Every finding on record at Prairie Ridge Care Center

Based on clinical record review, policy review and staff interview, the facility failed to document non-pharmacological interventions prior to administering anti-anxiety medication for anxiety and/or agitation for 1 of 1 resident sampled (Resident #60). The facility identified a census of 80 residents. Findings include: Resident #60's Medication Administration Record (MAR) for March 2026 documented Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg). Administer three times a day as needed for agitation. The MAR further documented the nurse administered Lorazepam 10 times during the month. The supplemental documentation lacked documentation of nonpharmacological interventions tried prior to administering Lorazepam. Resident #60's Medication Administration Record (MAR) for May 2026 documented Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg). Administer three times a day as needed for agitation. The MAR further documented the nurse administered Lorazepam 5 times during the month. The supplemental documentation lacked documentation of nonpharmacological interventions tried prior to administering Lorazepam. Resident #60's Medication Administration Record (MAR) for June 2026 documented Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg). Administer three times a day as needed for agitation. The MAR further documented the nurse administered Lorazepam 2 times during the month. The supplemental documentation lacked documentation of nonpharmacological interventions tried prior to administering Lorazepam. Resident #60's Progress Notes lacked documentation of interventions prior to giving the as needed Lorazepam. During an interview on 6/16/2026 at 12:05 PM the Director of Nursing (DON) reported she could not find proof of interventions tried prior to administering lorazepam. She reported the staff should be doing interventions prior to administering and documenting them. The facility policy titled Medications, Psychotropic Drug Usage and Monitoring revised 4/23/25 directed staff that psychotropic medications are only used as deemed necessary and non-pharmacological interventions are unsuccessful.

Based on clinical record review, staff interview, and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) for 2 of 3 residents (Resident #2, and #7) reviewed. The facility reported a census of 80 residents. Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of coronary artery disease, stroke, and non-Alzheimer's dementia. The MDS further indicated Resident #2 received diuretic medications for 7 of the 7 days during the look back period. Review of Resident #2's Electronic Healthcare Record (EHR) page titled, Active Orders revealed no order for diuretic medication.Interview 6/16/26 at 11:00 AM with the Director of Nursing (DON) revealed that Resident #2 is currently not on diuretic medication. Follow up interview 6/16/26 at 11:25 AM with the DON revealed that Resident #2 was never on diuretic medications, and this should not have been on the MDS. The DON further revealed that she was going to submit a correction for the MDS. 2. Review of Resident #7's MDS dated [DATE] revealed diagnoses of heart failure, diabetes mellitus, obesity, and respiratory failure. The MDS further indicated Resident #7 received insulin medication during the for 1 of the 7 days during the look back period. Review of Resident #7's EHR page titled, Active Orders revealed no order for insulin. Interview 6/16/26 at 1:50 PM with the DON revealed that Resident #7 is not currently taking insulin, but is taking Ozempic (glucagon-like peptide-1 (GLP-1) receptor agonists). The DON revealed that the MDS was marked incorrectly, and should not have been marked as taking insulin. Review of a facility policy titled, Minimum Data Set (MDS), Completion and Transmitting to State with an approval date of 4/20/26 indicated the MDS is a required tool that is used to develop a plan of care for each resident.

Based on clinical record review and staff interview, the facility failed to refer resident with a negative Level I result for the Preadmission Screening and Resident Review (PASARR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASARR evaluation and determination for 1 out of 1 residents (Resident #10) reviewed for PASARR requirements. The facility reported a census of 80 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] documented diagnoses of anxiety, major depressive disorder with severe psychotic symptoms, psychotic disorder, and Post Traumatic Stress Disorder (PTSD). Review of the EHR page titled, Current ICD-10 (International Classification of Diseases 10th revision) revealed diagnoses of:A. major depressive disorder, recurrent, severe with psychotic symptoms with a diagnosis date of 10/2/24. B. Post traumatic stress disorder, chronic with a diagnosis date of 4/14/20.Review of the PASARR dated 10/17/19 lacked inclusion of PTSD, and major depressive disorder, recurrent, severe with psychotic symptoms. The clinical record lacked an updated PASARR to include PTSD, and major depressive disorder, recurrent, severe with psychotic symptoms. Interview 6/16/26 at 2:20 PM with the Director of Nursing (DON) revealed that another PASARR should have been run related to the PASARR not being completed since 2019. The DON further confirmed Resident #10 had new diagnoses of PTSD in 2020, and major depressive disorder, recurrent, severe with psychotic symptoms in 2024. Review of the PASARR dated 10/17/19 indicated it is important for nursing staff to note if Resident #10 improves medically, has a change in symptoms, behavior or diagnosis changed, a status change may be submitted. No policy was available to review.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions, targeted behaviors and side effects related to high risk medications in 5 out of 18 sampled residents reviewed (Resident #13, #21, #25, #32 and #44). The facility reported a census of 83 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented diagnoses of anxiety disorder and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 99, which indicated severe cognitive impairment. Review of Active Orders for Resident #21 revealed the following orders: a. Celexa (antidepressant medication) 20 milligrams (mg) daily with an order date of 2/27/25 b. Remeron (antidepressant medication) 45 mg daily with an order date of 10/15/24 c. Zyprexa (antipsychotic medication) 7.5 mg with an order date of 5/31/24 Review of the April Medication Administration Record for Resident #21 revealed the following orders: a. Celexa (antidepressant medication) 20 mg daily with an order date of 2/27/25 b. Remeron (antidepressant medication) 45 mg daily with an order date of 10/15/24 c. Zyprexa (antipsychotic medication) 7.5 mg with an order date of 5/31/24 Review of the Care Plan for Resident #21 with a revision date of 3/7/25 lacked information on non-pharmacological interventions, targeted behaviors and side effects to watch for with the usage of antidepressants and antipsychotic medications. The Care Plan for Resident #21 also failed to show Haloperidol as a discontinued medication. 2. The MDS assessment dated [DATE] for Resident #25 documented diagnoses of depression. The MDS showed the BIMS score of 10, moderate cognitive impairment. Review of Active Order Summary Report for Resident #25 revealed the following orders: a. Remeron (antidepressant medication) 7.5 mg daily with an order date of 12/21/24 Review of the April Medication Administration Record for Resident #25 revealed the following order: a. Remeron (antidepressant medication) 7.5 mg daily with an order date of 12/21/24 Review of the Care Plan for Resident #25 with a revision date of 3/8/25 lacked information on non-pharmacological interventions and targeted behaviors to watch for in antidepressant medication usage. 3. The MDS assessment dated [DATE] for Resident #32 documented diagnoses of dementia and nontraumatic brain dysfunction. The MDS showed the BIMS score of 00, severe cognitive impairment. Review of Active Order Summary Report for Resident #32 revealed the following orders: a. Roxanol (pain medication) 5-10 mg as needed every two hours with an order date of 1/20/25 b. Zoloft (antidepressant medication) 50 mg daily with an order date of 10/6/23 c. Zyprexa 2.5 mg (antipsychotic medication) at bedtime with an order date of 1/20/25 Review of the April Medication Administration Record for Resident #32 revealed the following order: a. Roxanol (pain medication) 5-10 mg as needed every two hours with an order date of 1/20/25 b. Zoloft (antidepressant medication) 50 mg daily with an order date of 10/6/23 c. Zyprexa 2.5 mg (antipsychotic medication) at bedtime with an order date of 1/20/25 Review of the Care Plan for Resident #32 with a revision date of 4/5/25 showed diagnosis of depression. The Care Plan lacked information on non-pharmacological interventions, targeted behaviors and side effects to watch for with the usage of antidepressants, antipsychotic and pain medication usage. The Medications, Psychotropic Drug Monitoring policy last revised April 2009 identified the following. The policy lacked information regarding non-pharmacological interventions, targeted behaviors and side effects to watch for with the usage of psychotropic medications. POLICY: Psychotropic medications are to be used only as deemed necessary by the physician and are in the best interest of the residents overall well-being and non-pharmacological interventions are unsuccessful. PROCEDURE: Whenever a resident is started on a psychotropic medication, they need to have blood pressure checks for posterior hypotension once weekly for 4 weeks. Check lying, sitting, and standing (if able) pressures with each check. Then follow up checking blood pressure for postural hypotension one time monthly. Red alert the chart for a time period as deemed necessary with initiation or any change in psychotropic medications. Monitor for adverse effects and effectiveness of medication. Monitor residents for any side effects and effectiveness of psychotropic medication daily on the behavior monitoring flowsheet. Pharmacy consultants will review residents' medication monthly with reduction recommendations made and sent to doctors per federal regulations. Gradual dose reductions may be considered clinically contraindicated if a resident has had a previous unsuccessful GDR or the physician has documented the clinical rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. In an interview on 4/23/25 at 2:37 PM, the Administrator reported that she expected the care plan to contain information on non-pharmacological interventions, targeted behaviors and side effects to watch for with the usage of antidepressants, antipsychotic and pain medication usage. 4. The MDS dated [DATE] documented Resident #13 had a Brief Interview for Mental Status (BIMS) of 08 indicating moderate cognitive impairment. The MDS also documented Resident #13 had diagnoses of anxiety disorder, depression, psychotic disorder, and post traumatic stress disorder. Review of Resident #13's Physician Orders documented psychotropic medication orders for Lexapro (escitalopram) 20mg 1.5 tablets daily, bupropion 300mg daily, mirtazapine 45mg daily, zoloft 100mg daily and seroquel 100mg daily. Review of Resident #13's Care Plan revealed no non-pharmacological interventions or approaches for use of psychotropic drugs. 5. The MDS dated [DATE] for Resident #44 documented a BIMS of 99 indicating the resident was unable to complete the interview. The MDS also documented Resident #44 had diagnoses of Alzheimer's disease and depression. Review of Resident #44's Physician Orders documented psychotropic medication orders for Lexapro (escitalopram) 20mg daily, Zyprexa 2.5 mg daily at supper and Zyprexa 5mg daily at breakfast. Review of Resident #44's Care Plan revealed no non-pharmacological interventions or approaches for use of psychotropic drugs.

Based on observation, policy review, document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs for 25 of 83 residents reviewed. The facility reported a census of 83 residents. Findings include: Continuous observation of lunch meal service on 4/23/25 from 11:35 AM - 12:00 PM revealed no bread or margarine served to the residents that resided at [NAME] Run Cottage. Review of document titled, Diets revealed 25 residents resided at [NAME] Run Cottage. Review of document titled, facility Fall / Winter 2024-2025 Wednesday Week 1 Menu documented bread and margarine to be served at lunch meal. On 4/23/25 at 12:07 PM Staff D, Assistant Activities Director stated she took the lunch menu that was on the sign to all the residents and wrote what the residents wanted down on a piece of paper. Staff D acknowledged there was no bread on the menu sign and bread was not offered to any of the residents. Staff D explained if bread is sent down from the kitchen it would be offered to the residents but there was no bread sent from the kitchen for lunch on 4/23/25. On 4/24/25 at 7:32 AM Staff E, [NAME] acknowledged she did not puree any bread to send to the residents that required a pureed diet in [NAME] Run Cottage. Staff E stated she felt there was enough on the menu already and the puree did not need the bread. Staff E stated she typically followed the menu. Staff E stated if an item was on the menu then it should have been served. Staff E stated she sent the bread down with the utensils on 4/23/25. On 4/24/25 at 9:04 AM Staff G, Certified Nursing Assistant (CNA) acknowledged she served lunch on [NAME] Run Cottage on 4/23/25 to all the residents. Staff G stated sometimes the kitchen would send buns but yesterday it was only 2 slices of bread with butter. Staff G stated the bread was only sent about every other day. On 4/24/25 at 7:37 AM Staff F Certified Dietary Manager stated it was up to the host to ask the residents and to take the bread around and offer it. Staff F stated the facility's expectation was that bread and butter would be offered to everyone and should have been served to the residents that received pureed food as well. Staff F acknowledged that the bread was not served to the residents at [NAME] Run Cottage on 4/23/25 at lunch. Staff F stated she went to [NAME] Run Cottage and asked staff and they acknowledged they did not serve the bread with the meal at lunch time on 4/23/25. Staff F stated the staff said they forgot to offer the bread to the residents. On 4/24/25 at 7:53 AM the Administrator stated the facility's expectation was that the menu would be followed even by serving the bread and butter. Review of policy dated 7/11/24 titled, Menu Planning documented Menus were planned to meet the nutritional needs of patients in accordance with their physician's orders, the recommended dietary allowance as stated by the National Research Council and the Dietary Guidelines for Americans. The general menu was reviewed and modified by the CDM and was approved by the Registered Dietitian.

Based on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal preparation. The facility reported a census of 83 residents. Findings include: An observation on 4/23/25 at 9:00 AM revealed Staff E, [NAME] completed hand hygiene, obtained 5 portions of Swiss steak from the oven, placed them in them the processor, mechanical soft Swiss steaks removed from food processor and measured to 3 cups, reviewed puree sheet, serving sized determined to be #8. Staff E obtained 5 bowels from the cabinet and placed her ungloved fingers into 3 bowls and two ungloved fingers into 2 bowls with the other hand. Staff E used a #8 scoop to serve mechanical food in 5 bowls, bowls were placed in the microwave, the bowls were heated, the bowls were removed from the microwave, the bowls were placed in the steam table pan and the pan placed in the oven. Then 3 servings of Swiss steak were obtained from the pan, Swiss steak placed in food processor, food processor was turned on, Swiss steak was removed from processor with spatula into measuring cup, 3 bowls obtained with one hand placing fingers in each bowl, pureed Swiss steak placed in bowls, bowls placed in the microwave, bowls removed from the microwave, bowls placed in steam table pan and pan placed in oven. Staff E then walked to the freezer, obtained frozen pre-formed peas, obtained 3 bowls, placed the bowls in front of the microwave, applied gloves, removed frozen pre-formed peas from package, placed peas in the bowls with gloved hands, pressed the peas into the bowls, removed gloves, placed bowls in the microwave, bowls were removed from the microwave, bowls were placed in steam table pan and pan placed in oven. Staff E obtained bowls from the cabinet, applied gloves removed a frozen peach pie from the freezer, removed 3 servings of peach pie, placed her gloved hand on top of each piece of pie for support, placed pie in processor, removed gloves, obtained milk from the refrigerator, milk poured into the processor, removed pureed pie from the processor with spatula into bowls and placed in the refrigerator. On 4/24/25 at 7:37 AM Staff F, Certified Dietary Manager (CDM) stated the facility's expectation was hand hygiene should be completed before and after gloving and after coming in contact with contaminated surfaces. On 4/24/25 at 7:53 AM the Administrator stated hand hygiene should be completed before and after gloving and after coming in contact with contaminated surfaces. Review of policy with effective date of 12/29/23 titled, Hand Washing, Nutrition revealed food employees shall clean their hands and exposed portions of their arms, as specified under procedures; immediately before engaging in food preparation. Including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, after engaging in other activities that contaminate the hands, and don gloves after washing hands and before touching ready to eat foods.

Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing personal care to a resident and when providing care to a residents on enhanced barrier precautions (EBH) for 4 of 12 residents reviewed (Resident #15, #27, #33 and #45). The facility reported a census of 83 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS also documented Resident #33 utilized a suprapubic catheter and had a stage 2 pressure ulcer. Review of Resident #33's Physician Orders documented an order to change suprapubic catheter with an 18 fr with 10mL balloon to straight drainage every 3 weeks and PRN. Change monthly on the 6th. An observation on 4/22/25 at 9:00 AM revealed Staff H, Certified Nursing Assistant (CNA) and Staff I, Registered Nurse (RN) completing cares and a transfer with Resident #33. Staff H completed hand hygiene, applied gloves, did not don a gown, emptied catheter into a graduate with a barrier placed on the ground, cleansed the tip of the catheter and returned it to the locked position. Staff H removed gloves, completed hand hygiene and applied gloves. Staff I applied a sling to Resident #33's back and up between Resident #33's legs. Staff I did not complete hand hygiene or don gloves or gown. Staff I moved catheter tubing from under Resident #33's leg. Staff I secured the catheter into the leg strap without gloves or a gown. Staff I then completed hand hygiene. Resident #33 was lying in bed in a hospital gown. Staff H removed gloves and completed hand hygiene. Both staff applied shoes without gloves. Both staff applied lift straps under Resident #33's legs and attached to the lift cloth to the full body mechanical lift. Staff H ran the lift controls and Staff I helped with residents legs during transfer. Once Resident #33 was in the air Staff I supported Resident #33's back to direct position and was not wearing gloves at that time. Review of EHR titled, Progress Note dated 11/15/24 authored by Director of Nursing (DON) documented she visited with Resident #33 and son regarding Enhanced Barrier Precautions. Resident #33 adamantly does not want this used and states it is bull shit. Risk of infection explained to the resident and she states understanding and chooses to sign a Risk agreement. Review of Resident #33's Electronic Heath Record (EHR) titled, Care Plan documented Resident #33 had chosen to decline use of EBP to preserve her normal quality of life. Resident #33 was at increased risk for infection due to indwelling foley catheter. Resident #33's choice ot refuse EBP will be honored to allow her right to self-determination. Risk education and agreement had been completed. 44474 2. The MDS assessment dated [DATE] for Resident #15 documented diagnoses of dementia, chronic kidney disease and hypertension. The MDS showed a BIMS score of 7 indicating severe cognitive impairment. The MDS revealed Resident #15 has 1 or more Stage 3 unhealed pressure ulcers. Review of the Care Plan with a revision date of 3/5/25 revealed the resident currently has an open area to her left hip. Wound care is currently treating the area. Observation on 4/23/25 at 12:49 p.m., of Resident #15 with Staff A, Licensed Practical Nurse (LPN) entered the room and performed a pressure wound dressing on the left hip area. Staff A did not wear any EBP when performing pressure wound dressing change with Resident #15. 3. The MDS assessment dated [DATE] for Resident #45 documented diagnoses of benign prostatic hyperplasia, renal insufficiency, obstructive uropathy. The MDS showed a BIMS score of 15 indicating no cognitive impairment. The MDS revealed Resident #45 has an indwelling catheter. Review of the Care Plan with a revision date of 2/19/25 revealed the resident currently has a foley catheter. Observation on 4/23/25 at 12:41 p.m., of Staff B, Certified Nursing Assistant (CNA) entered Resident #45's room to empty the indwelling catheter bag. Staff B did not wear any EBP with catheter care. 4. The MDS assessment dated [DATE] for Resident #27 documented diagnoses of anoxic brain damage and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus) The MDS showed a BIMS score of 99 indicating the resident was unable to complete the interview. The MDS revealed Resident #27 had a feeding tube. Review of the Care Plan with a revision date of 3/5/25 revealed the resident currently receives tube feedings 4 times a day. Observation on 4/23/25 at 2:44 p.m., of Staff A entered Resident #27's room to administer tube feeding. Staff A did not wear any EBP when performing the administration of tube feeding. Interview on 4/23/25 at 2:57 p.m., with Staff A revealed she was aware of EBP usage for residents with devices. Staff A explained when a resident comes to the facility or is here and has a wound or a medical device the facility staff educate the family and residents on using the precautions and if they do not want the precautions they sign a waiver stating they do not the precautions used this way the resident does not feel out of place or feel like they have something. Review of facility provided policy titled Infection Control Program, Standard, Transmission, Droplet, and Airborne Precautions with a revision date of 4/21/25 revealed the following information: a. Enhanced Barrier Precautions refers to the use of gown and gloves worn during high-contact contact resident care activities for residents known to be colonized or infected with multi-drug resistant organisms (MDRO) as well as those considered high risk of MDRO acquisition. b. Those at high risk include residents with chronic open wounds or indwelling medical devices. Indwelling medical devices includes central vascular lines, indwelling urinary catheters, feeding tubes, and tracheostomy tubes. c. A chronic open wound is a wound that does not heal within 3 months. d. Examples of high contact care activities include: dressing, bathing/showering, transfers, providing hygiene, changing linens, changing briefs or assisting with toileting and wound care. Review of the Centers for Disease Control website titled Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2004 visited on 4/24/25 revealed the following information: a. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). b. The studies that informed EBP, including defining which care activities most commonly result in transfer of MDROs to staff hands and clothing, were conducted in adult nursing home populations. c. Assuming Contact Precautions do not otherwise apply, Enhanced Barrier Precautions are recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. d. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. Interview on 4/23/25 at 3:27 p.m., with the Director of Nursing revealed the facility has a policy on EBP and when a resident comes to the facility with a device the facility does education on the usage of EBP and explains both sides of the usage. If the family or resident does not want EBP used the facility has them sign a waiver they have been educated and do not want it. 44420 5. Observation on 4/23/25 at 11:35 AM showed Resident #70 lifted a medication cup to lips, ingested medication, then handed the empty medication cup to Staff C, Registered Nurse (RN). Staff C discarded the cup, failed to complete hand hygiene, then returned to the medication cart. Staff C touched the computer mouse, opened the medication cart and proceeded to prepare and administer medications to the next resident. Observation on 4/23/25 at 11:57 AM showed Staff C, RN picked up Resident #43's cup of water to assist the resident to sip during medication administration. Staff B then disposed of the medication cup, returned to the medication cart and touched the computer mouse, opened the medication cart and proceeded to prepare and administer medications to the next resident. Observation on 4/23/25 at 12:18 PM showed Staff C, RN picked up Resident 62's cup of water, handed the water and medication cup to the resident. Resident #62 lifted the medication cup to lips, ingested medication, then handed both of the empty cups to Staff C. Staff C placed the water cup back on the table, discarded the medication cup, failed to complete hand hygiene, then returned to the medication cart. Staff C touched the computer mouse, opened the medication cart and proceeded to prepare and administer medications to the next resident. Based on our acceptance of your credible allegation of substantial compliance and Plan of Correction, your facility will be certified in compliance with the health requirements effective April 29, 2025. The Handwashing, Instant and Regular policy last revised on 4/23/25 identified staff are to perform proper hand hygiene before and after each direct resident contact. INSTANT: To effectively kill bacteria and sanitize hands between hand washing or when soap and water are not readily available or convenient, a hand antiseptic is to be used as a supplement to handwashing, when hands are not visibly soiled. REGULAR: Handwashing is done to thoroughly cleanse hands and prevent the spread of infection. PROCEDURE: INSTANT: Apply to clean dry hands that are free of any visible debris. Apply sufficient amount to wet hands thoroughly. Rub hands together for at least 15 seconds, covering the entire surface, including nails. Allow to dry thoroughly. Store at 20-25 C (68-77 F). REGULAR: Turn on water and adjust temperature. Soap hands well. Rub hands briskly, pay special attention to the area between fingers for at least 20 seconds. Rinse with hands lowered to allow soiled water to drain directly into the sink. Do not allow hands to touch the sink. Dry hands well, especially between fingers. Use disposable hand towels to turn off faucets.

Based on observation, resident interview, staff interview, resident council notes, and policy review the facility failed to provide food at an appetizing temperature to 1 of 20 residents reviewed (Resident #17). The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 4/21/25 at 3:18 PM Resident #17 stated the food was sometimes served cold but less than weekly. An observation on 4/23/25 at 11:35 AM revealed lunch was delivered to [NAME] Run Cottage. Staff D, Assistant Activities Director served the lunch meal. Lunch services were completed at 12:00 PM and temperatures were obtained by Staff D. The temperatures of peas were 112 degrees, cauliflower 119 degrees, garlic parmesan potatoes 145, casserole 172 and Swiss steak 140 degrees. On 4/23/25 at 12:07 PM Staff D acknowledged that she did not usually serve lunch. Staff D stated she felt the temperatures should have been 165 degrees or above to be served. Staff D stated the temperature of the food was obtained after the food was served. Staff D stated she did not keep track of any of the food temperatures that were obtained. Staff D acknowledged the food temperatures were not adequate for that lunch service. On 4/24/25 at 7:37 AM Staff F, Certified Dietary Manager stated the staff should check the food prior to service and if it was under 135 would want it brought back up above 135 degrees. Staff F stated the facility's expectation was the food would be held at 135 or above during the meal service. On 4/24/25 at 7:53 AM the Administrator stated the facility's expectation was that temperatures of food would be held above 135 degrees until after meal services were completed. The Administrator explained that the facility did not have a policy on food holding temperatures.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #1). The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of dementia, anxiety disorder and non-traumatic brain dysfunction. The MDS identified the presence of short and long-term memory impairment. The Progress Note dated 4/27/2024 at 6:20 PM composed by Staff A documented the following: CNA approached this writer and stated she heard another CNA admit to doing something to a resident on the previous day, April 26th, while giving him a shower. CNA stated the other CNA said that while she was giving him a shower he became very aggressive and started swinging at her. CNA stated she put the showerhead spraying water on his face. Supposed CNA who took this action was already off shift when the CNA approached this writer to explain the conversation that took place. Call placed to DON. The untitled facility investigation completed by the Director of Nursing (DON) indicated on 4/27/24 at 6:15 PM the DON received a phone call from Charge Nurse, Staff A, Licensed Practical Nurse (LPN) with an alleged report from Staff B, Certified Nursing Assistant (CNA) that Staff B overhead Staff C, CNA tell Staff D, CNA while showering Resident #1 Staff C sprayed and held water on Resident #1 ' s face because the resident spat on Staff C. The facility investigation indicated next the DON called Staff C. Staff C stated, I would not do that. I know it is wrong. Staff C explained the resident did not spit on her during the shower. Staff C reported while washing Resident #1 ' s hair he attempted to hit her which caused the water to go in the resident's face and stunned him. Staff C reported she did not hold water to the resident ' s face. Staff C reported she moved the water away from the resident ' s face. In an interview on 11/25/24 at 9:43 AM, Staff B, CNA reported on approximately 4/27/24 while in the dining room Staff C, CNA informed a group of CNAs she was tired of Resident #1 spitting in her face. Staff C told the CNAs during his bath she sprayed Resident #1 in the face using the shower head. Staff B reported the conversation to Staff A, who then reported the incident to the DON. In an interview on 11/25/24 at 10:56 AM, Staff C, CNA, stated Resident #1 appeared to be agitated during the bath.Staff C sat the radio on the counter nearby in case she needed help. Staff C reported during the bath she tried to get away from the resident because he attempted to hit her. As the resident attempted to hit Staff C the shower head sprayed him in the face. Staff C stated, I wasn ' t trying to be mean or anything. Staff C then told Staff D, CNA what happened. Later the same day Staff B, CNA overheard Staff D, tell Staff E, CNA. Staff C stated, Staff B took it in the wrong context. The DON called Staff C to find out what happened. In an interview on 11/25/24 at 11:19 AM, The DON reported during the investigation she discovered a CNA overheard a conversation between two other CNA ' s. During the follow up Staff C, CNA explained while giving the resident a bath, his movements caused the shower head to spray him in the face. Staff C immediately redirected the spray away from his face. The DON reported having no other issues of allegations against Staff C and no resident complaints. The DON relayed she did not report the incident to DIAL because she felt there had been miscommunication between the CNA ' s. Staff B, CNA overheard the conversation between two CNAs about what Staff C said and misheard the facts. The DON reported Staff C continued to work in the same cottage because the DON determined abuse did not occur. The DON stated, We did end up assigning Staff C to another cottage. Staff C currently doesn ' t have anything to do with the resident. The Abuse Prevention and Response policy last revised on 10/14/24 identified reporting any suspicious injury and/or allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, missing money or property, or misappropriation of assets is to be reported immediately to the Nurse, Cottage Leader, DON or Administrator. If reported to the charge nurse or Cottage Leader, that person is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the lowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. A report shall be made by calling the Department of Inspections and Appeals reporting hotline at (877) [PHONE NUMBER], submitting an e-mail to the Department at HFD_Complaint@dia.iowa.gov. submitting an online report or sending a fax to (515) [PHONE NUMBER]. If the person in charge is the alleged abuser, the staff member shall directly report the abuse to the Department immediately, pursuant to the deadlines established above. If the allegations of dependent adult abuse involve a caretaker who is not an employee of the facility (e.g. family member, visitor), a report must also be made immediately to both the Iowa Department of Inspections & Appeals and the Iowa Department of Human Services (DHS) by phone call [PHONE NUMBER] and follow-up documentation is to be submitted to DIA and DHS as requested by DHS or if there is a reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement. While the federal regulations require all abuse allegations be reported to DIA within 2 hours, the Elder Justice Act has a different time frame for reporting to the police/sheriff. If the allegation of abuse (that results from a crime) results in serious bodily injury to a resident, a report must be made to law enforcement not later than two (2) hours after the allegation is made. Investigation Protocols- Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: Suspending the employee Segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. And in rare instances separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. Review documentation in resident record (including review of assessment if resident injury). Assess the resident for injury if the allegation involves physical or sexual abuse; Provide proper notifications to primary care provider, responsible party, etc. Attempt to obtain witness statements (oral and/or written) from all known witnesses. If there is physical evidence that can be preserved, attempt to do so, and maintain [NAME] safe location to minimize risk of evidence being tampered with. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections & Appeals. This written report shall be forwarded to the Department within five days of the initial report. Following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee may be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the Department concludes its investigation and issues the written results of its investigation. NOTE: if the DIA determines there was abuse (even though the facility did not substantiate the abuse), there is risk that DIA could cite the facility with Immediate Jeopardy, for allowing an abuser to have access to other residents while the matter was being investigated. In an interview on 11/26/24 at 12:40 PM, the DON reported a was not made to DIAL because the DON felt the CNA ' s had a miscommunication and determined no abuse occurred. The DON reported she now planned to report all allegations of abuse to DIAL.

Based on observation, infection control policy, clinical record review and staff interview, the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during a drainage of a Foley bag, wound care, and during a peg tube feeding for 3 out of 6 residents reviewed for infection control (Resident #4, #30 and #83). The facility reported a census of 81 residents. Findings Included: 1. Observation on 5/1/24 at 1:14 PM for Resident #4 showed Staff A, Certified Nurse Assistant (CNA), sanitized hands, donned gloves, placed the urine colander with the barrier on the floor, then placed an alcohol wipe packet directly on the floor. Staff A opened the Foley bag drainage valve, sanitized the valve with an alcohol wipe, partially drained the urine, reused the same alcohol wipe to sanitize the drainage valve then placed the valve back into the holder. Staff A next manipulated the measuring container within the Foley bag to allow the urine to drain into the bottom of the Foley bag. Staff A then reopened the Foley bag drainage valve, retrieved the alcohol wipe packet from the floor, opened the alcohol wipe and sanitized the drainage valve. Staff A drained the remainder of the urine then reused the same alcohol wipe to sanitize the drainage valve. Staff A next placed the drainage valve back into the holder then proceeded to place the Foley bag within the privacy bag and rearranged the resident's blanket without removing gloves or performing hand hygiene. During the procedure Staff A also failed to wear a gown as required per Enhanced Barrier Precautions (EBP). In an interview on 5/1/24 at 2:08 PM, Staff A reported she lacked knowledge of enhanced barrier precaution requirements. When asked if Staff A received education about EBP, she responded no. When asked if Staff A received education to wear a gown while draining urine from a Foley bag, Staff A responded, no. In an interview on 5/1/24 at 2:52 PM, the Director of Nursing (DON) reported that she expected staff to avoid placing alcohol wipe packets directly on the floor in preparation of emptying a Foley bag. The DON also expected staff to remove gloves and perform hand hygiene immediately after emptying a Foley bag. The DON explained from her understanding of the latest Centers for Medicare & Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) that facilities were not required to implement the new guidelines, per the verbage facilities should, therefore the DON ' s facility opted not implement EBP measures because the measures interfered with a home like environment for residents. The Catheter Care policy last revised August 2019 instructed staff to remove gloves and perform hand hygiene after emptying urine from a catheter bag. 50500 2. On 5/1/24 at 10:00 am, observation of wound care on Resident #83 completed by Staff B, Licensed Pratical Nurse (LPN). Staff B completed appropirate hand hygeine prior to donning gloves. No other EBP was worn. Staff B placed wound care supplies initially on bedside table then transferred to floor without a barrier between the supplies and floor (included scissors, skin prep package, mepilex package, hibicleanse bottle, wound cleanser bottle, tape). Staff B sat on floor to perform cares to Resident #83's left heel. Staff B used gloved hands to balance on floor and did not change gloves. Wound cares completed as per physcian's orders. During cares, Staff B was observed picking up supplies off the floor with gloved hands, opening packages, and continued with cares without changing gloves. Throughout observation, Staff B touched floor with gloved hands (x2) and resumed wound cares. On 5/1/24 at 2:00 pm, interview with Staff B completed. When asked, Staff B was not aware of any residents under EBP. Staff B was able to verbalize where proper personal protective equipment (PPE) was located on the unit. On 5/1/24 at 2:40pm, interview with Cottage Leader for Countryside completed. When asked, stated wound care supplies should not be placed on the floor. Appropriate equipment available to use, for example, bedside tables or plastic bins. 26527 3. On 5/1/24 at 10:00 a.m. Staff C, LPN washed her hands and applied gloves. Staff C checked Resident #30's feeding tube for residual, with none noted. Staff C cleaned the feeding tube insertion site and placed a towel around the feeding tube. She administered 9 medications separately with water flushes through an open ended syringe placed to the feeding tube. After the medications were in, Staff C started administering the formula for the feeding through the open ended syringe. Throughout the procedures, gloves were the only EBP used. 44474 4. Interview on 5/1/24 at 2:02 p.m., with Staff C, LPN revealed if someone was on EBP then the cottage leader would let the staff know and it would be communicated to them. She further revealed there is no one currently on EBP in the cottage. 5. Interview on 5/1/24 at 2:04 p.m., with Staff D, Registered Nurse (RN), Cottage Leader revealed she did not know what EBP were. She further revealed she was not aware anyone was on EBP in the cottage. Review of the facility provided policy titled Infection Control Program, Standard, Transmission, Droplet, Airborn, and Enhance Barrier Precaution with a revision date of 4/24 revealed the purpose is to provide for protection of residents and staff from the spread of infectious illness and disease. Enhanced Barrier Precautions definition is the use of Personal Protective Equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MRDO). Examples include dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care. EBP may be used for a resident with an active targeted MRDO. Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 5/1/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident ' s admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Interview on 5/1/24 at 11:33 a.m., with the Director of Nursing (DON) regarding EBP. She revealed the facility is not currently using EBP on residents as when the facility read the guidance it stated recommend and should and did not the word must. She further revealed the facility has a plan in place for the usage EBP when needed and all residents that would meet the requirements to be using EBP have been reviewed and do not have a MRDO and colonized with an MRDO.

Based on observation, document review, staff interview, and policy review the facility failed to store and prepare food in accordance with professional standards. The facility reported a census of 85 residents. Findings include On [DATE] from 10:05 AM through 10:45 AM continuous observation during the initial kitchen tour revealed: 1. Coleslaw in walk-in cooler noted with expiration date of [DATE]. Open date on coleslaw noted to be [DATE]. Applesauce in the walk-in cooler noted to be in a condiment dispensing container with blue tape without an open date. 2. Walk-in freezer had a bag of peas and onions open and undated, a bag of cod fish open and undated, a bag of cinnamon rolls open and undated, a bag of polish sausage open and undated, and a bag of sausage patties open and undated. 3. Small freezer next to fryer had a bag of cheese curds open and undated, a bag of sweet potato waffle fries open and undated, a bag of cod fish open and undated, a bag of French fries open and undated, a bag of chicken strips open and undated, and a bag of breaded asparagus open and undated. 4. Steam table noted to have [NAME] salt-free all-purpose blend that has expiration of [DATE] and an open date of [DATE]. 5. Bread freezer noted to have a bag of hot dog buns open and undated. Review of undated document on [DATE] at 11:00 AM, titled Date Marking & Disposal of Ready to Eat Potentially Hazardous Food. Food Code Fact Sheet #8, revealed the following: A. What foods need to be date marked? - Does the food require refrigeration? - If commercially packaged, has the original package been opened? - Is the food ready-to-eat? - Is the food potentially hazardous? - Will the food be in the establishment for more than 24 hours? If you answered yes to all 5 of these questions, then the food needs to be date marked. Review of document ,d+[DATE] - ,d+[DATE] on [DATE] at 10:23 AM, titled Facility Cleaning Sheet, revealed Friday AM cook duties included checking refrigerators for outdated food. In an interview on [DATE] at 9:16 AM, Staff B, stated if food is opened and the entire bag is used the bag would be thrown away. Staff B stated if the entire bag is not used the food item would be secured and dated with an open date. In an interview on [DATE] at 10:15 AM, Staff A, stated the facility ' s expectation is when a package of food is opened and not completely used the date the package is opened would be applied to the package. In an interview on [DATE] at 10:22 AM, Staff A, stated the facility's expectation is to look at expiration dates when item is opened. Staff A stated expired and outdated items are to be identified and thrown out weekly on Fridays according to the checklist on Facility Cleaning sheet.

Based on observations, interviews and record review, the facility failed to meet professional standards of quality for not priming insulin for 1 out of 2 residents reviewed, ( Resident #16) . The facility reported a census of 84 Residents. Findings Include: The Minimum Data (MDS) with an Assessment Reference Date of (ARD) of 5/12/21 for Resident #16 showed a Brief Interview Status Score (BIMS) of 15 intact cognitive skills. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Electronic Health Record showed Resident #16 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Vitals tab in the Electronic Health Record showed a blood sugar reading of 89 taken on 7/20/21 at 6:36 AM. Observation on 7/20/21 at 9:00 AM showed Staff A Registered Nurse (RN) obtain an [MEDICATION(S)] Flex Touch Pen from the medication cart and sanitized her hands, the cap was removed, the top of the pen was cleaned with an alcohol prep pad and the needle was applied to the pen. Staff A RN dialed the pen to 12 units. Staff A RN failed to prime the insulin pen with 2 units. Staff A RN applied gloves and prepped area on abdomen with request from the resident and injected the insulin. Needle cap was removed and disposed in the sharps container, gloves removed and hands sanitized, and cap placed on insulin pen and placed in medication cart. Review of the instruction sheet for [MEDICATION(S)] Flex Touch Pen stated, to prepare your pen, prime your pen. Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Staff A RN stated on 7/21/21 at 1:14 PM that she had never primed Insulin pens before and was unaware that priming needed to be done with each injection. Staff A RN stated she was never taught that priming needed to be completed. During interview with the DON on 7/21/21 at 1:24 PM she stated she was unaware that priming insulin pens needed to be completed. She stated she will be adding that all insulin pens need to be primed before each use. The DON stated now that she knows this, she expects the nurses to be priming the pens before each use. The DON stated they do not have a policy specific to insulin injection but they will be developing one.

Based on observation, interview, and record review, the facility failed to protect all residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to thoroughly screen and document staff results, from all facility departments, for COVID-19 prior to the staff working with and/or caring for residents in the facility. These facility staff cared for all residents of the facility and/or provided services to all residents of the facility. Furthermore, when facility staff reported having symptoms of possible COVID-19 infections, including cough and sore throat, there was no evidence of the facility following-up on the staff who reported these symptoms. In total, the facility failed to thoroughly screen staff and document the results of the screening in over 100 individual instances starting in March. A determination was made that the facility's noncompliance with one or more requirements of participation placed all residents in the facility in immediate jeopardy, beginning on [DATE]. On [DATE] at 2:30pm, the Administrator was notified of the immediate jeopardy at F880, Infection Prevention and Control. The immediate jeopardy was removed on [DATE] after the surveyor verified implementation of a removal plan. The scope and severity was lowered to an F (widespread potential for more than minimal harm). Findings include: - Review of CMS guidance, documented in QSO memo ,[DATE] NH, released [DATE], documented the following: How should facilities monitor or limit visitors? Facilities should screen visitors for the following: 1. International travel within the last 14 days to restricted countries. For updated information on restricted countries visit: https://www.cdc.gov/coronavirus/2019-ncov/[MEDICATION NAME]/index.html 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. Has had contact with someone with or under investigation for COVID-19. The guidance also documented: How should facilities monitor or restrict health care facility staff? The same screening performed for visitors should be performed for facility staff (numbers 1, 2, and 3 above). - Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work. - Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should: Immediately stop work, put on a facemask, and self-isolate at home; Inform the facility's infection preventionist, and include information on individuals, equipment, and locations the person came in contact with; and Contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment). On [DATE] at 9:00am, Nurse Aide (NA1) indicated that staff must screen themselves before beginning their shift. Staff would enter through the back door of the facility, clock in, walk down the east or west maintenance hall, and then exit in front of the entrance to the two east or west units. Staff would then enter the unit and screen themselves in the family room. The family rooms were the very first rooms someone would walk by when they entered the unit. NA1 indicated that staff would take their temperatures and answer a series of questions. Staff would document the information on a screening form. NA1 indicated that three residents and one one staff person developed COVID-19. On [DATE] at 9:16am, Licensed Practical Nurse (LPN1) indicated that staff must be screened before each shift. Staff would enter in the back door, clock in, walk through the back halls to their assigned unit, and screen themselves in the family room. LPN1 indicated that the staff must take their temperatures and answer a series of questions before working, and that this information would be documented on the screening log. LPN1 indicated that the facility currently had a COVID-19 unit, which housed two residents. Review of the facility's Employee-Visitor Screening Log documented that staff must write down the date, their name, temperature, and answer three yes or no questions: if they had shortness of breath, new or changed cough, or other respiratory symptoms. The log failed to include all screening questions, including travel and contact with someone with or under investigation for COVID-19. Review of the facility's screening logs, dated [DATE] forward, revealed the following: In the month of March, 2020, the facility failed to ensure that one visitor answered the screening questions and failed to ensure that a second visitor documented their temperature. The facility also failed to ensure that one staff person answered the screening questions. The facility failed to ensure that two staff documented their temperatures. The facility failed to ensure that two staff documented their temperatures and answered the screening questions. Additionally, NA2, responsible for assisting with the care of residents, reported experiencing possible signs or symptoms of COVID-19 on the 21st and 22nd. NA2 worked their shift both days that the symptoms were reported. In the month of April, 2020, the facility failed to ensure that a visitor answered the screening questions and document their temperature, failed to ensure that four visitors documented their temperatures, and failed to ensure that five visitors answered the screening questions. The facility failed to ensure that three staff documented their temperatures and answered the screening questions, failed to ensure that four staff answered the screening questions, and failed to ensure that seven staff documented their temperatures. In the month of May, 2020, the facility failed to ensure that three visitors documented their temperatures and answered the screening questions, failed to ensure that four visitors documented their temperatures, and failed to ensure that six visitors answered the screening questions. The facility failed to ensure that a staff person documented their temperature and answered the screening questions, failed to ensure that four staff answered the screening questions, and failed to ensure that ten staff documented their temperatures. NA2 worked their shift after reporting possible signs or symptoms of COVID-19. Additionally, an unknown person, who did not leave their name, reported possible signs or symptoms of COVID-19. In the month of June, 2020, the facility failed to ensure that five visitors documented their temperatures and failed to ensure that eight visitors answered the screening questions. The facility failed to ensure that two staff documented their temperatures and failed to ensure that two staff answered the screening questions. Additionally, NA3 worked their shift after reporting possible signs and symptoms of COVID-19 and two hostesses (H2 and H3) (staff that serve meals and assist with unit activities) worked their shifts after reporting possible signs and symptoms of COVID-19. H1 worked three shifts after reporting possible signs and symptoms of COVID-19 before each shift. In the month of July, 2020, the facility failed to ensure that two visitors answered the screening questions and failed to ensure that three visitors documented their temperatures. The facility failed to ensure that one staff documented their temperature and answered the screening questions, failed to ensure that one staff person documented their temperature, and failed to ensure that seven staff answered the screening questions. The facility failed to ensure that eight staff and one unknown person documented accurate temperatures, when they documented temperatures ranging from 69.9F to 90.6F. Additionally, NA6 worked one shift, and NA4 worked two shifts after reporting possible signs or symptoms of COVID-19. H1 and H2 worked their scheduled shifts after reporting possible signs or symptoms of COVID-19. NA5 worked their shift after reporting possible signs and symptoms of COVID-19, was tested the next day, and was found to have COVID-19 after working their scheduled shift providing care to the residents of the facility. In the month of August, 2020, as of [DATE], the facility failed to ensure that two staff answered the screening questions. NA4 and H1 each worked one shift after reporting possible signs and symptoms of COVID-19. On [DATE] at 9:30am, the Administrator indicated that H4 tested positive for COVID-19 following an exposure outside of work on [DATE]. H4 worked on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. H4 was not aware they were exposed until [DATE], at which point they did not return to work and were tested for COVID-19. H4 tested positive on [DATE]. On [DATE], a resident experienced a change in condition which required hospitalization . The resident was found to have COVID-19 on [DATE]. On [DATE], NA5 reported experiencing respiratory symptoms on the staff screening log, but worked their shift. On [DATE], NA5 reported congestion and loss of smell, and was sent home and tested for COVID-19. On [DATE], NA5's results were positive. On [DATE], the facility tested all residents on that end of the building with the rapid-result COVID-19 tests. The facility identified three positive cases, who were then tested again. One resident was negative, and two were positive. One of the two positive residents later expired, following a decline in condition. The facility isolated the residents in a negative air-pressure unit. On [DATE], the facility tested all staff who worked on that end of the facility. All tests came back negative. On [DATE], a staff person who tested negative on [DATE] required admission to a local hospital, and at that time tested positive for COVID-19. The Administrator indicated that the facility was unable to determine the cause of the positive cases, and indicated that they believed that it was caused by an asymptomatic staff person. On [DATE] at 1:11pm, the Director of Nursing (DON) indicated that staff must screen themselves prior to starting their shifts. The DON indicated that the staff were good about reporting what could be symptoms of COVID-19 to the charge nurses, and that the nurse managers for the units oversaw the screening process. The DON indicated that over the last three months, there were maybe two instances of staff reporting symptoms. The DON indicated that she was unaware of any issues with the staff screening process. On [DATE] at 2:00pm, the Administrator indicated that the DON was responsible for overseeing the staff screening process, and that she provided some assistance with the oversight. The Administrator indicated that she was unaware of any issues with the staff and visitor screening process. Review of the facility's policy, titled Infection Control Program, COVID-19, dated ,[DATE], documented: Monitoring employees for fever or respiratory symptoms, such as, cough or shortness of breath at the beginning of their shift. They will actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat.

Based on clinical record review, staff interviews and observations the facility failed to provide adequate supervision during transfers for 2 of 3 residents (Resident # 16 and Resident #38). The facility reported a census of 81. Findings include: 1. The annual Minimum Date Set ((MDS) dated [DATE] revealed Resident # 16's Brief interview for Mental Status (BIMS) of 4 out of 15, indicating severe impairment for cognition. The resident required extensive assistance of 1 staff for bed mobility, transfers, walking in and out of room, dressing, toileting and personal hygiene. Resident #16 used a walker and wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. Resident #16's Care Plan dated 4/5/26 included problem areas of falls related to weakness, poor cognition and history of falls. An approach dated 6/27/18 to use bed and chair alarm at all times. An update on 6/30/19 included: fall in room, do not leave her unattended in wheelchair, alarms at all times. The update on 7/5/19 included fracture to the left ankle and [MEDICAL CONDITION] in left lower leg. A Progress Note dated 6/30/19 at 10:05 AM documented by Staff H, Registered Nurse (RN) included, staff entered room and found Resident #16 on the floor laying on back, in front and beneath the sink in the bathroom. The Certified Nurse Aide (CNA) Staff I reported during process of toileting had disabled the wheelchair alarm and then had left the room briefly to answer another call light. When Staff I returned to the room, Resident #16 was found on the floor. The resident complained of left leg pain with intense pain when the left hip palpated. The residents left lower leg was rotated outward with slight shortening and complained of increased pain with slight movement of foot. No further Range of Motion (ROM) to left leg was conducted. Resident #16 also complained of lower back pain with minimal ROM to right lower leg. ROM to her upper extremities was within normal limits. No bruising noted at present. Residents head placed on pillow and blanket placed over lower body to provide as much comfort as possible. Difficulty obtaining vitals due to resident yelling out with blood pressure cuff tightening and moving arm. Does not comprehend situation. Discussed incident with staff on duty. Reviewed care plan and need to have bed and chair alarms activated at all times when unattended by staff. Staff I aware and admitted to disconnecting alarm and leaving to answer another light. The Post Fall Huddle for Resident #16 dated 6/30/19 noted the fall happened in the bathroom and the resident did not give an appropriate answer when asked what she was trying to do when she fell . It include the resident was sitting in her wheelchair in the bathroom before the fall and the alarm had been deactivated. Education completed by charge nurse and the CNA aware of error and admitted to disconnecting the alarm and leaving to answer another call light. The Progress Note dated 6/30/2019 at 10:20 AM noted the ambulance here and transported Resident #16 to the emergency room (ER). Progress Notes dated 6/30/2019 at 12:08 PM noted a call received from ER. Reported no fracture to lower extremities. Chest x-ray was negative. The ER nurse reported tenderness to lateral right rib area. Resident #16 tested positive for a urinary tract infection and will return on antibiotic. The resident had IV [MEDICATION NAME] (antibiotic) while at hospital. Daughter-in-law will transport back to nursing home per private car. At 2:30 PM the resident arrived per car with daughter. The residents daughter aware of orders. Staff assisted Resident #16 from the vehicle. The resident was alert and complained of left knee pain with movement and had bruising to left arm. Denies pain to right rib area with palpation. The Progress Notes dated 7/01/2019 at 3:02 PM included Resident #16 complained of pain in left leg, knee and ribs. Tylenol given during the day and ice applied to left knee. Resident stated some relief. No new bruises or further injury noted. An EZ stand was used during this shift to transfer resident. Will continue to monitor. At 9:43 PM noted the resident started crying in pain when moved left leg/knee area. Given PRN Tylenol. Needed to use EZ stand for transfers. Staff will monitor. The Progress Notes dated 7/02/2019 at 2:50 PM included the resident complained of pain in the left leg/knee area. [MEDICAL CONDITION] was noted to left knee and leg. Given PRN Tylenol. EZ stand used for transfers this shift and will continue to monitor. At 9:42 PM the resident voiced complaints of pain to left leg/knee area, the area is swollen. No further bruising or injury noted. Needed to use EZ stand for transfers. Will monitor. Progress Note dated 7/03/2019 at 2:30 PM included Resident #16 complained of pain this morning when getting up but is currently comfortable and denies any pain. Left lower leg has 2+ [MEDICAL CONDITION]. No new bruising noted. Resident is resting in her room, transfers with EZ Stand. Is unable to put weight on left leg. Will continue to monitor. Progress Note dated 7/05/2019 at 10:25 AM noted unable to obtain appointment at clinic. ER contacted and updated recent fall, swelling, warmth and painful lower left leg . Order for the resident to be seen in the ER. The emergency room Visit for Resident #16 dated 7/5/19 included reason for the visit today was ankle pain and the [DIAGNOSES REDACTED]. During an interview on 8/06/19 at 1:51 PM Staff H, RN acknowledged the CNA involved to be Staff I after reading the above Progress Note dated 6/30/19 During an interview on 8/06/19 at 4:00 PM Staff H acknowledged when she went into Resident # 16's room the alarm was not attached and the Staff I admitted she had disconnected the alarm before leaving the room. During an observation and interview on 8/07/19 at 12:59 PM Staff I took Resident #16 into room and called for assistance while hooking up the the Liko lift (a mechanical lift for non weight bearing transfers) to transfer her. Staff I acknowledged she unhooked the alarm and left Resident #16 alone in her wheelchair and left the room. Staff I stated she made a mistake and still felt bad about it. During an interview on 8/07/19 at 2:21 PM the Director of Nursing (DON) acknowledged she did do an investigation with Staff I and she made a mistake, we all make mistakes. During an interview on 8/07/19 at 3:03 PM Staff K, RN Unit Manager explained she would expect staff to not leave a resident alone with out an alarm hooked up if they normal had an alarm. 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #38 demonstrated long and short term memory problems and severely impaired skills for daily decision making. The resident depended on staff for transfers. The resident's [DIAGNOSES REDACTED]. The Care Plan revised 3/29/19 identified the resident with a self care deficit. The interventions included transfer with the mechanical lift with 2 assist. The Progress Notes dated 5/1/19 at 4:40 PM documented staff notified the nurse the resident was on the floor. The nurse entered the room and found the resident laying on the floor in the doorway of room with her head toward the bathroom. The resident had a raised bump to the back of her head. The Certified Nursing Assistant (CNA) indicated the resident slipped through the sling of the mechanical lift when transferring from the wheelchair to the toilet. The resident's foot was in the air, hooked on the sling, and the rest of her body on the floor. The nurse reviewed the proper use of the sling with staff. A Post Fall Huddle form dated 5/1/19 included education done at the the time if interventions were not followed: noted the sling not put on properly. During an interview on 8/6/19 at 11:00 AM Staff G, Registered Nurse (RN) stated worked the day the resident fell from the lift. Staff G stated Staff F, CNA called her to the room and the resident was on the floor. Staff G did not think the resident had the sling hooked up properly to the lift. Staff G did not think there was another CNA in the room with Staff F at the time of the incident. During an interview on 8/6/19 at 11:10 AM the Director of Nursing (DON) stated there was a student CNA assisting with the transfer at the time of the incident. At 1:45 PM, the DON stated the CNA students paired up with the CNA's and provided assistance. She said Staff F had not crossed the the straps between the legs, and admitted she had not always crossed them. During an interview on 8/6/19 at 4:40 PM Staff F stated she had not worked with the the facilities' mechanical lift before she came here and stated when she trained they did not tell her the straps needed to be crossed. She had used it before with this resident and not had any trouble when the straps were not crossed. A CNA Orientation Checklist documented all mechanical lifts must be demonstrated by the orientee to a CNA before the end of the orientation period. It included the total mechanical lift would be used to assist with transfer of a resident in a safe manner to prevent injury to staff and resident. The directions included to position the leg supports under the resident's thighs and cross the leg straps.

Based on observation, record review, and staff interview the facility failed to assure residents on a ground and pureed diet received the appropriate portions for 17 residents. The facility reported a census of 81 residents. Findings include: The noon menu for Wednesday 8/7/19 included 3 ounces of barbecue ribs for the regular diet, 3 ounces ground for mechanical soft diet and 3 ounces pureed for the pureed diet. The Cottage Food Directions identified 13 residents on mechanical soft diets (which included ground meat) or ground meat diets, 2 residents on ground meat if chose to, and 3 residents on pureed diets. During an observation on 8/7/19 at 10:13 AM Staff A, Cook weighed and ground 12, 3 ounce servings of ribs. She portioned 1/3 scoop servings into pans for each cottage, 2 for Grandview, 4 for Countryside, 7 for Pheasant Run, and 2 for Sunrise (for a total of 15). Pheasant Run had 1 resident on a trial of pureed meat and 1 who requested the alternate so only 5 would be served the ground rib (leaving 13). There was a large amount of (the 12 servings ground) ribs leftover. Staff A portioned 1 extra scoop of the ground ribs into each cottage pan. There was still a large amount of the ground ribs remaining, and Staff A pureed the remaining for 4 pureed diets. She portioned 12 servings of the ground ribs for 17 residents. During an observation of the noon meal service in Sunrise Cottage at 11:35 AM Staff C, Hostess served 2 residents a 1/3 cup scoop of ground meat. There was 1 scoop of ground meat leftover. Staff B, Hostess in Countryside Cottage stated she served the 4 residents on ground meat plus 1 additional resident (5 residents served) a 1/3 cup scoop of ground meat, with 2 scoops leftover. Staff D, Host in Pheasant Run stated he served 5 residents a 1/3 cup scoop of the ground ribs, and had 4 scoops leftover. Staff E, Hostess in Grandview stated she had served 1 resident a 1/3 cup scoop of ground ribs and had 2 scoops leftover. Staff served 17 residents (13 ground and 4 pureed) from 12 servings of meat and still had 9 (1/3 cup) scoops leftover. During an interview on 8/7/19 at 12:28 PM the Dietary Supervisor acknowledged the cook ground 12 servings of the ribs and that was used for all the ground (13) and pureed (4) meats. She said she asked Staff A about grinding and she usually didn't do so much at once. She said they did not have a policy directing how to grind multiple servings of meat to assure appropriate servings. The facility policy, Menu Planning revised 7/06 documented menus were planned to meet the nutritional needs of residents in accordance with their physician's orders [REDACTED].

Based on record review and staff interviews the facility failed to have staff complete the Mandatory Reporter for Dependent Adult 2 hour class within 6 months of hire. The facility reported a census of 81. Findings include; According to the new hire list provided by the facility, Staff M, Certified Nurse Aide (CNA) had an employment start date of 5/22/18. Staff M provided a certificate for Mandatory Reporter Certification: Child and Dependent Adult dated 6/20/2016. During an interview on 8/7/19 at 3:00 PM the Administrator acknowledged she did not know how many hours were included in the class and explained she would call the community college to find out. During an interview on 8/7/19 at 4:30 PM the Administrator explained she had gotten a call back and the class was 2 hours and included both child and adult.

Based on record review and observations the facility failed to develop a care plan for new [DIAGNOSES REDACTED].#30 and #46). The facility reported a census of 81. Findings include: 1) According to the Minimum Data Set with assessment reference date 5/29/19 Resident #30 had a BIMS score of 15, cognitively intact skills for daily decision making. The resident required extensive assist of one staff for eating. A Nursing Home Educational Form dated 3/18/19 revealed Resident #30 had a history of [REDACTED]. The Resident Progress Notes dated 5/17/2019 at 6:17 AM revealed Resident #30 had dark brown emesis on face and chest with a low grade fever noted. The Resident Progress Notes dated 5/17/19 at 10:50 PM revealed Resident #30 had course crackles and wheezes throughout her bilateral lung fields, difficulty breathing and abnormal vital signs. The Resident Progress Notes dated 5/18/2019 at 1:00 AM noted Resident #30 was seen in the emergency room and diagnosed with [REDACTED]. The Physician order [REDACTED].#30, dated 8/5/19 -10/5/19, included an order for [REDACTED]. Observation on 8/05/19 at 3:14 PM Resident #30 was in a recliner with feet elevated and oxygen concentrator next to her.The resident reported she wears oxygen at night and when needed. Resident #30 coughed frequently during the interview. Resident #30's Care Plan lacked [DIAGNOSES REDACTED]. 2) According to the Minimum Data Set with assessment reference date of 6/12/19 Resident #46 had a BIMS score of 5, severely impaired cognitive skills for daily decision making.The resident required extensive assist of one staff for toileting and was frequently incontinent of bowel and bladder. Resident #46's Face Sheet showed a [DIAGNOSES REDACTED]. A Resident Progress Note dated 6/10/19 at 5:38 AM noted Resident #46 had blood in his urine and increased incontinence. A Resident Progress Note dated 6/25/19 at 3:37 PM revealed the resident had increased restlessness. A Resident Progress Note on 6/27/19 at 4:36 AM noted the resident had increased confusion, increased incontinence and increased frequency of urine. A Resident Progress Note on 6/28/19 at 3:58 AM noted Resident #46 had increased anxiety, restlessness and hallucinations. Resident #46 had a Resident Progress Note on 7/01/19 at 12:09 PM resident with increased restlessness. A Resident Progress Note on 7/03/19 at 7:45 AM revealed the resident had increased confusion. A Resident Progress Note on 7/05/19 at 2:00 AM documented the resident had increased anxiety. The Resident Progress Notes on 7/09/19 at 12:10 PM revealed continued anxiety. At 1:35 PM the resident had been found on his knees. At 3:36 PM it was noted the resident had some blood in his urine. The Resident Progress Note on 7/10/19 at 2:47 AM revealed Resident #46 had droplets of blood in his urine. The Resident Progress Notes on 7/11/19 at 2:26 PM noted a new order for a UA related to hematuria. At 5:28 PM revealed UA results positive for moderate bacteria, moderate leukocytes, trace [MEDICATION NAME] and large amount of blood. A Resident Progress Note on 7/12/19 at 7:35 AM revealed family requested not to treat the Urinary Tract Infection. Resident #46's Care Plan did not include the [DIAGNOSES REDACTED].

Based on clinical record review, facility policy, observations and staff interviews the facility failed to properly handle the catheter during cares for 1 of 1 resident (Resident # 43). The facility reported a census of 81 residents. Findings include: The quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #43 revealed his Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating severe impairment for cognition. The MDS included he required extensive assistance of 1 staff for transfers, toileting and personal hygiene and had and indwelling catheter. Resident #43 had [DIAGNOSES REDACTED]. Resident #43's Care Plan dated 3/21/17 included a focus area for potential comfort and a self-care deficit related to indwelling Foley catheter. The approach to empty Foley catheter bag every shift and prn. (More frequently if needed), document amount and to provide catheter care every shift and prn. The facility policy Handwashing revised on 7/2006 included: staff are to perform proper hand hygiene before and after each direct resident contact. The facility policy Catheter Care revised on 4/2014 included urethral catheter insertion site cleaning. The policy directed staff to cleanse the catheter beginning at the insertion site and moving away from the site along the catheter at least 4 inches. During an observation on 8/06/19 at 11:52 AM Staff L, Certified Nursing Aide (CNA) entered room, undid alarm and lowered foot of the recliner. Staff L checked the resident's leg bag, donned gloves and grabbed the graduate. Staff L opened a cabinet and grabbed alcohol swab and placed the graduate on the floor, without a barrier, and emptied 50 cc of urine into the graduate. During an observation on 8/07/19 at 6:56 AM Staff J, CNA preformed peri-care and failed to cleanse the insertion site down the catheter tubing. Staff J, after dressing and transferring Resident #43 to his wheelchair, washed her hands, donned gloves, rinsed dentures and placed the top set then the bottom. Staff J, with same gloves, grabbed the graduate, opened the cabinet, grabbed alcohol swabs and then paper towels. Staff J placed paper towels on the floor and then placed the graduate on top. Staff J pulled up Resident #43's left pant leg up, opened the spout to the catheter leg bag, and emptied it into the graduate. Staff J took her hand and pushed it down the outside of the leg bag to make sure it was emptied and wiped the spout with alcohol swab and placed the graduate on the counter top to read the amount, 200 ml, before she emptied the graduate of urine into the toilet During an interview on 8/07/19 at 3:21 PM the Director of Nursing (DON) acknowledged she would expect staff to have a barrier down any time they set the graduate down to empty urine or if setting it on the counter. She explained the cleaning down the tubing of the catheter is on the policy and they should be doing that.

Based on observation, record review, staff interview and policy review the facility failed to assess residents for the need for, benefits and risks of, and consent for bed rails for 18 of 18 current residents with bed rails reviewed. The facility reported a census of 81 residents. Findings include: Observation of 18 out of 18 residents reviewed revealed all had bed rails installed on their beds. Review of 18 resident records failed to document an assessment for the need for bed rails, education regarding risk verses benefit or a consent for the use of bed rails from the resident or their representative. When interviewed on 4/25/18 at 10:07 a.m. the Director Of Nursing (DON) stated the facility does not complete an assessment for the need for bed rails nor do they obtain consent for the use of bed rails from the resident or their representative. She stated that when a room is vacated, the maintenance man does a check list including checking the bed rails, mattress, headboard and functioning of the bed. She stated that the facility reviews the use of bed rails at care plan meetings. During an interview on 4/25/18 at 1:40 p.m. the DON provided a policy entitled Partial Bed rail effective 4/2009. The DON stated that she revised the policy today to include that a consent form will be completed for the resident/family who wish to use bed rails and a bed rail observation assessment will be completed with each Minimum Data Set (MDS). The DON also created a Side Rails Informed Consent and Release form on 4/25/18. The DON provided a list of 65 out of 81 current resident who use side rails (bed rails).

Based on record review and staff interview, the facility failed to notify the physician of a change of condition for 1 of 18 active residents reviewed (Resident #38). The facility reported a census of 81 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #38 had [DIAGNOSES REDACTED]. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score 3, severe cognitive impaired. The MDS indicated the resident required extensive assistance with activities of daily living (ADL's) including eating. The Care Plan dated 3/1/16 with the next care conference date of 3/20/18 identified the resident with the potential for alteration in nutritional status. The interventions included to monitor weights. A Physician's Progress Note dated 12/29/17 documented the resident's weight down a little bit at 211 pounds (lbs). A Vitals Report showed the resident weighed 211 lbs on 12/6/17, and 192 lbs on 1/2/18, a 19 lbs or 9% loss in 1 month. The same report showed the resident weighed 223 lbs on 8/1/17, and 192 lbs on 1/2/18, a 31 lbs or 13.9% loss in less than 6 months. The Progress Notes dated 1/2/18 at 10:35 a.m. documented the resident weight down 11 lbs (actual weight loss of 19 lbs) this past month. The resident could be very lethargic at meals. They would do weekly weights. At 2:41 p.m. the resident's family notified of his weight loss, and aware that he slept much more recently. The family did not want extra measures done like nutritional supplement. The clinical record lacked any documentation the facility notified the resident's physician of the significant weight loss. During an interview on 4/25/18 at 11:22 a.m. Staff A, Cottage Leader stated she found a prepared facsimile (fax) in a box of papers with an FYI (for your information) to the physician of an 11 lbs weight loss (not the 19 lbs or 31 lbs losses noted above). She acknowledged they had no documentation that the fax was actually sent, and no return from the physician. She called the physician's office and they did not have record of the fax and stated the physician would not respond to an FYI fax.

Based on clinical record review, staff interview and facility policy review, the facility failed to assure residents were free from abuse for 2 of 4 residents reviewed (Residents #2 and #3). The facility identified a census of 82 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 10/26/16, Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident displayed severe cognitive impairment, wandered daily and identified the resident required supervision with bed mobility, locomotion off the unit, eating and toilet use. The MDS revealed the resident required limited assistance with dressing and personal hygiene. The care plan dated 10/20/16 directed staff to monitor for and document any aggressive/combative behaviors. The care plan directed staff to document interventions the staff implemented if the resident displayed combative behavior toward another resident and to notify the cottage leader and DON (Director of Nursing) as well. An update to the care plan dated 11/14/17 documented the resident could be combative during cares and directed staff to reassure the resident, explain procedures to him/her and not force him/her as this makes the resident more upset. Another update to the care plan dated 12/19/17 directed staff to monitor and supervise the resident so staff know the resident's location and keep him/her separate from Resident #3 as much as possible. Review of the Progress Notes revealed the following entries: a. On 11/2/16 at 4:48 p.m., Resident #2 was in and out of other residents' rooms and made numerous exit seeking attempts. When staff redirected the resident from other residents' rooms, Resident #2 put up his/her fists and stated, This fist can knock you to the ground. Staff calmly and effectively redirected the resident. b. On 11/4/16 at 4:00 p.m., Resident #2 went to Bingo with other residents. Resident #2 became agitated and started to hit Resident #3 with a book. Resident #2 threw candy wrappers at Resident #3, who became upset and told Resident #2 to stop. Resident #2 yelled, Don't f-king tell me what to do, I hate this damn game. c. On 11/4/16 at 4:45 p.m., the RN documented the activity assistant who witnessed the above altercation reported she stood between Resident #2 and Resident #3 as a barrier between the 2 residents so they could not see each other. As the group left, the activity assistant stood by Resident #2 who unexpectedly swatted a different resident from across the table with his/her notebook. The activity assistant reported the notebook only brushed the other resident's stomach and she was able to redirect Resident #2 back to the cottage. The activity assistant and the DON discussed the situation and thought was Resident #2 was overwhelmed by Bingo because he/she became frustrated and overstimulated when he/she could not play. d. On 11/25/16 at 10:03 a.m., Staff asked resident to undress for his/her shower and the resident began to punch staff in the face. Once in the shower chair, Resident #2 began to kick staff in the groin and attempted several more times to do so. Staff applied gripper socks to the resident's feet and had him/her leave the room and sit in a recliner. e. On 11/26/16 at 12:48 a.m., the resident became agitated when the staff attempted to help him/her to the toilet, threatened to kill staff and break their wrists and then grabbed their wrists and would not let go. Staff checked the resident for incontinence. The resident had not been incontinent so he/she left the bathroom. f. On 11/18/16 at 9:57 p.m., Staff attempted to change Resident #2's pants due to incontinence and the resident grabbed staff's wrists and would not let go. At bedtime, the resident refused to stay in bed. Staff attempted to take the resident to the bathroom, redirected him/her to the room multiple times, offered a snack, then gave him/her an as needed (prn) medication. When staff gave Resident #2 water, he/she hit the glass out of staff's hand and started to yell. g. On 11/29/16 at 11:39 p.m., Resident #2's room door was closed so staff opened it. Resident #2 stood in the doorway and his/her eyes were huge. The resident asked staff if they had locked the door and they told him/her the doors didn't lock. The resident stated, I'll have to trust you, but my first instinct is to kill you. The resident went back into their room. h. On 11/20/16 at 1:56 p.m., staff documented the resident could not stay in bed the night before and staff gave him/her [MEDICATION NAME](sleep medication). The resident still woke up early on (day) shift and remained short tempered and irritable. The resident was difficult to redirect and give medication to when Resident #2 looked for his/her spouse. A CNA found Resident #2 in another resident's room. Resident #2 was adamant he/she was going to wake the other resident. i. On 12/16/16 at 9:20 p.m., staff led the resident to the bathroom and he/she had grabbed the staff's wrist and called the staff a bastard. Another staff came in and attempted to divert the resident and told him/her she would help the resident get ready for bed. Resident #2 yelled and swore and attempted to grab staff as they tried to provide incontinence care. j. On 12/7/16 at 10:09 p.m., staff documented the resident was agitated that afternoon, grabbed a staff's wrist, and not let go. The resident then staff he/she was going to break staff's wrist and then kill her. Awhile later the resident told staff he/she killed his/her spouse and proceeded to continuously walk into another resident's room. The other resident told Resident #2 not to go in his/her room anymore. k. On 12/18/16 at 10:00 p.m., the RN documented staff had requested assistance. When the RN arrived, she documented she observed Resident #2 held a blood spattered pillow. The resident was angry and tried to swing his/her fists at staff. The CNA told the RN staff had redirected Resident #2 away from another resident's room. At the same time, a different resident (Resident #3) exited his/her room and Resident #2 approached Resident #3 to shake his/her hand. Resident #2 then squeezed Resident #3's hand tightly and would not let go. Resident #3 became upset and staff attempted to separate them. Before staff could do so, Resident #3 punched Resident #2 in the face and Resident #2's nose began to bleed. Extra staff arrived and were able to separate the residents and take them to different areas. Resident #2's nose (left nare) bled; he/she had blood in his/her mouth and sustained a 1 cm (centimeter) slit on the right lower lip. Staff applied a cold cloth to the nose and lip and saw a moderate amount of blood; however the bleeding stopped quickly after staff applied pressure. Staff separated the residents into their respective rooms. While staff assessed, applied pressure and cleaned the blood from Resident #2's face, he/she remained angry and stated someone was going to be killed and it was not going to be him/her. Staff assured Resident #2 he/she was safe. The record revealed Resident #2 calmed down but continued to wander while staff monitored him/her. l. On 12/19/16 at 10:33 AM revealed Resident #2 had no injuries or bruising noted to his/her face and remained calm. Resident #2 commented he/she had been punched last evening and did not want it to happen again. 2. According to the MDS dated [DATE], Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident displayed severe cognitive impairment, wandered daily and displayed physical and verbal behavioral symptoms directed toward others. The MDS revealed Resident #3 rejected care on 4 to 6 days during the assessment period and identified the resident required supervision with locomotion off the unit, dressing and personal hygiene. The care plan dated 8/30/16 directed staff when resident became anxious, try not to tell him/her no or you can't do that. Rather, attempt to redirect by asking questions and using positive reinforcement. Review of the Progress Notes revealed the following entries: a. On 9/15/6 at 3:52 p.m., the resident's spouse left for the day. The resident exited his/her room and asked where their spouse went. The RN told him/her their spouse went shopping. The resident became angry and slapped the RN's hand. The staff redirected Resident #3 with popcorn at the café. At 4:12 p.m., staff escorted the resident back from the café and he/she called staff a son of a b-tch (SOB). The RN attempted to give Resident #3 his/her medication. The resident slapped the medications out of the RN's hand and the medications flew everywhere. At 4:21 p.m., staff observed the resident pushing another resident in a Merry Walker. Resident #3 said the resident he/she was pushing was a cocky SOB and had run into him/her (Resident #3) with the Merry Walker. Staff was afraid Resident #3 might punch someone so they redirected him/her by asking the resident to fold washcloths. b. On 10/9/16 at 9:15 p.m., staff documented the resident called a staff member an SOB, verbally attacked other residents, and was extremely restless and agitated. Resident #3 got in another resident's face and told another resident he/she was a loser and a freeloader. c. On 10/11/16 at 9:20 p.m., staff documented the resident verbally attacked staff and acted extremely restless and agitated. The resident repeatedly asked for his/her spouse and sibling and became angry when told they were not there. d. On 10/24/16 at 1:20 p.m., staff documented the resident wandered in and out of rooms, looked for various people, and became more and more anxious. Staff attempted to visit with the resident and offered puzzles, but Resident #3 remained anxious. Staff administered as needed [MEDICATION NAME] for anxiety. e. On 11/15/16 at 3:27 p.m., the resident approached staff and asked them to call his/her spouse. Staff said she would call in a little while after the activity was finished. The resident stated, What's more important? The staff person turned to answer another resident's question and Resident #3 hit the staff in the back of the head. He she then became teary-eyed and walked away. f. On 11/18/16 at 2:48 a.m., Resident #3 wandered into another resident's room while staff prepared that resident for bed. Staff asked Resident #3 to leave and he/she became angry and slammed the door very hard. This frightened the resident the staff were helping. g. On 11/19/17 at 4:40 p.m., staff noted Resident #3 walked quickly past the kitchen counter, went into the hallway and yelled, get away from there. Staff responded and saw Resident #3 jerked around another resident's Merry Walker, and yelled, Stop touching that (the handrail). Resident #3 had one hand on the Merry Walker and one hand on the other resident's left arm. Resident #3 was very angry and continued to yell, He/she has no right to touch that (handrail). Staff removed the other resident from the area and Resident #3 calmed and told staff he/she tried to save the other resident from injury because everything happened so fast. Staff redirected Resident #3 to the dining room for a cup of tea and noted no further incidents. h. On 11/20/17 at 11:11 p.m., Staff documented the resident as agitated, anxious, demanding and threatening. The resident told staff they needed to get all those people out because it is his/her house. Staff redirected the resident several times (laundry and wiping handrails) and the resident was diverted for a short while, but then resumed pacing. i. On 11/28/16 at 10:06 p.m., Resident #3 walked into another resident's room while staff was helping that resident to bed. Resident #3 asked where his/her spouse was and when staff did not answer right away, the resident grabbed the staff person's arm and the EZ Stand. When staff tried to loosen the resident's grip, the resident grabbed the staff person's other arm and began to shake the staff member. Resident #3 then let go, reached for the staff member's neck, pushed her back, and then attempted to punch her in the face. Another staff heard the commotion and intervened. j. On 11/29/16 at 1:02 a.m., Resident #3 wandered in and out of other residents' rooms, turned on the lights, and woke them up. Staff redirected the resident multiple times until the resident went back to his/her room and went to sleep. k. Staff was in another resident's room and Resident #3 mistakenly thought staff was hurting the other resident. Resident #3 started to push the other resident (away from staff) and stated, You get off of (him/her) right now. The other CNA told Resident #3 she would remove the other resident from the situation and Resident #3 calmed down. l. On 12/12/16 at 9:44 p.m., Resident #3 wandered into another resident's room while staff helped get that resident ready for bed. Staff escorted Resident #3 out of the room and he/she began to yell and attempted to hit staff. Another staff intervened and Resident #3 did the same to the other staff member. The resident continued to be agitated, wandered around, and refused to go to bed. m. On 12/12/16 at 10:17 p.m., staff documented Resident #3 had been agitated all evening and displayed many physical behaviors. For no apparent reason, Resident #3 approached the nurse's station, yelled at the staff, called them inappropriate names, leaned over the nurse's station and tried to hit them. n. On 12/15/16 at 11:55 p.m., staff documented the resident had been agitated and aggressive that shift. Staff attempted to redirect Resident #3 several times with cleaning, a snack, and one-to-one interactions. Staff then gave an [MEDICATION NAME] (anxiety medication) to the resident but it was not effective. o. On 12/18/16 at 10:00 PM, Resident #3 had been in bed in his/her room. He/she got up and walked into the hall where he she encountered Resident #2. Resident #2 approached Resident #3 to shake his/her hand and then Resident #2 squeezed Resident #3's hand tightly and would not let go. Resident #3 became very upset. Staff attempted to separate the residents but before they could do so, Resident #3 punched Resident #2 in the face. Additional staff arrived and were able to redirect both residents to their respective rooms. When Resident #3 returned to his/her room, the resident did not remember he/she hit Resident #2 and said, that's a lie. The resident then rested in his/her room. During an interview with Staff A, CNA/Hostess on 1/17/16 at 4:35 PM, she stated Resident #2 had a history of [REDACTED]. Staff A reported the resident mostly became anxious with clothes changes, toilet use, and bedtime cares. Staff A stated on 12/18/16, staff attempted bedtime cares and the resident became anxious so staff left him/her in the room to calm down. The resident came out of his/her room with a pillow, hit staff, and then began to wander. At that time, Resident #3 exited his/her room and Resident #2 held out his/her hand to shake hands. Resident #3 shook his/her hand and Resident #2 squeezed Resident #3's hand. Staff A reported she stood in the middle of the residents and tried to separate their hands. Resident #3 became upset, reached around staff and struck Resident #2 in the face. Resident #2 had blood on his/her face and the nurse assisted him/her. Resident #3 became upset and scared to go to his/her room. Staff assisted Resident #3 to calm down. During an interview with Staff O, RN (Registered Nurse) on 1/19/17 at 11:20 AM, she stated she had been called to go to the unit. She saw Resident #2 had a nose bleed. Staff A assisted Resident #3 and cleaned the blood from Resident #2's face. She stated no treatment had been required and the bleeding stopped right away. Staff A reported the area on the lip had been superficial and Resident #3 calmed down and did not remember the incident. Resident #2 had been scared and stated he/he had been hit in the face. The resident wandered, settled around 11:00 PM to 11:30 PM, and then slept. During an interview with the Director of Nursing on 1/19/17 at 11:40 AM, she stated she investigated the incident the next morning and Resident #2 did not have an injury. She further stated Resident #2 had a history of [REDACTED]. Resident #2 also had a history of [REDACTED]. Review of the Policy and Procedure titled Abuse Prevention and Response dated 12/16 directed staff: a. Residents must not be subjected to abuse by anyone, including, but not limited to .other residents. Resident-to-resident physical contact that occurs, which includes but is not limited to hitting, slapping, pinching or kicking and results in physical harm, pain or mental anguish is considered resident-to-resident abuse. An example would be a resident slapping another resident who is physically or cognitively impaired; although the resident who was slapped showed no reaction, it is presumed the resident experienced pain.