Every finding on record at Red Oak Rehab and Care Center

Based on clinical record review, Medical Examiner records, staff interviews, first responder interviews, and policy review the facility failed to meet 1 of 3 resident's mental health needs (Resident #1), when they did not intervene per her care plan with her comments of wanting to die and did not update the provider of the ongoing comments. Resident #1 had diagnoses of depression, dementia with agitation, other symptoms/signs involving appearance and behavior, and altered mental status. The resident presented with a history of suicidal ideations, previous attempts while at the facility. The facility failed to notify the provider of the continued comments of wanting to die. On [DATE] at 9:43 PM a staff member found the resident with a plastic bag over her head, with no respirations and a faint pulse. Staff failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 immediately. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. On [DATE] at 9:45 PM the nurse pronounced the resident deceased . On [DATE] the facility staff self-reported the incident to the Department of Inspections, Appeals, & Licensing. The facility staff fully corrected the deficient practice on [DATE] prior to the start of the survey by completing the following:1. Suicide Safety and Precautions Policy training to all staff.2. Behavior Health Management Policy training to all staff.3. Notification of Changes Policy training to all licensed nurses.4. The electronic record's KARDEX system training to the nursing staff.The facility reported a census of 29 residents.Findings include: The Minimum Data Set (MDS) for Resident #1 completed on [DATE] revealed the Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The document revealed no acute onset of mental status change. The Resident Mood Interview revealed the resident indicated little interest or pleasure in doing things never or 1 day in the last 2 weeks,and feeling down, depressed or hopeless 2-6 days in the past 2 weeks. The document's Behavioral Symptoms indicated no hallucinations or delusions, verbal behavioral symptoms directed toward others 1 to 3 days, behavioral symptoms not directed toward others 1 to 3 days, and rejection of care 1 to 3 days. The MDS coded the resident required total assistance of staff for dressing, toileting, hygiene, and transfers. The document disclosed the resident's diagnoses renal insufficiency/failure/End-Stage Renal Disease, Non-Alzheimer's Dementia, Depression, Altered Mental Status, unspecified, and Other Symptoms and Signs Involving Appearance and Behavior. The document provided the resident received scheduled pain medication and as needed pain medication. The staff assessment of the resident's pain in the last 5 days revealed the resident exhibited pain daily by non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements. The document included the resident was prescribed antipsychotic, antianxiety, and opioid medications. The MDS revealed the resident received hospice services. Resident #1's Care Plan revised [DATE] disclosed a focus area that the resident exhibited suicidal ideation placing the resident at risk for self harm (initiated [DATE]) with staff interventions to initiate suicide precautions per facility policy ([DATE]), notify physician/provider of suicidal ideation and obtain/implement new orders as indicated ([DATE]), notify presponsible party per resident consent and facility policy ([DATE]), provide increased observation/monitoring per assessed level of risk ([DATE]) and remove or restrict access to potentially harmful objects per facility policy ([DATE]). The Medication Administration Record (MAR) 8/26 revealed the resident exhibited 5/10 pain on 8/10 and was provided with Hydromorphone HCI Oral Liquid 1 milligram (mg)/milliliter (ml) every hour as needed for pain (start date [DATE]). This is the only documented time the medication was provided in 8/26. The clinical record's Progress Notes 2/22/ 26 - [DATE] revealed the following entries:On [DATE] at 11:46 PM the resident made several comments during the evening about dying. The resident refused vitals, medications and repeated it won't do any good. The resident was assisted to bed and 15 minutes later at a recheck the resident was reaching for the trash can. When the resident was asked what she needed, the resident refused to answer and the staff removed the trash bag liner. The staff continued with rechecks and on the last recheck the resident was found with her gown wrapped around her neck. The nurse requested the staff get the resident up and bring to the nurses'station so we all can watch her. The document stated a fax would be sent to the provider. On [DATE] at 6:14 AM the resident was a 1:1 at the nurses' station due to attempting suicide during the night. The resident was resistant to all cares and medications. The primary care physician was notified and an order was received to send the resident to the emergency department (ED). The resident left at 8:20 AM by emergency medical services (EMS). On [DATE] at 2:22 PM the resident returned from the ED with no physical findings for the resident being suicidal. The facility continued 15 minute checks. The facility's document, Physician Communication Fax, dated [DATE] revealed the following communication to the provider: the resident made several comments this shift about wanting to die. The resident was found trying to grab a trash bag and stated she is going to kill herself. The document included the resident was placed on 15 minute watch and after an hour found the resident with a gown wrapped around her neck. The communication disclosed the resident was mobile in her wheelchair (w/c) and while at the nurses' station when the resident thought no one was watching she would attempt to grab any plastic bag she could to continue her plan. The communication to the physician concluded with any orders/concerns. The document included a response from the physician of why the resident wasn't sent to the ED after the first attempt or at least contacted the on-call provider. The facility's response to the physician's questions included the resident's refusal and following her rights. The physician's final documented response was the resident attempted suicide 3 times. The Emergency Department Report dated [DATE] revealed to continue current medications and observe closely for worsening depression or suicide attempt. The Physician Orders revealed the following orders:Celexa ordered [DATE] for other symptoms and signs involving appearance and behavior, and discontinued on [DATE]. Ativan, Benedryl, Haldol (ABH) Gel 1 ml topically to inner wrist or forearm twice daily for agitation start date [DATE].admission to hospice [DATE].The Hospice Orders, dated [DATE], revealed to notify hospice with questions, needs or any status changes. Resident #1's clinical record's Progress Notes from [DATE] - [DATE] revealed the following entries:[DATE] 6:06 AM The resident had a visitor who was heard to tell the resident if wasn't good she wouldn't get into heavenXXX[DATE] 4:23 PM The resident's emergency contact indicated he wanted all of the resident's visits with friends monitored as the resident became more depressed following the visits. [DATE] 2:49 PM The resident stated she couldn't get out of the facility unless she died. The resident was at the nurses' stationXXX[DATE] 5:21 PM The resident told the staff it was too late to ask for forgivenessXXX[DATE] 2:42 AM The resident continued to demonstrate a recurrent pattern of behaviors consistent with going behavioral health symptomalogy, including accusatory statements toward staff, expressions of perceived contamination, refusal of care and offered interventions, agitation during assistance with self cares, and episodic physical resistance toward staff. The behaviors appeared cyclical in nature and likely related to underlying psychiatric or mental health diagnoses. [DATE] 9:17 AM Hospice aware of behaviorsXXX[DATE] 4:57 PM Resident observed tearing up facial tissue and told staff she was going to hellXXX[DATE] 11:24 AM The resident stated she thought she had died on a previous dayXXX[DATE] 4:30 PM The resident during a Care Plan meeting wanted to know why she was still living in his manner, why she wasn't getting better and what purpose was her life in this state. [DATE] 4:24 AM The resident revealed to a nurse that she was in a shell now; I am not really alive anymore. [DATE] 1:23 AM The resident remembered telling staff that she had officially died. The resident also indicated she knew she had dementia and said it was dream-like. [DATE] 2:09 AM The resident was awake, agitated, attempted to throw herself out of her w/c and stated she would like to die. The resident was placed at the nurses' station under 1:1 supervisionXXX[DATE] 5:37 AM The resident was awake all night, second night in a row, hallucinating, manic eyes, hissing, hitting, attempting to bite and resisting all cares and as needed medicationsXXX[DATE] 5:34 AM The resident was rigidly still with manic eyes and had been awake for 72 hours. The resident was no longer able to safely swallow oral medication. Hospice contactedXXX[DATE] 5:13 AM The resident exhibited hallucinations, crawling out of bed, and using different voice inflections. The resident was placed at the nurses' station. [DATE] 4:55 AM The resident was awake until 4:30 AM. The resident refused all oral medications. [DATE] 2:24 AM The resident refused to go to bed, and had no hallucinations or negative vocalizations. The facility's 24 Hour Report for [DATE] revealed Resident #1 received Hydromorphone at 3:20 AM during the evening/overnight shift and the resident was tearful on morning/afternoon shift.Resident #1's clinical records Progress Notes [DATE] revealed the following entry:[DATE] 10:38 PM The nurse was called into the resident's room at 9:43 PM by the Certified Nursing Assistant (CNA) who found the resident with a plastic garbage bag over her head. The resident was assessed at 9:43 PM and found not to be breathing and had a faint heartbeat upon listening to the heart with a stethoscope. The resident passed at 9:45 PM when the pulse was no longer heard. The hospice nurse was notified at 10:00 PM who notified the hospice physician. The primary care physician was notified via fax at approximately 2:00 AM. The Medical Examiner was present due to the nature of the death. The EMS Agency Prehospital Care Report dated [DATE] revealed the Fire Department was contacted directly by a police officer regarding a possible suicide. The document revealed the four-lead cardiac monitor confirmed the resident's heart had stopped at 10:25 PM with no resuscitative efforts initiated. The report included the resident was found at approximately 9:43 PM with a bag over her head, and at 9:45 PM the resident did not have a pulse. The document disclosed the Dispatch Center was notified at 10:05 PM and EMS was requested to respond at 10:18 PM . The document included that staff had reported that the resident had previously been placed on suicide watch and the resident had previously attempted suicide by choking herself with the call-light cord.The Medical Examiner Investigator Report for the Incident on [DATE] revealed the Medical Examiner (ME) Investigator was notified by the Communications Center on [DATE] at approximately 10:16 PM of a suspected suicide. At that time it was noted that the fire department had not been notified as the resident was on hospice services. The report included the EMS personnel confirming the resident's death. The report included a staff statement that the resident had been found at 9:43 PM with a clear plastic bag over her head, with the bag drawn into her mouth, the bag was removed and additional staff were requested. The document included that at approximately 9:45 PM the resident no longer had a detectable heartbeat. The report included the staff statement of not contacting 911 as the resident received hospice services. The report included staff statements the resident had previously attempted suicide by attempting to strangle herself with the call light cord, suicide precautions had been put in place and they did not think the resident had any other attempts or comments since 2/26. The document concluded with the statement of due to the circumstances surrounding the death, including the reported use of a plastic bag over the resident's head, prior attempted suicide, the initiation of suicide precautions following the 2/26 incident, the death was referred to the Iowa Office of the State Medical Examiner for further investigation and autopsy.The Iowa Office of State Medical Examiner Preliminary Autopsy Report revealed the autopsy was completed on [DATE]. The Significant Gross Autopsy Findings revealed moderate pulmonary edema with a cause of death of suffocation with a manner of death as suicide. Pulmonary edema is defined as a fatal condition caused by fluid building up in the air sacs of the lungs. The fluid stops oxygen from entering the blood; death happens because the body and brain do not get enough oxygen, leading to respiratory failure or cardiac arrest. On [DATE] at 1:55 PM Staff A, Certified Nursing Assistant (CNA), stated Resident #1 made the statement that she wasn't worthy on [DATE] during the day shift. The staff reported she notified the hospice nurse who was present of the statement with the nurse responding the resident has been known to make those statements. When asked if she was aware of previous suicide attempts by the resident, Staff A responded she was not but asked if this had something to do with the resident's call light or putting facial tissues in her mouth. The staff stated anytime Resident #1 had facial tissues around her, she would remove them. Staff A stated she did not know anything about placement of a trashcan in the resident's room and was pretty sure the trashcan always had trash bags in it. On [DATE] at 2:55 PM the Fire Department Captain stated that the fire department was contacted by law enforcement on [DATE] regarding the need to confirm a resident's death who had been found with a plastic bag over her head. The Captain stated upon arrival at the resident's bedside around 10:20 PM and application of the four-lead cardiac monitor the resident was noted to be cool to the touch. The Captain stated the cardiac monitor confirmed the resident's death. The Captain stated he did recall the resident's call light lying across her as he had to move it to complete the assessment. The individual stated he remembered the bed being in a low position and the trashcan and nightstand were approximately 1 foot from the bed. On [DATE] at 3:45 PM the ME Investigator stated on [DATE] law enforcement was notified of a suicide at 10:05 PM. The ME Investigator stated he was notified at 10:18 PM. The individual stated while standing in the facility's parking lot around 10:30 PM he noted the facility's Administrator had gotten out of a vehicle with out of state license plates, indicating to him that the facility had notified administrative staff prior to contacting the law enforcement or EMS. The ME Investigator stated the Administrator told him the resident had a history of a suicide attempt with the use of a call light cord. During the interview on [DATE] the ME Examiner spoke with the Office of the State Medical Examiner who revealed the resident died from Pulmonary Edema and no foreign bodies had been found in the resident's mouth, nose or throat. The ME Investigator acknowledged the resident was on hospice services but that was not a normal way to die. On [DATE] at 9:22 AM Staff B, Registered Nurse (RN) stated she had worked for the facility since 5/26 and was the nurse on duty on [DATE]. The staff stated she had not received suicide policy training prior to [DATE] as it was not something you would see all of the time. Staff B stated she had not heard Resident #1 make suicide comments, but had heard from other staff the resident had attempted with the use of the call light cord and nightgown. The staff stated she was notified at the 6:00 PM shift exchange the resident had been visited by a friend and was tearful after the visitor had left. Staff B stated at approximately 9:40 PM the CNA ran down the hall to get her stating the resident had been found with a bag over her head. The staff stated when she went into the resident's room she knew she was on hospice care and could not provide any interventions. The staff stated she did not contact 911 services, but had contacted the current Director of Nursing (DON) that the resident had a faint pulse but was not breathing. The staff stated she knew she needed to contact upper management at the time of the incident as it was something out of the ordinary. The DON told the staff she would contact the Administrator and call her back. Staff B stated when the DON called her back Resident #1 had passed away. The staff stated while she was talking with the DON, the Administrator called the DON back and she had contacted the Regional [NAME] President of Operations who gave the directive to contact law enforcement. On [DATE] at 9:58 AM Staff C, RN/Regional Director of Clinical Operations for the contract hospice provider expected the facility staff to contact hospice or 911 right away. The staff stated hospice would have helped the facility figure out what was going on and what to do. The staff stated if hospice would have been contacted, they would have been directed to call 911 as they would be able to respond faster than hospice. Staff C stated Resident #'1's death was not a normal progression of death, it was an emergency. On [DATE] at 10:51 AM Staff D, Certified Medication Aide (CMA), stated the resident would make statements of not being worthy. The staff stated she was aware of the resident having a prior suicide attempt in 2/26 with stuffing facial tissues in her mouth. Staff D stated she was aware to keep facial tissues away from Resident #1, but knew nothing about the call light, nightgown, or trash bag. Staff D stated when the resident had friends visit she would become teary eyed after they left and sometimes staff could cheer the resident up and other times they would just leave her alone. On [DATE] at 12:18 PM Staff F, CNA, stated she had only worked for the facility a month. The staff stated she had not received suicide prevention training upon hire. The staff stated she should keep the resident's trash can away from the side of the bed, but she could have a call light and knew nothing about facial tissues. On [DATE] at 1:09 PM Staff G, current DON, stated she had been in the position since [DATE], but was going to be the interim prior to that as the previous DON was transitioning out of the facility. The staff acknowledged she was contacted by Staff B on [DATE] regarding finding Resident #1. Staff G stated she needed to contact the Administrator as she was not sure what the process was since the resident was on hospice services. On [DATE] at 1:43 PM Staff H, RN/prior DON, stated she had been the charge nurse for the day shift on [DATE]. The staff acknowledged the resident had been tearful during her shift, but did not recall if there were any visitors. The staff stated Resident #1 had a history of trying to stuff facial tissues in her nose and mouth, as well as placing a bag over her head. The staff stated the only precautions she knew of was Resident #1 should not have facial tissues or the trashcan near her bedside due to suicidal ideations in the past. On [DATE] at 4:15 PM Staff I, CNA, stated during the [DATE] 6:00 PM shift report it was reported the resident had been crying and stating she had made mistakes. On [DATE] at 12:44 PM the Housekeeping and Laundry Manager stated she had worked in the facility for over 6 years. The staff stated in that time she had never been trained to not give trash bags to individuals with suicide watch. On [DATE] at 1:08 PM Staff J, Housekeeping, stated she had never known of suicide precautions with residents prior to Resident #1's passing on [DATE]. The staff stated she was not aware of Resident #1 having a suicide risk prior to that. On [DATE] at 2:40 PM Staff O, CNA, acknowledged she was the staff on duty who had found Resident #1 with the trash bag on her face. The staff member stated she had assisted the resident to bed around 8:40 PM and the resident indicated she didn't need anything. The staff stated around 9:40 PM she entered the room to assist the roommate, when she noticed something on the resident's face and found the plastic bag over her head with the bag partially sucked into her mouth. The staff stated she removed the bag and went to get Staff B as she knew she was 2 doors down. Staff O stated while the nurse was attending to Resident #1, she continued to assist the roommate. The staff stated Staff B did not ask for assistance or ask the staff to make any phone calls. Staff O stated she did hear Staff B on the phone with the DON. On [DATE] at 10:05 AM the [NAME] President of Operations stated the staff should have called law enforcement first on the night of [DATE] instead of calling upper management for the directive to call law enforcement. The staff recognized the resident was receiving hospice services, but law enforcement needed to be notified.The facility's Suicide Safety and Precautions Policy revealed the following:If a resident is observed attempting suicide, call 911.If a resident is observed having suicidal talk or behavior it should be reported to the charge nurse who will contacted the DON/designee immediately. Remain with the resident until the nurse or social services arrives to assess the resident. Removal all potentially dangerous articles/equipment that could be used and/or cause harm.Determine if the resident has a plan. Notify the physician immediately to report the resident's thoughts and/or actions. A resident with a plan needs immediate interventions, one on one supervision, and mental health interventions.

Based on clinical record review, observations, staff interviews, and facility policy review the facility failed to revise Care Plans for 4 of 10 residents (Residents #1, #4, #7, #8) reviewed. The facility failed to update the Care Plans with the residents' change in status and fall interventions. The facility reported a census of 29 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #1, dated 6/1/26, revealed the Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS coded the resident required total assistance of staff for dressing, toileting, hygiene, and transfers. The document recorded the resident had 2 falls without injuries since the previous assessment.Resident #1's Care Plan revealed the resident had a self care performance deficit related to impaired balance (initiated 11/4/25) with an intervention to use a bed/chair alert device for safety; the device doesn't stop movement but alerts staff to prevent falls (initiated on 6/18/26). A focus area of the resident having an actual fall with no injury initiated on 12/15/25 contained a staff intervention for a bed alarm and chair alarm (initiated 1/31/26). The document contained a focus area of having a terminal illness with hospice services (initiated 2/28/26) with an intervention for staff to follow use of an alarm in bed/chair for safety (initiated 6/18/26). A facility document titled Physician Communication revealed a physician's order dated 7/16/26 to discontinue the bed and chair alarms. The order was noted on 7/16/26 and second noted on 7/19/26.The facility failed to update the Care Plan to reflect the physician order to discontinue bed and chair alarms. 2. The MDS Assessment for Resident #4, dated 6/30/26, revealed the Staff Assessment for Mental Status identified long term memory problems with the resident able to identify her own room and recognize staff faces/names, and severe impairments for daily decision making. The document disclosed the resident had no falls during the reporting period. Resident #4's Care Plan, revised 7/8/26, revealed a focus area with the resident having had an actual fall (initiated 12/28/24) with staff interventions of the resident will sit herself down on the floor (8/12/24), skid strips next to bed placed 6/16/26 (7/8/26). A focus area of self care deficit (4/13/24) provided staff interventions of the resident ambulates independently throughout the facility and need to observe to ensure safety and prevent falls (7/2/24). The focus area of risk for falls (1/1/24) with staff interventions to keep walkways clutter free and entryway rug position changed (9/23/25). A focus area of actual fall due to poor balance (12/28/24) contained staff interventions for bed in low position, disc call light in reach while in bed - resident keeps on bedside table (7/8/26). A facility document titled Physician Communication revealed a physician's order dated 7/30/26 for the resident to wear non-slip gripper rubber sock slippers during the day for fall intervention. The order was noted on 7/31/26 and second noted on 8/4/26.The facility failed to update the Care Plan to reflect the physician order for use of non-slip rubber sock slippers during the day for fall intervention.3. The MDS Assessment for Resident #7, dated 6/17/26, revealed a BIMS score of 15/15 indicating normal cognition. The document identified the resident had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The document coded the resident as independent with dressing, toileting, bathing and all mobility, and required setup for eating. Resident #7's Care Plan, revised 8/18/26, identified a focus area of the resident that did not harm self, new behavior potentially causing harm to self (episodic) (initiated 6/12/25 and revised 8/18/26). Interventions for staff to follow included the resident did not have access to sharps (6/12/25), if poses threat to staff/others notify physician (6/12/25), monitor for cognitive, emotional, or environmental factors that may contribute to violent behaviors (6/12/25), monitor to signs/symptoms of agitation (6/12/25), off resident acceptable alternatives to unacceptable behavior (6/12/25). A facility document for physician communication revealed the facility requesting an order for the resident to be removed from suicide watch as the resident was no longer upset about the change of rooms and moving of her items. The document included the resident could not have a fork or knife while on suicide watch. The document included the physician order for removal from suicide watch dated 6/17/25, noted 6/17/25 and second noted 6/18/25,Observed on 8/18/26 at 12:15 PM Resident #7 in her room consuming her noon meal. The resident's room tray delivery contained regular silverware including a knife and fork. Observed an additional knife and fork in a cup on the bedside table. The facility failed to update Resident #7's Care Plan from 6/17/25 to 8/18/26 with the removal of the suicide watch restriction of no access to sharps. 4. The MDS Assessment for Resident #8, dated 6/2/26, revealed a BIMS score of 6/15 indicating severe cognitive impairment. The document coded the resident as requiring setup for eating. The document included diagnoses of Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety, and psychotic disorder. Resident #8's Care Plan revised 8/17/26 identified a focus area relating to hoarding items including silverware and paper products (revised 9/3/25). The document included a staff intervention of identifying opportunities for hoarding at the dining room table - condiments/napkins/plastic silverware (initiated 2/5/24 and revised 8/17/26). Observed on 8/18/26 at 12:00 PM Resident #8 eat a noon meal with a regular spoon in the dining room.Observed on 8/19/26 at 12:10 PM Resident #8 eat food using her fingers and remove a regular spoon from the napkin and poke around with other food items. On 8/18/26 at 1:26 PM Staff L, Cook, stated Resident #8 only received a regular spoon due to confusion as she had attempted to eat with a knife at one time.On 8/18/26 at 1:30 PM Staff M, Cook, stated no resident has any silverware restrictions or recommendations.On 8/18/26 at 1:50 PM Staff N, Cook, stated Resident #8 was only provided with spoons for meals. The staff stated there had been an incident with a butter knife. On 8/18/26 at 1:58 PM Staff S, Dietary Aide, stated Resident #8 was given only spoons and there had been a previous incident with a small knife and inappropriate behaviors; therefore the resident continues to only get spoons. The facility failed to incorporate and notify all the necessary departments with a Care Plan revision related to the focus area of hoarding.On 8/20/26 at 9:00 AM the [NAME] President of Operations acknowledged the Care Plans require revisions to accurately reflect the residents' needs and need for involvement of all interdisciplinary team members to ensure implementation of interventions. The facility's Comprehensive Care Plans Policy, 2025 Revision, revealed the Comprehensive Care Plan will be prepared by an interdisciplinary team (IDT) including but not limited to a registered nurse responsible for the resident, a member of the food and nutrition services staff, a nurse aide, the physician or delegee and the resident and/or representative. The document included that the Comprehensive Care Plan would be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment. The policy included the qualified staff responsible for carrying out the interventions specified in the Care Plan will be notified of their roles and responsibilities.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide dignity and respect to residents during interactions and care for 2 of 3 residents (Residents #1, and #2) reviewed. The facility reported a census of 29 residents.Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #1 completed on 6/1/26 revealed the Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The document coded the resident required total staff assistance for toileting, hygiene, and transfers. The MDS indicated the resident was occasionally incontinent of bowel and bladder. Resident #1's Care Plan, revised 8/11/26, revealed a self care performance deficit related to impaired balance and limited range of motion (initiated 11/4/25) with staff interventions that the resident was bedfast all or most of the time (12/16/25), the resident required the use of dependent non weight bearing lift with 2 staff for all transfers, and the resident depended on 2 staff for toileting (12/16/25). On 8/17/26 at 1:09 PM Staff G, Registered Nurse/Current Director of Nursing (DON), stated she had heard that there had been a report of a staff member stating Resident #1 should be strapped to the toilet to have a bowel movement. The staff stated she was not directly involved with the incident and it had not been directly reported to her. On 8/18/26 at 1:10 PM Staff K, Certified Nursing Assistant (CNA), stated she had heard a previous staff member say they should strap Resident #1 to the toilet so she can go. The staff stated the resident utilized a bedpan and was incontinent. The staff stated she had never put the resident on the toilet/commode and used a dependent mechanical lift. On 8/18/26 at 2:40 PM Staff O, CNA, stated the resident Resident #1 utilized a bed pan not a toilet. On 8/19/26 at 11:15 AM Staff P, Previous CNA, stated Resident #1 was seated at the nurses' station moaning and appeared visibly uncomfortable. The staff stated the resident would go several days without eating or having a bowel movement. Staff P then said Staff H, RN/previous DON stated to strap the resident to the toilet already. The staff stated she immediately removed the resident from the area. Staff P stated she was sure the resident could have heard the statement, but did not show a response. The staff stated she reported the comment to Staff R, Business Office Manager (BOM). On 8/19/26 at 11:25 AM Staff H, RN/Previous DON, stated she had never said to strap Resident #1 to the toilet. The staff member stated at one time she directed staff to use the dependent mechanical lift to position a different resident to the toilet due to constipation and having been given a suppository that was not effective on the bedpan. On 8/19/26 at 11:30 AM Staff Q, CNA, stated she had heard Staff H make the statement about strapping Resident #1 to the toilet. The staff stated Resident #1 had been up most of the night and was having trouble having a bowel movement. The staff stated the resident had been provided her medication by the nurse. Staff Q stated Staff P removed the resident from the area and reported the incident to Staff R. Staff Q stated Staff P told her that statement was not OK to make as it was not respectful. Staff Q did not feel like Staff H had a joking tone in her voice and that Resident #1 could have heard the comment but did not show any reaction. On 8/19/26 at 12:35 PM Staff R stated she had been on duty on 7/4/26 when Staff P reported Staff H made the statement of strapping the resident to the toilet. Staff R stated Staff P reported she told Staff H no and removed Resident #1 from the area. Staff R stated she was hoping Staff H was joking. 2. Resident #2's Quarterly MDS Assessment revealed a BIMS score of 15/15 indicating normal cognition. The document included the resident presented with hallucinations and delusions. The document coded the resident was independent with dressing, toileting, hygiene, and all mobility. The document included the resident had diagnoses of anxiety and other mental disorders due to known physiological conditions. The resident's Care Plan, revised 8/18/26 revealed a focus area of exhibiting behaviors including verbal aggression towards staff, accusing staff of stealing and lying, writing letters about differed staff members to be copied and passed out to everyone; the resident has refused mental health services and medication (revised 8/12/26) with interventions for staff to follow including encouraging the use of 2 staff when de-escalating behaviors (8/18/26), redirecting the resident as needed (8/12/26), clearly explaining to resident what they (staff) are doing (8/12/26). An additional focus area identified a behavior problem related to attempting to manipulate conversations and interactions with staff and residents in order to influence situations to fit his own agenda (revised 8/18/26) with staff interventions to discuss the resident's behavior, if reasonable, and reinforce/explain why the behavior is inappropriate and/or unacceptable to the resident (8/12/26), and monitor behavior episodes and attempt to determine underlying cause (8/12/26). On 8/17/26 at 10:51 AM Staff D, Certified Medication Aide, stated Resident #2 would report various staff were not nice, would change stories and say things that were not true. On 8/19/26 at 10:53 AM Staff H stated there had been an instance with Resident #2 and a previous staff member, whereas the staff overheard the resident on the phone, entered his room and yelled at him for lying about the care he was receiving. Staff H stated there had been an investigation and the employee had been terminated. On 8/19/26 at 12:35 PM Staff R stated she had heard a previous staff member yelling at Resident #2 down the hall in her office. The staff stated she heard the staff and the resident yelling at each other. The staff stated she got Staff H to assist with intervening in the situation. Staff R stated as she and Staff H were going down the hall to intervene the staff involved in the incident had left the resident's room and were walking towards them. Staff R stated there had been an investigation with the staff member suspended and ultimately terminated. On 8/19/26 at 2:15 PM the [NAME] President of Operations indicated it was not acceptable to yell at residents or make statements about tying residents to toilets. The facility's Resident Rights Policy, revised 11/19, revealed all residents would be treated equally and the facility will ensure all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. The document included the resident had a right to be treated with respect and dignity, and a right to a safe, clean, comfortable and homelike environment including receiving treatment and support for daily living.The facility's Abuse Prevention Plan, reviewed 2/23, included that all residents had the right to be free from abuse, neglect, and any physical restraint. The document defined abuse to include the willful infliction of injury, intimidation or punishment with resulting mental anguish. The document included mental abuse is not limited to humiliation, harassment or threats of punishment. The document revealed emotional or psychological abuse included demeaning statements, intimidation, threats that resulted in mental or emotional suffering.

Based on clinical record review, staff interviews, and policy review the facility failed to notify the physician in a timely manner when a change in a medical condition occurred for 1 of 3 residents (Resident #1) reviewed. The facility failed to notify the primary care provider of a resident's multiple suicide attempts during a shift in a timely manner on [DATE] and failed to notify hospice/911 services at the time the resident was found unresponsive with a plastic bag over her head on [DATE]. The facility had a census of 29.Findings include: Resident #1's Minimum Data Set (MDS) Discharge with Return Anticipated, dated on [DATE], revealed the Staff Assessment for Mental Status identified the resident with short-term memory problems, severe impairments for daily decision making, continuous inattention and disorganized thinking, and fluctuating altered level of consciousness. The document included diagnoses in the last 7 days of the assessment included: diabetes mellitus, rhabdomyolysis (muscle tissue breakdown releasing harmful proteins and electrolytes into the bloodstream which is painful and causes difficulty moving), and unspecified altered mental status. The resident received scheduled pain medication, blood thinner, and insulin.The MDS for Resident #1 completed on [DATE] revealed the Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The document revealed no acute onset of mental status change. The Resident Mood Interview revealed the resident indicated little interest or pleasure in doing things never or 1 day in the last 2 weeks, and feeling down, depressed or hopeless 2-6 days in the past 2 weeks. The document's Behavioral Symptoms indicated no hallucinations or delusions, verbal behavioral symptoms directed toward others 1 to 3 days, behavioral symptoms not directed toward others 1 to 3 days, and rejection of care 1 to 3 days. The MDS coded the resident required total assistance of staff for dressing, toileting, hygiene, and transfers. The document disclosed the resident's diagnoses renal insufficiency/failure/End-Stage Renal Disease, Non-Alzheimer's Dementia, Depression, Altered Mental Status, unspecified, and Other Symptoms and Signs Involving Appearance and Behavior. Resident #1's Care Plan disclosed a focus area that the resident exhibited suicidal ideation placing the resident at risk for self harm (initiated [DATE]) with staff interventions to initiate suicide precautions per facility policy ([DATE]), notify physician/provider of suicidal ideation and obtain/implement new orders as indicated ([DATE]), notify presponsible party per resident consent and facility policy ([DATE]), provide increased observation/monitoring per assessed level of risk ([DATE]) and remove or restrict access to potentially harmful objects per facility policy ([DATE]). The clinical record's Progress Notes 2/22/ 26 - [DATE] revealed the following entries:On [DATE] at 11:46 PM the resident made several comments during the evening about dying. The resident refused vitals, medications and repeated it won't do any good. The resident was assisted to bed and 15 minutes later at a recheck the resident was reaching for the trash can. When the resident was asked what she needed, the resident refused to answer and the staff removed the trash bag liner. The staff continued with rechecks and on the last recheck the resident was found with her gown wrapped around her neck. The nurse requested the staff get the resident up and bring to the nurses' station so we all can watch her. The document stated a fax would be sent to the provider. On [DATE] at 6:14 AM the resident was a 1:1 at the nurses' station due to attempting suicide during the night. The resident was resistant to all cares and medications. The primary care physician was notified and an order was received to send the resident to the emergency department (ED). The resident left at 8:20 AM by emergency medical services (EMS). On [DATE] at 2:22 PM the resident returned from the ED with no physical findings for the resident being suicidal. The facility continued 15 minute checks. The facility's document, Physician Communication Fax, dated [DATE] revealed the following communication to the provider: the resident made several comments this shift about wanting to die. The resident was found trying to grab a trash bag and stated she is going to kill herself. The document included the resident was placed on 15 minute watch and after an hour found the resident with a gown wrapped around her neck. The communication disclosed the resident was mobile in her wheelchair (w/c) and while at the nurses' station when the resident thought no one was watching she would attempt to grab any plastic bag she could to continue her plan. The communication to the physician concluded with any orders/concerns. The document included a response from the physician of why the resident wasn't sent to the ED after the first attempt or at least contacted the on-call provider. The facility's response to the physician's questions included the resident's refusal and following her rights. The physician's final documented response was the resident attempted suicide 3 times. The clinical record's Physician Orders revealed an order for admission to hospice services on [DATE].The Hospice Orders, dated [DATE], revealed to notify hospice with questions, needs or any status changes. Resident #1's clinical record's Progress Notes from [DATE] - [DATE] revealed the following entries:[DATE] 2:49 PM The resident stated she couldn't get out of the facility unless she died. The resident was at the nurses' stationXXX[DATE] 5:21 PM The resident told the staff it was too late to ask for forgivenessXXX[DATE] 4:30 PM The resident during a Care Plan meeting wanted to know why she was still living in this manner, why she wasn't getting better and what purpose was her life in this stateXXX[DATE] 2:09 AM The resident was awake, agitated, attempted to throw herself out of her w/c and stated she would like to die. The resident was placed at the nurses' station under 1:1 supervision.The progress notes did not include notification to the resident's primary care physician or hospice services when these statements were made.Resident #1's clinical records Progress Notes [DATE] revealed the following entry: On [DATE] at 10:38 PM the nurse was called into the resident's room at 9:43 PM by the Certified Nursing Assistant (CNA) who found the resident with a plastic garbage bag over her head. The resident was assessed at 9:43 PM and found not to be breathing and had a faint heartbeat upon listening to the heart with a stethoscope. The resident passed at 9:45 PM when the pulse was no longer heard. The hospice nurse was notified at 10:00 PM who notified the hospice physician. The primary care physician was notified via fax at approximately 2:00 AM. On [DATE] at 9:58 AM Staff C, RN/Regional Director of Clinical Operations for the contract hospice provider expected the facility staff to contact hospice or 911 right away. The staff stated hospice would have helped the facility figure out what was going on and what to do. The staff stated if hospice would have been contacted, they would have been directed to call 911 as they would be able to respond faster than hospice. On [DATE] at 2:15 PM the [NAME] President of Operations stated the staff should have called the on-call physician and/or 911 after Resident #1's first suicidal attempt on [DATE]. The staff stated there should not have been a fax notification after multiple attempts on the overnight shift. The [NAME] President of Operations stated regarding the incident on [DATE] the facility should have contacted 911 and hospice immediately.The facility's Notification of Changes Policy, copyrighted 2025, revealed the resident's physician should be notified if there was a significant change in the resident's physical, mental, or psychosocial condition such as deterioration that may include life-threatening condition or clinical complications. The document included that the resident's physician is to be notified immediately with the death of a resident in accordance with State law.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to report an attempted suicide and violation of verbal abuse for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 29 residents.Findings Include: The Minimum Data Set (MDS) Assessment for Resident #1 completed on 6/1/26 revealed the Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The document coded the resident required total staff assistance for toileting, hygiene, and transfers. The MDS indicated the resident was occasionally incontinent of bowel and bladder. Resident #1's Care Plan, revealed a self care performance deficit related to impaired balance and limited range of motion (initiated 11/4/25) with staff interventions that the resident was bedfast all or most of the time (12/16/25), the resident required the use of dependent non weight bearing lift with 2 staff for all transfers, and the resident depended on 2 staff for toileting (12/16/25). A focus area included the resident exhibited suicidal ideation placing the resident at risk for self harm (initiated 2/23/26) with staff interventions to initiate suicide precautions per facility policy (2/23/26), notify physician/provider of suicidal ideation and obtain/implement new orders as indicated (2/23/26), notify presponsible party per resident consent and facility policy (2/23/26), provide increased observation/monitoring per assessed level of risk (2/23/26) and remove or restrict access to potentially harmful objects per facility policy (2/23/26).The clinical record's Progress Notes 2/22/ 26 - 2/23/26 revealed the following entries:On 2/22/26 at 11:46 PM the resident made several comments during the evening about dying. The resident refused vitals, medications and repeated it won't do any good. The resident was assisted to bed and 15 minutes later at a recheck the resident was reaching for the trash can. When the resident was asked what she needed, the resident refused to answer and the staff removed the trash bag liner. The staff continued with rechecks and on the last recheck the resident was found with her gown wrapped around her neck. The nurse requested the staff get the resident up and bring to the nurses'station so we all can watch her. The document stated a fax would be sent to the provider. On 2/23/26 at 6:14 AM the resident was a 1:1 at the nurses' station due to attempting suicide during the night. The resident was resistant to all cares and medications. The primary care physician was notified and an order was received to send the resident to the emergency department (ED). The resident left at 8:20 AM by emergency medical services (EMS). On 2/23/26 at 2:22 PM the resident returned from the ED with no physical findings for the resident being suicidal. The facility continued 15 minute checks. The facility failed to report to the State Entity the resident's multiple attempts of suicide from 2/22 - 2/23/26. On 8/17/26 at 1:09 PM Staff G, Registered Nurse (RN)/Current Director of Nursing (DON), stated she had heard that there had been a report of Staff H, RN/Previous DON stating Resident #1 should be strapped to the toilet to have a bowel movement. The staff stated she was not directly involved with the incident and it had not been directly reported to her. On 8/18/26 at 1:10 PM Staff K, Certified Nursing Assistant (CNA), stated Resident #1 utilized a bedpan and was incontinent. The staff stated she had never put the resident on the toilet/commode and used a dependent mechanical lift. On 8/18/26 at 2:40 PM Staff O, CNA, stated Resident #1 utilized a bed pan not a toilet. On 8/19/26 at 11:15 AM Staff P, Previous CNA, stated Resident #1 was seated at the nurses' station moaning and appeared visibly uncomfortable. The staff stated the resident would go several days without eating or having a bowel movement. Staff P stated Staff H said to strap the resident to the toilet already. The staff stated she immediately removed the resident from the area. Staff P stated she was sure the resident could have heard the statement, but did not show a response. The staff stated she reported the comment to Staff R, Business Office Manager (BOM). On 8/19/26 at 11:25 AM Staff H stated she had never said to strap Resident #1 to the toilet. The staff member stated at one time she directed staff to use the dependent mechanical lift to position a different resident to the toilet due to constipation and having been given a suppository that was not effective on the bedpan. On 8/19/26 at 11:30 AM Staff Q, CNA, stated she had heard Staff H make the statement to strap Resident #1 to the toilet. The staff stated Resident #1 had been up most of the night and was having trouble having a bowel movement. The staff stated the resident had been provided her medication by the nurse when the comment was made. Staff Q stated Staff P removed the resident from the area and reported the incident to Staff R. The staff stated Staff R interviewed her about the incident. Staff Q did not feel like Staff H had a joking tone in her voice and that Resident #1 could have heard the comment but did not show any reaction. On 8/19/26 at 12:35 PM Staff R stated she had been on duty on 7/4/26 when Staff P reported Staff H making the statement of strapping the resident to the toilet. Staff R stated Staff P reported she told Staff H no and removed Resident #1 from the area. Staff R reported she did speak with Staff Q who was mortified at Staff H's statement and thought Staff H was serious. Staff R stated she was hoping Staff H was joking. Staff R stated she emailed the Administrator, who was on medical leave, and the [NAME] President of Operations of the incident. The staff did not recall receiving a response from either staff. On 8/19/26 at 2:15 PM the [NAME] President of Operations stated he was not aware at the time of all that transpired with Resident #1 in 2/26 with the attempted suicides. The staff stated there should have been a self report made to the State Entity regarding the incident. The staff member stated he heard something said on this date about the incident involving tying a resident to a toilet and vaguely remembered it. The staff stated he then reviewed his email and found the notification. The [NAME] President of Operations stated this should have been a phone call notification not an email, it should have been investigated, and been a self report. The staff member stated there would be staff training on what is abuse, what to report, and when to report.On 8/19/26 at 3:30 PM the Administrator stated she did not take Staff H's statement about tying a resident to a toilet seriously and the resident was not tied to the toilet; therefore, it was not reported. The Administrator further revealed she did not realize Resident #1's suicide attempts in 2/26 needed to be reported. The [NAME] President of Clinical Services stated all allegations should be reported to the State Entity and investigations should be completed.The facility's Abuse Prevention Plan, reviewed 2/23, included that all residents had the right to be free from abuse, neglect, and any physical restraint. The document defined abuse to include the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or mental anguish. The document included mental abuse is not limited to humiliation, harassment or threats of punishment. The document revealed emotional or psychological abuse included demeaning statements, intimidation, threats that resulted in mental or emotional suffering. The document included the facility required all suspected maltreatment be reported to the Administrator and the State immediately. If the Administration is not in the building, notification would go to the Nursing Supervisor or other designee. The IAC 8/7/13 Inspections and Appeals (481) Chapter 50 Health Care Facilities Administration section 481-50.7, 50.7(5) the director of inspections and appeals or the director's designee shall be notified within 24 hours, or the next business day, by the most expeditious means available when a resident attempts suicide, regardless of injury.

Based on clinical record review, staff interviews and policy review the facility failed to develop and implement a Comprehensive Care Plan for 1 of 10 residents (Resident #1) reviewed. The resident's Care Plan failed to identify resident specific interventions for all staff knowledge regarding the resident's suicide risk. The facility reported a census of 29 residents.Findings include:The Minimum Data Set (MDS) for Resident #1 completed on 6/1/26 revealed the Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The document revealed no acute onset of mental status change. The Resident Mood Interview revealed the resident indicated little interest or pleasure in doing things never or 1 day in the last 2 weeks,and feeling down, depressed or hopeless 2-6 days in the past 2 weeks. The document's Behavioral Symptoms indicated no hallucinations or delusions, verbal behavioral symptoms directed toward others 1 to 3 days, behavioral symptoms not directed toward others 1 to 3 days, and rejection of care 1 to 3 days. The MDS coded the resident required total assistance of staff for dressing, toileting, hygiene, and transfers. The document disclosed the resident's diagnoses renal insufficiency/failure/End-Stage Renal Disease, Non-Alzheimer's Dementia, Depression, Altered Mental Status, unspecified, and Other Symptoms and Signs Involving Appearance and Behavior. The document provided the resident received scheduled pain medication and as needed pain medication. The staff assessment of the resident's pain in the last 5 days revealed the resident exhibited pain daily by non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements. The document included the resident was prescribed antipsychotic, antianxiety, and opioid medications. The MDS revealed the resident received hospice services. Resident #1's Care Plan disclosed a focus area that the resident exhibited suicidal ideation placing the resident at risk for self harm (initiated 2/23/26) with staff interventions to initiate suicide precautions per facility policy (2/23/26), notify physician/provider of suicidal ideation and obtain/implement new orders as indicated (2/23/26), notify responsible party per resident consent and facility policy (2/23/26), provide increased observation/monitoring per assessed level of risk (2/23/26) and remove or restrict access to potentially harmful objects per facility policy (2/23/26). The clinical record's Progress Notes 2/22/ 26 - 2/23/26 revealed the following entries:On 2/22/26 at 11:46 PM the resident made several comments during the evening about dying. The resident refused vitals, medications and repeated it won't do any good. The resident was assisted to bed and 15 minutes later at a recheck the resident was reaching for the trash can. When the resident was asked what she needed, the resident refused to answer and the staff removed the trash bag liner. The staff continued with rechecks and on the last recheck the resident was found with her gown wrapped around her neck. The nurse requested the staff get the resident up and bring to the nurses'station so we all can watch her. The document stated a fax would be sent to the provider. On 2/23/26 at 6:14 AM the resident was a 1:1 at the nurses' station due to attempting suicide during the night. The resident was resistant to all cares and medications. The primary care physician was notified and an order was received to send the resident to the emergency department (ED). The resident left at 8:20 AM by emergency medical services (EMS). On 2/23/26 at 2:22 PM the resident returned from the ED with no physical findings for the resident being suicidal. The facility continued 15 minute checks.On 8/13/26 at 1:55 PM Staff A, Certified Nursing Assistant (CNA), when asked if she was aware of previous suicide attempts by the resident, Staff A responded she was not but asked if this had something to do with the resident's call light or putting facial tissues in her mouth. The staff stated anytime Resident #1 had facial tissues around her, she would remove them. Staff A stated she did not know anything about placement of a trashcan in the resident's room and was pretty sure the trashcan always had trash bags in it.On 8/17/26 at 9:22 AM Staff B, Registered Nurse (RN) stated she had not heard Resident #1 make suicide comments, but had heard from other staff the resident had attempted with the use of the call light cord and nightgown. On 8/17/26 at 10:51 AM Staff D, Certified Medication Aide (CMA), stated Resident #1 would make statements of not being worthy and stuffing facial tissues in her mouth prior to the initiation of hospice services. The staff stated all she knew was the resident should not have facial tissues around her.On 8/17/25 at 12:02 PM Staff E, CNA/CMA stated Resident #1 could not be left in her wheelchair in her room as she would attempt to self transfer to bed. The staff stated items were not to be close to her bed to prevent injury if she tried to self transfer. The staff stated the resident's call light went on her right side, trash bags were in the trash can, and she knew nothing about facial tissues.On 8/17/26 at 12:18 PM Staff F, CNA, stated she should keep Resident #1's trash can away from the side of the bed, but she could have a call light and knew nothing about facial tissues.On 8/17/26 at 1:43 PM Staff H, RN/prior DON, stated Resident #1 had a history of trying to stuff facial tissues in her nose and mouth, as well as placing a bag over her head. The staff stated the only precautions she knew of was Resident #1 should not have facial tissues or the trashcan near her bedside due to suicidal ideations in the past.On 8/18/26 at 12:44 PM the Housekeeping and Laundry Manager stated she had worked in the facility for over 6 years. The staff stated in that time she had never been trained to not give trash bags to individuals with suicide watch or who was considered to be a risk for suicide. On 8/18/26 at 1:08 PM Staff J, Housekeeping, stated she had never known of suicide precautions with residents prior to Resident #1's passing on 8/10/26. The staff stated she was not aware of Resident #1 having a suicide risk prior to that or precautions.The facility's Comprehensive Care Plans Policy, 2025 Revision, revealed the Care Plan must be person-centered to meet each resident's medical, nursing, mental and psychosocial needs. The document included the services were to be provided to attain or maintain the resident's highest practicable mental and psychosocial well-being. The policy revealed qualified staff responsible for carrying out interventions specified in the Care Plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, staff interviews and policy review the facility failed to provide sufficient notice of discharge for 1 of 3 residents (Resident #2) reviewed. The facility failed to ensure proper discharge planning was documented prior to discharge. The facility reported the census was 28. Findings include: Resident #2's Entrance Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted from a short term general hospital.The Discharge Return Not Anticipated MDS assessment dated [DATE] revealed the discharge was unplanned and occurred on 4/29/26 to a short term general hospital. The document disclosed the facility staff completed the cognitive patterns indicating the resident presented with memory problems, severe impairment for daily decision making, and fluctuating inattention and disorganized thinking. The document included the resident had delusions, physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, rejection of care and wandering. The self care and mobility sections coded the resident required partial/moderate assistance with toileting hygiene and lower body dressing, and personal hygiene, oral hygiene and eating with setup, independent with upper body dressing, rolling in bed, ambulation and sitting to/from standing. The MDS Assessment included diagnoses of unspecified dementia, unspecified severity with other behavioral disturbances and restlessness and agitation. The document disclosed the resident took antipsychotic and antianxiety medications. The clinical record's census indicated the resident was admitted on [DATE] at 11:15 AM and discharged against medical advice (AMA) on 4/29/26 at 4:02 PM. Resident #2's Care Plan and Kardex for staff were not developed due to the limited time in the facility.The clinical record's Elopement Evaluation dated 4/28/26 identified the following area:History of elopement or an attempted elopement while at home.Verbally expressed the desire to go home, packed belongings, or stayed near an exit door.The resident wanders.Wandering is a pattern, goal directed (specific destination, going home).Recent admission and is not accepting of the situation. The clinical record's Physician Communication dated 4/28/26 revealed the physician was notified of the resident's elopement risk and need for a WanderGuard with a physician order for a WanderGuard and psychiatric evaluation; order noted by nursing on 4/29/26. The clinical record's Hospital Updates dated 4/27/26 contained the following entries: 4/24/26 at 3:11 PM resident verbalized desire to go home.4/24/26 at 4:23 PM resident ambulated in the hall and demanded to go home. 4/24/26 at 5:00 PM resident ambulated in the hall, steadily grew more anxious about leaving the facility. 4/24/26 at 5:49 PM resident continued to escalate in anxious behaviors stating she would walk out of the facility.4/24/26 at 6:17 PM resident ambulated in the hall and attempted to leave the facility to walk home; being closely monitored by staff at all times. 4/24/26 at 6:46 PM resident continued to ambulate in the hall stating she has rights and wanted to go home. 4/25/26 at 8:27 AM resident growing mildly anxious about going home, demanding staff let her leave and ambulating in the hall, intermittently attempting to find an exit. 4/25/26 at 3:17 PM resident grew more anxious about going home, provided scheduled Seroquel. 4/26/26 at 2:16 PM resident stated wanted to go home and became increasingly agitated. 4/27/26 at 1:00 AM resident was up and in the hallway and confused as to whereabouts.An entry made by the hospital's nurse practitioner on 4/24/26 revealed the resident was intermittently agitated and paranoid, believing staff were hiding things from her. The document included the resident had agitation, paranoia but no physical aggression. The document revealed the resident's spouse did not feel safe after the resident had physically assaulted him on 4/22/26.The clinical record's Hospital Discharge summary dated [DATE] revealed the resident had been left home alone and found wandering in the neighborhood, prompting a welfare check and transport to the hospital by the police. The document included the family reported escalating agitation at home, including physically attacking her spouse on 4/22/26. The clinical record's Medication Administration Record (MAR) included the following medications were dispensed:Quetiapine Fumarate Oral Tablet 25 mg, give 2 tablets at bedtime related to unspecified dementia, unspecified severity with other behavior disturbance with a start date of 4/28/26. Buspirone HCI Oral Tablet 10 mg, give 1 tablet two times a day (BID) related to restlessness and agitation with a start date of 4/28/26.Quetiapine Fumarate Oral Tablet 25 mg, 1 tablet BID related to unspecified dementia, unspecified severity with other behavior disturbance with a start date of 4/28/26The clinical record's Progress Notes disclosed the following entries:4/28/26 at 12:30 PM the resident admitted to the facility, independent with self care and mobility.4/28/26 at 2:11 PM the resident was at the nurse's station, very agitated and stated she was going home tonight.4/28/26 at 4:09 PM the resident was attempting to open the front door to go for a walk with a family member; the resident was redirected back down the hallway.4/28/26 at 4:24 PM the resident attempted to find an exit to the outside, trying multiple doors; the resident was upset and agitated.4/28/26 at 1:33 PM the resident's behaviors escalated during the day. The entry included the resident entered into other residents' rooms, demanded to nursing staff that she needed to leave to take care of her children at home, sat by the main door attempted to leave and unable to be redirected; notification to primary care physician (PCP) and fax sent to request PRN Ativan. 4/29/26 at 2:05 PM at 7:00 AM the resident was agitated, confused and combative, wandering into other residents' rooms, and she was in the facility by mistake. With interventions the resident made slapping gestures toward staff. At approximately 9:00 AM the resident attempted entry into other residents' rooms and refused to comply with care. The entry included the resident was exit-seeking, testing all facility doors and with multiple failed redirection attempts the resident became more belligerent and physically threatening. By noon, after further escalation, the DON and social services determined that the resident should leave AMA due to ongoing aggression. Family and law enforcement were contacted regarding the situation. 4/29/26 at 2:15 PM orders received for a WanderGuard and psychiatric evaluation. 4/29/26 at 2:24 PM spoke with PCP nurse, aware of the resident's return to the facility, and gave an update to PCP for a PRN medication for agitation. 4/29/26 at 2:44 PM the resident exhibited signs of anxiety and confusion and with redirection the resident became agitated, raised her voice and struck the staff on the arm with an open hand. Resident began packing belongings, moved towards the entrance, and the resident turned and struck staff on the side with a closed fist. The resident continued to demonstrate confusion, exit-seeking behavior, and intermittent physical aggression. 4/29/26 at 3:20 PM resident once again exited the front entrance into the parking lot. Police notified along with EMS, the resident was eventually loaded into an ambulance and transported to ER. The resident will not be returning to the facility. Granddaughter was notified who stated she is being kicked out of this facility too charge nurse continued to reiterate that d/t her exit seeking another facility would need to be located for her.4/29/26 at 4:02 PM Triage nurse was updated on the resident being transported to the community hospital and the facility was not able to take the resident back. The clinical record's Physician Communication dated 4/29/26 revealed the physician was notified the resident was increasing in agitation and restlessness, actively exit seeking, difficulty in redirecting, frequently stating I am leaving, and entering other residents' rooms without permission; noted during hospital stay that Ativan had been utilized and requested an order for Ativan as needed (PRN). The physician response included an order for stat Nexulti 0.5 mg once a day (QD) and Ativan 0.5 mg orally or injection BID PRN for agitation for 3 days. The physician order was signed on 4/29/26 and faxed on 4/30/26.The facility failed to notify the Primary Care Physician (PCP) in a timely manner of the need for medical assistance with the resident's escalating verbal, physical and exit seeking behaviors.The facility failed to notify the Medical Director of the resident's escalating verbal, physical, and exit seeking behaviors. The clinical record's Against Medical Advice (AMA) Discharge of Release of Responsibility Form revealed signatures of the resident, Staff A, Registered Nurse (RN)/previous Director of Nursing (DON), and the Director of Social Services. The facility failed to obtain a written order from the physician regarding the resident's transfer and unplanned discharge from the facility. The facility failed by allowing the resident to sign an AMA document when the resident's competency was in doubt, and contacting emergency services for transfer to the hospital and would not allow the resident to return. On 6/16/26 at 10:42 AM Staff C, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) stated she witnessed the resident yelling in the lobby and did see the resident outside of the facility with staff. On 6/16/26 at 2:15 PM the Director of Social Services stated she had visited with the resident at the hospital prior to the admission. The staff acknowledged she had reviewed the medical records. The staff stated when she had spoken with the family there was no indication of previous elopements other than what had happened on the day of the resident's admission to the hospital. The staff stated on the morning of the discharge it was revealed the resident had had a rough night and progressively escalated all day and although would occasionally respond positively to the staff, did in fact physically strike the staff. The staff acknowledged she and the DON had the resident sign an AMA document as she (the resident) did not have a Medical Power of Attorney (POA). The staff stated the resident's family thought they had POA paperwork, but in fact the document was for financial affairs. The Director of Social Services stated she did begin the process of getting Medical POA documents for the family by requesting the PCP to sign a letter of incompetence as the resident couldn't sign the document herself for a POA, and did send this document to the lawyer for the family to continue the process following discharge. The staff stated multiple attempts were made to contact the family without success for the need to send the resident to the hospital and find a different facility. On 6/16/26 at 4:20 PM the Administrator (in person) and Staff A (phone) in an interview discussed the details of Resident #2's admission and discharge. Staff A stated she was on the phone with the PCP's nurse at the time of the resident's transfer to the hospital and would notify the physician of the resident going AMA to the hospital. Staff A stated the resident had fluctuating bouts of agitation with calming when she would talk with staff, but eventually escalated to the point of leaving the facility. The staff stated she did return to the facility one time but did not de-escalate. The phone disconnected and the interview involving the Administrator and Staff A ended.On 6/16/26 at 4:25 PM the Administrator acknowledged she was aware of Resident #2's history of wandering and police involvement. The Administrator stated the Director of Social Services stated the resident was a nice lady pleasantly confused. The Administrator stated all department heads were involved with the admission process. The Administrator admitted she and the DON had the ultimate decision to admit a resident and allowed the resident to be admitted , although she had reservations. On 6/17/26 at 10:40 AM the [NAME] President of Operations for Nebraska and Iowa acknowledged the facility had not documented or obtained orders from the PCP or Medical Director for more rapid assistance in managing the resident's needs/behaviors or transfer to the hospital. The staff stated there was a request for a PRN medication but that intervention had not been implemented prior to discharge. The facility's Discharge (including AMA) and Transfer Policy and Procedure, revised 10/22, revealed the facility would evaluate and determine the level of care needed for each resident prior to the admission to ensure the facility's ability to meet the resident's needs. The document included if a discharge was initiated by the facility with return not anticipated reasons for discharge, the facility attempts to meet the resident needs and the service available at the receiving facility to meet the needs, as well as documentation any danger to the health or safety of the resident or other individuals that failure to transfer or discharge would pose. The policy included if a transfer/discharge was initiated by the facility for immediate safety and welfare of a resident physician orders were required stating the reason the transfer or discharge was necessary. The AMA portion of the policy included the family/legal representative should be informed of the risks involved with leaving the facility and the physician should be notified of the intended AMA discharge and be encouraged to talk with the resident and encourage staying at the facility.

Based on clinical record review, staff interviews, and policy review the facility failed to provide a bed hold and notify the Long-Term Care Ombudsman (LTCO) of transfer to a hospital for 2 of 3 residents (Residents #2, #5) reviewed. The facility reported a census of 28 residents. Findings include:1. Resident #2's Discharge Return Not Anticipated Minimal Data Set (MDS) assessment dated [DATE] revealed the discharge was unplanned and occurred on 4/29/26 to a short term general hospital. The clinical record's Census revealed Resident #2 discharged against medical advice (AMA) on 4/29/26 at 4:02 PM .2. Resident #5's Discharge Return Anticipated MDS assessment dated [DATE] revealed the resident had an unplanned discharge on [DATE]. The clinical record's Census revealed Resident #5 transferred to the hospital on 3/6/26 at 7:51 AM, and was discharged on 3/25/26. On 6/17/26 at 9:49 AM the Administrator stated a bed hold had not been completed on Resident #5. The Administrator stated at this time she had not located the LTCO report of notification for 3/26 and 4/26. On 6/17/26 at 10:40 AM the [NAME] President of Operations for Nebraska and Iowa disclosed the facility could neither produce a bed hold for Resident #5 nor LTCO Reports for notification of discharges for 3/26 and 4/26. The staff stated the expectation is that the bed hold document should be completed and notification to the LTCO be completed as required.The facility's Notice of Transfer or Discharge to Ombudsman Policy, revised 3/19, revealed notice to the ombudsman must occur at the same time the notice of discharge was provided to the resident and/or representative or as soon as practicable. The document included during emergency transfers a copy of the facility's bed-hold notice must be provided to the resident and resident representatives. The notice of emergency transfers should also be sent to the ombudsman, but may be included on a monthly basis.

Based on clinical record review, observations, staff interviews, and policy review the facility failed to represent an accurate assessment of residents' status during the observation period of the Minimum Data Set (MDS) Assessment for 1 of 6 residents (Resident #3) reviewed. The facility reported a census of 28 residents.Findings include: The MDS assessment dated [DATE] for Resident #3 identified a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment. The document coded the resident required partial/moderate assistance for sitting to/from stand, transfers to/from a chair and ambulation up to 150'.Resident #3's Care Plan revised 4/16/26 revealed a focus with alteration in activities of daily living (ADLs) (revised 3/31/23) with staff interventions of independence with transfers and ambulation with a wheeled walker (revised 7/17/24). A focus area identified an ADL self care performance deficit (revised 7/24/24) with interventions of transfers independent with use of a walker (11/19/24).The Kardex printed 6/16/26 revealed the resident was able to transfer himself independently with the use of a walker. The document included the resident was able to get himself in bed and make position changes. The document disclosed the resident was independent with transfers and ambulation with a wheeled walker. Observed on 6/15/26 at 1:05 PM Resident #3 seated in his recliner in his bedroom.Observed on 6/15/26 at 2:45 PM Resident #3 ambulating in his room using a 4 wheeled walker (4WW).Observed on 6/16/26 at 9:00 AM Resident #3 participating in a group activity.Observed on 6/16/26 at 11:40 AM Resident #3 walking to the dining room using a 4WW independently.On 6/16/26 at 10:27 AM Staff B, Certified Nursing Assistant (CNA) stated the resident may require cues to use a walker, but is independent with ambulation. The staff stated the resident is able to bend over or get down and pick something up from the floor and return to standing. On 6/16/26 at 10:42 AM Staff C, CNA/Certified Medication Aide (CMA) stated the resident was independent with walking around, and transfers - including walking to the dining room. On 6/16/26 at 10:55 AM Staff D, CNA/CMA, stated Resident #3 can get down on the floor to look for something and is able to walk in the halls using his 4WW independently.On 6/16/26 at 11:05 AM Staff E, CNA, stated the resident was independent with the use of a 4WW for mobility.On 6/16/26 at 11:18 AM Staff F, CNA/CMA, stated Resident #3 for the most part was independent with mobility, transition movements (sitting to/from lying). The staff stated the resident was independent to walk around the facility with a walker. The facility failed to code the MDS Assessment accurately regarding Resident #3's mobility. On 6/17/26 at 9:49 AM the Administrator stated the facility's corporate representative was assisting with the MDS Assessment. The Administrator stated there were frequent conversations with the staff. The Administrator expected the MDS Assessments to be correct. On 6/17/26 at 10:00 AM the [NAME] President of Operations for Nebraska and Iowa expected the MDS coding to accurately reflect what the residents' levels of care/assistance were. The facility's MDS Accuracy, Automation, and Validation Process Policy, revised 3/19, revealed the MDS Item Sets were to be completed accurately, and during each step of the process they would be screened for accuracy and validation.

Based on clinical record review, observations, staff interviews, and policy review the facility failed to revise Care Plans for 2 of 3 residents (Residents #1, #4) reviewed. The facility failed to update the Care Plans with the residents' change in status and fall interventions. The facility reported a census of 28 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document coded the resident was independent with toileting, dressing, grooming/hygiene, ambulation, transfers and bed mobility. The document provided the resident had a bed alarm that was used daily. The Care Plan revised 1/3/26 identified Resident #1 had functional performance deficits with staff interventions of dressing independent/1 person physical assistance (6/4/25), toilet use limited assist/no setup or physical help (6/4/25), walk in corridor independent/2 person physical assist (9/10/25) and walk in room - independent/setup help only (6/4/25). A focus area identified limited physical mobility related to weakness (revised 6/10/25) with staff interventions for ambulation with standby assistance (SBA) with 1 staff (revised 1/3/26). The Care Plan documented a focus area of the resident had an actual fall with no injury (revised 12/18/25) with interventions of bed/chair alarm in use (12/22/25), continue intervention on the at-risk plan (12/18/25), do not leave unsupervised on the toilet (12/23/25), and the resident instructed to use the call light for assistance with transfers to the toilet and ambulation (12/18/25). The Kardex printed 6/16/26 revealed the resident was weight bearing, SBA for ambulation with 1 staff, resident self transfers. Do not leave the toilet unsupervised, use a call light for transfers to the toilet and ambulation.The facility's document Physician Communication dated 1/4/26 revealed the resident sustained an unwitnessed fall in her bedroom. The facility's document Physician Communication dated 1/30/26 revealed the resident sustained an unwitnessed fall in her bedroom.The facility's document Physician Communication dated 2/14/26 revealed the resident sustained an unwitnessed fall leaving her bathroom. The facility's document Consultation Report dated 5/7/26 with orthopedic provider disclosed physician order for weight bear as tolerated with walker, did not need assistance and to follow up as needed. The facility's document Physician Communication dated 5/7/26 revealed the orthopedic physician indicated the resident could be up as tolerated with walker and does not need assistance. Request to discontinue the alarms to bed/chair or leave bed at night. The document included the physician order to discontinue alarm for chair, OK to leave bed alarm at hour of sleep (HS) for risk of falls, and resident to use her walker at all times. On 6/15/26 at 1:36 PM observed the resident ambulating independently in her room. On 6/15/26 at 7:45 AM observed Resident #1 up in her room when the breakfast tray was delivered. On 6/16/26 at 10:27 AM Staff B, Certified Nursing Assistant (CNA) stated staff can look at the resident's Care Plan or electronic documentation system to determine assistance needs. The staff stated Resident #1 was very independent and did not need assistance.On 6/16/26 at 10:42 AM Staff C, CNA/Certified Medication Aide (CMA) stated staff gained knowledge about a resident's level of care from other staff, the Care Plan and 24 hour report. The staff stated Resident #1 only has a bed alarm following a new physician order; the resident previously had 2 alarms. The staff stated the alarm was to notify staff when the resident was getting up in the morning. The staff stated the resident was independent with self care and ambulation. On 6/16/26 at 10:55 AM Staff D, CNA/CMA, stated information on a resident's needs comes from other staff members, therapy, the Care Plan and/or the Kardex. The staff stated Resident #1 was independent with mobility and self care. The staff stated the resident did have a bed alarm.On 6/16/26 at 11:05 AM Staff E, CNA, stated she obtained information on residents from other staff. The staff stated Resident #1 was very independent with self care and mobility. The staff stated they (staff) do not need to assist the resident with anything unless she requests assistance. The staff stated they had stopped the intervention of waiting for the resident outside the bathroom a few weeks prior when the doctor said she could get up on her own. Staff E stated the resident no longer has a chair alarm, only the bed alarm. On 6/16/26 at 11:18 AM Staff F, CNA/CMA, stated the Kardex, the Communication Book, Care Plans and shift to shift reports provide information on the residents' needs. The staff stated Resident #1 was mostly independent and staff did not need to wait outside of her bathroom door. The staff stated the resident will use the call light and request assistance when needed. The facility failed to update the Resident #1's Care Plan to reflect new fall interventions following the falls on 1/4/26, 1/30/26, and 2/14/26. The facility failed to update the Care Plan following the removal of interventions and increased levels of independence. 2. Resident #4's MDS assessment dated [DATE] revealed the staff completed the cognitive assessment with identification of memory problems for short term and long term memory, and severe impairment for cognitive skills for daily decision making. The document coded the resident required total assistance for all self care activities, sitting to/from lying with supervision/touching assistance, and transfers/ambulation up to 150' with supervision/touching assistance. The assessment included diagnoses of Non-Alzheimer's Dementia, seizure disorder or epilepsy and autism. The Care Plan, revised 3/28/26, identified a risk for falls (revised 1/1/24) with an intervention of the bed in a low position, and flat disc light by her hip when in bed (7/2/24). A focus area identified the resident had an actual fall related to poor balance, shuffling gait, and cognition issues (revised 12/28/24) with interventions for the bed in low position (7/2/24), direct resident away from items within facility that may pose fall risk for resident (entry rug, furniture in commons area, medication carts) (11/19/24), disc call light in reach while in bed (7/2/24), ensure resident's room is free of clutter and obstacles (2/12/25), entry rug changed (3/28/26), monitor resident while walking in congested areas (revised 7/10/24), offer w/c when having balance issues (12/5/24), and skid strips next to bed (8/25/25),The Kardex, printed 6/15/26, revealed the resident independently transfers self in and out of bed. The resident was able to reposition herself in bed with no assistance. Fall/Safety Interventions: bed in low position, flat disc light by hip when in bed, disc call light in reach while in bed, skid strips next to bed.Observed on 6/15/26 at 12:55 PM Resident #4 lying in bed with the bed positioned at the lowest position, flat disc call light on the nightstand (not within reach), and no skid strips present at the bedside.Observed on 6/15/26 at 1:55 PM Resident # 4 sleeping in a low bed and the call light on the nightstand.Observed on 6/15/26 at 2:49 PM Resident #4 sleeping in a low bed and the call light on the nightstand. Observed on 6/16/26 at 8:00 AM Resident #4 lying in a low bed and the call light at the head of the bed. Observed on 6/16/26 at 11:33 AM Resident #4 lying in a low bed and the call light at the head of the bed. Observed on 6/16/26 at 11:58 AM Resident #4 walking out of the dining room. Staff C approached the resident and offered her 2 activities with the resident choosing to go back to bed. The resident proceeded to walk independently back to her room, get into bed, roll around, and cover herself up.On 6/16/26 at 10:27 AM Staff B stated Resident #4 is able to get into and out of bed and ambulate by herself.On 6/16/26 at 10:42 AM Staff C stated Resident #4 was independent with all mobility, including getting into and out of a low bed. The staff stated if the resident was having difficulty getting up from the bed, she would scoot on her bottom to the hallway to look for help. On 6/16/26 at 10:55 AM Staff D stated Resident #4 was independent with mobility. The staff stated if she appears tired the staff will use a wheelchair (w/c). The staff stated the resident did not know how to use a call light due to cognitive impairment. The staff stated the resident did not understand cause and effect. On 6/16/26 at 11:05 AM Staff E stated Resident #4 could get up and down by herself most of the time. The staff stated occasionally staff will provide guidance for the resident to ensure she reached the appropriate destination - going to the dining room for a meal. The staff stated the resident did not know how to use a call light and it was used more at night.On 6/16/26 at 11:18 AM Staff F stated the resident was very active and would walk herself up and down the halls. The staff stated the bed was lowered to the floor and the resident always had non-skid socks for fall interventions. Staff F stated the resident may move the call light and acknowledged the resident did not know what the purpose of the touch pad call light was. The facility failed to update the resident's Care Plan to reflect current and appropriate fall interventions for Resident #4. On 6/17/26 at 9:49 AM the Administrator acknowledged Resident #1 was independent for all mobility and self care. The Administrator concurred the fall intervention for the resident to use a flat disc call light was not appropriate and the Care Plans needed revision. The Administrator expected the Care Plans match the residents' needs. On 6/17/26 at 10:00 AM the [NAME] President of Operations for Nebraska and Iowa confirmed the Care Plans were not consistent with the residents' current levels of care. The staff expected the Care Plans to be current with the residents' needs. The facility's Care Planning Policy, revised 3/19, revealed Care Plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur. The document included that the interventions must meet the individual's needs and requires active problem solving, and creative thinking to obtain the individual resident goals.

Based on observation, resident interview, clinical record review, facility policy review, and staff interviews the facility failed to re-evaluate the use of the motorized wheelchair quarterly to protect residents from accidents and injuries for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 30 residents. Findings include:Review of the Minimum Data Set (MDS) for Resident #1 dated 8/15/25 documented an admission date of 3/2/23 and a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented diagnoses of hemiplegia (a medical condition that causes paralysis or weakness on one side of the body) following cerebral infarction affecting left non-domical side, heart failure, atrial fibrillation, anemia (a condition where the body does not have enough healthy red blood cells to carry oxygen throughout the body), diabetes mellitus, respiratory failure, visual hallucinations, and nausea without vomiting. The MDS revealed the resident required a total dependence on staff to complete transfers and used a wheelchair for mobility. An observation of Resident #1 on 9/22/25 at 1:17 pm revealed the resident left the room to attend an outdoor activity. He was using a motorized wheelchair. He was leaning towards the left side heavily. The back of the chair wasn't tall enough to support his back and only extended to about half the height of his spine. A staff member noted in the hallway, stopped Resident #1 and offered to reposition him to bring him up to the center of the chair but he declined. In an interview with Resident #1 on 9/24/25 at 4:00 pm he stated he tended to lean to the left side in his wheelchair due to his stroke and that the facility's staff always seemed worried about it but he was not concerned about it. He stated that he was utilizing the motorized wheelchair for mobility and also used it outside of the facility for doctor's appointments. He stated that the facility maintenance staff assisted him with some minor adjustments when he needed any help with it. Resident's #1 roommate reported a user manual for the wheelchair was in a closet and at that time it was located in one of the drawers then taken to the administrator's office. A review of the Electronic Health Care (EHR) document titled Care Plan revised on 8/29/25 revealed Resident #1 had a history of hypoglycemia (low blood sugar) related to disease process and interventions directed staff to monitor, document, and report signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate, confusion, slurred speech, lack of coordination, and staggering gait. The Care Plan also documented a focus area of limited physical mobility revised on 5/12/23 and interventions were to provide supportive care, assistance with mobility as needed and to document assistance as needed. A review of the EHR Progress Notes for Resident #1 documented the following entries of altered cognition: On 7/26/25 at 12:00 pm: Resident appears more confused than normal. He thought he was out farming earlier this shift. Urine cloudy with foul odor. Fazed out for urinary analysis. On 8/16/25 at 5:49 pm: Resident at dinner table stating that there were moving bugs in his lettuce salad as he continued to eat the salad. After looking at his salad it was noted by the nurse and other staff including kitchen manager that it was cabbage and not bugs.On 8/17/25 at 10:00 am: Resident sitting up in wheelchair with a nail file and picking at his dentures. He stated that he was trying to get the metal out of his denture. Upon looking at his dentures there appears to be no metal visible. Explained to resident but continued to pick at denture. Resident also stated that he had rubber bands in his food. On 8/30/25 at 12:35 pm: At 11:35 am nurse called down to the resident room. The resident was not acting like himself. He had woken up and drove his power chair under the sink. The resident was leaning in his chair more than normal. Pupils equal, hand grasps equal, smile normal, speech is clear. The resident was complaining of neck pain after falling asleep in his power chair. The resident was given Tylenol for the neck pain. He stated that he did not sleep well last night. The resident roommate stated that he had been talking in his sleep a lot and was restless. The resident was able to take himself to the dining room in his power chair. The resident was having difficulty holding him to put back into his shirt pocket. Resident was able to feed self lunch without assistance. The resident was able to drive the power chair back to his room.A review of the EHR documented the following regarding his wheelchair:On 7/30/25 at 4:04 pm: Called NuMotion and spoke with a representative about the sensitivity of the motorized wheelchair. She verified that the wheelchair was delivered on 7/21/25 and that all other communication will have to go through the care coordinator. Left voicemail with facility number as call back. On 8/6/25 at 9:05 pm Skin/Wound Note Late Entry: Resident has bruising on his right arm. The bruise on the posterior arm is 9x5.5 cm in size. The bruise on the posterior lateral aspect of the right arm is 8x3 cm in size. The resident stated that he was attempting to reach into his cabinet and got his arm caught under the arm of his wheelchair. On 9/5/25 at 3:23 am: 4.5x 4 cm bruise found on the right posterior forearm which is dark purple in color. Resident denies pain/tenderness. Doctor notified.In an interview with the Administrator on 9/25/25 at 10:14 am, she confirmed her expectation was that the facility would perform a safety assessment on a resident with an electric wheelchair prior to using it and the Care Plan would need to be updated. In an interview with the Regional Clinical Coordinator on 9/25/25 at 9:45 am, he confirmed there was an expectation that a safety assessment would be performed for a resident that would be operating an electric wheelchair prior to operating it and he would provide a facility policy regarding an electric wheelchair use by a resident in the facility. In an interview on 9/25/2025 at 8:55 am with the Occupational Therapy (OT) department supervisor, she stated she had knowledge of Resident #1 delivery of the motorized wheelchair in July as she was informed by the NuMotion company they had the electric wheelchair and would be delivering to the facility on a specific date. She also stated she took the next step notifying the facility MDS coordinator of the delivery date. She confirmed that she had knowledge that the toggle controller was too quick when the resident was initially operating the wheelchair and confirmed there was no follow-up completed or in-person assessment completed by the OT department. She stated she was under assumption NuMotion delivery company would be completing a safety assessment. She acknowledged that the OT department had to request an order from a physician to assess the resident for safety once the motorized wheelchair arrived and it was not completed, therefore, the resident was not on their workload to be evaluated. She took further action to contact the NuMotion company and they were able to complete the assessment of the motorized wheelchair toggle controller and adjust it. In an interview with the Director Of Nursing on 9/25/25 at 9:47 am she stated that she did not double check if the Care Plan reflected Resident #1 use of the electric wheelchair and she relied on the MDS Coordinator to add the information to the MDS. She stated she would expect the information to be entered into the EHR by the MDS Coordinator and there was no follow-up in place on her behalf to further monitor if the MDS Coordinator completed the necessary documentation. The DON also stated to her knowledge, there was no special wheelchair safety assessment to be completed for a resident who newly obtained a motorized wheelchair. The DON also stated she felt that the motorized wheelchair safety assessment would be handled by the Occupational Therapy Department and that the NuMotion company that delivered the motorized wheelchair would also complete a safety assessment for Resident #1. She also reported she had knowledge of Resident #1 not capable of driving the motorized wheelchair only 1 time and he was not allowed to further operate the wheelchair until NuMotion came in and readjusted the drive switch sensor. A facility provided policy titled Motorized Wheelchair and Scooter Policy dated September, 2019 documented: The purpose of this policy and procedure is to protect:1. the safety of residents using motorized wheelchairs or scooters;2. the safety of other residents, employees and visitors; and3. the facility property from damageA resident has the right and privilege of using a motorized wheelchair or scooter within this facility and on its grounds, if he/she meets eligibility requirements and complieswith all policies and procedures of facility pertaining to motorized wheelchairs and scooters. The purchase and maintenance cost of motorized wheelchairs and scooters arethe responsibility of the resident and/or the resident's family.1. Eligibility requirements for use of a motorized wheelchair or scooter:a. The resident must have, maintain and demonstrate the physical and cognitive ability to safely operate the motorized wheelchair or scooter. Withoutlimitation, this includes the ability to: Grip hand controls and pull the brake lever as needed. Steer around obstacles. Judge distances needed for braking and steering while driving forward and back. Shift the resident's body weight as necessary for going around corners. Concentrate on both driving and the environment around the resident. React quickly in emergencies. Sit for long periods of time and get on and off without assistance. Use patience while in busy or congested areas. Remember safety procedures. Have awareness of the resident's surroundings and where the resident lives. See all obstacles both in front of and coming in from the side (peripheral vision).2. Facility's rules pertaining to the use of motorized wheelchairs or Scooters:a. Only the resident may operate such resident's motorized wheelchair or scooter.Letting another use the motorized wheelchair or scooter, giving rides or pulling something is not allowed.b. Operators must maintain complete control of their own motorized wheelchair or scooter at all times. They must operate their motorized wheelchair orscooter so as not to endanger themselves, other residents, staff, visitors, or Facility property.c. Operators must maintain safe speeds when in use within the Community or on its grounds. Safe speeds are defined as no faster than the average walkingspeed of the other residents in the building. The governor shall be set to a speed limit as determined by Facility.d. The On/Off switch must be turned off when not driving. Example: during transfers, at meals, activities, social events, religious services, etc.e. Operators must, at all times, yield to people/pedestrians and appropriately to other wheelchairs or scooters similar to the rules that apply when driving a car.f. Operators must avoid contact with fixed and moveable objects at all times.This includes people, walls, furniture, rails, tables, doorways, etc.g. Residents may not come within 12 inches of another person walking, in a wheelchair, or in another motorized wheelchair or scooter.h. Residents must be in an upright position at all times.3. Observing the resident's use of the motorized wheelchair or scooter:a. All staff will observe the resident for competent and safe practices and report any variances to the DON or ADON.b. If a resident does not comply with Facility's rules, policies and procedures regarding motorized wheelchairs and scooters, the DON or ADON will determine if a warning or revocation is necessary.c. Facility's interdisciplinary team will re-evaluate the physical and cognitive ability of each resident using a motorized wheelchair or scooter quarterly, or more frequently if deemed necessary. The interdisciplinary team will make recommendations regarding continued use or discontinuing use of the motorized wheelchair or scooter. Results are to be documented and saved in the resident's medical record and/or care plan.4. Facility response to the unsafe use, non-adherence to policy and observation of motorized wheelchair or scooter privileges:a. Facility reserves the right to immediately prohibit a resident's use of the motorized wheelchair or scooter if the resident is a danger to himself/herself or others and/or if substantial property damage has occurred.b. The final decision regarding the resident's use of a motorized wheelchair or scooter at all times rests exclusively with Facility's Administrator, with the advice of the interdisciplinary team. In the absence of the above named, the Director of Nursing or ADON may temporarily prohibit the use of and remove the motorized wheelchair or scooter based on the safety and well-being of residents, staff, or damage to Facility property until an appropriate evaluation can be made.A facility provided policy titled Resident Incident Report Policy revised March, 2019 documented:PROCEDURE1. A Resident Incident Report is completely filled out on all incidents (an incident is defined as anything out of the ordinary, unusual happening i.e.:skin tear, falls, family concerns, allegation of abuse or neglect, altercation between residents, etc.).a. ***IF IN DOUBT---COMPLETE INCIDENT REPORT. ***2. If the incident occurs to a resident, or between residents, thoroughly document the happening in the appropriate medical records. 3. The incident report is to be filled out by a licensed health care employee (LPN, RN, Social Worker, RPT, etc.). The employee filing the report shall fill out the appropriate type of incident report in Point Click Care (PCC). The incident report time must be updated to reflect the actual time of occurrence.4. The Falls Scene Investigation Form (attached to this policy) will be completed at time of incident, if incident is a fall. The completed form will be forwarded to nurse manager.5. IDT review at Quality Council meeting. Follow-up note to be completed in PCC.6. The Nurse Manager/designee will ensure that the incident and any update(s) are adequately documented in the resident medical record in the Nurses' Notes section.7. The Nurse Manager is to ensure that the resident care plan is revised/updated as necessary based on incident reports.8. It is the responsibility of each unit Nurse Manager to notify other appropriate departments of incidents that they are to be involved in the closure of.9. The appropriate family members and physician are to be notified in a timely fashion of the incident.10. An immediate intervention needs to be implemented after an incident to attempt to prevent a recurrence.11. After IDT review, the incident report will be locked by the Administrator, DON.12. The Medical Director will review incident reports during QAPI.13. The DON will be responsible for the compliance of this policy.

Based on clinical record review, family interview, staff interviews, and policy review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 13 residents (Residents #4 and #6). The facility failed to completely fill out the Medication Administration Record (MAR) - Treatment Administration Record (TAR) for the residents. The facility had a census of 30. Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status of 14/15 indicating normal cognition. The document provided the resident had diagnoses of Non-Alzheimer's Dementia, anxiety, depression, and chronic obstructive pulmonary disease (COPD) and took medications that included antipsychotics and antidepressants. The resident required oxygen. The resident's Care Plan dated 9/23/25 contained a focus area of shortness of breath related to COPD. Interventions for staff included use of oxygen. The document further contained focus areas with specific target behaviors identified with interventions of non-pharmacological interventions and documentation requirements. The document failed to identify skin integrity concerns for the resident's ears related to the use of the nasal cannula. The Clinical Physician Orders printed 9/25/25 revealed the following orders: Apply Vaseline to bilateral ears where oxygen tubing is rubbing three times a day (TID) for ear breakdown from oxygen tubing related to COPD dated 8/26/25 and revised 9/23/25. Remedy Specialized Protect with zinc oxide paste to buttocks, cleanse area with soap and water prior to application four times a day (QID) for skin integrity with start date of 7/23/25. Document suicidal ideation, anger outbursts and document behavior every shift with start date of 11/29/23. Resident #4's MAR - TAR 9/25 revealed lack of documentation for application of Vaseline for bilateral ears on the following dates/times: 9/5/25 5:00 AM9/14/25 5:00 AM 9/15/25 5:00 AM 9/17/25 5:00 AM 9/18/25 5:00 AM9/19/25 5:00 AM9/21/25 9:00 PMThe MAR - TAR 9/25 lacked documentation for treatment with the Remedy Specialized Protect on 9/21/25 at 9:00 PM and documentation for suicidal ideation, anger outbursts and behavior on 9/21/25 at 6:00 PM. On 9/23/25 at 10:40 AM the Director of Nursing (DON) stated Resident #4 was likely refusing the 5:00 AM treatment as she did not like to get up in the morning and did not like to be bothered. The staff further stated the resident had a history of refusing treatments and care. The staff did acknowledge if the resident was refusing it should be documented as such instead of left blank. 2. Resident #6's MDS dated [DATE] revealed the BIMS was completed by staff with the resident presenting with moderately impaired cognitive skills for daily living, but some short term and long term memory abilities. The document provided the resident utilized a wander elopement alarm daily. The resident's diagnoses included Non-Alzheimer's Dementia, epilepsy, autistic disorder and intermittent explosive disorder. The document provided the resident took antipsychotic, antianxiety, antidepressant, opioid and anticonvulsant medications. The resident's Care Plan dated 9/10/25 provided a focus area of an elopement risk revised 9/10/25 with non-pharmacological interventions dated 8/27/25 and a wander alert in place revised 1/6/25. An additional focus area related to antipsychotic medication dated 10/22/24 contained interventions that included medications, non-pharmacological interventions, and identification of behaviors. The Clinical Physician Orders printed 9/25/25 revealed the following:Push fluids - ice cream, Jell-O, soup, shakes, popsicles, chocolate milk etcetera every shift for dehydration with a start date of 3/25/25.BEHAVIORS - MONITOR for any during shift: 1. Pinching, 2. clawing, 3. Increased pacing DOCUMENT N if monitored and none of the above observed. Y if monitored and any of the above was observed, select chart OTHER/SEE NOTES and ENTER FINDINGS IN PROGRESS NOTE. INTERVENTIONS. 1. redirect 2. offer drink 3.music therapy. d/t behavior related to anxiety/agitation. Codes: 1. Behavior occurred y/n 2. Which behavior observed 3. Intervention 4. Result 5. Frequency BID for health maintenance with a start date of 10/22/24.Check wander guard every shift to ensure in place and to check for function BID for safety with a start date of 7/2/24. Resident #6's MAR - TAR 9/25 lacked documentation on 9/21/25 for behaviors at 8:00 PM, checking of wander guard at 8:00 PM, and pushing of fluids at 6:00 PM. On 9/23/25 at 10:40 AM the DON stated with review of the MAR -TAR 9/25 for Resident #4 and #6 she was unsure of what happened on the evening of 9/21/25, but overall it looked like things fell apart. The DON stated she expected staff to complete documentation. On 9/23/25 at 4:00 PM Staff A, Chief Nursing Executive, acknowledged lack of documentation would lead one to believe the treatments were not completed.On 9/24/25 at 1:30 PM the DON stated she put a notice up at the nurse's station that all areas on the MAR - TAR are to be green before leaving at the end of a shift. The staff stated Assistant Director of Nursing (ADON) stated on one instance overnight she had done the 5:00 AM treatment for Resident #4 but could not document the treatment as TAR had not opened yet as it was scheduled for 5:00 AM and treatment was done at 4:00 AM and she did not go back and document it. On 9/24/25 at 2:30 PM Staff B, Certified Medication Aide (CMA) stated she did not know of a reason to leave blanks on MAR-TAR. Staff stated if there was an unknown reason or refusal it would be documented as such. Staff stated she would not leave at the end of shift if everything was not green (completed). On 9/24/25 at 3:11 PM Staff C, CMA, stated she could not provide a reason as to why she would not document on the MAR-TAR or leave an empty space. Staff stated she would ask the charge nurse or administrator for assistance if there was something she could not document. On 9/25/25 at 8:00 AM the Administrator expected documentation regarding the MAR - TAR to be better than what they have and not be incomplete. The facility's Documentation System Policy revised 3/19 revealed that all services provided included observations, medications administered and services performed must be documented in the resident's medical record. The document also included entries into the medical record may only be made by licensed personnel in accordance with state and federal laws. Trained Medication Aides (TMAs or CMAs) will observe/monitor residents for side effects of medications and notify the nurses who will document onto MAR and into the resident's permanent record. The policy provided the medical record should be up-to-date at all times reflecting the current status of the resident.

Based on document review, staff interview and facility policy review the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 11 of 90 days reviewed (April 1st through June 30th 2024). The facility reported a census of 25 residents. Findings include: Review of the Payroll Based Journal (PBJ) staffing data report for the fiscal year quarter three (April 1st through June 30th, 2024) revealed there was no Registered Nurse (RN) hours for 4/29, 5/4, 5/18, 5/23, 5/31, 6/1, 6/2, 6/11, 6/15, 6/16, and 6/25/2024. Interview 10/22/24 at 12:52 PM with the Administrator confirmed that the facility did not have RN coverage listed on the PBJ. The Administrator confirmed these dates, and revealed that the facility only had one RN at the facility during this time. The Administrator revealed that her expectation would be for 8 hours RN coverage per day. Review of a facility provided document titled, Facility Assessment with a completed date of 7/15/2024 revealed: a. Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by improperly serving food and failing to ensure proper sanitizing solution concentration. The facility reported a census of 25 residents. Findings include: On 10/23/24 at 9:36 AM, Staff A, [NAME] and Staff B, Dietary Aide (DA) were unable to locate sanitizer test strips to perform a sanitizing solution concentration check. Staff B stated she used detergent to clean the dining room tables. On 10/23/24 observations in the kitchen revealed the following: At 11:45 AM, Staff A, Cook, grabbed potato chips from a bag and placed them on a resident's plate with gloved hands she previously used to touch other non-food items. At 11:55 AM, Staff A placed the mashed potato serving scoop in the mashed potatoes and the handle came in direct contact with the food. She picked it up and continued using it with the same gloves she had touched non-food items. At 12:00 PM, Staff A scooped meatloaf sauce into a bowl and used her right gloved hand to push the sauce off the rim and into the bowl and served it to a resident. She previously used the gloves to touch non-food items. At 12:04 PM, Staff C, Dietary Manager (DM), used her gloved hands to move menus and a tray from the serving window. She grabbed a plate with the same gloved hand and her thumb touched the food contact surface. At 12:05 PM, Staff A prepared fruit cocktail bowls for residents with gloved hands. She walked over to the service counter and stuck her gloved hand into the loaf of bread and grabbed two (2) slices. She put them on the resident's plate and spread peanut butter on one slice. She grabbed the jelly container and squeezed jelly onto the slice of bread. She picked up the slice of bread with the same left gloved hand and continued making the resident's sandwich. No hand hygiene or glove change was performed. On 10/24/24 at 8:34 AM, the DM stated staff should perform appropriate hand hygiene and the sanitizing solution strips should be accessible and used correctly. A policy titled Handwashing Guidelines for Dietary Employees and dated 2023 directed staff to clean their hands while preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Based on clinical document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for residents with an order for anticoagulants for 1 of 5 residents (Residents #10) reviewed. The facility reported a census of 25 residents. Findings include: Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed anticoagulant medication usage for 7 of the 7 day look back period. Review of Resident #10's Electronic Healthcare Record page titled Physician's Orders revealed an order for Apixaban 5mg oral tablet take 1 tablet by mouth twice daily. Review of Resident #10's Care Plan with a review date of 8/23/24 revealed no documentation of anticoagulant medications. Interview on 10/22/24 at 2:48 PM with Staff D, MDS coordinator, confirmed Resident #10 is on an anticoagulant. Staff D further revealed that anticoagulants should be on care plans. Interview on 10/22/24 at 3:03 PM with the Director of Nursing (DON) revealed that her expectation is for care plans to be complete and accurate. Review of a facility provided policy titled, Care Planning with a revision date of March 2019 revealed: a. Physician's orders are referenced in the resident's care plan.

Based on clinical record review, resident interview, staff interviews, equipment manual review, and policy review the facility failed to maintain patient care equipment in safe operating conditions by not completing safety and maintenance checks allowing the actuator mount to wear and break causing the resident to fall to the floor and sustain a compression fracture for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also reported use of a sit to stand mechanical lift for transfers. On 7/19/24 at 12:40 PM Resident #2 stated on 6/12/24 she was halfway to the standing position when the sit to stand lift broke. Resident #2 stated she fell to the ground onto her buttocks. Resident #2 stated her buttocks did not hurt at first but when she was moved a little bit later it hurt. Resident #2 stated she was sent to the emergency department for an x-ray but did not get the x-ray because she said she didn't need them. Resident #2 stated a couple days later she was in real pain and she wanted them then. Resident #2 stated she went to the hospital but told the physician she did not want the x-rays and did not get them at that time. Resident #2 stated the staff were using the lift appropriately. Resident #2 stated the lift just broke. Resident #2 stated she still has pain in her lower back and legs from the fall. Resident #2 stated she was still fearful of every transfer with any mechanical lift since the fall. The Physician Communication form dated 6/18/24 documented resident had a fall on 6/12/24 and has had back spasms and pain when she is being lifted in the sit to stand. Resident would now like an x-ray. Physician response documented an order for X-ray to T-spine and L-spine for pain. The Diagnostic Radiology form dated 6/19/24 documented the reason for exam as back pain and fall. The report impression revealed mild compression deformities present at T11 and L1. The General Message from the provider dated 6/20/24 documented the resident does show signs of compression fractures of her vertebrae. This could be related to her recent fall but may also be related to past difficulty and falls. Provider recommended proceeding with MRI. Review of the document titled Office Clinic Notes dated 6/26/24 documented that a review of Resident #2's MRI revealed a compression fracture of L1 and L3. Review of document titled, EZ Way Service Manual, revised date 10/2/23, documented the EZ Way Smart Stand requires a minimum of servicing to keep it in good working order. Nevertheless, it is important that certain basic checks be periodically made by maintenance staff to ensure on-going safety throughout the life of the device. The manufacturer suggests that the following components and operating points be scheduled for inspection at intervals not greater than six months. Any detected deficiency must be rectified before the stand is put back into service. Check mounting bolts of actuator top and bottom. Pay particular attention to the top bolt hole for elongation. Observation of a photo (image 20240617) of actuator arm failure from the failed sit to stand lift provided by Staff A of actuator top bolt hole revealed the top bolt hole had smooth rolled out metal with clear elongation similar to that in the photo of what to pay particular attention to in the document titled, EZ Way Service Manual. On 7/19/24 at 12:10 PM Staff A, Maintenance Director stated he had worked at the facility over 5 years. Staff A stated the mechanical lift failed where the actuator motor meets the actuator lifting arm. Staff A stated he had never seen anything like that prior. Staff A stated he completed a monthly safety inspection through the facility's computer program that has all the steps to go through. Staff A stated the sit to stand lift was an EZ-way lift model number 898 and was a 400 lbs capacity. Staff A stated he never took the sit to stand lift apart to inspect the actuator or actuator arm bolt connection. Staff A said the failure must have happened from years of use or possibly use with a heavy resident. Review of document titled, Lift Inspection Checklist for lift with serial #43887 documented to inspect all hardware. Document signed off as completed for last 12 months of service. On 7/19/24 at 1:27 PM Staff B, Certified Nursing Assistant (CNA) stated she was one of the 2 CNA's that were caring for Resident #2 during the fall on 6/12/24. Staff B stated she was using the controls and the other CNA was behind Resident #2 and they were going to put the resident on a commode. Staff B stated Resident #2 was being raised and then the resident was on the floor. Staff #2 stated the sit to stand mechanical lift had broken. Staff B stated she worked PM shift and did not know if the maintenance performed any inspections on the lifts. Staff B stated after the resident ended up on the ground she asked Resident #2 if she was okay and the resident said she was. Staff B stated they called the nurse who completed an assessment and vitals. Staff B stated they used the Hoyer full body lift to get Resident #2 off the floor. Staff B stated Resident #2 stated she did not want to go to the ER. Staff B stated they were utilizing the lift appropriately when the fall occurred. Stated in point of care (POC) there is a Kardex that tells how residents transfer. On 7/19/24 at 2:28 PM Staff D, Registered Nurse (RN) stated she was called to Resident #2's room and she did not remember what time it was. Staff D stated Resident #2 was seated in an upright position with a sling under her and the piston of the sit to stand lift was hanging out of the machine. Staff D stated you could see where the equipment failed. Staff D stated Resident #2 stated her head had not hit the floor. Staff D stated an assessment was completed at that time. Staff D stated range of motion (ROM) with arms and legs were per Resident #2's norm. Staff D stated Resident #2 denied pain with ROM. Staff D stated asked Resident #2 to go to the ER for evaluation and she refused. Staff D stated Resident #2 stated she was fine and wanted to get up off the floor. Staff D stated staff utilized a Hoyer full body lift to get the resident off the floor. Staff D stated the family requested she be sent to the emergency department (ED) a day later. Staff D stated ED called back and stated they did not see anything wrong with Resident #2 and Resident #2 refused the x-ray. Staff D stated all the straps were in place and the lift was utilized appropriately. On 7/20/24 at 12:55 PM Staff C, Certified Nursing Assistant (CNA) stated the EZ stand broke during the transfer of Resident #2. Staff C stated they utilized the sit to stand to transfer Resident #2 to the commode and the arm for the sit to stand lift broke. Staff C stated Resident #2 fell straight to the floor on her buttocks. Staff C stated she had never seen a sit to stand lift break before this incident. Staff C stated Resident #2 was crying. Staff C stated the nurse assessed and obtained vitals. Staff C stated a Hoyer full body lift and sling was utilized to get Resident #2 off the floor. Staff C stated the sit to stand did not have any problems prior to breaking. Staff C stated right when the sit to stand lift broke Resident #2 was crying but refused to go to the hospital. Staff C stated Resident #2 hit the floor pretty hard. Staff C stated maintenance never made any mention that the machine should be inspected prior to use. Staff C stated she had never seen maintenance inspecting the machine. On 7/20/24 at 9:03 AM the Administrator stated with the monthly maintenance the facility's expectation was the actuator arm would have been checked for any wear or damage. Review of the undated protocol titled, Instructions Conduct Mobile Lift Safety Inspection documented to inspect the lift actuator assembly to check for wear and damage. Protocol documented in bold to notify manufacturer and property manager if damage is found.

Based on observations, clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to transfer 1 of 3 resident (Resident #1) safely to prevent her from falling. Staff failed to obtain a gait belt prior to assisting Resident #1 from the toilet to the sink to wash her hands. Instead staff held on to the resident's pants during the transfer. As Resident #1 turned away from the sink, she lost balance, staff lost grip and the resident fell on her right shoulder. The resident was sent to the emergency room (ER) to be evaluated and was found to have a right proximal humerus fracture. The resident returned to the facility the same day with her right arm in a sling and recommendations to follow up with orthopedics. The facility reported a census of 28 residents. Findings include: According to the Admission Minimum Data Set (MDS) assessment tool with a reference date of 2/13/24 Resident #1 had a Brief Interview of Mental Score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS indicated Resident #1 utilized a walker and wheelchair for mobility. The MDS documented she used a walker and wheelchair and dependent on staff for toilet transfers. The MDS documented she had a fall in the last month prior to admission. She did have a fracture related to the fall in the 6 months prior to admission. Resident #1 had one fall with injury since admission. The MDS listed the following diagnoses for Resident #1: fractures and other multiple trauma, coronary artery disease, thyroid disorder, hip fracture, anxiety, and depression. The Care Plan focus area with an initiation date of 2/7/24 documented Resident #1 had a walk to dine program. The Care Plan indicated the resident was to use a hemi-walker with assistance of one staff, gait belt and wheelchair to follow, 2-3 times per day. A second Care Plan focus area with an initiation date of 2/7/24 documented she required assistance with her transfers, bed mobility and ambulation. The Care Plan indicated she required extensive assistance of one staff person with bed mobility, transfers, and ambulation. The Progress Notes documented the following notes: a. 2/10/24 at 2:57 PM skilled status note: resident's weight bearing tolerance has decreased since fall this morning. The need for assistance with a gait belt and walker has become more reliant on the assistance of one person than on herself. b. 2/25/24 at 3:32 PM this nurse was called to Resident #1's room for a witnessed fall. Observed resident lying on floor, supine with her knees bent. Bilateral forearms resting on resident's abdomen. This nurse sent Certified Nursing Assistance (CNA) to call for non-emergent transport to the emergency room at 1:08 PM. Resident complained of pain at 10/10 at right shoulder. She was able to move her fingers and bend at the elbow without discomfort or additional pain. Radial pulses equal bilaterally. Update received from the emergency department, resident was ready for transport back to facility. Resident had sustained a right humerus fracture and was stabilized with a sling. c. 2/25/24 at 4:08 PM Resident #1 returned to the facility at 3:49 PM in a shoulder/arm sling without a waist band. She stated her shoulder only hurts when she tried to use it or move it. The facility provided a hand-written statement from Staff E Activities Director/CNA. The statement documented the following: staff went to help Resident #1 off the toilet. She stood up by herself. Staff walked with Resident #1 holding the back of her pants, as there was no gait belt in sight. Staff walked with her to the sink where she washed her hands. As she turned around, Resident #1 lost balance. Staff's right hand was on Resident #1's right shoulder at the time she began to fall. Staff lowered her to the floor but lost grip. Resident #1 fell hitting her right shoulder on the floor. Staff E went to get the nurse who took vitals and instructed staff to call the nonemergency line to come take Resident #1 to the emergency room . Staff E signed the statement. The facility provided a report titled Fall dated 2/25/24 at 1:05 PM. Staff was called to Resident #1's room for a witnessed fall. An assessment was completed, resident complained of pain in her right shoulder. She was sent to the local emergency room (ER) to be evaluated. Review of a document titled Diagnostic Radiology with an admit and discharge date of [DATE] documented a right shoulder x-ray was completed. The following findings were documented: age-indeterminate but suspect acute mildly displaced humeral neck fracture, with suspect involvement of at least the surgical neck. The humeral shaft is superiorly displaced approximately 1.6 centimeter (cm) from the head. On 6/11/24 at 2:11 PM Staff E stated the day Resident #1 fell , she went in to assist her. The resident started to stand up before she could get a gait belt on her. They walked to the sink in her room, Resident #1 washed her hands, she turned around and she lost her balance as she picked up the walker instead of turning with the walker, and fell on her right side. Staff E stated she was holding Resident #1's pants and her hands slipped off her Resident #1's pants as she was falling and could not catch her, which resulted in her falling to the floor. When asked if Resident #1 had complained of pain after the fall, she indicated the resident said ow and that her shoulder was hurting, so she went and got the nurse. She acknowledged a gait belt is usually used when assisting Resident #1 with ambulation. She added the gait belts are occasionally on the back of the doors in the resident's rooms but sometimes they are not there. The day she fell , there were no gait belts on the back of her room door. Staff E stated at the time of the fall, Resident #1 required assistance of one staff, her walker and a gait belt with transfers and ambulation. When asked what she should have done if a gait belt was not in the resident's room, she stated she would make sure to ask the resident to sit back until she returned with a gait belt. She acknowledged she should have used a gait belt that day when she had assistance Resident #1. On 6/12/24 at 3:10 PM Staff B CNA indicated if a resident was to get up prior to applying a gait belt, she would find the nearest chair, ask the resident to sit back down, and to hold on while she goes to get one then assist the resident. When asked who requires the use of a gait belt is stated as far as she knew everyone that was ambulatory with staff assistance. On 6/13/24 at 11:22 AM Staff A CNA stated that if she could not find a gait belt prior to assisting a resident with a transfer, she would ask the resident to sit back down until she could get a gait belt. On 6/13/24 at 12:53 PM the Director of Nursing (DON) was asked if staff are assisting a resident and there is no gait belt in the resident's room what are staff supposed to do? She stated staff need to go find a gait belt, they have plenty in the facility. They should ask the resident to remain seated where they are until they find a gait belt. The DON indicated the gait belts are to be on the back of the doors in the resident's rooms, at times they get moved and are in the resident's closets. The facility provided a documented titled Transfer-Ambulation with Transfer Belt Policy with a revision date of March 2019. It is the policy of this facility that all associates utilize a transfer (gait) belt with residents during transfers, ambulation and gait training. The gait belt provides a firm grasping surface for the staff person and protects the resident from accidental trauma to the skin. It gives the resident a sense of security as it is tightened. The belt also allows the staff person to gradually lower a resident to the floor (if necessary) without injuring self or resident. Procedure: 4. If from chair, ensure resident's feet are flat on floor 5. Standing in front of resident, brace resident's lower extremities to prevent slipping. Staff person's knees bent, feet apart, back straight. 6. Place transfer (gait) belt low around resident's waist. Properly tighten belt to comfortably tight level. To bring the resident to standing position, keep your back relatively straight and pull on the gait belt. 8. Failure to use transfer belt with an assisted transfer is ground for disciplinary action and termination. 9. Grasp the belt on the resident's side, while assisting him/her to stand. 11. If ambulation, walk slightly behind and to one side of resident while holding on to the belt. 12. If resident begins to fall, draw the resident close to your body using the gait belt, and slowly lower the resident to the floor.

Based on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to ensure 2 of 3 (Resident #3 and #10) residents were treated with dignity and respect. The facility reported a census of 28 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment Resident #3 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS listed the following diagnoses: cancer, anemia, hypertension, neurogenic bladder, obstructive uropathy, septicemia, diabetes mellitus, depression, and insomnia. The Care Plan focus area with an initiation date of 2/20/24 documented Resident #3 exhibits the following behaviors: being non-compliant with the use of her call light, asking for assistance and walking without staff assistance. On 6/11/24 at 1:51 PM Resident #3 stated she could not recall staff telling another staff member to shove whipped cream in her face and if they did it was probably a joke. When asked how staff treat her, she stated they are great. Staff will laugh and joke with her and she will do the same with them. Resident #3 stated Staff B Certified Nursing Assistant (CNA) is good with her, she even braids her hair after her baths. Resident #3 added she has had no issues with the care provided by Staff B. On 6/11/24 at 2:16 PM Staff E Activity Director/CNA stated she was assisting with passing out lunch trays. They had desserts to pass out so she asked Staff B to pass them out. The dessert was blueberry cobbler and Resident #3 needed one. The resident asked for extra whipped cream and Staff B said to rub it in the resident's face. Staff E told Staff B that comment was not appropriate and should not say those things. Staff E stated Staff B said it jokingly and Resident #3 heard it because she smiled. Staff E indicated she has heard Staff B say off the wall comments before, she means them jokingly but those comments were not always taken that way. On 6/11/24 at 3:17 PM the Corporate Nurse Consultant stated he was in the building doing a mock survey when he heard Staff B say to shove the whipped cream in Resident #3's face. He overheard the comment, it sounded like a fly by, sarcastic comment. Judging by her demeanor it was just a sarcastic comment. He indicated it was not ok to say even if it was a sarcastic comment and he reported it to the Administrator right away. Since this he has learned this is Staff B's sarcastic mannerism. On 6/12/24 at 3:10 PM Staff B stated she got written up for making the comment to Resident #3 about shoving whipped cream in her face. She added it was a joke, but now knows she should not be joking about this. Since then she has watched videos on abuse, neglect, and resident rights. On 6/13/24 at 12:53 PM the Director of Nursing (DON) stated Staff B can be mouthy and rude, not sure how else to describe it. She did not witness Staff B make the comment to Resident #3 about shoving whipped cream in her face. Even if she was joking she should not have said that to the resident. When Staff B jokes, it's hard to interpret if she is joking or not. Residents with cognitive issues could take it differently so we need to be careful on what is being joked about. On 6/13/24 at 2:05 PM the Administrator stated it was no okay for Staff B to tell staff to shove whipped cream in Resident #3's face, even if she was joking, we don't joke like that here. On 6/13/24 at 2:24 PM the MDS Coordinator/Assistant Director of Nursing (ADON) stated Staff B can be hot headed and does not take well to changes that are made. When she is joking in her comments, you don't know other people well enough to say certain things. When she was made aware of Staff B stating to shove the whipped cream in Resident #3's face, she went to approach Staff B about it she threw her hands up in the air and said she did not want to talk to the MDS Coordinator/ADON about it. The Corporate Nurse Consultant was here at the time and took over the situation. 2. According to the quarterly MDS assessment tool with a reference date of 5/22/24 Resident #10 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented the following diagnoses: type 2 diabetes mellitus, amnesia, and pain in left lower leg. The Care Plan focus area with an initiation date of 8/28/23 documented Resident #10 is able to communicate and can understand what is said to her and able to make her needs known. On 6/11/24 at 9:47 AM Resident #10 stated she was kind of tired of Staff A CNA calling her brat. She would come in her room and say good morning brat, how are you brat. She does not think Staff A is doing it to be mean but it's very unprofessional, she says it a lot. On 6/13/24 at 11:22 AM Staff A was asked if she assists Resident #10 with her needs and she indicated she does. When asked if she calls the resident brat while speaking with her, she acknowledged she does and now calls her lovebug. She indicated brat is not very professional and only says it as a joke. Staff A indicated she asked Resident #10 if she liked it and she does. But she thought calling her lovebug would give the resident more spunk. She now sees that calling her brat was not very nice, it may be fun for some residents but not for others, that's why she changed it. On 6/13/24 at 12:53 PM the DON stated even if Staff A is joking she should not be calling a resident brat. She does not think that is appropriate. On 6/13/24 at 2:05 PM the Administrator indicated it is not ok for Staff A to call Resident #10 brat, even if she's joking it is not ok. She calls Resident #4 nanny. In this day an age you need to be careful on what you say. It's not appropriate to call anyone brat or nanny; staff can use their names. The facility provided a document titled Resident Rights Policy with a revision date of 11/2019 indicated the facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Resident Rights 1. Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 2. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 5. Respect and dignity. The resident has a right to be treated with respect and dignity.

Based on clinical record review, employee timecard review, resident interview, staff interviews, and facility policy review the facility failed to ensure 2 of 3 resident (Resident #4 and #5) were free from exploitation. Staff signed out Resident #4's Tramadol on the medication count sheet at 12:00 AM but her timecard documented she clocked out at 11:09 PM. Staff had signed out Resident #5's Hydrocodone (narcotic pain medication) as being given. When staff spoke with Resident #5 during his comprehensive assessment he stated he had not received his Hydrocodone for 2-3 weeks. The facility reported a census of 28 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/3/24 documented Resident #4 had severely impaired cognitive skills for daily decision making. The MDS documented Resident #4 received scheduled pain medications and received an opioid while a resident in the facility. The MDS documented the following diagnoses: autistic disorder, anemia, dementia, seizure disorder, respiratory failure, COVID-19, and hypoxemia. The Care Plan focus area with an initiation date of 12/18/23 documented the resident had chronic pain related to abnormal posture. The Care Plan directed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The Medication Administration Record (MAR) for May 2024 revealed Resident #4 had an order for Tramadol (treatment of severe pain) 50 milligrams (mg) every 8 hours for pain control. Review of the April and May 2024 MAR revealed Resident #4's Tramadol was scheduled to be administered at 12:00 AM, 8:00 AM and 4:00 PM. Review of a document titled Controlled Medication Utilization Record for Resident #4's Tramadol 50 mg every 8 hours revealed Staff C Licensed Practical Nurse (LPN) signed out that she administered the medication at 12:00 AM on 5/31/24. Review of the May 2024 MAR revealed Staff D Agency LPN documented 9 (see nurse notes) on 5/31/24 at 12:00 AM for Resident #4's Tramadol 50 mg every 8 hours order. Staff C failed to sign the order out as being given. Review of Resident #4's Progress Note titled, orders-administration notes, revealed Staff D documented the resident's Tramadol 50 mg scheduled for 12:00 AM had been signed out by Staff C as given already. On 6/11/24 at 3:06 PM Staff C acknowledged she did not sign out Resident #4's Tramadol order on the MAR because the facility had let her go without giving her time to catch up on her charting before she left the building. When asked why she signed it out at 12:00 AM on 5/31/24 but her time card shows she clocked out at 11:09 PM on 5/30/24, she stated she gave Resident #4 her Tramadol before she left at 11:00 PM. Staff C denied taking the Tramadol after signing it out as being given. On 6/13/24 at 10:39 AM Staff D stated on 5/31/24 Resident #4's Tramadol was signed out as being given by Staff C on the count sheet but she did not sign it out as being given on the MAR. She acknowledged the medication had been removed from the medication card. The night Staff C had quit, the Administrator asked her to come to her office because Staff C had quit and they needed a nurse to finish her shift. Her and Staff C completed a narcotic count then left the building. When Staff D looked at the MAR to see what needed done, Resident #4's Tramadol order needed to be carried out. She went to the narcotic book but the medication had been signed out as being given by Staff C. Staff D indicated this was a little after 11:00 PM because the Administrator texted her at 11:00 PM to come to her office. She arrived to her office about 2 minutes after that. Staff D indicated when she arrived to the Administrator's office Staff C was staying right outside of her office. When she noticed the medication had been signed out by Staff C at 12:00 AM on 5/31/24 and the medication was removed from the medication card. Staff D did not know if Staff C actually gave Resident #4 her medication because the order on the MAR was not signed out as being given either. Staff D stated Staff C was standing by the Administrator's office door when she arrived, they immediately did a narcotic count and Staff C left. There would no way Staff C could have signed out and gave Resident #4 her Tramadol as she documented. When asked if Staff D noticed if Resident #4 was in any pain that night, she stated she did not observe any changes in the resident that night. On 6/13/24 at 12:53 PM the Director of Nursing (DON) stated her thoughts on Staff C signing out Resident #4's Tramadol at 12:00 AM on 5/31/24; she either gave it at 9:00 PM and did not want to sign it out early or she took it. Review of Staff C's timecard revealed on 5/30/24 she clocked in at 6:00 PM and clocked out at 11:09 PM. 2. The annual MDS assessment tool with a reference date of 5/26/24 documented Resident #5 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented he received a PRN (as needed) medication or was offered and declined. The MDS documented he took an opioid medication. The MDS documented the following diagnoses for Resident #5: atrial fibrillation, diabetes mellitus, seizure disorder, anxiety, depression, bipolar, respiratory failure with hypercapnia, and obesity. The Care Plan focus area with an initiation date of 5/29/24 documented Resident #5 had chronic pain related to morbid obesity and immobility. Review of March 2024 Medication Administration Records (MARs) revealed Staff C signed out Resident #5's PRN Hydrocodone (treatment of pain) 5-325 milligram (mg) every 8 hours PRN on: a. 3/1 with a pain rating of 7 out of 10 b. 3/2 with a pain rating of 7 out of 10 c. 3/3 with a pain rating of 7 out of 10 d. 3/6 with a pain rating of 7 out of 10 e. 3/7 with a pain rating of 8 out of 10 f. 3/12 with a pain rating of 7 out of 10 g. 3/15 with a pain rating of 7 out of 10 h. 3/16 with a pain rating of 7 out of 10 i. 3/17 with a pain rating of 7 out of 10 j. 3/18 with a pain rating of 7 out of 10 k. 3/20 with a pain rating of 7 out of 10 l. 3/21 with a pain rating of 7 out of 10 m. 3/25 with a pain rating of 7 out of 10 n. 3/29 with a pain rating of 7 out of 10 o. 3/30 with a pain rating of 7 out of 10 p. 3/31 with a pain rating of 8 out of 10 Review of April 2024 Medication Administration Records (MARs) revealed Staff C signed out Resident #5's PRN Hydrocodone 5-325 mg every 8 hours PRN on: a. 4/4 with a pain rating of 7 out of 10 b. 4/8 with a pain rating of 8 out of 10 c. 4/26 with a pain rating of 7 out of 10 d. 4/27 with a pain rating of 7 out of 10 e. 4/28 with a pain rating of 7 out of 10 Review of May 2024 Medication Administration Records (MARs) revealed Staff C signed out Resident #5's PRN Hydrocodone 5-325 mg every 8 hours PRN on: a. 5/2 with a pain rating of 7 out of 10 b. 5/6 with a pain rating of 7 out of 10 c. 5/10 with a pain rating of 8 out of 10 d. 5/11 with a pain rating of 7 out of 10 e. 5/12 with a pain rating of 7 out of 10 f. 5/20 with a pain rating of 7 out of 10 g. 5/24 with a pain rating of 6 out of 10 h. 5/25 with a pain rating of 7 out of 10 i. 5/26 with a pain rating of 6 out of 10 On 6/11/24 at 1:41 PM Resident #5 stated he really has not had any pain when asked how his pain has been the last few months. If he did have pain, it's in his tailbone but staying in bed alleviates that pain. When asked when he last had his PRN Hydrocodone he stated he could not recall since it's been so long ago. He denied asking Staff C for anything for pain in the last month or so. On 6/11/24 at 10:13 AM Staff G Agency LPN stated Resident #5 does not ask for his PRN Hydrocodone nor does he ask for his PRN Tylenol. She added he may have asked for his PRN Tylenol when she first started working at the facility in April 2024. When she would get report, the off going nurse never reported he had received his PRN Hydrocodone on the previous shift. When they looked at the MARs they saw that Staff C had signed his PRN Hydrocodone out a lot. The narcotic counts were never off and the order was signed off as being give, so it looked like he was asking for it. On 6/11/24 at 3:06 PM Staff C when asked why she was the only staff member giving Resident #5 his PRN Hydrocodone, she stated he would ask for it when she would do medication pass. In April and May he would have right shoulder pain, rating it from a 6-8 out of 10. He also had pain everywhere. Staff C stated she only worked two nights a week, maybe three nights. She added the last time she worked he rated his pain a 2 so she did not give him anything. She denied taking the Hydrocodone herself after she signed his order out. The facility had suspected her of taking resident's medications, they suspended her but she quit. She added, she has been a nurse since 1993 and has never taken any resident's medications. When asked about the day she came to work acting out of her norm according to the facility, she stated when she got home that day, her mom checked her blood sugar and it was low at 41. On 6/13/24 at 10:39 AM Staff D stated Staff D stated Resident #5 was never in pain nor did he ask for his PRN pain medication while she worked. She recalled giving him a PRN once time at the end of February, but nothing since then. On 6/13/24 at 12:53 PM the Director of Nursing (DON) stated Staff C had previously worked as an agency nurse then came back full time. She always thought Staff C was doing her job when she was there at the facility. In the middle of May there was an episode where Staff C showed up for her shift unfit for work. She was banging on the main entrance, disheveled, and display erratic behavior. Staff C told them she had a headache, then she picked up the narcotic cards to do a count, stated she can't count these, threw them in the narcotic lock box and said I trust you. The DON asked her to go to her office while a replacement was found for her. Staff C indicated she thought her Zoloft was causing this behavior, then stated she thought she had cancer and needed to see the doctor but did not have health insurance. The DON wanted to give Staff C a ride home that day, when she went to get her stuff, Staff C had left the building. When the Assistant Director of Nursing (ADON) completed Resident #5's MDS assessment, she had completed the pain medication portion of the assessment and Resident #5 had stated he had no pain during the 5-day review period. When the ADON reviewed the resident's MAR, she noticed his PRN Hydrocodone was being given only by Staff C, this was a pattern. Staff C documented Resident #5's pain 7 out of 10 and 8 out of 10 but he had chronic pain of 3 out of 10. When staff spoke to Resident #5 he indicated he had not asked for his PRN Hydrocodone for 2-3 weeks prior to this ordeal. The Administrator was going to suspend Staff C while they continued to complete the investigation but Staff C ended up quitting. On 6/13/24 at 2:05 PM the Administrator stated between May 16-18th, she could not remember specifically what day, the DON called her about an incident with Staff C. She indicated Staff C came to the front entrance, when staff usually come through the west door. Staff C started pounding on the door with both her fists, stating she could not get in. The DON opened the front entrance doors and Staff C stated her key was not working. Staff C wore a t-shirt, hair was disheveled, no bra on, she did not look like she was ready to work. Staff C went to the medication cart, threw the medication cards in the narcotic lock box and said I can't count these, I trust you. She took an otoscope and put it in her mouth. When staff asked Staff C what she was doing, she told them she was getting a drink. The DON indicated she would take Staff C, so she went to put her things away and get her keys. When she returned staff had let Staff C out the front door. This kind of behavior prompted them to start looking in to their narcotic log to see if there were any patterns. When they reviewed Resident #5's Hydrocodone PRN order they noticed Staff C was the only staff member that had signed the medication as being given. When those spoke to Resident #5 about him needing his PRN Hydrocodone, he told them he had not taken it for two weeks. Once they called their corporate office, they decided the Administrator would come in at 10:30 PM during Staff C's next scheduled shift to talk with her about what was going on with Resident #5's PRN Hydrocodone order. She also wanted to address her attendance issues. When the Administrator arrived at 10:30 PM, she had Staff C come in to her office as well to talk about the behaviors staff observed a few weeks prior, along with their look in to Resident #5's PRN Hydrocodone order only being signed out by her. The Administrator informed her they were going to suspended her while they look further in to these issues. Staff C told the Administrator that she started taking metformin and was having a reaction. The Administrator indicated then we can clear this all up if you can get a doctor's note for them. That's when Staff C filled out a note that indicated she quit right then. Staff C waited in her office until 11:30 PM until Staff D came in to replace her. After Staff C left the building Staff D noticed Resident #4's 12:00 AM Tramadol order was signed out as being given at 12:00 AM by Staff C. Staff C was not in the building at that time and was with the Administrator from 10:30 PM until 11:30 PM so there was no way she could have given the medication during that time. On 6/13/24 at 2:24 PM the MDS Coordinator/ADON stated while she was completing Resident #5's MDS assessment she interviewed the resident and she stated he did not have any pain during the review period. While she was reviewing the MAR she noticed a lot of staff put he was not having any pain but there were nights where his Hydrocodone was being given consistently. Staff C had been the only administering his PRN Hydrocodone for pain. She went back to talk to Resident #5 about this and he stated he was having pain before his hospitalization but not since then. She let the Administrator know what she had found out. The facility provided a document titled Abuse Prevention Plan-Iowa Policy with a revision date of March 2019 documented in accordance with the Vulnerable Adult Law of the State and the Centers of Medicare and Medicaid (CMS), it is our policy that all residents resident in the facility will be protected from abuse, neglect, misappropriation of funds/property, exploitation or involuntary seclusion, mistreatment/maltreatment and that interventions are implemented to provide the vulnerable adult with a safe living environment. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Misappropriation of resident property/financial exploitation means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record review, hospital documents review, staff interviews and facility policy review the facility failed to update 1 of 10 resident (Resident #1) care plans after she sustained a fractured humerus. The facility reported a census of 28 residents. Findings include: According to the Admission Minimum Data Set (MDS) assessment tool with a reference date of 2/13/24 documented Resident #1 had a Brief Interview of Mental Score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS documented she used a walker and wheelchair and dependent on staff for toilet transfers. The MDS listed the following diagnoses for Resident #1: fractures and other multiple trauma, coronary artery disease, thyroid disorder, hip fracture, anxiety, and depression. The facility provided a report titled Fall dated 2/25/24 at 1:05 PM. The report documented staff was called to Resident #1's room for a witnessed fall. An assessment was completed, resident complained of pain in her right shoulder. She was sent to the local emergency room (ER) to be evaluated. Review of a document titled Diagnostic Radiology with an admit and discharge date of [DATE] documented a right shoulder x-ray completed. The following findings documented: age-indeterminate but suspect acute mildly displaced humeral neck fracture, with suspect involvement of at least the surgical neck. The humeral shaft is superiorly displaced approximately 1.6 centimeter (cm) from the head. The Care Plan focus area with an initiation date of 2/7/24 documented the resident had limited physical mobility related to a fracture of her left hip with nailing. The care plan failed to include her humerus fracture and interventions for staff to follow while caring for Resident #1 while her fracture healed. On 6/13/24 at 12:53 PM the Director of Nursing (DON) stated Resident #1's fall with fracture took place prior to her taking the DON position and prior to the new MDS Coordinator/Assistant Director of Nursing (ADON) starting. She acknowledged the humerus fracture should have been on Resident #1's care plan. The facility provided a policy titled Care Plan Revisions Upon Status Change Policy with an effective date of 4/23/19. The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. PROCEDURE Policy Explanation and Compliance Guidelines 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experience a status change. 2. Procedure for reviewing and revising the care plan when a resident experience a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or another designated staff member. g. The Charge Nurse or other designated staff member will communicate care plan interventions to all staff involved in the resident's care.

Based on observation, staff interview, and record review, the facility failed to protect residents against burn hazards from the baseboard heating elements in their rooms for 1 of 6 residents reviewed. All 6 of the residents in the sample occupied beds facility staff had placed in a parallel position next to the baseboard heaters under the windows in their rooms. Resident #13 had a diagnosis of [CONDITION(S)] and utilized an adjustable bed next his in-room heating element. On 3/16/21 at 2:10 PM, staff found Resident #13 on the floor between his bed and the wall. His backside lay against the baseboard heater, which resulted in 1st and 2nd degree [CONDITION(S)]. These findings constituted an Immediate Jeopardy (IJ) to the residents' health and safety. The facility reported a census of 22 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 12/22/20, Resident #13 scored 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated intact cognitive abilities. The MDS documented the resident required extensive assistance of two staff for bed mobility and remained totally dependent on one staff for surface-to-surface transfers. An MDS dated [DATE], showed the resident's cognitive stated had declined prior to the month before, The MDS documented the resident scored 11 on the BIMS test, which meant the resident showed moderate cognitive deficits. An MDS dated [DATE] showed the resident's cognitive status had again deteriorated. The MDS revealed the resident could not participate in the BIMS test and scored 0 out of a possible 15, which meant the resident displayed severe cognitive impairment. A care plan last updated on 3/18/21 revealed Resident #13 admitted to the facility on [DATE] with diagnosis that included: [CONDITION(S)], [CONDITION(S)], chronic pain, [CONDITION(S)] and muscle weakness. A focus area initiated on 1/8/19, documented the resident had expressive dysphasia related to a [CONDITION(S)] (CVA, or stroke). The care plan directed staff to offer the resident a note pad to utilize if he had difficulty communicating. The care plan also included an impaired mobility focus area related to [CONDITION(S)] and identified the resident utilized 2 assist bars on the bed to help him with body positioning. According to the electronic chart census page, Resident #13 admitted to Hospice services on 2/2/21. A nursing note dated 3/18/21 at 11:33 PM documented the resident passed away in bed on 3/18/21 at 10:29 PM. A fall assessment dated [DATE] documented Resident #13 had not had any falls in the previous 6 months. An incident report dated 12/11/20 at 4:48 AM revealed staff found the resident on the floor and next to the bed with his head at the foot of bed. The resident stated at that time he was unaware of how he had gotten there. A fall assessment dated [DATE] at 11:56 AM identified the resident as at a high risk for falls. The assessment lacked information related to any fall interventions or protocols initiated by the facility at that time. A nursing note dated 3/16/21 at 2:15 documented staff found the resident floor in his room, laying in-between the bed and the baseboard heater. Staff had completed resident rounds at 1:50 PM that day and saw the resident asleep in bed. At 2:10 PM, staff filled water pitchers and delivered linens and found the resident on the floor. The nursing note described [CONDITION(S)] identified on the resident's body. Staff notified the hospice nurse and primary care physician, and administered pain and antianxiety medications given for pain and comfort. Facility staff also moved the resident's bed to the A side of the room (near the door, opposite side of the room from the heater), put it in in low position, and notified family. According to the incident report dated 3/18/21, staff found Resident #13 on the floor on 3/16/21 at 2:10 PM. The subsequent nursing assessment revealed the resident had sustained a 1st degree burn on his upper back that measured 5.0 centimeters (cm) x 1.5 cm and a 2nd degree burn to the right trochanter (hip/thigh area) that measured 6.0 cm x 14.0 cm. The report documented the facility moved the resident to a room located closer to the nurse's station. The incident report revealed staff conducted an audit of the rooms on 3/16/21 to determine if any other residents were at risk of injury due to bed placement. They determined that no other residents were at risk. The leadership team met to discuss the fall and possible solutions. The US Department of Health and Human Services, Centers for Disease Control and Prevention provided the following description of burn injuries to the skin: 1) A first degree burn involves the top layer of the skin and presents as red and painful to the touch and the skin will show mild swelling. 2) A second degree burn involve the first 2 layers of skin. These may present as deep reddening of the skins, pain, blisters, glossy appearance from leaking fluid and possible loss of some skin. Retrieved on 3/23/21 from https://www.cdc.gov/masstrauma/facesheets/public/[CONDITION(S)].pdf Observations: On 3/18/21 at 1:15 PM Registered Nurse (RN) Staff C provided a wound treatment for Resident #13. The burn to his right trochanter was red with some bloody drainage, and the resident did not interact or respond to the staff as they turned him from side to side to change the bedding. Staff C cleaned the area and applied a new Xeroform dressing. The resident record revealed an order dated 3/16/21 at 6:15 PM that directed staff to apply Xeroform (a moist dressing often used for [CONDITION(S)] and skin graft sites) to the right hip wound and cover with a dry dressing. Observation of Resident #13's room with the Director of Nursing (DON) on 3/18/21 at 1:15 pm revealed the heating unit set at high. The DON used a surface thermometer to test the temperature of the top of the heating unit and she measured the following temperatures in three different areas of the baseboard heater: 146 degrees, 155 degrees, and 131 degrees. On 3/18/21 at 1:00 PM, observation revealed 19 rooms in the facility had baseboard heaters similar to the type that caused Resident #13's [CONDITION(S)] and 7 of those rooms contained the 2 x 4 boxes framed around the heating units. Observation also revealed 5 of the 19 rooms unoccupied, 9 contained a furniture arrangement with the bed not positioned parallel to the heater, 5 rooms were occupied with no 2 x 4 boxes and arranged as follows: 1) Room 103 revealed Resident #20's bed positioned parallel to the heater. An MDS dated [DATE] showed Resident #20 scored 11 out of possible 15 (moderate cognitive impairment) and remained independent with transfers and bed mobility. 2) Room 100 revealed Resident #72's bed arranged parallel to the heater. The resident's MDS dated [DATE], showed a BIMS test score of 12 (moderate cognitive impairment) and documented the resident required extensive assistance of one staff for transfers and locomotion. 3) Room 203 revealed Resident #9's bed arranged parallel to the heater. An MDS dated [DATE], showed Resident #9 scored 15 on the BIMS test (intact cognition) and remained independent with bed mobility and transfers. 4) Room 208 revealed Resident #3's bed sat parallel to the heater. The MDS dated [DATE] showed a BIMS score of 15 (intact cognition) and required assist of one staff for transfers and locomotion. 5) Room 210 revealed Resident #14's bed set parallel to the heater. The MDS dated [DATE], identified Resident #14 scored 15 on the BIMS test (intact cognition) and remained independent with bed mobility and transfers. Interviews: 1) On 3/18/21 at 9:51, the DON reported approximately a year earlier, a resident had rolled out of bed and sustained [CONDITION(S)] from the baseboard heater. She said they subsequently hired a heating and cooling specialist to test the heaters and the technicians found the heaters emitted the correct amount of British Thermal Units (BTU's, a measure of the heat content of energy sources). She stated the facility also considered purchasing smaller heaters, but those would not supply an adequate amount of heat for the rooms. She added they then decided to add a 2 x 4 box built as a barrier around the heaters, and then moved the residents with lower BIMS scores in the rooms that contained the barrier. She said although at the tie it seemed to work but acknowledged the solution as problematic because the resident could still fall on top of the heating unit. The DON acknowledged Resident #13 had not been in a room with the 2 x 4 barrier at the time of his fall. She added Resident #13 had a health decline in health with increased confusion late in January and was admitted to Hospice services in February. The DON said Resident #13 had a diagnosis of [CONDITION(S)] and he would use his upper body to reposition himself in bed with the use of the assistive bars on his bed. She said that after much discussion with the staff, they believe that he may have been trying to reposition himself in bed and hadn't realized where the lower part of his body was in bed. She surmised this pulled him off balance, off the side of the bed and onto the floor next to the heater. The DON stated Resident #13 had not gone to the hospital after the fall and the Hospice nurse was closely involved in his follow up care. The facility notified the physician regarding the burn and obtained an order for wound care. The DON completed the assessment after the fall and she said that the resident had a blister on the trochanter area that she had determined to be a stage 2 burn. The DON stated after the incident with Resident #13 on 3/16/21, they decided to order some covers for the baseboard heaters that were due to be delivered quickly, but the company would not guarantee that this would prevent [CONDITION(S)]. 2) On 3/22 at 10:12 AM, the DON reported Resident #13 often suffered with phantom pain and spasms in his legs so he would use his call light to ask the nurses for pain medications. She said that he would also try to move his lower body to relieve the pain and he wasn't always aware of the position of his lower body. 3) On 3/22/21 at 10:30, Certified Nursing Assistant (CNA) Staff A said she had been working with Staff E the day of the fall and Resident #13's bed had been parallel to the baseboard heater under the window. When she came into the room, the resident lay on the floor between the bed and the heater. They found the resident's head positioned on the floor and facing the head of the bed. She stated he wore a hospital gown with bare skin touching the heater, with legs positioned straight out; his calves did not come into contact with the heater. She saw a blanket on the floor in front of him and she tucked it behind the resident, between his body and the heater. Staff A reported the resident had been moaning but hadn't said much other than that his knee was burning. She said she thought that he may have been confused because it was the back of his leg that was burnt. Staff A said that she hadn't noticed the burn at that time and the nurses came in and moved him with the sheet, then used the Hoyer lift to transfer him to bed. Staff A reported prior to his decline in health, the resident could move himself from side to side using his upper body strength. 4) On 3/22/21 at 10:40 AM Staff E, Licensed Practical Nurse (LPN ) recalled she worked the 6 am-6 pm shift the and the 2-10 staff had just reported to work the day Resident #13 fell out of the bed. She also recalled the CNA had mentioned she had shut Resident #13's door due to the loud television across the hall from his room. Staff E commented the resident had usually preferred to have his door closed. At 2:13 PM the CNA's started to pass ice, but soon after they told her they found Resident #13 on the floor. She entered the room and saw Staff A sitting on the floor with the resident and he sat upright with a blanket behind his back with Staff A's support. Staff E reported they obtained the resident's vital signs, utilized the blanket to pull him away from the heater, lay him on the floor, put the [NAME] sling under him, and transferred him to the wheel chair while they waited for a replacement bed. She stated when staff transferred him back to bed, the DON discovered the [CONDITION(S)] on the resident's backside. Staff E offered, before his decline, Resident #13 used his upper body to assist staff with bed mobility, but a few weeks before his fall, he hadn't had the strength to help as much. She added the resident had his call light attached to the grab bar on the right side of the bed and often used it, usually to ask for a pain pill. 5) On 3/22/21 at 11:00 AM, Staff D, LPN recalled when the Resident had fallen in 12/2020 of 2020, she had worked in the 300 hall because the facility had used the 100 hall for the Covid positive residents (Resident #13 had lived in room 111). She remembered she had gone into his room to administer a medication close to 5:00 AM and found him on the floor with his head at the foot of the bed. He reported he didn't know how he had gotten into that position. Staff D stated the CNA took vital signs, checked for injury, obtained the Hoyer and transferred him back into bed. She said he could use his call light, especially if he had pain. He also wanted his door closed most of the time. Staff D reported he pulled himself up and roll over, so after the 12/2020 fall, they checked him hourly to ensure his safe positioning in bed. She commented on their surprise about the 12/2020 fall due to his lack of a fall history. 6) On 3/22/21 at 2:00 PM CNA Staff B reported on 3/16/21, she and another CNA had just began their shift and started filling the residents' water and ice at the end of the hallway. When they entered Resident #13's room they heard him moaning but did not see him at first, but then found him on the floor between the bed and the heater. They then pulled the bed away from him and Staff E went to the floor to pull him away from the heater. Staff B left the room to get the nurses. Staff B said that while in bed, the resident often pushed against the wall to move the bed away from the wall because he wanted his bed positioned diagonally to better see out of the window. When Staff B returned to the room, Staff E had remained on the floor with Resident #13 while he sat up with her support. She reported that they obtained vital signs and checked him every 5-10 minutes after the fall. Staff B said she moved the bed because the heaters could get very hot. She added Resident #13 liked to keep his room very warm, although she did not know of any other residents that kept their rooms that warm. Staff B stated she returned to the room with a Hoyer lift and they had replaced his bed with a different one. When asked why they switched beds, she reported she thought they replaced the one he had because he could adjust it; he refused to keep his bed in low position because he wanted to look out the window. 7) On 03/22/21 03:39 PM, the DON reported they replaced Resident #13's bed with a different one after his fall because the original bed did not adjust to the lowest position possible. She added that after his fall, they felt they needed to give him a bed that would go into a lower position. 8) On 03/23/21 11:09 AM, the DON said that the 2 x 4 barrier solution installed after the fall and that resulted in a burn on 1/23/20 was not completely fail safe. She said she believes it helps for those in wheel chairs to keep their distance from the heaters, but she sees where it is still a problem because a resident could fall on top of it. 9) On 3/22/21 at 4:29 PM, a service technician said when he was at the facility on 1/27/20, he found the heating units in working condition but confirmed the baseboard heaters would definitely get very hot. He said in his opinion, a resident falling to the floor next to the heater would have less severity if the resident had lain 3 inches away from the heating unit. 10) On 3/22/21 at 12:45 PM, a representative from the company that distributed the baseboard heating units reported unit UL number F2548NWC (the unit identification number located on the baseboard heater involved in Resident #13's incident could reach 150 degrees and should not be touched. He recommended the facility should keep items at least 6 inches away from the baseboard heater and added the heater could actually get hotter with items placed in the immediate proximity if it restricted the heating element's air flow. The facility was notified of the Immediate Jeopardy situation on 3/23/21. The IJ was also removed on 3/23/21 when they implemented the following: Room 103 and 100 beds were moved to the opposite side of the room from the heating element. Rooms 203, 208 and 210, the beds were repositioned to have the head of the bed up against the heater with bedside tables next to the bed. When the facility completed the above actions, the scope and severity of the IJ was lowered to an E. 03/24/21 11:41 AM, rooms 204, 203, 210, 103 108 all had new safety covers assembled over them. The DON said that they set all the heaters to medium heat and the residents could not access the knob without assist of maintenance staff. She added the facility ordered more covers with delivery expected within a couple of weeks.

Based on observations, record review, staff interviews, and the facility investigative documents revealed the facility failed to keep 1 of 3 residents (Resident #1) free of accidents. Resident #1 was found to have rolled out of her bed on to the floor board heater that her bed was next to. Resident #1 sustained [MEDICAL CONDITION] her left upper arm, left posterior axillary area, and left anterior and lateral thigh. The facility reported a census of 28 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool dated 11/6/2018, Resident #1 had the following Diagnoses: [REDACTED]. The MDS documented Resident #1 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #1 required extensive assistance of 2 staff for bed mobility, transfers, and toilet use. The Care Plan for Resident #1 included she required extensive assist of 2 staff with a gait belt for transfers, initiation date of 01/09/2018. Her Care Plan contained a focus area with an initiated date of 1/9/2020, provided she was dependent upon staff for locomotion in her wheelchair. On 2/10/2020 her Care Plan indicated she at times will fidget and grab items, her family brought in a baby toy that staff may give her when she is fidgety or grabbing at items. Review of Resident #1's Electronic Health Record (EHR) revealed an incident report completed by Staff A Registered Nurse (RN) dated 1/23/2020 at 11:50 PM with the following description: resident rolled on to the floor heating device next to her bed, resident was unable to give description of what happened. The incident report indicated Resident #1 was oriented to person and obtained the following burns: left upper posterior arm measuring 18.5 centimeters (cm) x 11cm, side of left breast measuring 15cm x 9 cm and left hip measuring 18.5cm x 11cm. The incident report provided the following immediate action was taken: resident was placed back in to bed and a full body assessment was completed. The on call doctor was called and ordered antibiotic ointment to all areas, cover with dry dressing every day and apply a cold pack to the areas for 20 minutes then off for 20 minutes. The facility scheduled an appointment for Resident to see her Primary Care Provider (PCP) the next day for follow. Staff moved her bed to another wall that was further away from the heater. Review of the facility's investigation revealed a statement dated 1/23/2020 from Staff B, Certified Nursing Assistant (CNA) that stated she had passed water pitchers at 11:50 PM when she walked in to Resident #1's room she found her lying on the heater. Staff B pushed the resident's call light and notified the nurse on duty. She indicated Staff A came to the room and assisted her with putting Resident #1 back to bed. Staff B indicated she did rounds at 10:00 PM, at that time the resident was checked on, changed and repositioned in bed. Lastly, she indicated Resident #1 had her call light within reach. Review of the facility's investigation revealed a statement dated 1/23/2020 from Staff A that stated at 11:50 PM she was called to Resident #1's room by Staff B. When she arrived to the resident's room, she found her on the floor heating device next to her bed. Staff assisted her back to her bed. Staff A stated she completed a full body assessment, called the on call doctor to receive orders, and called the Director of Nursing (DON). Staff A indicated she had been in Resident #1's room at 11:15 PM to administer her roommate's medication and noted Resident #1 to be lying in the middle of her bed on her right side with a pillow under her left hip. She stated she was sleeping and her bed was in the low position. Review of the facility's investigation revealed a statement dated 1/23/2020 from the DON that stated she was notified by Staff A at 12:07 AM of the incident with Resident #1. She arrived to the facility at 12:15 AM to begin the investigation. She assisted Staff A with measuring Resident #1's wounds and after Staff A called the on call doctor, she assisted her with the treatment orders she had received. When she asked Staff A and Staff B to reposition Resident #1 in the position she was in when they saw her last at 11:15 PM, they positioned her on her right side in the middle of the bed with a pillow under her left hip. They stated she did have a turn sheet under her for positioning. Resident was lying around a 30 degree angle with the pillow under her left hip. Resident #1's bed was moved to another wall in the room further away from the heater and she was resting comfortably when the DON left the facility. Review of Resident #1's EHR revealed the following: -Office/Progress Note dated 1/24/2020 at 1:54 PM completed by her PCP. The note listed a chief complaint [MEDICAL CONDITION] the left arm and left side from an incident that took place at the nursing home. Under the Subjective section was stated: second-degree burn of left arm, left posterior axilla, and left anterior thigh. Resident #1 had very severe dementia, she cannot care for herself, she is wheelchair-bound, required assistance with eating, and she is essential non-verbal. As the story is reported, she was discovered last evening by staff in her room, where her bed was near a heat register in the nursing home room. She was found up against the heat register on her left side. When she was removed from the heat register, it was noted she had [DIAGNOSES REDACTED] and blisters along the lateral aspect of her left upper arm, left posterior axilla area, and left anterior upper thigh area. Topical bandages were applied and she was brought to the office for an evaluation. Resident #1 does not seem to be in any type of significant pain at that time of her appointment. The PCP documented the following exam findings, assessment and plan: a) Area #1: this is the area of the left posterior upper arm. There was a ruptured blister present consistent with a second-degree burn, it measured 10cm x 4cm but an area of [DIAGNOSES REDACTED] extended approximately 10cm x 6cm. This encompassed the posterior one half of the circumference of the arm. They will get a wound consult and ordered [MEDICATION NAME] daily to area, covered daily with either gauze or ABD dressing then lightly cover with Ace wrap to hold the bandage in place. b) Area #2: this is the area of the left posterior axillary line near the junction of the thorax that measured 9cm x 2cm of an intact [DIAGNOSES REDACTED]tous blister consistent with a second-degree burn. He used a #11 scalpel blade to rupture the blister and serous drainage was returned. They will get a wound consult and ordered [MEDICATION NAME] daily to the area, keep area covered daily with ABD or gauze pad. There was no need to tape as resident is non-ambulatory. c) Area #3: this area to the left anterior lateral thigh area is just distal to the flexion crease of the left thigh. The area measured 14cm x 5cm with a large serous colored water blister. Used a #11 scalpel blade to rupture the blister and serous drainage was returned. There was no full-thickness burn noted. They will get a wound consult and ordered [MEDICATION NAME] daily to the area, keep covered with a 4x4 gauze pad in the skin fold area where the fold is present. No need to tape in this area as the pressure of the skin fold should be able to hold it in place. -a Consultation Report with wound care dated 1/29/2020. In the services to be rendered area staff documented: wound care to evaluate and treat Resident #1's left side burn areas; left lateral breast measuring 7.5cm x 1.5cm x 0.2cm, left upper arm measuring 3.6cm x 12cm x 0.2cm, and left lateral hip measuring 16cm x 5cm x 0.1cm. The report documented the following Physician Assessment/Recommendations/Orders: discontinue the antibiotic ointment and on shower days cleanse wounds with soap and water, rinse well with spray. Staff were to cover wounds with single layer of xeroform gauze and cover with ABD pads and kerlix to area. Staff were to change the dressing daily and as needed (PRN) if wounds are exposed and to avoid tape if possible. Staff were to monitor for signs and symptoms of infection. Resident #1 scheduled to return to the wound clinic on 2/7/2020 at 9:45 AM. -an Office Note documented by her PCP on 1/30/2020 at 11:37 AM while at the facility. The note stated wound care nurse has been consulted and Resident #1 did have bandages over the wounds. The PCP documented the following: a)Area #1 left posterior upper arm: still measures around 10cm in diameter, there was some eschar present over the area, no [DIAGNOSES REDACTED] around the area. The wound nurse recommendations have been noted and implemented with xeroform. b) Area #2 left posterior axillary line near the junction of the thorax and breast: area was approximately 9cm x 4cm with deep yellow eschar present, minimal [DIAGNOSES REDACTED] around the area, no drainage noted. Wound nurse recommendations have been noted and implemented with xeroform. c) Area #3 left anterior lateral thigh just distal to the flexion crease of the left thigh: area was approximately 14cm x 5cm with large eschar yellow-brown in color. There was no [DIAGNOSES REDACTED] around the edges, some bleeding at the posterior aspect of the eschar, just a few drops but no active bleeding noted. She did appear to have some discomfort over that particular area, the other areas did not seem to be as tender. The PCP noted he reviewed where Resident #1 bed location was at during the time of the visit. He documented it was along an interior wall with the long axis against the wall that was not associated with a heat register. The head of her bed was against the wall that does have the heat register, but far enough away that there was not potential interaction with sleeping and the heat register. There was a wood barrier that extended out approximately 12 inches away from the floor heat register where an object cannot be placed any closer because of the barrier being in place; this is an intervention that was put in place after the incident with Resident #1. He documented the bed was designed to be lowered to nearly the floor level and when the nursing staff demonstrated the bed level that the resident's bed was in the night of the incident, the top of her bed was about even with the top of the heat register along the floor (approximately 10-12 inches off the surface of the floor). Nursing staff told him that the bed was lowered in case she would roll out of bed, she would minimize injury at that level, rather than at a full height bed top. After staff demonstrated the height of the bed, the height of the register, and the bed position that was parallel with the heat register along the long axis the night of the incident; he determined that the [MEDICAL CONDITION] were a result from the heat register with her lying on her left side. The injuries were consistent with the layout of the room at that time. The PCP documented Resident #1 remained unchanged from her cognitive standpoint, she did not appear to be in any type of pain except when the bandages were manipulated specifically area #3 outlined as above. -A Consultation Report with wound care dated 2/7/2020 indicated wound care to evaluate and treat left sided burn areas: left lateral breast- 5cm x 1.2cm with brown necrotic slough, left upper arm: 2.5cm x 1cm, and left lateral thigh- 15cm x 5cm with born necrotic slough-appears deep than other 2 areas. In the physician assessment/recommendation/orders: 1) cover left breast and left upper arm with [MEDICATION NAME] and ABD pad, change daily, 2) left lateral thigh [MEDICATION NAME] alginate and ABD, change every other day 3) may shower or whirlpool on bath days to help loosen necrotic tissue, rinse well and pat dry 4) monitor for signs and symptoms of infection. Resident #1 had a follow up appointment on 2/14/2020 at 9:45 AM. -A Consultation Report with wound care dated 2/14/2020 indicated wound care to evaluate: left hip 14cm x 4.5cm, necrotic with purulent dressing; left arm 3.5cm x 2cm x 0.2 cm and 2.5cm x 2cm x 0.2cm with necrotic tissue removed; left breast 4.5cm x 1cm x 0.2cm with necrotic tissue removed. New orders documented: left arm and breast: change dressing daily, cleanse with soap and water then rinse well. Cover with xeroform gauze and cover; left hip-cover with dry Band-Aid and change as needed to control drainage. -A Consultation Report with wound care dated 2/26/2020 documented the following Physician Assessment/Recommendations/Orders: return to wound clinic in one week, change dressings daily and PRN. Staff are to clean the wounds with soap and warm water, wash and dry well, apply xeroform gauze to wounds and cover left arm and left breast wounds with [MEDICATION NAME] and tape. Staff are to cover left thigh wound with ABD and tape. -A Consultation Report with wound care dated 3/4/2020 documented the following Physician Assessment/Recommendations/Orders: return to wound clinic on 3/18/2020 at 10:00 AM. Staff were instructed to clean left thigh, breast and arm ulcers with saline and cover with xeroform gauze. Staff were to put [MEDICATION NAME] over the gauze on her left arm and breast and cover left thigh with ABD pads and secure with tape. Staff were to change dressing daily and PRN. -A Physician Communication Facsimile (fax) dated 3/17/2020 contained the following comments-wound care appointment was cancelled to limit resident's risk of exposure. Resident #1's wounds continue to greatly improve with no signs and symptoms of infection. The physician replied, noted. -A Physician Communication fax dated 3/23/2020 contained the following comments-updated on burns: upper left arm was measured as 2 separate areas as wound was healed between them. Lateral aspect is completed healed, and 0.7cm x 0.7cm blister remained to medial aspect. Left posterior axilla completely healed, left thigh improved and measured at 5.4 cm x 1.6 cm x 0.1cm with 100% granulation tissue. May the treatments be discontinued to healed areas and the physician responded with ok to discontinue treatment and call with status report in 1 week. -A Physician Communication fax dated 3/31/2020 stated burn to left upper arm has healed and burn to left thigh measured 4.5cm x 1.9cm, 100% granulation, no signs of infection. The fax asked to discontinue treatment to left upper arm. The physician replied ok to discontinue treatments to left arm. -A Physician Communication fax dated 5/5/2020 stated the burn to Resident #1's left thigh has now healed (all three areas have healed). The physician stated noted and staff were to continue to monitor status of the wound sites. During a staff interview on 11/17/2020 at 10:45 AM Staff A was asked to describe the night of the incident with Resident #1. She stated she went in to her room to administer pain medications to Resident #1's roommate and noted she was on lying on her right side, does not remember time, but she was resting well. She stated she then went down the hall and 15 minutes later the CNA told her to come back. She stated when she arrived the resident was laying on the heater as her bed rested against the wall with the heater. She and Staff B rolled resident after they moved the bed away from the wall. She stated she called the DON, the on call physician, obtained treatment orders and started treatments. Staff A stated Resident #1 was a texture person so they believed she was rubbing the wall with her hands and may have rolled out. Staff A when asked what assistance Resident #1 required she stated she needed assistance in bed with repositioning. Staff A stated after the incident resident's beds were moved from heaters, they assessed cognitive levels and assistance levels of all residents that night. During a staff interview on 11/17/2020 at 10:57 AM Staff C CNA stated Resident #1's assistance level was extensive to total assistance and never had issues with her rolling out of bed. Staff C stated Resident #1 was able to move arms and legs over but not her core. He stated after the incident they moved her bed away from heater then put a wooden barrier around heater. He stated they then moved Resident #1 to other side of the room away from the heater. Staff C stated Resident #1 would brush her hands up against the wall, she liked different textured things. Staff C stated there were no other issues with residents rolling on to the heaters. During a staff interview on 11/17/2020 at 11:07 AM Staff D CNA stated the facility put some barriers around the heaters. When asked what staff were told to do when taking care of Resident #1, she stated they are not to have her too far over on her side, while repositioned in bed. Staff D stated they moved the resident to the other side of the room and have not had other issues. She stated they moved other residents away from the floor heaters. During a staff interview on 11/17/2020 at 11:15 AM the Maintenance Supervisor stated after that incident happened they looked at ways to keep the beds away from the floor heaters. Staff obtained BIMS scores on all of the residents to determine who would be cognitive enough to stay away from the floor heaters. They then installed wood barriers around the heaters. He stated once the barriers were in place they told the DON and she would check them off the list. He stated the barriers are on heaters with residents that are not cognitively intact. He provide that a local heating company came to the facility make sure the temperature was regulated appropriately, were cleaned, did not get too hot, and shut off appropriately. He provided that all of the heaters were functioning appropriately. He described the heaters as having a dial thermostat, are set at the Resident's desired temperature, and contained heat sensors so once at desired temperature they would shut off and turn on when needed to heat the room to the desired temperature. During a staff interview on 11/17/2020 at 11:21 AM Staff E CNA stated they have had no other incidences like what happened with Resident #1. When asked what assistance Resident #1 required for bed mobility and transfers, she stated extensive assistance of 1 or 2 staff. She stated she was texture driven, would pretend to measure stuff in the air, and liked to touch various things. During a staff interview on 11/17/2020 at 11:54 AM the DON was asked what her part was after the incident occurred with Resident #1. She stated after they called her, she came to the facility, took care of the resident first while she was in bed. She stated she did another assessment to ensure she was comfortable. She stated Staff A called the on call, received orders, and assisted her with the treatments per the new orders. She stated she had Staff A and Staff B reenact the incident prior to it happening and how they found her. The resident was calm the whole time, but gave her a PRN for pain anyways just to keep her comfortable. Staff A and herself went up and down the hall to see who needed their beds immediately moved. She believed they moved 2 other beds initially. She indicated she came in early that next day, to do room by room audits. She obtained a BIMS list, those with low BIMS score would not be placed next to the floor heaters. She believed there were 9 people that they either moved or placed the barriers around the heaters. The day after the incident they had their heaters inspected and were found to be functioning properly. She stated Resident #1 was seen by her doctor and he ordered her to be followed by a wound nurse. She went only a few times because it was healing so well. During a staff interview on 11/18/2020 at 12:36 PM Staff F CNA stated she went in Resident #1's room, but does not remember why, the night of the incident. When she entered she had found that she had rolled out of bed on to the heater and she called for help. She stated the resident was not yelling when she went there and did not appear to be in any pain. When asked if Resident #1 was on top of the heater or if she was against it, she stated she thought she was against the heater. Staff C stated Resident #1 required assistance of two staff and they do a sit to stand transfer with her. Staff F was asked when the last time she saw her before the incident, she stated she could not remember because it was so long ago. After reading her statement to her, she stated they do rounds at shift change about 10:00 PM and the last time she had eyes on the resident. She stated the resident was in bed asleep on her right side at that time.

Based on record review, staff interview and review of the policy and procedures, the facility failed to provide ongoing assessments and alert the physician when Resident #4 had a change in skin condition. The sample consisted of 12 residents and the facility reported a census of 52 residents. Findings included: 1. An admission Minimum Data Set (MDS) with an assessment reference date of 10/21/16, identified Resident #4 with [DIAGNOSES REDACTED]. The MDS documented a BIMS (brief interview of mental status) score of 15. A score of 15 identified the resident had no cognitive problems. The MDS further documented the resident required extensive assistance of 2 or more staff with bed mobility, transfer, dressing, toileting and bathing. The MDS documented moisture associated skin damage (MASD) with treatments of pressure reducing device in the chair and bed and applications of ointments/medications other than to the feet. The MDS also documented the resident as occasionally incontinent of bowel with a urinary catheter in place. The MDS identified an admission date of [DATE]. Review of a fax to the physician dated 10/12/16 information that the resident had an open area on the left buttock from moisture and requested an order to apply a [MEDICATION NAME] dressing and change every 3 days and as needed. The physician agreed. Review of a treatment administration Record (TAR) dated 10/1/16-10/31/16 identified a physician order dated 10/18/16 (3 days later) for a [MEDICATION NAME] dressing to the left buttock every 3 days and as needed. A temporary Care Plan dated 10/14/16 identified an intervention dated 10/15/16 which directed staff to apply barrier cream to the resident's buttocks after toileting. A comprehensive evaluation of skin inspection and risk factors form dated 10/14/16 indicated the resident had fragile skin and contributing [DIAGNOSES REDACTED]. The form documented the following skin inspection results: Bruising on the chest 7.0 centimeter (cm) x (by) 8.0 cm, Groin -no measurements excoriation, Other bruising- Left abdomen- 15.0 x 8.0 cm, Other bruising- Right abdomen- 30 cm x 24.0 cm, Other MASD left buttocks- 2.0 x 1.5 cm. Review of a weekly wound documentation form dated 10/20/16 revealed MASD of the left buttock measuring 5 x 4 cm with instruction that if the wound declined or had no change that the physician and family were to be notified. Review of a weekly wound documentation form dated 10/27/16 revealed MASD of the left buttock measuring 2 x 1 cm. Review of the progress notes revealed the resident was sent to the emergency roiagnom on [DATE] at 22:30 (10:30 PM) and admitted to the hospital on [DATE] until 11/9/16. A comprehensive evaluation of skin inspection and risk factors form dated 11/9/16 identified the resident as incontinent of bowel, chair fast, at risk for shear and friction with contributing [DIAGNOSES REDACTED]. The form documented the following skin inspection results: Left gluteal fold excoriation- no measurements Right gluteal fold excoriation- no measurements Right forearm bruising- 2 x 3 cm Left forearm bruising- 3 x 3 cm Left chest surgical incision- no measurements Analysis of risk factors and interventions portion of the assessment instructed a registered nurse to provide analysis of risk factors and interventions, to inspect the skin within 2 hours of admission/readmission and weekly for 4 weeks. Review of a weekly wound documentation form dated 11/10/16 revealed the following wounds: Left gluteal fold MASD- no measurements Right gluteal fold MASD- no measurements Left forearm bruising- 2 x 1.4 cm Right forearm bruising- 3.2 x 3.0 cm Review of a weekly wound documentation form dated 11/17/16 revealed the following wounds: Left gluteal fold MASD- 7.8 x 3.0 cm Right gluteal fold MASD- 6.5 x 2.6 cm The record revealed no further weekly wound forms after 11/17/16. A Progress Note dated 11/26/16 at 16:43 (4:43 PM) indicated the resident continued with increased respirations and was admitted to the hospital via non-emergent transport. Review of a treatment administration Record (TAR) dated 11/1/16-11/30/16 revealed no physician order for [REDACTED]. The Progress Notes identified the following: On 11/23/16 at 12:33 PM the identified only bruises monitored. On 11/23/16 at 2235 (10:35 PM), the resident had excoriation to the buttocks with a dressing to the buttocks. On 11/24/16 at 17:05 (5:05 PM) excoriation to the buttocks with barrier cream. On 11/25/16 at 2:27 AM [MEDICATION NAME] dressing to the buttock. On 11/25/16 at 2:18 AM indicated no treatments or dressing. On 11/25/16 at 21:30 (9:30 PM) indicated an open area on the buttock covered with [MEDICATION NAME] dressing. On 11/25/16 at 1400 (2:00 PM) an open area on the buttocks; dressing clean and intact with [MEDICATION NAME] to area. On 11/26/16 at 1537 (3:37 PM) indicated no documentation regarding wounds. Review of a policy and procedures titled Skin Program and updated on 4/2016 directed the staff to: (5) When a skin ulcer is identified, a comprehensive wound assessment will be completed. This assessment will include, a) Site, stage, size, appearance of wound bed, (use%) undermining, depth,, drainage,(amount, color, type, consistency and odor) and status of the peri-wound tissue; b) treatment of [REDACTED]. plan of care and medical status-any other possible risk factors, impaired healing due to diagnoses; e) Type of skin ulcer (physician is asked to identify the type of ulcer, for example, pressure, stasis (venous), ischemic(arterial), or neuropathic, and provide skin treatment orders. Reassess the wound at least weekly; including a)-c) above. If the wound has not improved within 2-3 weeks, contact the physician for a change in treatment. During an interview with the resident's physician on 11/29/16 at 3:05 PM, he stated he would expect the facility to contact him if the wounds were worse and for the facility to measure wounds and complete weekly skin assessments at a minimum. During an interview with the Director of Nursing (DON) on 11/30/16 at 3:14 PM, she stated she expected her staff to complete skin assessments weekly.

Based on clinical record review, facility policy review and interviews, the facility failed to properly assess and intervene when 1 of 4 residents (Resident #4) had a change in condition that warranted a thorough assessment. The facility reported a census of 45 residents. Findings include: 1. The Admission Minimum Data Set ((MDS) dated [DATE] documented [DIAGNOSES REDACTED].#4. The same MDS documented a Brief interview of mental status score of 15 which indicated intact cognition. The assessment identified Resident #4 required extensive assistance of two staff for completion of transfer, bed mobility, ambulation, dressing, toileting and personal hygiene. The assessment revealed Resident #4 had moisture-associated skin damage (MASD) and required application of ointments, medications other than to the feet. The care plan initiated 6/21/16 identified the resident had MASD to the buttocks and directed staff to apply barrier cream PRN (as needed). The care plan also identified the resident preferred to sleep fully clothed in his/her chair and directed staff encourage the resident to rest, reposition, or utilize relaxation or distraction techniques to alleviate pain. The care plan indicated the resident preferred a whirlpool bath with the directive for staff to monitor the resident's skin during bathing and care for signs of irritation or breakdown and further evaluate the area/s. Review of the 48-hour sheets for the Transitional Care Unit (TCU) revealed the following: 8/1/16 6 PM-the resident incontinent and the blister open, sweat pants put on resident 8/5/16 6 AM-raised red spot on the back of the right thigh 8/6/16 6 AM-boil on the back of the right leg which measured 6.2 centimeters (cm) x 4.0 cm and heat applied 8/6/16 6 PM- quite a bit of drainage on dressing 8/7/16 6 AM-contact the physician office in the morning-BIG BOIL needs to be seen and also documented the resident with increased incontinence possibly related to pain 8/7/16 6 PM-needs appointment made! also documented the resident given Tylenol and ice applied to the area 8/8/16 6 PM-staff changed the bandage 2 times and ice applied to the area made the resident feel better 8/9/16 6 AM-changed the dressing 2 times on the affected area 8/9/16 6 PM-leg draining and the dressing changed 8/10/16 6 PM-resident hospitalized Review of the resident's physician orders [REDACTED]. The Resident Incident Report completed by Staff A on 8/6/16 documented a boil measuring 6.2 cm x 4.0 cm found indicated the area located on the right posterior inner thigh by a circle on an anatomical drawing on the Report. The Report documented the treatment given as heat to draw the area up and applied an [MEDICATION NAME] (an adhesive dressing for collection of drainage) to the area. Staff A stated staff on the TCU were aware of the area and documented information regarding it on the 48-hour sheets completed at the end of every shift. A facility communication form dated 8/8/16 completed by the Advanced Registered Nurse Practitioner (ARNP) documented the resident had a large area to the right upper thigh. The ARNP documented the area appeared to look like a boil and she assessed the area as [MEDICAL CONDITION], red, warm, firm with serosanguinous drainage. The ARNP ordered staff administer [MEDICATION NAME] (an antibiotic) 500 milligrams daily for 10 days and [MEDICATION NAME] (an antibiotic) 1 gram by intramuscular (IM) injection daily for 3 days and directed the resident be examined on Wednesday before the 3rd dose of [MEDICATION NAME] is administered. The Progress Notes dated 8/10/16 at 17:13 (5:13 p.m.) documented the resident had a follow-up appointment with the physician for a boil on the back of the right thigh and had been admitted to the hospital for [MEDICAL CONDITION] (inflammation of the cells). Review of the Narrative Notes and Progress Notes contained in the resident's electronic medical record revealed no identification or assessment of the area on the resident's posterior right thigh. During interview on 8/31/16 at 8:45 a.m., the Director of Nursing (DON) stated she worked the 6 PM-6 AM 8/7-8/8/16. At that time she noted the resident had a reddened area on the upper inner thigh which felt warm, had some drainage, and the resident complained of pain; she applied ice to the area. The DON confirmed no assessments of this area contained in the resident's clinical record until the entry completed by Staff C, licensed practical nurse (LPN) on 8/8/16 at 10:54 a.m., which documented an appointment scheduled for the ARNP to see Resident #4 and the primary care physician not available. The DON stated she believed staff documented information regarding this area on the 48-hour report sheets but stated she knew these sheets are not part of the resident's clinical record. Review of the TCU schedule for 8/1/16-8/10/16 revealed Staff A; registered nurse (RN) worked 6 AM-6 PM on 8/1/16, 8/5/16, and 8/7/16 and 6 AM-12 N (noon) on 8/2/16; 6 AM-10 PM on 8/6/16 and 6 PM-6 AM on 8/8/16. During interview on 8/31/16 at 4:51 p.m., Staff A stated that she noted a reddened area about the size of a dime on the resident's posterior right thigh when she assisted the resident in the bathroom and perineal care on 8/1/16. She asked Resident #4 if it would be okay to remove his/her pants and lay down in bed. She cannot remember if the resident agreed to do lay down but did recall the resident did agree to have sweat pants on to take some of the pressure off the area. On 8/5/16 Staff I, certified nursing assistant (CNA) reported to her the resident had an area on the right upper posterior thigh. She stated she assessed the area and found a fluid-filled red raised area about the size of a half-dollar. She stated she told the resident s/he needed to remove his/her slacks and lay down in the bed. On 8/6/16 (Saturday) she stated she completed an Incident Report on the area on the resident's posterior thigh. She stated the physician office not open and she talked to the resident about going to the emergency room but the resident stated s/he felt there was nothing anyone could do about it and adamantly refused to go. Staff A stated she applied heat to the area to see if it would release the area, but it only made the area bigger so she stopped applying heat and use an ice pack and she felt the area got a little better. Staff A stated she had the ability to call an on-call physician and/or to send a fax report to the office but she did not do so because the resident did not want her to do so. Staff A could not recall if she documented her assessment and resident interview in the resident's clinical record. She did state she did not notify the resident's responsible party about the area because the resident told her s/he had already told the responsible party about it. During interview on 8/31/16 at 11:30 a.m., Staff G, certified medication assistant (CMA)/CNA, stated she worked 8/2/16 on the TCU and Staff C reported to her the resident had a boil. Staff G stated she saw the area and assisted the resident to change his/her pants to sweat pants and the resident complained the pants s/he had on hurt the area. She stated the area on the resident' thigh appeared raised, could not recall the color of the area. She also saw the area on 8/3/16 and 8/4/16 but did not report it as she knew the nurses were aware of the area. During interview on 8/31/16 at 2:50 p.m., Staff C, stated she did not recall knowing about or seeing the area on the resident's thigh prior to 8/8/16 but did check the schedule and confirmed she worked on the TCU on 8/2/16 from 12 N-6 PM with Staff G; and again on 8/4/16 from 6 AM-6 PM with Staff G. During interview on 8/31/16 at 6:45 p.m., Staff H, LPN, stated he worked as the charge nurse for the whole facility on 8/2/16 on the evening shift. He stated Staff I, CNA, reported the resident had an area on his/her bottom and he observed a red welt about the size of the end of his pinky finger. Staff I stated he did not document this in the resident's clinical record as it had been reported around 5 AM and he had many medications to pass but thought he wrote it on the 48-hour sheet. Staff H stated he went on vacation after the end of his shift and the resident admitted to the hospital before he returned from vacation. Review of the 48-hour sheet for 8/2/16 revealed the notation ok for Resident #4. During interview on 8/31/16 at 6:50 PM, Staff I, CNA, stated she usually works 6 PM-6 AM on the TCU. Staff I reviewed the schedule and stated on 8/2/16 she saw what she thought was a boil about the size of a quarter on the back of the resident's right thigh where his/her incontinent brief rubbed. She stated she reported the area to Staff H and he did observe the area. A few days later she saw the area looked way bigger, about the size of a fist, and it upset her. She stated she reported the area to the DON, who was the charge nurse, and told her she had reported the area earlier. During interview on 8/31/16 at 7:10 PM, Staff B, LPN, stated she is normally scheduled on the TCU 6 PM-6 AM. She stated she had observed the area on the resident and it looked like a non-raised pimple. She stated that she and Staff A discussed the area during shift change report, but cannot recall if she documented her observation of the area but stated she knew staff were aware of the area. During interview on 8/31/16 at 10:29 AM, Staff E, CMA, stated she worked on the TCU 6 AM-6 PM on 8/8/16 although she does not normally work on that unit. Staff I reported to her at shift change that she reported the area to Staff I at some time and nothing had been done. Staff E stated the area appeared about the size of a golf ball, red, raised and draining blood and pus; she notified Staff C to come and observe the area and the resident went to the doctor that day. During interview on 9/16/16 at 9:50 AM, Staff D, LPN, stated she cared for Resident #4 after s/he had returned from the physician visit. Review of the TCU schedule confirmed Staff D worked 6 PM-6 AM on 8/9-8/10/16. She stated the area on the back of the right thigh was red, warm, very painful to touch and had a large amount of malodorous purulent drainage. She recalled she had to change the dressing a couple to times on her shift. Staff D stated she cannot recall if she documented her assessment of the area in the resident's clinical record and cannot check because she is no longer employed by the facility. The facility's Change of Condition or Status policy revised 7/2015 directed the following: Physician Notification: In the event of a change in status, use the following criteria to discern immediate versus next day contact of the physician. B. The resident's condition is assessed and reported in a timely manner either verbally or written if the resident experiences: 2. change in skin integrity, not addressed through the facility's skin care protocol. 3. Signs and symptoms of infection. During interview on 9/1/16 at 1:59 PM the resident's primary care physician stated he expects nurses to document any condition that is out of the norm for a resident, to document ongoing assessment of the change and to notify him, or his designee, promptly of any deterioration in resident status. The physician inquired as to the timeline of the resident's condition in the facility prior to hospitalization and relayed to him the 48-hour sheet documentation. The physician stated he would have expected the facility to obtain orders for ice packs, heat packs and dressings prior to their initiation and staff waited too long to notify himself, or his designee, of the resident's change. He stated the facility has access to a physician at all times. The physician stated he examined the resident on 8/10/16 and his documentation showed the area measured 7 cm in diameter, with purulent drainage and surrounded by bruised-looking skin. The physician stated the initial [DIAGNOSES REDACTED]. The area was then determined to be an abscess [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus) drainage and required debridement, IV antibiotics and placement of a wound vac. The resident continues to be hospitalized for [REDACTED]. The physician stated he is the facility's medical director and will address resident assessment/intervention concerns with the facility at the next quality assurance meeting.

Based on record review, observations, staff interviews and review of the facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from self and failed to provide services in order that the resident's needs are met when staff had known the resident would remove an assistive device (Resident #1). The sample consisted of 5 residents and the facility reported a census of 40 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 7/2/13. The assessment reflected the resident had [DIAGNOSES REDACTED]. The same assessment revealed a brief interview for mental status (BIMS) of 10. A score of 10 identified the resident as moderately cognitively impaired. Resident #1 required the extensive assistance of two plus people for transfer assistance. Review of the Care Plan Report, dated 10/24/12 and most recently review on 9/17/13, identified a problem with the resident at risk for injury in regards to a seizure disorder, impaired mobility and a history of a fall. The interventions directed staff to: A risk assessment to be done quarterly and as needed (PRN), bed alarms when in bed, fall mat at side of bedside, Dycem (no slip mat) in wheelchair seat, a sign placed in the resident's room to remind the resident not to get up without assistance and not to unhook the bed alarm (9/21/17). The Care Plan did not include interventions to address the problem of the resident's history of unhooking the bed alarm prior to the fall on 9/17/13 which resulted in a fractured hip. Review of the Resident Incident Report dated 9/17/13 revealed Resident #1 fell at 0150 (1:50 AM). The report reflected staff found the resident on the floor next to the bed. The resident voiced complaints of left leg pain and the facility had the resident transferred to the hospital emergency room and then on to another hospital due to a hip fracture. The facility placed a sign in the resident's room to remind him/her not to get up without assistance and not to remove the alarm. A Fall Scene Investigation Report dated 9/17/13 reflected the resident used an alarm but the resident had unhooked the alarm. The DON (Director of Nursing) documented a narrative which identified the resident was in bed and attempting to self-transfer. No alarm sounded and the resident was found sitting on the floor next to the bed. The resident voiced complaints of left leg pain and had possible shortening of the left leg. The staff assisted the resident to bed with a Hoyer lift and the assistance of 2 people. The facility contacted the physician and received orders to send the resident to the emergency room . A report from the emergency room identified the resident had a fractured left hip. The DON documented it appeared the resident removed and unplugged the alarm. The night staff had checked the alarm at the beginning of the shift for proper functioning. On 10/30/13 at 10:20 PM, Staff C, CNA (Certified Nursing Assistant) was interviewed and stated she had checked the function of the alarm prior to the fall but Resident #1 does " mess " with the alarm all of the time. Staff C stated the resident had removed the alarm at times. On 10/29/13 at 10:30 PM, Staff A, Certified Medication Aide/CAN, was interviewed and stated she and another person found the resident after the fall. They were in the hallway and heard some tapping coming from her/his room by the bed. Staff A stated she observed the alarm in the bed, unfastened from the resident. Staff A stated she had just went through and checked the alarm when she passed new water pitchers. The resident ' s alarm was fastened to her/his gown. Staff A stated the resident had a history of [REDACTED]. Resident #1 had a history of [REDACTED].#1 would unfasten his/her alarm. Staff A further stated she had not been aware of anything new to do (intervention) since the resident unfastens the alarm. During an interview on 11/25/13 at 10:08 AM, Staff B, CNA stated the resident had been known to shut off their alarm. Staff B stated the facility staff were expected to tell the nurse and he could not remember if he told a nurse that the resident would unplug the alarm. Staff B stated one of the resident's visitors would shut the alarm off too. On 11/25/13 at 10:35 AM, Staff D, CNA was interviewed and stated when she worked evenings (a few months ago), Resident #1 liked to unplug his/her alarm a lot. She stated she then would just check on the resident numerous times and she reported it to the charge nurse. On 11/25/13 at 10:45 AM, the Director of Nursing (DON) was interviewed and revealed prior to the resident's fall on 9/17/13; no one had told her the resident unhooked the alarm. If she had known, the facility would have done other interventions (like a wireless alarm or keeping it out of reach). Since the fall, the facility provided education about resident care plans and new interventions to staff. The facility policy titled Alarms for Bed and Chair, revised on March 2013, identified the policy of the facility is to provide a safe and comfortable environment for the residents of the facility. Bed and chair alarms would be used as appropriate to assist in the fall reduction/safety of the residents and the facility. The procedures included that the residents assessed as needing an alarm for their bed or chair would be evaluated for the appropriateness of the device (E: length of cord, ability to remove the alarm, etc.). On 10/29/13 at 10:45 PM, observation revealed the resident in bed and resting on right side. Observation revealed the alarm clipped to the top of the resident ' s gown and out of reach.

Based on clinical record review and staff interviews, the facility failed to implement interventions and provide adequate supervision designed to prevent accidents for 1 of 7 residents reviewed. Resident #1 fell and sustained a fractured left hip, with no safety interventions functioning to alert the staff of his/her supervision needs. The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The assessment mentioned Resident #1 had score a 2 (two) on the Brief Interview for Mental Status (BIMS), revealing he/she had severe cognitive impairments. The assessment documented Resident #1 required extensive staff assistance for bed mobility, transfers and he/she had impairments on his/her lower extremities. The MDS documented Resident #1 could not balance when walking and during transitions (such as when moving from a seated position to standing, or when turning around or when moving from surface to surface); and was unsteady and only able to stabilize with human assistance. The Care Plan Report dated 5/25/11 indicated Resident #1 at risk for falls due to a history of falls and a [DIAGNOSES REDACTED]. The care plan mentioned Resident #1 had been on a Falling Star Program and staff should update the fall risk assessment quarterly and as needed (PRN). The care plan directed staff to provided assistance of one staff for transfers with the use of a gait belt. The interventions included a pull tab alarm while in bed, and a pressure pad in bed and when in the wheelchair. On 8/10/11, a floor mat was placed beside the bed with an alarm floor mat placed on top of the floor mat.The care plan indicated on 8/19/11 the resident had a fall with a hip fracture.The pull tab alarm had a line drawn through it with the words discontinued on 8/24/11, a new low bed from hospice. A Fall Risk assessment dated [DATE] revealed a score of 16, indicating the resident at a high risk for falls. An Incident Report dated 8/19/11 at 7:05 a.m., documented a Certified Nurse Aide (CNA) went into the resident's room to get the resident up for the morning. The aide found the resident laying on the floor on their left side. The incident report documented the bed alarm was in place on the bed. The Nurse assessed the resident and noted no deformities on the resident's left leg or arm. The resident complained of pain in his/her hip. The Nurse contacted the physician and sent the resident to the emergency room . The incident investigation report indicated the resident had been last checked at 6:00 a.m., and the report asked whether Resident #1 had been using any safety devices such as a personal alarm, bed alarm, floor alarm, and pad beside the bed. The report showed no safety devices had been checked and no malfunction of any safety devices. A Radiology Report dated 8/19/11, revealed the resident had fallen at the nursing home and complained of left hip and shoulder pain. The report indicated Resident #1 sustained a left hip femoral neck fracture. During interview on 9/7/11 at 8:15 a.m., Staff D, CNA stated approximately 7:30 a.m., Resident #1's alarm had been going off and she went into the resident's room and found the resident laying in bed sleeping. Staff D stated the alarm had been set off again for the second time. Staff D stated she had reset the alarms prior to leaving the room each time. The third time she went to check on the resident she entered the room and noticed Resident #1 had been on the floor. The alarm was not sounding and the alarm connected to the bed (bed alarm) had been plugged in. Staff D stated they found the resident on the right side of the bed with the mat in place. Staff D stated the alarms were checked every day on each shift. During interview on 9/7/11 at 8:25 a.m., Staff E, Licensed Practical Nurse, (LPN) stated at approximately 7:05 a.m., Staff D came to another resident's room and informed her Resident #1 had fallen and was on the floor. Staff E stated as they went to the resident's room, and she did not hear any alarms prior to the incident. Staff E stated she assessed Resident #1 and did not see anything irregular but the resident complained of left leg pain when Staff E moved his/her left leg. They transferred the resident and placed him/her into a chair but he/she would not sit in the chair and leaned forward. The resident complained of pain and the physician was notified. Resident #1 was transferred to the emergency room . Staff E stated when she had entered the room the bed alarm was in place on the bed but was not sounding. Staff E stated Staff D reported she had just checked the alarms and they were working. Staff E reported she did not hear any alarms going off during the time she was working down the hall that morning. Staff E stated she did not check the bed alarm when in the room and she only made an observation that the bed alarm was in place. Staff E stated the facility implemented an alarm book to document verification of functioning alarms after the resident's fall. Staff E stated when the Administrator checked the alarm, the alarm sounded muffled like a weak battery. During interview on 9/7/11 at 10:45 a.m., Staff B, CNA stated they worked the opposite hallway the day of the fall. Staff B stated they did not hear any alarm sounding that morning, though it would be difficult if they were in a resident room. Staff B did know the resident was a fall risk and had many interventions implemented for fall prevention, including a bed alarm and floor mat.

Based on observation, record review and interviews, the facility failed to plan for and direct nursing services to ensure two of four residents received adequate supervision from hazards. Resident #4 leaned over and fell out of a bath/shower chair and consequently the staff did not use the chair belt to secure the resident. Resident #4 sustained injuries to his/her face and knees. The onsite observation showed another resident, Resident #5's care plan safety intervention were not in-place until the surveyor alerted the facility staff. The facility reported a census of 32 residents with 9 current residents and one former resident reviewed. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 3/14/11 included [DIAGNOSES REDACTED]. The MDS documented Resident #4 required extensive assistance of 2 staff for bed mobility, transfers, toileting, dressing, and personal hygiene. The MDS documented bilateral impairments of both upper and lower extremities with range of motion. The MDS documented Resident #4 un-steady when moving between surfaces such as transferring between a bed and wheelchair/chair, etc. and only able to stabilize self with staff assistances. Review of the Care Plan dated 12/9/10 for Resident #4 identified the resident as at risk for falls and directed two staff to provide assistances with Hoyer lift transfers. Resident #4's Interdisciplinary Progress Note dated 3/19/11 documented the resident was getting a bath and leaned over and fell out of the shower (bath) chair. The resident hit his/her knees and then his/her face on the floor and was face down. The resident ' s pain rate was reported at 8 out of 10 and the staff contacted the physician who ordered the resident be sent to the emergency room . Review of a Resident Incident Report dated 3/19/11 documented that Resident #4 fell out of the bath chair at 9:30 AM. The report documented the resident had been face down on the floor and had a nose bleed. The report documented the resident had been rolled to midline position and his/her neck was secured for possible neck injury. The nurse assessed the resident ' s hand grasp and described them as equal and weak. The injuries documented included contusion to the nose and swelling of the right and left knees. During an interview with the DON (Director of Nursing) on 3/30/11 at 11:00 AM she identified that a belt should have been used on the bath chair when transferring Resident #4. The DON stated that the belt had not been used and identified Staff S, CNA as the person giving the shower. The DON identified that Staff S had been trained on the correct way to give showers. The DON stated that she had found the belts for the shower chair in the shower room drawer. During an interview with Staff S on 3/31/11 at 1:45 PM she stated the bath chair had been taken to Resident #4's room. Staff M and Staff S transferred Resident #4 via Hoyer lift to the bath chair. Staff S stated Staff M pushed the resident in the bath chair to the shower room and then Staff M left the shower room. Staff S stated Staff J, RN re-wrapped the resident's leg wraps in shower room. Staff S usually did not give baths, and could not find the belt. Staff S stated after the resident fell , a staff found the belts the next day. Staff S stated she did not always use the belts until the recent training, and did not remember whether she had been trained on how to give a shower at this facility, although she had received training during her CNA class. Review of the Employee General Orientation Checklist did not identify that Staff S had been trained on bathing/shower techniques. Observation on 3/30/11 at 3:30 p.m. revealed the shower chair had 2 sets of loops for use with 2 seat belts. During an interview with the DON on 3/31/11 she identified that the general orientation for Staff S had been completed by the previous Social Service Director and the previous DON. During telephone interview on 4/13/11 at 7:10 a.m., Staff M stated that Staff S asked him to help transfer Resident #4. Staff M and Staff S transferred the resident via the lift to the chair. Staff M stated he pushed Resident #4 in the bath chair (off the carpet on the 300 hall) to the shower room. Staff M did not use a belt at the time of the transfer. Staff S and Staff M did not discuss putting a belt on the resident and normally they did not use one. Staff M stated only one other resident used a chair belt at that time. Staff M stated neither Staff S nor himself had given residents' baths in years as the facility had a bath aide. Staff M stated now he knows where the belts are kept. During telephone interview on 4/12/11 at 3:45 p.m., Staff J stated she did not see the resident transfer from bed to the shower chair. However, after Resident #4's shower, Staff S called her to the shower room via the call light; the resident's bottom had been bleeding. Staff J did not remember seeing a belt on the resident when she entered the shower room. Staff J obtained supplies and crouched behind and below the resident while s/he sat in the shower chair. Staff J applied triple antibiotic ointment and then the resident fell on the floor. Staff J stated she asked Staff S why the resident was not belted in. Staff S replied that she couldn't find the belts, but she did not know if Staff S had looked for a belt. During telephone interview on 4/13/11 at 1:45 p.m., the DON stated the facility uses a handbook for the whirlpool chair/shower chair and staff also called it a bath chair. The DON stated staff are trained and the facility used the video for at least the last 3 years. The video shows the same techniques as described in the handbook for how to use the whirlpool chair/shower chair. The DON stated it is rare for CNAs to give showers/baths as the facility had a bath aide. The bath aide does baths and showers on Monday through Friday and sometimes residents have their bath the next day, if she can't get all baths done. Resident #4 was scheduled to bathe on Friday, so his/her bath was rescheduled to Saturday. Since the fall, she in-serviced all but 2 staff on how to use the whirlpool chair safely and the belts are hanging on hooks in the shower room. Review of handbook for Cascade Sit-Bath system revealed instruction on page #8 to check that the seat belt is in place and ready to strap in the resident after they are in the tub. On page #9, the handbook instructed to attach the seat belt around the resident using the D rings on the seat belt. 2. According to the MDS assessment dated [DATE] Resident #5 had [DIAGNOSES REDACTED]. The review of the MDS dated [DATE] the resident required extensive assistance of 2 plus persons physical assistance for transfers, toilet use, and ambulation in his/her room. According to the MDS the resident did not have a fall history prior to admission or prior to 2/21/11. The review of the care plan dated 2/22/11 revealed the resident had a fall on 2/22/11, 3/11/11, 3/17/11 and 3/27/11. The staff added an intervention on 3/11/11 that included the placement of an alarmed floor mat. The observation made on 3/30/11 at 4:15 p.m. revealed the resident laid in bed. Staff H, certified nursing assistant, offered to toilet the resident and the resident refused. Staff H gave the resident a drink of water. The observation revealed the alarmed bed pad laid under the bed and did not lay on either side of the bed. The observation revealed Staff H left the room at 4:17 p.m. The continued observations made on 3/30/11 at 4:35 p.m. and 5:00 p.m. revealed the alarmed pad remained under the bed. After identification of the concern at 5:05 p.m. to the director of nursing she pulled the alarmed pad from under the bed and placed the alarmed mat on the left side of the resident's bed.