with an oxygen saturation of 77% on room air. I later spoke to his wife and she says he has not been eating or drinking for several days now. He can ambulate with standby assistance but has not been able to do that for several days. There has been a cough. Physical Assessment: Oral membranes are dry. His lungs are with decreased breath sounds and rhonchorous breath sounds as well. He is easily agitated with attempts at movement or body position change. Plan: Patient is clinically dehydrated. Poor oral intake for several days of both food and water likely contributing to hypotension, increase in creatinine and hypernatremia. Will admit for COPD exacerbation secondary to acute bronchitis and possible bronchopneumonia, secondary hypoxemia as well as dehydration with hypernatremia. Interview on 11/7/24 at 8:10 a.m., the facility Director of Nursing (DON) confirmed and verified that the facility staff are expected to notify the physician of any changes in a residents neurological assessment and to follow the facility policy and procedure, the director of nursing also confirmed with the physician that the expectation of the staff are to notify the physician of any changes in a resident neurological assessment. The Neurological Assessment Policy and Procedure dated 2024, documented that the purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. Neurological assessments are indicated: 1) Upon physician order; 2) Following an unwitnessed fall; 3) Following a fall or other accident/injury involving head trauma; or 4) When indicated by resident's condition. 5) Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately. Reporting 1) Notify the physician of any change in a resident's neurological status. 2) Notify the supervisor if the resident refuses the procedure. 3) Report other information in accordance with facility policy and professional standards of practice.

Based on interviews, clinical record review, and policy review, the facility failed to accurately account for administered, and destroyed narcotic medication for 1 of 1 resident reviewed (Resident #164). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 4/12/24, listed diagnoses for Resident #164 included left femur fracture, fracture of right foot and muscle weakness. The MDS indicated the resident required substantial assistance with transferring, and reported frequent pain. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had intact cognition. According to the Care Plan initiated 4/12/24, Resident #164 had self-care deficit related to fracture of femur. The census tab showed that she was admitted on [DATE] and discharged on [DATE]. A document titled, Controlled Medication Utilization Record showed a sticker from the pharmacy with an order for tramadol 50 mg 1 and 1/2 tabs every 6 hours as needed for pain. The document showed that the medication was given on 4/11/24 at 4:45 PM, 4/11/24 at 9:00 PM and 4/12/24 at 1:45 AM. The last dose was given on 4/12/24 with amount remaining; 9 doses. The documentation of the destruction of the remaining narcotics was dated 4/18/24 and staff failed to enter the total number of doses destroyed. The electronic Medication Administration Record (MAR) showed that just one, 50 mg tab of tramadol was given on the 12th at 1:45 PM for the entire stay. On 5/15/24 at 1:44 PM, the Director of Nursing (DON) agreed that the disposal of the remaining tabs should have indicated the total number of pills that were destroyed. She agreed that the MAR documentation should have matched the Controlled Medication Utilization Record. A facility policy titled: Medication Management-Discontinued/ Disposing of Meds 2024, showed that the disposing of unused narcotics were to be co-counted by 2 nurses, destroyed, documented on narcotic record and noted in the nurses notes.

Based on clinical record review, policy review and resident and staff interviews the facility failed to ensure that all residents are treated with dignity and respect, and free from abuse during resident care tasks for 1 of 4 residents reviewed (Resident #7). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 2/17/24, listed diagnoses for Resident #7 included cerebral palsy, hemiplegia (paralysis or weakness on one side of body), seizure disorder, anxiety disorder and intellectual disabilities The assessment indicated the resident required substantial assistance for upper and lower body dressing, personal hygiene, and dependent for transfers. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating a moderate cognitive impairment. The Care Pan updated on 6/20/23 included a focus area regarding Resident #7 becoming frustrated with situations in the environment that he could not control. Interventions included: offering reassurance, and allowing opportunities to express his feelings and concerns. The Care Plan also included a focus area for assistance with Activities of Daily Living and impaired balance. Interventions included: two staff assisting with a mechanical lift for transfers. According to a document titled: Allegation of Abuse Investigation, dated 4/22/24, it was reported to the Director of Nursing (DON) by Staff A, Certified Nursing Assistant (CNA), that on 4/22/24, Staff B, CAN had been rough when caring for Resident #7. The resident was having difficulty using the mechanical sit to stand lift, and needed to rest. When the resident asked to try again, Staff B yelled at him f*** no and that she had things to do. Staff A reported that Staff B used more force than necessary when assisting him into bed. The investigation included interviews with staff and residents and is had been mentioned that Staff B sometimes would rush through cares and would be rough. On 5/14/24 at 9:40 AM, Staff A, CNA stated on 4/22/24, she assisted Staff B, CNA to put Resident #7 to bed for the night. When they transferred him with the mechanical lift, the resident said that he needed to sit down so they lowered him to sit on the bed. When the resident asked if they could try it again, Staff B got in his face and said f*** no The resident did not say anything but he had a nervous laugh. They unhooked him from the lift and with Staff A at the top half the body, and Staff B at the feet, they guided him to the laying position and Staff B held onto his legs and threw him into bed. The resident then said whoa! and nervously laughed again. Staff B then said I got shit to do On 5/13/24 at 11:10 AM, Staff B, CNA denied that she was rough with the resident or swore at him. She denied having any disciplinary reports in her personal file. On 5/14/24 at 10:01 AM, Staff C, Registered Nurse (RN) said that she was the nurse on duty on the evening of 4/22/24. She had been busy with passing the evening medications and was not aware of an incident between the CNA's and Resident #7. Staff C said that Staff B had been frustrated that day because she worked a 12-hour shift. She was tired and anxious to get home. On 5/15/24 at 8:45 AM, Resident #8 (MDS dated [DATE] showed BIMS score of 15) said that she knew Staff B and she was nice to her. The resident said that Staff B didn't yell at her or get upset with her but there were times that she heard her get upset with other residents. On 5/15/24 at 8:50 AM, Resident #3 (MDS dated [DATE] showed a BIMS score of 14) said that she remembered Staff B because she would kind of yell and get in a hurry. She said that if the staff member was in a bad mood, she would yank her shoes off forcefully and throw them across the room. It was too bad, because otherwise she could be a decent person. On 5/15/24 at 8:01 AM, the Director of Nursing (DON) said that Staff B was suspended while they investigated the allegations of abuse, and later they did terminate her. They terminated her because they felt that there were discrepancies in the recall of the events on 4/22/24, and they did have reports that she would get frustrated and displayed that frustration in front of residents. A facility policy titled: Abuse Prevention, Identification, Investigation and Reporting Policy, dated January 3, 2024 showed that personal degradation included willful acts or statements intended to shame, degrade, humiliate or otherwise harm the dependent audit's personal dignity.

Based on observations, interviews and record review the facility failed to ensure comfortable positioning, and securement of the safety straps when using a mechanical lift device for 2 of 3 residents reviewed (Resident #22, Resident #30). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 4/6/24, listed diagnoses for Resident #22 included cerebrovascular accident (stroke), aphasia (impaired communication), and hemiplegia right side dominant (paralysis/impaired function of right side). The MDS assessed the resident required substantial assistance for mobility and all transfers. A Brief Interview for Mental Status (BIMS) could not be completed due to the resident being rarely/never understood. The Care Plan updated on 4/24/24 included a focus area Activities of Daily Living for Resident #22. Interventions included the use of an EZ Stand (type of mechanical lift) of two staff for transfers. In an observation on 5/13/24 at 12:05 PM, Resident #22 could be heard from the hallway making loud utterances. Staff F, Certified Nurse Aide (CNA), and Staff G, CNA entered the room to find the resident leaning to the right in his wheel chair. They prepared to transfer him with the use of the EZ Stand. Staff F assisted the resident to sit forward in the wheel chair and as she attempted to apply the sling behind his back, he hollered out in pain. The resident's right arm was stuck between the handle of the wheel chair and the padded cushion that extended up the side of the wheel chair. Staff F helped the resident free his arm. The staff proceeded to hook the sling up to the lift and placed his feet on the platform. The staff did not lock the wheels of the lift. The resident rocked back and forth with his feet, causing the lift to move as the staff raised the device. The resident was not holding onto the handles and grabbed the front of the machine as staff began to change his incontinence brief. While in a standing position, Staff G strapped the residents legs to the lift, and failed to tighten the buckle around his torso. 2) According to the MDS, dated [DATE], listed diagnosis for Resident #30 included diagnoses of displaced intertrochanteric fracture of left femur, pain in left shoulder, muscle weakness and Chronic Obstructive Pulmonary Disease (COPD). The MDS assessed the resident as dependent on staff for all transfers, and use of the toilet. The resident had a BIMS score of 4 out of 15, indicating severely impaired cognition. Resident #30's Care Plan, updated on 2/7/24, included a focus area to address the need for assistance with Activities of Daily Living (ADL's). Interventions included the assistance of two staff to use the toilet, and the assistance of 2 staff for transfers using the EZ Stand. In an observation on 5/13/24 at 12:23 PM, Staff G, CNA and Staff H , CAN transferred Resident #30 with the use of the EZ Stand. They situated the sling behind the resident's back while she was in the wheel chair and attached it to the lift. The resident held onto the padded handles of the lift, but her right arm was under the sling. When the resident was raised up to the standing position, staff failed to tighten the buckle around her torso. They moved her to the toilet and when she was finished, the sling on the right side was adjust to be under her arm. As they raised her off the toilet and she was in the standing position, they provided peri care, and failed to tighten the buckle. On 5/15/24 at 1:50 PM the Director of Nursing (DON) said that they have a skill fair where they teach the staff how to properly use the mechanical lift. She provided and audit checklist titled: Mechanical Lift Transfer Audit. The document lacked direction to tighten the waist belt once the resident was standing on the EZ Stand. According to the EZ Way Smart Stand Operators Instructions dated 7/30/18, staff were directed to position the patients arms on the outside of the harness and have them place their hands on the padded handles. As the patient was being raised, simultaneously tighten the safety strap buckled around their torso.

Based on clinical record review, staff interviews and facility policy review the facility failed to provide a bed hold upon hospitalization for 2 of 2 residents reviewed (Resident #38, #114). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessemnt,dated 6/24/23, for Resident #38 identified a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The diagnoses for Resident #38 included coronary artery disease, hypertension (high blood pressure), diabetes mellitus, and Alzheimer's disease. The Clinical Census revealed the resident discharged to the hospital on 9/13/23. A Nurses Note dated 9/13/23 at 9:43 PM revealed Resident #38 was admitted to the hospital for a fractured hip. The clinical record lacked documentation the facility provided a bed hold notice to Resident #38 and/or the residents respresentative upon discharge to the hospital. On 5/14/24 at 2:52 PM, the Director of Nursing (DON) reported she could not locate a bed hold form for Resident #38. She stated it was an expectation for the nurses to complete the bed hold when sending someone to the hospital. 2. The MDS assessment, dated 12/2/23, for Resident #114 identified a BIMS score of 15 out of 15, inicating intake cognition. The MDS included diagnoses of coronary artery disease, hypertension (high blood pressure), osteoporosis, seizure disorder, chronic obstructive pulmonary disease, and other fractures. The Clinical Census revealed Resident #114 was discharged to the hospital on 12/15/23. A Nurses Note, dated 12/16/23 at 12:40 AM, revealed Resident #114 was admitted to the hospital for a fractured left ankle. The Clinical record lacked documentation the facility provided a bed hold notice to Resident #114 and/or Resident #114's representative upon discharge to the hospital. On 5/16/24 at 9:25 AM, the DON acknowledged and verified a bed hold notice was not completed for Resident #114. A facility policy, dated 2024, titled Bed Hold Policy Statement: Prior to and upon transfer of a resident to a hospital or the resident goes on therapeutic leave, the facility will provide written notice to the resident and/or representative of the bed-hold policy. The policy implementation documented at the time of the transfer, or in case of emergency, within 24 hours resident and/or representative will be notified of bed hold notice. Initial notification may be via phone and followed up with written form. The written bed hold notice will specify: *The duration of the bed-hold policy during which the resident is permitted to return and resume residence in the facility. *The reserved bed payment policy. The rate for holding a bed will be determined by the resident ' s payer source. *The facility policy regarding bed-hold periods regarding permitting residents to return to the facility. The policy further documented that the facility agreed to hold the bed of any resident upon the return of a signed bed hold agreement or the verbal confirmation obtained by the facility. Each time a resident goes out of the building; a new bed hold agreement must be obtained.

Based on clinical record review, staff interview, and policy review, the facility failed to report a fall with major injury (right femur fracture) that required hospitalization to Iowa Department of Inspections and Appeals for 1 of 3 resident reviewed for falls (Resident #9). See F689 for additional information. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS described Resident #9 as independent with bed mobility, transfers and walking 10 feet with a walker. The MDS included diagnoses of diabetes mellitus, Alzheimer's disease, Non-Alzheimer's disease, depression, polymyalgia rheumatica (an inflammatory condition that causes pain and stiffness in the neck, shoulders, and hips) and peripheral venous insufficiency (impaired veins in the legs). The Fall-Witness report dated 11/22/23 at 9:30 PM reflected Resident #9 fell , went to the emergency room (ER), received a diagnosis of a right hip fracture, and admitted to the hospital. The Care Plan revised on 6/12/23 indicated Resident #9 required assistance of one person with a walker during ambulation and transfers. Resident #9's November 2023 Documentation Survey Report listed an ambulation task. The documentation identified Resident #9 levels of assistance varied during the month from supervision and set up to limited assistance of one-person physical assistance. The facility provided Self-Report Notifications to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) lacked a report of Resident #9's fall with injury on 11/22/23. On 1/22/24 at 4:00 PM, the Director of Nursing (DON) verified the facility did not report the fall with injury to DIAL. The DON said she did not report Resident #9's fall due to October 2023's completed MDS that reflected Resident #9 as independent with transfers and ambulation. The Resident Accidents and Incidents-Investigation and Reporting policy dated 2023 directed the staff to follow the guidance for self-reporting falls with injury that required treatment greater than first aid. 46875 2. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS described Resident #9 as independent with bed mobility, transfers and walking 10 feet with a walker. The MDS included diagnoses of diabetes mellitus, Alzheimer's disease, Non-Alzheimer's disease, depression, polymyalgia rheumatica (an inflammatory condition that causes pain and stiffness in the neck, shoulders, and hips) and peripheral venous insufficiency (impaired veins in the legs). The Facility Incident Reports (IR) documented from September 2023 - January 2024 listed Resident #9 fell on [DATE], 9/29/23, 11/10/23, and 11/22/23. The Fall Risk Screening Tools completed on 9/2/23, 9/29/23, 11/10/23 and 11/22/23 narrative summary of the assessment documented Resident #9 was at risk for falls. The screening tool did not provide fall risk scores. The narrative summary on 9/29/23 documented Resident #9 had poor safety awareness and balance. The narrative summary on 11/10/23 documented Resident #9 was weak and had memory loss. The narrative summary on 11/22/23 documented Resident #9 was very unsteady on her feet, used a walker and tripped often. The narrative further documented Resident #9's posture was poor, stooped and walked with her head down. The Care Plan with a target date of 3/9/24 indicated Resident #9 had a risk for self-care deficit and falls related to requiring assistance with activity of daily living, impaired balance with transitions/walking, poor safety awareness, incontinence, neuromuscular/functional impairment and the use of medications that may increase fall risk. The Interventions included the following: a. 3/1/23: Encourage the use of the walker at all times b. 5/3/23: Tennis balls to walker c. 5/18/23: Leave night light on in room/bathroom d. 5/25/23: Allow resident to sit on the floor as she wishes e. 6/12/23: Changing self-care status to assistance of one person f. 6/30/22: Anticipate needs and provide prompts assistance as indicated g. 6/30/22: Toileting- assistance of one person h. 6/8/23: Increase physician activities i. 9/2/23: Remind staff of assistance of one status j. 9/29/23: Restorative for ambulation and active range of motion - resolved 11/17/23 k. 11/10/23: Skid strips to the bathroom floor l. 11/22/23: Sent to emergency room , Bolster Mattress and Physical/Occupational Therapy m. 11/29/23: Anti-roll back device added to temporary wheelchair Resident 9's Care Plan History reflected the facility revised the Care Plan on 6/12/23, it directed staff to help with one person, a walker for transfers, and ambulation. The Care Plan history indicted on 11/23/23 the facility revised the Care Plan for Resident #9 to be independent with transfers and ambulation with a walker. The update to the care plan occurred the day after Resident #9 fell on [DATE], fracturing her right hip, and required hospitalization . The Care Plan lacked information or direction on when to apply the gait belt with transfers and ambulation and/or what to if Resident #9 refused to wear it. The Care Plan also lacked information on what to do if Resident #9 was resistant and did not let staff help her during transfers and ambulation. An IR dated 9/2/23 at 6:45 PM revealed Resident #9 was sitting in a chair by the front entrance of the unit, when she got up to ambulate with her walker, lost balance and fell backwards landing on her bottom and hitting her head on the leg to the chair. Resident #9 reported her legs just gave out. The assessment revealed a small raised area with a superficial abrasion noted to the back of the head. The staff applied an ice pack and started neurological (neuro) checks. The IR documented the Intervention as to remind staff of assistance of one status. There were no additional resident specific interventions implemented. The Fall Scene Investigation dated 9/2/23 at 6:50 PM described Resident #9 as a fall risk, with several falls that month. The Investigation described Resident #9 as having an unsteady gait, with a walker that seems to not fit her very well, and she needs reminded to use the walker at times. The facility form titled Root Cause Analysis (RCA) - 5 Why's dated 9/2/23 directed the staff to ask why the problem was happening and to complete the 5 Why's. The form listed the following answers to the 5 whys: 1.Why: poor safety awareness 2. Why: ambulating without assistance 3. Why: Lack of Supervision 4. Why: Lighting Poor 5. Why: Resistive with interventions 6. Conclusion: Fall occurred due to ambulating without assistance. An IR-witnessed dated 9/29/23 at 7:15 PM reflected Resident #9 lost her balance while ambulating with her walker, falling in her room and landing on her bottom. The IR failed to document what level of assistance Resident #9 received prior to the fall occurring. The intervention on the IR directed to initiate a restorative program. A facility form titled Fall Scene Investigation dated 9/29/23 at 7:15 PM reflected the following conclusion: Resident #9 had a risk for falls, with several falls that month. The Investigation described Resident #9 as having an unsteady gait, a walker that seemed to not fit her well, and she needs reminded to use the walker at times. The facility form titled Root Cause Analysis (RCA) - 5 Why's dated 9/29/23 directed the staff to ask why the problem was happening and to complete the 5 Why's. The form listed the following answers to the 5 whys: 1. Why: Lost balance 2. Why: Poor safety awareness 3. Why: Grumpy behaviors 4. Why: Blank - not filled out 5. Why: Blank - not filled out 6. Conclusion: Add restorative for ambulation and active range of motion (AROM) exercises An IR dated 11/10/23 at 4:30 AM indicated a Certified Nursing Assistant (CNA) found Resident #9 on the floor in her room with no injuries noted. The IR documented the fall occurred due to a slick floor with the intervention to add skid strips to the bathroom floor. The Clinical Record lacked a Fall Scene Investigation form for 11/10/23. The facility form titled Root Cause Analysis (RCA) - 5 Why's dated 11/10/23 directed the staff to ask why the problem was happening and to complete the 5 Why's. The form listed the following answers to the 5 whys: 1. Why: Slick floor 2. Why: Up without assistance 3. Why: Forgets to use call light 4. Why: Poor safety awareness 5. Why: cognitive impairment Conclusion: Fall occurred due to slick floor An IR-witnessed form dated 11/22/23 at 9:30 PM reflected Resident #9 walked in the hallway with her walker, when she turned around, got her feet tangled, fell , and landed on her right side. Resident reported she had tripped on her feet. The IR documented two staff assisted Resident #9 with a gait belt, she complained of pain to the right leg when putting full weight on it. The staff assisted Resident #9 to a wheelchair and took her to her room, where they assisted her to bed with two staff and a gait belt. Resident #9 complained of pain to the right mid-thigh. Resident #9 could pull, push with both feet, and lift both legs. The staff called the PCP and received an order to transport Resident #9 to the emergency room for x-rays. The IR predisposing situation factors indicated Resident #9 walked without assistance. The IR documented the fall occurred due to poor safety awareness. The IR listed the intervention as the facility sent Resident #9 to ER. The evaluation found a right hip fracture. The IR included the facility would follow-up on the physician recommendation for post right hip fracture, Physical Therapy (PT), Occupational Therapy (OT) and a bolster mattress (mattress with elevated edges). A facility form titled Fall Scene Investigation dated 11/22/23 at 9:30 PM recorded a conclusion of Resident #9 had a risk for falls due to unsteady gait, and poor posture when walking. The facility form titled Root Cause Analysis (RCA) - 5 Why's dated 11/10/23 directed the staff to ask why the problem was happening and to complete the 5 Why's. The form listed the following answers to the 5 whys: 1. Why: Poor safety awareness 2. Why: cognitive awareness 3. Why: up without assistance 4. Why: does not remember to use call light 5. Why: blank - not filled out 6. Conclusion: Fall occurred due to poor safety awareness. A Progress Note Titled Restorative on 11/17/23 at 11:20 AM documented due to Resident #9's refusal to participate, the facility discontinued her restorative walking and AROM program at this time. The emergency room Report dictated on 11/24/23 reflected Resident #9 presented to the ER due to a fall at the nursing home with pain to the right hip and thigh with limited weight-bearing. The CT image of the right hip dated 11/23/23 at 2:34 AM revealed a right subcapital fracture (fracture of the upper bone of the thigh that extends from the hip to the knee). The ER report documented they transferred Resident #9 to a higher acuity facility (orthopedic for hip fracture). The Hospital After Visit Summary dated 11/27/23 revealed Resident #9 returned to the facility after receiving surgical intervention with orders for toe touch weight bearing to the right leg and PT/OT evaluate and treat. On 1/23/24 at 8:00 AM, Staff H, Registered Nurse (RN) reported on 11/22/23, as Resident #9 walked down the hall with her walker, she went to turn around, lost her balance, and fell . She said Resident #9 had a staff member within a few feet of her. She added Resident #9 required assistance of one person with ambulation. She reported Resident #9 could get aggravated when staff tried to help her and the facility determined she could do it on her own. She stated generally staff uses a gait belt when someone needs assistance of one but she did not think Resident #9 had one on. She stated Resident #9's feet got tangled and with the staff not close enough to catch her. She explained she stood at the medication cart doing count with a CMA (Certified Medication Aide) when she witnessed the fall. She stated she wasn't far from her but could not get there in time. She said Resident #9 commonly ambulated alone. She reported she sent Resident #9 to the ER and received a call that she had a right hip fracture due to the fall. She explained she assessed Resident #9 on the floor before getting her up. She stated Resident #9 had pain to the right leg, with a little bit of external rotation to the right leg. She reported Resident #9 wanted to go to bed and lay down. She stated two other staff members and herself assisted Resident #9 off the floor with a gait belt. She explained they had a staff member on each side of Resident #9, while she stood behind her. She stated as they stood her up she brought a chair underneath her. She stated Resident #9 didn't put weight on her right leg. She stated they did the same transfer when they assisted her to bed. On 1/23/24 at 8:40 AM, the Director of Nursing reported that no one assessed or evaluated Resident #9 for independence with transfers or ambulation with a walker. She stated she did restorative for a short period of time for AROM exercise and ambulation, but Resident #9 refused to participate in therapy. On 1/23/23 at 11:57 AM, Staff G, RN stated she thought Resident #9 was up on her own in September. She described Resident #9 as a fall risk, with sundowning during the night, and would get combative/mean. She reported Resident #9 had times that she wouldn't let anyone touch her in the evenings. She stated you had to stand beside her and just be there. She added if you tried to get close to her, touch her, and/or put your hands on her, it would make it worse. On 1/23/24 at 12:17 PM, Staff I, CNA, explained she worked the evening of 11/22/23. Staff I reported Resident #9's roommate exited the room first and then Resident #9 followed. Staff I stated she attempted to redirect both residents back to their room. Staff I stated she walked the roommate back to the room first as she was more compliant. She stated Resident #9 walked in the opposite direction of her room at the end of the hallway. She stated Resident #9 didn't make it very far before she returned to assist her. She said she tried to put a gait belt on Resident #9, but she refused. She stated she walked beside Resident #9, but she got upset, so Staff I walked ahead of her. Staff I stated when she turned around she saw Resident #9 stumble over her feet and fall. Staff I described the Nurse and CMA as counting medications, leaving her as the only person on the floor providing care at that time. Staff I described Resident #9 as a pretty good walker before she fell . She stated Resident #9 needed standby supervision while walking. She stated she would have to look at the care plan to see if that was correct. Staff I stated if Resident #9 wasn't walking the best, she would try to put a gait belt on her but she would refuse most of the time. She stated Resident #9 would get upset and irritated if you bothered her so sometimes you would just have to let her go on her own but keep an eye on her. On 1/23/2024 at 3:42 PM, the Administrator reported the facility did not have any witness statements for Resident #9's falls on 9/2/23, 9/29/23, 11/10/23 and 11/22/23. On 1/24/24 at 11:04 AM, Staff J, CNA, stated Resident #9 needed assistance of one person with a gait belt and walker for transfer and ambulation. He stated she would refuse to wear the gait belt quite a bit. He stated when she would refuse the gait belt, he would stand behind her to make sure she would not fall.

Based on clinical record review, staff interviews, and hospital record review, the facility failed to prevent injuries for 2 of 3 residents reviewed (Residents #7 and #8). Resident #7's fall risk assessments and care plan identified her as a high risk for falls due to impaired balance and poor safety awareness. The staff observed Resident #7 on the floor of the living room after she sustained her ninth fall in a two-month period on 11/29/23. Of the 9 falls, the staff only observed 1 fall. Following the falls, the facility failed to provide consistent neurological (neuro) checks to rule out a brain injury. The fall required a transfer to the emergency room and resulted in a subdural hematoma (bleed on the brain) that led to death. Resident #8 sustained a fall on 1/1/24 and hit his head, the facility failed to complete a complete neuro assessment after the initial set completed right after the fall. The facility failed to do neurological assessments or complete assessments with any unwitnessed falls. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS included diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, chorea (involuntary movements of the limbs or facial muscles) and essential tremors. Resident #7's Care Plan included the following Focuses dated 8/15/23: a. She had a cognitive impairment reflected by short-term memory, impaired decision making, and Alzheimer's dementia. b. She had a potential for falls related to impaired balance, poor safety awareness, incontinence, neuromuscular/functional impairment (rhythmic shaking), and the use of medications that increase fall risk. The undated Neurological Assessment policy instructed to complete an assessment of the resident's neurological status with any suspected injury to the head. This includes unwitnessed falls. The first neuro check needs completed prior to moving the resident after a fall. Neuro checks need performed at least: a. Every 15 minutes times four b. Every 30 minutes times two c. Every hour times four d. Every shift for 24-hours If any abnormal neurological findings are apparent, take neurological checks more often than noted above. Notify the resident's physician immediately of the incident/accident and any abnormal findings. Utilize the Neurological Assessment Form to document the following information: date, time, temperature, pulse, respirations and blood pressure. The policy directed the staff to use the neurological form. The Incidents by Incidents Type Report printed on 12/1/23 indicated Resident #7 had the following 7 unwitnessed falls: a. 10/22/23 at 2:19 PM b. 10/23/23 at 2:00 AM c. 10/26/23 at 6:15 AM d. 10/29/23 at 3:54 AM e. 10/30/23 at 6:00 AM f. 11/26/23 at 1:20 AM Review of the Facility's Fall Risk Screening Tool completed from 7/26/23 to 11/29/23 revealed that Resident #7 was at high risk for falling. The clinical record review from 10/22/23 to 11/29/23 included only one completed Neurological Flow Sheet on 10/22/23 and one partially completed on 10/26/23. The clinical record lacked additional Neurological Flow Sheets following 10/26/23. The Nurses Notes dated 11/29/23 at 5:03 PM reflected the staff found Resident #7 sitting on the floor in the dining area leaning against the cabinet. Another resident reported as Resident #7 came out of the television room, she lost her balance. Resident #7's had her legs straight out in front of her. The staff assisted Resident #7 from sitting to standing and Resident #7 complained of pain to her right leg. When Resident #7 refused to put weight on her right leg, the facility sent her to the emergency room (ER). The emergency room Report dated 11/30/23 indicated Resident #7 presented to the ER due to a complaint of a hip/thigh problem. After Resident #7 fell at the facility, she refused to bear weight on her right leg. Resident #7 has dementia and choreiform movement (involuntary movements) disorder. The symptoms affect the right hip with a pain severity of moderate. Resident #7 has no ability to bear weight due to a fall that caused the injury. Resident #7 had no history of gout, a hip fracture, a hip dislocation, hip operation, or arthritis. The Physical Examination section described Resident #7 as alert, in mild distress, with mild hip tenderness, and repetitive choreiform movement. The CT scan (diagnostic imagining) of her head without contrast listed uncertainty of Resident #7 having a subdural hematoma low-attenuation (represented as shade of gray on a CT scan) or hygroma (a collection of cerebrospinal fluid without blood in the brain). The image reflected a mass effect (signs of increased pressure in the brain) without a midline shift (the pressure doesn't cause a shift in the brain passed the middle). The section labeled Discharge reflected the hospital discharged Resident #7 back to the nursing home in poor condition. The physician educated the family about her test results, treatment, and prognosis. The physician told her family about her subdural hematoma and that she couldn't have surgery due to her advanced dementia. The physician started Resident #7 on fentanyl for her pain. The Certificate of Death listed Resident #7's date of death as 12/7/23 at 2:15 AM. The medical cause of death information reflected the immediate cause of death as a subdural hematoma due to a fall. The manner of death listed an accident. The description of injury indicated Resident #7 fell from a standing position. Interview on 1/18/24 at 12:08 PM Staff G, Registered Nurse, (RN) reported that they completed the neuros after Resident #7 fell for the majority of the times, unless they found her sitting up next to the bed on the fall mat. Staff G provided examples of Resident #7 kneeling down on one knee beside her bed by her bedside table or when she said she did not hit her head. Staff G explained they can clearly determine that is the truth based on their assessment from Resident #7's position. Another example, Staff G observed Resident #7 sitting in the middle of a big fluffy comforter on her fall mat beside her bed where she got up and sat down. Then when she slid down the wall to sit down outside the bathroom door to wait for her turn, because the resident from the room next door was using it when she got up with her walker to go pee. Interview on 1/18/24 at 1:00 PM the Director of Nursing (DON) reported that if the resident could say if they hit their head then they didn't require a neurological assessment done. The DON explained they expected if the resident is in the dementia unit or has a low BIMS score, then the nurse must complete a neurological assessment. 46875

Based on clinical record review, staff interview, pharmacy interview and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 1 resident reviewed (Residents #3). The facility failed to implement a new physician order in a timely manner. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] assessment identified she couldn't complete the Brief Interview for Mental Status (BIMS). The Staff Assessment for Mental Status revealed Resident #3 as severely impaired with decision making. The MDS described Resident #3 as independent with bed mobility, chair/bed to chair transfers, and ambulation. Resident #3's MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, anxiety disorder, depression, and dysphagia (difficulty swallowing). The Nurses Note dated 12/20/23 at 3:09 PM documented notification to the provider of Resident #9's complaints of abdominal pain, having large black formed stools, and emesis (vomiting) consistency of coffee grounds (signs of bleeding). The Nurses Note dated 12/20/23 at 8:53 PM documented a new order for omeprazole (used to block acid production to promote healing) 40 mg (milligrams) by mouth every day and to obtain a CBC (laboratory test). A Physician order dated 12/20/23 directed staff to administer omeprazole 40 mg by mouth one time a day related to gastroesophageal reflux disease without esophagitis (a digestive disease in which stomach acid or bile irritates the food pipe lining). The Nurses Note dated 12/21/23 at 1:07 PM listed the facility hadn't received omeprazole from the pharmacy. The Nurses Note dated 12/21/23 at 6:28 PM reflected omeprazole hadn't arrived from the pharmacy. The Nurses Note dated 12/22/23 at 5:01 PM indicated the pharmacy hadn't delivered the omeprazole. The Nurses Note dated 12/26/23 at 12:59 PM documented a phone call to the Pharmacy to follow up on the omeprazole. The pharmacy reported they hadn't sent the medication, but they have it scheduled for delivery at 2 PM. On 1/23/24 at 1:20 PM, the Pharmacy Technician reported the pharmacy received the physician's order on 12/24/23 for the omeprazole from the facility. The pharmacy sent the omeprazole to the facility on the 12/26/23. The Clinical Record lacked notification to Resident #3's primary care provider (PCP) that she didn't start her omeprazole until 12/27/23. The Orders - Standards of Practice policy effective 9/22/17 directed that medication needs initiated on the date the physician gives the order. The policy directed staff to utilize the Ekit (locked supply kit used in an emergency if the resident hasn't received their medication) as needed and/or contact the pharmacy for delivery. If there is a delivery delay contact the Physician to start the medication when it arrives or ask to change the medication to a similar medication available in the Ekit. On 1/23/24 at 4:37 PM, the Director of Nursing (DON) reported they expected the nurse to fax the physician order to the pharmacy after receiving the order and follow up with the pharmacy if the facility hasn't received the medication in a timely manner. The DON added they expected the nurse to follow up with the doctor if they couldn't initiate or give the medication per the physician's order.

Based on observation, clinical record review, staff interview, facility policy and procedures the facility failed to provide an environment free from sexual abuse for residents that are not able to consent to sexually aggressive behavior such as inappropriate touching, grabbing, fondling, and/or kissing for 2 of 17 residents in the Memory Care Unit (Residents #2 and Resident #6). On two different occasions in the facility's dining room revealed Resident #6 and Resident #2 kissing, fondling, and touching each other over their clothes with other residents sitting at tables in the dining room observing, while a staff member assisted other residents, unaware of the situation. A serious adverse outcome is likely to occur as the facility additionally failed to report and thoroughly investigate all allegations of abuse. In addition, without a thorough investigation, the facility did not know of other residents identified as affected. The facility had an immediate need to take steps to ensure the protection of all residents from the risk of abuse. In addition, the facility failed to prevent assault from one resident to another resident, after a resident discovered another resident in their bed for 1 of 17 residents reviewed (Resident #3). When Resident #3 entered her room with a staff member, she found Resident #2 sleeping in her bed. Resident #3 started yelling at Resident #2 to get out of her bed. Resident #2 got upset and pushed Resident #3 then attempted to choke her. Resident #2 then attempted to choke the staff member who attempted to intervene. On November 11th, 2023 at 5:00 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on November 15th, 2023 after the facility completed the following: a. Implemented new CCDI Assessment of Awareness related to identifying upon admission residents who may be overly affectionate and potential tendencies for sexual behaviors. The facility completed the assessment on all current residents. The facility will complete the assessment again with any noted significant change. b. Re-educated staff on the expected care for residents who have tendency to show public displays of sexual behavior. (prior attachment competency) to include reporting such behavior. Also educated staff on being aware of the environment outside of what they are focusing on. Provided direct staff education on assisting the resident back to their room. c. Leadership staff understand the importance of completing an investigation re: any resident-on-resident behaviors to include those sexual in nature. d. Separation: In both instances that occurred on 11/4/23, the staff separated the residents when noted kissing / touching each other. In both instances, the staff intervened within 5 minutes. e. The facility implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any noted behaviors re: if resident is cognitively or not. f. The facility reviewed both Care Plans and updated in relation to sexual behaviors. The facility added one-to-one (1:1) intervention to aid in ensuring redirection of the residents, if they attempt to approach each other inappropriately. g. The facility ordered a mannequin with the planned delivery of that evening (November 11, 2023) to offer Resident #6 the opportunity to enjoy affection in privacy while in her room. h. The facility discussed the possibility of finding another placement for either resident, however, at that time that is not an option. i. A physician assessed the resident this past Sunday and determined it would be more detrimental to discharge resident than to continue her care at the facility. The family voiced the preference for her to continue receiving care at the facility. The facility lowered the scope from a K to an E prior to the end of the survey. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The MDS indicated that Resident #2 did not display physical behavioral symptoms directed towards others (grabbing, abusing other sexually). The Care Plan Focus dated 9/18/23, indicated that Resident #2 had a potential for alteration in behavior related to a history of behaviors that make providing him care difficult for staff at times. As Evidenced By (AEB): potential for being aggressive due to his cognitive disease. The Interventions include: * (9/18/23) Redirect and provide a calm environment. Approach resident with a calm demeanor. * (9/18/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli * (11/15/23) 1:1 as needed for overly assertiveness behaviors observed. * (11/15/23) Sexual affection seeking behavior Intervention: redirect with activity * (11/15/23) Redirect from female peers. The Progress Notes documented on these dates and times the following behaviors: *9/14/2023 at 8:32 p.m., Note Text: Resident had no inappropriate sexual behavior. He is awake and walking the hall. No further aggressive behaviors. *10/9/2023 at 11:27 a.m., Social Service Note: Discussed with Resident #2's Power of Attorney (POA) about affection shown to him by another resident. *10/24/2023 at 11:59 a.m., Social Service Note: The facility notified Resident #6's POA about finding him and another peer found in the peer's room. *10/24/2023 at 3:04 p.m., Note Text: Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. *11/4/2023 7:46 a.m., Note Text: Resident #2 appeared to hover behind the upper back and neck of their peer. Resident #2 attempted to kiss, hug, and grope their peer's breast. His peer did not respond to this and stayed still with their eyes closed. The nurse redirected Resident #2 to another dining table and explained this was inappropriate and not acceptable. Later during breakfast Resident #2 returned to the same table next to the same peer, attempting to kiss her. The Certified Nurse Aide (CNA) redirected Resident #2 to another table before he could make contact. On 11/9/23 at 12:00 p.m., observed Resident #2 sitting at the dining room table with another male and female resident on his left side. When attempted to interview Resident #2 about the incidents that occurred on 11/4/23, he could not recall the incidents. On 11/13/23 at 2:00 p.m., when inquired about the the documentation in Resident #2's progress notes, the facility Administrator, Staff F, Assistant Director of Nursing (ADON), and the corporate quality assurance nurse confirmed that the facility lacked knowledge of the allegation of fondling, kissing, groping. They verified that they did not initiate an investigation. They expected the staff to notify the facility administration of the incident. On 11/14/23 at 9:00 a.m., Staff B, Licensed Practical Nurse (LPN) recalled working on the unit on 11/4/23. Around 7:20 a.m., Staff B, came into the dining room and observed Resident #2 standing/hovering over Resident #6's back. Resident #2 kissed Resident #6's face and neck, then fondled, and groped her breast. Staff B, reported that they redirected Resident #2 by taking his hands and then sat him at a different table from Resident #6. Staff B, verified that they failed to do an incident report or notify other staff members to keep extra supervision on Resident #2. In addition, they did not notify the administration of the incident between the two residents. 2. Resident #6's MDS assessment dated [DATE] identified a score of 6 on the BIMS, indicating severe cognitive impairment. The MDS reflected that Resident #6 had physical behavioral symptoms directed towards other (grabbing and abusing others sexually) during the assessment period. Resident #6 required partial/moderate assistance with toilet use and personal hygiene. The MDS listed Resident #6 as independent with transfers, ambulation in the room, on the corridor, on and off the unit. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, non-Alzheimer's dementia, and chronic kidney failure. The Care Plan Focus revised 7/21/23, indicated that Resident #6 had a potential for an alteration in behavior related to a history of behaviors that make providing her care difficult for staff at times. AEB: combative, negative verbalizations, resists care, and affection seeking. The Interventions include: * (4/12/23) Calm environment, reproach later, give a meaningful activity. * (4/12/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, and remove from unwanted stimuli * (7/21/23) Room moves to have resident by self currently. * (11/13/23) Behavior: Sexual Affection seeking Intervention redirect with activity * (11/14/23) Resident 1:1 supervision when out of room. The Progress notes documented on the dates and times the following behaviors: *11/9/2023 at 4:29 p.m., Social Service Text: Called POA and notified them of residents experiencing affectionate behaviors with other residents. *10/24/2023 at 11:56 a.m., Nurses Note Text: Housekeeping staff reported to this nurse that residents were lying in bed together with eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. On 11/9/23 at 12:15 p.m., during an interview, Resident #6 could not recall the incident with Resident #2. On 11/14/23 at 11:00 a.m., Staff E, CNA, recalled working in the unit on 11/4/23 around 7:40 a.m. She explained that she came into the dining room and observed Resident #2 and Resident #6 at the dining room table kissing each other on the lips. Staff E, stated that they removed Resident #2 by assisting him to standing and then proceeded to ambulate with him out of the dining room. Staff E, declined knowing of the prior incident between Resident #2 and Resident #6. On 11/14/23 at 1:00 p.m., Staff F reported that they did not know about the incident between Resident #2 and Resident #6. Staff F, confirmed that no one completed an incident report. Staff F identified their self as the staff on-call the weekend of the incident. Staff F denied that she knew about the incident. She expected the staff to call and notify her or the administrator of the alleged incident. In addition, she expected the staff to keep the two residents separated from each other. Staff F confirmed the facility did not complete or start an investigation of the 11/4/23 incident. An email provided by Staff F on 11/14/23 at 1:39 PM included two videos of Resident #2 and Resident #3 engaging in a public display of affection. In the video dated 11/4/23 at 7:16 AM starts with Resident #2 walking from his side of the table to Resident #6 as two other female residents sit at the table, two male residents sit two tables behind Resident #2, and another female resident sits at the table behind Resident #6 with no staff in the dining room. At 5 seconds, Resident #2 bends down and puts his left arm around Resident #6 with his right hand holding her neck. Resident #6 has her left hand resting on Resident #2's right arm. At 11 seconds, Resident #6 turns away from Resident #2 as he continues to kiss the right side of her face. At 25 seconds, Resident #6 remains turned away from Resident #2 as he wraps his left arm further around her massaging her upper arm. At 34 seconds, he takes Resident #6's face and walks a little closer to be more face to face with her. Then he bends down with his hand on her chin and starts to kiss her. At 39 seconds, Resident #6 attempts to turn away again. Resident #6 appears to talk to someone while waving her left hand away from Resident #2. At 46 seconds, Resident #2 brings his left hand up to Resident #6's face. He continues to kiss the right side of Resident #6, as she uses her right arm to rub his right arm and her left hand on her chin. At 1 minute 8 seconds, Resident #2 moves his to the back side of Resident #6 and slides his right arm down across her chest toward her left breast. He continues to kiss the back of Resident #6's neck and she holds his arms. At 1 minutes and 15 seconds, Resident #6 starts to look up and then Resident #2 starts to pull down the left sleeve of her sweater and then leans forward to start kissing her again. At 1 minute 19 seconds, Resident #6 and Resident #2 start to kiss together on the lips. Resident #2 continues to kiss Resident #6 as she has half of her face looking away. At 1 minute and 56 seconds, Resident #2 grabs Resident #6's head with both hands and bends down to kiss her on the lips. At 2 minutes and 2 seconds, Resident #6 puts her right hand on Resident #2's right arm. At 2 minutes and 8 seconds, Resident #6 moves her left hand up towards her face. At 2 minutes and 14 seconds, Resident #2 moves his face away from Resident #6's face and release his grip on her face. He continues to rub her left shoulder with his right hand with his left hand on her left chest. At 2 minutes and 24 seconds, Resident #2 bends down again to start kissing Resident #6. They stop kissing at 2 minutes and 29 seconds, then start again at 2 minutes and 33 seconds while fondling her chest. At 2 minutes and 50 seconds, Resident #2 starts to kiss Resident #6's neck just below her chin. Then at 3 minutes and 8 seconds he returns to her face. At 4 minutes and 36 seconds, a staff member slowly walks in. She walks over to Resident #2 starts to talk to him and adjusts Resident #6's sweater. At 4 minutes and 52 seconds, the staff member walks Resident #2 to a different table with a different female resident. The video then ends. In the video dated 11/4/23 at 7:33 AM, around 2.5 minutes into the video Resident #2 and Resident #6 start to hold hands. As one CNA sat behind them, helping another resident eat. Around 3 minutes and 20 seconds, Resident #6 starts to rub Resident #2's arm. At 4 minutes and 20 seconds, Resident #2 bends down and kisses Resident #6's hand. At five minutes Resident #2 moves his chair closer to Resident #6 and kisses her hand. Resident #6 placed her head down on the table. At 6 minutes and 54 seconds, Resident #2 bends down again and kisses Resident #6's hand, as the staff member gets up and walks around the room. At 7 minutes and 10 seconds, the staff member returned to the table to clean up the dishes. At 7 minutes and 24 seconds she goes back across the dining room. At 7 minutes 32 seconds another staff member enters the room pushes in a chair then leaves the room. At 7 minutes 36 seconds, Resident #2 leans over as Resident #6 leans into him then start to kiss. At 7 minutes and 39 seconds, the staff member returns running to intervene between Resident #6 and Resident #2 separating them. At 8 minutes and 9 seconds, the staff member pulls Resident #6 away from Resident #2. Then Resident #2 walks out of the video. Resident #6 continues to sit at the table until the end of the video. The undated Resident Rights pamphlet, described the purpose as to ensure that residents understand that they have certain right and protections under Federal law that ensures that they receive the care and services they need. The section labeled Respect and Dignity directed that residents have the right to respect and dignity. In addition, residents have the right to be free from mental abuse, physical abuse, corporal punishment, involuntary seclusion, physical and chemical restraints. The undated facility policy/procedure labeled Inappropriate Behaviors directed that staff must monitor for and respond to inappropriate behavior in a timely manner. Some residents may exhibit inappropriate behavior. (i.e. behavior that is not socially acceptable). Such behavior may take a variety of forms. The list is not all inclusive. Examples of inappropriate behavior(s) may include: *Inappropriate grabbing or touching of staff, other tenants, and/or visitors. *Engaging in sexual type behaviors (kissing, fondling, grabbing, etc.) PROTOCOL: When a resident engages in inappropriate behavior, address the behavior immediately. For residents who may not know that their behavior is inappropriate and/or unable to control the behavior: *Try to redirect the resident who is engaging in the behavior. Diverting the resident's attention to another activity may effectively stop the behavior. *Document the incident in the Progress Notes. *Note when and what occurred, including the resident's response to the redirection. *If appropriate, consult with family member(s) for input and suggestions on how to handle inappropriate behavior. *If a resident has demonstrated a tendency to engage inappropriate behavior, Document: *The behavior and the techniques shown to be effective in addressing the behavior in the care plan The Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/8/20, directed that all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and, physical or chemical restraint not required to treat the resident's medical symptoms. No residents should experience abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, other agencies serving the resident, family members, legal guardians, friends, or other individuals. Resident to resident sexual harassment, sexual coercion, or sexual assault could result in abuse. The facility will presume that instances of abuse cause physical harm, pain, or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain, or mental anguish, in the absence of evident to the contrary. All staff should report any allegations of resident abuse, neglect, exploitation, mistreatment, and/or misappropriation immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator or designated representative. 3. Resident #3's MDS assessment dated [DATE] identified that she had short- and long-term memory impairment with severely impaired daily decision-making abilities. The MDS reflected that Resident #3 displayed verbal behaviors (threatening, screaming, and cursing at others) during the assessment period. Resident #3 required extensive assistance from one person for dressing, toilet use and personal hygiene. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer disease, anxiety, and depression. The Care Plan Focus revised 4/1/22, indicated that Resident #3 used psychotropic medications related to cognitive impairment, irritability, anger, anxiety, and depression. An intervention dated 9/14/23 directed to keep her separated from Resident #2 as much as able. The Progress Notes related to Behaviors: *9/14/23 at 6:15 p.m., Note Text: A staff member informed the nurse that a male resident (Resident #2) grabbed another resident (Resident #3) by the neck, shoved her back, and then thumped her on the forehead with his finger and thumb. When the staff intervened, the male resident grabbed the staff member by the neck leaving red marks and then threatened to bash her head in. The nurse checked on the female resident and saw no marks from the altercation. While in bed, the female resident reported being afraid to go to sleep. The nurse assured the resident that she would keep him out of her room and that she was safe. As the nurse attempted to calm down the female resident, the male resident attempted to grab the nurse by the neck and threatened to bash their head in. *9/15/23 at 10:07 a.m., Note Text: follow up for behaviors - no concerns noted this shift, resident had no altercations with the other resident. *9/16/23 at 12:05 p.m., Note Text: No resident to resident altercation this shift. *9/17/23 at 9:55 a.m., Note Text: follow up altercation - resident remained in his room that morning with no altercations with the other resident. The staff-maintained separation between the two residents. On 11/9/23 at 11:45 a.m., Resident #3 could not recall any incidents that have occurred with Resident #2. The Incident/Accident/Physical Report dated 9/14/23 at 6:17 p.m. indicated that a staff member informed the nurse that a male resident (Resident #2) grabbed another resident (Resident #3) by the neck, shoved her back, and then thumped her on the forehead with his finger and thumb. When the staff intervened, the male resident grabbed the staff member by the neck leaving red marks and then threatened to bash her head in. The nurse checked on the female resident and saw no marks from the altercation. While in bed, the female resident reported being afraid to go to sleep. The nurse assured the resident that she would keep him out of her room and that she was safe. As the nurse attempted to calm down the female resident, the male resident attempted to grab the nurse by the neck and threatened to bash their head in. The section labeled Resident's Description revealed that Resident #3 was afraid to go to sleep. The Intervention section directed to keep separated from Resident #2 as much as able. Resident #2's Incident/Accident/Physical Report dated 9/14/23 at 6:17 p.m. listed a Nursing Description: that Resident #2 became aggressive with his peer when she asked him to get out of her bed. He put his hand around Resident #3's neck, shoved her away, and then thumped her in the forehead with his finger and thumb. When staff attempted to remove him from the situation he grabbed the staff around the neck leaving claw marks and threatened to bash her head in. When the nurse attempted to calm Resident #2, he attempted to grab her by the neck and threatened to bash their head in. The section labeled Immediate Action Taken: Indicated that the staff separated the residents from each other. The nurse attempted to talk with Resident #2 to calm him when he attempted to grab their neck and when they backed away he threatened to bash their head in. The nurse removed myself from the situation and let him pace while monitoring him to keep his peers away. The Interventions section directed to keep separated from Resident #3 as much as able. The undated Facility Self-Investigation for the resident to resident investigation included the Summary of Incident on 9/14/23 at 6:04 p.m., as Resident #2 wandered into Resident #3's room and laid down on her bed. At 6:08 p.m., Resident #3 and Staff D, CMA (certified medication aide), entered Resident #3's room and noticed Resident #2 sleeping on her bed. Resident #3 began hollering at Resident #2 to get out of her bed. Resident #2 became angry and made physical contact with Resident #3's neck as he hollered at her to be quiet. Staff B, CMA, intervened immediately. Resident #3 remained in her room. The staff assisted Resident #2 out of Resident #3's room, but he remained angry at the staff. The section labeled Facility Actions reflected that the facility immediately separated the residents at the time of the incident. The nurse completed an assessment Resident #3 that revealed no injury, range of motion within normal limits, and provided reassurance to her. The Intervention section directed to keep separated from Resident #2 as much as able. Both residents have a BIMS score of 00 and have cognitive impairments. Both residents speak negatively about other residents, staff, and visitors. No prior history of physical contact with other residents.

Based on clinical record review, staff interview, and facility policy/procedure the facility failed to notify the Administration of an incident of sexual nature between two residents with the inability to consent. Despite the facility learning of the incident and watching the video, the facility reported they felt the incident did not need reported. As the facility did not notify the Iowa Department of Inspections, Appeals, and Licensing (IDIAL) this increased the likelihood of future incidents occurring. The facility reported a censure of 63 residents. On November 11th, 2023 at 5:00 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on November 15th, 2023 after the facility completed the following: a. Implemented new CCDI Assessment of Awareness related to identifying upon admission residents who may be overly affectionate and potential tendencies for sexual behaviors. The facility completed the assessment on all current residents. The facility will complete the assessment again with any noted significant change. b. Re-educated staff on the expected care for residents who have tendency to show public displays of sexual behavior. (prior attachment competency) to include reporting such behavior. Also educated staff on being aware of the environment outside of what they are focusing on. Provided direct staff education on assisting the resident back to their room. c. Leadership staff understand the importance of completing an investigation re: any resident-on-resident behaviors to include those sexual in nature. d. Separation: In both instances that occurred on 11/4/23, the staff separated the residents when noted kissing / touching each other. In both instances, the staff intervened within 5 minutes. e. The facility implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any noted behaviors re: if resident is cognitively or not. f. The facility reviewed both Care Plans and updated in relation to sexual behaviors. The facility added one-to-one (1:1) intervention to aid in ensuring redirection of the residents, if they attempt to approach each other inappropriately. g. The facility ordered a mannequin with the planned delivery of that evening (November 11, 2023) to offer Resident #6 the opportunity to enjoy affection in privacy while in her room. h. The facility discussed the possibility of finding another placement for either resident, however, at that time that is not an option. i. A physician assessed the resident this past Sunday and determined it would be more detrimental to discharge resident than to continue her care at the facility. The family voiced the preference for her to continue receiving care at the facility. The facility lowered the scope from a K to an E prior to the end of the survey. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The MDS indicated that Resident #2 did not display physical behavioral symptoms directed towards others (grabbing, abusing other sexually). The Progress Notes documented on these dates and times the following behaviors: * 9/14/23 at 8:32 p.m., Note Text: Resident #2 did not display inappropriate sexual behaviors. He observed awake and walking the hall, with no further aggressive behaviors. *10/9/23 at 11:27 a.m., Social Service Note: Discussed with Resident #2's Power of Attorney (POA) about affection shown to him by another resident. *10/24/23 at 11:59 a.m., Social Service Note: The facility notified Resident #6's POA about finding him and another peer found in the peer's room. *10/24/23 at 3:04 p.m., Note Text: Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. *11/4/23 at 7:46 a.m., Note Text: Resident #2 appeared to hover behind the upper back and neck of their peer. Resident #2 attempted to kiss, hug, and grope their peer's breast. His peer did not respond to this and stayed still with their eyes closed. The nurse redirected Resident #6 to another dining table and explained this was inappropriate and not acceptable. Later during breakfast Resident #6 returned to the same table next to the same peer, attempting to kiss her. The Certified Nurse Aide (CNA) redirected Resident #6 to another table before he could make contact. On 11/13/23 at 2:00 p.m., when inquired about the documentation in Resident #2's progress notes, the facility Administrator, Staff F, Assistant Director of Nursing (ADON), and the corporate quality assurance nurse confirmed that the facility lacked knowledge of the allegation of fondling, kissing, groping. They verified that they did not initiate an investigation. They expected the staff to notify the facility administration of the incident. On 11/14/23 at 9:00 a.m., Staff B, Licensed Practical Nurse (LPN) recalled working on the unit on 11/4/23. Around 7:20 a.m., Staff B, came into the dining room and observed Resident #2 standing/hovering over Resident #6's back. Resident #2 kissed Resident #6's face and neck, then fondled, and groped her breast. Staff B, reported that they redirected Resident #2 by taking his hands and then sat him at a different table from Resident #6. Staff B, verified that they failed to do an incident report or notify other staff members to keep extra supervision on Resident #2. In addition, they did not notify the administration of the incident between the two residents. 2. Resident #6's MDS assessment dated [DATE] identified a score of 6 on the BIMS, indicating severe cognitive impairment. The MDS reflected that Resident #6 had physical behavioral symptoms directed towards other (grabbing and abusing others sexually) during the assessment period. Resident #6 required partial/moderate assistance with toilet use and personal hygiene. The MDS listed Resident #6 as independent with transfers, ambulation in the room, on the corridor, on and off the unit. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, non-Alzheimer's dementia, and chronic kidney failure. The Progress notes documented on the dates and times the following behaviors: *11/9/23 at 4:29 p.m., Social Service Text: Called POA and notified them of residents experiencing affectionate behaviors with other residents. *10/24/23 at 11:56 a.m., Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. On 11/14/23 at 11:00 a.m., Staff E, CNA, recalled working in the unit on 11/4/23 around 7:40 a.m. She explained that she came into the dining room and observed Resident #2 and Resident #6 at the dining room table kissing each other on the lips. Staff E, stated that they removed Resident #2 by assisting him to standing and then proceeded to ambulate with him out of the dining room. Staff E, declined knowing of the prior incident between Resident #2 and Resident #6. On 11/14/23 at 11:15 AM the Administrator said that the residents have the right be affectionate with other residents. The facility contacted the families to notify them that some of the residents are getting mroe affectionate with other residents and that those resident have a right to be affectionatte in a loving manner. The facility did not feel that they needed to report the incidents. On 11/14/23 at 1:00 p.m., Staff F reported that they did not know about the incident between Resident #2 and Resident #6. Staff F, confirmed that no one completed an incident report. Staff F identified as the staff on-call the weekend of the incident. Staff F denied that she knew about the incident. She expected the staff to call and notify her or the administrator of the alleged incident. In addition, she expected the staff to keep the two residents separated from each other. Staff F confirmed the facility did not complete or start an investigation of the 11/4/23 incident. The Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/8/20, directed that staff should report all allegations of resident abuse, neglect, exploitation or mistreatment and misappropriation immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator or designated representative. The facility should report all allegations of resident abuse to the Iowa Department of Inspections and Appeals not later than two (2) hours after a report of an allegation. Everyone having knowledge of the criminal act, has independent duty to report to DIA. Several covered individuals having knowledge may file a single report that includes information about the suspected crime from each covered person.

Based on clinical record review, policy review, staff interview, the facility staff failed to thoroughly investigate all allegations of abuse, and separate a possible abuser from other residents. The facility lacked documentation of thorough investigations. The facility failed to conduct resident and staff interviews to determine the extent of the allegations, if other residents were involved. A serious outcome was likely to occur as the facility failed to report and thoroughly investigate all allegations of abuse. Additionally, without the thorough investigation, it was unknown if other residents were involved. Despite the facility learning of the incident and watching the video, the facility reported they felt the incident did not need reported. There is an immediate need for the facility to conduct a thorough investigation all allegations of abuse to protect all residents form the potential of sexual abuse. The facility reported a census of 63 residents. On November 11th, 2023 at 5:00 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on November 15th, 2023 after the facility completed the following: a. Implemented new CCDI Assessment of Awareness related to identifying upon admission residents who may be overly affectionate and potential tendencies for sexual behaviors. The facility completed the assessment on all current residents. The facility will complete the assessment again with any noted significant change. b. Re-educated staff on the expected care for residents who have tendency to show public displays of sexual behavior. (prior attachment competency) to include reporting such behavior. Also educated staff on being aware of the environment outside of what they are focusing on. Provided direct staff education on assisting the resident back to their room. c. Leadership staff understand the importance of completing an investigation re: any resident-on-resident behaviors to include those sexual in nature. d. Separation: In both instances that occurred on 11/4/23, the staff separated the residents when noted kissing / touching each other. In both instances, the staff intervened within 5 minutes. e. The facility implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any noted behaviors re: if resident is cognitively or not. f. The facility reviewed both Care Plans and updated in relation to sexual behaviors. The facility added one-to-one (1:1) intervention to aid in ensuring redirection of the residents, if they attempt to approach each other inappropriately. g. The facility ordered a mannequin with the planned delivery of that evening (November 11, 2023) to offer Resident #6 the opportunity to enjoy affection in privacy while in her room. h. The facility discussed the possibility of finding another placement for either resident, however, at that time that is not an option. i. A physician assessed the resident this past Sunday and determined it would be more detrimental to discharge resident than to continue her care at the facility. The family voiced the preference for her to continue receiving care at the facility. The facility lowered the scope from a K to an E prior to the end of the survey. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The MDS indicated that Resident #2 did not display physical behavioral symptoms directed towards others (grabbing, abusing other sexually). The Care Plan Focus dated 9/18/23, indicated that Resident #2 had a potential for alteration in behavior related to a history of behaviors that make providing him care difficult for staff at times. As Evidenced By (AEB): potential for being aggressive due to his cognitive disease. The Interventions include: * (9/18/23) Redirect and provide a calm environment. Approach resident with a calm demeanor. * (9/18/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli * (11/15/23) 1:1 as needed for overly assertiveness behaviors observed. * (11/15/23) Sexual affection seeking behavior Intervention: redirect with activity * (11/15/23) Redirect from female peers. The Progress Notes documented on these dates and times the following behaviors: *9/14/2023 at 8:32 p.m., Note Text: Resident had no inappropriate sexual behavior. He is awake and walking the hall. No further aggressive behaviors. *10/9/2023 at 11:27 a.m., Social Service Note: Discussed with Resident #2's Power of Attorney (POA) about affection shown to him by another resident. *10/24/2023 at 11:59 a.m., Social Service Note: The facility notified Resident #6's POA about finding him and another peer found in the peer's room. *10/24/2023 at 3:04 p.m., Note Text: Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact. The staff redirected the residents and brought them out to the lobby. *11/4/2023 7:46 a.m., Note Text: Resident #2 appeared to hover behind the upper back and neck of their peer. Resident #2 attempted to kiss, hug, and grope their peer's breast. His peer did not respond to this and stayed still with their eyes closed. The nurse redirected Resident #6 to another dining table and explained this was inappropriate and not acceptable. Later during breakfast Resident #6 returned to the same table next to the same peer, attempting to kiss her. The Certified Nurse Aide (CNA) redirected Resident #6 to another table before he could make contact. On 11/9/23 at 12:00 p.m., observed Resident #2 sitting at the dining room table with another male and female resident on his left side. When attempted to interview Resident #2 about the incidents that occurred on 11/4/23, he could not recall the incidents. On 11/13/23 at 2:00 p.m., when inquired about the documentation in Resident #2's progress notes, the facility Administrator, Staff F, Assistant Director of Nursing (ADON), and the corporate quality assurance nurse confirmed that the facility lacked knowledge of the allegation of fondling, kissing, groping. They verified that they did not initiate an investigation. They expected the staff to notify the facility administration of the incident. 2. Resident #6's MDS assessment dated [DATE] identified a score of 6 on the BIMS, indicating severe cognitive impairment. The MDS reflected that Resident #6 had physical behavioral symptoms directed towards other (grabbing and abusing others sexually) during the assessment period. Resident #6 required partial/moderate assistance with toilet use and personal hygiene. The MDS listed Resident #6 as independent with transfers, ambulation in the room, on the corridor, on and off the unit. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, non-Alzheimer's dementia, and chronic kidney failure. The Care Plan Focus revised 7/21/23, indicated that Resident #6 had a potential for an alteration in behavior related to a history of behaviors that make providing her care difficult for staff at times. AEB: combative, negative verbalizations, resists care, and affection seeking. The Interventions include: * (4/12/23) Calm environment, reproach later, give a meaningful activity. * (4/12/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, and remove from unwanted stimuli * (7/21/23) Room moves to have resident by self currently. * (11/13/23) Behavior: Sexual Affection seeking Intervention redirect with activity * (11/14/23) Resident 1:1 supervision when out of room. The Progress notes documented on the dates and times the following behaviors: *11/9/2023 at 4:29 p.m., Social Service Text: Called POA and notified them of residents experiencing affectionate behaviors with other residents. *10/24/2023 at 11:56 a.m., Nurses Note Text: Housekeeping staff reported to this nurse that residents were lying in bed together with eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. On 11/9/23 at 12:15 p.m., Resident #6 could not recall the incident with Resident #2. On 11/14/23 at 9:00 a.m., Staff B, Licensed Practical Nurse (LPN) recalled working on the unit on 11/4/23. Around 7:20 a.m., Staff B, came into the dining room and observed Resident #2 standing/hovering over Resident #6's back. Resident #2 kissed Resident #6's face and neck, then fondled, and groped her breast. Staff B, reported that they redirected Resident #2 by taking his hands and then sat him at a different table from Resident #6. Staff B, verified that they failed to do an incident report or notify other staff members to keep extra supervision on Resident #2. In addition, they did not notify the administration of the incident between the two residents. On 11/14/23 at 1:00 p.m., Staff F reported that they did not know about the incident between Resident #2 and Resident #6. Staff F, confirmed that no one completed an incident report. Staff F identified their self as the staff on-call the weekend of the incident. Staff F denied that she knew about the incident. She expected the staff to call and notify her or the administrator of the alleged incident. In addition, she expected the staff to keep the two residents separated from each other. Staff F confirmed the facility did not complete or start an investigation of the 11/4/23 incident. The Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/8/20 instructed that if someone reports an incident or suspected incident of resident abuse, the Administrator or their designee would designate a member of management to investigate the alleged incident. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. a. Review documentation in resident record (including review of assessment if resident injury). b. Assess the resident for injury if the allegation involves physical or sexual abuse; c. Provide proper notifications to primary care provider, responsible party, etc. d. Attempt to obtain witness statements (oral and/or written) from all known witnesses. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections and Appeals. The facility should forward their written report to the Department within five days of the initial report. Initial/Immediate Protection During Facility Investigation: Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to provide one-on-one (1:1) supervision on an ambulatory cognitively impaired resident for 1 of 17 residents in the secure memory unit. (Resident #2) Resident #2 had documentation from the physician that the resident needed to be in a locked unit to prevent elopement and had exhibited exit seeking behaviors for several days prior to exiting the facility unsupervised. On 9/24/23, Resident #2 while left unsupervised, exited the facility after going to church on the unlocked first floor of the facility. Around 9:00 a.m., a staff member observed Resident #2 on the south side of the facility in the alley. Resident #2 exited the building without authorization. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. On November 16, 2023 at 11:10 a.m., the Iowa Department of Inspections, Appeals and Licensing (IDIAL) staff contacted the facility to notify them the Department staff determined an Immediate Jeopardy (IJ) situation at the facility. The facility removed the IJ prior to the survey on 9/24/23, resulting in past noncompliance. The facility removed the Immediate Jeopardy through the following actions: * The facility educated the staff on the definition of elopement. Elopement is the ability of a cognitively impaired resident, who is not capable of protecting themselves, to successfully leave the facility unsupervised and unnoticed, potentially coming to harm. * Memory [NAME] Units: Any resident who is exit seeking should not go out of the units without 1:1 supervision and a wanderguard (special bracelet that sets off a specific door alarm to alert staff of potential exit). * Admission and Re-Admission checklist - Elopement Risk Screening Tool = If a high risk apply a wanderguard on the resident at admission. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The resident exhibited wandering behaviors for 4-6 days of the observation period. The Baseline Care Plan dated 9/6/23, identified Resident #2 as an elopement risk. The section regarding wanderguard indicated that Resident #2 lived in the locked unit. Resident #2 had no history of abusive behaviors. The ~SNF - Elopement Risk Screening Tool ~ - V 1 dated 9/6/23 at 12:24 p.m., listed a score of 10, indicating a high risk for elopement. The form described Resident #2 as independently mobile, wanders, and has a dementia diagnosis. The Care Plan Focus dated 9/24/23, identified that Resident #2 had a risk of injury due to wandering behavior and the use of a wanderguard bracelet. The connected goal indicated that Resident #2 could wander in a safe environment without the occurrence of injury, while maintaining his dignity. The Interventions dated 9/25/23 directed the following: * Wanderguard placed on resident, Rexulti (medication used to treat agitation in a person with dementia) every day, and added to hot charting to monitor behaviors. * Assist me to a high traffic area when up in wheelchair to insure frequent visualization * Observe my wanderguard bracelet for placement and function every shift-change as indicated * Offer to assist with needs, desires, offer redirection, or a diversional activity if staff note Resident #2 appeared to wander without a purpose. The Care Plan Focus dated 9/26/23 indicated that Resident #2 had a self-care deficit related to dementia as evidenced by requiring assistance with activity of daily living (ADL). The connected Goal listed to maintain current self-performance abilities without decline through the next review. The Interventions dated 9/26/23 reflected the following: * Ambulation - Independent no assistive device * Locomotion - Independent no assistive device * Transfer - Independent no assistive device On 11/9/23 at 12:00 p.m., observed Resident #2 ambulating up and down the hallway independently without an assistive device. On 11/13/23 at 1:00 p.m. observed Resident #2 ambulating up and down the hallway independently without an assistive device. Progress Notes related to exit seeking behaviors: *9/8/23 at 1:35 p.m., Late Entry: Resident #2 wandered throughout the day and conversed well with others. Resident #2 would stand by the exit door at times but can redirect easily. *9/9/23 at 1:31 p.m., Note Text: Wanders the unit throughout the day. *9/11/23 at 6:18 a.m., Note Text: Wanders the unit throughout the day and evening. Resident #2 had no complaints of pain while pacing or ambulating in the unit. *9/13/23 at 8:47 p.m., Note Text: Resident #2 wandered around the unit, including in and out of another residents' room. Resident #2 attempted to exit seek at times but easily redirected. *9/15/23 at 2:59 p.m., Note Text: Received doctor's progress notes from 9/10/23 that reflected that Resident #2 remained appropriate for intermediate care facility (ICF) level of care with the direction that he needed to remain on a locked unit to prevent elopement. *9/19/23 at 10:27 a.m., Note Text: The nurse monitored Resident #2 related to a resident to resident altercation. The staff observed Resident #2 wandering around the unit, exit seeking at times, and asking to go home. Resident #2 easily redirects. Went to bible study with staff. *9/21/23 at 6:58 p.m., Note Text: Resident #2 continued to pace the hall and check the doors all shift. *9/21/23 at 7:47 p.m., Note Text: Resident #2 continued to pace and exit seek, while trying to open the doors. He wandered around the building. *9/22/23 at 10:52 a.m., Note Text: Noted to be wandering around and exit seeking, but redirected easily. *9/24/23 at 9:25 a.m., Note Text: A housekeeping staff reported seeing Resident #2 wandering outside. An employee observed Resident #2 going down the street by the employee entrance. While at the end of St. [NAME]'s hallway, a Housekeeper spotted Resident #2. The nurse and a CNA (certified nursing assistant) went outside to redirect him back inside. They entered through the employee entrance. The assessment did not reveal injuries on Resident #2. Resident #2 denied pain at that time. He paced most of the day and needed reminded to rest periodically. He swore due to this. Resident has full ROM, only alert to self however unable to verbalize situation. Pulses within normal limits, lung sounds clear, skin cool to touch, color with in normal limits, pupil's reaction with in normal limits. No bruising noted, and he continued to ambulate per his usual. The staff checked the door alarms and they functioned as they should. The staff notified to watch for any further activity. The facility collected staff statements, placed a wanderguard on Resident #2, and ensured it functioned. *10/20/23 at 2:08 a.m., Note Text: At 11:00 p.m., observed Resident #2 up and walking in room, banging on dresser, walking over to roommate, and standing over him multiple times. The staff approached Resident #2 while in room to remove him from roommate's side of the room as he appeared agitated and unaware of what could happen. The staff had difficulty redirecting Resident #2 to his side of the room or to go out to the common lobby. When attempted to ask Resident #2 he yelled, said get out, has a stern look on his face, and clenched his fists. As the nurse calmly approached Resident #2 to attempt to give him Ativan (antianxiety medication), he threw water on the nurse from a water cup. The nurse directed staff to leave Resident #2 alone if he is not harming himself or roommate, due to his physical threats of harm to staff. The Incident Report labeled Elopement dated 9/24/23 at 9:00 a.m., reflected that a housekeeper called the nurse who reported they saw Resident #2 wandering outside. They observed Resident #2 going down the street by the employee entrance. At the time, the housekeepers worked at the end of St. [NAME] hallway when they spotted Resident #2. The nurse and a Certified Nurse Aide (CNA), went outside to redirect Resident #2 back inside the facility. They entered through the employee entrance. The nurse assessed him for injuries, took his vital signs, and placed a Wanderguard on Resident #2. The Notes section reflected the following Interventions: wanderguard placed on Resident #2 and staff to attend any activities for assistance with issues that may arise. On 11/15/23 at 3:00 p.m., Staff A, CNA, recalled that on 9/24/23, at about 8:30 a.m., the volunteers asked Resident #2 if he would like to go for church service. Staff A proceeded to take Resident #2 off the locked unit and ambulated him to the first-floor lobby area, where they sat Resident #2 by another resident. Staff A, then returned to the secure memory unit. Staff A, explained that they did not know that Resident #2 needed supervision when off the unit. On 11/14/23 at 9:00 a.m., Staff B, LPN (licensed practical nurse) recalled that on 9/24/23 at approximately 9:00 a.m., Staff B went outside and assisted Resident #2 in through the employee entrance of the facility after Staff C, Housekeeper, notified them of Resident #2 outside on the south side of the facility in the alley. Staff B confirmed that Resident #2 needed to have supervision when off the secure memory unit. On 11/15/23 at 1:30 p.m., Staff C recalled that on 9/24/23 at approximately 9:00 a.m., they noticed Resident #2 ambulating in the alley way on the south side of the facility without a staff member present. Staff C went to Staff B and notified them of observing Resident #2 outside without supervision. On 11/15/23 at 2:00 p.m., the Administrator, Director of Nursing (DON), and Quality Assurance Nurse verified that Resident #2 needed supervision when taken off the secure memory unit. The expected the staff is to stay with any resident when off the units. An investigation self-report dated 9/25/23 at 2:23 p.m., submitted to IDIAL by the facility included the following: on 9/24/23 after the end of church services, Resident #2 wandered into St Luke's unit then opened the north door in St Luke's and walked out into the side walk. The alarms sounded and a housekeeper nearby alerted nursing staff. The Nursing staff assisted Resident #2 into the facility at 9:15 a.m. The Corrective Action Notice dated 9/24/23 identified that Staff A, CNA, received verbal coaching for improvement related to leaving a resident unattended, causing that resident to leave the building. The In-Service Form dated 9/25/23 identified the topics covered as policies, procedures, drill, documentation, devices, and alarms. The summary of the training session defined elopement as the ability of a cognitively impaired resident, who is not capable of protecting themselves, to successfully leave the facility unsupervised and unnoticed, potentially coming to harm. The evaluation, comments, suggestions section reflected that any resident on the memory care unit who exit seeks should not go out of the unit without 1:1 supervision and a wanderguard. The staff signed the Elopement In-Service and Elopement Drill Sign-in Sheet on 9/27/23. The Standards and Processes for Elopement Risk/Elopement Process dated 9/22/17 defined wandering as movement about the area without a fixed goal. The document defined elopement as slipping away secretly, running away, or leaving without accompaniment or knowledge of the staff. The section labeled Implementation instructed the following: *Assessment and Identification of wandering residents = The facility will assess the following related to an elopement risk assessment upon admission, readmission, quarterly, annually and with a significant change MDS. *mobility status - is resident independently mobile with or without an assistive device *does the resident have a history of wandering *does the resident have Alzheimer or other diagnosis of dementia *talks about leaving the facility *if resident has 3 yes answers from questions 1-8, they are at risk for elopement. *Residents whose assessment identifies them as a risk for elopement, the facility will take the following steps: *Apply an alarm bracelet on the resident to audibly alert staff of their attempt to exit the facility. *Update the resident's Care Plan to address behaviors using resident specific goals and/or approaches based on the resident's assessment. *Maintain a current picture of the resident in the facility *The facility staff will immediately respond to all exit alarms *The staff will encourage activities that the resident enjoys to occupy/distract them

Based on observation, record review, policy review, and staff interview the facility failed to adequately supervise residents while outside the facility smoking for 1 of 2 residents reviewed. Staff did not provide adequate supervision to a resident who walked away from the facility while staff failed to maintain constant supervision of the resident as the care plan directed. This resulted in past noncompliance immediate jeopardy for the facility. The facility reported a census of 65 residents. Findings include: Resident #1's Minimum Data Set (MDS) with a completion date of 12/9/19, listed [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) test identified the resident with a score 8 (moderate cognitive impairment). The MDS documented the resident wandered daily. The resident was independent with ambulation, however, supervision when off the unit. Care Plan: A Care Plan problem area with onset date of 11/27/19, identified the resident at risk for wandering throughout the neighborhood and at times exit seeking behavior related to [DIAGNOSES REDACTED]. The care plan failed to identify that the resident had a wander guard alarm/bracelet in place. The care plan was updated to include the following interventions: medication adjustment (12/17/19), staff to monitor whereabouts and not allow resident to leave unit (12/17/19), and 15 minute checks (12/18/19). Care plan problem area with onset date of 12/7/19, identified the resident as a smoker and able to smoke in a designated area with constant supervision. Interventions included: staff must remain outside in the designated smoking area and maintain constant supervision while the resident smokes. This problem was discontinued on 3/17/20. The care plan failed to identify the resident required 2 staff present when out to smoke. Care Plan problem area with onset date of 11/27/19, identified the resident with potential for alteration in behavior related to history and [DIAGNOSES REDACTED]. The care plan was updated to include no smoking (12/17/19). An Elopement/Wandering Risk Assessment with a completion date of 12/8/19, identified the resident at high risk for wandering due to mobility, history of wandering, [DIAGNOSES REDACTED]. A Safe Smoking Risk assessment with a completion date of 12/7/19, identified that the resident required supervision while smoking. An incident report dated 12/17/19 at 2:57 PM, revealed Resident #1 left the facility grounds at 12:50 PM. Narrative of incident and description of injuries: resident left facility grounds at 12:50 PM and no injuries noted upon skin assessment. Immediate actions taken: called 911, searched community, resident returned to the facility safely. The incident report failed to document the time the resident returned to the facility or vital signs taken upon the return. A Perry Police Report, Call for service record with a call number of 78, at 1:11 PM on 12/17/19, revealed Perry Lutheran Home reported a missing resident. Dispatcher notified the sergeant and at the same time received call from the maintenance man at the Perry Super 8 Motel, reporting female matching description. Perry Police relayed the information to Perry Lutheran Home and the facility sent someone to get the resident. Review of Elopement Risk information book, located in the financial office: Front pocket contained document titled placement of wander guard dated 1/1/18 and Missing resident code pink document undated 1st tab contained the residents from the 1st floor of the facility that were elopement risk, with their pictures attached to their face sheets 2nd tab contained the residents from St. Johns secured unit that were elopement risk, with their pictures attached to their face sheets 3rd tab contained the residents from St. James secured unit that were elopement risk, with their pictures attached to their face sheets The Elopement information book was not up to date with the current residents who the facility identified as elopement risk. Review of Report book on 6/30/20, for each secured unit contained: Document titled missing resident procedure undated Daily QA condition change audit dated 6/29/30, with residents changes and information pertinent for the staff Report sheets Document titled Assessment thought process guidelines, undated Documentation reminder Review of an undated document titled Missing Resident Procedure: The missing resident episode must be documented in the resident's chart and incident report completed Resolution of the episode shall be documented in the resident's chart and incident report Upon return to the facility, head to toe assessment shall be completed and documented in the resident's chart Review of an undated document titled Assessment Thought Process Guidelines, directed staff of areas to assess during a head to toe assessment; included vital signs. Review of Communication book on 6/30/20, for St. John's secure unit: Document titled St. John's staff dated 4/9/20 - informed staff about the communication book: read & initial daily, located on medication cart or nurses desk, any staff can add pertinent information about residents, and is available for all staff to provide the most up to date care on all St. John residents Pocket care plan sheets dated 6/29/30 Environmental Aide schedule No signature sheets included Review of Communication book on 6/30/20, for St. James secure unit: Document titled St. James staff dated 3/3/20 - informed staff about the communication book: read & initial daily, located on medication cart or nurses desk, any staff can add pertinent information about residents, and is available for all staff to provide the most up to date care on all St. John residents Pocket care plan sheets dated 6/29/30 Environmental Aide schedule Document titled 4/7/20 St. James staff - explained the pocket care plans and that they would be updated on Mondays and Thursday/Friday Signature sheet in back 5 staff signed and dated 3/3/20 and 1 staff signed an dated on 3/5/20 Review of progress notes: 12/7/19 at 1:02 PM, telephone order per the resident's primary care physician, ok to leave nicotine patch on and allow the resident to smoke outside with staff two times a day. 12/7/19 at 1:34 PM, documented finally got an order for [REDACTED]. 12/17/19 at 2:52 PM, documented the resident left the facility grounds at 12:50 PM, called 911, searched community, and resident returned to the facility safely. Head to toe assessment completed and no abnormalities. The entry did not contain assessment of vital signs. Resident #1's Electronic Health Record (EHR) for 12/17/19, did not contain vital signs documented in the Vital Signs section. Policy: Document titled Missing Resident dated September 2017 with a revision date of April 2019, stated upon return of the missing resident nursing would: Examine resident for injuries Contact the attending physician and report findings and condition of the resident Contact the residents legal representative Complete an incident report Make appropriate entries in the residents medical record During Entrance Conference on 6/29/20 at 1:15 PM with the DON, he stated he did not know if the facility had a policy regarding residents smoking, however, would look into it. The DON stated the facility was a non-smoking facility and made an exception for this resident due to her increased behaviors. The DON stated the facility tried to allow the resident to smoke instead of medication use for her behaviors. During initial interview with the Administrator on 6/29/20 at 3:03 PM, she stated the facility was a Smoke Free Facility since 2013 and was unaware if there was a smoking policy. When questioned on 6/30/20 at 9:03 AM and 10:44 AM, the DON again stated did not know if the facility had a smoking policy. On 6/30/20 at 11:16 AM the DON provided the surveyor a copy of the Accidents and Supervision Smoking Policy undated. The DON stated on 6/30/20 at 3:58 PM, that he located the policy on the computer and that the facility policy book did not contain this policy. The DON stated he would not expect staff to comply with the policy due the policy not available for staff in the policy book and facility a smoke free facility. On 6/29/20 at 2:25 PM, Staff A CMA (certified medication aide), stated she took Resident #1 out to smoke on 12/17/19. Staff A stated she was scheduled on 12/17/19, as Restorative Aide however, assisted residents on secured unit with lunch when Resident #1 continuously asked to go outside for a cigarette. Staff A stated staff usually took the resident out to smoke after lunch, however, the facility did not have scheduled smoke times. Staff A stated she knew the resident had exit seeking behavior and always wanted to go home. Staff A stated she did not previously ever take Resident #1 out to smoke. On 12/17/219 Staff A took the resident downstairs and out the East door to smoke. Staff A proceeded to demonstrate how she handed Resident #1 her lighter and cigarette and reset alarms. Staff A stated she stopped at the cigarette stack (fire proof container where cigarette butts are placed after smoking) with her back to the resident. She stopped at the cigarette smoke container due to cigarette butts on the top and she needed to push them down into the container. Staff A stated she talked to Resident #1 while she did this, however, the resident stopped talking and Staff A turned around to find the resident gone. Staff A believed the time as less than 30 seconds. Staff A stated she asked a construction crew working on the front side of the building if they observed the resident and they said no. However, Staff A stated when other staff asked the construction crew, they reported the resident got into a white car at the corner of Willis Street. Staff A stated she looked in the parking lot briefly and around the building prior to going inside service door to notify administration. On 6/29/20 at 3:03 PM, the Administrator stated she thought Staff A was tried helping by taking Resident #1 outside to smoke. The Administrator stated staff on the secure unit told Staff A she needed 2 staff present when taking Resident #1 outside to smoke. The Administrator played the facilities video footage from 12/17/19 at 12:48 PM, observation of the footage showed Resident #1 come from the east entrance of the facility onto the ramp, stopped approximately half way down the ramp, and then proceeded to the end of the ramp and turned to her left, where she stopped again. The resident proceeded down the sidewalk, heading north towards Willis Street when she is no longer visible and a white car is seen driving east on Willis. The elapsed time from when you first see the resident until you no longer can visualize her, and the white car is seen on Willis is 8 seconds. From the video footage, Staff A, looked to the left of the ramp, towards Willis and then the right, into the facility parking lot. The Administrator stated Staff A came into the facility to inform them and immediately conducted an internal and 2 block external sweep. The Administrator stated she returned inside to view with video footage and call the police. The Administrator stated within a short time the police called back to the facility to inform them of a pleasantly confused lady at the Super 8 Motel matching Resident #1's description. The Administrator stated the facility staff knew the resident required 2 staff to go outside and smoke from the unit communication book, stated she would provide the documentation. The Administrator stated she did not know any behaviors the day Resident #1 eloped. The Administrator stated she did not know if staff completed a vital sign assessment upon Resident #1's return to the facility. The Administrator stated they learned their lesson and they are a Smoke Free Facility, and no exceptions. On 6/29/20 at 4:28 PM, Staff A stated she did not know of a smoking policy. Staff A stated she knew the residents needed to wear a smoke apron and thought one staff could take the residents out to smoke. Staff A stated if there was a change in how many staff needed to take Resident #1 out to smoke a cigarette, the charge nurse who gave her the cigarette should have informed her of that. On 6/30/20 at 7:59 AM, Staff J CNA stated she never took Resident #1 outside to smoke. Staff J stated Resident #2, located downstairs, was previously upstairs in a secure unit and the facility allowed him to go outside to smoke with 1 staff, however, no longer allowed him to smoke. Staff J stated she would check the pocket care plans for instructions when taking residents out and number of staff required. On 6/30/20 at 7:59 AM, Staff I CNA stated she never took Resident #1 outside to smoke. Staff I stated 2 staff would usually take the resident out and did not know if one staff ever took the resident out. Staff I stated she never took Resident #2, located downstairs, out to smoke either. Staff I stated she worked at the facility for one year and since that time Resident #2 lived downstairs. Staff I stated she would check the pocket care plans for instructions when taking residents out and number of staff required. On 6/30/20 at 9:03 AM, the DON stated Resident #1 could smoke in attempt to decrease her behaviors. The DON stated they initially made the decision on a weekend (12/7/19) due to Resident #1 throwing a vase at a window, however, they determined 2 staff needed to accompany the resident when she went out. The DON stated immediately following the incident, Resident #1 could not go out of the facility to smoke. The DON identified Resident #1 as new to the facility and did not have a history of elopement at previous facility due to her being allowed to smoke. The DON stated when Resident #1 admitted to Perry Lutheran they initially did not allow the resident to smoke and she developed behaviors. The DON stated staff took Resident #1 outside the facility on 12/17/19, right after lunch with one staff present. The DON stated Resident #1 went out previously to smoke, however, 2 staff always accompanied the resident. The DON stated the facility suspended Staff A for 7 days due taking Resident #1 out to smoke alone and could no longer take residents outside alone. The DON stated Staff A can no longer work as a Restorative Aide and float to units or first floor. Staff A is required to be scheduled as CNA or CMA on a specific unit/floor. On 6/30/20 at 9:56 AM, Staff B Certified Nurse's Aide (CNA), confirmed she worked on the secured unit on 12/17/19, the day Resident #1 eloped. Staff B stated Resident #1 usually asked around 10:30 AM, to go outside to smoke, however, she did not recall if staff took the resident outside at that time or not. Staff B stated that either right before or right after lunch Resident #1 asked again and staff informed her she needed to wait until later. Staff B stated Resident #1 cried and appeared agitated due to wanting to go outside to smoke. Staff B revealed 2 CNA's worked on the secured unit and one nurse so they offered Resident #1 coffee and attempted to make her comfortable. Staff B did not recall why Staff A came to the unit. Staff B stated Staff A offered to take Resident #1 outside to smoke, however, Staff B informed Staff A she did not think it was a good idea. Staff B stated she felt Resident #1 was pretty smart and felt concern she would attempt to leave due to the resident wanting to go home. Staff B stated she did not tell Staff A to take 2 staff when she took Resident #1 out to smoke due to not present when Staff A and Resident #1 left the secure unit. Staff B stated she yelled down the hall at Staff C CNA, to have her tell Staff B that the resident required 2 staff to go with her to smoke. Staff B stated she took Resident #1 outside the facility to smoke in the past and always with another CNA. Staff B stated when she took Resident #1 off the secure unit to smoke, the resident did not attempt to leave the smoking area. Staff B stated Resident #1's behavior on that day (12/17/19) did not appear any different than her regular behaviors. Staff B stated she knew the resident required 2 staff to take her outside to smoke due to a note in the communication book. Staff B stated she did not recall if the note was before or after the incident. Staff B stated if she identified a missing resident she would alert the nurse on duty and follow instructions in the book on the unit. On 6/30/19 at 10:42 AM, Staff C CNA, confirmed she worked on the secured unit on 12/17/19, the day Resident #1 eloped. Staff C stated Resident #1 appeared anxious that morning and wanted to go outside to smoke. Staff C identified staff as busy and unable to take the resident out to smoke. She informed the resident that she would have to wait until after lunch. Staff C stated the resident got upset and wanted to go right now. Staff C stated Staff A came to the secured unit at lunch for restorative and offered to take Resident #1 outside to smoke. Staff C stated that she and Staff B informed Staff A that 2 staff needed to go with the resident to smoke. Staff C stated she received the information regarding the resident needing 2 staff during report. Staff C stated she never took Resident #1 outside of the facility to smoke. Staff C stated if she discovered a missing resident she would notify the DON & Administrator and follow the elopement book instructions located in the Financial office. On 6/30/20 at 10:44 AM, the DON stated he did not have documentation from the communication book that identified when Resident #1 could go out of the facility to smoke with 2 staff present. The DON stated the staff must have wrote a note in regards to this but he did not have anything. The DON stated Staff D Licensed Practical Nurse (LPN) was transitioning into her current role as Assistant Director of Nursing (ADON) and making changes in the communication books on the units for the staff. The DON stated Staff D is currently putting a Quality Assurance (QA) report in the communication book every morning with changes that staff need to be aware of. On 6/30/19 at 10:56 AM, Staff D LPN stated the day Resident #1 eloped (12/17/19) she worked in the office of the MDS Coordinator. Staff A came in to ask if she could take Resident #1 outside for a cigarette. Staff D stated herself and the MDS Coordinator informed Staff A she could take Resident #1 outside for a cigarette, however, she needed another staff to go with as the resident required 2 staff present. Staff D stated she did not know how Staff A obtained Resident #1's cigarette and lighter. Staff D stated a report book contained information that Resident #1 required 2 staff to take her outside of the facility to smoke. Staff D stated she could not locate the report book at this time. Staff D stated the units now have communication books in place so any staff can make notes in it. She places QA sheets in them daily with updates or changes for residents. Staff D stated she verbally tells staff of changes, anything new, or requests staff to make sure to read the communication book. Staff D confirmed she completed the incident report on 12/17/19 when Resident #1 eloped. Staff D stated she took the residents vital signs upon return to the facility, but she can not find them documented in the nurse's notes or on the incident report. Staff D stated she went with the MDS Coordinator to the Super 8 Motel to get Resident #1 following police notification. Staff D stated the motel front desk said they did not know what to do with the resident so they gave her a room upstairs. Staff D stated the MDS Coordinator went upstairs to get the resident and they returned the resident to the facility without incident. Staff D stated she never took Resident #1 out to smoke and did not think the resident would attempt to leave. On 6/30/20 at 11:14 AM, Staff E CMA confirmed she administered medications on the secure unit on 12/17/19, the day Resident #1 eloped from the facility. Staff E stated Resident #1 constantly asked to go outside to smoke but staff could not take her due to lunchtime preparations. Staff E stated Staff A CMA, who worked restorative on 12/17/19, came to the secure unit to assist with lunch. Staff E stated initially Staff A told Resident #1 she needed to wait to go outside to smoke and then agreed to take her out. Staff E stated Staff A received the directive that the resident required 2 staff with her to go out to smoke, however, Staff A spoke with another resident's family member at the time and maybe Staff A did not hear staff telling her that. Staff E stated she did give Staff A Resident #1's cigarette and lighter while she administered medications. She stated she did not observe to ensure Staff A had another staff person with her. Staff E stated if she discovered a missing resident she would notify department heads, complete a head count of the residents, and call police. Staff E identified books in the units with procedure to follow for elopements. Staff E stated she never took Resident #1 outside to smoke. Staff E stated staff informed each other of Resident #1's requirement of 2 staff to take her outside to smoke. She did not recall if this was on the residents pocket care plan. On 6/30/20 at 11:37 AM, the MDS Coordinator identified self as not on the unit on 12/17/19, prior to Resident #1's elopement. The MDS Coordinator stated she did not know Staff A took Resident #1 outside to smoke until she received notification of the elopement. The MDS Coordinator stated she did not remember Staff D and Staff A entering her office to ask about taking Resident #1 outside to smoke. The MDS Coordinator stated Resident #2 could go outside and smoke with only 1 staff present. The MDS Coordinator stated she understood that the DON called the facility on 12/7/19, when Resident #1 could go outside to smoke, and he informed the staff that the resident required 2 staff to take her out. The MDS Coordinator stated at the time of the elopement (12/17/19) the staff did not have pocket care plans. The MDS Coordinator stated she did not know if the QA sheet in the secured unit directed staff to user 2 staff. The MDS Coordinator stated she never took Resident #1 outside to smoke. The MDS Coordinator stated if there a resident is missing, call code pink and staff would go to the Administrators office with the Elopement book and follow the policy. The MDS Coordinator stated she went to the Super 8 to bring Resident #1 back to the facility. The MDS Coordinator stated Resident #1 easily returned to the facility, however, did not want to return to the secure unit and cried. On 6/30/20 at 11:57 AM, Staff F Registered Nurse (RN) confirmed she worked as float nurse on 12/17/19, the day Resident #1 eloped. Staff F identified a new admission arrived that day and when going to the new admit's room, she observed Resident #1 in her room. Staff F stated when she came out of the new admit's room, they informed her Resident #1 eloped. Staff F stated she did not know Resident #1 went out to smoke. Staff F stated she knew the resident required 2 staff to go outside to smoke. She stated she believed the care plan contained the information and staff also discussed it in report. Staff F stated she called the police department and they informed her a lady fitting that description found at the Super 8 Motel. Staff F stated upon Resident #1's return she appeared anxious, sad and confused. Staff F stated Resident #1 had money in her coat pocket when she returned and they placed it in the nurse's cart. Staff F stated Resident #1 asked to smoke upon return, however, did not attempt to leave. Staff F stated with missing residents she would follow the Elopement book; notify the DON & Administrator, call the police and check outside. On 6/30/20 at 2:04 PM, Staff A stated she never took Resident #1 out to smoke prior to the elopement on 12/17/19. Staff A stated she did not know of any type of staff education, information, or procedure review completed prior to staff taking Resident #1 out to smoke on 12/7/19. Staff A stated she did not recall asking Staff D or the MDS Coordinator if she could take Resident #1 out to smoke on 12/17/19 (day of elopement). Staff A stated she did not hear the other staff on the unit tell her she needed to take 2 staff out with Resident #1 when she took her out to smoke and those staff should have stopped Staff A. On 6/30/20 at 2:57 PM, Staff G CMA stated she took Resident #1 outside the facility for a cigarette with 2 staff prior to the 12/17/19 elopement. Staff G stated she came on duty on 12/7/19, when facility administration decided Resident #1 could go outside to smoke with 2 staff. Staff G stated she never had issues with Resident #1 attempting to leave when taken outside to smoke. Staff G stated she worked 2-10 PM on 12/17/19 (day of elopement), and Resident #1 appeared anxious upon return and wanted a cigarette. Staff G stated she took Resident #1 to her room and would talk about her family, boyfriend, and other things to distract her. On 6/30/20 at 3:25 PM, the DON stated the Administrator and Staff H Business Office were responsible for updating the elopement book with current residents' information. The DON stated some of the residents no longer have a wander guard and do not need to be in the elopement book. The DON stated if a resident had a wander guard he would expect their information to be in the elopement book. The list of residents provided to the surveyor had 12 residents listed that had wander guards, however, there were only 8 residents' information in the elopement book. The DON stated they needed to do better with updating the Elopement book. Interview on 7/1/20 at 8:07 AM, the Administrator stated she does not update the Elopement book. She stated she did not know if that was the MDS Coordinator or Staff D kept the elopement book updated. The Administrator stated she did not exactly know the process of how they decided what residents were in the book and stated there was probably a process breakdown. The Administrator stated she did not know why the residents with wander guards were not in the elopement book. The Administrator stated the facility no longer allow residents to smoke. The Administrator stated they reviewed the Elopement policy and completed an encompassing review of Resident #1 regarding what they knew prior to admit and what they didn't know in regards to her smoking and behaviors. The Administrator stated staff present on 12/30/19 for education signed in and the facility called other staff to inform them. She stated she did not know where the complete list of staff was located. The Administrator stated she did not speak with anyone that worked at the Super 8 Motel. On 7/1/20 at 8:51 AM, the Director of Environmental Services (ES) stated she or Staff K emptied the smoke stack ashtray located at the East entrance weekly. The Director of ES identified a sign off sheet for staff to complete emptied, however, it never filled up. The Director of ES stated cigarette butts could have plugged the stack because of the narrow opening, maybe the size of a 50 cent piece or little bigger. The Director of ES stated the facility disposed of the smoke stack ashtray in March when the facility no longer allowed anyone to smoke. On 7/1/20 at 10:14 AM, the owner of the Super 8 Motel stated he did not recall a resident from the facility dropped off at the motel on 12/17/19. The owner stated it occurred too long ago and his video recordings are only available for 4-5 days maximum. On 7/1/20 at 10:38 AM, the DON stated all staff received education prior to returning to work after the 12/30/19 education regarding elopement and smoking. The DON stated they also placed the Elopement policy in the communication/report books on the units at that time. On 7/1/20 at 11:58 AM, the MDS Coordinator stated Resident #1's base line care plan and comprehensive care plan should have stated the resident required assist of 2 staff to go outside to smoke when it was put into effect. The MDS Coordinator stated she knew verbally that Resident #1 required 2 staff, however, she thought the DON updated the resident's care plan. The MDS Coordinator stated when she went to the Super 8 Motel to get the Resident #1, she went directly up to the room to get her. The MDS Coordinator stated the front desk gentleman stated 2 people dropped her off. The MDS Coordinator stated she did not speak directly with the gentleman at the desk. The MDS Coordinator stated she did not update the Elopement book and did not know who was responsible, stated it was never clarified. On 7/1/20 at 1:32 PM, the DON stated during the elopement in service he discussed that Resident #1 no longer smoked and Resident #2 would continue to require constant supervision with smoking until they made further arrangements. On 7/1/20 at 3:25 PM, the DON stated the elopement education began on 12/30/19 and all staff completed education prior to working their next shift if they did not attend the meeting. The DON stated administration talked about the elopement, however identified no formal education prior to 12/30/19. On 7/1/20 at 4:17 PM, Staff L Medical Records confirmed she was with the MDS Coordinator and Staff M at the Super 8 Motel on 12/17/19 to pick up Resident #1. She did not talk to the gentleman at the front desk. Staff L stated she was just there, as all staff were looking for the resident. Staff L stated she did not know of anyone talking to the gentleman at the front desk. Staff L stated she suspected the white car picked Resident #1 up, as it was in the Super 8 parking lot with 2 females in it, however, Staff L did not go talk to them. On 7/1/20 at 4:22 PM, Staff M Former Facility Marketer confirmed she was with the MDS Coordinator and Staff L at the Super 8 Motel on 12/17/19 to pick up Resident #1. he did not specifically talk to the gentleman at the front desk. Staff M stated she did not recall if the gentleman stated the car dropped her off or if someone brought the resident inside. On 7/1/20 at 4:37 PM, Staff N CNA stated she took Resident #1 outside for a cigarette one time with another CNA. Staff N stated Resident #1 did not attempt to leave facility at that time. On 7/2/20 at 9:39 AM Staff O CNA, stated he took Resident #1 outside to smoke one evening around 7 PM to 8 PM with another CNA. Staff O stated Resident #1 stood beside them and never displayed any aggressive behavior or attempted to leave the facility. On 6/29/20 at 2:25 PM and on 7/1/20 at 9:00 AM, the surveyor observed the area where the resident eloped, along with Staff A CMA. Observation and description from the CMA, showed the area where the resident came out of the facilities east door onto the ramp and the resident stopped half way down ramp, approximately 5 feet. The distance the resident traveled from the end of the facility ramp to the busy intersection at Willis Street was approximately 35-40 feet, taking less than 30 seconds to travel. Abatement: The facility abated the immediate jeopardy on 12/30/19 when they educated staff on the elopement policy and procedure and that residents allowed to go outside to smoke would have constant supervision. This resulted in past noncompliance for the facility. As of 3/7/20, the facility became Smoke Free Facility and no residents are allowed to smoke. The facility was notified of the immediate jeopardy on 7/1/20.

Based on clinical record review, observation, and staff interview, the facility failed to ensure that a resident with pressure sores received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of three residents sampled with ulcers (Residents #4, #5 and #1). The facility reported a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS) assessment with a reference date of 9/15/18 assessed Resident # 4 with memory problems and moderately impaired decision making skills. The resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The MDS identified the resident with a Stage 2 pressure sore. Departmental notes dated 9/15/18 at 5:31 a.m. identified the resident with a sore on the sacrum. The area appeared as a brown spot that measured 1 centimeter (cm.) with redness measuring 11 cm. going down the left buttock. The resident admitted to the hospital 9/15/18 for dehydration and returned 9/19/18 at 11:30 a.m. A wound assessment report dated 9/19/18 identified the area on the left buttock as unchanged. The left buttock contained a Stage 1 area measuring 3.5 inches by 7 inches and Stage 2 area measuring 0.5 by 1.5 inches. The report identified the area as an abrasion. During interview on 10/24/18 at 1:02 p.m. Staff A RN (Registered Nurse) identified the 9/19/18 area as the same area present on 9/15/18. On 10/22/18 at 9:45 a.m. the resident went to the wound center for evaluation of the area. The wound center identified the area as a Stage 3 pressure ulcer. The length measured 1.3 cm., width 1.8 cm. by 0.1 depth. Observation on 10/23/18 at 12:35 p.m. showed that when staff transferred the resident to a recliner, the chair did not contain pressure reduction. The resident remained in the recliner without pressure reduction at the following subsequent observations: 1 p.m., 1:10 p.m., 1:35 p.m., 1:45 p.m. At 2:15 p.m., staff transferred the resident to the wheelchair (1.5 hours without pressure reduction) and at 2:27 p.m. Staff A and Staff B RN provided treatment to the resident's pressure ulcer. The right buttock contained a closed red rashy area measuring 10.5 cm. by 10 cm. The left upper buttock coccyx area was open and measured 1.4 cm. by 2.1 cm. with depth of 0.1 cm. The area was surrounded by a 4.5 cm. by 5.5 cm. reddened area. Observation on 10/24/18 at 12:02 p.m. showed the resident in the recliner without pressure reduction. The resident remained in the recliner until 1:30 p.m. when she attempted to get out of the recliner per self (1.5 hours without pressure reduction). Staff then transferred the resident to the wheelchair. At 2:20 p.m. the resident sat in a recliner and observation revealed a a urine odor at the time. The surveyor asked Staff C CMA (certified medication aide) and Staff D CNA (certified nurse aide) if they took the resident to the bathroom or checked her that day. Staff C and Staff D said no. On 10/25/18 the surveyor viewed camera footage for 10/24/18. Footage showed staff assisted Resident #4 to use the toilet at 9:27 a.m. and then not again until 2:41 p.m., after the surveyor questioned toilet use (5 hours). On 10/24/18 at 3 p.m. Staff D stated the resident was incontinent when they took her to the toilet at 2:41 p.m. The care plan dated 1/22/18 documented staff applied an air overlay mattress to the resident's bed on 9/30/18 (15 days after the pressure ulcer developed). The care plan did not contain a repositioning program intervention until 10/15/18 (a month after the pressure ulcer developed). The care plan also directed staff to take the resident to the toilet before and after meals and at bedtime. The care plan did not address pressure reduction in the chair. On 10/24/18 at 5:30 p.m. the Director of Nursing identified the repositioning program as every two hours. 2. The MDS assessment with a reference date of 8/21/18 assessed Resident #5 with a brief interview for mental status (BIMS) score of 2, indicating severe cognitive impairment. The resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS identified the resident at risk for pressure sores and no sores present at the time of the MDS assessment. A physician fax dated 10/11/18 revealed staff reported a 3.5 cm. by 4.5 cm. non blanchable red discoloration to the resident's left heel and a 1 cm. by 0.5 cm. area of non-intact skin to the left heel. The area appeared as a deep tissue injury. The physician responded on 10/11/18 to float her heels in bed and pad well. A telephone order dated 10/17/18 identified the resident with a left heel necrotic diabetic ulceration. The physician ordered to apply [MEDICATION NAME] (antiseptic) and foam every other day until the ulceration improved. Maintain bunny boot with darker blue material against the sole of the foot to better offload. Observation on 10/23/18 at 1:35 p.m. revealed the resident in bed to receive a treatment to the heel. At 1:50 p.m. observation showed no dressing on the heel when staff removed the bunny boot. When asked about the lack of dressing to the resident's heel, Staff A RN (registered nurse) and Staff B RN stated the resident had a shower that morning. After the treatment Staff C stated the resident got a shower yesterday, not today. Observation on 10/24/18 at 1:30 p.m. showed the resident in a recliner with her left heel in a bunny boot resting on the foot of the recliner. The left heel remained on the foot of the recliner until 3:20 p.m. when the surveyor informed the Administrator. The Administrator stated the heel was not free floating and she educated staff to use a pillow to free float the resident's heel. A wound assessment report dated 10/23/18 recorded the left heel area measured 3.5 cm. long and 3.5 cm. wide. The wound assessment report identified the area as a pressure ulcer. The resident's care plan updated on 10/11/18 documented skin injuries to the left heel and directed to float the resident's heels. 3. The MDS assessment with a reference date of 8/10/18 assessed Resident #1 with a BIMS score of 12, indicating moderate cognitive impairment. The resident required extensive staff assistance with bed mobility, dressing, toileting and personal hygiene. The MDS identified the resident with MASD (moisture associated skin damage). The resident utilized a suprapubic urinary catheter. The care plan dated 2/25/18 directed staff to turn and reposition the resident every 2 hours. Observation showed on 10/22/18 at 1:30 p.m. the resident in bed on his left side with a wedge behind his back. The resident was still in this position at 3:30 p.m., 4:15 p.m. and 4:30 p.m. (at least 3 hours). On 10/23/18 at 12:20 p.m. observation showed the resident's coccyx area covered with a dressing. The right groin and the area under the abdominal fold were reddened. A Skin assessment dated [DATE] at 8:29 a.m. recorded the resident had an 18 cm. by 14 cm. red and moist area to the buttocks, maceration to the peri-rectal area with superficial open areas and a 0.9 cm. by 0.6 cm. open area to the left buttock.

Based on clinical record review, facility policy review, and interviews, the facility failed to implement written policies and procedures to ensure residents in 1 of 2 memory care units (St. John's) to prevent unwanted resident to resident altercations for 4 of 6 residents reviewed (Residents #3, #5, #6 and #7). The facility identified a census of 66 residents. Findings include: 1. According to the Minimum Data Set (MDS)assessment tool dated 10/18/16, Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident exhibited verbal behaviors 1-3 days of the assessment period, wandered daily, and was independent with ambulation (walking). The Interdisciplinary Care Plan effective 10/17/16 identified the resident was affected by dementia, [MEDICAL CONDITION] and agitation and is generally pleasant and content, but has a history of becoming agitated and aggressive/combative towards staff when assisting the resident with personal care. The care plan instructed staff to give the resident a doll to care for, or take the resident for a walk to decrease his/her agitation with the goal for the resident to not have behavioral episodes that result in self harm or harm of others. The Care Plan also identified the resident could ambulate independently and has a tendency to wander. According to the MDS dated [DATE], Resident #3 had [DIAGNOSES REDACTED]. The MDS documented Resident #3, required extensive assistance for transfers and utilized a wheelchair for locomotion. The Interdisciplinary Care Plan effective 8/9/16 and revised 11/1/16 identified the resident resides in the St. John's dementia unit and required staff to visually check him/her every 15 minutes. The Care Plan did not identify any behavior issues with Resident #3. The Care Plan revealed the resident could self-propel his/her wheelchair for short distances. Two separate Incident Report - Resident to Resident dated 9/18/16 documented staff prepared to assist Resident #3 out if his/her room by wheelchair at 5:15 PM, however Resident # 5 stood in the doorway. When staff asked Resident #5 to step out of the way, he/she became upset and struck Resident #3 across the left cheek. The Departmental Notes dated 9/18/16 at 6:05 PM documented Resident #3 became upset for a very short period of time, but no marks were noted on the resident. The Departmental Notes documented the following: a. On 9/18/16 at 10:21 PM, Resident #5 walked by a staff member, slapped her on the back of the head, tried to slap the nurse, and then kicked at another staff member. Staff redirected the resident to his/her room. Staff then observed the resident closely when he/she left the room and walked in the hallways. They also directed him/her away from other residents. b. On 9/19/16, The resident behaved very aggressively, hit staff, and refused morning medications. The physician ordered staff to transfer the resident due to increased behaviors. c. On 9/20/16 at 9:39 AM documented the resident was not transferred to the hospital until this time. The hospital planned to discharge the resident the same day due to negative test results. The director of nursing (DON)called the resident's daughter and told her the resident could not come back without treatment due to the potential harm to other residents. The daughter stated she would call the hospital back or take the resident to another hospital. d. On 9/20/16 at 10:11 PM, the resident returned to the facility with orders to increase the resident's dosage of [MEDICATION NAME] (an antidepressant) from 50 milligrams (mg) to 100 mg, start [MEDICATION NAME] (an antipsychotic) 10 mg by intramuscular injection (IM) every 6 hours PRN (as needed) for delusional behavior and to follow up with the physician in 2 weeks. e. On 9/25/16 at 2:01 AM, the resident attempted to get into bed with another resident. When the nurse redirected the resident out of the room, the resident attempted to hit her. The nurse blocked the resident's hands so he/she could not strike her; the resident then spat in her face. f. On 9/29/16 at 5:44 PM, the memory unit's camera tape revealed Resident #5 slapped another resident across the face with no injuries noted. During an interview on 11/9/16 at 12:50 PM, Staff A, Licensed Practical Nurse (LPN) reported Staff B, Certified Nursing Assistant (CNA) reported to her Resident #3 said someone had slapped him/her. Staff B reviewed the camera tape and observed Resident #5 slap Resident #3. Staff A stated she separated the residents. Staff A stated Resident #5 can be content one minute, and the next minute he/she may slap staff. Staff A stated Resident #5 usually slaps staff but has witnessed him/her slap Residents #6 and 7. Staff B stated the resident is independent with ambulation and his/her mood is unpredictable. During an interview on 11/10/16 at 9:30 AM Staff C , CNA, stated when she came out of another resident's room, Resident #3 appeared upset and stated a lady slapped him/her on the face. Staff C reported the incident to Staff A. During an interview on 11/10/16 at 9:40 AM, Staff B stated she came out of another resident room and saw Resident #3 looked very distressed. The resident told her someone ran him/her into the wall and hit him/her. Staff B stated she went downstairs to review the unit camera tape and observed Resident #5 come up behind Resident #3 and try to push him/her down the hall in the wheelchair. Resident #3 grabbed the handrail with one hand and then got his/her other hand on the rail and pulled him/herself close to the wall. Staff B stated Resident #5 reached from behind and tried to remove Resident #3's hands from the handrail. Resident #3 would not let go, she observed Resident #5's hand make contact, like a slap, with Resident #3's arm and then walk away. She reported the contents of the tape to Staff A and provided a written statement about what she observed. Staff B stated Resident #3 remained upset and kept telling other residents not to do things, like pick objects off the table, because they would get hit also. Staff B stated she provided reassurance to Resident #3 that he/she was safe. The Departmental Notes entered by the DON on 9/30/16 at 11:23 AM documented she reviewed the tape of the incident from last evening. She called the physician and received new orders to increase [MEDICATION NAME] (an antipsychotic) from 10 mg to 12.5 mg and to start [MEDICATION NAME] acid (a medication used to treat [MEDICAL CONDITION] disorder) 250 mg 2 times a day (BID) for 1 week. The Departmental Notes documented the following: a. On 10/4/16 at 8:24 PM, Resident #5 hit a CNA numerous times during care provision and wandered around the unit and into other residents' rooms. b. On 10/5/16 at 2:57 PM, the physician saw the resident and ordered [MEDICATION NAME] acid 500 mg every night ([MEDICATION NAME] acid is an anti-[MEDICAL CONDITION] medication also used for behavioral issues associated with [MEDICAL CONDITION] and dementia, according to http://whatmeds.stanford.edu/medications/[MEDICATION NAME].html). c. On 10/22/16 at 2:42 PM, Resident #5 punched the nurse in the jaw/cheek with a closed fist. The resident glared at staff and then giggled. 2. The MDS dated [DATE] documented Resident #6 had a [DIAGNOSES REDACTED]. The MDS revealed Resident #6 exhibited no behaviors during the assessment period, and required extensive assistance with ambulation and locomotion. The Interdisciplinary Care Plan effective 3/28/16 and revised 10/8/16 identified the resident had a history of [REDACTED]. The Care Plan documented the resident utilizes a wheelchair for mobility and directed staff to intervene when another resident is observed to be pushing the resident in the wheelchair. The Departmental Notes dated 10/27/16 at 10:20 PM documented another resident tried to push Resident #6 in the wheelchair. Resident #6 asked the other resident to stop and then that resident punched Resident #6 in the back of the head. The Incident Report - Resident to Resident dated 10/27/16 documented Resident #5 punched Resident #6 in the head with a closed fist at 9:00 PM. 3. The MDS dated [DATE] documented Resident #7 [DIAGNOSES REDACTED]. The MDS revealed the resident, exhibited verbal and other behaviors, wandered, and resisted care 1-3 days of the assessment period. The Interdisciplinary Care Plan effective 12/8/15 and reviewed in 8/2016 identified the resident resided on the locked St. John's unit and required staff perform visual checks of the resident approximately every 15 minutes. The Care Plan revealed Resident #7 could ambulate unassisted with the use of a cane and was usually pleasant and sociable as long as the resident did not feel rushed. The Departmental Notes for Resident #5 dated 11/6/16 at 1:53 PM, documented the resident walked up to a recliner to pick up a doll when another resident touched him/her on the shoulder; Resident #5 then slapped that resident across the face and caused him/her to stumble. The Incident Report - Resident to Resident dated 11/6/16 documented Resident #5 slapped Resident #7 across the face at 1:20 PM. The facility's Resident-To-Resident Altercation policy reviewed 2/20/16 directed staff: each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. (The)resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to assure 7 of 8 residents who resided in a Memory Care Unit were free from abuse. The facility identified a census of 68 residents. Findings include: Review of the Perry Lutheran Home Resident to Resident Altercation policy and procedure form revised 3/3/16 the purpose read as follows: Each resident had the right to have been free from abuse. Residents must not have been subjected to abuse by anyone, including, but not limited to, facility staff, other residents, or other individuals. 1. Resident #6's Minimum Data Set (MDS) assessment with an reference date of 5/24/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident had a BIMS score of 1 out of 15 which revealed he/she had severe cognitive impairments. An Interdisciplinary Care Plan with an effective date of 5/24/16, indicated the resident could become combative and agitated with cares, especially when he/she felt rushed or had been made to do things. An Incident Report form dated 7/11/16 at 9:20 p.m., indicated a Certified Nurse Aide heard shouting and entered the hallway to find the resident kicked another resident in the face and yelling stop it. The resident's left bottom lip had a scant amount of blood and redness but he/she refused any cares at that time but the area had been cleansed during hour of sleep (HS) cares. The Departmental Notes indicated the following as dated: a. 7/11/16 at 11:33 p.m. - At 9:20 p.m. a CNA heard shouting and approached the TV room from the hallway to find the resident kicking another resident in the face with his/her stocking feet while both residents sat on the same love seat. The resident shouted stop it. The resident had a scant amount of blood on the left side of his/her upper and lower lips. The resident had been angry and refused treatment at the time however the area had been cleansed during bedtime cares. During an interview 7/28/16 at 10:57 a.m., Staff G, CNA indicated he/she had been charting in the hallway around 9 p.m. and heard Resident #6 yelling stop it. The staff member ran into the TV room and observed the residents sitting beside each other on the sofa and Resident #6 kicking Resident #7 in the face. The staff member reported no injuries to Resident #7. During an interview 7/28/16 at 3:22 p.m., Staff H, LPN indicated he/she had been down the hallway and heard a ruckus and responded. Staff G said he/she observed Resident #6 lying on his/her back on the love seat kicking Resident #7 in the face. When Staff H arrived both of the residents had been sitting there and Resident #6 said Resident #7 hit him/her. The staff member noted 2 spots on the upper lip of Resident #6 had started to bleed. The staff member attempted to cleanse the area however the resident refused assistance. The staff member indicated neither resident as crying and said Resident #7 just sat there undisturbed. 2. Resident #7's MDS assessment with an reference date of 4/26/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident had a BIMS score of 0 out of 15. The resident sometimes had the ability to make him/her(self) understood and understand others, with short and long term memory deficits, fluctuating inattention and disorganized thinking and no behaviors. An Interdisciplinary Care Plan with an effective date of 4/26/16, indicated the resident resided in the locked unit due to his/her [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an Incident Report form dated 7/11/16 at 9:20 p.m., a CNA heart shouting and approached from the hallway to find the resident had been kicked by another resident in the face while seated in the love seat. The staff observed redness to the left cheek at the time however the redness had subsided by bedtime. The Departmental Notes indicated the following as dated: a. 7/11/16 at 11:42 p.m. - (see above documentation) b. 7/25/16 at 5:03 p.m. - At 2 p.m. the resident had been walking with another resident's visiting family members and their dog when the resident wanted the dog leash. When given the dog leash the resident hit one of the family member lightly on the left side of his/her chest. When the nurse tried to redirect the resident he/she hit the nurse two times on the right side of his/her face. The family member stated it had been fine and the nurse sustained no injuries. 3. Resident #1's Minimum Data Set (MDS) assessment with a reference date of 7/5/16 revealed the resident had [DIAGNOSES REDACTED]. The assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, usually understood and had the ability to understand others, with no [MEDICAL CONDITION] but had behaviors not directed toward others 1 to 3 days. An Interdisciplinary Care Plan effective date 4/5/16, documented the resident with a cognitive impairment due to a [MEDICAL CONDITION]. His/her memory as impaired and he/she suffered from severe depression. He/she had difficulty coming up with words to say and getting them out. He/she could have been short - tempered at times. The Departmental Notes indicated the following as dated: a. 6/19/16 at 11:06 p.m. - At approximately 10:30 p.m. the resident physically assaulted a certified nursing assistant (CNA) by striking him/her approximately 4 times in the right upper arm with a closed fist and yelled at the CNA to get out of there. Review of Incident Report Forms revealed the following as dated: a. 7/14/16 at 11:45 a.m. - The resident had been in his/her room and had a disagreement with his/he roommate ( Resident #2). The roommate pushed the resident into the door hitting his/her head on the door then his/her legs gave out and the resident fell to the floor. 4. Resident #2 had an MDS assessment with a reference date of 6/7/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident with severe cognitive impairments with a BIMS score of 0 out of 15. The assessment revealed Resident #2 usually understood or had the ability to express ideas and wants and did not have clear comprehention of understanding others. The assessment identified the resident had continuous inattention and disorganized thinking and with physical and verbal behavior directed towards others 1 to 3 days. An Interdisciplinary Care Plan with an effective dated 4/27/16, documented the resident with cognitive loss which caused him/her to have delusions and some minor problems with communication. The resident also displayed verbal and physical behaviors which he/she managed with scheduled medication and staff's non-pharmaceutical interventions. Review of Incident Reports revealed the following as dated: a. 6/9/16 at 7:15 p.m. - A resident to resident altercation. (No description documented). b. 7/11/16 at 8:45 p.m. - The resident walked up to another resident and began to embrace and kiss each other on the face and lips. c. 7/14/16 at 11:45 a.m. - The resident pushed his/her roommate, the roommate hit his/her head on the door and fell to the floor with no injury reported. The Departmental Notes indicated the following as dated: a. 6/19/16 at 10:45 p.m. - The resident struck another resident in the face which caused redness. b. 6/22/16 at 4:27 p.m. - The resident attempted to urinate in a trash can in the dining room, staff attempted to assist the resident into the restroom and there resident bit the staff members forearm, breaking the skin and drawing blood. c. 6/25/16 at 11:43 p.m. - The resident became agitated a few times on the 2 p.m. to 10 p.m. shift and became verbal with other residents and staff. d. 7/11/16 at 10:18 p.m. - The resident walked up to another female resident who had been sitting in the TV room and bent over and started hugging and kissing the other resident on the cheek and lips. Another resident alerted the nurse and staff of the actions of the two residents. The nurse asked the two residents to stop at which time they did until the nurse turned his/her back and they started embracing and kissing again until separated. The resident then went up behind the resident who brought the incident to the nurse's attention and acted like he/she planned on striking the other resident in the head. During an interview 7/22/16 at 12:37 p.m., Staff A, CNA indicated he/she responded to hollering in the resident's room. Upon arrival he/she heard Resident #2 telling Resident #1 to get of there. The staff member tried to redirect the resident without success. The staff member then started to remove Resident #1 as Resident #2 lunged at the resident with both hands up and shoved him/her in the chest area. Resident #1 fell back against the door, hit the back of his/her head and slid to the floor as he/she began to cry. The staff member called for the assistance of Staff B, Licensed Practical Nurse (LPN). Upon arrival Staff B assessed Resident #1 and found no injury so both staff members assisted the resident to a standing position as Resident #2 smacked the resident two times on the back. The two residents were separated with no further incidence. During an interview 7/27/16 at 12:02 p.m., Staff B indicated when he/she arrived in the residents room, Resident #1 had been positioned on the floor and Resident #2 had been on his/her side of the room. The staff member assessed the resident, found no injury and started to stand the resident as Resident #2 came over and acted like he/she planned to hit the resident. The staff members separated the residents with no further incidences. 5. Resident #5's MDS with an assessment reference date of 6/14/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident with severe cognitive impairments with a BIMS score of 3 out of 15. An Interdisciplinary Care Plan with an effective dated of 4/27/16, indicated the resident with a history of verbal outbursts. The Departmental Notes indicated the following as dated: a. 6/7/16 at 9:53 p.m. - The resident had been yelling and cussing at other residents and staff most of the night. b. 6/19/16 at 10:58 p.m. - The nurse had been called to the common area near the nurse's desk by a CNA at approximately 7:15 p.m. who stated the resident had been struck by another resident in the face. Upon arriving to the area the nurse noted the resident sat in his/her wheel chair asking the other resident why he/she hit him/her. (no injury occurred) c. 7/9/16 at 1:01 a.m. - The resident had been kicking at doors, throwing medical equipment and various items across the room. When redirected the resident became verbally aggressive to the nurse and knocked things off the shelves. The resident stated f(expletive) you? I'll do whatever I want to do and kiss my a (expletive) d. 7/15/16 at 11:38 p.m. - The resident had a short episode of inappropriate verbal interaction with another resident who had been acting out. During an interview 7/28/16 at 10:08 a.m., Staff D, LPN indicated Resident #5 sat in a wheel chair as Resident #2 walked up and smacked him/her upside the head around the temporal region. The staff member felt Resident #5 did not like it to well however he/she did not strike back. Resident #5 sustained some redness to the area at first which subsided. During an interview 7/28/16 at 10:26 a.m., Staff F, CNA indicated he/she came around the corner from the kitchen area in the unit and observed the resident arguing and Resident #5 leaning forward in the wheel chair towards Resident #2 threatening each other. The staff member did not witness the physical contact and did not know where the resident had been hit. 6. Resident #3's MDS assessment with an reference date of 5/24/16 revealed he/she [DIAGNOSES REDACTED]. A Interdisciplinary Care Plan with an effective dated of 5/24/16, indicated the resident had a history of [REDACTED]. An Incident report dated 6/26/16 at 4:08 p.m., indicated the resident grabbed the breast of Resident #4 in the dining room. The Departmental Notes indicated the following as dated: a. 6/26/16 at 4:08 p.m. - The resident grabbed another resident's breast in the dining hall. An addendum to the previous statement dated 6/27/16 at 5:13 p.m. indicated the nurse had redirected the resident to quit rubbing another resident's back prior to the incident. b. 7/11/16 at 10:02 p.m. - As the resident sat in his/her usual chair in the TV room another resident walked up to him/her and started hugging and kissing him/her on the cheek and lips. Another resident alerted the nurse and another staff member to the actions of the two residents. The nurses asked the two residents to stop at which time they did until the nurse turned his/her back and the other resident stated they had been doing it again. Upon turned back around the two residents were in an embrace and kissing once again until separated. c. 7/12/16 at 10:11 p.m. - The resident had only one attempt at attempting to kiss another resident. During an interview 7/27/16 at 2:35 p.m., Staff C, CNA confirmed he/she witnessed the resident touch other residents inappropriately and witnessed the resident kiss and fondle Resident #2 in the living room. During an interview 7/28/16 at 1:25 p.m., Staff D, LPN indicated another resident informed him/her two residents were doing something. As the staff member went around the corner in the TV room Resident #3 sat in his/her normal chair as Resident #2 was bent over the chair hugging and kissing the resident. The staff member told them to stop when Resident #3 asked why. The residents stopped so the staff member turned around as the other resident stated they had been doing it again. When the staff member turned around again the residents were again hugging and kissing until separated. During an interview 7/27/16 at 2:28 p.m., Staff E, CNA confirmed he/she witnessed Resident #3 exhibiting sexual behaviors. The staff member confirmed he/she witnessed the resident fondle the breast of Resident #4 who seemed confused and did not say anything to the resident at the time. 7. Resident #4's MDS with an assessment reference date of 7/5/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident with severe cognitive impairments with a BIMS score of 4 out of 15. An Interdisciplinary Care Plan with an effective dated 4/5/16, indicated the resident with dementia that affected his/her short term memory. An Incident report dated 6/26/16 at 4:08 p.m., indicated the Resident #3 grabbed the resident's breast in the dining room. The Departmental Notes indicated the following as dated: a. 6/27/16 at 4:02 p.m. - At 4:08 p.m. on 6/26/16 as the resident sat by Resident #3 the resident reached over and touched her breast. When approached Resident #3 stated she had been touching the fabric on the resident's shirt. The Resident #3 exhibited no appearance of being upset or distraught.

Based record review, facility policy, and staff interview, the facility failed to ensure residents in the memory care unit received adequate supervision to prevent unwanted resident to resident altercations for Residents #1, #2, #3, #4, #5, #6 and #7). The facility reported a census of 68 residents. Findings include: Review of the Perry Lutheran Home Resident to Resident Altercation policy and procedure form revised 3/3/16 the purpose read as follows: Each resident had the right to have been free from abuse. Residents must not have been subjected to abuse by anyone, including, but not limited to, facility staff, other residents, or other individuals. 1. Resident #6 ' s Minimum Data Set (MDS) assessment with an reference date of 5/24/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident had a Brief Interview Mental Status (BIMS) score of 1 out of 15 which revealed he/she had severe cognitive impairments. An Interdisciplinary Care Plan with an effective date of 5/24/16, indicated the resident could become combative and agitated with cares, especially when he/she felt rushed or had been made to do things. An Incident Report form dated 7/11/16 at 9:20 p.m., indicated a Certified Nurse Aide heard shouting and entered the hallway to find the resident kicked another resident in the face and yelling stop it. The resident's left bottom lip had a scant amount of blood and redness but he/she refused any cares at that time but the area had been cleansed during hour of sleep (HS) cares. The Departmental Notes indicated the following as dated: a. 7/11/16 at 11:33 p.m. - At 9:20 p.m. a CNA heard shouting and approached the TV room from the hallway to find the resident kicking another resident in the face with his/her stocking feet while both residents sat on the same love seat. The resident shouted stop it. The resident had a scant amount of blood on the left side of his/her upper and lower lips. The resident had been angry and refused treatment at the time however the area had been cleansed during bedtime cares. During an interview 7/28/16 at 10:57 a.m., Staff G, CNA indicated he/she had been charting in the hallway around 9 p.m. and heard Resident #6 yelling stop it. The staff member ran into the TV room and observed the residents sitting beside each other on the sofa and Resident #6 kicking Resident #7 in the face. The staff member reported no injuries to Resident #7. During an interview 7/28/16 at 3:22 p.m., Staff H, LPN indicated he/she had been down the hallway and heard a ruckus and responded. Staff G said he/she observed Resident #6 lying on his/her back on the love seat kicking Resident #7 in the face. When Staff H arrived both of the residents had been sitting there and Resident #6 said Resident #7 hit him/her. The staff member noted 2 spots on the upper lip of Resident #6 had started to bleed. The staff member attempted to cleanse the area however the resident refused assistance. The staff member indicated neither resident as crying and said Resident #7 just sat there undisturbed. 2. Resident #7 ' s MDS assessment with a reference date of 4/26/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident had a BIMS score of 0 out of 15. The resident sometimes had the ability to make him/her(self) understood and understand others, with short and long term memory deficits, fluctuating inattention and disorganized thinking and no behaviors. An Interdisciplinary Care Plan with an effective date of 4/26/16, indicated the resident resided in the locked unit due to his/her [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an Incident Report form dated 7/11/16 at 9:20 p.m., a CNA heart shouting and approached from the hallway to find the resident had been kicked by another resident in the face while seated in the love seat. The staff observed redness to the left cheek at the time however the redness had subsided by bedtime. The Departmental Notes indicated the following as dated: a. 7/11/16 at 11:42 p.m. - (see above documentation) b. 7/25/16 at 5:03 p.m. - At 2 p.m. the resident had been walking with another resident's visiting family members and their dog when the resident wanted the dog leash. When given the dog leash the resident hit one of the family member lightly on the left side of his/her chest. When the nurse tried to redirect the resident he/she hit the nurse two times on the right side of his/her face. The family member stated it had been fine and the nurse sustained no injuries. 3. Resident #1 ' s Minimum Data Set (MDS) assessment with a reference date of 7/5/16 revealed the resident had [DIAGNOSES REDACTED]. The assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, usually understood and had the ability to understand others, with no delirium but had behaviors not directed toward others 1 to 3 days. An Interdisciplinary Care Plan effective date 4/5/16, documented the resident with a cognitive impairment due to a brain injury. His/her memory as impaired and he/she suffered from severe depression. He/she had difficulty coming up with words to say and getting them out. He/she could have been short - tempered at times. The Departmental Notes indicated the following as dated: a. 6/19/16 at 11:06 p.m. - At approximately 10:30 p.m. the resident physically assaulted a certified nursing assistant (CNA) by striking him/her approximately 4 times in the right upper arm with a closed fist and yelled at the CNA to get out of there. Review of Incident Report Forms revealed the following as dated: a. 7/14/16 at 11:45 a.m. - The resident had been in his/her room and had a disagreement with his/he roommate ( Resident #2). The roommate pushed the resident into the door hitting his/her head on the door then his/her legs gave out and the resident fell to the floor. 4. Resident #2 had an MDS assessment with a reference date of 6/7/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident with severe cognitive impairments with a BIMS score of 0 out of 15. The assessment revealed Resident #2 usually understood or had the ability to express ideas and wants and did not have clear comprehention of understanding others. The assessment identified the resident had continuous inattention and disorganized thinking and with physical and verbal behavior directed towards others 1 to 3 days. An Interdisciplinary Care Plan with an effective dated 4/27/16, documented the resident with cognitive loss which caused him/her to have delusions and some minor problems with communication. The resident also displayed verbal and physical behaviors which he/she managed with scheduled medication and staff's non-pharmaceutical interventions. Review of Incident Reports revealed the following as dated: a. 6/9/16 at 7:15 p.m. - A resident to resident altercation. (No description documented). b. 7/11/16 at 8:45 p.m. - The resident walked up to another resident and began to embrace and kiss each other on the face and lips. c. 7/14/16 at 11:45 a.m. - The resident pushed his/her roommate, the roommate hit his/her head on the door and fell to the floor with no injury reported. The Departmental Notes indicated the following as dated: a. 6/19/16 at 10:45 p.m. - The resident struck another resident in the face which caused redness. b. 6/22/16 at 4:27 p.m. - The resident attempted to urinate in a trash can in the dining room, staff attempted to assist the resident into the restroom and there resident bit the staff members forearm, breaking the skin and drawing blood. c. 6/25/16 at 11:43 p.m. - The resident became agitated a few times on the 2 p.m. to 10 p.m. shift and became verbal with other residents and staff. d. 7/11/16 at 10:18 p.m. - The resident walked up to another female resident who had been sitting in the TV room and bent over and started hugging and kissing the other resident on the cheek and lips. Another resident alerted the nurse and staff of the actions of the two residents. The nurse asked the two residents to stop at which time they did until the nurse turned his/her back and they started embracing and kissing again until separated. The resident then went up behind the resident who brought the incident to the nurse ' s attention and acted like he/she planned on striking the other resident in the head. During an interview 7/22/16 at 12:37 p.m., Staff A, CNA indicated he/she responded to hollering in the resident's room. Upon arrival he/she heard Resident #2 telling Resident #1 to get of there. The staff member tried to redirect the resident without success. The staff member then started to remove Resident #1 as Resident #2 lunged at the resident with both hands up and shoved him/her in the chest area. Resident #1 fell back against the door, hit the back of his/her head and slid to the floor as he/she began to cry. The staff member called for the assistance of Staff B, Licensed Practical Nurse (LPN). Upon arrival Staff B assessed Resident #1 and found no injury so both staff members assisted the resident to a standing position as Resident #2 smacked the resident two times on the back. The two residents were separated with no further incidence. During an interview 7/27/16 at 12:02 p.m., Staff B indicated when he/she arrived in the residents room, Resident #1 had been positioned on the floor and Resident #2 had been on his/her side of the room. The staff member assessed the resident, found no injury and started to stand the resident as Resident #2 came over and acted like he/she planned to hit the resident. The staff members separated the residents with no further incidences. 5. Resident #5 ' s MDS with an assessment reference date of 6/14/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident with severe cognitive impairments with a BIMS score of 3 out of 15. An Interdisciplinary Care Plan with an effective dated of 4/27/16, indicated the resident with a history of verbal outbursts. The Departmental Notes indicated the following as dated: a. 6/7/16 at 9:53 p.m. - The resident had been yelling and cussing at other residents and staff most of the night. b. 6/19/16 at 10:58 p.m. - The nurse had been called to the common area near the nurse's desk by a CNA at approximately 7:15 p.m. who stated the resident had been struck by another resident in the face. Upon arriving to the area the nurse noted the resident sat in his/her wheel chair asking the other resident why he/she hit him/her. (no injury occurred) c. 7/9/16 at 1:01 a.m. - The resident had been kicking at doors, throwing medical equipment and various items across the room. When redirected the resident became verbally aggressive to the nurse and knocked things off the shelves. The resident stated f(expletive) you? I'll do whatever I want to do and kiss my a (expletive) d. 7/15/16 at 11:38 p.m. - The resident had a short episode of inappropriate verbal interaction with another resident who had been acting out. During an interview 7/28/16 at 10:08 a.m., Staff D, LPN indicated Resident #5 sat in a wheel chair as Resident #2 walked up and smacked him/her upside the head around the temporal region. The staff member felt Resident #5 did not like it to well however he/she did not strike back. Resident #5 sustained some redness to the area at first which subsided. During an interview 7/28/16 at 10:26 a.m., Staff F, CNA indicated he/she came around the corner from the kitchen area in the unit and observed the resident arguing and Resident #5 leaning forward in the wheel chair towards Resident #2 threatening each other. The staff member did not witness the physical contact and did not know where the resident had been hit. 6. Resident #3 ' s MDS assessment with an reference date of 5/24/16 revealed he/she [DIAGNOSES REDACTED]. A Interdisciplinary Care Plan with an effective dated of 5/24/16, indicated the resident had a history of [REDACTED]. An Incident report dated 6/26/16 at 4:08 p.m., indicated the resident grabbed the breast of Resident #4 in the dining room. The Departmental Notes indicated the following as dated: a. 6/26/16 at 4:08 p.m. - The resident grabbed another resident's breast in the dining hall. An addendum to the previous statement dated 6/27/16 at 5:13 p.m. indicated the nurse had redirected the resident to quit rubbing another resident's back prior to the incident. b. 7/11/16 at 10:02 p.m. - As the resident sat in his/her usual chair in the TV room room another resident walked up to him/her and started hugging and kissing him/her on the cheek and lips. Another resident alerted the nurse and another staff member to the actions of the two residents. The nurses asked the two residents to stop at which time they did until the nurse turned his/her back and the other resident stated they had been doing it again. Upon turned back around the two residents were in an embrace and kissing once again until separated. c. 7/12/16 at 10:11 p.m. - The resident had only one attempt at attempting to kiss another resident. During an interview 7/27/16 at 2:35 p.m., Staff C, CNA confirmed he/she witnessed the resident touch other residents inappropriately and witnessed the resident kiss and fondle Resident #2 in the living room. During an interview 7/28/16 at 1:25 p.m., Staff D, LPN indicated another resident informed him/her two residents were doing something. As the staff member went around the corner in the TV room Resident #3 sat in his/her normal chair as Resident #2 was bent over the chair hugging and kissing the resident. The staff member told them to stop when Resident #3 asked why. The residents stopped so the staff member turned around as the other resident stated they had been doing it again. When the staff member turned around again the residents were again hugging and kissing until separated. During an interview 7/27/16 at 2:28 p.m., Staff E, CNA confirmed he/she witnessed Resident #3 exhibiting sexual behaviors. The staff member confirmed he/she witnessed the resident fondle the breast of Resident #4 who seemed confused and did not say anything to the resident at the time. 7. Resident #4 ' s MDS with an assessment reference date of 7/5/16 identified the resident had [DIAGNOSES REDACTED]. The assessment documented the resident with severe cognitive impairments with a BIMS score of 4 out of 15. An Interdisciplinary Care Plan with an effective dated 4/5/16, indicated the resident with dementia that affected his/her short term memory. An Incident report dated 6/26/16 at 4:08 p.m., indicated the Resident #3 grabbed the resident's breast in the dining room. The Departmental Notes indicated the following as dated: a. 6/27/16 at 4:02 p.m. - At 4:08 p.m. on 6/26/16 as the resident sat by Resident #3 the resident reached over and touched her breast. When approached Resident #3 stated she had been touching the fabric on the resident's shirt. The resident #3 exhibited no appearance of had been upset or distraught.

Based on observation, clinical record review and staff interviews, the facility failed to provide adequate supervision to protect 3 of 4 residents reviewed from accidents. Resident # 1 was left unattended and fell , sustaining a fracture. Staff failed to place a safety alarm for Resident # 3. Resident # 4 was left unattended during toileting. The facility reported a census of 58 residents. Findings include: 1. Resident # 1 had a Minimum Data Set (MDS) assessment with a reference date of 09/05/14 which identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident usually understood others, but missed some part or intent of the message. The resident's Brief Interview for Mental Status (BIMS) score was 1 out of 15. A score of 1 identified the resident as very severely cognitively impaired. The resident had fluctuating periods of disorganized thought and an altered level of consciousness. The resident required extensive assistance of one staff to ambulate, transfer, and toilet. The resident's 06/27/14 Interdisciplinary Care Plan dated 08/15/14, reflected the resident fell and fractured the left wrist. After the resident's fall 08/15/14 fall, the resident required the assistance of one staff while ambulating. (Prior to the fall, the resident was independent with ambulation). The resident had an additional fall on 09/09/14. The Fall Risk assessment dated [DATE], reflected the resident had a fall risk score of 13. A score of 13 identified the resident at a high risk for falls The Department Notes dated 8/15/14 at 2:59 P.M. identified when the nurse entered the dining room; she noted the resident sitting on the floor. The resident had said she/he was walking and lost her/his balance. The resident voiced complaints of severe pain the left forearm area. The resident was sent to the local hospital emergency room for an evaluation. The hospital telephoned the facility and reported the resident had a fractured left wrist and the facility would schedule an appointment for the orthopedist physician. The resident returned to the facility with a temporary brace to the left wrist. The Incident Report reflected the resident attempted to walk and said she/he fell to the floor. The report reflected the facility documented a pressure pad alarm would be placed on chairs while the resident sat in chairs in order to prevent a similar incident in the future. The Department Notes dated 8/19/14 at 5:05 p.m. revealed the resident returned to the facility and had a bright red cast over the left wrist and forearm The Departmental Notes dated 09/25/14 at 9:02 PM reflected Resident # 1 at times attempted to get up and ambulate per self. The Departmental Notes dated 09/26/14 at 1:06 PM revealed the resident was sitting on the bathroom floor. Staff applied ice to the resident's right shoulder. The resident's right shoulder was dented, with an abnormal form. The resident was unable to move this arm. There was also a 1 by 3/4 centimeter (cm, approximately a half inch by one third inch) skin tear on top of the resident's right wrist. The resident was transported to a local hospital emergency room for evaluation at 12:25 PM. Per the 09/26/14 3:59 PM entry, resident # 1 returned to the facility wearing a shoulder immobilizer due to a fractured humerus (upper arm bone). An Incident Report dated 9/26/14 at 12:15 P.M. revealed Resident # 1 fell into the wall, landing on their right shoulder. The incident occurred in the resident's bathroom. The recommendation to avoid a similar future incident was documented to stay at the resident's side when the resident was on the toilet. The 09/26/14 12:15 PM FSI - Fall Scene Investigation Report revealed the resident was confused prior to the incident. The staff member documented the resident as up on the toilet, and the staff turned to plug in the resident's oxygen concentrator. The resident stood up, and fell against the wall. The 06/27/14 Interdisciplinary Care Plan recorded the resident fell on [DATE]. The resident now had a shoulder immobilizer and required the assistance of one staff member with a gait belt. This document directed facility staff to not leave the resident unattended on the commode. The updated 04/10/14 Fall Prevention policy revealed that a resident with a history of falls was at risk for additional falls. This document directed facility staff to assist unsteady residents while ambulating and to provide a device (alarm) to alert staff when the resident attempted to ambulate unassisted. The updated 4/5/14 Restorative Program Independent with Ambulation directed facility staff to always use a gait belt (safety belt placed around a resident's mid torso to allow staff to safely ambulate or transfer a resident at risk for falls. The updated 4/5/14 Transfer, One or Two person Assist directed staff to always use a gait belt for the protection of both the resident and the staff member. The 09/24/14 Alarm Worksheet revealed Resident # 1 had a pressure pad alarm in both their bed and their chair. The C.N.A. (certified nurses ' aide) Orientation Checklist directed staff to use a gait belt with all transfer unless contraindicated by the resident's individual care plan. This same document directed staff to not leave a resident assessed as at risk for falls unattended while on the toilet. Staff A, a CNA, signed this document on 08/15/13. Staff A signed a statement on 09/26/14. The statement revealed Staff A assisted Resident # 1 to the toilet at 12:15 PM on 09/26/14. Staff A told Resident # 1 she was plugging in the resident's oxygen. Staff A then turned away from Resident # 1 to plug in the resident's oxygen. Staff A was about 4 feet away from the toilet. Staff A heard resident # 1 stand up. As Staff A walked towards Resident # 1, the resident fell against the wall, hit their right shoulder and then slid down the wall. Staff A assisted the resident to the floor and called for help. On 10/15/14 2:54 PM, Staff A was interviewed and reported being a CNA for a year. Staff A stated he normally worked on Resident # 1's dementia unit. Staff A had received training on ambulation and transferring residents during orientation training. Staff A reported that if a resident required an alarm due to being a fall risk, the resident should not to be left unattended during cares which precluded the use of an alarm. The resident could not be left alone without the alarm. Staff A had cared for Resident # 1 prior to 09/26/14. Staff A had taken Resident # 1 to the resident's room as the unit day room was full. Staff A stated after assisting Resident # 1 to the commode, he turned away from the resident to plug in the oxygen concentrator. The nurses had stressed that Resident # 1 needed oxygen. Staff A planned to transfer Resident # 1 to the recliner after toileting. Staff A left the bathroom door open. The outlet was behind the bathroom door while the door was open. Staff A was 2 to 3 feet away from Resident # 1. Resident # 1 stood up. Staff A looked up and saw Resident # 1 leaning into the bathroom wall across from the commode. The resident started sliding down the wall. Staff A stated he knew that Resident # 1 had previously fallen and sustained a fractured wrist. Staff A stated the resident ' s fall could have been prevented if he had not left the resident ' s bathroom. Staff A stated if he had been in the bathroom, he could have told Resident #1 to not get up. Observation on 10/15/14 at 2:54 P.M. with Staff A present, revealed Resident # 1's bathroom. A brown recliner was adjacent to the left of the bathroom door. There was an electrical outlet behind the open bathroom door. Staff A stated he was on the far side of the recliner when the incident occurred. The surveyor estimated that Staff A would have been approximately 6 feet away from Resident # 1 when the resident stood and fell . On 10/16/14, at 2:00 PM, Staff A confirmed staff was not to leave an alarmed, at a risk for falls resident unattended when the resident was not wearing the alarm. This policy was in place prior to Resident # 1's fall. On 10/14/14 at 2:28 P.M. Staff D, Licensed Practical Nurse, (LPN) was interviewed and reported staff are to ambulate and transfer residents requiring assistance with a gait belt. This was facility policy. If a resident required an alarm, staff were to stay with the resident anytime the resident did not have the alarm active. If a resident was a falls risk, Staff D stayed in the bathroom with the resident while toileting. Staff D was working on Resident # 1's unit on 09/26/14. Staff D stated Staff A could not reach the resident in time on order to prevent the fall. Staff B, a CNA, was interviewed on 10/14/14 at 4:10 PM. Staff B had been trained to use a gait belt with an unsteady resident, as well as a resident who needed assistance with ambulation and/or transfers, or who was at risk for falls. Staff B stated if a resident needed an alarm and didn ' t have one, then staff needed to stay with the resident. If toileting an alarmed resident, then should be close enough to "grab" the resident as the resident would not be wearing the alarm. On 10/15/14 at 1:40 p.m., Staff C, registered nurse, was interviewed and reported being frequently assigned to Resident # 1's unit. It was mandatory to use a gait belt with a resident who was unsteady or required assistance with ambulation or transfers. If the resident required an alarm, but the alarm was not active due to cares, staff was to stay within arm's reach any time the resident's alarm was not on the resident. Resident #1 was a falls risk. The resident often thought he/she was capable of doing more than the resident was actually able to do. On 10/15/14 at 5:00 PM, Staff E, nursing assistant was interviewed and stated had worked at the facility for about a month. Staff E reported that any time a resident required an alarm and did not have it active, and then staff needed to supervise the resident by staying within arm's reach of the resident. If a resident required assistance with either ambulation or transfers, staff should use a gait belt. On 10/16/14, at 10:27 AM, the Director of Nursing (DON) was interviewed and reported Resident # 1's memory fluctuated. If a resident needed assistance with ambulation and transfers, staff were to use a gait belt. Additionally, staff were to hold onto the gait belt with at least one hand. If a resident required the use of an alarm, staff were to be right there when the resident did not have the alarm for any reason. When Resident # 1 fell , Staff A should not have turned his back on the resident. After the incident, the staff have been retrained on transfers and gait belt use. On 10/14/14, at 10:15 AM, observation revealed a sign in Resident # 1's bathroom directing facility staff to not leave Resident # 1 unattended. At 10:20 AM, Resident # 1 sat on a pressure alarm pad. The resident was in the dementia unit dining room. 2. Resident # 4 had [DIAGNOSES REDACTED]. Resident #4 had a MDS assessment with a reference date of 9/16/14. The MDS reflected the resident had a BIMS score of 0. A score of 0 identified the resident has severely impaired cognitively. The MDS reflected the resident typically missed part of a message (when speaking to the resident). The MDS reflected Resident # 4 had delusions, or persistent fixed, false beliefs. The resident wandered daily. Additionally, Resident # 4 required the extensive assistance of one staff to ambulate and transfer. The resident was unsteady when moving on or off of the toilet. The resident had a history of [REDACTED]. According to the 9/18/14 Fall Risk Assessment, Resident #4 had a score of 15, a score of 10 or more identified a resident at a fall risk. The Departmental Notes dated 10/08/14 10:42 AM revealed staff heard Resident # 4's alarm sounding and found the resident on the room floor at 06:35 AM. The note reflected the resident as bleeding from a right forehead laceration. The facility sent the resident to the emergency room for an evaluation and returned with sutures (stitches to close wound). On 10/15/14, at 4:50 PM, Staff E and Staff F assisted Resident # 4 via Merry Walker to the resident's room bathroom. Resident # 4 had sutures above the right eye. Staff E and F placed a gait belt on Resident # 4, then assisted Resident # 4 to the commode. Staff E left the bathroom and went to the adjacent room sink. As Staff E was at the sink, Staff F left the resident unattended in the bathroom. Staff F also went to the room sink. Resident # 4 then stood up and walked to the bathroom door. The two staff noticed Resident # 4 walking to the doorway and Staff E reached Resident # 4 approximately the same time the resident entered the doorway. Staff E directed Resident # 4 to sit on the commode. Staff completed incontinency care for Resident # 4 without incident. 3. Resident # 3 had [DIAGNOSES REDACTED]. Resident #3 had a MDS assessment with a reference date of 10/07/14 which identified the resident had no problems with short term memory but had difficulty in decision making with new situations. The resident required extensive assistance from staff to transfer and ambulate. The Incident Report dated 10/07/14 at 08:41 AM revealed the resident had fallen. The resident voiced complaints of pain in the right thigh and had limited movement in the right leg. The recommended falls prevention intervention included a pressure pad in the resident's bed and chair. The Departmental Notes dated 10/07/14 9:32 AM, revealed Resident # 3 reported she/he tried to get to his/her chair for breakfast and fell to the floor around 8:41 A.M. The facility transported the resident to a local hospital for an evaluation. The Departmental Notes dated 10/7/14 11:34 AM reflected, the family reported Resident # 3 had a fractured femur (thigh bone). The notes dated 10/13/14 3:39 PM reflected the resident returned to the facility. The Interdisciplinary Care Plan dated 8/20/14 directed facility staff to use a pad alarm in Resident # 3's bed and chair as of 10/07/14. As of 10/13/14, Resident # 3 was non- weight bearing for transfers. Observation on 10/14/14, at 2:20 PM, revealed Resident # 3 lying in bed. Observation identified an alarm box on a shelf above the left side of the resident's bed. A cord ran from the box to the resident's bed covers. The pad could not be seen, as the resident appeared to be asleep. On 10/16/14, at 1:20 PM, Staff F and Staff G used a Hoyer lift (mechanical device that uses a hammock like sling to transfer non- weight bearing residents) to transfer Resident # 3 to a recliner in the resident's room. There was no alarm pad in the recliner. Staff transferred the resident to the recliner. When asked by the surveyor, Staff F stated Resident # 3 did not have the pad alarm active and/or in place. Staff F and Staff G placed an alarm under the resident then and readjusted the resident ' s recliner. Staff G attached the pad cord to the alarm box and placed the alarm box on the back of the recliner.

Based on observation, record review and staff interviews the facility failed to provide adequate supervision to protect Resident #2 from hazards from self or elements in the environment. Resident #2 was left outside and unsupervised which resulted in the resident going down 3 steps in a wheelchair and fell which resulted in a fractured hip. The facility reported a census of 60 residents and the sample consisted of 4 residents. Findings Include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 5/20/14 which reflected the resident had a Brief interview for Mental Status (BIMS) score of 6 out of 15. A score of 6 identified the resident as severely cognitively impaired. The MDS identified the resident required limited to extensive staff assistance for activities of daily Living (ADL ' s) skills. The resident could walk short distances with staff assistance, a gait belt and walker. The MDS identified the resident had [DIAGNOSES REDACTED]. The Interdisciplinary Care Plan dated 5/21/14 for Resident #2, under the heading of Safety, identified the resident had experienced 2 significant falls. The falls occurred on 6/25/13 and 6/26/13. A pressure pad (alarm device) for the bed was discontinued on 3/11/14. The Care Plan directed the staff to monitor the resident for any self-transfer attempts. On 3/17/14 Resident #2 was found standing at her/his bedside. The pressure pad was returned and added to the bed on 3/17/14. The Care Plan identified a concern with the resident ' s mobility. The plan informed staff the resident ambulated with extensive assistance of 1-2 (staff) and the walker. The Care Plan reflected the resident primarily used the wheelchair and staff were to encourage the resident to self-propel the chair. The Care Plan identified the resident required special needs and required encouragement and cueing for tasks. Resident #2 would say many times " I don ' t want to " and then do the task on own. The Nurse ' s Notes dated 7/29/14 at 4:04 P.M. reflected Resident #2 was seated in a wheelchair, outside at the front entrance. The resident headed for the steps and then fell down 3 steps and landed on her/his left side. Resident #2 was unable to state what happened. Two office employees witnessed the resident fall down the steps, but were unable to get to the resident in time to stop the fall. After the fall the resident complained of pain in the left leg. The Departmental Notes (nurse ' s notes) reflected an addendum was added on 7/31/14 at 12:01 P.M. The note documented the resident was witnessed sitting outside the door by office staff prior to the fall. Moments later the same staff noted the resident heading to the steps and the staff person attempted to get to the resident. Staff were unable to reach the resident before the resident fell down the 3 steps in her/his wheelchair. Prior to the fall the resident was alert as per usual self. Resident #2 had never attempted to go outside without assistance. The Departmental Notes (nurse ' s notes) dated 7/29/14 at 4:51 P.M. noted the facility had received the order to transfer the resident to the hospital via ambulance. The Departmental Notes (nurse ' s notes) on 7/30/14 at 5:15 A.M. reflected the nurse telephoned the (hospital) emergency room for an update on the resident. The note reflected the resident had been admitted for a urinary tract infection. The Departmental Notes (nurse ' s notes) dated 7/31/14 at 11:46 A.M. reflected the Assistant Director of Nursing (ADON) telephoned the hospital (at 9:45 a.m.) for another update and was advised Resident #2 also had an impacted left hip fracture. The family and physician were discussing the possibility of surgery. The Incident Report form dated 7/29/14 at 1515 (3:15 P.M.) documented Resident #2 was outside and seen by office staff heading for the steps. The staff were unable to reach the resident before the resident fell down the 3 steps and landed on his/her left side. The staff assisted the resident up, and into wheelchair and back in the facility. The nurse began neurological checks and continued every 15 minutes until Resident #2 left for the hospital at 1715 (5:15 P.M.). On 8/4/14 at 1:45 p.m. the Assistant Director of Nursing (ADON) was interviewed and reported the hospital did a CT (computerized tomography) scan on 7/31/14. The facility was advised the resident sustained [REDACTED]. On 8/4/14 at 1:10 p.m. Staff A (Office worker/licensed practical nurse) was interviewed and reported she was working on a board project on the day Resident #2 fell . Staff A stated she was able to see straight to the front door. Staff A stated she saw Resident #2 sitting just outside the front door. Staff A stated when she saw the resident; she thought she should watch her/him. Staff A then went back to her work. When she finished her board project she looked again for Resident #2 and noted the resident was headed toward the steps. Staff A stated if she had to do it over again she would have gotten the resident and then telephoned the nurses ' station. Staff A stated the resident was wearing her/his glasses at the time of the fall. On 8/5/14 at 9:15 A.M. Staff B (office staff) was interviewed and reported she had gotten up to go to the bathroom when she looked out the front and observed Resident #2 rolling toward the steps. Staff B stated she yelled for Staff A and then ran outside to Resident #2. Staff B stated she was unable to reach her before the resident fell down the steps. Staff B reported if she had seen Resident #2 sitting outside she would have called a nurse or a Certified Nurse ' s Aide (CNA). Staff B reported there are a few residents who are allowed to go outside on their own, but Resident #2 wasn ' t one of that group. Staff B stated Resident #2 often sits in the TV/Lobby area. Staff B stated she was unaware of any elopements the past 6 months. On 8/4/14 at 3:45 P.M. Staff D (Certified Nursing Assistant) was interviewed and stated he had been working with the resident since the resident ' s admission. Staff D stated the resident was confused and this was the last time the resident had ever been outside alone. Staff D thought someone took the resident outside. Staff D reported on 7/29/14 Resident #2 had gone upstairs for an activity. When the activity was over staff brought Resident #2 back down stairs and placed the resident in front of the nurse ' s station at about 3:00 P.M. Staff D took Resident #2 to her/his room and toileted the resident. When finished, Staff D took Resident #2 to the TV/Lobby area to sit with other residents per the usual routine. Staff D reported there are a group of about 5-6 residents who can go outside on their own. He stated some assisted living residents come over and take other residents outside to visit. Staff D reported it was a very unusual event for Resident #2 to go outside. On 8/4/14 at 3:30 P.M. Staff E (Licensed Practical Nurse) was interviewed and reported Resident #2 was usually required an assistance of 1 (staff person) for cares. Most of the time staff pushed the resident in the wheelchair to meals. Resident #2 self-propelled for a feet then staff pushed her/him the rest of the way. Staff E reported she didn ' t notice any signs of a possible UTI from Resident #2 before the fall. Staff E did not work the day of the incident. Staff E reported Resident usually attended an afternoon activity. Staff toileted Resident #2 after the activity and then would be taken to the TV/Lobby area to sit with other residents and waited for the evening meal. Staff E reported Resident did not usually move on her/his own. Staff E reported Resident #2 may have pushed the handicapped buttons on the doors but is not sure if she/he could move quickly enough or make the curve from one door to the next to get outside. Staff E stated Resident #2 often sat and looked out the window and doors, but had never attempted to go outside. The Admission Nursing Evaluation document dated 8/1/14 at 11:30 a.m. revealed the resident arrived from the local hospital via an ambulance. The resident voiced complaints of pain all over (body). The Departmental Notes (nurse ' s note) late entry for 8/1/14 at 11:30 a.m. revealed the resident returned The Departmental Notes (nurse ' s note) dated 8/2/14 at 12:41 A.M. reflected Resident #2 lying in bed with eyes open and stating I don ' t feel well. Resident could not relate where the pain was (located) or if it was something else. Resident has difficulty turning due to left hip pain. Resident remains alert to self. Staff gave Resident #2 a Percocet (narcotic analgesic) at 6:00 P.M.

Based on record review and interviews, the facility failed to assess, intervene and notify the physician when Resident #2 had a change in condition. Concerns were identified for 1 of 9 residents reviewed (Resident #2). The facility reported a census of 57 residents. Findings included: Resident #2's [DATE] Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognitive function. The assessment documented the resident had [DIAGNOSES REDACTED]. On [DATE] History and Physical listed [DIAGNOSES REDACTED]. The report identified the resident had returned to the emergency room with complaints of hip pain on [DATE]. The resident had a fall on [DATE] and at that time was evaluated in the emergency room but against medical advice (from the emergency room ) wanted to wait. Since that time, the resident had increase pain in the left hip and decided now he/she wanted surgery. The Plan of Treatment from Outpatient Rehabilitation signed by the physician on [DATE] identified Resident #2 had therapy goals for strengthening with the intent on independence with toileting and upper body dressing. The Departmental Notes dated [DATE] at 5:48 pm., included the following information: Resident #2 vitals as follows: blood pressure (BP) measured ,[DATE] and their pulse rate at 86 beats per minute. The notes revealed the resident was alert and oriented x 2 with occasional confusion. The resident had been pleasant and cooperate with cares. The Department notes included the following information: On [DATE] at 3:33 p.m. the resident BP at,[DATE], pulse rate at 76. The resident continues skilled services and was pleasant and cooperative with cares. The resident showed many improvements. On [DATE] at 3:26 p.m. the resident BP at ,[DATE], pulse rate at 60. The resident had been alert and oriented, pleasant and cooperative during cares. On [DATE] at 1:15 a.m. (Staff A), documented in Departmental Notes the resident had been complaining of an increased nauseated feeling with a large amount of brown tinged emesis. Staff administered pain medication upon the resident's request and documented the resident had not been running a temperature and vital signs measured within normal limits. On [DATE] at 5:25 a.m. Staff A documented the resident had been up all night complaining of stomach pain. She documented the resident appeared very anxious due to an appointment to have stitches removed. Staff A documented the resident monitored frequently throughout the night and repositioned for comfort. The record lacked any documentation indicating Staff A palpated the resident's abdomen for any tenderness or masses or that she had listened to the resident's bowel sounds to identify a possible obstruction. On [DATE] at 6:24 a.m. Staff A documented the following recorded values: the resident's blood pressure (BP) at ,[DATE] and pulse rate at 43. The record lacked any documentation of the resident's temperature or respirations.The resident ' s record lacked documentation the physician had been called. On [DATE] at 8:44 a.m. staff documented the resident expired at 6:45 a.m. and the physician was called to get an order to release the resident's body. On [DATE] at 9:38 a.m. staff documented in the Departmental Notes finding the resident lethargic, very weak and unable to communicate. Staff could not obtain a blood pressure. Staff documented at 6:45 a.m. no heart beat could be felt and staff immediately contacted the physician. The resident's record lacked documentation the physician had been called until [DATE] at 6:45 a.m. During an interview with Staff A, RN (Registered Nurse) on [DATE] at 10:39 p.m. she reported she worked the night of [DATE] from 6 PM to 6AM; and stated her login for the new electronic system was invalid so she used Staff E's. Staff A stated she didn't recall if she palpated the resident's abdomen or assessed bowel sounds. Staff A stated the pulse and blood pressure recorded at 6:24 a.m. had been taken prior to the 1:15 a.m. documentation. She agreed the pulse rate 43 beats per minute was not normal for Resident #2. She believed she took the resident's temperature but didn't remember what it had been or know why it had not been recorded. During and additional interview on [DATE] at 8:54 a.m. Staff A and Staff B stated no documentation could be found indicating the resident's heart rate had ever been as low as 43, so this was not normal for Resident #2. During interview on [DATE] at 12:03 p.m. the MDS Coordinator stated no documentation could be found indicating staff took the resident's temperature (on [DATE] at 6:24 p.m.) The surveyor asked about the pulse rate at 43 and the notation that the resident's vitals were WNL (within normal limits). The coordinator reported the pulse rate of 43 was not within the normal limits. During interview on [DATE] at 12:44 p.m. the Assistant Director of Nursing (ADON) stated in her estimation a pulse rate of 43 would not be normal for Resident #2. The ADON reported there was no record found to indicate the resident's physician had been notified of his/her condition prior to the lethargic condition. During interview on [DATE] at 12:03 p.m. the MDS Coordinator stated she would expect staff to assess bowel sounds and palpate the abdomen of a resident experiencing nausea, vomiting and abdominal pain. During interview on [DATE] at 11:58 a.m. Staff B stated the 9:38 a.m. entry had to have occurred after 6:00 a.m. because Staff C, who made the entry, didn't come to work that day until 6:00 a.m. The entry had to have occurred before 6:45 a.m. because that was when the resident had died . The Certificate of Death dated [DATE] documented the resident's death caused by Acute [MEDICAL CONDITION] Infarction. During interview on [DATE] at 10:22 a.m., the resident's physician stated he was not on call the night Resident # 2 became ill. He checked his records and found no documentation of a call that night. However, if the facility called the on-call doctor, he would not have a record of it. When asked if assessment of bowel sounds and palpation of the resident's abdomen would have been appropriate, the physician stated that would be reasonable given the resident's symptoms.

Based on clinical record review, observation and staff interview, the facility failed to provide complete assessment and intervention for 2 of 9 residents reviewed (Residents #1 & #6). The facility identified a census of 61 current residents. Findings include: 1. According to the MDS (minimum data set) assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with eating. The assessment also documented the presence of a swallowing disorder as the resident coughed or choked during meals or when swallowing medications. The Interdisciplinary Care Plan updated 1/22/14 directed staff to monitor for signs and symptoms of aspiration, to assist at meals as needed and to cue the resident to eat slowly and chew his/her food well. Review of the Departmental Notes dated 2/16/14 at 9:37 PM documented staff sent a facsimile to the doctor reporting the resident coughed after eating and drinking thin liquids at meal times and the resident up and out for all meals for the day. The document failed to include any resident assessment following the coughing at meal times. The Departmental Notes dated 2/17/14 at 1:36 PM recorded the facility received a return fax from the physician with new orders for speech therapy evaluation. Staff observed the resident to cough sporadically throughout meal times and verbally reminded the resident to take smaller bites, chew food thoroughly and take a drink in between bites. Staff documented the verbal cueing seemed to help and the resident appeared to cough less. Staff completed no physical assessment following the coughing at meals. 2. According to the MDS assessment dated [DATE] Resident #6 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility and transfers. Review of the Departmental Notes dated 2/20/14 at 12:02 PM revealed staff entered the resident's room and found the resident leaning to the right over the arm of the recliner. The resident could not straighten up to a sitting position without assistance and staff noted a small amount of drool from the right side of the mouth. The resident identified 3 fingers held up with only 2 actually held and identified seeing a double staff member. Staff attempted to contact the physician multiple times. Staff then called the on-call physician at 11:55 AM who returned the call at 12:15 PM. The resident then went to physician's office at 1:45 PM. The clinical record lacked a full resident assessment. Review of the hospital report dated 2/20/14 revealed family members transported the resident to the hospital and s/he admitted with [DIAGNOSES REDACTED]. During an interview on 2/26/14 at 11 AM with Staff B, LPN (Licensed Practical Nurse), she stated she took the resident's blood pressure and pulse and wrote them on the 24 hour report sheet. Staff B did not record the measurements in the resident's chart because everything happened so fast.

Based on record review and interviews with staff and physician, the facility failed to monitor anticoagulant medication for one (1) of (6) residents reviewed. Resident #1 had an increased INR (International Normalized Ratio)/test for blood clotting) in [DATE] when the nursing staff administered Bactrim DS (antibiotic) and [MEDICATION NAME]/[MEDICATION NAME] (blood thinner) concurrently. The physician ordered Bactrim DS again in [DATE] as Resident #1 continued to take his/her [MEDICATION NAME] medication without monitoring the impact of the anticoagulant medication. The resident sustained [REDACTED].). The facility did not adequately monitor the INR, even though evidence of a prior interaction existed in the record. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 48 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with impaired long and short term memory and the resident only knew location of his/her room. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident required extensive assistance with dressing, toileting, personal hygiene and total assistance with bathing. The MDS identified the resident as independently ambulatory. The [DIAGNOSES REDACTED]. A care plan dated [DATE] revealed the resident received [MEDICATION NAME] (a blood thinner) and contained a goal that the resident would not have negative effects from [MEDICATION NAME] usage. The care plan directed staff to monitor skin carefully related to [MEDICATION NAME] and conduct blood testing per physician orders. Past history of Bactrim/[MEDICATION NAME] ([MEDICATION NAME]) interaction per record review: A PharMerica form, dated [DATE], located in the resident's record indicated the pharmacy alerted the facility of Resident #1's antibiotic Bactrim medication interacts with the [MEDICATION NAME] ([MEDICATION NAME]) medication. The form revealed that Bactrim would likely alter the effectiveness of [MEDICATION NAME] ([MEDICATION NAME]) and the facility should consider increased monitoring of [MEDICATION NAME]. The form recommended that the facility check the resident's PT/INR (test for blood clotting ability). In addition, the facility should increase monitoring for unexplained bruising or bleeding that may be symptomatic of [MEDICATION NAME] toxicity. The facility should report any symptoms of [MEDICATION NAME] toxicity immediately to the physician. A handwritten notation indicated the resident as due for INR testing on [DATE]. The PharMerica long term care nursing drug handbook listed [MEDICAL CONDITION] as the major adverse effect of [MEDICATION NAME] medication. Nurses notes dated [DATE] at 2 p.m. identified the facility made 3 attempts to perform the INR test without success. The facility notified Staff W (assistant director of nursing) of the inability to perform the test but did not notify the physician. Nurses notes dated [DATE] at 8:45 a.m., stated the facility refaxed the PharMerica interaction form to the physician. The physician did not respond to the PharMerica drug interaction form. A facsimile (fax) to the physician, dated [DATE], identified an INR of above 7.5 (normal range is 2.0 to 3.0) and recorded the resident received [MEDICATION NAME] 4 mg. daily. The physician returned the fax on [DATE] and directed the facility to stop the [MEDICATION NAME] and check the INR on [DATE]. A fax dated [DATE] identified the INR as 5.5. Another INR check performed on [DATE] identified the INR as 1.7 and the physician resumed the [MEDICATION NAME] dose at 1 mg. daily. February/[DATE] Incident: An INR test performed on [DATE] identified the INR as 2.8 (within normal limits). The facility informed the physician who directed staff to check the INR in one month. A February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) daily. A physician order [REDACTED]. The physician progress notes [REDACTED]. The Bactrim DS administration ended on [DATE]. A fax to the physician dated [DATE] indicated Resident #1 had a bloody nose after getting punched in the face by another resident. The physician directed staff to treat the resident's discomfort with ice. The nurses notes dated [DATE] at 3 p.m., documented Resident #1 did not eat lunch and wanted to stay in his/her room. The note mentioned the resident had a cardiologist appointment in the morning. The nurses notes dated [DATE] at 8:30 p.m. revealed the resident refused supper and slept all shift. The nurse ' s notes dated [DATE] at 2:30 p.m. revealed the resident returned from his/her cardiologist appointment with no changes to his/her medications. The cardiologist documented an office recheck form dated [DATE] revealed Resident #1 had a past history of [MEDICAL CONDITION], [DIAGNOSES REDACTED], hypertension [MEDICAL CONDITION](cardiovascular accident). The physician documented the resident had started on anticoagulation ([MEDICATION NAME] ) medication after being hospitalized in [DATE]. The form identified the resident ' s current medications and did not list the Bactrim DS. The plan of treatment identify there was no change in the resident ' s medical therapy today. The nurses notes dated [DATE] at 6:20 p.m. revealed the resident had been found sitting in his/her room unresponsive with no breath sounds and heart rate irregular. The nurse documented Resident #1's airway opened by reposition and the following vitals: blood pressure "58/?" ; respiration 8; unable to obtain pulse reading; the resident's hands & feet were cold and purple; and his/her face gray in color. The nurse alerted the physician and the resident ' s family who requested comfort measures. An assessment documented in the nurses notes dated [DATE] at 6:40 p.m. revealed the resident started slowly responding (verbally) with BP of ,[DATE] & respiration at 14. A later assessment at 7:30 p.m. documented after the nurse assessed Resident #1 she informed the resident ' s family member of improvements. A [DATE] MAR indicated [REDACTED]. An emergency room (ER) note dated [DATE] revealed the resident injured his/her right arm in a fall at the nursing home. Staff noted swelling of the proximal humerus and the resident favored the arm resulting in the ER examination. X-rays showed a comminuted [MEDICAL CONDITION] humerus. While in the ER, the physician performed an INR test and found the INR elevated at 15 (normal limits are 2.0 to 3.0). ER staff administered Vitamin K (to clot his/her blood) 10 mg. subcutaneously. They placed the resident's arm in a sling and observed the resident over the next 5 hours. They identified the resident as stable and s/he transferred back to the nursing home with the fractured arm in a sling. The physician directed the facility to stop the [MEDICATION NAME] and repeat INR in the morning. Nurse's notes identified the resident returned to the facility from theER on [DATE] at 2:30 p.m. Nurses notes, dated [DATE] at 6:30 a.m. identified a condition change. The resident's blood pressure readings fluctuated and their radial pulse measured 40, at times very weak and other times bounding. The resident's skin felt cold and clammy at times. When the resident sat up, s/he became unresponsive and limp with [MEDICAL CONDITION] activity. The resident's lips turned blue , their tongue protruded and s/he had a bowel movement with bright red blood. The facility paged the physician who directed staff to administer Vitamin K (to clot blood) 5 mg. IM (intramuscular) and staff administered the injection at 7:15 a.m. At 8:30 a.m. staff notified the resident's regular physician of their inability to sit up without becoming unresponsive. A late entry identified the resident's INR at 3 at 8:30 a.m. At 3:30 p.m. the physician phoned and wanted a CBC(complete blood(cell) count) and INR drawn immediately. At 4 p.m., the resident expired. On [DATE] at 12:30 p.m. Staff CC (licensed practical nurse) stated she worked on [DATE] at 10 p.m. until 6 a.m. on [DATE]. She stated the resident was "pretty with it" through the night. She put the resident to bed after midnight. During 5:30 a.m. rounds she noticed bright red blood with the resident's bowel movement. She thought it was blood from hemorrhoids and identified it as a small amount. She stated the resident appeared very weak through the night and it evidently the resident's blood pressure bottomed out when staff attempted to stand the resident. The Director of Nursing (DON)'s written report dated [DATE] of the incident to the Department identified the following: Regarding the incident on [DATE] at 7:30 a.m., Resident usual routine was to wake early, take him/herself to the bathroom and dress him/herself before going to the dayhall for breakfast. This morning was different because at approximately 6:20 p.m. on [DATE], Resident #1 had an episode which is further explained in the nurses notes provided (nurses notes dated [DATE] at 6:20 p.m.). On [DATE] the nurse allowed Resident #1 to sleep longer due to this event. Staff checked on Resident #1 frequently throughout the night and morning. At 7:30 a.m. just moments after nursing staff checked on him/her, the housekeeping staff found Resident #1 on the bathroom floor with a puddle of urine & the resident ' s pants down. The DON documented as a result of the resident ' s fall, he/she was sent to the emergency room where he/she was diagnosed with [REDACTED]. The DON documented the ER physician on call felt this was related to the episode that occurred on [DATE] at approximately 6:20 p.m. On [DATE] the resident passed away. The DON documented a different physician stated the cause of death was a GI (gastrointestinal) bleed. On [DATE] at 1:20 p.m. the resident's physician stated he did not think the elevated INR contributed to the resident's death because the resident received Vitamin K in the ER. He identified the resident's cause of death as [MEDICAL CONDITION] due to the resident's long standing severe cardiac issues. He stated he included GI (gastrointestinal) bleeding as a condition that contributed to the resident's death because the facility told him the resident had some rectal bleeding. He stated the Bactrim DS the resident received could have caused the resident's INR level to elevate and any antibiotic would cause this effect. He stated he did not know of the resident's previous elevated INR with Bactrim use in [DATE]; the information about the interaction was in the resident's record. If staff would have made him aware, he would have checked the INR sooner and monitored closely. He stated he still probably would have ordered the Bactrim. The Residnet#1's record lacked any alert or warnings for nursing staff to monitor Resident #1 for possible drug interactions between [MEDICATION NAME] ([MEDICATION NAME]) and Bactrim DS once the resident started the Bactrim DS on [DATE]. The [DATE] telephone order that contained the Bactrim DS order was signed by Staff F (registered nurse). On [DATE] at 3:30 p.m. Staff F stated the physician did not comment about a potential Bactrim/[MEDICATION NAME] interaction when he ordered the Bactrim. She stated she did not bring it to the physician's attention because she was not aware of the interaction. Resident #1's record lacked any notices from the facility's pharmacist to inform/alter the facility of the potential interaction between the Bactrim DS and [MEDICATION NAME] after when Resident #1 stared the Bactrim DS on [DATE]. On [DATE] at 4:09 p.m. the pharmacist stated the pharmacy failed to alert the facility to the potential interaction and should have alerted them. At 5:50 p.m. the pharmacist stated she educated the pharmacy staff regarding the need to send the interaction alerts. The facility educated the nurses, on [DATE] after the investigation commenced, regarding [MEDICATION NAME]/[MEDICATION NAME] and antibiotic concomitant use and the side effects and interactions that may occur. At the same education session, nurses received education regarding sending faxes to the physician. If the physician does not respond to the fax in 24 hours then they should call the physician. The facility abated the IJ on [DATE] when they implemented the following system on their computer system and electronic MARS: #1. [MEDICATION NAME] orders will list a " Warning " that serious adverse interactions occur between this medication and all antibiotic, and to discuss with the physician before giving any antibiotic. #2. An additional warning that will come up with each and every medication pass for a resident who is taking [MEDICATION NAME]. #3. Is an allergy box that pops up when the resident's medication is first entered on the MAR (to give an alert that they are on [MEDICATION NAME]). #4. Another warning on the computer system that the resident is on [MEDICATION NAME]. The facility updated residents records by placing a large warning at the beginning of each residents chars. The example provided to the Department showed the following : Warning, Resident on [MEDICATION NAME]. Check with the physician before starting any Antibiotic. Antibiotic affect the way [MEDICATION NAME] works, increase the INR/PT checks and/or physician may want to HOLD [MEDICATION NAME] while on Antibiotic. Before starting any new medication, check the Drug Book for any contraindications. The facility updated their Policy to reflect that INR checks can be done per nursing judgment and the medical director/ physician was aware and agrees with this. The facility discussed the prior interventions on [DATE], and noted on residents are currently on [MEDICATION NAME]. The facility held an in-serviced all their nurses on [DATE]. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of residents medications and their computer system and electronic MARs.

Based on observation, clinical and facility record review and interviews, the facility failed to direct nursing services to ensure two of six residents received adequate supervision against hazards and failed to implement care plan directives to meet residents safety needs. Resident #5 admitted to the facility on [DATE] and suffered 4 falls in 7 months when he/she attempted to self transfer and failed to use the call light. Two of the falls resulted in fractured hips. The facility failed to provide adequate intervention to prevent falls. Resident #6 had multiple falls. The facility failed to implement new interventions after falls. The facility identified a census of forty-eight (48) residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] assessed Resident # 5 with a brief interview for mental status (BIMS) score of 12 (moderate cognitive impairment). The resident experienced disorganized thinking, a sign and symptom of delirium. The resident required extensive assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The MDS indicated the resident did not ambulate. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface to surface transfers (transfers between bed and chair). The resident had [DIAGNOSES REDACTED]. The MDS identified one fall with no injury since the prior assessment. A patient transfer form identified the resident admitted to the facility on [DATE] following hospitalization for acute renal failure. The transfer form identified the resident should ambulate with a front wheeled walker and assistance of one. An incident report dated 8/16/12 at 8:30 p.m. revealed the resident fell when he/she attempted to stand up from the wheelchair. The resident slipped and lost balance and did not sustain injury. Following the incident, in the area entitled, What was done to avoid a similar incident in the Future, staff documented to monitor the resident, use a personal alarm and check with therapy regarding what the resident can do for him/herself. A post fall assessment dated [DATE] identified the resident attempted to self transfer from chair to bed and walk with a device. The resident did not activate the call light which appeared within reach. The resident received physical therapy (PT) beginning 8/14/12. The last PT note prior to 9/7/12 identified the resident with increased ankle swelling and increased difficulty with sit to stand activity. An incident report dated 9/7/12 at 10:45 a.m., recorded staff heard hollering and upon entering the room found the resident on his/her back in the corner of the room by the bathroom door laying on the left side with wheelchair on top of the resident. The resident stated he/she tried to get the bathroom door open. Nurses notes dated 9/7/12 at 10:45 a.m. documented the resident generally did not attempt to transfer him/herself due to weakness. The call light was within easy reach and not activated. Staff previously educated the resident to use the call light. Staff saw the resident moments before in his/her wheelchair. Nurses notes dated 9/7/12 at 5 p.m. identified the resident admitting to the hospital with a left femur fracture. The resident returned to the facility on [DATE] at 4:30 p.m. after surgical repair of the left hip fracture. A major injury determination form dated 9/10/12 identified the left femur fracture as NOT a major injury. The form stated the resident would go back to using wheelchair with assistance of one or two staff as before. A care plan dated 8/22/12, identified after the 8/16/12 and 9/7/12 falls that the facility would not implement an alarm. An addendum, dated 10/1/12, to the care plan identified the sign on the bathroom door no longer appropriate since the resident moved to a semi private room. An incident report dated 12/20/12 at 6:45 p.m. revealed the resident fell in his/her room after attempting to transfer to the recliner from the wheelchair. Staff observed the resident on his/her left side between the chair and bed. The resident did not use the call light which was within reach. The resident sustained [REDACTED]. Following the incident, in the area of What was done to avoid a similar incident in the Future, staff documented they told the resident to use the call light and put up a sign to remind the resident to use the call light. An incident report dated 3/19/13 at 8:45 p.m. and written by Staff A (licensed practical nurse) revealed the resident got up from the recliner, used the wheelchair to walk, attempted to ambulate across the room and fell , hitting his/her head. The report indicated the resident's call light activated. On 3/20/13 at 4:15 p.m. the resident's roommate (identified as interviewable) stated Resident #5 fell while the roommate watched television. Resident #5's roommate pulled the call light to get help for Resident #5. Resident #5 stated he/she could walk by self so the resident got up and fell . The incident report dated 3/20/13 at 10:30 a.m., revealed staff sent the resident to the hospital for examination. At 12:30 of the same date, the hospital informed staff the resident sustained [REDACTED]. A hospital patient discharge form dated 3/25/13 identified the resident underwent [REDACTED]. An operative report dated 3/20/13 identified the resident with an impacted subcapital right hip fracture and underwent a right hip percutaneous pinning. On 3/20/13 at 4:15 p.m. the surveyor viewed the scene of the incident with Staff A (licensed practical nurse) and, at that time, Staff A stated the resident's roommate pulled the call light after the resident fell . Observation of the scene showed the recliner beside the bed facing the television. At that time, the surveyor did not observe a sign on the wall that directed resident to use the call light and wait for help. On 3/21/13 at 3 p.m., the resident's roommate stated the sign reminding the resident to use the call light was gone 'longer than a month ago". On 3/25/13 at 10:37 a.m. Staff A (on duty when the 3/19/13 fall occurred) stated she did not know if the sign telling the resident to use the call light for help was up when the resident fell . On 3/25/13 at 4:20 p.m. Staff O (nurse aide) stated she worked the evening the resident fell and around 8 p.m. she asked the resident asked the resident if he/she wanted to go to bed and the resident said no. Around 8:30 p.m. to 8:45 p.m. she heard the nurse call for help. Staff O wrote a statement regarding the incident on 3/20/13 and while visiting with the surveyor she added information to the bottom of the statement. Staff O wrote that the sign that told the resident to use the call light and wait for help sat on the floor by the television when the incident occurred. On 3/25/13 at 3:07 p.m. Staff I (nurse aide) worked the night of the incident. He stated he did not remember seeing the sign in the resident's room. He stated the resident does try and get up by him/herself but not often. He stated he would let the nurse know when the resident made attempts. On 3/25/13 at 10:38 a.m. Staff L (nurse aide) stated on the Monday before the resident went to the hospital, the resident attempted to get from the wheelchair to the recliner by him/herself. The resident would state he/she could do it. Staff L stated also on that date the resident stated he/she got into bed by him/herself and put gown on without help the night before. Staff L informed the nurse. Staff L stated she had not seen the sign on the resident's wall for a couple weeks. On 3/25/13 at 10:50 a.m. Staff DD (housekeeping) stated housekeeping pulls all the furniture in the resident's room on Mondays so if the sign was on the floor on that date (3/18/13) housekeeping staff would see it on the floor at that time. Staff DD stated it must have fallen down after 3/18/13. She stated it was attached to the wall with tape and now she fastened it to the wall with a tack to ensure it doesn't fall. On 3/25/13 at 4:10 p.m. observation showed the resident up in a recliner in his/her room with call light available and pressure alarm on. Observation showed a large area of bruising on the right side of their head. The resident stated when he/she fell on [DATE], he/she tried to get up alone and couldn't do it. Observation showed a sign across the room by the television that told the resident to use the call light. The surveyor asked the resident if he/she could read the sign and the resident could read it. The care plan, dated 2/6/13, did not identify a care plan intervention for a sign on the wall. The care plan identified a need for one to two staff to assist the resident with ambulation, toileting and transfers. The care plan did not identify the resident may attempt to self transfer but it did state the resident "had some significant falls". 2. The MDS with assessment reference date of 1/1/13 assessed Resident # 6 with a BIMS score of 12 (moderate cognitive impairment). The resident required extensive staff assistance with transfers and limited staff assistance with ambulation. A balance during transitions and walking test revealed the resident as not steady and only able to stabilize with staff assistance while walking and during surface to surface transfers (transfer between bed and chair) The resident had 2 falls with no injury and 2 falls with injury since the prior assessment. Review of incident reports identified the following falls: 10/9/12 at 11 p.m. The resident fell due to seizure and sustained a laceration to the head. 10/13/12 at 4:35 a.m. Staff found the resident sitting on the coccyx in front of a recliner. The resident tried to stand. The intervention after the incident was: Check chairs for height 11/11/12 at 4:45 a.m. Staff found the resident on the floor. The resident tripped leaving the bathroom. The resident sustained [REDACTED]. There was no intervention following the fall. 11/17/12 at 5 a.m. The resident tried to get out of bed to the bathroom and fell . The resident sustained [REDACTED]. The intervention after the fall was: Half rails and pressure pad in bed 11/20/12 at 1:40 p.m. The resident got up from the chair at the table and fell back landing on his/her bottom. The resident did not sustain injury. The intervention following the incident was: Assist getting up. According to 10/15/12 care plan this intervention was already in place. Staff did not follow the care plan. 11/21/12 at 1:30 p.m. The resident leaned over to throw papers in the garbage and fell to the side landing on the right hip. The resident did not sustain injury. The intervention following the incident was: Assess with rehab for walking. 11/25/12 at 1:45 p.m. The resident had a seizure and fell . The resident sustained [REDACTED]. The intervention following the incident was: Resident to have staff with when walking. According to the 10/15/12 care plan this intervention was already in place. Staff did not follow the care plan. 12/3/12 at 10:15 p.m. The resident walked to recliner and fell . Staff could not reach the resident in time. The resident did not sustain injury. The intervention following the incident was: Monitor for restlessness after supper. The 10/15/12 care plan already directed staff to walk with resident. Staff did not follow the care plan. 12/9/12 at 9:15 p.m. Staff noted the resident on floor numerous times. The resident started to get up and threw self to the side hitting forehead sustaining a laceration to left eyebrow. The intervention following the incident was: Reevaluate medications and for ambulation. The ambulation evaluation was already listed as an intervention on 11/21/12. 12/24/12 at 11:15 a.m. The resident walked to the table holding another resident's hand, lost balance and fell . The resident did not sustain injury. The intervention after the fall was: Assist with walking. According to 10/15/12 care plan this intervention was already in place. Staff did not follow the care plan.. 1/2/13 at 7 p.m. The resident ambulated across floor to other chair and fell to the right knee. The resident sustained [REDACTED]. The intervention following the incident was: Reinforce walker with rehab. The facility already listed the Rehab intervention on 11/21/12. 2/6/13 at 1:30 p.m. The resident put self on floor and sustained 1 centimeter (cm.) by 0.5 cm. skin tear to elbow. No new intervention identified. On 3/21/13 at 12:50 p.m. the Director of Nursing stated when the 11/21/12 intervention talked about rehab it meant restorative and on 11/27/12 restorative gave the resident a walker. The resident was not referred to physical therapy. Restorative/rehab did nothing further with the resident after the 12/9/12 and 1/2/13 falls, even though rehab was the listed intervention after those falls. A care plan dated 10/15/12 and 1/21/13, identified the resident at risk for falls. The care plan directed staff to assist the resident. An addendum dated 1/2/13 stated the resident refused hipsters. An addendum dated 2/13/13 stated the resident requests to sit on floor at times. Staff to provide a mat for safety. An addendum dated 3/20/13, stated staff moved the bed against the wall. Observation showed, on 3/14/13 at 12:07 p.m. the resident sitting in a rocker in day room holding a glass and drinking through a straw. Observation showed no alarm. On 3/20/13 at 4:55 p., the resident stood up and sat back down in straight chair with no alarm sounding. At 5:25 p.m. the resident sat at the table. Observation showed the resident constantly getting up and down with no alarm present. On 3/21/13 at 9:08 a.m. observation showed the resident in a chair with clip alarm on. On 3/25/12 at 11:30 a.m. observation showed the resident up in a recliner with a clip alarm on. Review of the resident's care plan dated 3/21/13 identified the resident should utilize a personal alarm unless under direct supervision. On 3/21/13 at 9:33 a.m. Staff R (restorative) stated she thought the resident used a clip alarm for a couple months. On 3/25/13 at 6:40 p.m., Staff W (MDS coordinator) stated staff informed her they used the personal clip alarm on the resident before last Thursday (3/21/13). On 3/21/13 at 2:12 p.m. Staff E (licensed practical nurse) stated the resident did not use an alarm last week when she worked. She stated at one time staff tried a seat alarm for awhile. 3. On 3/21/13 at 12:50 p.m. the Director of Nursing stated the facility put a plan in place on 3/21/13 to ensure staff will implement appropriate interventions after falls occur. She then provided the surveyor with a copy of the quality assurance plan. The plan identified the facility would educate all nurses regarding interventions after any incident. Education started 3/21/13.