Every finding on record at Pillar of Cedar Valley

Based on clinical record review, document review, policy review and staff interview, the facility failed to provide one to one supervision for resident safety for 1 of 10 residents sampled (Resident #4). The facility reported a census of 136 residents. Findings include:1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 3 out of 15 indicating a severe cognitive loss. Resident #4 exhibited physical behaviors (hitting, kicking, pushing, scratching, grabbing) 1-3 days and rejection of care 1-3 days of the lookback period. Resident #4 was independent with chair/bed to chair transfers and could walk distances of 10-150 feet independently. The MDS listed diagnoses of bipolar disorder, unspecified, Non-Alzheimer's Dementia, and anxiety disorder. Resident #4's Care Plan revised 4/17/26 specified the resident demonstrated physical aggressive behaviors toward staff and resident peers related to dementia and mental illness. Resident #4 would frequently yell, curse, scratch, pinch, hit, and bite staff when they attempt care. The Care Plan directed the staff in the following:a. Carry out frequent checks for resident' whereabouts and safety, 6/29/24.b. Motion sensor installed on room door to sound in the nurse's station to alert staff when resident leaves her room and may be in the presence of resident peers, 3/18/25.c. Resident #4 provided a private room for the safety of resident peers, 10/9/25. d. After episode of peer-to-peer aggression initiated by Resident #4 on 4/10/26, staff to provide 1 to 1 supervision during waking hours. A Behavior Progress Note dated 5/31/26 at 11:02 PM written by Staff A, Licensed Practical Nurse, (LPN) documented she was called to the hallway by Resident #12. Resident #12 stated Resident #5 was upset because Resident #4 had slapped her. A Certified Nursing Assistant (CNA) took Resident #4 back to her room. She was unable to tell what happened. 2. Resident #5's MDS dated [DATE] showed a BIMS score of 9 out of 15 indicating moderate cognitive loss. Resident #5 was dependent in chair/bed to chair transfers and able to propel a manual wheelchair up to 50 feet. The MDS listed diagnoses of schizoaffective disorder, bipolar type and anxiety. The Care Plan revised 9/5/25 documented Resident#5 had the potential to demonstrate verbal and physical aggressive behaviors related to multiple psychiatric diagnoses as evidenced by a history of actual aggression toward others. The Care Plan directed the staff to intervene before agitation escalates, guide away from source of distress; engage calmly in conversation, if response is aggressive, staff to walk away and approach later. The 5/31/26 Daily Schedule documented Staff B, CNA, scheduled to provide 1 to 1 supervision on the Oaks Unit from 2:00 PM to 8:00 PM. Staff B's 5/31/26 Time Card Report documented she clocked in at 2:00 PM and clocked out at 7:00 PM. A Facility Self-Reported Incident dated 5/31/26 at 8:52 PM on file with the Iowa Department of Inspection, Appeals and Licensing (DIAL) documented an Incident Summary at 5/31/26 at approximately 8:00 PM Resident #12 alleged to Staff A, Resident #4 made contact with Resident #5 in the Oaks common area. Resident #4 was unable to recall the incident. Resident #5 stated Resident #4 did make contact with her. Under Corrective Action Description both residents were separated, the incident was unwitnessed, and no injuries were found. A 5/31/26 Written Statement by Staff C, CNA, detailed she and another aide were helping other residents into bed that night. She nor the other CNA with her witnessed the resident-to-resident contact. An Undated Witness Statement written by Staff D, CNA documented she and Staff E CNA were laying people down. Staff D last saw Resident #4 at 7:00 PM when Staff B went on break. A 5/31/26 Written Statement written by Staff E documented she was laying residents down with other aide on the Oaks (Unit). The last Staff E knew Staff B went to break and Resident #4 was still in her room. Staff E last saw Resident #4 in bed at 7:00 PM. A 5/31/26 Written Statement written by Staff F, Certified Medication Aide (CMA), documented she was in a resident room and was unaware they didn't have 1 to 1 (supervision) with Resident #4. A 5/31/26 Written Statement written by Staff G, LPN documented she was not on the floor at 7:30 PM and did not see Resident #4 after 7:00 PM. The Facility Investigation 5/31/26 Facility Camera Review documented the following:a. 7:00 PM Resident #5 sat in her wheelchair between the unit nurse's station and lounge, facing the nurses station.b. 7:10 PM Staff A observed on the opposite end of hallway at the medication cart from where Resident #4's room was located. c. 7:12 PM Resident #4 walked out of her room. Staff A remained at the same location. d. 7:13 PM Resident #4 pulls a dining chair out in the unit lounge and sits down. e. 7:14 PM Resident #4 stood up to sit in a recliner. Resident #5 propelled a foot or so closer to the nurse's station. The residents are approximately 10+ feet away with no interaction identified. f. 7:15 PM Staff F walked to the nurse's station to assist a resident. As she exited the area, Resident #4 sat in the recliner with her back facing Resident #5.g. 7:16 PM Staff C was across from the nurse's station, Resident #5 was in visual proximity. Staff C exited the area shortly after.h. 7:16:31 PM Resident #4 stood up, folded a blanket and walked to a recliner across the room to place a towel down. i. 7:16:39 PM Resident #4 walked from the dining and lounge area to Resident #5 near the nurse's station/Resident #5's room. It appears Resident #4 and #5 had a conversation. After this interactions Resident #4 walked behind Resident #5 and placed her hands on the handles of Resident #5's wheelchair. Resident #4 began to push Resident #5 in the wheelchair past the front of the nurse's station, past the large elevator, stopping at the window in the middle of the unit hallway right before the small elevator. No verbal interactions were noted. j. 7:20 PM Resident #4 stopped pushing Resident #5 in the wheelchair. Resident #4 walked in front of Resident #5 and appeared to be adjusting Resident #5's gown, trying to help her. k. 7:20:18 PM Resident #4 and Resident #5 are seen swatting hands toward each other. Resident #4 turned and walked toward the unit dining room. It appeared that Resident #5 did not want help from Resident #4. l. 7:22:26 PM Resident #5 walked back to the dining seat where she was at the beginning of the film footage. At this time Resident #12 propelled by Resident #5 and the two exchanged words. m. 7:22:45 PM Resident #12 propelled to a staff member to report Resident #4 punched Resident #5 in the face. A Typed Statement by Staff H, Assistant Director of Nursing (ADON) documented a follow up call placed 6/2/26 at 1:50 PM to Staff B. Staff B stated she was assigned 1 to 1 with Resident #4 on 5/31/26. When she left at approximately 7:00 PM, Resident #4 was in bed resting. Her demeanor at that time was calm and pleasant. She reported off to staff upon leaving Resident #4 was in bed. She had no concerns with Resident #4 when she left. Observation of the Camera Footage on 6/9/26 at 9:40 AM with Staff I, Maintenance Director, and Staff H showed Resident #4 on 5/31/26 from 7:12 PM to 7:22 PM without 1 to 1 supervision. The Camera footage showed there was no physical altercation and no hand contact between either resident. Resident #4 did not punch Resident #5 in the face. The Camera Footage showed Staff A remained on the hallway passing medications to resident rooms without eyes on Resident #4. Interview on 6/9/26 at 4:36 PM Staff B reported on 5/31/26 she left between 7:05 PM - 7:10 PM. She reported to Staff A she didn't take her break so she was leaving and Staff A said it was okay. When she left Resident #4 was laying on her right side facing the wall. The resident was calm. Two aides had assisted her to change the resident before bed and she was agitated, but calmed down once care was done. The Resident was laying down so she left. Resident #4 had been on 1 to 1 supervision since the last resident to resident incident. Observation on 6/10/26 at 8:13 AM Staff J, CAN, exited Resident #4's room. Resident #4 lay on her left side in bed, eyes open, fully dressed with her tennis shoes on. Staff J walked from Resident #4's room approximately 15 feet out the door to the utility room. Staff J entered the utility room out of the visual line of Resident #4 to get ice for another resident. At 8:15 AM Staff J came out of the utility room and handed the other resident a bag of ice, the went back into the utility room a second time out of visual line of Resident #4. Interview on 6/10/26 at 8:15 AM Staff J verbalized in her opinion, she felt Resident #4 maybe a risk to other residents without supervision. She is unpredictable and anything can trigger her. Resident #4 will say she loves you and appreciates you, and then turn on you. She thought Resident #4 was placed on 1 to 1 supervision after a resident-to-resident altercation. A 6/10/26 review of Resident #4's 5/31/26 Fifteen Minute Checks for Residents documentation showed Staff A signed off the 7:00 PM and 7:15 PM checks. During an interview on 6/10/26 at 9:40 AM Staff H, reviewed the 5/31/26 Fifteen Minute Check documentation for Resident #4. The Fifteen Minute Check Sheet, 5/31/26 showed Staff A signed off the 7:00 PM, 7:30 PM and 7:45 PM 15-minute checks. The Camera Footage viewed with Staff H on 6/9/26 revealed Staff A in the hallway passing medication. Resident #4 visualized on camera footage without 1 to 1 supervision while in the unit hallway, lounge, around the nurse's station and with Resident #5. Staff A not observed on camera checking on Resident #4's whereabouts. Staff H confirmed Resident #4 was to be under 1 to 1 supervision and to have 15-minute checks. Staff H confirmed the supervision was not provided at that time. During an interview on 6/10/26 at 3:53 PM Staff A reported she was passing medications down the hallway that evening on 5/31/26. Staff B came down the hallway. She asked Staff B if Resident #4 was asleep. Staff B replied no but she was calm and laying down. Staff B reported she had already talked with the aides. Staff A thought Staff B was leaving to go on break. Staff B did have her purse with her but she didn't know she was leaving for the night. Staff A voiced as far as she knew, staff were not to leave early if Resident #4 was down in bed. Staff B should have been there the time she was scheduled. Resident #4 had hurt another resident so they put her on 1 to 1 supervision. Staff A reported there is a little box in the nurse's station that alarms when Resident #4 leaves her room. Staff G had been at the desk, but got called away so she wasn't there to hear the alarm when Resident #4 got up. The aides were all busy putting residents to bed when Staff B left. None of the staff knew that Resident #4 was left unsupervised. She thought the resident was being taken care of and someone was with her. Most of the time Resident #4 is sweet and then she can be unpredictable and will hit someone. They can only hear the room alarm, if they are up by the nurse's station. She cannot hear Resident #4's door alarm ding if she is at the end of the hallway passing medications. Resident #4 was to have 1 to 1 supervision when she was up. In an interview completed on 6/11/26 at 8:48 PM the Administrator verbalized that if a resident requires frequent checks, she expects the staff to lay eyes on the resident every 15 minutes or sooner. If a resident is on 1 to 1 supervision, she expects the employee to be there and have eyes on the resident the whole time. If the employee needs to take a break, a team member needs to fill in that spot. The Standard Supervision and Monitoring Policy dated 11/25/19 directed the guideline emphasized a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. The Procedure specified when a resident cannot be guided, supervised or redirected during regular intervals of rounds, the resident may require 30-minute, 15 minute or 1 to 1 supervision.

Based on clinical record review, staff interviews, and policy review, the facility failed to protect and prevent resident to resident abuse for 2 of 2 residents reviewed (Residents #1 and #5). The facility reported a census of 136 residents.Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 99, signifying the interview could not be completed. The MDS documented during the lookback period Resident #2 had physical behavior symptoms directed toward others that occurred daily. In addition, the MDS documented Resident #2 had verbal behavior symptoms directed toward others that occurred 4 to 6 days during the lookback period. Resident #2 had behaviors of rejection of care that occurred daily. The MDS included diagnoses of depression, anxiety, post-traumatic stress disorder (PTSD) and bipolar disorder (mental health condition causing extreme mood swings that include emotional highs, called mania, and lows, known as depression).The Care Plan Focus revised 11/5/25 identified Resident #2 frequently demonstrated physical and verbal aggressive behaviors toward staff or peers related to mental illness. The aggressive behaviors included yelling, screaming, name-calling, hitting, kicking, spitting, hair-pulling, throwing objects at others, and calling the police or sheriff to make false accusations or demands. The Interventions directed the staff to:Analyze behaviors for key times, places, circumstances, triggers, and what de-escalates behaviors. Document as needed.Document observed behavior and attempted interventions as needed.For details on managing Resident #2's behaviors, staff to refer to Temporary Crisis Plan located in a binder at the nurse's station on her unit.Give Resident #2 as many choices as possible about care and activitiesProvide physical and verbal cues as able to alleviate anxiety such as giving positive feedback, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.When Resident #2 becomes agitated intervene before agitation escalates; guide away from source of distress; and attempt to engage calmly in conversation. Provide for the safety of others by removing them from the immediate area. If response is aggressive, staff to walk calmly away, and approach later.Intervene as necessary to protect the rights and safety of others. Approach and speak to her in a calm manner. Divert attention if able, remove from situation and take to alternate location as needed.Staff to provide cares in pairs.The Progress Notes dated 11/6/25 at 1:30 PM described Resident #2 as verbally aggressive with staff and towards other residents in the common area and when walking down the hallway. Resident #2 attempted to intimidate another resident (Resident #5) in the hallway due to her being in her way and not moving fast enough. As Resident #5 walked by Resident #2 in the dining room to get into the activity cabinet, Resident #2 became verbally aggressive towards Resident #5.The Progress Notes dated 11/13/25 at 10:22 AM indicated the staff observed Resident #2 being verbally aggressive toward a peer in the common area. She started yelling and using inappropriate language. The staff intervened by placing a petition between Resident #2 and her peer upon Resident #2's request. The staff reminded Resident #2 that if she has an issue, concern, and/or a compliant she should reach out to the staff for assistance.Review of Resident #2's Individual Program Plan dated 11/13/25 directed the staff the following:Immediately clear other residents out of the area for safetyStaff should be aware of their spatial positioning and stand at least an arm's length away from Resident #2 if possibleStaff may use the protective mats to deflect Resident #2's attempts at aggression towards staff and peers.Staff should assist Resident #2 in going to a calm, quiet space to de-escalate. Staff may approach Resident #2 to debrief when calm.Interdisciplinary team members or on-call designees will determine if increased supervision is necessary.The Individual Program Plan lacked updates following the resident-to-resident incidents.The Progress Notes dated 11/14/25 at 7:25 AM documented the staff heard Resident #2 yelling at someone. As the Certified Nursing Assistants (CNAs) started running toward the person and Resident #1, Resident #2 struck Resident #1 in the right ear. The Resident-to-Resident Incident Investigation Summary dated 11/14/25 reflected Resident #2 became physically aggressive toward Resident #1. After attempting to engage in aggression toward a staff member and missing, Resident #2 hit Resident #1 without intention. Resident #2 wore her noise canceling headphones at the time of the incident. The staff immediately separated the residents and initiated frequent checks with Resident #2. The Behavior Charting dated 11/15/25 at 8:58 AM identified as Resident #2 walked by a peer (Resident #1), who sat in his doorway/hallway visiting with the maintenance staff, she them in the ear with a closed fist. The staff escorted Resident #2 to her room and became combative/ verbally aggressive with staff during her care. Resident #2 stated Resident #1 called her a c*nt and made a hand gesture suggesting f*llatio. The Progress Notes dated 11/16/25 at 2:45 PM listed personal time (no individual attention). At 6:00 AM, the staff observed Resident #2 in the dining area yelling at other clients using profanity. Resident #2 walked aggressively in hallway toward them in an attempt to intimidate the other residents. When the staff approached to offer assistance with cares, Resident #2 attempted to strike staff while continuing to yell. The staff made several de-escalation attempts but Resident #2 refused to follow directions. Resident #2 had disruptive behaviors of screaming, yelling, or hitting made throughout the day. The staff offered breaks to Resident #2, but her behavior continued. The staff gave Resident #2 3 opportunities to settle down and eventually the staff assisted her to her room a few times when she wouldn't de-escalate. Resident #2 laid calmly in a recliner for two hours without an incident. Staff attempted verbal redirection, assisted to a calm area, or back to her room, and used protective mats in a non-restrictive measure. At lunchtime, Resident #2's family arrived for a visit. The staff didn't observe escalation during Resident #2's time with their family until she sat at table for lunch. At that time, the staff effectively redirected Resident #2 to not to yell at the table.The Progress Notes dated 12/9/25 at 6:53 AM identified as Resident #2 talked very pleasant with the staff, she turned and saw Resident #1 walk over. Resident #2 called him a name and then hit him in the back of head. Resident #1 then struck Resident #2 in the right hip. The staff separated the residents at that time and escorted Resident #2 to her room and removed Resident #1 to his table. The assessment of each resident determined no injuries to either resident.The facility lacked a Behavior Charting evaluation for the 12/9/25 incident of Resident #2 altercation with Resident #1.The Behavior Charting dated 12/10/25 at 2:45 PM reflected Resident #2 refused to shower despite several verbal prompts and encouragement. Resident #2 refused to take her scheduled medication after multiple prompts. Resident #2 struck another resident (Resident #5) after the staff instructed her to not touch others. Resident #2 struck the writer in the back of the head while they assisted with providing her care. The staff redirected Resident #2, who completed her remaining cares independently. Resident #2 initially requested staff to assist them with tasks they could perform independently. The staff required the use of mats multiple times that day due to Resident #2's continued hitting behavior. Resident #2 continued to call the staff and other residents names. The staff attempted redirection and coping skills without success. Resident #2 came out name calling and starting hitting staff members. The staff went to assist and redirected Resident #2 to her room. The staff directed Resident #2 to take a break in her room and when her behaviors got better to come and join the others. In addition, Resident #2 dug her nails in to a staff member's arm.The Physician's Order Note dated 12/10/25 at 2:48 PM identified Resident #2 had 2 resident-to-resident altercations with Resident #1. The author requested to have the Advance Registered Nurse Practitioner (ARNP) see her and do a medication review. At 10:39 AM the Physician Office Registered Nurse (RN) questioned if the altercations occurred that day, as they already had Resident #2 on the schedule for that Monday. The Physician Office RN reported they would update the ARNP so she could review the medications and the EKG (external testing of the heart) if available by then. At 10:54 AM the Physician office RN indicated the ARNP directed to increase guanfacine (medication used to treat attention deficit hyperactivity disorder ADHD) 1 milligram (mg) by mouth twice daily.The facility lacked a Resident-to-Resident Incident Investigation Summary for 12/10/25.The Progress Notes dated 12/13/25 at 10:21 AM documented at 8:40 AM, Resident #2 approached Resident #5. Resident #2 continued to engage Resident #5, despite Resident #5's request to be left alone. Resident #2 moved into Resident #5's personal space. Resident #5 lightly kicked Resident #2's walker, causing Resident #2 to lose her balance and fall to the floor. The staff immediately intervened and separated both residents. The staff implement an intervention to maintain separation and prevent further incidents.The Progress Notes dated 12/15/25 at 3:15 PM described Resident #2 as restless throughout the first shift. Resident #2 displayed aggressive behaviors including hitting, yelling, and calling staff names. While ambulating past peer Resident #5, Resident #2 stated, I'm going to take a big sh*t and drop it on you. After snack time, Resident #2 exited their room late and became upset about missing snack. As the staff redirected Resident #2 back to her room, she walked past Resident #5 and struck him on the head and back multiple times. The staff redirected Resident #2 back to her room, where she continued yelling and using profanity toward staff and struck the writer in the face. The staff used the mats to assist with de-escalation. Resident #2 remained in her room until the next snack time. Staff reported while Resident #2 walked past Resident #5's room she yelled out Resident #5 I'm looking for you, in a singing voice. In addition, Resident #2 came out calling Resident #1's names.The Resident-to-Resident Incident Investigation Summary dated 12/15/25 at 10:57 AM indicated the Inter-disciplinary team received notification of a physical altercation between Resident #2 and Resident #5. The staff immediately separated the residents, and redirected Resident #2 to her room for a break while the staff monitored for safety and de-escalation. During that time, Resident #2 remained physically and verbally combative toward staff. Review of the undated Temporary Crisis/Behavior Plan for Resident #2 directed the Management of verbal or physical aggression in common areas - If Resident #2 became verbally disruptive or physically aggressive toward staff or peers, staff may implement the following:Use protective mats in an open, upright position to decrease visual stimulation and/or create a safe space between Resident #2 and others.Redirect Resident #2 to a quieter environment, such as her room, when possible.Maintain safe staffing proximity and monitor for escalation.During an interview on 12/22/25 at 3:33 PM Resident #1 stated his name, date and where he resided. Resident # 1 verbalized Resident #2 has hit him on 3 separate occasions. Resident #1 reported he Resident #2 back. One of the times Resident #2 hit Resident #1, he reported his ear swelled up after being hit. Resident #1 denied being afraid of Resident #2.During an interview on 12/22/25 at 3:38 PM Staff C, CNA, reported she receiving training for dependent adult abuse (DAA). Staff C verbalized being familiar with Resident #2. Staff C reported Resident #2 has hit multiple residents and employees. Staff C stated Resident #1 tried to scare residents. Staff C couldn't recall dates or names of the residents Resident #2 hit.During an interview on 12/22/25 at 3:48 PM Staff A, CNA, stated she received training for DAA. Staff A verbalized she would report allegations of abuse to her supervisor, the nurse, or the ADON. Staff A reported being familiar with Resident #2. Staff A acknowledged Resident #2 has hit Resident #1 and #5. Staff A stated she witnessed Resident #2 hit Resident #1 during meal time. Staff A verbalized Resident #1 sat at the table when Resident #2 made a comment and used the back of her had to hit him on the shoulder. Staff A reported Resident #2 sought out Residents #1 and #5. During an interview on 12/23/25 at 9:28 AM, Resident #5 verbalized her name, the date, and where she resided. Resident #5 stated a female resident had hit her in the shoulder and in the back of the head. Resident #5 denied being afraid of the female resident but more so afraid of what she will do. During an interview on 12/23/25 at 10:16 AM Staff B, Licensed Practical Nurse (LPN), acknowledged he received DAA training. Staff B reported allegations of abuse are reported to the ADON or the Director of Nursing (DON) as soon as possible. Staff B acknowledged being familiar with Resident #2. Staff B said Resident #2 had a couple incidents with hitting another resident. Staff B reported on 11/14/25 as he walked with Resident #1, Resident #2 came out of her room and hit Resident #1 in the ear. Staff B verbalized Resident #2 talked with him and witnessed her walk up to Resident #1, hitting him in the back of his head. Staff B stated Resident #1's ear turned red without injury.During an interview on 12/23/25 at 10:29 AM Staff D, ADON reported she received training on DAA. Staff D verbalized being familiar with Resident #2 and acknowledged she had behaviors. Staff D acknowledged Resident #2 hit Resident #1 on 11/14/25 and 12/9/25. Staff D explained Resident #1 didn't actually touch Resident #5 on 12/10/25. Staff D remembered talking with the DON about a third incident with Resident #1 where they needed to amend the reported summary to the Department of Inspections, Appeals, and Licensing (DIAL). Staff D verbalized Resident #2 hit staff daily with her aggression getting worse. Staff D reported they installed a door bell on Resident #2's door to alert staff when she exits her room. Staff D reported Resident #2 the staff provide one-to-one supervision when she exits her room. The Skilled and Senior Living Abuse, Neglect and Exploitation Policy and Procedure dated October 2022 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Review of the facility policy titled Standards and Guidelines: PMI (Person with Mental Illness) Reporting Guidelines - Resident to Resident issued 8/15/22 directed the facility to ensure residents are free from abuse, neglect, and exploitation and are protected from harm by other residents. Resident-to-resident altercations will be assessed on an individual basis and reported when required by Iowa law, DIAL expectations, or federal regulations. Reporting determinations will consider injury, changes in supervision or level of care, and patterns of aggressive behavior indicating potential failure of current interventions or increased risk to resident safety.2. Resident #1's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. The MDS documented Resident #1 had verbal behavior symptoms directed toward others that occurred daily during the lookback period. In addition, Resident #1 experienced behaviors of rejection of care for 1 to 3 days during the lookback period. The MDS included diagnoses of anxiety and schizophrenia (mental health condition that affects how people think, feel and behave). The Progress Notes dated 11/14/25 at 7:42 AM indicated the staff heard a resident yelling at someone. As the CNAs started running toward the person and Resident #1, the other resident struck Resident #1 in the right ear. The staff separated the residents and escorted the other resident (Resident #2) to her room. Resident #2 gave no reason for hitting Resident #1.The Progress Notes dated 12/9/25 at 7:14 AM Resident #1 sat at a table with another resident. Resident #2 saw Resident #1 and approached him, she called him a name and hit him on the back of the head. Resident #1 then hit Resident #2 in her right hip. The staff separated both residents.3. Resident #5 MDS assessment dated [DATE] documented a BIMS score of 14, indicating intact cognition. The MDS documented the resident had verbal behavior symptoms directed toward others that occurred 1 to 3 days during the look back period. The MDS included diagnoses of anxiety and bipolar disorder. The Progress Notes dated 12/15/25 at 10:35 AM indicated Resident #5 and the Social Worker met following an altercation between Resident #5 and Resident #2 in the common area. The staff witnessed Resident #2 approach Resident #5 from behind and, without provocation, struck Resident #5 on the shoulder and back of the head. In addition, the staff reported Resident #2 stated, I am going to take a big sh*t and put it on you. Staff immediately intervened, separated the residents, and redirected Resident #2 to her room to de-escalate. Resident #5 reported as she sat in the common area, Resident #2 struck her from behind three times. Resident #5 stated she felt fine physically but expressed emotional distress related to feeling Resident #2 didn't like her. Resident #5 Progress Notes lacked documentation of the resident-to-resident altercation from 12/10/25.

Based on clinical record review, facility records, policy review, resident and staff interviews, the facility failed to report alleged violations of physical abuse within the required time frame to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 3 of 4 incidents (11/14/25, 12/10/25 and 12/15/25) reviewed. The facility reported a census of 136.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 99, signifying the interview could not be completed. The MDS documented during the lookback period Resident #2 had physical behavior symptoms directed toward others that occurred daily. In addition, the MDS documented Resident #2 had verbal behavior symptoms directed toward others that occurred 4 to 6 days during the lookback period. Resident #2 had behaviors of rejection of care that occurred daily. The MDS included diagnoses of depression, anxiety, post-traumatic stress disorder (PTSD) and bipolar disorder (mental health condition causing extreme mood swings that include emotional highs, called mania, and lows, known as depression).The Care Plan Focus revised 11/5/25 identified Resident #2 frequently demonstrated physical and verbal aggressive behaviors toward staff or peers related to mental illness. The aggressive behaviors included yelling, screaming, name-calling, hitting, kicking, spitting, hair-pulling, throwing objects at others, and calling the police or sheriff to make false accusations or demands. The Interventions directed the staff to:Analyze behaviors for key times, places, circumstances, triggers, and what de-escalates behaviors. Document as needed.Document observed behavior and attempted interventions as needed.For details on managing Resident #2's behaviors, staff to refer to Temporary Crisis Plan located in a binder at the nurse's station on her unit.Give Resident #2 as many choices as possible about care and activitiesProvide physical and verbal cues as able to alleviate anxiety such as giving positive feedback, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.When Resident #2 becomes agitated intervene before agitation escalates; guide away from source of distress; and attempt to engage calmly in conversation. Provide for the safety of others by removing them from the immediate area. If response is aggressive, staff to walk calmly away, and approach later.The Care Plan Report lacked direction for staff to report resident-to-resident altercations and interventions to prevent further incidents following the incidents that occurred on 11/14/25, 12/9/25, 12/10/25 and 12/15/25.The Progress Notes dated 11/14/25 at 7:25 AM documented the staff heard Resident #2 yelling at someone. As the Certified Nursing Assistants (CNAs) started running toward the person and Resident #1, Resident #2 struck Resident #1 in the right ear. Resident #2 didn't give a reason for hitting Resident #1. The staff notified the Assistant Director of Nursing (ADON), physician, and husband.The Progress Notes dated 12/9/25 at 6:53 AM identified as Resident #2 talked very pleasant with the staff, she turned and saw Resident #1 walk over. Resident #2 called him a name and then hit him in the back of head. Resident #1 then struck Resident #2 in the right hip. The staff separated the residents at that time and escorted Resident #2 to her room and removed Resident #1 to his table. The assessment of each resident determined no injuries to either resident. The staff reported the incident to the Director of Nursing (DON), impact, and husband.The Behavior Charting dated 12/10/25 at 2:45 PM reflected Resident #2 refused to shower despite several verbal prompts and encouragement. Resident #2 refused to take her scheduled medication after multiple prompts. Resident #2 struck another resident (Resident #5) after the staff instructed her to not touch others. Resident #2 struck the writer in the back of the head while they assisted with providing her care. The staff redirected Resident #2, who completed her remaining cares independently. Resident #2 initially requested staff to assist them with tasks they could perform independently. The staff required the use of mats multiple times that day due to Resident #2's continued hitting behavior. Resident #2 continued to call the staff and other residents names. The staff attempted redirection and coping skills without success. Resident #2 came out name calling and started hitting staff members. The staff went to assist and redirected Resident #2 to her room. The staff directed Resident #2 to take a break in her room and when her behaviors got better to come and join the others. In addition, Resident #2 dug her nails into a staff member's arm.The Progress Notes dated 12/15/25 at 3:15 PM described Resident #2 as restless throughout the first shift. Resident #2 displayed aggressive behaviors including hitting, yelling, and calling staff names. While ambulating past peer Resident #5, Resident #2 stated, I'm going to take a big sh*t and drop it on you. After snack time, Resident #2 exited their room late and became upset about missing snack. As the staff redirected Resident #2 back to her room, she walked past Resident #5 and struck him on the head and back multiple times. The staff redirected Resident #2 back to her room, where she continued yelling and using profanity toward staff and struck the writer in the face. The staff used the mats to assist with de-escalation. Resident #2 remained in her room until the next snack time. Staff reported while Resident #2 walked past Resident #5's room she yelled out Resident #5 I'm looking for you, in a singing voice. In addition, Resident #2 came out calling Resident #1's names.Review of the facility self-reported list of incidents reported to the Department of Inspections, Appeals, and Licensing (DIAL) revealed a report filed on 12/9/25 for an incident between Resident #2 and Resident #1. The list lacked reports for incidents that occurred on 11/14/25, 12/10/25 and 12/15/25.During an interview on 12/22/25 at 3:48 PM Staff A, CNA, stated she received training for Dependent Adult Abuse (DAA). Staff A verbalized she would report allegations of abuse to her supervisor, the nurse or the ADON.During an interview on 12/23/25 at 10:16 AM Staff B, Licensed Practical Nurse (LPN), acknowledged he received DAA training. Staff B reported allegations of abuse are reported to the ADON or the Director of Nursing (DON) as soon as possible. During an interview on 12/23/25 at 11:40 AM with the Assistant Administrator and Administrator present, the DON acknowledged the facility should have reported the incidents on 11/14/25, 12/10/25 and 12/15/25 to DIAL. Review of the facility policy titled Standards and Guidelines: PMI (Person with Mental Illness) Reporting Guidelines - Resident to Resident issued 8/15/22 directed the facility to ensure residents are free from abuse, neglect, and exploitation and are protected from harm by other residents. Resident-to-resident altercations will be assessed on an individual basis and reported when required by Iowa law, DIAL expectations, or federal regulations. Reporting determinations will consider injury, changes in supervision or level of care, and patterns of aggressive behavior indicating potential failure of current interventions or increased risk to resident safety. The policy listed the following Reporting Criteria for a resident-to-resident altercation when any of the following occur:InjuryAny altercation resulting in physical injury requiring assessment, treatment, or medical intervention.Injuries of unknown source reasonably suspected to have resulted from residentinteraction.Change in Level of Care or SupervisionThe incident results in:o Increased supervision or staffingo Environmental modificationo Initiation of 1:1 supervisiono Transfer, emergency services involvement, or hospitalizationPattern of AggressionRepeated aggressive behaviors by the same resident that demonstrate:o Escalation in severity or frequencyo Failure of existing program plan interventionso Increased risk to other residents or staffPatterns may indicate potential inadequate supervision and shall be reviewed for reportability.External ReportingIncidents meeting reporting thresholds shall be reported in accordance with:o Iowa Code Chapter 235B (Dependent Adult Abuse) when abuse, neglect, or exploitation is suspectedo DIAL reporting expectations for incidents impacting resident safetyo Federal CMS requirements related to abuse, neglect, or injuries of unknown sourceReporting determinations will be made promptly and in consultation with facility leadership as appropriate.Review of the facility policy titled Skilled and Senior Living Abuse, Neglect and Exploitation Policy and Procedure dated October 2022 directed any employee who suspects an alleged violation immediately notify the Administrator. The Administrator notifies the appropriate state agency of allegations of neglect, exploitation, misappropriation of resident property or mistreatment that do not result in serious bodily injury in no later than 24-hours. Allegations of abuse resulting in serious bodily injury must report immediately, but not later than 2 hours after the allegation is made. Initial reports must include sufficient information to describe the alleged violation with as much information as possible based on the knowledge at the time of the submission and indicate how resident(s) are being protected. The results of all investigations are reported to the Administrator and to the appropriate state agency as required by state law and/or within five (5) working days of the alleged violation.

Based on clinical record review, facility policy review, and staff interviews the facility failed to thoroughly investigate and put interventions in place following a resident-to-resident abuse for 1 of 3 residents reviewed (Resident #2). The investigation determined Resident #2 hit Resident #1 and Resident #5 on different occasions. The facility failed to conduct resident and staff interviews for the date of the incidents to determine the extent of the allegation or determine if other residents had been affected. The facility reported a census of 136 residents.Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 99, signifying the interview could not be completed. The MDS documented during the lookback period Resident #2 had physical behavior symptoms directed toward others that occurred daily. In addition, the MDS documented Resident #2 had verbal behavior symptoms directed toward others that occurred 4 to 6 days during the lookback period. Resident #2 had behaviors of rejection of care that occurred daily. The MDS included diagnoses of depression, anxiety, post-traumatic stress disorder (PTSD) and bipolar disorder (mental health condition causing extreme mood swings that include emotional highs, called mania, and lows, known as depression).The Care Plan Focus revised 11/5/25 identified Resident #2 frequently demonstrated physical and verbal aggressive behaviors toward staff or peers related to mental illness. The aggressive behaviors included yelling, screaming, name-calling, hitting, kicking, spitting, hair-pulling, throwing objects at others, and calling the police or sheriff to make false accusations or demands. The Interventions directed the staff to:Analyze behaviors for key times, places, circumstances, triggers, and what deescalates behaviors. Document as needed.Document observed behavior and attempted interventions as needed.Give Resident #2 as many choices as possible about care and activitiesProvide physical and verbal cues as able to alleviate anxiety such as giving positive feedback, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. When Resident #2 becomes agitated intervene before agitation escalates; guide away from source of distress; and attempt to engage calmly in conversation. Provide for the safety of others by removing them from the immediate area. If response is aggressive, staff to walk calmly away, and approach later.The Care Plan Report lacked direction for staff to report resident-to-resident altercations and interventions to prevent further incidents following the incidents that occurred on 11/14/25, 12/9/25, 12/10/25 and 12/15/25.Resident #2's Progress Notes included documentation of resident-to-resident altercations on 11/14/25, 12/9/25, 12/10/25 and 12/15/25.The Resident-to-Resident Incident Investigation Summary dated 11/14/25 reflected Resident #2 became physically aggressive toward Resident #1. After attempting to engage in aggression toward a staff member and missing, Resident #2 hit Resident #1 without intention. Resident #2 wore her noise canceling headphones at the time of the incident. The staff immediately separated the residents and initiated frequent checks with Resident #2. The facility lacked a Resident-to-Resident Incident Investigation Summary for 12/10/25. The Resident-to-Resident Incident Investigation Summary dated 12/15/25 at 10:57 AM indicated the Inter-disciplinary team received notification of a physical altercation between Resident #2 and Resident #5. The staff immediately separated the residents and redirected Resident #2 to her room for a break while the staff monitored for safety and de-escalation. During that time, Resident #2 remained physically and verbally combative toward staff. During an interview on 12/23/25 at 11:40 AM with the Assistant Administrator and Administrator, the DON explained when resident-to-resident incidents residents are assessed. The Administrator stated they would investigate every incident with investigations to include staff interviews, chart reviews, review of cameras and follow up with interventions. The DON reported the facility didn't complete an investigation for the incident on 12/10/25 between Resident #1 and Resident # 5. Review of the facility policy titled Skilled and Senior Living Abuse, Neglect and Exploitation Policy and Procedure dated October 2022 directed any employee to take appropriate steps to ensure that all alleged violations of the federal and state laws which involve abuse are reported immediately to the administrator of the community. The community investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator, as well as to the State agencies, as required by State and Federal law.

Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual the facility failed to transmit Minimum Data Set (MDS) assessments timely for 2 of 3 residents reviewed (Residents #29 and #139). The facility reported a census of 136 residents. Findings include:1. Resident #29's MDS Quarterly assessment listed a completed date of [DATE]. The record lacked a transmitted status.On [DATE] at 11:12 AM Staff M, MDS Coordinator, reported their electronic health record (EHR) program directed to not submit the MDS, so she didn't submit the assessment. She reported she didn't know why the MDS got coded like that.On [DATE] at 11:20 AM the Administrator reported the facility didn't have a policy, they used the RAI manual.The RAI manual dated [DATE] on page 2-18 directed to transmit the Quarterly MDS no later than 14 days after the completion of the assessment.2. Resident #139's MDS Death assessment with assessment reference date [DATE] was completed on [DATE]. The record identified the facility transmitted the assessment on [DATE].Resident #139's Progress Note dated [DATE] at 10:35 AM documented they died in the facility.On [DATE] at 11:15 AM Staff M reported she didn't know the MDS needed transmitted within a certain timeframe.The RAI manual dated [DATE] on page 2-20 documented the Death MDS needed transmitted no later than 14 days after the resident's date of death .

Based on observations, clinical record review, policy review, and staff interviews, the facility failed to follow a resident's Care Plan for 1 of 2 residents reviewed (Resident 5). The facility reports a census of 136.Findings include: On 9/9/25 at 1:49 PM observed Resident #5's wheelchair without anti-tippers on front of the wheelchair, no pressure relieving cushion, or non-slip material (Dycem) in the wheelchair.The Care Plan Focus dated 9/25/19 reflected Resident #5 had a risk of falls. The Care Plan directed the following Interventions:a. 9/25/19: Front anti-tippersb. 9/15/22: Dycem for the wheelchair.The Care Plan Focus dated indicated Resident #5 had a potential for pressure ulcers. The Intervention dated 9/3/20 directed to place a pressure reduction cushion in the wheelchair. On 9/10/25 at 7:33 AM observed Resident #5 sitting in a wheelchair in the hallway. Her wheelchair lacked the cushion, anti-tippers, and Dycem.On 9/10/25 at 9:24 AM Staff A, Registered Nurse (RN), verbalized she said she didn't know anything what Resident #5 needed for her wheelchair. On 9/10/25 at 9:26 AM Staff K, Certified Nurse Aide (CNA), reported she never saw a cushion or Dycem for Resident #5's wheelchair. On 9/10/25 at 1:15 PM, the Director of Nursing (DON) reported she expected the staff to follow the Care Plan Interventions. The Interim and Comprehensive Care Plans policy revised September 2011 directed staff to review and update the Care Plan every quarter at minimum.

Based on observation, clinical record review, policy review and staff interview the facility failed to provide a palm splint to the left hand to reduce/prevent contracture for 1 of 1 resident's sampled (Resident #15). The facility identified a census of 136 residents.Findings include:Resident #15's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. The MDS documented Resident #15 had a functional limitation in range of motion to one upper extremity (shoulder, elbow, wrist, hand) and depended on staff for eating, oral hygiene, toileting, upper/lower body dressing and personal hygiene. The MDS listed diagnoses of non-traumatic brain dysfunction, stroke and hemiplegia/hemiparesis (paralysis or loss of muscle function on one side of the body).An Occupational Therapy (OT) Home Therapy Program dated 1/17/25 signed by Staff I, Assistant Director of Nursing (ADON), directed the staff to apply a soft carrot splint with larger end toward the 5th digit (pinky finger) to prevent the fingers from digging into the palm and contracture. Staff to apply in the morning (AM) and wear all day as patient tolerated. The staff could take the splint off at night. Resident #15's Care Plan revised 3/13/25 documented a potential for development of pressure ulcers or other skin injuries related to impaired mobility due to left hemiplegia. The Care Plan Intervention initiated 1/20/25 directed staff to apply a carrot splint to the left hand with the large end toward the 5th digit go prevent contracture and pressure to the palm from fingers. The staff could remove at night. The Activities of Daily Living Self Care Performance Deficit Care Plan revised 3/13/25 included an Intervention dated 3/27/24 that directed Resident #15 to wear a wrist splint on his left hand/wrist. He needed assistance with putting on/taking off the splint. The Order Review History Report acknowledged by the Provider on 8/27/25 at 1:38 PM documented a physician order initiated 1/29/25 per therapy apply a soft carrot splint with the larger end toward the 5th digit to prevent fingers from digging into the palms and contracture. Staff to place in the morning and take off at night as Resident #15 allowed. Observation on 9/8/25 at 11:49 AM Resident #15 sat in the wheelchair at the dining room table. Resident #15 had their left wrist/hand flexed inward at the wrist with the fore, middle, ring and pinky fingers curved inward toward the palm. Resident #15 did not have a carrot splint in their left palm/hand.Observation on 9/9/25 at 12:55 PM revealed Resident #15 sitting in the high back wheelchair at the dining room table. No carrot splint observed in the left hand with the fore, middle, ring and pinky finger all curved inward toward the palm/hand.Observation on 9/9/25 at 2:16 PM Resident #15 sat in the high back wheelchair in the dining room. Resident #15's left hand laid in his lap curved inward with the fore, middle, ring and pinky fingers curled inward toward the palm and the wrist flexed inward at the wrist with no carrot present in the left palm/hand.Observation on 9/9/25 at 2:18 PM revealed Resident #15 sitting in the wheelchair with his left wrist flexed inward with the fore, middle, ring and pinky fingers folded inward toward the palm. Resident #15 did not have a palm carrot in the left palm/hand. At 2:19 PM Staff C, Certified Nursing Assistant (CNA), assisted Resident #15 back to his room. Staff C and Staff D, CNA, transferred Resident #15 from the wheelchair to the bed, performed incontinence care and repositioned him. Staff C and D exited Resident #15's room without offering to place the palm carrot in Resident #15's left palm/hand. Resident #15's left wrist was flexed inward at the wrist with the fore, middle, ring and pinky fingers flexed inward toward his palm positioned along his left side. During an interview on 9/9/25 at 2:35 PM Resident #15 reported he would wear the palm carrot to his left hand if the staff offered it to him, but that didn't happen often. During an interview on 9/10/2025 at 10:21 AM Staff F, CNA, reported Resident #15 should be asked everyday if he wanted to wear the carrot splint, but she only goes in to help him as needed. If he refused the carrot splint, the staff should document it in the behavior charting and let the nurse know Resident #15 refused the carrot splint.Observation on 9/10/25 at 10:23 AM Resident #15 sat in the wheelchair with his left wrist flexed inward with the fore, middle, ring and pinky fingers folded inward toward the palm. Resident #15 did not have a palm carrot in his left palm/hand.Interview completed on 9/10/2025 at 10:25 AM Staff G, CNA, reported Resident #15 has a small, padded glove that staff put on him at night to keep his hand open. He does not have anything that he wears or uses in the left hand during the daytime. Staff G added sometimes they offer him a rolled-up wash cloth for his left hand when they lay him down in bed during the day. Observation on 9/10/25 at 1:31 PM revealed Resident #15 sitting in the wheelchair with a rolled washcloth in his left palm/hand.Interview on 9/10/25 at 1:32 PM Staff E, Licensed Practical Nurse (LPN), reported he signs in the Electronic Treatment Administration Record (ETAR) that staff place Resident #15 carrot splint in his hand every morning. Staff E voiced he thought the resident works it out of his hand but didn't know for sure. He didn't usually go visually check to ensure the staff placed the carrot splint in Resident #15's left hand, he just goes on the fact that the carrot splint is listed under Resident #15's name on the Resident Care Sheet. The carrot splint is listed for Resident #15 to wear every day on the Resident Care Sheet which Staff I updated every day. Staff E provided a copy of the current Resident Care Sheet. Staff E voiced he didn't know where the CNA staff signed or documented regarding Resident #15's carrot splint. He had plenty to do every day and he just made sure he marked the boxes in the resident ETAR, so they turned green to show completion of the orders/tasks. Staff E verified the ETAR contained an order to utilize a carrot splint to Resident #15's left palm/hand. A 9/10/25 review of the Resident Care Sheet updated 8/21/25 provided by Staff E lacked documentation or direction to the staff that Resident #15 needed a carrot splint placed in the left hand to prevent/minimize contracture.A 9/10/25 review of the September 2025 ETAR showed Staff E signed Resident #15 wore the carrot splint to the left palm/hand on September 8, 9, and 10. Interview on 9/10/25 at 1:38 PM Staff J, CNA, explained they document the application of Resident #15's carrot splint in the Point of Care (POC) Electronic Healthcare Record. If Resident #15 refused the carrot splint, the program had an option to document the refusal.During an interview on 9/10/25 at 1:54 PM the Director of Nursing (DON) voiced she expected if the Care Plan included a splint, the staff should attempt to place the splint as a measure to prevent contractures. If a resident refused the splint, the staff should document the refusal. If the resident continued to refuse, they should have a referral to therapy services.On 9/11/25 at 12:17 PM the Administrator corresponded the facility didn't have documentation to support Resident #15 recently refused his left carrot splint.

Based on observations, staff interviews and policy review, the facility failed to lock up hazardous tools when they didn't have staff present in resident areas. The facility reported a census of 136 residents.Findings include: During a continuous observation on 9/8/25 at 1:38 PM of the 3rd floor west side hallway noted the housekeeping closet open and unattended with a wheeled cart in front of the doorway. The unattended wheeled cart had a box cutter, pipe wrench, fire fighter eliminator 1330 (non-toxic antifreeze solution for fire sprinklers), and an impact drill. Observed 3 residents go by the area with no staff present. At 1:42 PM the contracted sprinkler company staff came to the housekeeping closet and worked with the cart items, shut the housekeeping closest, and left shortly after arriving with the cart of tools and antifreeze.During a continuous observation on 9/9/25 at 8:54 AM of the 3rd floor west side hallway noted the housekeeping closet open and unattended with a wheeled cart in front of the doorway. The wheeled cart noted a box cutter, pipe wrench, fire fighter eliminator 1330, and an impact drill. Observed a resident continuously walking around the area and several residents in their rooms not far from the area. At 9:07 AM the contracted sprinkler company staff came to the housekeeping door and began working with the fire fighter eliminator. They then took the cart and shut the door when done. During a continuous observation on 9/9/25 at 8:54 AM the 3rd floor west side hallway oxygen room noted the key hanging in the keyhole of the door. The key connected to a metal piece with 6 heavy chain links then a long wooden stick attached to the chain links. The wooden stick looked about a foot long. The continuous observation noted the key remained in the door with several staff and residents walking by. Staff O, Certified Nurses' Aide (CNA), removed the key at 9:44 AM. On 9/11/25 at 10:49 AM Staff L, Assistant Maintenance, reported Monday and Tuesday, the facility had a contracted sprinkler company there. He reported maintenance gets them all ready to do the stuff they needed to do. They educate them to keep them behind the locked doors, but they do not stay with them while at the facility. He reported he didn't know the company left hazardous tools out without staff nor the contracted company to keep an eye on them. He reported they shouldn't leave tools around. On 9/11/25 11:01 AM Staff B, Assistant Director of Nursing (ADON), verbalized the key for the oxygen is located in the nurses' station. She reported staff are to return the key when done and not leave it in the door or sitting out anywhere. On 9/11/25 at 11:25 AM the Administrator reported she expected maintenance to be with the sprinkler company when they worked on things. She added she expected staff to put back the oxygen key and not leave it in the door as those are hazardous things that wouldn't be good if a resident got a hold of them. The facility policy titled Physical Environment -Maintenance Repair Request revised 7/15/25 directed to ensure all tools, equipment, and furnishings are in good repair and working order, including security measures.

Based on observation, clinical record review, policy review and staff interview, the facility failed to implement current physician orders for oxygen therapy for 1 of 1 resident's sample (Resident #15). The facility identified a census of 136 residents.Findings include:Resident #15's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. The MDS documented Resident #15 exhibited shortness of breath (SOB) trouble breathing with exertion, at rest and while lying flat. The MDS documented diagnoses of chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause ongoing breathing problems characterized by narrow airways which make it difficult to breath, irritation and mucus of the airways that worsen breathing over time) and respiratory failure with use of oxygen therapy. Resident #15 Care Plan revised 3/13/25 documented a diagnosis of COPD and the resident utilized oxygen as needed. The Care Plan directed the staff to give oxygen therapy as ordered by the physician and to check the flow rate routinely for accuracy, as the resident chooses to change settings without consulting the nurse.An Electronic Healthcare Record (EHR) Census documented Resident #15 discharged to the hospital on 8/19/25 and returned to the facility on 8/26/25.A Summary of Hospitalization dated 8/26/25 documented a Principal Problem of acute on chronic respiratory failure with hypoxia (a condition where the body's tissues do not receive enough oxygen) and hypercapnia (a condition where there is excessive amount of carbon dioxide in the blood stream and the body is unable to eliminate it efficiently through breathing) and Active Problems of shortness of breath, pulmonary emphysema (a chronic lung condition that causes permanent damage to the lung air sacs) and respiratory failure (a condition where the lungs cannot adequately provide oxygen to the body or remove carbon dioxide). The Summary under Hospital Course documented Resident #15 arrived at the emergency department (ED) with shortness of breath and difficulty breathing with a history of COPD and aspiration pneumonia (a particle not part of the lungs enters the lungs and causes an infection). The Summary listed a physician order for oxygen 3 liters per minute (LPM) continuous. Observation on 9/8/25 at 11:49 AM Resident #15 sat in the wheelchair with oxygen running at 2 liters per minute (LPM) via nasal cannula. Resident #15 leaned to the right with his right arm hanging off by the lower part of the right wheel of his chair. He made no attempts to change his oxygen setting.Resident #15 observed 9/9/25 at 11:13 AM sitting up in bed with oxygen running at 2 LPM via nasal cannula. Resident #15 had the oxygen concentrator positioned on the left side of the bed where he couldn't touch the concentrator.An observation on 9/9/25 at 12:48 PM revealed Resident #15 sat in the high back wheelchair in the dining room with an oxygen concentrator running at 2 LPM via nasal cannula. Resident #15 had the oxygen concentrator positioned to the right side of his wheelchair. Resident #15 made no attempts to adjust his oxygen concentrator.Observation on 9/10/25 at 10:17 AM Resident #15 sat in the wheelchair in the dining room with his oxygen on 2 LPM on via nasal cannula. Observation on 9/9/25 at 2:18 PM revealed Resident #15 sitting in the wheelchair in the dining room with his oxygen concentrator set at 2 LPM. He had the oxygen concentrator positioned approximately 2 feet from Resident #15's right side out of his reach. At 2:19 PM Staff C, Certified Nursing Assistant (CNA), unplugged Resident #15's oxygen concentrator, took off his nasal cannula, and proceeded to wheel him approximately 60 feet from the dining area to his room. Staff D, CNA, took Resident #15's oxygen concentrator back to his room. Staff C and Staff D donned (put on) an isolation gown, gloves, and masks, then assisted him via the full mechanical lift from his wheelchair to the bed. Staff C and D provided incontinence care and then positioned Resident #15 in the bed. At 2:32 PM Staff C placed the oxygen cannula on Resident #15 and turned on his oxygen concentrator. Resident #15 asked Staff C to put his head of the bed up. Resident #15 went without continuous oxygen for 13 minutes.A review of the August and September 2025 Electronic Treatment Administration Records (ETARs) reflected the staff signed Resident #15 used oxygen at 3 LPM to keep oxygen saturations above 89 % from 8/26/25 to 9/10/25. The September 2025 ETAR showed Staff E, Licensed Practical Nurse (LPN) documented Resident #15 received oxygen at 3 LPM to keep saturations above 89% from 9/8/25 to 9/11/25. The ETAR didn't document the oxygen as continuous per the physician order.Interview on 9/10/2025 at 10:18 AM Staff F, Certified Medication Aide (CMA), stated Resident #15 used 2 liters of oxygen. She didn't see him try to change his oxygen rate since he returned from the hospital.Interview completed on 9/10/2025 at 10:25 AM Staff G, CNA, voiced they tried to place the concentrator where Resident #15 couldn't change it. The concentrator is to be set at 2 LPM. She tries to check his concentrator is set to 2 liters whenever she walked by him. He only used the oxygen concentrator and didn't use any portable oxygen. Interview on 9/10/25 at 10:26 PM Staff H, CNA, explained they check Resident #15 oxygen concentrator often to be sure it is set to 2 liters.Interview on 9/10/25 at 10:42 AM Staff I, Assistant Director of Nursing (ADON), stated Resident #15 received oxygen at 2 LPM as he blows himself out and gives himself exacerbations of COPD. The nurses are to check the oxygen concentrator liter flow every shift and document it on the ETAR. The aides check the concentrator liter flow with cares. All the staff know he is to be on oxygen at 2 LPM. At 10:44 AM Staff I checked Resident #15 Summary of Hospitalization to confirm the oxygen order at 2 LPM. Staff I reported she made a mistake and confirmed Resident #15's oxygen order as 3 liters continuous. She hadn't placed the current oxygen order in the EHR. During an interview on 9/10/25 at 11:57 AM the Director of Nursing (DON) voiced she expected the staff to follow the physician's order. She didn't know for sure if the facility had a policy for following physician orders, but they had an oxygen policy, and they should follow the physician's order.The Respiratory Care and Oxygen Administration Policy, revised April 2025, provided by the facility, directed the facility to provide guidelines for safe oxygen administration. The Policy Guidelines directed the nurse to verify the physician's order for oxygen use and oxygen administration.

Based on observation, clinical record review, policy review, manufactures instructions for use, and staff interviews, the facility failed to ensure residents didn't receive expired insulin to diabetic residents for 2 of2 residents sampled (Residents #401 and #9). The facility reported a census of 136 residents.Finding include:1. Resident #401 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The MDS listed a diagnosis of diabetes mellitus. In addition, the MDS identified Resident #401 utilized insulin seven days a week.The Order Review History Report acknowledged by the provider on [DATE] at 13:38 PM listed the following physician orders:a. Humalog Injection solution 100 units (U) per milliliter (ML) injection 2 U subcutaneously twice a day for diabetes.b. Humalog Injection solution 100 U/ML inject 2 units per sliding scale for a blood sugar of 151-200.Observation on [DATE] at 8:23 AM Staff A, Registered Nurse (RN), reviewed Resident #401's [DATE] Electronic Medication Administration Record (EMAR). The EMAR listed the following orders:a. Humalog Injection solution 100 units (U) per milliliter (/ML) injection 2 U subcutaneously twice a day for diabetesb. Humalog Injection solution 100 U/ML inject 2 Units per sliding scale if blood sugar 151-200 give 2 units.Staff A performed hand hygiene, applied gloves, removed a bottle containing a vial of Humalog insulin, drew up 4 units of Humalog insulin into a syringe, and proceeded to administer the insulin to Resident #401 without verifying the expiration date of the insulin. Further observation revealed the insulin vial contained an open date of [DATE] and an expiration date of [DATE].Interview completed on [DATE] at 8:25 AM Staff A, voiced she should have checked the expiration date on the bottle of insulin, and shouldn't gave it to Resident #401.Interview completed on [DATE] at [DATE] at 8:30 AM Staff B, Assistant Director of Nursing (ADON), explained insulin is good for 28 days after opening. She expected the nurses to check the expiration date prior to administering insulin.A [DATE] review of Resident #401's [DATE] EMAR revealed they received Humalog insulin several times a day by several different nurses from [DATE] to [DATE].During an interview on [DATE] at 11:57 AM the Director of Nursing (DON) voiced the facility didn't have an insulin policy but with the facility medication administration policy medication rights, she expected a nurse to check the medication expiration date and not administer expired medication. She stated it wasn't the first time she found expired insulin in the medication cart.The Medication Administration Policy revised on [DATE], provided by the facility, directed the individual administering medication should verify the medication, dose, time, and method ofadministration. The policy lacked direction within the rights of medication administration to verify the expiration date of the medication prior to administration.The Novolog Highlights of Prescribing Information (manufacturer's instructions for use) revised [DATE] under Summary of Storage Conditions listed Humalog insulin vials as good for 28 days once opened.2. Resident #9's MDS assessment dated [DATE] showed a BIMS score of 12/15 indicating intact cognition. The MDS listed a diagnosis of diabetes mellitus and documented Resident #9 utilized insulinseven days a week.The Order Review History Report acknowledged by the provider on [DATE] at 13:38 PM listed the following physician orders:a. Novolog Injection solution 100 U/ML inject 3 U subcutaneously twice a day for diabetes.b. Novolog Injection solution 100 U/ML inject 2 U per sliding scale, for blood sugars of 350-399, give 4 units of insulin.Observation on [DATE] at 8:24 AM revealed Resident #9's vial of Novolog insulin had an open date of [DATE] and an expiration date of [DATE].Interview completed on [DATE] at 8:25 AM Staff A confirmed she gave Resident #9 her scheduled AM dose of Novolog insulin [DATE] from the expired insulin vial. Staff A voiced she shouldhave checked the expiration date on the bottle of insulin and not administered the insulin from that expired vial.A [DATE] review of Resident #9's September EMAR revealed they received Novolog insulin several times a day by several different nurses from [DATE] to [DATE].

Based on observation, policy review, and staff interviews the facility failed to have patient care equipment in good repair for 1 of 1 resident reviewed (Resident 37). The facility reported a census of 136 residents.Findings include: On 9/8/25 at 11:20 AM observed Resident 37's bed frame had plastic protective edging loose and sticking up at the foot of bed.On 9/9/25 at 9:53 AM observed Resident 37's bed frame plastic edging remained loose and sticking up at the foot of bed.On 9/10/25 at 7:15 AM observed Resident 37's bed frame plastic edging remained loose and sticking up at the foot of bed.On 9/11/25 at 11:10AM Staff N, Assistant Maintenance, reported the staff email or verbally call them if something needed fixed. In addition, Residents also let them know verbally.On 9/11/25 at 11:30 AM Administrator described the process of repairing things as an email sent to maintenance. They print the email out to know what needs fixed. The facility policy titled Physical Environment - Maintenance Repair Request revised 7/15/25 documented per regulations, inspections are completed on a routine basis, ensuring equipment and furnishing are free from safety hazards.

Based on policy review, Center for Infection Control and Prevention (CDC) Guidelines, and staff interview, the facility failed to perform an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; and failed to identify measures to monitor and prevent the growth of opportunistic waterborne pathogens and facility staff failed to use enhanced barrier precautions when assisted a resident with a tube feeding, (Resident #52). The facility identified a census of 132 residents. Findings include: According to the CDC Legionnaires' disease is a serious type of pneumonia caused by bacteria, called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. During an interview on 10/02/24 at 10:50 AM Staff A, Maintenance Supervisor reported they did not have a water mapping or plan, but the facility does have a Legionella Policy. He verbalized they have never had low census so resident rooms are never vacant. They have not had to flush rooms, kitchens, water fountains or shower rooms, because everything is always in use. All laundry, kitchen, fountains and showers are in use daily so they have not identified any dead ends in the water system that require flushing at this time. On 10/02/24 at 1:05 PM Staff A verbalized they had always just given the Legionella Policy to the State and it was fine. He reported he did not have a written assessment pertaining to where Legionella could grow and he did not have a water plan that identified measure to prevent the growth of Legionella and how to monitor for Legionella. Staff A confirmed the facility had municipal water lines coming into the facility, an eye wash station in the laundry room with a back-flow valve, several shower rooms in use and a large kitchen with an ice machine. During an interview on 10/02/24 at 1:48 PM the Administrator reported she had only been with the facility for a month, but she had worked on Legionella assessment and water plans for facilities back in 2019. She stated she understood the facility needed a water management plan and the facility would be working on developing one. During an interview on 10/03/24 at 9:05 AM the Director of Nursing (DON) reported she had gone to a meeting on Legionnaires disease. She brought the information back and reviewed with maintenance, but honestly there has been no communication between the infection control preventionist and maintenance to work on the Legionnaires and a water management plan. She reported they had just gone through a water main break not that long ago and they did not have a water plan in place. On 10/02/24 at 11:58 the facility provided the Legionella Policy. The Section T Legionella Policy reviewed 2/2024 directed when the facility maintenance director identifies potentially hazardous conditions that promote Legionella, the facility will conduct a Legionella Environmental Assessment. There will also be a risk assessment completed annually only upon any major alteration of the physical plant or new structure erected that may cause water condition to change. The assessment provided by the CDC will assist the facility to assess water systems, determine if Legionella environmental sampling is required and developing a plan. When conducting a hazard assessment, the maintenance director will pay special attention to: a. Locations in the water system where water may stagnate, such as storage tanks, and components that have been isolation and no longer maintain a significant flow of water or infrequently used faucets. b. Hot water recirculation systems. c. Side-stream plumbing equipment not experiencing regular flow, such as expansion tanks, hammer arrestors, or by-pass lines. d. Cross-connections between domestic and process water system. d. Backflow prevention devices. 48888 2. The Minimum Data Set (MDS), dated [DATE], revealed Resident #52 had delusions and modified independence for decision making regarding tasks of daily life. Resident #52 required dependance upon staff for hygiene tasks, dressing, and transfers. Diagnoses included Schizophrenia, dysphagia (difficulty swallowing), and flaccid hemiplegia (paralysis of one side of the body) affecting left side. The Care Plan, revised on 9/24/24, revealed Resident #52 had a Percutaneous Enteral Gastrostomy (PEG) tube placed 9/16/24 related to dysphagia with the goal for insertion site to remain free of signs and symptoms of infection through the review date. Intervention instructed provide localized care to G-tube site as ordered, and observe for signs and symptoms of infection. On 09/30/24 at 12:43 PM, observed an Enhanced Barrier Precautions sign posted on Resident #52's door to room. On 10/01/24 at 11:10 AM, Resident #52 sat in wheelchair at dining room table disconnected from feeding tube pump. Staff G, Licensed Practical Nurse (LPN), entered dining room with feeding tube pump attached to rolling pole. Staff G lifted Resident #52's shirt to expose gastrostomy tube (g-tube) and with ungloved hands, no additional Personal Protective Equipment (PPE) worn, cleaned g-tube port with an alcohol wipe and attached the end of feeding tube to the g-tube port. Staff G then resumed continuous enteral tube feeding at 85 mL per hour. Various residents and staff remained in area as nurse reattached and resumed Resident #52's enteral feeding. On 10/01/24 at 2:00 PM, Staff G, LPN, informed that the Enhanced Barrier Precautions (EBP) sign, posted on Resident #52's door, was for additional PPE to be worn when completing wound care related to an open area on bottom. On 10/01/24 at 2:53 PM, Staff H, Registered Nurse (RN) and Assistant Director of Nursing (ADON), revealed that the EBP sign on Resident #52's door was to instruct staff to don additional PPE (gown, gloves) when attaching or removing the feeding tube. On 10/01/24 at 2:55 PM, Director of Nursing (DON) revealed the expectation that nursing staff provide appropriate infection control practices when administering tube feedings. The facility policy titled, Gastrostomy Tube Care, not dated, instructed staff to wash hands and don gloves before handling gastrostomy tubes and attachments to decrease the risk of infection.

Based on observation and staff interview, the facility failed to post notice of the availability of the most recent survey reports and failed to have survey reports readily accessible to residents, family members and legal representatives of the most recent survey of the facility. The facility reported a census of 132 residents. Findings include: Observations 9/30/24 and 10/1/24 revealed a three-ring white binder labeled Department of Inspection and Appeals (DIA) Survey Book 1/6/22 to present lay flat on a rolling rack inside of double set of doors labeled community room. The area was a hallway that went down to the facility conference room and the therapy room. The area outside of the Community Room did not publicly display and post that facility survey results were available for review and where to find the survey book. During an observation on 10/2/24 at 9:52 AM the white three ring binder labeled DIA Survey Book 1/6/22 to present continued to lay flat on a rolling rack inside a set of double doors labeled community room. No residents had been observed accessing the area. Interview on 10/2/24 at 9:53 AM Staff B, Scheduler reported she didn't know why the survey book was on a rack inside the inner hallway. Staff B stated she only does the scheduling. On 10/2/24 at 1:13 PM the wheeled cart observed in a cove off of the main entrance hallway area with coat hooks and wet floor signs with a red and black broom sitting up against the wall. Observation at this time revealed no posting to notify residents, family, legal representatives or the general public of the location to review the facility's most recent survey results. During an interview on 10/3/24 at 9:15 AM the Director of Nursing reported she was not aware they needed to post survey reports were available and where to find the them. She reported they had recently repainted and the cart got moved, but the facility had not posted survey reports were available and where to find them. They would get a sign posted.

Based on observations, clinical record review, and resident, family, and staff interviews, the facility failed to treat residents with dignity and respect while affirming each resident's individuality during random observations of staff and resident interactions conducted during our unannounced visit. This was found during review of 3 of 3 residents (Resident #29, Resident #27, and Resident #52). During an observation of Resident #29's room it was noted that there was no curtain hanging between Resident #29's designated room space and his roommate Resident #64's room space, removing all privacy for Resident #29. Resident #29 did not have decision making abilities to approve that there be no curtain. It was observed that Resident #64 could not enter or exit their shared room without walking through Resident #29's designated room space. During an observation Resident #27 turned her call light on and wanted assistance to get out of bed as she was hot and visibly sweaty. Staff returned to the room [ROOM NUMBER] minutes later with a lift to transfer Resident #27 out of the room. An observation revealed that Resident #52's tube feeding was hooked up in a common area in front of several other residents. The facility reported a census of 132. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE], documented diagnoses for Resident #29 included schizophrenia. A Brief Interview for Mental Status (BIMS) documented that this resident was rarely/never understood. It documented this resident knew the location of his own room and knew staff names and faces. On 10/1/24 at 8:54 AM, Resident #29 was lying in his recliner on his side with recliner reclined. There was no curtain between this resident and his roommate. His roommate was also lying in bed with covers on him. Resident #64 stated he did not mind there being no curtain. Resident #29, was not able to respond. On 10/1/24 at 1:39 PM, Staff A, Assistant Director of Nursing (ADON) and the Maintenance Supervisor acknowledged there was no curtain between Resident #29 and Resident #64. This ADON and the Maintenance Supervisor noted there was a track on the ceiling for a curtain but did not know why there was not a curtain in place. They stated maybe it was being laundered. They stated they would look for a work order to figure out why the curtain was not in place. Staff A and the Maintenance Supervisor concurred that there was no way for Resident #64 to enter and/or exit his allotted space in the room without walking through Resident #29's space. On 10/2/24 at 10:20 AM, the Maintenance Supervisor acknowledged the concerns with no direct access to the door without passing through another resident's room space, and no curtain hanging between the above two residents. He stated they think that Resident #64 tore down the curtain. 42134 2. The MDS for Resident #27 dated 6/10/24 documented diagnoses including anxiety disorder and schizoaffective disorder. The MDS documented a BIMS score of 15 indicating intact cognitive functioning. The interventions on the Care Plan for Resident #27 included assist of 1 for turning and repositioning in bed, transfer with assist of 2 using mechanical lift and encourage use of call light During an interview on 9/30/24 at 2:13 PM with Resident #27, Staff E, CNA, answered the resident's call light. The resident explained to the CNA she was hot and wanted to get out of bed. The resident was visably sweating. Staff E explained to the resident that she was just coming on shift and could not get the resident out of bed at this time. She explained she would be back in 5-7 minutes. She then asked the resident to turn off her call light. While under continuous observation on 9/30/24 from 2:13 PM until 2:28 PM Staff E entered the resident's room at 2:33 PM. She did not take the mechanical lift or the resident's w/c in the room. She was in the room at 2:34 PM. As soon as the CNA left the room the resident's call light came back on. At 2:37 PM the resident was calling out that she wanted to get out of bed. At 2:39 PM Staff E and Staff F, CNA, entered the resident's room with the mechanical lift and turned off the call light. At 2:40 PM Staff F exited the room and took the w/c into the resident's room. At 2:48 the resident, Staff E and Staff F exited the resident's room. During an interview on 10/2/24 at 4:56 PM the DON explained she would expect call lights to be answered in no more than 15 minutes. She further explained if a resident was given a timeframe when the staff would return, they would return during that time frame. She explained that even if the staff needed to get assistance or was otherwise unable to meet the resident's need fully, they should attempt to alleviate the immediate discomfort. 48888 3. The MDS dated [DATE], revealed Resident #52 had delusions and modified independence for decision making regarding tasks of daily life. Resident #52 required dependance upon staff for hygiene tasks, dressing, and transfers. Diagnoses included Schizophrenia, dysphagia (difficulty swallowing), and flaccid hemiplegia (paralysis of one side of the body) affecting left side. The Care Plan, revised on 3/27/24, revealed a focus area problem identified for psychosocial well-being due to diagnoses and symptoms of Paranoid Schizophrenia and Major Depressive Disorder. Intervention instructed staff to provide Resident #52 assistance and support to identify, reduce, or eliminate causative and contributing factors to feelings of isolation, anger, and frustration. The Medication/Treatment Administration Order, dated October 2024, revealed an order, started on 9/19/24, for Resident #52 to receive enteral feed, at a rate of 85 milliliters (mL) per hour for 12 hours, followed by a water flush of 100 mL per hour for 10 hours daily. Nursing Progress Notes, dated 9/26/24 at 1:49 PM, revealed Resident #52 had expressed depressive thoughts related to new feeding tube. On 10/2/24 at 11:26 AM, note indicated Resident #52 had been verbalizing unhappiness with tube feeding related to being hooked up to tube during the day and also due to limitations on oral intake. On 10/1/24 at 11:10 AM, Resident #52 sat in wheelchair at dining room table disconnected from feeding tube pump. Staff G, Licensed Practical Nurse (LPN), entered dining room with feeding tube pump attached to rolling pole. Staff G lifted Resident #52's shirt to expose gastrostomy tube (g-tube) and with ungloved hands, cleaned g-tube port with an alcohol wipe and attached the end of feeding tube to the g-tube port. Staff G then resumed continuous enteral tube feeding at 85 mL per hour. On 10/1/24 at 2:00 PM, Staff G, LPN, stated Resident #52 had gastrostomy tube in place for approximately 2 weeks and received tube feeding for difficulty with swallowing and risk for aspiration. Staff G informed that enteral feedings are started daily between 4:00-6:00 AM in resident's room and that it did not bother Resident #52 to have enteral feeding in common areas. On 10/1/24 at 2:53 PM, Staff H, Registered Nurse (RN) and Assistant Director of Nursing (ADON), revealed that Resident #52 had been very depressed after having g-tube placed and does not like to have tube feeding out of his room. ADON planned to inform Dietitian and Physician with request to have tube feeding completed during the night shift. On 10/1/24 at 2:55 PM, Director of Nursing (DON) revealed that hooking a feeding tube to resident in dining room was a concern for resident dignity. The facility policy titled, Resident Rights, dated October 2022, revealed that resident's in the community have the right to be treated with dignity and respect in full recognition of the resident's individuality and be treated in a manner that enhances the resident's quality of life. The policy additionally informed that residents have the right to be fully informed in advance about care and treatment and any changes in that care or treatment that will affect the resident's well being.

Based on observation, interview, clinical record review, and facility policy review, the facility failed to apply continuous oxygen at 2 liters (L) per minute via nasal cannula, as ordered by Provider, for 1 of 1 resident (Resident #52) reviewed for respiratory care. The facility reported a census of 132 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #52 had delusions and modified independence for decision making regarding tasks of daily life. Resident #52 required dependance upon staff for hygiene tasks, dressing, and transfers. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with hypoxia, Schizophrenia, dysphagia (difficulty swallowing), and flaccid hemiplegia (paralysis of one side of the body) affecting left side. The MDS indicated Resident #52 had shortness of breath both with activity and at rest but lacked indication that Resident #52 required oxygen therapy or respiratory treatments. The Care Plan, revised 3/27/24, revealed a focused area for Resident #52 diagnosis of COPD with a goal that resident would display optimal breathing patterns daily and intervention to give oxygen therapy as ordered by the physician. The Medication and Treatment Administration Record (MAR/TAR), dated September 2024, revealed an order for oxygen administration at 2 liters per minute to keep oxygen saturation above 89%, initiated on 3/12/24. The MAR/TAR, dated October 2024, revealed a new order for nursing to assess Resident #52 lung sounds twice per day and notify provider or any changes from baseline, order initiated 10/2/24. On 9/30/24 at 10:55 AM, Resident #52 sat in dining room, oxygen worn via nasal cannula with flow set at 6 liters per minute. On 9/30/24 at 2:16 PM, Resident #52 laid in bed, oxygen worn via nasal cannula with flow set at 5 liters per minute. On 10/1/24 at 11:10 AM, Resident #52 sat in dining room, no oxygen applied. Noted oxygen concentrator remained in resident's room running at 4.5 liters per minute. At 12:06 PM, Resident #52 continued to be without oxygen therapy. On 10/1/24 at 2:00 PM, Staff G, Licensed Practical Nurse (LPN), stated Resident #52 mainly wore oxygen when in bed and stated that oxygen is provided as needed to Resident #52 when he is in common areas. On 10/1/24 at 2:53 PM, Staff H, Registered Nurse (RN) and Assistant Director of Nursing (ADON) revealed Resident #52 had order for oxygen to be given continuously at 2 liters per minute but informed that at times Resident #52 refused to wear oxygen outside of his room. On 10/1/24 at 2:55 PM, Director of Nursing (DON) revealed the expectation was that nursing staff follow physician's orders. On 10/3/24 at 11:57 AM, the Facility Administrator denied having a policy related to respiratory care or oxygen therapy.

Based on observation, interview, clinical record review, and facility policy review, the facility failed complete resident fall assessment or neurological checks following a resident reported, unwitnessed, fall for 1 of 3 residents (Resident #53) reviewed for accidents. The facility reported a census of 132 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. Resident #53 able to transfer, ambulate and perform personal hygiene tasks independently. Diagnoses included Schizoaffective disorder, anxiety disorder, depression, and polyneuropathy. The MDS indicated Resident #53 had 2 or more falls with minor injury since previous assessment. The Care Plan, revised on 7/31/24, revealed Resident #53 had been at risk for falls related to daily use of psychotropic medications, chronic pain, and hammer toes with the intervention to educate resident about safety and remind her what to do if a fall occurs. The Care Plan revealed that Resident #53 had a fall on 7/25/24 and 7/30/24. In a Nursing Progress Note, dated 9/29/24 at 6:32 PM, documentation revealed that Resident #53 had been yelling from inside room, staff approached, and noted Resident #53 had been on hands and knees, crawling around room. Resident #53 stated she was attempting to clean out the drawers next to her bed. The note revealed staff assisted resident into bed. On 9/30/24 at 1:12 PM, Nursing Progress Note included documentation that Resident #53 reported to non-staff that she had fallen and when asked, could not remember the details of when, where, or how she had fallen. Note revealed that no injuries related to a fall were noted. Review of Resident #53's Incident Reports and Electronic Health Record (EHR) assessment tab, lacked a fall incident report or completion of fall assessment related to observation of resident crawling on floor or resident self-report of a fall. On 9/30/24 at 12:08 PM, Resident #53 reported to Staff I, Certified Nursing Assistant (CNA), that she had fallen in room. Staff I went into nurses station, no additional questions or assessment observed by nursing staff following resident's fall report. On 9/30/24 at 12:22 PM, Resident #53 again stated she had fallen and crawled across the floor using the bed to get self up. Resident #53 informed she had hurt her hands and knees during incident. A small scratch noted to left pinkie finger with scant amount of blood. State Inspector notified Staff H, Assistant Director of Nursing (ADON) of Resident #53 self-reported fall and blood noted to left pinkie finger. Staff H checked Resident #53's hand, applied a Band-aid, and reminded resident to notify staff if fallen and not to try and get self up. On 10/1/24 at 2:00 PM, Staff G, Licensed Practical Nurse (LPN) revealed that Staff I, CNA, had informed LPN that Resident #53 reported a fall on 9/30/24 at 12:08 PM. Staff G stated Resident #53 often had attention seeking behaviors and could not have fallen as she did not recall details of when, where, or how she had fallen. On 10/1/24 at 2:53 PM, Staff H, ADON, revealed that she had asked Resident #53 about a fall, resident had been unable to state details of fall, then reminded her to let someone know if she falls. On 10/1/24 at 2:54 PM Director of Nursing (DON) revealed the expectation that nursing would assess a resident, complete incident report, and neurological assessment for any resident self-reported or unwitnessed fall. The facility policy, titled Fall Prevention and Fall Review Policy, revised 1/2023, revealed the expectation for fall response to include: an investigation into fall circumstance, creation of risk management report in EHR, and completion of fall assessment to include checking for injury and pain. Nursing staff instructed to record and implement an immediate fall intervention.

Based on observation, record review, and staff interview, the facility failed to ensure residents were safe from accidents and hazards for 1 of 3 residents reviewed (Resident #79). Staff failed to supervise Resident #79 in the shower room. The resident fell while in the shower. The facility reported a census of 132 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #79 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated severe cognitive impairment. The MDS documented the resident had diagnoses of hypertension, dementia, Parkinson's Disease, anxiety and depression. The Care Plan for Resident #8 with a revised date of 9/26/24 with a focus area ADL Self Care revised on 7/03/24 directed staff for bathing the he required assistance of 1 with staff. Review of Resident #79's Electronic Health Record Progress Notes revealed a Nursing Progress Note dated 7/19/24 at 5:17 PM documented Resident #79 was in the shower unattended when staff found him on the floor in the shower room no injuries noted. In an interview on 10/1/24 at 3:49 PM, the Director of Nursing reported Resident #79 should have not been left in the shower unattended.

Based on observation, interview, clinical record review, and facility policy review, the facility failed to apply gloves or additional Personal Protective Equipment (PPE) for infection prevention during administration of enteral tube feeding for 1 of 1 residents (Resident #52) reviewed for tube feeding. The facility reported a census of 132 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #52 had delusions and modified independence for decision making regarding tasks of daily life. Resident #52 required dependance upon staff for hygiene tasks, dressing, and transfers. Diagnoses included Schizophrenia, dysphagia (difficulty swallowing), and flaccid hemiplegia (paralysis of one side of the body) affecting left side. The Care Plan, revised on 9/24/24, revealed Resident #52 had a Percutaneous Enteral Gastrostomy (PEG) tube placed 9/16/24 related to dysphagia with the goal for insertion site to remain free of signs and symptoms of infection through the review date. Interventions instructed staff to check for tube placement and gastric contents/residual volume per facility protocol, provide localized care to G-tube site as ordered, and observe for signs and symptoms of infection. The Medication/Treatment Administration Order, dated October 2024, revealed an order, started on 9/19/24, for Resident #52 to receive enteral feed, at a rate of 85 milliliters (mL) per hour for 12 hours, followed by a water flush of 100 mL per hour for 10 hours daily. On 09/30/24 at 12:43 PM, observed an Enhanced Barrier Precautions sign posted on Resident #52's door to room. On 10/01/24 at 11:10 AM, Resident #52 sat in wheelchair at dining room table disconnected from feeding tube pump. Staff G, Licensed Practical Nurse (LPN), entered dining room with feeding tube pump attached to rolling pole. Staff G lifted Resident #52's shirt to expose gastrostomy tube (g-tube) and with ungloved hands, no additional Personal Protective Equipment (PPE) worn, cleaned g-tube port with an alcohol wipe and attached the end of feeding tube to the g-tube port. Staff G then resumed continuous enteral tube feeding at 85 mL per hour. Various residents and staff remained in area as nurse reattached and resumed Resident #52's enteral feeding. On 10/01/24 at 2:00 PM, Staff G, LPN, stated Resident #52 had gastrostomy tube in place for approximately 2 weeks and received tube feeding for difficulty with swallowing and risk for aspiration. Staff G stated that enteral feedings are started daily between 4:00-6:00 AM in resident's room and that it did not bother Resident #52 to have enteral feeding in common areas. Staff G stated the Enhanced Barrier Precautions (EBP) sign, posted on Resident #52's door, was for additional PPE to be worn when completing wound care related to an open area on bottom. On 10/01/24 at 2:53 PM, Staff H, Registered Nurse (RN) and Assistant Director of Nursing (ADON), revealed that the EBP sign on Resident #52's door was to instruct staff to don additional PPE (gown, gloves) when attaching or removing the feeding tube. On 10/01/24 at 2:55 PM, Director of Nursing (DON) revealed that hooking a feeding tube to resident in dining room was a concern for resident dignity and expected nursing staff to provide appropriate infection control practices when administering tube feedings. The facility policy titled, Gastrostomy Tube Care, not dated, instructed staff to wash hands and don gloves before handling gastrostomy tubes and attachments to decrease the risk of infection.

Based on observations, interviews and record review, the facility failed to ensure a minimum of 80 square feet of personal room space for residents with roommates for 1 of 1 resident reviewed (Resident #29). During an observation it was noted that Resident #29 had a smaller room space than his roommates. The facility reported a census of 132 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #29 included schizophrenia. A Brief Interview for Mental Status (BIMS) documented that this resident was rarely/never understood. It documented this resident knew the location of his own room and knew staff names and faces. A Care Plan with a Bed Mobility intervention initiated on 4/20/21, directed staff that Resident #29 chose to sleep in a recliner; Resident #29 did not have a bed. On 10/1/24 at 1:39 PM, the Maintenance Supervisor measured the room space for Resident #29. The measurements were 82 inches by 98 inches. Both Staff A, Assistant Director of Nursing (ADON) and the Maintenance Supervisor confirmed the measurements. On 10/2/24 at 10:20 AM, the Maintenance Supervisor stated they were having discussions regarding moving Resident #29 to the room next door and to keep room [ROOM NUMBER] a 3 resident room instead of a 4 resident room. He stated the room above room [ROOM NUMBER] on the 3rd floor was currently a 3 person room and mirrored room [ROOM NUMBER]. He stated that room [ROOM NUMBER] was certified for 4 resident occupancy at some point and what they think might have happened was when the facility was mandated to add a bathroom to each of the resident's rooms, the square footage per resident decreased. This Maintenance Supervisor acknowledged that Resident #29's room was less than 80 square footage and that the measurements of 82 inches by 98 inches was a little over 55 square feet. The facility did not have a policy that addressed square footage in resident rooms.

Based on observations, interviews and record review, the facility failed to ensure residents had direct access to an exit corridor from their designated room space in a room shared by 4 residents for 4 of the 4 residents reviewed (Resident #29, Resident # 60, Resident #64 and Resident #92). Resident #64 would need to exit through Resident #29's designated room space to exit the room and access the hall. Resident #60 would need to exit through either Resident # 64's space and then into Resident #29's designated space or would need to exit through Resident #92's designated space. The facility reported a census of 132 Residents. Findings include: On 10/1/24 at 1:39 PM, Staff D, Assistant Director of Nursing (ADON) and Staff A, Maintenance Supervisor concurred that there was no way for in and out of the room for the 2 residents in the back of the room Resident #29 and Resident #60 to enter and/or exit their allotted space in the room without walking through Resident #64's and/or Resident #29's space. On 10/2/24 at 10:20 AM, Staff A stated the facility was having discussions regarding moving Resident #29 to the room next door and then to keep room [ROOM NUMBER] a 3 resident room. Staff A stated the room above it on the 3rd floor was a 3 person room and mirrors room [ROOM NUMBER]. He stated that at some point room [ROOM NUMBER] was certified for 4 residents. Staff A stated that what they think might have happened was when the facility had to add a bathroom to each of the individual rooms, the square footage per resident decreased. Staff A acknowledged the concerns with no direct access to the door without passing through another resident's room space. The facility did not provide a policy regarding direct access to an exit corridor.

Based on clinical record review, observations and staff and resident interviews, facility staff failed to provide the breakfast meal, failed to always provide interventions to promote nutrition and failed to monitor food consumption for 3 of 3 residents sampled with known weight loss and weight loss interventions in place (Residents #4, #8 and #9). The facility reported a census of 131. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required the assistance of 1 staff for transfers, walking, dressing, personal hygiene and bathing. Resident #4 utilized a walker to move about the facility. The assessment documented the resident with severe cognitive and memory impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. The resident required supervision with eating. Review of the resident's Care Plan, revised on 12/2/21, revealed the resident with a problem of low body weight related to limited oral intake due to Alzheimer's disease. The resident could feed herself after she received set-up assistance and required cueing from the staff during meals to promote her intake. The Care Plan instructed staff to encourage the resident to accept the ordered supplement and nutrition related medications to maintain an adequate micronutrient intake. The Care Plan also directed staff to monitor the resident's weight and oral intake as ordered by her physician. Observation on 12/27/21 at 9:55 a.m. revealed Resident #4 lying in bed, appearing to be asleep. Staff A, CNA (Certified Nursing Assistant) entered the room. Staff a stated it looked like Resident #4 had not been up yet this morning. Staff A stated the resident did not receive breakfast this morning. Review of Resident #4's weight history revealed the following weight measurements: a. On 6/8/21 the resident weighed 119 pounds. b. On 7/27/21 the resident weighed 111 pounds. c. On 8/17/21 the resident weighed 117 pounds. d. On 9/1/21 the resident weighed 119.5 pounds. e. On 10/5/21 the resident weighed 121 pounds. f. On 11/2/21 the resident weighed 123 pounds. g. On 12/17/21 the resident weighed 118 pounds. Review of a Nutrition/Dietary Note dated 11/26/21 revealed the resident's weight as under her ideal body weight of 123 pounds and she had a 2.5% weight loss in the last month. The Dietician recommended to offer the resident 8 ounces of Ensure (a nutritional supplement) twice daily, to continue to provide meal set up and monitor her oral intake. Review of the Meal Consumption Report dated 12/17/21 - 1/4/22 revealed the staff failed to document meal consumption for 43 out of 60 meals. Review of the Diet Type Report dated 12/15/21 revealed Resident #4 had a regular consistency diet with a house supplement of 4 ounces of Might Shake daily. 2. The MDS assessment dated [DATE] documented Resident's #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 7 which indicated severe memory and cognitive impairment. The resident required limited assistance of 1 staff for transfers, ambulation, dressing and hygiene. The resident required supervision during meals. The resident's Care Plan, revised on 12/8/21, indicated she had an unintended weight loss related to poor appetite as evidenced by meal refusals, trouble swallowing, dementia and a [CONDITION(S)] disease diagnosis. The resident required a mechanically altered diet. The Care Plan directed staff to supervise the resident during meals for safety, utilize a lipped plate to promote independence, encourage whole milk at meals, offer a mechanically altered diet as order and to monitor for swallowing problems. The Care Plan also directed staff to offer a snack at bedtime, to encourage the resident to consume supplements as ordered and honor her food preferences. Review of the Meal Consumption Report dated 12/17/21 - 1/4/22 revealed the staff failed to document meal consumption for 48 out of 60 meals and during 8 of those meals, the resident consumed less than 25% of her meals. Observation on 12/27/21 at 11:09 a.m. revealed Resident #8 lying in bed with her night clothes on. Staff B, RN (Registered Nurse) and Co-Director of Nurses asked the resident if she had been up yet this morning. Resident #8 replied no but she would like to get up and get dressed. The resident stated she has not had breakfast yet that day. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 12/27/21. Review of a Diet Type Report dated 12/15/21 indicated Resident #8 ordered to have a pureed, regular fluid consistency, no added salt diet. The report did not record the resident should have whole milk at meals, that she consumed a supplement or that she utilized a lipped plate. Observation on 12/27/21 at 11:09 a.m. revealed Staff B assisted the resident to the standing scale and the resident's weight at that time measured 118 pounds. Review of the resident's weight history revealed the following weight measurements: a. On 6/29/21 the resident weighed 147.5 pounds. b. On 7/20/21, the resident weighed 146 pounds. c. On 8/17/21, she weighed 143 pounds. d. On 9/28/21, the resident weighed 150 pounds. e. On 10/26/21, she weighed 129.5 pounds. f. On 11/23/21, the resident weighed 129 pounds. g. On 12/17/21 and 12/27/21, the resident's weight measured 118 pounds. The resident had a total weight loss of 29.5 pounds since 6/21. Observation on 12/27/21 at 11:57 a.m. revealed Resident #8 sitting in a wheelchair in the main dining room waiting to eat lunch. The resident had her head down and she appeared to be asleep. At 12:15 p.m. staff served the resident her noon beverages which she picked up and began to drink immediately. Resident #8 drank a cup of coffee with milk and 1/2 glass of water. The resident pushed herself away from the table and did not eat food at the time. The staff failed to redirect the resident back to the table. Observation on 1/4/22 at 12:13 p.m. revealed dietary staff served Resident #8 a carton of skim milk which the resident readily drank. 3. According to the MDS assessment dated [DATE], Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required limited assistance of 1 staff for transfers, walking, dressing, toilet use and personal hygiene. The resident had a BIMS score of 13, indicating intact memory and cognition. The resident utilized a walker to move about the facility. The resident required supervision during meals. The resident's Care Plan, updated on 12/1/21, informed staff the resident had a potential for unintended weight loss related to variable oral intakes and dysphasia. The Care Plan directed staff to supervise the resident during meals, follow safe swallowing techniques, monitor and record meal intakes, offer bed time snack daily, serve supplements as order and to provide her altered diet as prescribed by the physician. Review of the Meal Consumption report dated 12/17/21 - 1/4/22 revealed the staff failed to document meal consumption for 49 out of 60 meals and during 2 of those meals, the resident consumed less than 25% of her meals. Review of a Quarterly Dietary Note dated 12/1/21 revealed the resident's current weight at 136 pounds, down 3.4% in last 6 months. The resident received a pureed diet, had [CONDITION(S)] and her meal observations revealed poor overall dietary intakes. The Dietician noted the resident liked to receive her supplements with meals. Review of the Diet Type Report dated 12/15/21 indicated Resident #9 had a regular, pureed with regular consistency liquid diet. The diet order sheet did not indicate the resident received dietary supplements, with or without her meals. Observation on 12/27/21 at 11:27 a.m. revealed Resident #9 in her bed with night clothes on. Staff A entered the room and stated the resident had not been up yet today. When asked if she had been up this morning, Resident #9 stated no, no one helped her that morning. The resident denied having breakfast that morning when asked. Review of the resident's weight history revealed the following weight measurements: a. On 5/10/21 the resident weighed 140.8 pounds. b. On 6/28/21 the resident weighed 131 pounds c. On 7/29/21 the resident weighed 130 pounds. d. On 8/23/21 she weighed 129 pounds e. On 9/27/21 the resident weighed 127 pounds f. On 10/25/21 the resident weighed 133 pounds g. On 11/16/21 the resident weighed 136 pounds h. On 12/27/21 she weighed 136 pounds. Observation on 12/27/21 at 12:40 p.m. revealed Resident #9 sitting alone in the dining room. The resident consumed a container of vanilla pudding and drank a glass of thickened water independently, but the plate of pureed food in front of the resident was untouched. The dietary staff failed to serve the resident a supplement with this meal. During an interview with Staff G, Food Service Supervisor on 1/4/22 at 1:43 p.m. Staff G stated they do not have a solid method to tell if a resident came to the dining room for a meal. Staff G stated the nursing staff are responsible to fill out the dietary request slips but they are not consistently done. Dietary staff would know at the end of serving a meal, if the dietary slip remained, the resident did not show up for a meal, but stated again the dietary slips are not consistently completed. The facility had no real way to tell if a resident attended a meal. Staff G stated the nursing department is responsible to complete and document the resident's meal consumption for each meal. They are documented in Point Click Care electronic charting. During an interview with Staff I, Registered Dietician on 1/5/22 at 10:30 a.m. Staff I stated she was aware of the issues regarding Residents #4, #8 and #9 not getting down to breakfast the morning of 12/27/21. Staff I stated she is following all three of the residents for weight loss. Staff I stated the dietary department has system breakdowns and is working with the FSS and other dietary staff to put measures in place to assure the residents get to meals.

Based on observations, staff and resident interviews and clinical record review, the facility failed to ensure 1 of 4 sampled residents received nursing supervision while consuming an altered textured diet and failed to protect residents against hazards in the environment. Resident #4 returned from the hospital to the facility on [DATE] and was placed in isolation. Resident #4 was to receive a pureed diet and was to be supervised while eating due to the altered textured diet, a diagnosis of dysphagia and the need for cueing Resident #4 received a mechanically soft diet (wrong diet) and was not supervised during his breakfast meal on [DATE]. Resident #4 choked on the food given to him and required staff to administer the [MEDICATION(S)] maneuver to remove the food trapped in his airway. Resident #4 died the following morning less than 24 hours after the incident occurred. This situation constituted Immediate Jeopardy to resident health and safety. The facility identified a census of 116 residents. Findings include: 1. A Face Sheet titled Admission Record printed on [DATE] at 3:26 p.m., documented Resident #4's most recent hospital stay was [DATE] to [DATE]. It documented diagnoses included [CONDITION(S)] disorder, mild intellectual disabilities, mixed obsessional thoughts and acts, polydipsia (constant excessive drinking related to excessive thirst) and dysphagia (swallowing difficulties). Date of discharge was documented as [DATE] with mortician name and license number left blank. A care plan with a focus date of [DATE], directed staff that resident had a diagnosis of dysphagia. The resident was on a pureed diet with pudding thick consistency liquids. The goal was that Resident #4 would continue to remain free from aspiration with an intervention directing staff to follow diet recommendations. The care plan with a focus date of [DATE], directed staff that resident had a mental health disorder: [CONDITION(S)] disorder with a goal the resident was to remain free from major injury. An intervention directed staff to notify psychiatrist of any acute changes in behavior. A progress note dated [DATE] at 2:57 p.m., stated resident had a weight loss and a house supplement was added as well as antibiotic: [MEDICATION(S)] for possible aspiration and [MEDICATION(S)] for behaviors. A progress note dated [DATE] at 3:47 p.m., documented resident made himself fall over a mat and his mental status was definitely in question. A progress note dated [DATE] at 4:30 documented that IMPACT (geriatric care team) ordered that Resident #4 be sent to the hospital for altered mental status. In an interview on [DATE], the DON provided scanned documentation of papers that were sent with resident to the hospital on [DATE]. The papers included a Medication Review Report printed on [DATE] at 4:41 p.m., which documented Regular Diet Pureed Texture, Honey consistency. A Nutrition Note dated [DATE] at 10:09 a.m., documented by the hospital dietitian showed the resident's diet was mechanical soft ground meat with honey thick liquids. Dietitian visited with resident in his room. A sitter was at his bedside. A Nutrition Note dated [DATE] at 11:23 a.m., the hospital dietitian documented resident's diet was mechanical soft ground meat with honey thick liquids. Dietitian visited with resident in his room. A Patient Care Tech (PCT) was also present. The PCT reported the resident was on his 3rd meal tray already that day. In an interview on [DATE] at 1:08 p.m., the hospital dietitian stated she did not know for sure if resident had a sitter with him for all meals while he was at the hospital. She stated a Speech Therapist would have decided if a sitter was needed. The dietitian then stated it did not look like a speech therapist saw him at the hospital. The dietitian verified PCT meant Patient Care Technician. She said that if a resident has a sitter it would be ,d+[DATE]. A sitter could be there for various reasons. She did believe this resident did have a sitter with him. In an interview on [DATE] with the Director of Risk Management at the hospital verified that resident did have a sitter with him. She stated when the resident was initially admitted they monitored him per video. The next day on the [DATE] they started staffing a sitter. She reported this resident could become violent and he was agitated at times. They found it best to have someone with him. He had intellectual disabilities. He started seeking food at 5 in the morning. They ordered more food to the unit. They did not want him to leave and felt it best that they had someone with him ,d+[DATE]. A Discharge Diet communication from the discharging hospital dated [DATE], documented the resident's diet as regular mechanical soft and honey thick liquid diet. Progress note entries dated [DATE] documented the facility had entered orders. Progress note dated [DATE] at 4:58 a.m., documented this resident left his room several times during the shift. The nurse attempted to explain the purpose of isolation and COVID monitoring measures but the resident was unable to follow the teaching due to intellectual disabilities. A progress note dated [DATE] at 9:58 a.m., documented IMPACT was notified regarding resident's refusal to stay in his room and resident knocking trays and food off the tables in the hallway. An order for 1 mg [MEDICATION(S)] intramuscular (injection) was obtained. A progress note dated [DATE] at 7:52 p.m., documented the resident forgot he ate supper and lunch, and that resident is supposed to be on precautionary isolation but doesn't understand that he needs to stay in his room. A progress note dated [DATE] at 5:33 p.m., documented resident was still exit seeking and leaving his isolation room. A progress note dated [DATE] at 12:39 p.m., documented new orders received that included a Speech Therapist to evaluate resident and a pureed diet. A progress note dated [DATE] at 1:06 p.m., documented resident was compliant with isolation precautions only leaving room to come to the nurses' station a few times. A progress note dated [DATE] at 2:50 p.m., documented resident did not meet SNF (skilled nursing) and will be notified to change level of care to ICF (intermediate level of care). A progress note dated [DATE] at 8:25 a.m., documented LPN was called into resident's room to assess resident, resident was laying on back in bed with eyes open and breakfast tray in front of him. Resident was not able to respond when asked if he was okay. The LPN performed the [MEDICATION(S)] maneuver and resident started to spit food up. Resident then took a deep breath and started talking. The writer checked resident's mouth for any remaining food and encouraged to spit out any food on the floor which resident did. It was noted that resident was given a mechanical soft diet for breakfast instead of pureed, the tray was promptly removed. Primary care provider was notified of incident with no new orders. Kitchen was notified of diet error. Head of bed was placed at 90 degrees and resident was encouraged to sit up. A progress note dated [DATE] at 12:00 p.m., documented the nurse sat with writer during lunch for safety. A progress note dated [DATE] at 6:53 p.m., documented the resident ate 100% of his supper and staff monitored resident while he ate. When he was done he asked for some pie. Resident took medications crushed and in pudding without any difficulty. A Progress note dated [DATE] at 5:57 a.m., documented resident's family was notified the resident had passed away. Record review revealed there were no progress notes between the [DATE] at 6:53 p.m. entry and the [DATE] at 5:57 a.m. entries. A Progress note dated [DATE] at 6:00 a.m., documented the medical examiner was paged to discuss if case needed to be examined. An Incident Report dated [DATE] at 8:05 a.m., documented there were no witnesses of the [DATE] 8:25 choking incident and that the resident was unable to give a description. The notes on the Incident Report documented: 1. [DATE] Tray card system defaulted to previous diet. Has been updated and is accurate. 2. [DATE] Staff to be educated to be present if on an altered diet in isolation. 3. [DATE] will review all diets of residents that eat in their rooms will be done to ensure the residents on altered diets are eating in supervised setting or supervised by staff in lounge or dining room. 4. [DATE] dietary seating charts updated and staff notified for supervision of residents with altered diets. On [DATE] the Nursing Home Administrator (NHA) provided a copy of the 4 above interventions with handwritten notes. The notes documented that in Oaks and Elms there was no one on isolation with altered diet. ,d+[DATE] updated seating chart nurses' station and dining room. Willowwood- no changes. This resident was the only one in isolation with an altered diet. Informed immediate education to those present. Also on Nurse 24 hour report A Report Sheet dated [DATE] directed staff that resident is on a pureed diet, choked on breakfast this a.m., [MEDICATION(S)] performed, and directed staff resident needs supervision with meals and vital signs completed every shift for 72 hours. In an interview on [DATE] at 2:00 p.m., the NHA stated resident did not pass away from being served the wrong diet. The NHA said they investigated the incident and the dietary supervisor did not know that when she put his diet order in the system, it didn't save. The resident received a mechanical soft diet while at the hospital and when he returned he was placed on a mechanical soft diet on [DATE] per doctor's order. The NHA reported the diet was changed to a pureed diet with honey consistency on [DATE] per doctor's orders, and added the medical examiner declined to come to the facility and said it was a [CONDITION(S)]. In an interview on [DATE] at 2:10 p.m., the DON stated she talked with the county medical examiner (ME) and he said he didn't feel he needed to come and see the resident unless the medical director or family requested it. Family was notified and they declined further ME intervention. The DON added IMPACT was notified, and 2 ARNP's and 1 physician made the decision it was not necessary for the medical examiner to review. The DON reported the IMPACT team was aware of the choking episode per progress note on [DATE] at 10:02 a.m. and ordered vital signs for 72 hours. An undated email from IMPACT ARNP (Advanced Registered Nurse Practitioner) to the Director of Nursing (DON) documented the death certificate was completed by the ARNP and Cause of Death was Cardiorespiratory arrest. In an interview on [DATE] at 12:45 p.m., Staff A Licensed Practical Nurse (LPN), reported she had done the [MEDICATION(S)] on this resident that morning. It was at breakfast time and Staff B Certified Nurse Aide (CNA), told Staff A that this resident was choking. Staff A said she immediately noticed he was delivered the wrong diet. Staff A stated there might have been scrambled eggs and pancakes. Staff A knew that he was supposed to have pureed food. Staff A asked the Assistant Director of Nursing (ADON), to complete a respiratory assessment to confirm accuracy of Staff A's assessment. Staff A educated staff that residents on specialized diets should not be eating by themselves. She added the resident was on quarantine and his tray had already been delivered his tray. Staff A reported she observed the resident eating his pureed lunch and coached the resident to slow down as he was eating a little fast. Staff A stated the dietary staff do pass meal trays to residents in isolation and identified Staff D, Dietary Aide/CNA as the person who gave this resident the tray with the food that he choked on that morning. Staff A stated the ADON had a conversation with Staff D. Staff A reported the resident came back from the hospital on a mechanical soft diet and on [DATE] the order was changed to pureed. Staff A stated she was there the night of [DATE] and ensured he received the right diet. In an interview on [DATE] at 1:18 p.m., Staff B, CNA, stated they were passing trays the morning of the choking episode. Staff B stated Staff D thought the resident was choking. Staff B stepped into the resident's room and then grabbed Staff A; the resident had been laying on his back but Staff B did not know this resident very well. Staff B was making the trays and Staff D was delivering them. The resident's diet went from mechanical soft when he came to the unit to a pureed diet. Staff B reported the nursing and dietary staff got into it over what the resident's diet was. Staff B said if she remembers right, he received mechanical soft the first day he was on Willowwood. Staff B had not seen the resident's tray before it went into the room. Staff B reported residents with altered diets usually eat in the common area, but this resident was in isolation at that time. Staff B said that normally they leave the trays outside of the room for those residents that are on an altered diet and was unsure why the resident got his tray. Staff B's understanding is that somebody needed to be in the room with this resident while he ate his meal. Staff B said there is often miscommunication between dietary aides and nursing staff in general, for example taking trays into isolation rooms. Staff B reports she knows residents diet from slips or word of mouth. Usually slips are accurate on trays. Staff B said there is a verbal shift to shift report between CNA's. The ADON told staff after this incident to be with residents on altered diets in their rooms. Staff B mentioned another resident who they all knew prior to him going into isolation so knew he had to be supervised eating, but added Staff B was unfamiliar with this resident because he had resided in the Aspen (Intermediate Care) wing prior to returning from the hospital to Willowwood. In an interview on [DATE] at 1:50 p.m., Staff D Dietary Aide/CNA, had brought resident his tray that day. It was on the ticket as mechanical soft. One day he would get pureed and another day he would get mechanical soft. He was in isolation and it was the first time Staff B brought his tray. He was sitting on the edge of the bed and Staff D sat the tray on the tray table, left the room, and continued to pass trays. She was opening a milk for a resident who was across the hall from Resident #4, when she heard choking, so she went out into the hall, called out Resident #4's name and when he didn't answer she looked into his room. She say the resident laying on his bed and she went and got Staff B. Staff D stated that usually people in isolation are on Elms right. This resident was on a locked unit- Willowwood. Staff D said that residents that need supervision sit out in the dining room and usually would already be out there in the dining room so that's where she would deliver the trays. Staff D said the diets are on the tickets. Staff D had not received training on supervision with altered diets and said they don't tell us dietary aides which residents should be supervised and who isn't. Staff D went on to say that as a CNA you get told all that kind of stuff. This was the first time she had seen this resident and she did not know he was up there as she usually serves trays on Pine. In an interview on [DATE] at 2:02, Staff D stated the resident received scrambled eggs that morning with toast. She reported the diet was not altered at all. She believed he received some kind of cold cereal but did not remember what kind and could not remember what this resident had to drink. In an interview on [DATE] at 4:30 p.m., Staff U stated she sat with resident during supper the evening of the choking episode. Staff U stated resident did fine at supper and was up walking around. He did request pie but Staff U did not give it to him as he was on a pureed diet. Staff U does not recall if nursing staff sat with resident during mealtime in his room prior to the choking incident. In an interview on [DATE] at 11:00 a.m., Staff E, Licensed Practical Nurse (LPN), from Aspen (the ICF unit resident lived on prior to going to the hospital and returning to Willowwood SNF), stated they would have to remind this resident to slow down as he would shovel in food. Resident's diet was pureed with honey thick (liquids). Staff E stated if there was ample staff this resident would eat in the PT (physical therapy) area and would sit by the wall otherwise he would eat in the community room. The resident did not eat in his room. This resident would eat too fast and too much and would cough occasionally. Staff E was here the day that resident was sent to the hospital. Staff E stated this resident had always been on a pureed diet since the day he admitted to the facility. In an interview on [DATE] at 11:50 a.m., the DON stated this resident went to the hospital for increased behaviors. He was to be admitted to psych but they would not take him because he had a g-tube. She said his hemoglobin level was low so he was admitted and procedures were ordered, and then he returned to the facility in isolation. She verified the resident was at the hospital from [DATE] through [DATE]. In an interview on [DATE] at 11:55 a.m., the NHA stated this resident was so excited to come back to the PMI unit (Willowwood) as he had wanted to go to that unit all along. The NHA concurred the isolation was set up for the resident upon his return with a cart outside of his room. In an undated typed and signed statement, Staff F, Dietary Director stated this resident's diet was downgraded to pureed on [DATE]. Staff F had the assistant manager change the already printed tickets through Wednesday [DATE] and that a ticket must have gotten missed because the resident received pureed up until that day. Staff F had an email out to the company that provided the food to see if there was a time and date stamp of diets changed. In an interview on [DATE] at 11:30 a.m., Staff F, Dietary Manager stated on Friday the 25th of September she was off work and the ADON had emailed Staff F regarding a diet change for Resident #4. Staff F explained that she was off Friday and Monday so she had printed tickets through the next Wednesday on Thursday, the day before she had received the email from Staff C. Staff F reports she called Staff G, Dietary Director, (Staff F's assistant) who had quit during this survey, and told Staff G that this resident's diet was changed and to change the tickets. Staff F came in on Saturday [DATE], cooked breakfast, worked breakfast and lunch with no concerns brought to her Saturday, Sunday, Monday or Tuesday. Staff F cooked breakfast on Wednesday morning. Staff D told her that a resident had choked on his omelet. Staff F said she had made him a pureed tray. Staff F went in to her computer program to see if diet had been changed to mechanical soft. She noticed Staff G had not changed the diet in the system because the tickets were printed through Wednesday. Staff G would have handwritten on the tickets. Staff F stated she could have caught it after breakfast on that Wednesday because she would have printed off new tickets. Staff F stated she talked with Staff G about it and Staff G told her she had hand written pureed on all of his tickets. Staff F said when Resident #4 lived on Aspen he was always on a pureed, honey thick diet. This resident went to the hospital and they put him on mechanical soft. He returned to the facility on mechanical soft. Then the diet was downgraded to pureed on the 25th (of September). This resident had never been on Mechanical soft prior to that. He had always been pureed. All tickets said mechanical soft until Staff F reprinted after changing the diet in the system on that Wednesday. Staff F said that dietary staff do not serve trays to isolation rooms. Staff F stated she was not made aware that Staff D had even done that (brought tray to a resident in an isolation room). Staff F said in all fairness the only isolation rooms were in Elms prior to this resident going to Willowwood. Staff F said she knew this resident was in isolation because he had returned from the hospital. Staff F stated she had not changed the diet order in the system. In an interview on [DATE] at 11:07 a.m., the ADON, stated she came into the facility shortly after the choking incident had happened and was notified when she came to the unit that the [MEDICATION(S)] had been done. Staff A asked her to check Resident #4's lungs because she had done an assessment but was having difficulty with the resident moving around. The ADON listened to the resident's lungs, the resident did fine with lunch, and Staff C received no reports of any further concerns. The ADON stated after finding out about the diet, she had asked who had served him the tray, and then spoke with Staff F about the tray ticket. Staff F said she had changed it in the system but it hadn't saved correctly and Staff D served the resident a mechanically altered. The ADON told Staff D that if a resident has an altered diet you cannot leave a tray in a resident's room; anybody in isolation and on an altered diet had to have staff stay with them in the room. The ADON stated she educated staff on Willowwood and added there are seating charts for all units and she, the DON, Staff F, and another ADON had met after this incident and went over seating charts to make sure everyone was out of their rooms who had an altered diet. On [DATE] at 12:05 p.m., Staff C stated she had put up the isolation sign before Resident #4 came back from the hospital. Staff C set an isolation bin outside of room door and garbage and laundry bins inside of the room. The isolation sign went on the mantle of the door. Staff C reiterated that the resident had all isolation set up prior to him coming back from the hospital. The Isolation cart had gowns, gloves, goggles, and face shields. In an interview on [DATE] at 12:12 p.m., Staff H, Development Assistant (DA), stated he worked with this resident in Aspen prior to his hospitalization and verified the resident ate a pureed diet in the common PT area so staff could be present when he ate. Staff D added the resident drank honey consistency liquids and was on the same diet the whole time he was in Aspen. Staff H said he had no problems with the resident choking but staff had to remind him to take a drink in between bites. In an interview on [DATE] at 2:30 p.m., Staff G, Dietary Director, heard Staff F say that she (Staff F) could not believe that she (Staff F) did not change the slips on the day the resident choked. Staff G stated that when diets needed to be changed somebody would tell Staff F what the changes were and Staff F would update the computer. Staff G said the residents who came to the dining room already had COVID-19 and those who hadn't ate in their rooms. Staff G added she was the evening supervisor, did not deliver trays, and was never told to change diet slips for this resident. Staff G said Staff F never said anything about changing diet slips. When asked about Staff F calling her to ask her to change the slips, Staff G checked her phone and said she did not receive any calls from Staff F on [DATE]. Staff G has gotten an email before. Staff G, when asked if she received any communication either email, a phone call, etc., about changing the diet tickets for Resident #4, Staff G stated she did not. Staff G stated she did not change any slips, she did not cross out mechanical soft diet and did not write pureed on this resident's diet slips. An email correspondence dated [DATE], was initiated by the Speech Therapist at 12:01 p.m. and sent to the ADON and documented the resident came back from hospital with orders of an upgraded diet to mechanical soft diet. The Speech Therapist had called the hospital and there was no record of speech therapy. The Speech Therapist requested Staff C get an order to return resident to pureed with honey liquids. Staff C responded at 12:04 p.m. and forwarded on to Staff F asking Staff F to downgrade Resident #4's diet to pureed with honey thick. Staff C wrote that she had requested the order to be officially changed but for nursing judgement can change it now. Staff F responded at 1:24 p.m., OK. The mechanical soft made me (face emoji with a straight lined mouth). In an interview on [DATE] at 4:00 p.m., Staff F stated she had taken everything off of her phone and there was no way to show that she had called Staff G to ask her to change the order on diet tickets. When asked about her call history, Staff F stated, no, that it wouldn't be in there. Staff F said she remembers seeing tickets that had the changes written on them. Staff F said other dietary staff could verify. Staff F said Staff I would have worked some of the days during the time the tickets were changed. In an interview on [DATE] at 4:05 p.m., Staff I, FSW, stated she didn't remember this resident having changes on his ticket/slip but she sees hundreds of tickets each day. Staff I said she did not remember seeing anything scratched out or written on this resident's diet slips. Staff I verified that she worked some of the days between [DATE] to [DATE]. In an interview on [DATE] at 1:44 p.m., Staff J, Facility Contracted Dietitian, Staff J stated she would evaluate a resident returning from the hospital if she was requested to do so. Staff J stated she was unaware of an issue with Resident #4. Staff J works on Minimum Data Sheets (MDS) for residents. Staff J prints weight reports then she deals with concerns by faxing the ADONs to do follow up and added she had sent emails to Staff F when she would like to add pudding or something for an individual resident. Staff J reported a lot of information is communicated through emails and the nurses are responsible to obtain any doctor's orders. In a progress note dated [DATE] at 4:16 p.m., Staff J documented weight decrease for Resident #4. Due to pureed diet with honey thick liquid diet and fluid restriction, Staff J recommended trying a yogurt as am snack with no fruit pieces and a pudding as an afternoon snack to see if the snacks would satisfy his hunger and stop him from going to the kitchen to obtain food and see if his weight would then be maintained. Staff J faxed the doctor with this information and recommendation for adding 4 ounces of honey thick [NAME] twice a day to help stabilize his weight. In an interview on [DATE] at 9:54 a.m., Staff K Speech Therapist for facility, stated she had checked with the hospital after resident had returned from the hospital to see if resident had been seen by speech therapy there. Staff K stated whenever someone is on an altered diet they should have somebody with them during meals. Resident #4 had coughing and eating difficulties. He was unable to follow strategies due to Intellectual Disabilities and poor impulse control. Staff K stated if this resident was on anything other than a pureed diet then he would have been at risk for choking as his impulses could not be controlled and he required constant reminders. Staff K said the resident returned on the 24th (of September) and she did her evaluation on the 25th (of September). After changing a resident's diet, Staff K's expectation would be for staff to monitor a resident and to observe and report any difficulties. Staff K had seen Resident #4 previously so pureed texture wasn't a new diet but mechanical soft was. Based on prior knowledge of diet, Staff K changed him back to pureed diet stating he felt it was for his safety. An email dated [DATE] at 10:52 was provided by Staff K on [DATE]. The email went to Team Pillar and received by Staff K. It stated Resident #4 would be returning that day to Room 221 Willlowwood. Staff K stated she was alerted to the resident's return from the hospital by this email. In a Speech Therapy SLP evaluation and Plan of Treatment dated [DATE], Staff K documented her goal was to determine safest diet and clarify diet change upon re-admit. Potential for achieving rehab goals was documented as excellent with staff participation. Staff K documented that the current referral reason was Resident #4 resided at the facility and was placed in the hospital. Resident returned to this facility with orders for Speech Therapy to evaluate and treat as indicated. Resident left with orders for a pureed diet. Resident returned with orders for mechanical soft diet with no explanation of the change given. Staff K documented the prior treatment outcome was compensatory strategies to upgrade from pureed diet to mechanical soft diet was addressed. After multiple sessions, the resident was not able to independently use the strategies and was at risk for aspiration. The resident was discontinued on a diet of mechanical soft food. The prior level of function was documented as pureed consistencies, honey liquid thick liquids with minimum of close supervision. Under the Current Level of Function and Underlying Impairments, Staff K documented swallowing abilities was minimum of close supervision. Liquids assessed during evaluation were honey thick liquids and solids assessed during evaluation were mechanical soft textures and pureed consistencies. A mechanical soft assessment showed moderate clinical signs and symptoms of dysphagia as the resident had a wet voice and refused more than two bites. The swallow onset time was 4 seconds and the pureed assessment showed clinical signs and symptoms of dysphagia was resident filled his spoon with as much food as the spoon would hold. This resident ignored cues to take smaller bites and had minimal mastication (chewing). Swallow onset time was 3 seconds. Staff K documented her clinical impressions as: resident presented with confabulation, stating he had not had breakfast and wanted bacon and eggs. This resident presented with difficulty with mechanical soft food and showed no signs or symptoms of aspiration with pureed texture. The reason documented for therapy was skilled services for dysphagia were warranted to assess and determine least restrictive diet. Services were required due to the resident having difficulty learning new information. The risk factor for skilled intervention was that without skilled therapeutic intervention the resident was at risk for aspiration. Staff K documented recommendations as pureed consistency diet with honey thick liquids. Resident to have close supervision. The resident should be upright to eat and staff should cue resident to take small bites and swallow before taking another bite. Staff K documented that resident was unable to cooperate for further examination or consult related to this resident was unable to cooperate and the results would not change the clinical management of the patient. An undated list of diet orders revealed the following diet orders for Resident #4: [DATE] Regular diet Pureed texture, pudding consistency, discontinued [DATE] [DATE] Regular diet, Pureed texture, Honey consistency, discontinued [DATE] [DATE] House supplement, discontinued [DATE] [DATE] Regular diet, Mechanical Soft texture, Honey consistency, discontinued [DATE] [DATE] CCHO (Consistent Carbohydrate diet for diabetics) diet pureed texture with honey consistency, discontinued [DATE] A Doctor's Order dated [DATE], directed dietary to serve the resident a Regular diet with Mechanical Soft texture and Honey thickened fluids. Review of a physician's order dated [DATE] documented a CCHO diet with pureed texture and honey thickened fluids was ordered to start on [DATE] The situation detailed above resulted in Immediate Jeopardy (IJ) for the facility. The facility was notified of the Immediate Jeopardy on [DATE]. The facility abated the IJ Jeopardy situation on [DATE]. The scope and severity of the deficiency was lowered from a J to a D. The facility abated the IJ by developing, implementing, and educating staff regarding required nursing supervision of all residents in isolation on altered diets. The education included dietary staff. The facility informed them

Based on observation and staff interview the facility failed to assess bed side rails for the risk of entrapment to ensure gaps in side rails were not large enough for residents to be at risk of serious injury, impairment or death, placing the residents in immediate jeopardy for 26 of 83 resident beds observed. (Resident #84, #2, #82, #63, #20, #29, #11, #61, #7, #46, #13, #66, #80, #38, #37, #7, #24, #72, #47, #83, #28, #74, #58, #15, #36 & # 4) The facility census was 83. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed Safety Workgroup article, Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings dated (MONTH) 2003, indicated, in pertinent part, .Use of bed rails should be based on patients assessed medical needs and should be documented clearly and approved by the interdisciplinary team .Bed rail use for patients mobility and/or transferring, for example, turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan .Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment of patient needs, considering all relevant risk factors .If it is determined that bed rails are required .The mattress to bed rail interface should prevent an individual from falling between the mattress and bed. Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist items .should be ongoing According to the FDA's Guidance for Industry and FDA Staff article, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued [DATE], For [AGE] years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. FDA received approximately 691 entrapment reports over a period of [AGE] years from (MONTH) 1, 1985 to (MONTH) 1, 2006. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or footboards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings . A facility Bed Rail Policy revised [DATE], included the following section titled Overview of the U.S. Food and Drug Administration's (FDA) Potential Zones of Bed Entrapment: -Zone 1:Within the Rail-any open space between the perimeters of the rail can present a risk of head entrapment. FDA recommended space:less than 4 ,[DATE] inches. -Zone 2: Under the rail, between the rail supports or next to a single rail support-the gap under the rail between the mattress, may allow for dangerous head entrapment. FDA recommended space: less than 4 ,[DATE] inches. -Zone 3: Between the rail and the mattress-this area is the space between the inside surface of the bed rail and the mattress, and if too big can cause risk of head entrapment. FDA recommended space: less than 4 ,[DATE] inches. - Zone 4: Under the rail at the ends of the rail-a gap between the mattress and the lower most portion of the rail poses a risk of neck entrapment. FDA recommended space: less than 2 ,[DATE] inches. On [DATE] at 9:35 a.m., observation revealed the side rails on the bed in Room ,[DATE] appeared to be larger than 4 and ,[DATE] inches. At that time the surveyor asked the facility Director of Nursing (DON) if the facility assessed side rails for the risk of injury or entrapment. The facility Director of Nursing stated the facility maintenance department measured all side rails. At that time Staff I, Maintenance Director accompanied the surveyor to room ,[DATE]. Staff I then held out two small wood blocks (2 and 4) and stated the facility had used them to measure the distance from the mattress to the side rail, and the distance from the top of the mattress to the top of the side rail. Staff I stated the facility did not complete any other measurements to assess for side rail safety because they had not been aware they needed to measure anything else. Staff I then used a four inch wood block and measured the distance of the gap within the upper side (head) rail and found it to be eight inches by eight inches. Staff I stated there had been no resident assigned to the bed but verified a resident could be admitted and assigned to it. Upon completion of the observation the surveyor notified the facility DON of the findings. At 9:55 a.m., the facility Maintenance Director measured the following gaps within side rails on surveyor request: -room [ROOM NUMBER], Resident # ,[DATE] inches x 7 ,[DATE] inches, plastic side rail -room [ROOM NUMBER], Resident #2- 9 inches x 7 ,[DATE] inches, center metal rail -room [ROOM NUMBER], Resident #,[DATE] inches x 7 ,[DATE] inches, plastic rail -Room ,[DATE], Resident #63, 7 inches x 7 ,[DATE] inches -Room ,[DATE], Resident #20, 7 inches x 7 ,[DATE] inches -Room ,[DATE], Resident #29, 7 inches x 7 ,[DATE] inches, plastic rail -Room ,[DATE], Resident #11, 7 inches x 7 ,[DATE] inches, plastic rail -Room ,[DATE], Resident #61, 7 inches x 7 ,[DATE] inches, plastic rail At that time the facility Maintenance Director stated they had not been aware of the requirements for the measurement within the side rail. The surveyor informed the Maintenance Director the gaps had been an entrapment risk and they stated they had been in the process of correcting the issue and measuring all side rails. The facility Maintenance Director then measured the side rail in room [ROOM NUMBER], Resident #7 with gap in plastic rail of 7 inches x 7 ,[DATE] inches. (total of 9 beds/rails this observation) At 10:26 a.m., surveyors measured a gap between bars of the upper (head) side rail in room [ROOM NUMBER], Resident #82 and found it to be seven inches (top to bottom, inside of rail gap) by seven and one half inches (across, inside of rail gap). The surveyors head easily fit through the rail. At 10:39 a.m., observation revealed Resident # 2 in Room ,[DATE] to be lying in bed with an upper (head) side rail in the up position. One side of the bed had been against the wall and one side of the bed had the upper (head) rail up. (earlier measured at 9:55 a.m. observation with gap 9 inches x 7 ,[DATE] inches) At 11:02 a.m., surveyor observations revealed the following beds assigned to residents with side rails having greater than a 4 and ,[DATE] gap within the rail bars: -Resident #46, Room ,[DATE] -Resident #13, Room ,[DATE] -Resident #66, Room ,[DATE] -Resident # 80, Room ,[DATE] -Resident # 38, Room ,[DATE] -Resident #37, Room ,[DATE] -Resident #7, room [ROOM NUMBER] -Resident #24, room [ROOM NUMBER] -Resident # 72, Room ,[DATE] -Resident # 47, Room ,[DATE] -Resident #83, Room ,[DATE] -Resident # 28, Room ,[DATE] -Resident #74, Room ,[DATE] -Resident # 58, Room ,[DATE] -Resident #15, Room ,[DATE] -Resident # 36, room [ROOM NUMBER] -Resident # 21, room [ROOM NUMBER] (total of 26 rails) Staff E, Registered Nurse stated on [DATE] at 3:30 p.m., no side rail safety assessments had ever been completed by the nursing department in the facility for any resident with a side rail. The facility abated the Immediate Jeopardy on [DATE] at 3:30 p.m. by implementation of the following actions: -11:00 a.m., facility maintenance staff were re-trained and immediately began process of assessment of facility side rails to identify beds that did not meet regulatory standards. -Registered Nurse Unit Managers reviewed the resident's plan of care and the actual bed device usage and made lists of all residents who use devices attached to the beds on the 3 units. -Assistant Administrator, Provisional Director of Health Services and Provisional Administrator reviewed the lists and identified beds which were available to be utilized with the positioning devices. -12:30 p.m., side rails on beds that did not meet guidelines were disabled with a tie down device that is not able to be cut off for release per usual measures to ensure no risk for entrapment starting on the Oaks unit, completed as soon as the list complied to remove the opportunity of any resident entrapment risk. -Beds found to be within compliance standards were relocated to accommodate residents who were in need of an assistive device for spatial identity or a grip device for positioning aide. Side rails that were not used for this purpose were also disabled from use, using the tie down mechanism. Residents were not allowed to return to their bed until a safety check had been completed and relocation of a new bed if necessary. -12:50 p.m., Assistant Administrator and Provisional Director of Health Services went to Oaks unit to supervise bed relocation process. -1:55 p.m., Oaks unit bed relocation process complete. -Maintenance moved to Willow-Wood unit to complete bed relocation process. -2:05 p.m., Assistant Administrator to Oaks unit to complete final review of bed relocation. -2:30 p.m., informed surveyor team of plan of corrective action taken to address practice. -2:45 p.m., one-half of Willow-Wood unit completed. -3:30 p.m., Willow-Wood unit completed with final bed audit completed by Assistant Administrator. A review of positioning bed device will be completed on all residents that currently use a bed positioning device and will be completed quarterly or more frequently if condition warrants. Alternate devices for consideration may include wing mattresses for persons who benefit from a spatial identity device, and grip device to be used for positioning. Only devices that pass the measurement test will remain in service. On [DATE] at 8:07 a.m., Staff I verified the facility had also found a total of 26 occupied beds that were found to have greater than 4 ,[DATE] inch gaps within side rails. Staff I verified remedies were made to all beds during the abatement process on the previous day.

Based on observation, clinical record review and staff interview, the facility failed to identify the risk factors to prevent a pressure area from developing for which resulted in the resident acquiring an avoidable pressure ulcer while at the facility for 1 of 3 residents reviewed with pressure ulcers (Resident #10). The facility reported a census of 106 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool dated 7/6/17, for Resident #10, documented the resident with [DIAGNOSES REDACTED]. The MDS documented the resident with a Brief Interview for Mental Status score of 0, which identified the resident cognitively impaired. The assessment revealed the resident requires total dependence for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture), transfers, and personal hygiene. The MDS documented the resident with functional limitation in range of motion in both sides of lower extremity (hip, knee ankle, foot), and used a indwelling catheter. The assessment revealed the resident at risk for developing pressure ulcers and a pressure relieving devices were used. The Braden Scale completed 7/6/17, identified the resident with no sensory impairment, rarely moist, chairfast, slightly limited with mobility, potential problem with friction/shear and also at risk with a terminal condition. The Braden Scale documented a score of 17, for which indicated moderate risk and to implement Pressure Ulcer Prevention Protocol 1. The resident Care Plan with an original date of 4/21/17, identified a problem of at risk for developing pressure ulcers related to altered mobility related to end stage [MEDICAL CONDITION], cognitive impairment and fecal incontinence. Approaches directed staff to keep resident skin clean, dry and keep linens free of wrinkles. Staff would monitor the resident's skin integrity when providing care and with each shower/bath, turn and position frequently as resident allows. An alternating pressure reducing mattress and roho/mosaic chair cushion were used to ensure inflation standards are met. A Non-Pressure Skin Condition Report dated 7/22/17, documented right buttock, 1.8 centimeter by 1.6 centimeter red area with a 0.6 centimeter by 0.5 centimeter open area inside. A Non-Pressure Skin Condition Report dated 7/14/17, documented right exterior heel, 4.0 centimeters by 1.5 centimeters, bright red in surrounding skin color, no odor or drainage. A Weekly Pressure Injury Record dated 7/15/17, documented a Stage 1, (intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury) 2.5 centimeter by 2.5 centimeters to right lateral heel with wound bed defined as dark edge-center, white/soft, surrounding skin color as pink/intact. Response to treatment/comments documented to leave open to air and apply pressure reduction boots, and request Prevelon boots to be ordered. Preventive Measures/Progress: documented turn frequently, as resident tolerates, may use pillow pressure reduction boots, will request to order Prevelon boot on at all times. A Weekly Pressure Injury Record dated 7/21/17, documented the right lateral heel as unstageable, (full-thickness skin and tissue loss in which the extent of tissue damage with in the ulcer cannot be confirmed because it is obscured by slough or eschar). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed) measures 2.5 centimeters by 2.5 centimeters, wound bed as calloused border from 9 to 3 o'clock, wound flush with per tissue. Response to treatment/comments: site beginning to callous, flush with surround skin, intact. Heel firm to palpation. Preventive Measures/Progress: turn frequently as resident allows, cushion boots, pressure reduction overlay mattress, up one hour before/after meals. A Weekly Pressure Injury Record dated 7/26/17, documented the right later heel as unstageable, 1.0 centimeter by 0.5 centimeters, with the wound bed being intact callous, heel firm, color per race. Interview on 7/25/17 at 1:30 p.m., Staff C (registered Nurse) stated the pressure ulcer to the right heel of the resident is a non-stageable pressure area acquired at the facility due to staff failing to reposition the resident from side to side; and the Prevalon boots been applied to the resident right heel on 7/24/17, which needed to be placed on the heel upon initial assessment. The blue bunny boots that were on the resident's heel when the area was found had no padding to keep the heels floated. A prior MDS assessment reference dated 4/9/17, documented Resident #10 with a BIMS score of 0, requires extensive assistance with bed mobility, transfer, personal hygiene, has functional limitations on both sides of lower extremity. The MDS documented the resident at risk for developing pressure ulcers, and has one or more unhealed pressure ulcer at Stage 1 or higher. The MDS documented (1) Stage 2 ulcer present on 2/23/17, with the most severe tissue for any pressure ulcer being granulation tissue-pink or red tissue with shiny, moist, granular appearance, and pressure ulcer care and treatment. The prior Care Plan with an effective date of 11/10/16, documented on 2/2/17 red spot on right buttock, 2/10/17, open area lower left buttock. Interventions include to apply air mattress to bed, call light with in reach, provide rest periods throughout the day.

Based on record review, observation and staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazards and failed to transfer the resident with equipment when the resident could no longer bear weight (Resident #6). The sample consisted of 7 residents and the facility reported a census of 115 residents. The facility staff knew the resident ' s knees had buckled in the past and the resident would fall. The staff knew the resident would become weak after dialysis. The staff did not transfer the resident with safety equipment. The resident expressed pain and an x-ray in the emergency room determined the fracture to be the distal femur (thigh bone). Findings include: 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of 1/21/15. The MDS identified the resident had [DIAGNOSES REDACTED].), chronic kidney disease and osteoarthritis. According to the MDS, the resident depended upon staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The MDS reflected resident scored 15 out of 15 on the BIMS (Brief Interview for Mental Status). A score of 15 identified the resident with no cognitive impairment. The MDS identified the resident exhibited delusions. The MDS revealed the resident had impaired functional limited range of motion of both upper extremities and both lower extremities. The Plan of Care dated 2/4/15, identified the resident had a risk for injury due to poor mobility and arthritis. The listed interventions included: use wheelchair for all mobility, use Hoyer lift for transfers, may use assist of two and gait belt, side rails up while in bed and call light within reach at all times. . An Unusual Occurrence Report dated 12/19/14 at 6:00 p.m. reflected the staff transferred the resident from a wheelchair to a recliner with the assistance of two people and a gait belt. The resident did not bare weight, which caused the staff to lose their balance and fall backwards onto the floor and the resident fell on top of the staff member. The report identified during the transfer, the resident ' s knees buckled and the resident refused to bear weight. This caused the staff and resident to fall. The Care Plan intervention directed staff to make sure the resident stood and had weight bearing on both legs before assisting to the wheelchair. A Hospital Report dated 12/20/14 reflected the resident presented to the emergency room due to a fall. The resident fell while transferred between a wheelchair and another chair. The resident ' s legs buckled and the resident fell to the ground, and landed on the right knee. Since then the resident complained of continued pain to the right knee with mild swelling. The resident received dialysis routinely three times a week, Mondays, Wednesdays and Fridays. The Nurse's Notes dated 3/24/15 at 4:50 p.m. identified the staff called the nurse to the resident ' s room. The resident laid on the floor with the right foot lying flat on the floor. The C.N.A.s (certified nursing assistants) and resident all reported the resident fell off the toilet and all heard the resident ' s knee pop. The resident also had skin tears to the left arm. The nurse contacted the physician and received an order to send the resident to the hospital by ambulance. The Nurse ' s Notes (late entry) on 3/24/15 at 4:50 p.m. reflected the C.N.A.s reported to the nurse the resident to be a good 2 person transfer to the toilet. When ready to transfer back to the wheelchair, the nursing assistants put the gait belt on the resident and each nursing assistant on each side of the resident, assisted to a standing position. During the pivot, the resident ' s leg buckled and the nursing assistants heard a popping noise. The nursing assistants set the resident gently on the floor and called for the nurse. On 3/24/15 at 6:50 p.m. the hospital emergency room telephoned the facility and reported the resident had a fractured right knee. On 3/24/15 at 8:00 p.m. the hospital gave an update and stated the resident had fractured the right femur and not the knee. A Transfer Form completed by the nurse, Staff F, on 3/24/15 noted the reason for the transfer was because the resident fell off the toilet and the right knee popped. The nurse documented the ambulatory status as Hoyer lift, alert and confused. The form reflected the resident had 2 skin tears on the left forearm from the fall. A hospital radiology report dated 3/24/15 reflected the resident had a spiral fracture of the distal femur. emergency room note dated 3/24/15 indicated the resident arrived to the emergency room . The transfer record indicated the resident fell off the toilet. The facility staff reported the resident did not fall, he/she was lowered to the floor by the staff due to pain. The resident reported his/her leg started to hurt after the staff dropped him/her. When interviewed on 3/30/15 at 4:15 p.m. a staff agency nursing assistant, Staff G stated on 3/24/25 she assisted the resident on the toilet with the assistance of C.N.A., Staff H. Staff G stated her assignment sheet indicated the resident was assist of two/Hoyer transfer and that meant they could either use the Hoyer or the assistance of two persons. They placed the resident's wheelchair in front of the sink. They used a gait belt. They assisted the resident to stand with no problem, the resident turned around, they pulled the resident's pants and brief down and the resident sat down on the toilet. Staff H left the resident's room. Staff G left the bathroom and stayed in the resident's bedroom. After about five or seven minutes, Staff G called Staff h for assistance. Staff G stood on the resident's left side and Staff H stood on the resident's right side. They grabbed the gait belt and stood the resident up. Staff G let go with her right hand to assist the resident with perineal cleansing. The resident stated, "I don't think I can stand." and "I don't think I can do this." Staff G reported the resident was leaning forward and suddenly got very heavy. Staff G grabbed the gait belt and it slid up. Staff H stepped out of the bathroom. When they pivoted, the resident did not move his/her feet, the staff manually pivoted the resident. Staff G stated they needed to lay the resident down. The resident slid down the door casing, the door frame to the floor. Staff G heard a noise like knuckles cracking. Staff G had to step over the resident's legs. The resident stated, "Oh, my leg hurts." When the resident was on the floor the resident again complained of leg pain. Staff G obtained a Hoyer sling and Staff H went to get the Hoyer lift. The resident then complained the door frame was hurting his/her back. Staff G laid the Hoyer sling on the floor and asked the resident to lay on the sling. Staff G then pulled the resident on the sling. The resident lay on his/her side. Staff G pulled the resident so the resident then lay on his/her back. When interviewed on 3/30/15 at 3:45 p.m. the nurse, Staff F (nurse) stated the resident had been out of the facility that day and returned to the facility after the 2:00 p.m. change (start of next shift)/ Staff F knew the resident would be tired and instructed the staff not to lay the resident down (in bed) until after the evening meal. Staff F stated he was called to the resident's bedroom at which time he observed the resident on the bedroom floor. The resident laid on back. The resident stated his/her knee popped. Staff G also stated the resident's knee popped. The resident's pants and brief were just above the resident's knees. Staff F stated he documented in the Nurse's Progress Notes and on the hospital transfer sheet that the resident fell off the toilet due to it was his impression from what the staff informed him, that the resident had fallen off the toilet. After the resident left the facility he talked with both staff again about what had occurred. At that time he was informed the resident had not fallen from the toilet, they stood the resident up, his/her knees collapsed and they lowered the resident to the floor. Staff F stated he did not assess the resident as he could tell from the look of the resident's foot/leg that the resident needed to be sent to the hospital. The nurse asked the C.N.A. to check the resident's vitals. He also stated the resident had two skin tears on his/her forearm. The nurse asked the C.N.A. to wet a hand towel and wrap the skin tears with the wet towel. When interviewed on 3/31/15 at 3:00 p.m. a nursing assistant, Staff H, described the transfers for this resident were "iffy". Staff H stated if the resident went to dialysis that day, he/she would be zapped. The resident believed he/she would still do what he/she could do years ago. On 3/24/15 Staff G had taken the resident to the bathroom in his/her wheelchair. The wheelchair was positioned in front of the sink, next to the toilet. The resident stated to hurry up. She assisted to transfer the resident on the toilet and then left the room to care for another resident. When she returned, the resident had a bowel movement in the toilet. Staff H was on the side of the wheelchair and Staff G was next to the wall. As they stood the resident up, the gait belt slid. Staff H stated she knew it would be a miracle if they could get the resident to the wheelchair. Staff G did pericare when they stood the resident up. Staff H stated she knew right away the resident was unable to stand. The resident struggled to stand up. The resident did not move his/her feet. The resident was slumped over and they tried to get the resident in the wheelchair. They could not set the resident in the wheelchair due to the resident's bottom was lower than the wheelchair seat. The resident's knees buckled. The resident's knees had buckle so many times prior to this incident. Staff H stated he/she could transfer with assistance of two, however he/she could not stand/assist with the transfer and his/her knees would buckle. Staff H stated normally she used the Hoyer mechanical lift to transfer the resident. The resident did not like the Hoyer lift. Staff H stated again the resident's knees would buckle all the time. Staff H stated as the day went on the resident got weaker and more tired. Staff H stated the resident was a dialysis (removal of waste from the blood) resident so therefore one minute he/she would be up and the other minute he/she would be down/weak. Staff H stated the transfer did not go well. When interviewed on 3/31/15 at 9:45 a.m. Staff A stated on 3/24/15, she observed Staff F (nurse) come down the hall and she asked the nurse what was wrong. The nurse informed her the resident had fallen. Staff A went to the resident's room. The resident laid on the floor in the bedroom. Staff A reported the resident complained of leg pain. Staff A stated she removed the resident's shoes and the resident cried out in pain. Staff A also removed the resident's pants due to the pants were around the resident's knees. The resident remained on the floor until the ambulance attendants arrived. When interviewed on 3/31/15 at 10:00 a.m. the resident's family member stated he/she talked to the physician in the hospital and he/she saw the x-rays. The family member stated he/she observed the long fracture and the smaller crack. The physician stated the resident had a spiral fracture and the physician also stated he/she could not say how the fracture occurred. When interviewed on 3/31/15 at 8:45 a.m. the resident stated he/she was in severe pain. The resident complained of pain in his/her right leg and on his/her coccyx. The resident denied recall of the fall occurred. The resident stated he/she could not touch (eat) the breakfast meal due to his/her pain. When interviewed on 3/30/15 at 11:30 a.m. the Director of Nursing stated at the time of the resident's fall/fracture, the resident was planned to be either a two-person transfer or a Hoyer Lift transfer. The resident would make the decision on how the staff transferred him/her. The staff transferred the resident onto the toilet with the assistance of two persons and then when they went to transfer her off the toilet, the resident stated he/she could not do it, the staff then attempted to get the resident into the wheelchair and then onto the floor. The resident's leg gave out during the transfer and the gait belt slid up the resident's trunk during the transfer. The resident's legs would not move so they put the resident on the floor. The resident's Individual Program Plan included target behaviors and barriers to success included poor judgment skills. The resident received dialysis three days a week and was notably more impatient and sleepy following this procedure. The plan also addressed the resident's memory and confusion problems. The plan reflected the roles and responsibilities of the unit staff included all staff that worked with this resident would be specially trained to understand working with mentally ill individuals. The resident's plan of care identified the resident's [DIAGNOSES REDACTED]. A Hospital Procedure Report dated 3/25/15 indicated the resident's [DIAGNOSES REDACTED]. Review of the typed facility investigation report reflected on 3/24/15 at 4:50 p.m. two staff members assisted the resident to the toilet. The staff then stood the resident up from the toilet and completed the pivot transfer to the wheelchair when the resident's legs gave out and the heard a popping noise. The staff gently laid the resident on the floor. The staff notified the nurse of the event and the pain in the resident's right leg and the popping noise. The nurse noted the resident's right foot abnormally positioned to the side.

Based on record review and staff and resident interviews, the facility failed to perform a thorough assessment obtain timely medical services after one of six residents sampled for review, fell and sustained a new fracture. The facility staff failed to assess Resident #2 when the resident informed the staff he/she had fallen, had increased pain/discomfort, and sustained a fracture, which resulted in the resident ' s necessity to call 911 and seek emergency treatment for [REDACTED].#2). Findings include: 1. A Psychiatric Dx or Reason for Presence form (not dated) identified Resident #2 had [DIAGNOSES REDACTED]. A Hospital Encounter Note dated 4/2/13 identified active [DIAGNOSES REDACTED]. The physician noted the resident was seen for follow-up of the right plateau and plafond ORIF (open reduction internal fixation/surgical repair) and noted mild tenderness to palpation (feeling) of the malleoli (bony prominence on each side of the ankle) and pain with knee and ankle range of motion. A hospital consultation note dated 12/3/13 reflected the resident had a history of [REDACTED]. The resident presented to the emergency room with depression and suicidal thoughts/threats. The admission nursing physical assessment dated [DATE] reflected the resident was alert and oriented, reported chronic pain to the right lower leg, and wore a brace to the right leg since the surgery in January of 2013. A Minimum Data Set (MDS) assessment, with the reference date of 9/11/14 noted the resident scored 15 out of 15 in the cognitive test (no cognitive impairment), exhibited no behaviors which included rejection of care, and required no assistance or supervision for transfers, walking, eating and toilet use. The MDS also reflected the resident experienced occasional moderate pain. The Plan of Care conducted on 9/11/14 indicated the resident's problems included altered health maintenance related to previous lifestyle and mental illness, risk of injury related to an unsteady gait and injured right leg with immobilizer use, skin impairment related to poor mobility and a history of [MEDICAL CONDITION], diversional activity deficit due to depression, anxiety and adjustment disorder, and nutritional risk due to adjustment disorder with depressed mood and type one diabetes. The interventions on the Plan Of Care included and directed the staff to validate feelings and provide realistic solutions to concerns, encourage problem solving, encourage to be independent with all cares, wheelchair use for appointments, encourage to use walker for all activities on the unit, record meal intakes daily, and monitor for signs and symptoms of hypo/[MEDICAL CONDITION]. A physician's orders [REDACTED]. Facsimile (fax) reports found in the resident's clinical record included: On 8/20/14 and documented at 3:45 p.m., the resident complained of weakness and the blood sugar tested 47 (low). Glucose gel (simple sugar) given along with milk and a sandwich. A recheck of the blood sugar tested 56. The supper insulin was held. After supper, the blood sugar tested 76. The fax report reflected the facility sent this fax to the physician's office on 8/21/14 at 2:31 p.m. (normal blood sugar reading are 70-110) On 8/26/14 and documented at 3:55 p.m., the blood sugar tested 37. The resident received orange juice and a peanut butter and jelly sandwich. A recheck blood sugar tested at 161. The fax report reflected the facility sent this fax to the physician's office on 8/27/14 at 5:43 a.m. On 9/8/14 at 5:40 p.m. the Nurse ' s Notes reflected the resident complained of weakness and dizziness before the evening meal. The resident voiced being very agitated. The blood sugar tested 40. The resident was given 8 ounces of grape juice and two large cookies. A meal tray was ordered to the unit. The resident ate 100% of the meal. A recheck blood sugar registered at 204. The resident only wanted 10 units of Humalog. The fax report reflected the facility sent this fax to the physician's office on 9/9/14 at 6:19 a.m. On 9/23/14 the facility staff faxed [MEDICATION NAME] (Sugar) Flow Sheet for September 2014 included readings as: 9/8/14 at supper time: 40 9/11/14 at supper time: 41 9/23/14 at bedtime: 48 9/24/14 at supper time: 31 The Nurse's Notes dated 9/8/14, reflected the nurse sent a condition report to the physician. On 9/9/14 at 5:15 p.m. the nurse received a return fax from the physician with a new order. Review of the clinical record revealed the nurse did not document the low blood sugar and assessment of Resident #2 on 9/11/14 (when blood sugar at bedtime was 41). Review of the record also reflected the nurse did not inform the physician of this low blood sugar either by phone or fax. The Nurse's Notes revealed on 9/23/14 at 9:35 p.m. the blood sugar at 8:15 p.m. registered 48. A fax was sent questioning any new orders. The Nurse's Notes dated 9/29/14 at 1:55 a.m. directed staff to see the Unusual Occurrence Report. The blood sugar registered 43, at 2:18 a.m. and [MEDICATION NAME] Gel and a sandwich was given to the resident. The notes reflected no documentation the nurse called the physician to report the low blood sugar as ordered. The MAR (Medication Administration Report) reflected on 9/29/14 at 3:45 a.m. the nurse gave the resident Tylenol ([MEDICATION NAME]) due to the resident reported right leg pain. The resident rated the pain at eight out of ten in severity. Review of the September MAR indicated [REDACTED]. An Unusual Occurrence Report dated 9/29/14 at 1:55 a.m. noted the resident used the call light. Staff found the resident on the floor next to the bed. The resident reported he/she was half asleep and was going to walk to the bathroom and slid down on butt due to shoes were not on right (correctly). The resident ' s wraps were in place on the lower legs. The resident ' s blood sugar registered 43. The eight hour follow up reflected the resident up per usual with a walker and without noted injury. The sixteen hour follow up reflected the nurse received a call from the 911 dispatch who reported the resident called 911 and reported he/she fell and broke his/her knee. The nurse informed the 911 dispatch the resident did not fall, the resident slid from the bed. The 911 dispatch informed the nurse an ambulance has to be sent. The report reflected the incident was unwitnessed and the resident had acute pain. The resident attempted to get to the toilet. Prior to the incident, the resident was walking and the walker was being used. An emergency report dated 9/29/14 revealed the resident reported he/she injured the right knee in the night after sustaining a fall. At the time discovered the blood sugar registered low. Blood sugar on arrival, after two tubes of oral glucose tested 49. The resident complained of right knee pain. The resident reported he/she was walking to the bathroom at 3:00 a.m. when his/her right foot slipped, and fell on to the right knee. The resident reported he/she was in a lot of pain and could not walk on it well. The resident reported he/she was a diabetic and did not eat due to the facility staff would not give him/her a wheelchair to go to lunch, so he/she did not eat and his/her blood sugar dropped. The resident's blood sugar registered 41 in the emergency room . EMS (emergency medical services) gave the patient two glucose tablets prior to arrival. The physical examination revealed tenderness and swelling of the resident knee. The physician documented a fibula fracture and [DIAGNOSES REDACTED]. Staff A telephoned the hospital. The hospital staff informed Staff A of the resident's condition at which time Staff A informed the hospital staff the resident had not fallen. The hospital staff informed Staff A of the resident's new fracture status. A Physician's Consultation form dated 10/2/14 identified a new [MEDICAL CONDITION] fibula with ecchymosis (bruising). The physician ordered no walker and [MEDICATION NAME] (narcotic) for pain. On 10/20/14 at 1:22 p.m. the Director of Nursing (DON) was interviewed and stated she was on vacation at the time of this incident. The DON stated she returned to work on 9/30/14. The Assistant Director of Nursing (ADON) sent the DON a text message on 9/29/14. The ADON informed the DON Resident #2 had fallen and the ADON would obtain staff statements. The DON reviewed the documentation on 9/30/14. The DON received a telephone call from hospital staff who informed her of their concerns regarding this resident's fall with fracture, low blood sugar with a missed meal. The DON instructed Staff B (licensed practical nurse) to document the events on her shift for 9/29/14. The DON stated the staff informed her they encouraged the resident to walk to the noon meal and the DON believed the staff served the resident the noon meal on the unit. The DON stated their policy was to encourage residents to eat the meals in the main dining room, and if the resident was unable to go to the dining room, staff would order a room tray and serve the resident on the unit. The DON stated her expectation for any unusual occurrence was for the nursing staff to complete follow up assessments, check for changes in range of motion and any complaints of pain. Review of 3 separate meal intake records with 3 separate persons documenting all on the noon meal of 9/29/14 revealed the resident did not receive or consume the noon meal. One staff member documented the resident was already in the hospital. One staff member documented refusal of the meal and one staff member failed to document for that meal. When interviewed on 10/20/14 at 2:45 p.m. the ADON stated she recalled being on this resident's unit on 9/29/14. The ADON stated she reviewed the incident report that morning during the department head meeting. She recalled the resident had multiple complaints. Although the ADON talked to the resident that day, she felt she should not bring up the incident or ask the resident how he/she felt. The ADON stated it was important for the resident to eat his/her meals and snacks as planned so his/her blood sugars would not drop during the night. The ADON stated any other time this resident had mass complaints and the ADON did not want to be confrontational with the resident. The ADON stated she could not recall what she said to the resident that day; however the ADON believed the resident probably had a complaint of some sort. The ADON stated when the resident went to the emergency room ; the resident informed the hospital staff he/she was denied his/her noon meal. The resident also reported being in excruciating pain and no one at the nursing home would help him/her. The ADON reported her expectation of the 8-hour follow up on the incident report would be for the nurse to assess the resident for any signs of injury such as a bruise, complaints of pain, she would also expect the nurse to document the resident's assessment of pain, any visual signs of pain, range of motion assessment, and if the resident complained of pain, was the pain chronic or new. The ADON denied performing any assessment of the resident on 9/29/14. On 10/20/14 at 3:20 p.m. Staff F (second floor registered nurse (RN) supervisor), was interviewed and stated on 9/29/14 she was covering the resident's unit. Her duties included assisting and sending residents out to the hospital and skin assessments. She came to work that morning. She knew this resident had fallen. Staff F denied talking to the resident that day. Later in the day, the paramedics arrived at the facility due to the resident called 911 and reported he/she had fallen and broke his/her leg. Staff F read the nursing 24 hour report and the incident report that morning. Staff F denied performing an assessment of the resident. Staff F stated she expected the eight hour incident report follow up assessment to include mobility, weight bearing ability and any pain. She also expected if the resident expressed pain for the nurse to have the resident rate the pain. She also expected the nurse to document a visual assessment of the area of pain. Staff F reported being dumb founded when the EMS showed up. Staff F denied having contact with the resident. On 10/20/14 at 2:06 p.m. Staff B (licensed practical nurse (LPN) was interviewed and stated she was informed during the shift change on 9/29/14 at 6:00 a.m. Staff B stated she was informed the resident slid off the edge of the bed onto his/her butt. Staff B stated she was also informed the resident complained of pain in the right knee. Staff B then saw the resident at approximately 7:00 a.m. in his/her bedroom. The resident told the LPN he/she fell by the bathroom and fell on his/her knee. The resident informed the nurse he/she did not know if he/she could go to the breakfast meal due to the pain in his/her knee. Staff B observed the resident's right knee. The nurse noted a non-tender, slightly raised, pink area by the knee. The nurse did not believe this was anything of concern. She denied documenting her assessment of the resident's knee. The nurse denied assessing range of motion of the resident's knee and denied performing a thorough assessment of the resident, including vital signs (blood pressure, heart rate, respirations). The nurse encouraged the resident to go downstairs to the dining room for breakfast. Staff B stated she did not believe the resident when the resident informed her of falling on his/her right knee and falling by the bathroom due to the resident's history of many untruths. The resident did go to the breakfast meal. Staff B stated about lunch time the resident was sitting in the unit lounge. The resident informed the nurse; he/she could not get up and walk to the noon meal. The nurse encouraged the resident to walk to the first floor for the noon meal. The resident informed the nurse of his/her pain in the knee. The nurse denied assessing the resident at that time. At this time, the resident was the only resident on the unit due to all other residents were in the main dining room on the first floor. When interviewed for a second time, on 10/20/14 at 11:50 a.m. Staff B stated in the past when the resident refused to go to the first floor dining room, the nurse would remind the resident he/she was a diabetic. On 9/29/14 Staff B gave the resident his/her insulin injection prior to noon. The resident informed her of his/her increased pain around the knee. The resident refused pain medication. The resident made it clear, he/she was not going to get up and go to the noon meal. The nurse denied offering to walk with the resident to the meal due to the nurse was busy documenting flu shot vaccinations given that morning. Staff B reported all nursing assistants (CNA) were on the first floor assisting with the noon meal service. When asked if Staff B would do anything different, Staff B stated she probably would call a CNA up from the dining room, however Staff B stated she knew the kind of person this resident was. Staff B stated the resident informed her, that he/she broke his/her leg. Staff B stated her assessment of the resident that day was the resident was up as usual with walker without noted injury. The nurse denied removing the resident's leg wraps that morning to assess the resident's leg due to the resident informed her it was his/her knee that hurt. Staff B stated she was informed in report the resident complained of pain in his/her knee. The nurse denied asking the resident to rate or describe the pain. The nurse reported the resident complained frequently of not being able to walk to meals when he/she first came to their unit. The nurse stated there was always something the resident could not do. The nurse stated she believed the resident's knee looked different that morning. Staff B denied ordering the resident a room/unit tray on 9/29/14 at the noon meal. Staff B stated she knew of the resident's recent drops in blood sugar and denied checking the resident's blood sugar after giving the resident insulin. The nurse also denied assessing the resident or talking to the resident in the afternoon on 9/29/14. The facility Insulin Administration policy/procedure (not dated) identified complications to guard against hypoglycemic reactions and diabetic acidosis. The policy reflected one cause of hypoglycemic reactions as too little food. When interviewed on 10/23/14 at 4:15 p.m. a second shift LPN, Staff A stated she reported to duty on 9/29/14 at 2:00 p.m. During shift change report, Staff B informed her the resident's blood sugar was low during the night and slid off the bed. Staff B also informed Staff A the resident complained of pain. Staff A observed the resident sitting in the unit lobby. Staff A reported being busy that day. Staff A reported the resident was upset and hollering that he/she needed to go to the hospital. The resident continued to say his/her leg was broken. The resident was complaining of pain. Staff A denied assessing the resident. The resident was very adamant he/she had fractured his/her knee. The resident informed the nurse he/she had fallen. Staff A received a telephone call from the 911 dispatch who informed her the resident had called 911. Staff A informed the 911 dispatch that the resident had not fallen. Staff A reported she did not believe anything was wrong with the resident. Staff A believed the resident was having a bad day. Staff A also stated on 9/29/14 the resident was over the top, he/she was not his/her normal self. Staff A reported she believed the resident called 911 as an attention seeking behavior. When the resident continued to call out that his/her knee was broken, the nurse believed it was attention seeking behavior. When interviewed on 10/22/14 at 11:30 a.m. a certified medication aide, (CMA), Staff C stated she worked as a medication aide on this resident's unit during the day shift on 9/29/14. During the shift change report at approximately 6:00 a.m. she was informed the resident had slid on his/her bottom. Staff C stated the resident had a history of [REDACTED]. Staff C denied knowing if the resident ate the breakfast or noon meal that day. Staff C reported the resident normally ate 100% of all meals. On 9/29/14 the resident complained of his/her leg. The resident was doing a lot of whining to everyone. The resident was basically telling everyone that he/she was in pain and could not walk and he/she had a fracture. Staff C reported the facility's standard of practice was only the LPN could request a room/unit meal tray for a resident. Staff C stated the whole day, the resident was whining he/she was in pain. The resident was saying above his/her knee was hurting. Staff C stated this was new for the resident to complain of pain above the knee. The resident was really persistent to tell everyone he/she was in pain. The resident was telling all the other resident's his/her leg was broken. The other residents were sympathetic to him/her and the other residents were turning on the staff due to they were not doing their job. The resident was talking loud enough so everyone could hear him/her that his/her leg was broken. Staff was informing the resident that the nurse was taking care of it. The medication aide, Staff C did not give this resident any pain medication that day. The resident informed Staff C he/she fell during the night. Staff C estimated the resident's pain level on 9/29/14 at a 7 or a 6 on a scale on one to ten with ten being the most severe. Staff C reported on a normal day, he/she did not say much about pain, something was different that day. Staff C stated normally she would check a resident's MAR (medication administration record) to see if the resident had an order for [REDACTED]. When interviewed on 10/21/14 at 1:47 p.m. a certified nursing assistant (CNA), Staff D stated on 9/29/14 she was informed in report the resident slid off the bed. On 9/29/14 the resident walked with a walker and dragged his/her right leg. Staff D stated the resident always drug the right leg. Staff D stated when residents report pain and/or discomfort to her; she would report the alleged pain to the nurse. Staff D stated this resident had his/her own wheelchair which the facility stored due to the resident was to walk with the use of a walker. On 9/29/14 the resident made it very clear he/she was not going to the dining room for the noon meal. Staff D stated the resident was a constant complainer. Staff D observed the resident sitting in the unit lobby when she left the unit to assist with the noon meal, and when she returned after the noon meal service. When she left for the day at 2:00 p.m. the resident was still sitting in the unit lounge. Staff D stated the resident was a hypochondriac. Staff D stated she had never know the resident to not get up and go to a meal. Staff D stated that if a resident is sick or something is wrong, if they eat the breakfast meal and refuse lunch, they can skip one meal. The CNAs do not order unit trays. Staff D stated normally this resident would eat everything. Staff D reported examples of this resident's complaints in the past included the resident reported vomiting when in reality the resident spit, or the resident would report diarrhea when staff never observed any loose stools. When interviewed on 10/21/14 at 1:07 p.m. a CNA, Staff E stated she did not recall if the resident complained of pain on 9/29/14 due to the resident often complained of leg pain due to [MEDICAL CONDITION]. The resident normally walked with a stiff gait. The resident was very cautious. Normally the resident would go the first floor dining room for all meals. The resident was normally one of the last residents to go to the noon meal service due to the resident would wait for the nurse to check his/her blood sugar. Normally the resident would go to the dining room sometime between 11:45 a.m. and 12:05 p.m. If a resident failed to go to the dining room the nurse would order a room/unit tray. Staff E never knew the resident to skip a meal. Staff E stated in the past the resident would complain of pain in his/her leg; however he/she never complained of it being broken. Staff E thought the resident was lonely and wanted someone with him/her. On 10/22/14 at 8:10 a.m. Resident #2 was interviewed and stated he/she hurt his/her right leg about a year and a half ago and had surgeries on the leg. He/she stated he/she had pain in the leg ever since. He/she stated recently he/she woke up in the night and needed to use the bathroom and fell while walking to the bathroom. The resident stated was half asleep and landed on the right knee. Resident #2 stated he/she knew right away had hurt the knee. His/her right leg normally hurt, however this was different. This was sharp pain. The resident told the night nurse about the pain, the nurse gave him/her Tylenol which did nothing for the pain. He/she then told the morning nurse, Staff B that he/she had fallen on his/her knee during the night and thought it was broken. Staff B ignored him/her. He/she also informed the girl that passed out medications about the pain. The staff ignored his/her statements of pain. He/she told the staff he/she could not walk to the noon meal. When Staff B gave him/her the noon insulin, he/she told Staff B he/she could not walk due to the knee pain; however Staff B ignored him/her. The resident then just sat in the lobby. The pain got worse as the day went on and he/ knew he/she could not walk to the noon meal. No one would help him/her. No one brought him/her the noon meal or offered him/her his/her wheelchair to go to the dining room. Finally when he/she could not take the pain any longer and he/she called 911 and informed the 911 operator of the fall during the night and broke his/her knee. The resident also informed the 911 operator he/she was a diabetic, had received the noon insulin and the staff refused to bring him/her the noon meal and he/she felt his/her blood sugar was low. The ambulance arrived. He/she told the hospital staff that he/she had fallen and broke his/her knee and missed his/her noon meal due to the staff refused to help him/her and felt his/her blood sugar was low. The resident stated his/her knee was broken and his/her blood sugar was low.

Based on record review and staff interviews and review of facility elopement policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from self (Resident #4, #5). The facility utilized alarms to alert staff when Resident #4 would attempt to ambulate so staff could attend to the resident. The staff could not hear the activated alarms. Resident #4 fell and fractured a hip while attempting to self- transfer. Resident #5 made repeated attempts to elope from the facility and staff did not implement interventions to prevent the resident from eloping. The facility reported a census of 120 residents and the sample consisted of 6 residents. Findings include: 1. Resident#4 had a Minimum Data Set (MDS) assessment, with a reference date of [DATE], which identified [DIAGNOSES REDACTED]. The MDS reported the resident required extensive assistance with bed mobility, transfers, walking, eating, dressing, toilet use and personal hygiene. The MDS reflected the resident had impaired balance during transfers and walking and was described as not steady and only able to stabilize self with staff assistance. According to the Brief Interview for Mental Status (BIMS) cognitive test, Resident #4 scored 10 of 15 which identified moderate cognitive impairment. The MDS reflected the resident had disorganized thinking and inattention, delirium and delusional behaviors. An Advanced Registered Nurse Practitioner (ARNP) progress note dated [DATE] identified the resident as very weak and had experienced frequent falls. An ARNP progress note dated [DATE] reported the resident's condition rapidly deteriorated due to cancer. The resident's Plan Of Care identified problems as early as [DATE] and updated by staff on [DATE]. The following problems were: a. Health maintenance related to mental illness, risk for injury due to cognitive/judgment deficits and medications, b. Altered thought processes due to schizoaffective disorder/schizophrenia, c. Nutritional risk due to psychotic disorder, schizophrenia, hypertension and osteoporosis, d. Risk for pain due to cancer. The Plan Of Care identified the facility had a goal that the resident would have no injuries from falls that required emergency room visit or hospitalization . The interventions for the fall risk problem directed the staff to assess the home for safety hazards, accompany resident when out of unit/home, check floor for wet spots, rise slowly to prevent dizziness, side rails up if resident desired, place call light within reach and bed in low/locked position. An intervention added to the Plan Of Care on [DATE], noted for staff to encourage to ask for assistance when feeling weak. An intervention added [DATE] noted weakness especially when smoking, monitor wrist for increased swelling and redness. An intervention added [DATE] noted the use of a personal alarm when in bed and chair. An intervention added on [DATE] noted the use of a pressure alarm on a high/low bed and a mat on the floor. The Unusual Occurrence report identified the following falls: An Unusual Occurrence Report (incident report) dated [DATE] reflected the resident fell at 4:50 p.m. when he/she lost their balance and fell . The staff documented on this report a new intervention for staff to follow. The intervention directed the staff to walk with the resident, with the use of a gait belt to ensure the resident's gait was steady. An Unusual Occurrence Report dated [DATE] reflected the staff found the resident on the floor at 9:40 p.m. The report revealed the staff sent Resident #4 to the emergency room due to right shoulder pain and the right side of face swollen. The report noted the staff applied an alarm to the resident's bed after the resident returned from the emergency room . An Unusual Occurrence Report dated [DATE] reflected the staff found the resident on the floor at 4:15 a.m. The staff documented the resident had removed the body alarm prior to the fall. Staff applied a new pressure alarm to the resident's bed. An Unusual Occurrence Report dated [DATE] at 3:00 p.m. reflected the staff observed the resident up in his/her bedroom with a walker and fell to the floor. The resident informed the staff he/she was on his/her way to breakfast. Review of the Unusual Occurrence Report and Plan of Care revealed a lack of a new intervention at the time of this fall. An Unusual Occurrence Report dated [DATE] at 11:00 a.m. staff observed the resident stand up from his/her wheelchair, stumbled backwards and fell to the floor. The resident struck the back of his/her head and fell to his/her left side. Review of the Unusual Occurrence Report and Plan of Care revealed a lack of a new intervention at the time of this fall. An Unusual Occurrence Report dated [DATE] noted an unwitnessed fall at 4:45 p.m. Review of the Unusual Occurrence Report and Plan of Care revealed a lack of new interventions at the time of this fall. An Unusual Occurrence Report dated [DATE] at 4:35 a.m. noted staff found the resident on the floor in the bedroom doorway. The resident reported the need to use the bathroom. Staff noted an alarm on, however the alarm only beeped once when touched. The staff changed the battery to the alarm without an improvement noted. Staff then applied a pull tab alarm. Review of the Unusual Occurrence Report and Plan of Care revealed a lack of new interventions at the time of this fall. An Unusual Occurrence Report dated [DATE] at 3:00 p.m. noted staff found the resident on the bedroom floor. The resident reported a broken hip. Both alarms (bed and pull) were sounding. Staff notified the physician and sent the resident to the emergency room . The Nurse ' s Notes dated [DATE] at 2:45 p.m. reflected the nurse was called to the resident ' s room and found the resident lying on right side. The alarms both sounded. The resident voiced the hip was broken (fractured). The nurse contacted the ambulance, which transported the resident to the hospital. The Nurse ' s Notes dated [DATE] at 6:00 p.m. reflected the resident was admitted into the hospital and a waiting surgery (for repair) of right hip. The hospital notes dated [DATE] reflected the x-ray identified a fracture through the right femoral neck (hip) and extending into the intratrochanteric region with some superior and lateral angulation present. Review of a written statement by Staff I (certified nursing assistant) reflected on [DATE] at 2:30 p.m. another resident alerted her to an alarm sounding from Resident#4 ' s bedroom. When interviewed on [DATE] at 3:20 p.m. Staff I reported when Resident #4 lived on Pine hall, the resident's roommate would run down the hall and alert staff when the resident was getting up unassisted. Staff I stated she could not hear the resident's alarm sound while working with residents living in Pine hall. Staff I reported typically the resident was trying to use the bathroom or go to a meal when he/she would fall. Staff I reported when she observed the resident sitting up in bed, she would assist the resident to the bathroom. On [DATE], another resident informed Staff I of Resident #4's alarm was sounding and the resident was attempting to get up (unassisted). Staff I stated she had not heard the alarm sound. Staff I then went to the resident's bedroom where she found the resident on the floor, against the bathroom door. On [DATE] at 2:53 p.m. Staff G (licensed practical nurse), was interviewed and stated Resident #4 was independently ambulatory when admitted to the facility. Staff G noted a physical decline which exacerbated approximately the end of June of 2014. Staff G stated he also observed the resident's increase in confusion. The resident did not always follow instructions however the resident's roommate would watch out for Resident #4. The alarms were ineffective for preventing the resident from attempting to transfer and/or walk independently. The resident would not use the call light and would not ask for assistance. The roommate would often come to the staff and report when the resident would get up unassisted. The roommate was really good to come and get the staff when the resident needed something. The roommate then discharged from the facility. Shortly after the roommate discharged to another facility, the staff moved the resident to a private room. Prior to moving to the private room, the resident would remove his/her alarms. On [DATE], shortly after receiving the change of shift report, a C.N.A. came to him and informed him the resident had fallen in his/her bedroom. He went to the resident's room where he observed the resident lying on the floor by the bathroom door. He observed urine on the floor. He began to assess the resident when he/she yelled out in pain and reported he/she broke his/her hip. Staff G reported the nurses check for alarm placement. He reported the nurses did not check the alarms to ensure they (the alarms) worked properly. A Summary of Investigation (not dated) and signed by the Director of Nursing, reflected on admission that the resident was self- ambulatory with focus on mental health management. The resident demonstrated an aggressive progressive decline in functional status since July of 2014. The resident returned to the facility and comfort cares were administered per the facility, Hospice and the ARNP. The resident expired on [DATE] at 2:00 a.m. The medical cause of death was identified as respiratory failure due to a consequence of metastatic [DIAGNOSES REDACTED]. On [DATE] at 2:50 p.m. Staff H (registered nurse) was interviewed and stated when the resident began to have falls, they applied alarms, and however, the staff could not hear the alarms sound due to the resident's bedroom location. The resident moved to a private room on [DATE]. Staff H denied assessing the resident and/or the resident's falls for root cause analysis (to determine the cause of the falls). Staff H stated after each fall she would attempt to implement new interventions, however, with this resident, she could not think of any new interventions. Staff H denied implementing new interventions after each fall. Staff H stated after [DATE] the resident did not utilize the call light. Staff H denied increasing supervision for this resident after the resident began falling. 2. The Annual Individual Program Plan (IPP) created on [DATE] reflected Resident #5, was admitted to the facility from a residential facility. The IPP identified the resident's [DIAGNOSES REDACTED]. The Individual's Priority Needs included: a history of substance abuse/dependency, poor decision-making/judgment skills in addition to memory problems, required direction when completing activities of daily living, did not always get along well with others, could get moody, irritable, confrontational, could be mischievous and would steal things from others. Target Behaviors included: polydipsia, self- abusive behaviors, intentional defiance of rules, inappropriate comments and verbal aggression. Environmental factors influencing behaviors included when the resident believed he/she was not being observed he/she would attempt to take things that did not belong to him/her. The IPP noted over the past thirty (30) days, the resident experienced delusions, anxiety/worry, restlessness, conflicts with others, self- injurious/self- abusive behaviors, resistance to receiving care, withdrawn behavior and wandering. The resident made suicide attempts in the past. The resident continued to make poor decisions regarding his/her safety. The long term goals listed in the IPP included participation in activities, bathing, voiding in appropriate receptacle and will take his/her medications. The IPP noted all staff that work with this resident were specially trained to understand and work with mentally ill individuals. The Director of Behavioral Health and the Behavioral Support Specialist will assist the resident in learning and using positive coping skills to help him/her deal with his/her mental health symptoms and situations in his/her life. Discharge Planning on the IPP noted the resident would require constant monitoring for both medical and mental health needs and assistance with cares. For the resident to be successful out in the community, he/she would need a strong support system, involvement in community activities and to consistently see his/her physician for medical and mental health maintenance. The resident would require safety measures in place such as locks on windows and doors, smoke detectors, 24-hour supervision, and emergency phone numbers posted for caretakers. The Nurse's Notes reflected the following: On [DATE] at 9:00 a.m. the resident cut the Wander Guard device off and staff placed another on the resident. On [DATE] at 5:00 p.m. the ARNP changed the resident's insulin to once a day and discontinued the insulin before meals On [DATE] at 12:30 p.m. at approximately 8:50 a.m. the C.N.A. noted the resident in the elevator. The C.N.A. came to the desk to check if the resident wore a Wander Guard. The C.N.A was advised yes and he (CNA) went to find the resident, who had exited the front door. The CNA noted the resident to be walking toward the airport alongside of the road. The resident willingly got into the car for return to the facility. The resident had the following vital signs: Temp: 97.7 (normal 98.6), Pulse 110 (normal ,[DATE]), Respirations: 24 (normal ,[DATE]), Blood pressure: ,[DATE]. The resident ' s skin was clammy, and the accu check (blood sugar test) registered at 150 (a normal reading is ,[DATE] per accu check. The resident was noted to take a butter knife from the cart at breakfast. The staff removed the knife, checked the Wander Guard and performed 15 minute checks as usual. The staff reapplied the Wander guard after readmit to the facility. An Online Incident Report submitted by the Director of Behavioral Health, Staff L reported on [DATE] the resident was observed taking a butter knife from the dirty dish cart and putting it in his/her pocket. The staff intervened and removed the knife. The resident went to his/her bedroom and shortly after, he/she walked off the unit wearing his/her roommate's jacket. The Wander Guard alarm did not sound. Staff K, certified nursing assistant, observed the resident getting on the elevator. Staff K thought the resident was supposed to wear a Wander Guard. Staff K returned to the unit and confirmed the resident was supposed to have a Wander Guard on. The staff then started to look for the resident. Another resident on the unit reported seeing the resident walking up the driveway towards the road. Staff K ran outside to see the resident walking up the road. Staff K was able to pick up the resident and return the resident to the facility. On [DATE] at 11:09 a.m. the State Climatologist reported the weather conditions at the local airport on [DATE] at 8:54 a.m. as 42 degrees Fahrenheit, an east wind at 6 miles per hour, with a wind chill factor of 38 degrees. The Nurse's progress notes included: On [DATE] at 5:15 a.m. the resident dressed self, wore roommates coat, attempting to walk towards doorway to leave the station, confronted him/her, returned to room. On [DATE] at 5:30 a.m. while attempting to try to walk down the hallway to leave station, was redirected (by staff). The resident was administered Ativan (anti-anxiety) given. On [DATE] at 3:00 p.m. (staff) faxed ARNP with a request for a pharmacy consult of medications. On [DATE] at 11:05 a.m. heard alarm sounding and didn ' t' see the resident. Received phone call from front office. The resident going out the front door. The C.N.A. was behind the resident and brought him/her back into the facility. Resident informed staff he/she wanted to get the (expletive) out of her. The Plan of Care dated [DATE] identified the resident had anxiety and the interventions included and directed staff to encourage the resident to problem solve with staff redirection, discuss inappropriate behavior and inform of behavioral expectations and refer to social services as needed. Another problem listed noted risk for injury related to medications and cognitive/judgment deficit and refusal to fasten shoes. An intervention dated [DATE] instructed the staff to check the Wander Guard (device) daily. The Plan Of Care did not address the resident's risk for elopement and the history of the resident attempting to leave the unit and cutting off the wander guard. The Plan Of Care also lacked interventions to increase supervision at times of increased risk for elopement such as stealing of knifes, cutting of wander guard and/or being informed he/she could not discharge from the facility. Review of the Behavior Intervention Plan initiated on [DATE] included the resident had positives: intelligent, sense of humor and good with money. Interests: food, drink, playing Monopoly, real estate, sports and playing cards. Successful Learning Conditions: play Monopoly and going for walks outside. The Summary of Milieu Disruptions included: On [DATE], the resident was observed with a wander guard off (bracelet). Resident reported he/she cut the wander guard off at supper. A new wander guard was applied. On [DATE], the staff found resident in the hallway. The resident reported he/she cut off the wander guard last week. A new Wander Guard was applied. On [DATE], the resident attempted to take the knife off of the food cart. The Summary of Information and Behavior function for milieu disruptions: Resident #5 struggled to comply with the following rules: making eye contact and speaking to staff when spoke to, denying or lying about any negative behavior when directly challenged, kleptomania, going into other resident rooms, poor hygiene, disheveled appearance with pants falling down, use of profanity, hoarding of cups and inappropriate behavior specifically being naked in room with door open. Disruptive an unwanted behaviors increase during meal times. Strategies to strengthen appropriate behavior included be cautious of his dignity when addressing disruptive or unwanted behaviors in common areas. The facility Elopement Prevention policy/procedure identified the purpose was to identify residents that have a high risk for elopement, to put interventions into place to prevent elopement for individual resident, and to ensure facility specific interventions are in place and effective. The elopement was identified as leaving a designated area, without sanction or supervision, posing risk to the resident. The risks include falls, hyperthermia, hypothermia, traffic accidents and assaults. The procedures included to identify at risk resident of exit risk or elopement and specific interventions on the Plan Of Care such as Wander Guard, alarms etc. Make sure all staff are aware of those individuals considered at risk. Monitor resident at risk for signs of early agitation. Increase supervision during these periods. A Psychiatric Evaluation dated [DATE] indicated the resident seemed to minimize some of his/her problems. The resident reported in the past when he/she felt depressed he/she tended to feel sad, blah, gloomy, hopeless, helpless, and tended to withdraw from people. The resident exhibited limited insight and judgment. Observation revealed Country View was located in the country, north east of the airport on a blacktop road. The speed limit was 55 miles per hour. The black top was currently being used as a detour for Highway 63 due to major road construction. The facility was surrounded by fields with a few farm houses. The resident was found approximately one mile from the front door. When interviewed on [DATE] at 4:45 p.m. Resident #5 stated he/she left on Sunday and was going to hitch hike to Iowa City and go home. The resident was leaving the facility due to a staff member (Staff M) said he/she would live at Country View forever. The resident stated even though he/she was court ordered he/she did not believe he/she would always need to be here (at the facility). Resident #4 stated he/she was upset and thought about it all day on Saturday. The resident stated he/she planned on how and when he/she was going to leave. He/she planned on cutting the wander guard off with a knife. He/she got the knife from the soiled dishes after breakfast. He/she left the unit. Resident #4 stated he/she ran into Staff K on the way to the first floor and then went to the first floor. He/she then walked out the front door and walked up the driveway to the road. The resident voiced he then turned right and walked along the road. When interviewed on [DATE] at 8:35 a.m. Staff M, the Behavior Support Specialist, stated she has worked with the resident for 7 ? months. Staff M stated she has known the resident to remove the Wander Guard four different times. The last time was when she had a conversation with him/her that Country View was a permanent placement for him/her. The resident did not believe he/she was mentally ill. The resident was constantly seeking to go to California and sell real state. The last time the resident cut off the Wander Guard she had just had a conversation with him/her, and he/she wanted to go to another facility where he/she could smoke. This time she had the same conversation with the resident. Staff M stated she talked to the resident on the 24th and then left for a week for training. She did not think the resident would try to elope. The resident had attempted to leave the unit maybe 3 to 7 times that she knew of in the last 7 months. The resident was very smart and if he/she saw the Hoyer (mechanical lift) gone, then he/she knew two staff were busy. On [DATE] at 9:10 a.m. Staff H (Unit Manager), was interviewed and stated the resident was a very intelligent person and very impulsive. Staff H identified the resident as very sneaky and clever. He /she watched to see when staff were busy to take items from other residents. If the resident got told something he/she did not want to hear, then the resident would go to his/her room. When the resident thought the staff were not looking, he/she would go out the door. The resident had gotten out of the unit a couple of times. Staff H stated the staff knew they had to keep an eye on him/her.