Every finding on record at Rehabilitation Center of Hampton

Based on clinical record review, facility policy review, staff and family interviews, the facility failed to have a clear and accurate code status across all documentation records for 1 of 16 residents reviewed for Advanced Directives (Resident #34). The facility reported a census of 39 residents.Findings include:Resident #34's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The Care Plan Focus initiated [DATE] listed Resident #34's Advanced Directives Status - Pursuant to resident rights, personal choices, and their desire to retain control over their health decisions, Resident #34's Representative chose Full Code. The Intervention dated [DATE] directed staff to go to the Electronic Medical Record (EMR) chart to identify Code Status. The Staff updated the Care Plan on [DATE] to Do Not Resuscitate (DNR). The Clinical Physician Orders printed [DATE] included an order dated [DATE] for DNR. The admission Record dated [DATE] identified an Advanced Directive of DNR. Resident #34's [DATE] Medication Administration Record (MAR) listed a code status of DNR. Resident #34's Iowa Physician Orders for Scope of Treatment (IPOST) signed [DATE] by Resident #34's Power of Attorney (POA) indicated they desired Full Code status if her heart stopped beating. The physician signed the IPOST on [DATE]. The IPOST book at the nurse's station contained the IPOST signed [DATE]. The IPOST book lacked the updated order from [DATE]. During an observation on [DATE] at 10:08 AM, Resident #34 didn't have an IPOST in the IPOST book. Resident #34's Progress Notes lacked a note after [DATE] on their Advanced Directives. On [DATE] at 8:15 AM, Staff A, Licensed Practical Nurse (LPN), stated she knew many residents' code statuses, but if she didn't know, she'd look in the EMR, if she logged on. If she didn't log on, she'd look at the IPOST in the IPOST book. On [DATE] at 11:50 AM, Staff B, Registered Nurse (RN), stated if she needs to know someone's code status, she looked in their EMR. The other option included looking in the IPOST binder. On [DATE] at 12:15 PM, Resident #34's brother, who acts as the Durable Power of Attorney (DPOA), stated Resident #34 should've been DNR on admission as that's what his paperwork stated. What he signed on admission for Full Code didn't reflect the correct choice, and he recently corrected it with the nursing staff. He didn't sign anything for the correction. On [DATE] at 12:50 PM, the Director of Nursing (DON) stated she recently talked with Resident #34's brother, and Resident #34 shouldn't have a Full Code status since that didn't match what he wanted. She switched it to DNR on [DATE]. She thought she put in a progress note, but she noticed she didn't when she checked. She stated she should've also updated the IPOST in the IPOST book and the Care Plan, but the staff hadn't updated either one. She'd take care of it as soon as possible. The Code Status Identification and CPR policy revised [DATE] instructed physician's orders related to a resident's code status and/or DNR/limited treatment documentation get completed by the licensed nurse or social services director/designee and entered into the EMR as part of the resident's electronic medical record. It directed that direct care staff with EMR access receive education during orientation and as needed on system identification of patient code status. If the center experiences an EMR failure or utility loss, staff must follow backup procedures and the EMR failure plan. The policy directed to identify code status on the paper MAR/Treatment Administration Record (TAR).

Based on observation, facility policy review, resident and staff interviews, the facility failed to maintain an effective pest control program so that the facility was free of pest for 6 of 6 residents reviewed. (Resident #1, #2, #3, #4, #5, and #60. The facility identified a census of 44 residents.Finding include:1 The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) score of 12 indicating no cognitive impairment for decision making abilities and is able to make self-understood and understands others.Review of Resident #1's Electronic Health Record (EHR) documented resident resided in room [ROOM NUMBER].On 11/19/25 at 1:20 PM, Resident #1 stated that he was in room [ROOM NUMBER] and it was awful with flies, and then he was moved to room [ROOM NUMBER] and does not see the number of flies that were in room [ROOM NUMBER].2 The MDS dated [DATE] for Resident #2 documented a BIMS score 12 indicating no cognitive impairment for decision making abilities and is able to make self-understood and understands othersReview of Resident #2's EHR documented resident in room [ROOM NUMBER].On 11/19/25 at 1:00 PM, Resident #2 stated that he has a fly swatter in his room to kill the flies that come in. Resident #2 stated that he opens his window at night to let air in and there is no screen on the window.Observation on 11/19/25 at 1:00 PM, a fly landed on Resident #2 left leg and no screen on his window.3 The MDS dated [DATE] for Resident #3 documented a BIMS score of 15 indicating no cognitive impairment for decision making abilities and is able to be understood by others.Review of Resident #3 EHR documented resident in room [ROOM NUMBER].On 11/19/25 at 1:54 PM, Resident #3 stated that he takes his blanket and will wave it in the air to get the flies off of him, 4 The MDS dated [DATE] for Resident #4 documented a BIMS score of 13 indicating no cognitive impairment for decision making abilities and is able to be understood by others and is able to understand others.Review of Resident #4's EHR documented resident in room [ROOM NUMBER].On 11/19/25 at 3:54 PM, Resident #4 stated that there are a couple of times that flies come into her room, it has gotten a lot better, but for a while seemed like an endless number of flies. Resident #4 uses a magazine to swat them away or kill them. 5 The MDS dated [DATE] for Resident #5 documented a BIMS score 15 indicating no cognitive impairment for decision making abilities and is able to be understood by others and usually understands.Review of Resident #5's EHR documented resident in room [ROOM NUMBER].On 11/19/25 at 12:55 PM, Resident #5 stated that she has two fly swatters to kill the flies that come into her room. They are not as bad now as they were a month ago, but some do come into her room.6 The MDS dated [DATE] for Resident #6 documented a BIMS score of 6 indicated moderately impaired decision-making abilities and is able to be understood by others and usually understands.Review of Resident #6, EHR documented resident in room [ROOM NUMBER].On 11/19/25 at 1:09 PM, Resident #6 stated that he sleeps with a sheet over his head to keep the flies off of his face.Observation on 11/19/25 at 1:09 PM, a fly landed on Resident #6 right pant leg.On 11/19/25 at 12:45 PM, Staff A, Housekeeper, stated that the facility has been dealing with flies for the past month, and that residents are given fly swatters to use to kill the flies. On 11/19/25 at 2:00 PM, Staff B, Certified Nursing Assistant (CNA), verified that there are flies in the facility and residents are given fly swatters to kill the flies. On 11/19/25 at 2:00 PM, Staff C, CNA, verified that some of the resident rooms have flies and that the residents are given fly swatters to kill the flies.On 11/19/25 at 2:55 PM, the facility Administrator stated that the facility does their own pest control system, and no outside company is contracted or used.On 11/19/25 at 3:05 PM, Staff D, Director of Maintenance, stated that he was aware of the fly issue at the being of November and did interviews with staff and they said that the flies were not that bad and did not go any further with the concern. He also verified that the facility does their own pest control system and does not contract an outside company. Staff D confirmed that he did not do any interview with residents. The Pest Control Policy dated October 2023, documented the purpose is to ensure there is an effective pest control process in the building. If there is a suspicion or actual problem with pest, the facility will contact a pest control company to inspect presence of a potential pest concern. Pest control company will determine if follow-up treatment or further inspections is needed.

Based on clinical record review, staff interviews and facility policy review, the facility failed to appropriately implement interventions to protect 1 out of 1 resident (Resident #3) reviewed from financial exploitation. The facility reported a census of 45 residents.The facility corrected the noncompliance prior to the start of the survey by conducting staff in-services on 6/12/25, 6/16/25, and 6/17/25 regarding accepting gifts or payments from the residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 showed the Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented diagnoses of depression, post-traumatic stress disorder, hypertension, and diabetes mellitus. Review of the facility self-report revealed the facility was made aware of the incident on 6/12/25 by Resident #1's family members. The family member sent a video of a woman entering Resident #1's residence to the Director of Nursing (DON). The DON was able to identify the woman as Staff A. Staff A worked at the facility as a housekeeper. Review of the facility investigation self-report incident occurring on 6/12/25 at approximately 11:00 AM revealed the following:According to an interview conducted with Staff A, Housekeeper, she reported that Resident #1 asked her to clean his house and gave her a key to get in. Staff A stated she went twice and looked at the house but never took anything. Staff A stated she did not clean because the house was in rough shape. The Administrator questioned Staff A if Resident #1 paid her for anything and she responded he gave her $35 for gas money. On 10/6/25 at 1:00 PM the Administrator, stated she got a call from the DON and Assistant DON (ADON) stated Resident #1's family member said she saw on video surveillance someone go into Resident #1's home. The Administrator stated the family member sent the video to the facility where they were able to identify Staff A going into the house. The Administrator stated they called Staff A in to interview her, Staff A stated that Resident #1 gave her around $30 in gas money to go clean his house so he could go home. The Administrator stated that she explained to Staff A that she was an employee of the facility and that she was not able to accept payment from Resident #1. The Administrator stated Staff A returned the key to Resident #1's house to the facility and stated she didn't give a specific date on when the money or key was exchanged. Staff A stated she had gone to his house twice. The Administrator stated Staff A didn't do any cleaning, due to the house being in rough shape. On 10/7/25 at 3:30 PM Staff A stated that Resident #1 had asked her to clean his house because he wanted to go home. Staff A stated that he had given her a key to his house, but that key didn't work. Staff A stated she had given the key back and Resident #1 gave her another key. Staff A stated that the key worked and she was able to get into the house. Staff A stated Resident #1 had given her $35 for gas money to go to the house. Staff A stated that she took another person with her because it was scary for her to go by herself. Staff A stated the first time she went she also took someone with her, but she could not remember who it was, but they couldn't get into the house at that time. Staff A stated that she did not clean Resident #1's house, she stated that it was in rough shape. Staff A stated she told Resident #1 she wasn't going to clean it because of the condition of the house, she stated Resident #1 explained to her his family member is going to take care of it. Staff A stated she did not take anything from the house. Staff A stated that she didn't think of this as anything as she needed the money and she wanted to help him out because he wanted to go home. She stated she didn't give the money back because she put it in her car for gas to go to his house. Staff A stated she would give the $35 back to the facility. Staff A stated that she had not been to his house or taken any money previously from him or any other resident prior to this incident. She stated I wasn't aware that this was so serious. She stated my job was to clean houses. Staff A stated that she did not tell anyone about this because she didn't think it was such a serious matter, she thought she was helping him out. She stated that Resident #3 had called her a couple of months ago and she told him no because she had gotten in trouble for this last incident. Review of the facility policy named Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation dated September 2025 revealed the purpose is to provide professional care and services in an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The definition of misappropriation of resident property - the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a patient's belongings or money without the patient's consent. In response to allegations of abuse, neglect, exploitation, or mistreatment, injuries of unknown origin, or misappropriation the facility must:- Have evidence that all alleged violations are thoroughly investigated.- Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.- Report all allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections, Appeals and Licensing and any other required state agency if applicable (ie: law enforcement). Reports of abuse or if there is resulting bodily injury, the facility should report immediately and not later than two (2) hours. Allegations of neglect, exploitation, misappropriate of resident property, or mistreatment to be reported not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Based on observation, record review, staff interviews, and policy review, the facility failed to use appropriate infection control practices during urinary catheter care and wound care for 2 of 4 residents reviewed (Residents #14 and #32). The facility reported a census of 42 residents. Findings include: 1. Resident #14's Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) didn't get completed as Resident #14 is rarely/never understood. The MDS listed Resident #14 had an indwelling urinary catheter. The MDS included diagnoses of medically complex conditions, neurogenic bladder (impaired bladder control), and diabetes mellitus. The Care Plan with a target date of 7/22/25 included the following Focuses: a. Resident #14 had an indwelling catheter due to a neurogenic bladder from a previous stroke. The Intervention directed: i. The Care Plan instructed staff to provide catheter care. b. Resident #14 required enhanced barrier precautions (EBP) related to the use of an indwelling catheter, pressure wounds, and MDRO ESBL (a multidrug-resistant organism that breaks down certain antibiotics, making them ineffective). The Intervention directed: i. Staff to wear a gown and gloves while performing high-contact care activities (high contact care activities include: bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device such as: urinary catheter and feeding tube care). On 5/20/25 at 2:50 PM, observed Staff A, Certified Nursing Aide (CNA), perform Resident #14's catheter care. During the entire catheter care process, Staff A failed to wear a gown. During an interview on 5/20/25 at 3:54 PM, Staff A reported she understood EBP. They explained the process, including wearing a gown. Staff A acknowledged she didn't wear a gown during Resident #14's catheter care. She verified she should wear a gown to be compliant with EBP guidelines and protocols. During an interview on 5/21/25 at 10:54 AM, the Director of Nursing (DON) stated they expected staff to wear a gown during Resident #14's catheter care for compliance with EBP and infection control practices. 2. Resident #32's MDS assessment dated [DATE], identified a BIMS score of 5, indicating severe cognitive impairment. The MDS included diagnoses of progressive neurological conditions, coronary artery disease and diabetes mellitus. The MDS listed Resident #32 had a pressure ulcer/injury and had a risk of developing pressure ulcers/injuries. The Care Plan with a target date of 8/6/25, included the following focus areas: a. Resident #32 had a risk for altered skin integrity related to incontinence and limited mobility. On 11/4/24, the staff found a stage 2 pressure ulcer to his left buttock. The Interventions directed the following: i. Administer treatment per physician orders. b. EBP related to pressure area on his left ischial (area on the buttock) area. i. Staff to wear a gown and gloves while performing high-contact care activities. Resident #32's Order Entry dated 5/7/25 included an order for Dr. [NAME] paste to apply to his wound bed and surround the area with vitamin A&D ointment three times a day for his left ischial buttock wound. The Secure Conversations progress note dated 5/20/25 regarding Resident #32's Weekly Skin Assessment. The Progress Note documented his ischial area measured 7.5-centimeter (cm) x 11.2 cm. The wound contained no open areas, measured the pink/red area instead. The note reflected they would continue with the treatment orders and continue to monitor the area. On 5/21/25 at 7:15 AM, observed Staff B, Licensed Practical Nurse (LPN), perform Resident #32's wound care him to his right side. As Staff B cleaned the area with a wipe, witnessed the area on the left ischial as red/pink with excoriation (a superficial loss of skin, often caused by trauma, scratching, or rubbing. It can result in a raw, irritated lesion or a thin crust forming after blood and fluids emerge from the skin's surface) with several unhealed pinpoint areas. Staff B removed her gloves, did hand hygiene, and applied new gloves. Staff B applied the Dr. [NAME] paste to wound bed with a q-tip, then with a new q-tip applied A and D ointment around the outside of the wound. She then placed a clean brief under Resident #32 and rolled him back. Staff B removed her gloves and did hand hygiene. During the process Staff B didn't use full EBP for the wound care, as she didn't wear a gown during the treatment of the wound. During an interview on 5/21/25 at 10:00 AM, Staff B reported the facility put EBP on the door either on the outside or inside of the residents' room. She reported Resident #32 didn't need EBP anymore due to his wound only being excoriated. During an interview on 5/21/25 at 10:54 AM, the DON stated during Resident #32's skin assessment the day before they believed the wound closed and added they wound wasn't open. They sent a secure communication to the Primary Care Physician (PCP) regarding the skin assessment. The DON explained as the skin assessment didn't show the wound open, they believed staff didn't need to wear a gown during wound care. She reported they started the process of stopping doing EBP with Resident #32 that morning and stopping it on the Care Plan. The DON acknowledged his Care Plan still contained EBP. The DON stated if a resident had a chronic wound they followed all precautions for EBP, or if the resident had an open wound. On 5/21/25 at 1:10 PM, observed Resident #32's wound area with Staff D, facility Nurse Consultant. The observation revealed Resident #32's wound remained the same as that morning with excoriation noted with several pinpoint areas and a scant amount of blood coming from the pinpoint areas. The facility's Infection Control Policy, reviewed September 2022 defined EBP as an approach of a targeted gown and glove use during high contact resident care activities. The policy instructed EBP could be implemented for residents with any of the following: a. Wounds - Generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. i. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers. b. Indwelling medical devices, regardless of MDRO colonization status. Examples of indwelling medical devices include, but are not limited to indwelling urinary catheters.

Based on clinical record review, resident interviews, staff interviews, and policy review the facility failed to ensure residents were transported within the facility in a safe manner. Residents #10 and #8 were pushed in the dining room and hallway in their wheelchairs without foot pedals in place for safety. The facility reported a census of 42 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. Resident #10 required partial to moderate assistance with bed to chair transfers. The MDS indicated Resident #10 used a walker or wheelchair for mobility. The Care Plan Focus with a target date of 9/2/24 reflected Resident #10 had a risk for falls related to confusion, aggressive behaviors towards staff, and dementia. The Interventions instructed the staff to ensure he wore appropriate food when transferring or mobilizing in his wheelchair. On 7/5/24 at 5:27 PM observed Staff A, Dietary Aide, push Resident #10 through the dining room in his wheelchair without foot pedals. Resident #10 attempted to stay at the speed using his feet in a quick walking motion along the floor. His blue gripper socks caught on the floor 3 times as he tried to keep up, pulling that foot backwards. On 7/6/24 at 2:41 PM Staff D, Nurse Consultant, stated the facility trained staff on safe wheelchair transportation at the skills fair annually and during orientation. She said the policy directed to have foot pedals in place if staff pushed a resident. If a resident usually self-propelled, they should keep the pedals connected to the wheelchair but not engaged, ensuring the pedals are available as needed. On 7/7/24 at 9:23 AM Staff C, Administrator in Training, stated they discussed wheelchair safety in stand up meetings and thought the staff sometimes forgot that when residents can self-propel they still needed pedals on the wheelchairs prior to pushing them. 2. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #8 required total staff assistance with bed to chair transfers. The MDS indicated Resident #8 used a manual wheelchair for mobility. The Care Plan Focus with a target date of 8/11/24 indicated Resident #8 had a risk for falls related to weakness and occasional poor safety awareness. The Interventions instructed to ensure she wore appropriate footwear while she transferred or mobilized in her wheelchair. On 7/5/24 at 6:17 PM observed Staff B, Registered Nurse, offer to push Resident #8 to her room, she agreed. Staff B pushed her wheelchair down the hallway from outside of the dining room, around the corner, and half way down another hallway to her room without foot pedals on the chair. On 7/7/24 at 9:18 AM Resident #8 stated staff didn't put foot pedals on her wheelchair, and they never did because she didn't like them. On 7/7/24 at 11:06 AM the Administrator stated staff attended in-services earlier in the year regarding wheelchair safety. On 7/7/24 at 11:14 AM the Administrator provided a document titled CNA Orientation Checklist which included use of foot pedals at all times when pushing a resident in their wheelchair. Additional documents provided titled In-Service Training Report and dated 2/16/24, 2/23/24, 3/8/24, 4/12/24, and 5/24/24 revealed both Staff A and Staff B attended training that addressed wheelchair safety.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 out of 3 residents reviewed for falls with injuries (Resident #1). Resident #1 experienced a fall from a full-body mechanical lift that resulted in a left arm injury. The facility failed to inspect a sling prior to transferring a resident with a mechanical lift which resulted in one strap breaking causing the resident to fall approximately 41 inches to the ground. While in the hospital, three months after the fall, an X-Ray revealed a fracture to her left proximal humerus (break in the upper part of the left bone of the arm near the shoulder). Findings include: Resident #1 ' s Minimum Data Set (MDS) assessment dated [DATE] documented diagnoses of anemia (low iron in the blood), anxiety, depression, heart failure, hypertension(high blood pressure), diabetes mellitus, post traumatic stress disorder, and below the knee amputation to the left leg. The MDS included a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. The MDS indicated Resident #1 required total dependence of 2 persons with transfers and did not walk. The Care Plan with a target date of 1/18/24 reflected that Resident #1 had a risk for falls related to impaired mobility and episodes of decreased alertness. The care plan interventions included the following: Be sure that my call light is within reach and encourage me to use it for assistance as needed. Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that I am wearing appropriate footwear when I am mobilizing in my wheelchair. I have been provided with an extra long reacher. I have fallen out of my wheelchair trying to get something from under my bed. Please encourage me to use it and please make sure it is where I can reach it. Please do not leave me in my wheelchair in my room. I have fallen out of it trying to reach for things. If I want to be in my room, please assist me to bed. Resident #1 ' s Fall Risk Evaluations on 6/6/23 documented a score of 8 (A score greater than 10 or more represents high risk for falls). The Incident Report (IR) Note on 10/2/23 at 8:20 AM documented that someone summoned Staff E, Licensed Practical Nurse (LPN), to Resident #1 ' s room because she fell from the mechanical lift. Resident #1 landed on her buttocks and laid back against the lift. Resident #1 rested her head on the lift with her left arm up on the mechanical lift leg, and her right arm at her side. Resident #1 placed her right leg over the bed frame with her left prosthetic pushed against the bed frame. Resident #1 answered questions by yelling WHAT. The note described Resident #1 ' s left lower arm just below the elbow as light blue in color. Resident #1 moaned and cried out when moving her left arm. Resident #1 rated her pain a 7 (7 out of 10 on a numerical pain scale indicated severe pain) to the left arm. The Investigative Report dated 10/2/23 completed by the DON (Director of Nursing) with Staff A, CNA (certified nursing assistant), and Staff B, CNA showed the CNA ' s reported that they connected the loops of the mechanical lift sling to the mechanical lift. Staff A and Staff B reported Resident #1 did not look crooked in the mechanical lift sling. As Staff A operated the mechanical lift buttons, Staff B got the wheelchair from approximately 10 feet away. They reported Resident #1 ' s bottom fell to the floor first, approximately 41 inches. They immediately called for the nurse. They denied hearing anything when the black loop on the sling snapped. Staff E, LPN, assessed Resident #1 and someone called the DON to assess the situation. The DON assisted Staff E and Staff F, RN (Registered Nurse), to remove the lift from behind Resident #1. They completed range of motion (ROM) to Resident #1 ' s four extremities noting pain to the left arm with bruising. Resident #1 had a history of pain to left arm prior to the accident. When they notified the Primary Care Physician (PCP), they ordered an x-ray of the left arm. The facility examined the sling and found no abnormalities, except the bottom black loop. A Progress Note dated 10/2/23 at 11:45 AM revealed the facility sent Resident #1 to the emergency room for x-rays of the left arm and shoulder. The Hospital Diagnostic Radiology report dated 10/2/23 revealed x-rays completed to Resident #1 ' s right humerus and right forearm. The impression of the report showed no right humerus or right forearm fracture. A Hospital Diagnostic Radiology Report dated 1/3/24 at 8:16 PM documented an x-ray of the left humerus was taken due to pain. The findings revealed a proximal humerus fracture at the level of the neck with callus formation. The impression documented a left proximal humerus subacute fracture with correlation for recent traumatic injury. The impression further documented an underlying pathologic lesion was not excluded. The impression suggested short term follow up radiograph to assure appropriate healing. An Emergency Department (ED) Nursing Progress Noted date 1/3/23 at 8:58 PM documented the ED received a call from Staff C, LPN who requested the left arm x-ray report. The ED note documented Staff C reported Resident #1 had a fall in October and x-rays were ordered but the x-rays were done on the right arm instead of the left arm. On 10/2/23 the DON filled out a Food and Drug Administration (FDA) Form 3500 (used for mandatory reporting of medical device adverse events by manufacturers, user facilities and importers) stating that the company sling rated for 1000 pounds failed. The form documented the mechanical lift sling failed when the black leg loop split while the staff were transferring Resident #1. According to the form, Resident #1 fell to the floor, falling approximately 41 inches. No major injury determined from the fall at the time of the incident. During interview on 1/8/24 at 3:34 PM, Staff E reported that she worked on 10/2/23 and got called to Resident #1 ' s room by the CNA ' s. Staff E reported she observed Resident #1 on the floor but could not remember exactly how Resident #1 laid. Staff E reported feeling confident Resident #1 went for x-rays. Staff E reported two CNA ' s utilized the hoyer lift. Staff E described the break as a clean snap on the hoyer lift sling from the hook on the hoyer lift. Staff E reported she couldn ' t remember the CNA staff members during the incident. Staff E reported she didn ' t remember the intervention put in place or any education provided regarding the hoyer lift after the incident. During interview on 1/9/24 at 12:15 PM, Staff D, Environmental Services, reported she audited the hoyer lift slings quarterly to check and make sure they have no rip/tears and if they did she removed the slings from use. Staff D reported completing an audit on 10/5/23. The facility put four new slings in place on 11/28/23. Staff D explained she writes the serial number off of the slings so when she does the audits she can check off that the sling is good. Staff D reported she also checks the slings that are in the residents wheelchairs. They replace the slings yearly. Staff D reported she took the gray looped slings out of commission due to there not being any residents at the facility that is under 100lbs. Staff D made a list of what color sling each resident must use. Staff D reported that she didn ' t do anything with educating the staff regarding lifts and slings, as the DON did that. On 1/9/24 at 2:40 PM, observed the mechanical lift sling used to transfer Resident #1 on 10/2/23. The sling did not have a tag or serial number. As the sling did not have any identification, there was no way to verify when the facility purchased the sling or put it into use in the facility. In addition, the observation revealed the torn left lower black loop, a frayed green loop, and the sling ' s green color looked faded. On 1/9/24 at 3:30 PM, the DON reported on 10/2/23, the day of the fall, someone called her to Resident #1 ' s room. The DON reported she witnessed Resident #1 laying on the floor with her head resting on the lift bar, her right foot resting in a gap on the bed, her left arm tucked between her body, and the lift. The staff assisted Resident #1 into bed from her wheelchair as she just finished her shower. The DON reported when Staff A and B transferred Resident #1, strap on the hoyer lift sling broke. The DON described Staff A and Staff B as very nervous as these types of things should not happen. The DON reported when the left loop of the hoyer sling snapped it caused Resident #1 to lean to the left side and slide out of the hoyer lift sling onto her buttocks. The DON reported the loop had a straight tear in it. The DON reported the sling didn ' t have evidence of any wear or tear. The staff members are good about turning in slings to Staff D and if they have concerns, then Staff D will reorder new hoyer lift slings. The Corporation instructed her to fill out an FDA report since they had faulty medical equipment. The report triggered the hoyer lift/sling company. The DON reported phone calls and email communication with the lift/sling company. She added that she took pictures and sent them to the lift/sling company. The DON reported she did not feel there was a breakdown in the facility process. The DON reported that staff are aware to check the hoyer lift slings each time with use and also when they are laundered. The DON reported the facility replaced four new hoyer lift slings in October or November 2023. The DON reported that she did training regarding the hoyer lifts during the facility skills fair. She added that she did spot checking and gave real time education to the staff. The DON reported when she is out and about, she didn ' t hesitate to give education in the rooms when needed. The DON reported she provided training using the electronic health record (EHR) and main dashboard as needed. She reported after another resident ' s fall she provided education to the staff about having two staff members with all transfers, having the wheelchair close by, properly placing the wheelchair, and not lifting the hoyer lift high. The DON explained they trained the staff how to use the hoyer lifts on orientation. The Nursing Assistant Skill Mechanical Lift Quarterly Audit revised January 2006 lacked direction regarding checking the slings before each use, making sure the sling is appropriate for residents, and when not to lock the brakes when utilizing the mechanical lift. On 1/9/24 at 4:42 PM, Staff B reported she entered the room after Staff A gave Resident #1 a bath. Resident #1 laid in bed, Staff A and B connected her to the hoyer lift to transfer her to the wheelchair. Staff B reported she hooked up the right side of the sling to the hoyer lift. She denied seeing any issues with the straps when she connected them. Staff B reported that she went around the bed to get the wheelchair as Staff A lifted Resident #1 up in the hoyer lift, when the strap broke, and Resident #1 fell on the floor. Staff B did not see the other side of the sling. Staff B reported if she had issues with the hoyer sling that she would give it to Staff D or to the DON. She received education every year. Everyone is always willing to help and answer any questions. Staff B reported the facility had let the staff know when a new resident is admitted , what sling they needed. On 1/10/24 at 9:15 AM Staff A reported they placed the sling under Resident #1. As the Resident #1 already had the sling in her room, Staff A didn ' t check the hoyer sling before she placed it under her. Staff A learned black is back and green is groin at the college she had attended. Staff A hooked up the top with the black loop and the bottom with the black loop. Staff A explained the bottom loop should have been on the green loop. Staff A reported that they crossed the legs of the sling. While lifting Resident #1 up in the lift, Staff B went to get the wheelchair. Staff A described Staff B ' s location as about 3 feet away. As she turned Resident #1 in the lift to place her in the wheelchair, the bottom left strap on the sling broke and Resident #1 fell to the floor. When she fell , she hit her head on the lift. When she first started at the facility she had a checklist regarding the lifts/slings and the CNA ' s showed her how to use the lifts/slings. Staff A reported that after the fall, the DON talked to her about the fall. The DON re-enacted the fall with her. On 1/10/24 at 9:42 AM the mechanical lift company ' s Safety Program Coordinator reported they could not determine the age of the sling, as no one at the facility could read the tag. She reported she received pictures of the sling from the facility and from the pictures she could tell the sling was not brand new, was used, and due to the color coming out of the green she knew they washed it, but she could not determine the age. She reported when a sling breaks it usually comes down to inspecting the sling before each use. She reported the company sends a Care Insert Page with each purchase of a sling that directs the facility to inspect the sling before each use for wear, tear, and frays. On 1/10/24 at 11:40 AM during a follow-up interview, Staff D reported the slings went to the laundry during the second and third shift. The laundry washed them and hung them to dry while inspecting them. Staff D reported that on 10/5/23 the facility had approximately 27 hoyer lift slings in the facility and at the time of the fall on 10/2/23 the facility did not have a formal audit done on the slings. Staff D reported she randomly went through the slings if needed and replaced them. Staff D reported that before she started her formal audits, the CNA ' s and laundry checked the slings. Staff D reported that after the fall on 10/2/23, she started doing formal audits of the slings and put a QAPI process in place. Staff D reported she recorded the serial numbers of the new slings and dated them in black permanent marker to help keep track of them when she put them out in 2023. On 1/10/24 at 11:40 AM observed a pile of ten slings next to Staff D ' s desk. Staff D reported the hoyer slings as questionable. Staff D showed the shower sling that had a tear near a handle. The laundry basket contained approximately 5 one-year old slings behind her that appeared in good condition. Staff D reported that she read the Hoyer lift company ' s recommendations and they recommended replacement after one year or if the sling or harness shows any sign of damage or wear. She explained the Administrator gave her recommendations. The Quality Assurance Report dated 11/9/23 indicated the first audit done on the slings. On 1/10/24 at 11:43 AM, the Hoyer Company ' s Representative reported one of their employees completed a wellness check on a Hoyer on 4/11/23. They described a wellness check as evaluating and testing the machine. She described herself as the person in charge of the safety and inspection program for the company. She reported that the facility didn ' t participate in the program. She reported the program did cost, but is optional. She reported an employee completed a wellness check on 11/9/22 that consisted of four stands and four lifts. She explained she did not have specific notes on any inservice or training provided to the facility recently. She reported there is a note that an employee did an inservice in February 2020. The facility taped that inservice and had fifteen staff members present. The Hoyer Company ' s Representative said according to the purchase history the facility purchased four large regular slings the year of 2023 (November 27). She added that the facility purchased several slings in October 2022. She reported she would send the 2022 and 2023 purchase history. The Hoyer Company Representative explained their recommendation is to replace the sling at the first sign of wear, tears, or after one year of use. She added the slings came with a six month warranty. The purchase history dated 10/21/22 listed the facility purchased fourteen slings (six medium, six large, and two extra large). On 1/10/24 at 12:50 PM Staff I reported completing the maintenance checks on the lifts bi-weekly and recorded it on a form called the Bi-Weekly Patient Lift Inspection Sheet. Staff I reported that they ordered parts through the website which is through the Hoyer lift company. They reported the last time they inspected the equipment as 12/20/23 and they planned to do it again that week. Staff I described the parts they usually ordered as more cosmetic things like the rubber green tabs for the hooks and the green/black tabs on the thumb buttons. Staff I reported that they constantly fell off even if he super glued the green tabs on the hooks due to the friction of the slings. Staff I reported that he never ran into any sharp areas. On 1/11/24 at 9:15 AM observed Staff L, CNA, and Staff M, CNA, transfer Resident #5 with a mechanical lift. They placed the mechanical lift sling under Resident #5 and connected it to the mechanical lift. Staff L put the black loop on top and the green loop on the bottom, with all four sling loops doubled looped. Staff M held Resident #5 ' s legs to help guide them to the wheelchair. Staff L turned the lift to sit Resident #5 in a wheelchair. Staff L locked the wheels on the mechanical lift while lowering the Resident #5 down into the wheelchair. Once in the wheelchair, Staff L and Staff M unhooked Resident #5 from the sling. Then Staff L unlocked the mechanical lift ' s wheels. On 1/11/24 at 10:10 AM observed Staff L and Staff N transfer Resident #6 with a mechanical lift. They placed the mechanical lift sling under Resident #6 and hooked the sling to the mechanical lift. The observation revealed all 4 loops on the black loops and doubled loops. Staff L lifted Resident #6 up in the mechanical lift sling and turned the mechanical lift towards the recliner. With Staff N next to Resident #6, they transferred them to the recliner. Staff L placed Resident #6 over the recliner and locked the wheels on the mechanical lift. Staff L lowered Resident #6 into the recliner. Once in the recliner they unhooked from the sling, and Staff L unlocked the mechanical lift wheels. On 1/11/24 at 10:15 AM Staff L reported that she had in-services on the hoyer lifts. Staff L reported that on the hoyer lifts the wheels are to be locked when raising and lowering the resident. Staff L also reported that if they had a problem with the sling that they took it to Staff D. On 1/11/24 at 10:15 AM Staff N reported that she watched an outside contracted educational video regarding the use of the hoyer lifts. Staff N said she last watched the video two years ago. Staff N also reported to lock the hoyer lift wheels, when raising and lowering the resident. Staff N added that if they found a problem with the sling that they would take it to Staff D. On 1/11/24 the observations completed on all mechanical lifts, revealed no sharp edges on the hooks and all in working order. The undated Company's Accessory Inspection Checklist instructed before operating the unit, ensure the accessory is not ripped, frayed or showing signs of wear: Check binding and loops for any fraying, wear, nicks or tears. Replace if fraying or wear is found. Check sling or harness body fabric for any rips, holes, fraying or weak spots. Hold sling up to a light, the sling must be replaced if any light shows through. Check all stitching of strap connections, for loose stitches. Check all binding stitching for loose stitches. Pull on all straps/loops in opposite directions and note if stitching becomes loose or comes apart. Remove from service if stitching tears. Check handles for loose stitches and tears. Remove from service if any found Check all straps where they attach to the sling hanger bars for wear. Remove from service if any fraying is found. The Company offered a 6 month warranty on slings and harnesses. They recommended replacing them after one year or if the sling or if the sling/harness shows any sign of damage or wear. On 1/10/24 at 2:22 PM, the Administrator provided the facility hoyer lift policy and reported the facility follows the manufacturers guidelines for each brand of lift. On 1/11/24 12:30 PM, the DON reported they expected the colors of the loops to match. The DON reported staff are informed based on resident positioning,Therapy alerts and provided demonstrations.

Based on clinical record review, hospital record review, staff and Physician interviews, the facility failed to appropriately provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review and staff interviews revealed a Physician order was obtained and transcribed incorrectly which resulted in an x-ray being completed on the wrong arm after a fall from a hoyer (mechanical) lift for 1 of 3 residents (Resident #1) reviewed for falls. Three months later it was determined the resident had a left proximal humerus fracture. The facility reported a census of 41 residents. Findings include: Resident #1 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 09, indicating moderately impaired cognition. The MDS identified Resident #1 required extensive assistance of two persons with bed mobility and toilet use. The MDS identified Resident #1 required total dependence of two persons with transfers and was unable to ambulate. The MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus, heart failure, peripheral vascular disease, and below the knee amputation of the left leg. The Care Plan with target date of 1/18/24 revealed Resident #1 needed assistance with activities of daily living related to impaired mobility from the left below the knee amputation, weakness, pain and fluctuating alertness. The care plan directed staff to use a mechanical lift with total assistance of 2 persons. The care plan also revealed Resident #1 was at risk for falls related to impaired mobility and episodes of decreased alertness. A Progress Note titled Incident Report dated on 10/2/23 at 8:20 AM revealed Resident #1 had fallen from the mechanical lift. The note revealed Resident #1 ' s left lower arm just below the elbow was light blue in color and Resident #1 moaned/cried out when left arm was moved. Resident #1 rated her pain a 7 to the left arm. (7 to 10 on numerical pain scale indicated severe pain). A Verbal Order dated 10/2/23 at 11:31 AM revealed a one time Physician order for a 2 view x-ray of the right radial/ulna and humerus due to pain and bruising. The order was confirmed by the Director of Nursing (DON) and signed by the ordering Physician on 10/2/23. The verbal order was noted by a Licensed Practical Nurse (LPN) on 10/2/23. A Hospital Diagnostic Radiology Report dated 10/2/23 revealed images of the right forearm and right humerus showed no fractures. A Progress Note titled Shift Follow Up to Incident Note dated 10/2/23 at 9:18 PM documented Resident #1 ' s left outer arm/elbow extending downwards had a light purple bruise. Resident #1 cried out in pain when the left arm was lifted up. The note documented a hard area to the left arm that measured 7 cm x 4.5 cm. The note revealed the left arm was negative for a fracture per the x-ray. A Progress Note titled Shift Follow Up to Incident Note dated 10/3/23 at 1:40 AM documented Resident #1 ' s pain was worse to the left arm than normal and the pain continued when the arm was lifted up. The note further documented the left arm was negative for a fracture per the x-ray report. A Physician Progress dated for 10/5/23 documented Resident #1 had a fall from the mechanical lift due to the sling strap breaking. The note documented Resident #1 had an injury to her left arm with significant pain. The note revealed Resident #1 also had bruising to the upper back. The note documented Resident #1 was sent for x-ray of the arm and was negative for a fracture. The note directed staff to start Melatonin 3 mg (milligrams) at bedtime for insomnia (not able to sleep), apply ice to the arm three times a day and encourage elevation until the arm was better. A Progress Note tilted 1 week Follow Up to Incident dated 10/9/23 at 10:49 AM documented Resident #1 ' s left arm continued to be sore when moved and bruised. The note revealed the anterior left forearm had a light blue/green discoloration that measured 19 cm (centimeters) (length) x 9 cm (width) and above the left elbow posterior had a faint discoloration that measured 8 cm (length) x 15 cm (width). The note also documented the left hand was edematous. A Progress Note titled Transfer to Hospital Summary dated 1/3/24 at 6:58 PM documented Resident #1 was transferred to the hospital by ambulance due to unresponsiveness. A Hospital Diagnostic Radiology Report dated 1/3/24 at 8:16 PM documented an x-ray of the left humerus was taken due to pain. The findings revealed a proximal humerus fracture at the level of the neck with callus formation. The impression documented a left proximal humerus subacute fracture with correlation for recent traumatic injury. The impression further documented an underlying pathologic lesion was not excluded. The impression suggested short term follow up radiograph to assure appropriate healing. An Emergency Department (ED) Nursing Progress Noted date 1/3/23 at 8:58 PM documented the ED received a call from Staff C, LPN who requested the left arm x-ray report. The ED note documented Staff C reported Resident #1 had a fall in October and x-rays were ordered but the x-rays were done on the right arm instead of the left arm. On 1/9/24 at 2:32 PM, Staff C, LPN reported the emergency room had called and asked if Resident #1 had fallen recently as she was diagnosed with a left proximal humerus fracture. Staff C stated Resident #1 had a fall from the hoyer lift on 10/2/23 and also a fall in November. Staff C stated x-rays were done on 10/2/23 but the right arm was x-rayed instead of the left arm. Staff C reported she called the DON regarding the fracture and the DON was in disbelief. Staff C stated she also notified the Administrator and Resident #1 ' s brother regarding the left humerus fracture and that Resident #1 was being transferred to another Hospital. On 1/9/24 at 3:30 PM, the DON reported she had received a call on the evening of 1/3/24 and was told Resident #1 had a fractured left humerus. The DON stated she did not believe it as she knew there had been x-rays completed. She stated she was the one who got the verbal order from the Physician at the clinic. The DON stated she had transcribed the verbal order into the computer incorrectly. She stated she had talked to the ordering Physician and the Physician stated that she should have caught the mistake. She stated the facility did provide ice and elevation to the left arm after the fall in October. On 1/10/24 at 8:10 AM, the Primary Care Physician (PCP) reported she was aware of the left humerus fracture from the x-ray on results on 1/3/24. The PCP stated there was a good chance that the fall from the hoyer lift in October caused the fracture. The PCP stated the callus formation documented on the x-ray meant the fracture was starting to heal. The PCP stated she was suspicious of a fracture to the left arm after the fall and was surprised the x-ray from 10-2-23 was negative. She stated she did not catch that the right arm was x-rayed instead of the left arm. She stated she should have made sure when reviewing the x-ray report the correct arm was x-rayed. On 1/11/24 at 9:26 AM, the Administrator reported the appropriate steps for taking a verbal order and carrying it out is based on the standard of care for each individual order. Depending on the order, the steps could be different.

Based on record review, resident interviews, staff interviews and policy review the facility failed to make efforts to investigate or resolve resident grievances regarding lost cell phone for 1 of 1 resident reviewed (Resident #13). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) for Resident #13 dated 5/31/23 listed diagnoses included hemiplegia (referring to right side paralysis as a result of a stroke), diabetes and heart disease. The MDS documented Resident #13 had clear speech, was usually understood. The MDS section for Brief Interview of Mental Status (BIMS) scored 15 indicated resident cognition was intact. The Care Plan revised 6/15/23 documented resident preferences, included the importance of having a phone. Noted, it important to me to be able to use a phone in private. If I receive a phone call, please assist me with privacy. I do have my own cell phone. The Care Plan also documented to please assist me by charging my phone nightly. The Progress Notes on 5/31/2023 at 1:30 PM documented by Activity Coordinator, Staff E acknowledged the missing phone. Noted, had a conversation with Resident #13 about not having funds to purchase a new cell phone at this time, but reassured him that he can make a phone call from the activities department phone anytime he would like, until a new cell phone could be purchased. On 7/17/23 at 10:56 AM Resident #13 stated my phone is gone, a few months ago staff took it to plug it into the charger and I don't know where it went, have not heard anything. Resident relayed the time and day was not displaying on the phone. I told the staff about that and they took it to plug it in and check it out, have not seen it since. Resident relayed the staff would plug the phone up in his room or usually at the nearby nurse's station. Resident relayed had made multiple staff aware that the cell phone is missing. On 7/18/23 at 4:38 PM Resident #13 reiterated the cell phone has been gone about 2 months, stated the staff charged it at the nurse's station likely because my charger was not working and that was last he saw it. Resident relayed staff alert when he gets a call and help him up to respond (requires a mechanical lift for transfers). Reported he last spoke with his wife who is long distant about two weeks ago at the main nurse's station phone, relayed family cannot always get through the main phone due to the busy lines. On 7/19/23 at 2:10 PM Certified Nurse's Assistant (CNA) Staff A relayed, yes, I am aware Resident #13 phone is missing, I believe it was lost with his room change a few months ago. On 7/19/23 at 2:15 PM CNA, Staff B relayed, I know Resident #13 did have a cell phone, I am not sure what happened to it. On 7/19/23 at 2:17 PM CNA Staff C relayed, the phone became missing right after he moved rooms, that is when it was gone. On 7/19/23 at 2:21 PM Nurse, Staff D, relayed, I recall looking through everything in his room awhile back, we have no idea where it went, I would assume it went in the garbage. Staff D acknowledged the phone was frequently charged at the nurse's station, relayed was common practice to help him manage it. Discussion followed regarding process when something is lost, Staff D relayed when something is lost it is reported to the administration, usually the DON or the Administrator. On 7/20/23 at 11:00 AM during an interview with the Administrator for discussion on quality assurance, included the grievance process overview. Administrator relayed there is a posting and a drop box at the main door, she is the grievance officer and anyone can file a grievance. As far as resident grievances, the Administrator relayed a resident can file a written grievance or staff are trained to file a grievance on behalf of residents, for instance when something is lost. Grievance folder requested for review at this time and received. On 7/20/23 at 11:15 The DON explained staff are trained to file grievances on behalf of residents at hire and reminders with additional training. The DON relayed a grievance initiates an action plan that is put in place. The completed forms are in the grievance folder. On 7/20/23 at 11:45 PM Resident #13 relayed he now has to go the nurse's station if he wants to use a phone. On 07/20/23 on 12:03 PM Administrator relayed she was not aware that Resident #13 had lost a phone. She acknowledged there is not a grievance form on file, not in the folder, nothing was submitted by any staff member related to Resident#13 loss of his cell phone. The Administrator stated it was obviously looked into since was discussed with Social Services referring to the Progress Note on 5/31/23 by Staff E. The Administrator reiterated that the admission agreement stated items brought into the facility, that the facility is not responsible for and voiced even if an item is in the possession of staff. The Administrator relayed Staff E was aware of the lost phone and as a designee she felt it was properly handled. Staff E joined and relayed the Progress Note on 5/31/23 was her investigation. Staff E acknowledged no thorough investigation or documentation of a thorough investigation as outlined in the Policy for Lost/Damaged, personal items. Policy from facility titled Lost/Damaged Personal Adaptive Devices and Other Personal Items documented the Administrator or designee is responsible for completing a thorough investigation, document the findings which should include: 1. Detailed description of what was reported, when and by whom. 2. Description of the item including appearance, make/model, age and other identifying characterizes. 3. If item is damaged, details and statements outlined. 4. If item is lost or misplaced, when and where it was last seen, by whom, what areas or locations have been searched and by whom and statements of people interviewed and whether they can corroborate the initial report. 5. If the item is alleged to have been stole or theft suspected, a record of required notification made to the policy and the survey agency. Grievance policy was explained, requested copy was not presented.

Based on clinical record review, interviews and policy review, the facility failed to ensure before and after dialysis assessments were completed for 1 of 1 resident reviewed with dialysis required (Resident #98). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] reflected resident admission to the facility, coded to reflect nursing facility admission from the hospital. The MDS dated [DATE] was in process and documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition. The Care Plan dated 7/7/23 included diagnoses of end state renal disease, heart failure, acute respiratory failure and hypertension. The Care Plan focus area on dialysis noted interventions: dialysis on Monday, Wednesday and Friday, monitor fatigue, pallor and dizziness for signs and symptoms of anemia, monitor for electrolyte imbalance by checking heartrate, nausea, vomiting and metal status changes, complete a dialysis assessment on dialysis days to ensure auscultation of thrill (refers to listening for the blood flow at the fistula (a site created surgically for dialysis access). The Care Plan noted resident has a history of clogged fistula. On 7/18/23 at 1:47 PM Registered Nurse (RN) Staff F relayed, could not locate a specific assessment for dialysis, stated only the daily skilled assessments specific to the skilled therapy was documented in residents clinical record. On 7/18/23 at 2:03 PM during interview with resident and spouse, confirmed resident had dialysis scheduled consistently while living at the facility, Monday, Wednesday, Friday last week and again yesterday, Monday 7/17/23. Resident could not recall assessments prior to leaving for dialysis or when returned back to the facility from dialysis. On 7/18/23 at 3:30 PM Director of Nursing (DON) relayed the nurses were doing skilled assessments daily but, not dialysis specific assessments. DON acknowledged the skilled assessments did not consist of evaluating resident pre and post dialysis treatment and that the skilled assessments did not evaluate resident's fistula for blood flow. The DON relayed the facility did not have a policy on dialysis. The DON supplied a copy of Centers for Medicaid Services (CMS) document titled Dialysis Critical Element Pathway, CMS 20071 dated 5-2017. The DON stated the highlighted section is used as a guide. The pathway included directions, to assess and document vital signs, include blood pressure in the arm where the access site is located, weights if ordered and communication of information between the dialysis facility prior to and after the dialysis treatments. The pathway directed visual monitoring of the access site (fistula) before and after dialysis, ongoing monitoring and care of the fistula and for dialysis related complications included bleeding, access site infection or hypotension (low blood pressure) and included documentation of specific information.

Based on interviews and record reviews, the facility failed to prevent unauthorized use of residents' personal information for 1 out of 3 residents reviewed (Resident #1). The facility employed Staff A, Social Services Designee who bought items for her personal use by using Resident #1's credit card number without Resident #1's knowledge and without Resident #1's permission. The facility reported a census of 50 residents. Findings include: A Minimum Data Set assessment dated [DATE], documented that Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and anxiety. Resident #1 had a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. This resident was independent for transfers and ambulation in her room, and required supervision of 1 for ambulation outside of her room. A Facility Self Report dated 3/27/23 at 6:22 p.m., was filed by the Director of Nursing (DON). The type of report was identified as Allegation of Abuse with approximate time and date of occurrence of 3/27/23 at 2:00 p.m. The date the facility became aware was 3/27/23. It documented that law enforcement was notified. The incident summary was documented as the following: Resident #1 noticed charges on her credit card that she didn't recall making. Resident #1 reported her and her husband were the only 2 that had physical credit cards. Resident #1 did say she had given her credit card to former employee Staff A to make purchases for her in 11/2022, but had not made or had any requests for purchases to be made since then. Further investigation details to follow. The Corrective Action was documented as a call placed to credit card fraud department. Credit card cancelled. New card will be issued to resident. The employee no longer worked at the facility. The Facility Self Report Amendment section updated on 4/6/23 at 1:51 p.m., documented that on 3/31/23 at approximately 1300 the Police Chief visited the facility with an update. The Police Chief verified that Staff A did use Resident #1's credit card information at Walmart. The Police Chief reported he would be contacting Staff A to come to the police department and if she did not do willingly, a warrant would be issued for her arrest. A State of Iowa vs (Staff A) police report dated on 4/25/23, documented the description of the crime as unauthorized use of a credit card over $1500 and under $10,000. It documented this crime was a Felony D. It documented the range of the crime dates were from 12/2/22 to 2/14/23. The narrative was written that on or about the above stated date and time, the defendant did use a credit card to obtain property or services, valued in excess of $1,500 but not in excess of $10,000, knowing that the credit card was stolen, forged, revoked, canceled or otherwise used without authorization. (Staff A) made 22 fraudulent charges on (Resident #1's) credit card for a total amount of $3,691.26. On 4/26/23 at 11:11 a.m., Resident #1, when asked about the fraudulent charges on her credit card, stated that when she moved into the facility she was trying to acclimate to living at the facility and Staff A, Social Services Designee, was really nice to Resident #1. When asked what Staff A's position was, Resident #1 stated that Staff A was a Social Worker. Staff A talked about going to church and her church life. Resident #1 stated she had talked to Staff A about wanting a refrigerator and a big screen TV. It was around Black Friday and Staff A stated they had real good deals on both. Staff A had told Resident #1 that the refrigerator was only about $200. The refrigerator seen at the time of the interview was the size of a college dorm room refrigerator. Resident #1 gave Staff A her credit card to purchase the items. Resident #1 stated they (Resident #1 and her husband) did not order on line and they did not have a car, so they did not go to Walmart. Resident #1 stated that she told Staff A that Resident #1 had noticed charges on her credit card after the TV and refrigerator were purchased that Resident #1 nor her husband had made. Resident #1 stated that Staff A told Resident #1 that Staff A had talked to some Indian guy. Staff A said they were going to get it all figured out and Staff A told Resident #1 not to worry about it. Resident #1 stated after that there were more and more changes. Resident #1 stated she was so god damn mad at herself that she fell for this. Resident #1 stated she was so embarrassed and then she cried about the situation and then Resident #1 really got mad at Staff A. Resident #1 stated it was almost like having a death and going through the grieving process. Resident #1 stated they hardly used their credit card throughout their lives. Resident #1 stated they usually pay with cash so that they did not have any bills. Resident #1 stated they cancelled their cards then got new ones. Resident #1 stated that Staff A told her that the charges from Amazon were on the wrong account, those charges were supposed to be on another account. Resident #1 stated that Staff A bought the TV and the refrigerator and put the information in a folder but Staff A never brought the folder to Resident #1 and Staff A never showed Resident #1 the receipts. Resident #1 stated she wanted to see the manufacturer's guidelines and Staff A just kept saying that she would keep everything safe in a folder in her office, but Staff A would not ever show the information from those purchases to Resident #1. Resident #1 stated she was not for sure how the facility found out about the fraud. She stated that the Director of Nursing had been really helpful since the facility became aware. Resident #1 stated she gives all her stuff to the Director of Nursing since then. Resident #1 stated their town's Police Chief talked to Staff A and he told Resident #1 that Staff A either needed to turn herself in or they would put out a warrant for her arrest. Resident #1 stated that Staff A had been charged now. Resident #1 stated the funny thing was that Staff A had another job in another town. Resident #1 stated she worried about Staff A taking advantage of other people. Resident #1 stated she would like to punch Staff A in the face. Resident #1 stated they had always been so careful with their money and credit card use. On 5/1/23 at 3:45 p.m., Resident #1's husband stated he too did not think Staff A would have done something like this. He stated he was pretty upset about it but was glad it was getting taken care of. He stated they both have credit cards and he would have trusted her with his card too. He did not have anything further to say about it. On 4/25/23 at 11:45 a.m., the Administrator stated there was some falsification on Staff A's part upon hire. The Administrator stated that Staff A had told them she was a Social Worker, and they found out that Staff A was not licensed as a Social Worker, after this incident came to light. On 4/25/23 at 1:45 p.m., the Administrator provided the police report along with pictures of Staff A and her car at Walmart along with the receipts. The Administrator stated that the Police Chief stated the receipts were only from Walmart, he had not gotten the Amazon receipts, but there was enough to charge Staff A with what he had from Walmart. On 4/26/23 at 11:35 a.m., the Administrator stated that Resident #1 had requested to speak with the new Social Worker (Staff B). The Administrator stated before this the Social Worker (SW) nor anyone else at the facility had heard about the fraudulent charges. The Administrator stated they investigated a little further than immediately called the police and notified DIA (Department of Inspections and Appeals). The Administrator stated they requested the following day that the Chief of Police do the investigation. On 4/26/23 at 12:22 p.m., Staff B stated she had started at the end of February. Staff B had gotten a message that Resident #1 wanted to talk with Staff B. Resident #1 had a stack of bills (money owed) and she was confused about what to do with them. Resident #1 brought Staff B a stack of bills and said none of these charges were Resident #1's. Resident #1 told Staff B that Resident #1 had given her credit card to the person in Staff B's position before Staff B went into that position. Resident #1 identified that person as Staff A. Staff B stated Resident #1 gave Staff A the credit card to make a couple of purchases, including a TV. Staff B stated Resident #1 had said she had not used her credit card since. Staff B stated the resident said she did not use Amazon and she did not shop on line. Staff B stated this resident said she had paid off her credit card in full and did not feel she had used the credit card since. Staff B stated she then took the credit card into the Administrator and then the DON had at some point also went in and talked to Resident #1. Staff B stated the DON then did the mandatory report for suspicion of financial exploitation to DIA and contacted the police. Staff B did not remember what the date was. She stated that the Administrator and the DON had really been the ones to deal with it. Staff B stated she had gone to Resident #1 a couple of times to see how she was doing. One of the times Staff B talked to Resident #1, Resident #1 told Staff B that she still had a balance. Staff B stated she then went to the Administrator, and the Administrator affirmed that they were working with Amazon. Staff B stated that the Administrator said there was a hiccup with Amazon and they were still working through that so Amazon could reimburse this resident. Staff B stated that Resident #1 told Staff B that she (Resident #1) had been taken aback and was shocked about Staff A using her credit card. Resident #1 told Staff B that she (Resident #1) thought she could trust Staff A and obviously she couldn't. Resident #1 had stated that she wished that it could be resolved faster than it had been as far as getting reimbursed. The Amazon charges were still on the bill and that bothered Resident #1. Staff B stated that Resident #1 had said she was not used to carrying a balance. Staff B stated she didn't know if Resident #1 had paid for any fee charges before this incident. On 4/27/23 at 12:57 p.m., the Administrator stated a resident heard this morning on the local radio station while he was going to or was at dialysis that Staff A's name was mentioned on a local radio station regarding financial exploitation. When asked about the Amazon charges, the Administrator stated she was assisting Resident #1 with getting all charges removed, including the fees. The Administrator stated Amazon could not give them information regarding what was ordered as Resident #1 or the facility's name were not on the account. Amazon could only give information to the account holder. On 5/1/23 at 10:45 a.m, the Chief of Police stated that Staff A refused to be interviewed. He stated she lived in a nearby town. He stated he left her a message and about an hour later he received a call from Staff A's lawyer. The Chief of Police stated that during the conversations with the attorney, the attorney asked if Staff A could just pay the money back. The Chief of Police stated he told the attorney if Staff A didn't come in to the station, he would put a warrant out for her arrest. The Chief of Police stated Staff A then ended up turning herself in. He stated when she came in to the police department, she wouldn't talk but she turned herself in to be charged. When asked about the Amazon charges, he stated the charges were the same time frame and some are on the same days as the Walmart purchases. The Chief of Police stated he obtained photos from Walmart showing Staff A's vehicle driving into the Walmart's parking lot and walking into Walmart on the days and times that lined up with the purchases Resident #1 was disputing. The Chief of Police stated the following: Staff A -was obviously the one who was picking the items up from Walmart. -had the card number not the card. -was purchasing products all online, both from Walmart and from Amazon. -was doing in store pick up at Walmart. -was getting the purchases directly delivered from Amazon. The Chief of Police stated he could prove the Walmart purchases, but it was more difficult to prove the Amazon charges. He stated that after this incident happened, they have had a call come in to their department that a family member's father's wallet went missing and Staff A was taking care of him. He stated the family member reported it happened in 2021. On 5/1/23 at 1:09 p.m., when asked about the above police report, the DON stated that she never thought that that Staff A would ever do anything like that and that it was pretty shocking. When asked why Staff A left employment, the DON stated that Staff A had gotten hurt outside of the facility and then she was going to have to come back with some pretty significant lifting restrictions. The DON stated the office was trying to get more information from Staff A's physician regarding the workman's compensation. The DON stated the documents the office was receiving did not seem legit. The DON stated then Staff A just never came back. The DON stated she found out about the fraud when Staff B came up to the front office with a stack of credit card statements. The DON took the credit card statements and told Staff B that they needed to call the fraud department right away. The DON stated she called the fraud department and Resident #1 was there during the call. The DON stated that the person from the fraud department said that she was going to start a case file. The person from the fraud department called back and stated that it was site to store pickup. The DON stated that Staff A was the only other person who had possession of the card and the ability to call (Walmart) and to pick up (the items purchased). The DON stated she then called the police department the same day she called the fraud department. The DON also reported to DIA on the same day. They sent an officer out that night at 5 p.m. and then the next day the facility called and talked to the Chief of Police. The DON stated the Chief of Police came back a few days later and he had pictures from Walmart with Staff A in the pictures at the time the pick-ups from Walmart were made. The DON stated that Resident #1 did not think it would have been Staff A who made the purchase. The DON stated that Resident #1 could not believe it at first and then Resident #1 became angry. The DON believed that it was determined that she didn't physically have the card when the purchases were made, that Staff A must have written down the card information, because Staff A had purchased a refrigerator, a TV and some dog items for Resident #1 and then gave the card back to Resident #1. The DON said that Resident #1 stated she had talked to Staff A about the credit card bills kept coming in and Resident #1 didn't understand and Staff A told Resident #1 that it just took a while for the charges to fall off. The DON stated that Resident #1 didn't know what Amazon even was. A Mandatory Reporting of Dependent Adult Abuse, Crimes and Other Notifications policy dated 4/3/17, directed staff members and employees in their facilities and assisted living programs will make every effort to insure that reasonable suspicions of dependent adult abuse and other required notifications are reported within the timeframes established by law and administrative rules. This policy defined caretaker within a Nursing Facility/Skilled Nursing Facility NF/SNF meant a person who is or was a staff member of a facility who provides or provided care, protection or services to a dependent adult voluntarily, by contract, through employment or be order of the court. This policy defined a dependent adult as a person eighteen years of age or older whose ability to perform the normal activities of daily living or to provide for the person's own care or protection is impaired, temporarily or permanently. This policy defined dependent adult abuse as any of the following because of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances: 7) Exploitation (named as one of the types of abuse) of a dependent adult which meant a caretaker knowingly obtaining, using, or trying to obtain to use, or who misappropriates, a dependent adult's funds, assets, medications or property with the intent to temporarily or permanently deprive the dependent adult of the use, benefit, or possession of the funds, assets, medication, or property for the benefit of someone other than the dependent adult.

Based on record review and interviews, the facility failed to put a stop date on an as needed (PRN) [CONDITION(S)] medication for 1 of 5 residents, (Resident #29) reviewed. Resident #29 had an as needed [MEDICATION(S)] ([MEDICATION(S)])(anti-anxiety medication) ordered in 3/2021 and discontinued in 7/2021 without a 14 day stop date and without supportive rationale from the prescribing practitioner. The facility had a census of 48. Findings include: A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #29 included [CONDITION(S)] and dysthymic disorder. The Brief Interview for Mental Status revealed a score of 15 out of 15 indicating this resident's cognition was intact. The resident required assist of 2 for bed mobility, transfer and dressing. A Doctor's Order directed staff to administer [MEDICATION(S)] Tablet 2 MG (milligrams) 1 tablet via G-Tube every 8 hours as needed for [CONDITION(S)]/agitation related to stiffness of unspecified joint, muscle spasm and restlessness and agitation. The order was started on 3/16/21 and was discontinued on 7/8/21. A Medication Administration Record for the 4/2021, documented that PRN [MEDICATION(S)] was given 4 times in that month. Pharmacy Review Assessments dated 4/26/21, 5/18/21, 6/14/21, and 7/12/21 did not address the PRN usage of [MEDICATION(S)]. On 2/2/22 at 3:51 PM, the Director of Nursing (DON) stated she would check with their ARNP provider as she felt the ARNP had addressed this. The DON returned and reported it was not addressed and concurred it should not have been ordered for more than 14 days without documented provider rationale. On 2/3/22 at 10:54 AM, the Consulting Pharmacist stated a recommendation to stop PRN [MEDICATION(S)] after 14 days or a recommendation for the provider to give rationale to continue for more than 14 days should absolutely have been made when the monthly review assessments were done. He stated if it is not in the electronic health record, then it was not done. The facility was unable to provide supporting documentation that recommendations were given from the pharmacist nor that supportive rationale was given from the provider for this PRN [MEDICATION(S)] to be ordered for more than 14 days. A Documentation and Communication of Consultant Pharmacist Recommendations policy dated 11/28/17, directed the consultant pharmacist documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for prescirber. It directed comments and recommendations concerning medication therapy were to be communicated in a timely fashion. In the event of of an irregularity requiring the immediate attention of the prescriber, the responsible physician or physician's designee is contacted by the consultant pharmacist or the facility and the prescriber's response is documented in the resident's record. It directed that the physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.

Based on clinical record review, observation, staff interview and policy review, the facility failed to update and revise 1 of 12 residents care plans reviewed, (Resident #8). The facility reports a census of 48 residents. Finding Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 entered the facility on 2/3/21. Resident #8's MDS indicated severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 2 and active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS was coded as receiving antianxiety and antidepressant medications. Progress Notes indicated the following need for [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 10/22/21 at 1:08 PM, Resident #8 was up wandering most of the shift. Walked into others rooms. Sat down for meals. Her interactions consisted of her saying the word salad when spoken to. 2. On 10/30/21 at 5:31 AM, Resident #8 stated she could hear someone yelling loudly and wanted to help them. Taken back to her room. Resident was upset by the yelling. Resident was put back to bed after being helped in the bathroom. 3. On 11/1/21 at 1:04 PM, Resident #8 was seen by Advanced Registered Nurse Practitioner (ARNP) related to her behaviors. Orders received to discontinue [MEDICATION(S)] and [MEDICATION(S)]. New orders were received for [MEDICATION(S)] and [MEDICATION(S)] increase. Family was notified and approved. 4. On 11/1/21 at 9:45 PM, Resident #8 was noted to be more anxious and talked about working and cleaning. Resident did sleep briefly in her chair otherwise was awake and restless. 5. On 11/2/21 at 5:11 AM, Resident #8 was more confused tonight. Hard to redirect resident. Resident needed bed changed and to be cleaned up. Word salad spoken and unable to understand what is being said. 6. On 11/2/21 at 9:26 PM, Resident #8 has been calmer this shift, not as restless and not going into other residents rooms. 7. On 11/3/21 at 5:03 PM, a Quarterly Assessment by the Social Worker stated resident has had signs and symptoms of behaviors noted during the assessment including wandering and restlessness. Resident #8's medications have recently been changed to [MEDICATION(S)] and [MEDICATION(S)] for signs and symptoms related to dementia related behaviors. Resident was awake in room in the bathroom looking through her garbage. 8. On 12/2/21 at 12:31 PM, Resident #8 was seen by ARNP related to her wandering, rummaging through the garbage, restlessness and crying. Received new orders for [MEDICATION(S)]. Family notified and agreed to medication change stating do what you need to do to keep her comfortable. 9. On 12/3/21 at 9:46 PM, Resident #8 was very busy all shift trying to help residents, going into other rooms and not easily redirected. Resident remained in own room after getting the [MEDICATION(S)] but not sleeping. 10. On 12/4/21 at 2:33 AM, Resident #8 has been walking down south hall non-stop and not easily redirected. Resident was sitting in south nurses station for approximately 30 minutes working on a crossword puzzle. Resident then went back to her room and was pacing inside her room non-stop. Stating she needed to get work done. 11. On 12/11/21 at 9:45 PM, Resident #8 was very busy this shift, following staff into other resident's rooms and into the nurses station. She was also rummaging through garbage, picking up small pieces of trash off the floor. Pleasant but unable to redirect. 12. On 12/12/21 at 8:53 PM, Resident #8 was found smearing strawberry ice cream on one of the staff laptops. She had a bowel movement, removed the soiled briefs and was found shredding them and stuffing them into the toilet. She has been looking in drawers, opening doors, picking up garbage off the ground and staying very busy. 13. On 1/4/21 at 9:24 PM, Resident #8 has been wandering ceaselessly this shift. She has gone into multiple other resident rooms and the nurses station and was trying to interact with other resident's while they were eating. Resident has been very difficult to redirect at times, physically pushing staff away and adamant in her tasks. Resident did sit with staff towards the end of the shift for about 5 minutes but kept busy by moving papers. 14. On 1/8/21 at 3:40 AM, Resident #8 has been up the entire shift rummaging through things in her room and wandering into other resident's rooms. Resident difficult to redirect. Certified Nurse's Assistant (CNA) assisted her to bed and within minutes she was back up and wandering and rummaging. Resident #8's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 15 milligrams (MG) tablet - 1 tablet by mouth one time a day for anxiety, wandering, and little sleep related to dementia with behavioral disturbance (start date of 11/1/21). 2. [MEDICATION(S)] HCL 25 MG tablet - 1 tablet by mouth one time a day for anxiety and wandering related to generalized anxiety disorder (start date of 11/1/21.) 3. [MEDICATION(S)] 0.25 MG tablet - 1 tablet by mouth two times a day for agitation, delusions, and crying related to dementia with behavioral disturbance (start date of 12/2/21). In an observation on 1/31/22 at 1:35 PM, Resident #8 was seated in a chair at the nurses station outside her room with a surgical mask on. She was interacting with staff in the area. Resident had a wander guard bracelet on her right wrist. In an observation on 1/31/22 at 1:54 PM, Resident #8 was noted to get up from chair at the nurses station and ambulate to her room independently. In an interview on 2/3/22 at 10:35 AM, the Director of Nursing (DON) acknowledged that when a resident is put on a [CONDITION(S)] medication it should be addressed on the Care Plan. In an interview on 2/3/22 at 12:09 PM, the DON stated they do not have a specific policy for care planning. They follow the Resident Assessment Instrument (RAI) manual for direction.

Based on clinical record review, staff and family interviews and observation, the facility failed to appropriately supervise one of five sampled (Resident #57) who fell from a lift chair and sustained cervical and left orbital fractures. The facility reported a census of 58 residents. Findings include: According to Minimum (MDS) data set [DATE] Resident #57 had severely impaired cognitive skills for daily decision making, required extensive assistance of two staff to transfer, had frequent bowel and bladder incontinence and [DIAGNOSES REDACTED]. The resident had one fall without injury. The MDS dated [DATE] revealed the resident transferred to acute hospital, long and short term memory impairment, delusions and one fall with no injury and one with a major injury. The Care Plan revealed Resident #57 had a risk for falls and directed the staff to ensure call light within reach, encourage to use call light for assistance, throws call light off my chest, explain importance of having call light within reach and remind me to use it. The Care Plan updated 5/4/19 directed the staff to use a total mechanical lift for transfers. The Care Plan updated 9/27/19 revealed Resident #57 elevated in the lift chair which caused her to slide out of the chair. Resident #57's family requested to allow Resident #57 independence with controls to the lift chair. The Care Plan updated 9/29/19 directed the staff to place dycem in wheelchair and recliner. The Care Plan updated on 10/8/19 revealed a plan to provide a manual recliner upon return to the nursing facility. Review of the Incident Report dated 7/4/19 1:45 a.m., revealed the staff found Resident #57 on the floor, sitting on her buttocks with both legs extended. Resident #57 fell out of recliner. No injuries noted at this time. All interventions in place. At 2:10 p.m., Resident #57 admitted to hospital with a urinary tract infection [MEDICAL CONDITION]. Review of the Incident Report dated 9/27/19 at 12:40 a.m., revealed the staff summoned Staff I (Licensed Practical Nurse) to Resident #57's room. Staff I observed Resident #57 seated on the floor with her back and head against the cushion of the recliner. Head noted in full upright position. Chair also noted in full upright position. No injury noted, skin intact. Range of motion normal and no concerns voiced. Placed in bed for comfort. Family to be notified in morning due to late hour. Review of the Incident Report dated 10/5/19 at 8:40 p.m., Staff H (Licensed Practical Nurse) heard someone yelling. Staff H investigated and found the lights off and Resident #57 face down on the floor in front of the recliner. Staff H noticed a pool of blood under Resident #57's head and a laceration on her forehead. Resident #57 transferred to the emergency room . The Progress Note dated 10/17/19 revealed Resident #57 returned to the facility wearing a Philly Collar and unable to move neck due to cervical fracture. The Progress Note dated 10/23/2019 documented Resident #57 hospitalized for [REDACTED]. Resident #57 had the stitches removed from her face today. Resident #57 finds the neck brace difficult to adjust and served soft foods. A Late Entry at 10:28 p.m., revealed Resident #57 removed the Philly collar and found on the floor by the bed. The staff noticed the foam inserts removed from the collar numerous times in the night. The Progress Note dated 10/31/19 revealed Resident #57 started on puree diet and refused to open mouth to eat. The Progress Note dated 11/2/19 revealed Resident #57's family visited and inform of not eating or drinking well. Resident #57 passed away on 11/4/19 at 2:35 a.m. The History and Physical dated 10/6/19 included: Patient sent from nursing home after he/she sustained a fall. Patient was sitting in a chair and got up by self, lost balance and fell . Patient was sitting in a chair and got up by self, lost balance and fell on face. Patient was taken to emergency room and is on [MEDICATION NAME]. Neurosurgeon was called and recommended a C-collar. CT spine showed left posterior arch C 1 and C 2 transfers process fracture and oblique fracture of odontoid extending into the base posterior. The History and Physical also documented the resident had a left orbital floor fracture. The Death Record signed by the physician on 11/5/19 included: Principal Cause of Death - [MEDICAL CONDITION] with dementia leading to fall. Additional contributing causes of death if any - C-1 fracture. During an interview on 12/4/19 at 7:30 a.m., Staff A (Director of Nursing) reported the facility had no particular lift chair policy, they reviewed residents case by case, therapy evaluates residents and would have brought it to the facility's attention if they felt the chair was not safe. On 9/27/19 when the resident fell , the case was discussed with family member. Staff noted the lift chair in the upright position and the resident slid out with no injury. The family member wanted to make sure the resident still had access to the remote. The facility has guidance as to what is considered a restraint. If the resident was up ad-lib, and they took away the remote, it would be considered a restraint. On 10/5/19 when the resident fell , the spouse had just left. Since January, 2019 the resident had three falls; 7/19, 9/19 and 10/19. The (MONTH) and (MONTH) fall reports indicated the resident had the call light within reach but not activated. When the resident fell on (MONTH) 27, 2019 the family member wanted the resident to have access to the remote. The (MONTH) 5 fall resulted in a cervical fracture and the resident wore a C-collar, received Occupational Therapy and Speech Therapy upon return to the facility and had to be assisted in the dining room. The resident stopped eating, received Hospice services and passed away. Staff A was interviewed again on 12/4/19 at 3:15 p.m., along with Staff B (Corporate Nurse). In January, 2019 the family member asked the facility to remove the bed from the resident's room due to non-use. Physical Therapy assessed the resident for transfer assistance in May, 2019. In (MONTH) the resident slid out of the lift chair, the husband sat with the resident throughout the majority of the time, and the facility provided frequent checks. The resident knew how to make her needs known, could pick out clothes. If a chair prevented a resident from rising, that would be considered a restraint. The resident would get angry if staff took away the remote, he/she wanted to be in control of it. The resident's falls from the lift chair occurred after the spouse had left. The resident thought he/she could walk and did not want to wait for staff assistance. During an interview on 12/4/2019 at 8:00 a.m., Staff C (Co-Director of Nursing) revealed Staff C (Licensed Practical Nurse) discussed options with the family member after the (MONTH) fall. The resident had room changes, the last room had high hall traffic and staff checked on the resident frequently. The resident often yelled at staff as they walked by if he/she wanted assistance. The resident received psych services to assist with dealing with loss of independence. The resident's BIMS score did not give an accurate reflection of the cognitive status as the resident refused to answer questions. The resident refused to cooperate with therapy. During an interview on 12/4/19 at 4:00 p.m., Staff D (Care Plan Coordinator) reported when the resident readmitted after the 10/5/2019 fall, Staff D and the resident's family member went around the facility and found a suitable chair. They found a push back recliner without a lever. The resident did not have enough strength to raise or lower it without staff assistance. The resident slept in the bed after that fall. During an interview on 12/4/19 at 10:00 a.m., Staff [NAME] (Occupational Therapy) revealed every room is equipped with a recliner or lift chair. Staff [NAME] knew the resident a number of years. Therapy tends to look at the lift chair operation/control if the resident is going to be more independent. When residents admit to skilled, therapy screens and evaluates them for safe transfers and what their goal is. If they have a lift chair at home, they would work towards the goal of being able to return to that. The resident had a gradual decline due to [MEDICAL CONDITION]. He/she had a lot of pain due to arthritis, the lift chair provided comfort and the resident required staff assistance for positioning. The resident was not realistic, demanded her husband help her and had a lot of barriers with [MEDICAL CONDITION]. The resident frustrated easily and did not want to work on walking. They had no lift chair policy, it depended on goals and abilities. The facility has since discussed the possibility of doing a screen. No staff or family reported a concern regarding the lift chair. Staff [NAME] indicated in (MONTH) the resident could utilize the call light and lift chair remote. The resident also called out for help and the spouse sat with him/her most of the day. During an interview on 12/4/19 at 9:30 a.m., Staff F (Minimum Data Set Coordinator) revealed the resident's family member frequently visited. The resident often refused therapies, had falls and frequent non-compliance. The resident could put the call light on and they had signs in the room reminding her. Staff did frequent checks. When a resident admits, if they have a lift chair in the room, they show them how to use it. They do not have a formal assessment tool. Staff F observed the resident raising the chair up and would remind him/her not to. The resident had Dycem in the chair and would call out for help. Initially the resident's spouse attempted to help the resident and wanted the resident to return to assisted living. During an interview on 12/4/19 at 9:00 a.m., Staff G (Registered Nurse) reported speaking to the family member after the resident fell on [DATE]. Staff G indicated she asked family if they wanted the resident to have the chair. The family member indicated he/she was fine with the resident keeping the lift chair. The resident could use the call light, the husband spent the entire day with the resident. Staff G had observed the resident raise the chair up late one night. The resident could make needs known. Staff G failed to recall if she discussed putting the remote out of reach, though it would be considered a restraint. Staff G did discuss whether the resident should keep the chair with the family member. During an interview on 12/4/2019 at 1:50 p.m., Staff H (Licensed Practical Nurse) reported working on 10/5/19 when the resident fell from the lift chair. Staff H observed the resident's spouse leave the facility at approximately 8:30 p.m. The spouse did not indicate the resident needed any assistance. Approximately ten minutes later, the resident screamed for help. Staff H failed to recall if the call light had been activated and had seen the resident prior between 7:00 p.m. and 8:00 p.m., during medication pass. Anytime Staff H observed the resident raise the lift chair, she would remind and educate her. The majority of the time the resident's spouse sat with the resident and failed to remind the resident not to raise it up. Staff had discussed the resident's lift chair in nurse to nurse report. The resident's memory had declined over the last few months. When Staff H called the family member to report the fall, she asked if the resident had the remote. Staff H told the family member the resident had the remote because it would be considered a restraint to place it out of reach. During an interview on 12/4/19 at 3:45 p.m., Staff I (Licensed Practical Nurse) reported working on 9/27/19 when the resident fell from the lift chair. The resident raised the chair in the upright position and slid out onto his/her buttocks. A Nurse Aide found the resident on the floor. The resident had a Dycem in the chair and had no injury. Staff I indicated her intervention was to remove the remote from reach. Staff I did not call the family as the fall occurred late at night, the resident had no injury, therefore day shift staff notified the family. Staff I did observe the resident raise the chair on another occasion. During an interview on 12/4/2019 at 11:10 a.m., Staff J (Registered Nurse) reported the resident progressively declined during her stay. The resident refused cares, yelled at family and staff and progressive dementia. Staff J did observe the resident raise lift chair up. Staff would educate the resident and the spouse. Sometimes the spouse would notify staff that the resident had raised the chair up. Staff J indicated any chair would have been unsafe, she needed to raise her feet up due to bad circulation. The resident had been on fifteen minute checks and then had fewer attempts to get up unassisted. CNA's did report the resident did put his/her chair up. Staff J thought the resident knew she was not supposed to stand. The resident also had a custom wheel chair and had no falls from it. Staff educated and reminded the resident and spouse not to get up unassisted. Family was okay with the resident having the lift chair and the remote. The resident would not have been able to use the lever on a manual recliner. When the resident returned to the facility after the last fall, they found a manual recliner that the resident could lower the foot rest using his/her legs. During an interview on 12/4/19 at 11:30 a.m , Staff K (Nurse Aide) reported working on 10/5/19 when the resident fell from the lift chair. The resident's spouse had left about ten minutes prior. Staff K did occasionally observe the resident raise the lift chair and at times the spouse was present. Staff K reported it to the charge nurse. The resident knew she required assistance but wanted to be independent. Staff checked on the resident frequently. During an interview on 12/4/19 at 1:15 p.m , Staff L (Nurse Aide) reported the resident admitted to the facility and required assistance of one to transfer and ambulate. During the resident's stay the resident declined and progressed to an E-Z stand and in the end, she required a Hoyer lift to transfer. The resident thought she could do things on his/her own, was non-compliant with using the call light or waiting for assistance. The resident slept in the lift chair and could make her needs known. At times the resident screamed for help. Staff had to keep an eye on the resident; she would raise the lift chair way up and wanted to get up to breathe easier. Staff discussed putting the remote out of reach; the spouse would give the remote to the resident and would have given the resident anything. The resident yelled at the spouse and staff if they did not give her what she wanted. The chair would not have been considered a restraint if the resident cannot walk independently. During an interview on 12/4/19 at 2:30 p.m , Staff M (Nurse Aide) worked on 10/5/19 when the resident had her last fall from the lift chair. The nurse summoned staff to the room and Staff M responded. Staff M did at times observe the resident attempt to raise the chair up. Staff checked on the resident frequently, they walked by and kept the room door open. The resident preferred sleeping in the lift chair. Staff M indicated they provided incontinence cares after supper and then transferred the resident to the lift chair. Typically, they would check and change the resident again at approximately 9:00 p.m. after the spouse left for the night. Staff knew the resident raised the lift chair and rarely used the call light. During an interview on 12/4/19 at 2:40 p.m., Resident #57's family member reported the resident used the lift chair for quite some time, and the facility provided the chair. The resident preferred sleeping in the lift chair. The last couple of years at the facility the resident became less mobile and had refused therapy at times. The end of (MONTH) the resident had a fall from the lift chair due to raising the chair up. After that fall the family member asked staff if they could put the remote in the side pocket, and staff indicated that would be considered a restraint. He/she then asked if the resident could have a manual recliner and was told that would be considered a restraint since the resident would not be able to raise or lower the foot rest. There were times when family visited when the resident raised the chair up and the family had to remind the resident not to. The resident enjoyed the lift chair but they never offered the resident a safer alternative. The resident had dementia, and the family member did not think the resident knew the risk. They had discussed the chair at some point, most likely a care conference, and facility's solution was to have staff do frequent checks. During an interview on 12/4/19 at 12:50 p.m., Resident #57's spouse reported the resident sustained [REDACTED]. The spouse visited every day and stayed most of the day until approximately 8:00 p.m. The last fall occurred approximately 10 minutes after the spouse left for the night. The resident fell from the lift chair and had fractured vertebrae. The spouse told the facility to get rid of the lift chair. The facility Physical Restraint Usage policy included each resident will attain and maintain the highest practicable well-being in an environment that prohibits the use of physical restraints unless warranted by medical symptoms. The Procedure described a physical restraint as any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts the freedom of movement or normal access to one's body. Physical restraints include but are not limited to placing a resident in a chair that prevents them from rising.

Based on observation, record review and staff interview the facility failed to assess and obtain informed consent for the use of bed rails, specifically grab bars, for 14 of 17 residents reviewed in the final sample (Resident #2, 11, 14, 18, 19, 20, 24, 42, 44, 56, 58, 166 and 266). The facility reported a census of 66. Findings include: 1. The MDS (Minimum Data Set) assessment tool, dated 1/30/2019, listed [DIAGNOSES REDACTED]. The MDS stated the resident independent for bed mobility and transfer. The MDS documented the residents BIMS (Brief Interview for Mental Status) as 13 out of 15, indicating intact cognition. A care plan, dated as revised on 10/25/18, directed grab bars on bed to help the resident get out of bed safely. Observation on 2/18/19 at 11:51 AM, revealed grab bars attached to Resident #18's bed, with call light attached to rail. The resident confirmed utilized bed rails for repositioning, The Facility failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #18. 2. The MDS assessment tool, dated 12/17/2018, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of two staff for bed mobility and transfer. The MDS documented the residents BIMS as 14 out of 15, indicating intact cognition. A care plan, dated as revised on 12/08/18, directed grab bars on bed to help the resident get out of bed safely. Observation on 2/18/19 at 10:10 AM, revealed grab bars attached to Resident #27's bed. The Facility failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails. 3. The MDS assessment tool, dated 1/02/2019, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of two staff for bed mobility and transfer. The MDS documented the residents BIMS as 15 out of 15, indicating intact cognition. A care plan, dated as revised on 8/14/14, directed grab bars on bed to help the resident get out of bed safely. Observation on 2/19/19 at 9:38 AM, revealed grab bars attached to Resident #44's bed. The Facility failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #44. 4. The MDS assessment tool, dated 1/23/2019, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of two staff for bed mobility and total dependence on two staff for transfer. The MDS documented the residents BIMS as 4 out of 15, indicating severe cognitive impairment. A care plan, dated as revised on 10/11/18, failed to direct the use of grab bars. Observation on 2/19/19 03:00 PM, revealed grab bars attached to Resident #58's bed. The Facility failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #58. In an interview on 2/19/19 at 3:50 PM, the ABCM Nurse Consultant stated the facility unable to provide documentation of assessment or consent for grab bar for Resident's #2, 11, 14, 18, 19, 20, 24, 42, 44, 56, 58, 166 and 266. The Nurse Consultant further stated being aware of the regulation that required the facility to complete an assessment and obtain consent for grab rails and explained the corporation had begun to revise the policy and assessment forms. In the same interview Co-Directors of Nursing, Staff A and Staff B, confirmed the facility had failed to complete assessment or obtain consent for residents with grab bars attached to their beds, 5. The MDS (Minimum Data Set) assessment tool, dated 11/14/18, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of two staff for bed mobility, transfer, dressing and toilet use. The MDS documented the residents BIMS (Brief Interview for Mental Status) as 7 out of 15, indicating cognitive impairment. A care plan, dated as initiated on 5/07/18, indicated that grab bars were used on both sides of the bed to assist with transfers and bed mobility. Observation on 2/19/19 at 3:30 PM, revealed that grab rails were attached to the bed frame in the upright position. The Facility failed to provide an assessment for the use of the grab rails, and failed to provide documentation of informed consent for use of grab rails. 6. The MDS assessment tool, dated 1/2/19, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance for toilet use and one person assist for dressing. The MDS documented the residents BIMS as 15 out of 15, indicating no cognitive impairment. A care plan, dated as initiated on 2/18/19 indicated that grab bars on bed are used. Observation on 2/19/19 at 3:31 PM revealed the grab rail attached to the resident's bed and in the upright position. The Facility failed to provide an assessment for the use of the grab rails, and failed to provide documentation of informed consent for the use of the grab rails. 7. The MDS assessment tool, dated 11/14/18 listed [DIAGNOSES REDACTED]. The MDS stated that the resident required extensive assistance for bed mobility, personal hygiene, and dressing. The MDS documented the resident was not able to complete the BIMS test which indicated severe cognitive impairment. A care plan, dated as initiated on 2/14/17 indicated that grab bars were used on two sides of the bed. Observation on 2/19/19 at 3:35 PM revealed grab rails attached to the resident's bed and in the upright position. The Facility failed to provide an assessment for the use of the grab rails, and failed to provide documentation of informed consent for the use of the grab rails. 8. The MDS assessment tool, dated 2/12/19 listed [DIAGNOSES REDACTED]. The MDS stated that the resident required extensive assistance for bed mobility, transfer, and personal hygiene. The MDS documented the resident BIMS score was 12 which indicated moderately impaired cognition. A care plan, dated as 2/5/19 indicated that grab bars on the bed were used to get in and out of bed safely. Observation on 2/19/19 at 8:00 AM revealed grab bars on the resident's bed and in the upright position. The Facility failed to provide an assessment for the use of the grab rails, and failed to provide documentation of informed consent for the use of the grab rails. 9. The MDS assessment tool, dated 11/21/18 listed [DIAGNOSES REDACTED]. The MDS stated that the resident required extensive assistance for bed mobility, transfer, and personal hygiene. The MDS documented the resident BIMS score was 3 which indicated severe cognitive impairment. A care plan, dated as 12/13/16 indicated that grab bars were used on the bed to help with mobility. Observation on 2/19/19 at 4:24 PM revealed grab bars attached to the resident's bed and in the upright position. The facility failed to provide an assessment for the use of the grab rails, and failed to provide documentation of informed consent for the use of the grab rails. 10. The MDS assessment tool, dated 1/30/2019, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assist of 2 staff with bed mobility and transfer. The MDS documented the residents BIMS as 9 out of 15, indicating moderate cognitive impairment. A care plan, with intervention date initiated on 10/5/18, directed grab bars on bed to assist with transfers and bed mobility. Observation on 2/19/19 at 3:30 PM, revealed grab bars attached to Resident #2's bed. The Facility failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #2. 11. The MDS assessment tool, dated 11/21/2018, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assist of 2 staff for bed mobility and total dependence on 2 staff for transfers. The MDS documented the residents BIMS as 10 out of 15, indicating moderate cognitive impairment. A care plan, dated as initiated on 2/16/2019, directed grab bars on bed to allow resident to assist with bed mobility and transfers. Observation on 2/19/19 at 3:30 PM, revealed grab bars attached to Resident #19's bed. The Facility failed to provide assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #19. 12. The MDS assessment tool, dated 12/5/2018, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assist of 2 staff with bed mobility and transfer. The MDS documented the residents BIMS as 0 out of 15. Indicating severe cognitive impairment. A care plan, dated 12/18/2018, directed grab bars on bed to allow resident to assist with bed mobility and transfers. Observation on 2/19/19 at 3:30 PM, revealed grab bars attached to Resident #24's bed. The facility failed to provide assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #24. 13. The MDS assessment tool, dated 1/23/2019, listed [DIAGNOSES REDACTED]. The MDS stated the resident was independent for bed mobility and transfer. The MDS documented the residents BIMS as 3 out of 15, indicating severe cognitive impairment. The care plan, dated 10/29/2015 with a target date of 4/23/2019, directed grab bars on bed to allow resident to assist with transfers and bed mobility. Observation on 2/19/19 at 3:30 PM, revealed grab bars attached to Resident #56's bed. The facility failed to provide assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #56. 14. The MDS assessment sheet was not yet completed on newly admitted Resident #266. The care plan, with admitted as 2/13/2019, directed grab bars on bed to allow resident to assist with transfers and bed mobility. Observation on 2/19/2019 at 3:30 PM, revealed grab bars attached to Resident #266's bed. The facility failed to provide assessments for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails for Resident #266.

Based on observation, record review and staff interviews the facility failed to follow safe smoking procedures to ensure that one resident received adequate supervision to prevent injury from unsafe smoking in 1 of 1 residents reviewed (Resident #266) The facility reported a census of 66 residents. Findings include: Resident #266 was admitted to the facility on [DATE]. A document titled Admission/Readmission Nursing Assessment/Baseline Care Plan with an effective date of 2/13/19 affirmed the resident to be a smoker and to see smoking assessment for assistance/safety equipment needed. The care plan further identified resident to have yellow nail beds and to have several hard yellow scab like calluses on first 3 fingers of right hand that resident stated were chronic areas from smoking. In an observation on 2/18/19 at 1:15 PM, Staff C, Certified Nursing Aide (CNA), assisted resident outdoors to smoke. Staff C lit the resident's cigarette, handed the pack of cigarettes and lighter to the resident, then left resident outside. Resident smoked one cigarette down to the filter then threw the cigarette into the designated receptacle. Resident lit a second cigarette after attempting to light the cigarette over 60 times. He then smoked the cigarette down to the filter and attempted to throw the cigarette into the receptacle. The cigarette missed the receptacle landing in the snow by some bushes. The resident had a circular discolored mark on the right middle finger between the second and distal knuckle where the cigarette rested while resident smoked and another larger discolored area on the outside tip of resident's right index finger. The resident had slow deliberate movements in both arms. The resident was not wearing a smoker's apron and the resident was not supervised by staff. Resident activated the doorbell signaling the staff that he was ready to go back indoors. The facility failed to ensure the cigarette was disposed of in the proper receptacle. On 2/19/19 at 10:27 AM observation revealed the resident smoking outside. Staff B, Co-Director of Nursing (Co-DON), confirmed resident was brought outside, given two (2) cigarettes and a lighter and was smoking his first cigarette. Resident finished smoking his first cigarette, smoking the cigarette down to the filter and attempted to throw the cigarette butt into the receptacle. Resident missed the receptacle and the butt landed on the snow covered ground. Resident then lit the second cigarette on his first try. Resident stated the circular area on his middle finger is from burning himself while smoking where the lit end of a cigarette touched his skin. The resident stated the lateral area on his index finger was from trying to light a cigarette from a lit match he was holding in his right hand. Resident said the lit match burned his skin. The resident said that both of these incidents happened at his home. The resident confirmed he would wear a smoker's apron. The resident finished smoking his second cigarette down to the filter and attempted to throw the butt into the receptacle. The butt of the cigarette hit the rim of the receptacle but then fell on to the snow covered ground. Resident was not wearing a smoker's apron. The resident then activated the door bell and staff responded. Staff D, Licensed Practical Nurse (LPN), pushed resident's wheelchair back into the facility and removed a folded blanket from the resident's lap. Staff D verified the blanket was a normal blanket used for warmth (not a smoker's apron). Staff D reported to Staff B, Co-DON, that the resident should wear a smoker's apron. Staff D confirmed there were ashes on the blanket. The facility failed to ensure safety precautions were in place (smoking apron and supervision) for this resident and for the facility. In an interview directly following this observation Staff B, Co-DON confirmed she will do another smoking assessment after lunch on this resident and update the care plan to include a smoker's apron and supervision of staff along with any other necessary changes. Policy review. An undated policy titled Resident Smoking Privileges directed a smoking assessment to be done and reviewed by the interdisciplinary team for residents who wish to smoke. The policy directed the interdisciplinary team to determine whether the resident can have independent smoking privileges and if the resident will require staff supervision. The policy further directed that each resident will wear a smoker's apron while smoking and if the resident refuses to wear a smoker's apron a negotiated risk will be completed with the resident. In an interview on 2/19/19 at 2:00 PM, Staff A, Co-DON, confirmed resident should have had a smoker's apron on per their policy. Staff A confirmed the policy directed a negotiated risk to be done on residents who do not wear a smoking apron and confirmed this was not done. Staff A further confirmed that members from the interdisciplinary team were not notified of the smoking assessment outcome per the facility's policy. The facility failed to ensure safety precautions were in place (smoking apron and supervision) for this resident and for the facility. In an interview on 2/19/19 at 2:14 PM with Staff E, Licensed Practical Nurse (LPN), Staff E confirmed she did the initial the smoking assessment on 2/15/19. Staff E confirmed she did not place a smoker's apron on this resident and stated she was unaware that the policy stated residents should wear a smoker's apron when smoking unless a negotiated risk was completed. Staff E further confirmed she did not contact any interdisciplinary team member after she completed the smoking assessment per policy direction. Smoking Assessment A document titled Smoking assessment dated [DATE] was completed and did not direct the use of adaptive equipment. On 2/19/19 at the conclusion of the findings portion of the survey, Staff B Co-DON reported the resident with the unsafe smoking, a new assessment has been completed and now is supervised with a smoking apron in place.

Based on clinical record review, facility policy review and staff interview, the facility failed to report resident to resident allegations of abuse to the State survey agency as required for six of 18 residents reviewed. (Resident #6, #9, #10, #16, #17 & #18 ) The facility census was 68 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. The MDS documented the resident had physical and other behaviors directed toward others and required extensive assistance with bed mobility, transfers, toilet use and personal hygiene and limited staff assistance with ambulation in the room and corridor. The care plan with an initiation date of 4/19/15, identified the resident struck out or attempted to harm someone when upset related to dementia. Interventions included the following: a. The resident's triggers for physical aggression included becoming upset when asked to do something the resident disliked at the time and directed staff to give the resident time to calm down and approach later. b. Monitor behaviors, interventions, and any signs of possible danger to self or others. c. Psychiatric services. d. Offer many choices about care and activities. Care Plan interventions dated 7/6/15 included: a. Assist to alleviate anxiety, encourage verbalization of cause of anxiety, and encourage to notify staff when agitated. b. Attempt to anticipate needs related to thirst, food, toileting, comfort, positioning, and pain. c. Try to intervene before agitation escalates, redirect away from source, and when responses become aggressive, walk away and approach later. An Incident Report notes documented within electronic record Progress Notes revealed the following resident to resident incidents in the CCDI unit: a. An MDS dated [DATE], identified Resident #16 with severe cognitive impairment, continuous inattention and disorganized thinking that had not fluctuated, delusions, physical behaviors, rejection of care, and wandering. The MDS revealed the resident ambulated in the room with staff supervision and in the corridor with limited staff assistance. An Incident Report dated 8/19/15 at 3:20 p.m., identified Resident #10 slapped Resident #16 on the left hand and kicked the resident in the right outer thigh. Neither resident had any type of injury. The report documented staff reviewed Resident #10's care plan. b. An MDS dated [DATE], identified Resident #6 with severely impaired cognition, an altered level of consciousness that fluctuated, delusions, and required limited staff assistance with ambulation in the room and corridor. An Incident Report dated 9/16/15 at 7:00 p.m., documented Resident #10 was restless, appeared upset and angry, and had hit out at staff. The report revealed Resident #10 became upset because Resident #6 had a napkin and hit Resident #6 on the left arm. Neither resident had any type of injury. During interview on 11/24/15 at 9:20 a.m., the co-DON (Director of Nursing), stated the resident to resident incident was not reported to the DIA (Department of Inspection and Appeals). c. An MDS dated [DATE], documented Resident #17 with severe cognitive impairment, without [MEDICAL CONDITION] and behaviors, and ambulated in the room and corridor with staff supervision. An Incident Report dated 10/7/15 at 12:45 p.m., documented Resident #10 hit Resident #17 on top of the buttocks with the right hand with palm open when a staff member ambulated with Resident #17. Neither resident had any type of injury. An Incident Report dated 11/13/15 at 6:32 p.m., documented Resident #10 in the lobby talking to Resident #17, Resident #10 wanted Resident #17 to go with him/her, Resident #17 said no, and Resident #10 became angry and hit Resident #17 in the stomach area with a closed fist. Resident #17 stated the hit hurt. The report documented the residents located in the lobby with a CNA (Certified Nursing Assistant) providing direct supervision and other interventions in place and appropriate. d. An MDS dated [DATE], documented Resident #18 with severe cognitive impairment, continuous inattention and disorganized thinking that fluctuated, physical behaviors, and wandered. The MDS documented the resident required staff supervision for ambulation in the room and corridor. An Incident Report dated 10/28/15 at 5:59 p.m., documented Resident #10 walked past Resident #18 and hit Resident #18 in the abdominal area. Neither resident had any type of injury and staff separated the residents. e. The Minimum Data Set assessment dated [DATE], documented Resident #9 had a a [DIAGNOSES REDACTED]. An Incident Report dated 9/16/15 at 7:20 p.m., documented Resident #9 was up wandering in the day lobby. Resident #9 went up to another resident in the unit who was sitting in a chair. Resident #10 grabbed Resident #9 by the hand and bit Resident #9's left index finger and thumb. Resident #10 did not break the residents skin. An assessment was completed. Resident #9 had pink marks on the left hand, unable to measure, very faint markings. Resident #9's responsible party and physician were notified of the incident. The facility Reportable Occurrence Decision Tree, revised 11/16/15, directed staff to report any suspicion of a crime against a resident, including abuse, to DIA within 2 hours when resident injury occurred and within 24 hours without resident injury, including weekends and holidays.

Based on record review and staff interview, facility staff failed to immediately report an allegation of abuse to a charge person for one of five residents reviewed (Resident #1). The facility reported a census of 57 residents. Findings Include: 1. According to the Minimum Data Set (MDS) assessment tool dated 11/19/14, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident was severely cognitively impaired and required extensive staff assistance with transfers and toilet use. The MDS also documented the resident displayed physical behavioral symptoms directed toward others occurring 4 to 6 times a day. The resident's Care Plan, with a initial date of 8/18/14, identified the resident displayed significant memory loss related to dementia. The Care Plan revealed the resident became agitated and physically aggressive during cares at times and directed staff to pause, reassure the resident and explain the care given. The Progress Notes dated 1/26/15 at 6:18 revealed Staff A, Certified Nursing Assistant reported on 1/25/15 at 9:45 p.m., she witnessed an incident on 1/21/15 between another CNA and a resident. She reported they were assisting Resident #1 in the bathroom with bedtime cares when the resident became agitated and physically aggressive. She reported she stood in front of the resident and attempted to direct his/her hands to the walker to avoid the resident from his/her using the elbows to strike out at staff. She heard and observed Staff B, CNA, forcefully placed an open hand on the resident's upper/middle back. Staff A reported she stood in front of the resident, maintained the resident's balance and used the walker to guide the resident out of the bathroom. She stated both CNAs assisted the resident to bed. During an interview on 2/16/15 at 2:35 p.m., Staff A reported she and Staff B completed the resident's cares in the bathroom on 1/25/15 around 8:30 p.m. or 9:00 p.m. She stood in front of the resident and the walker, while Staff B stood behind the resident. Staff A stated Resident #1 hit Staff B in the stomach with his/her elbow and Staff B gritted her teeth in response. Staff A also stated she did not know if Staff B's hand was already on the resident's back, or if she placed her hand between the back shoulder blades. At that time, she heard a dull, "Thump" that sounded on the resident's back, which resulted in a shove. Staff A reported the resident quickly went forward and put his/her hands on to the walker. Staff A noted the resident would have fallen forward if she hadn't stood in front of him/her and held the walker. She reported she felt Staff B was rough with the resident. Staff A stated she knew she should have reported it as soon as it happened, but had to think about it for 4 days. Staff A replied she worried if she reported the incident it would hurt her friendship with Staff B. During an interview on 2/17/15 at 1:53 p.m., Staff C, Co-Director of Nursing, reported she worked the evening on 1/25/15 when Staff A reported the incident. She said she asked Staff A if she knew she should have reported the incident when it happened, and Staff A said yes, she knew that. Record review of Staff A's employment showed a hire date of 5/13/14 with a completion of Dependent Adult Abuse: Mandatory Training on 5/22/14. Record review of the facility's Job Title: Certified Nursing Assistant dated 10/2012 showed they report to the Charge Nurse. Essential Job Functions included: report resident incidents, complaints, allegations of abuse, problems and health complaints in a timely manner to the charge nurse. The Reporting Guidelines in the Abuse Policy included Mandatory Reporters (3) a: If the observation or occurrence meets the definition of any of the 8 types of dependent adult abuse, described - the employee or staff member shall immediately notify the person in charge or the person's designated agent..."

Based on clinical record review, Federal document review and staff interview, the facility failed to with hold billing for care provided to a resident after the facility issued Notice of Medicare Provider Non-Coverage and Skilled Determination On Continued Stay forms and the resident/family requested an appeal following a skilled nursing stay for one of four residents reviewed with (SNF) Skilled Nursing Facility services (Resident #15). The facility census was 63 residents. Findings include: 1. Review of Resident #15's record revealed he/she received Medicare skilled services from 6/12/14-7/16/14. The facility issued form CMS (Centers For Medicare and Medicaid Services) # (otherwise known as Notice Of Medicare Provider Non-Coverage) and a family member signed the form 7/14/14. The form notified the resident/family current skilled nursing services ended 7/16/14 and directed the resident/family how to appeal the decision, how to ask for an immediate appeal, and documented other appeal rights. A Skilled Determination on Continued Stay form documented the resident's skilled nursing services ended and 7/17/14 the first date of non-covered services. Resident #15's family member signed the form 7/14/14 and checked letter A, that directed the facility to submit a bill to Medicare (appeal) for a payment decision for services. The form documented the resident was not required to pay for services which could be paid by Medicare until a decision had been made. The form lacked resident notification of any fee for services until a decision made. During interview on 9/30/14 at 3:20 p.m., the Corporate Nurse stated the facility mistakenly billed the resident on 8/1/14 for services provided beginning 7/17/14 and refunded the resident $2796.94 on 9/5/14 when the facility discovered the mistake. During interview on 9/30/14 at 3:35 p.m., the Corporate Nurse stated the resident's spouse paid the facility $5984.85 on 8/4/14 after the facility billed the resident on 8/1/14. The Corporate Nurse stated central office completed all billing and planned to send additional information. During interview on 10/1/14 at 1:37 p.m., with the Corporate Nurse and the Administrator, the itemized copies of resident billing was reviewed. The resident was billed $152.00 per day for 34 days, 7/17/14 to 8/20/14 when the resident discharged to home. The facility presented a copy of a letter the facility sent to WPS (Wisconsin Physicians Service, the Medicare Fiscal Intermediary) 2/22/12. The letter requested a response whether or not the facility was allowed to bill the resident for the coinsurance after a Demand Bill requested. The letter informed WPS the following resources stated facilities allowed to bill the resident for coinsurance: the previous intermediary (Cahaba) had published information from 2005, page 23 of an undated Medicare Coverage of Skilled booklet, and CMS . The staff presented a copy of a letter from WPS, dated 4/23/12, that stated according to the facilities references, WPS agreed with Cahaba that the provider/facility can collect Medicare Part A coinsurance while Demand Bills pending a response. The facility presented a copy of CMS (Demand Billing Review) dated 6/2007 that allowed providers to bill the resident the coinsurance while Demand Bill was processed. An updated CMS (Liability Notices & Beneficiary Appeal Rights Review), dated 2/2013, directed facilities charging residents for Medicare Part A services while a Demand Bill pending was a violation of the facility's provider agreement for resident billing requirements and referred to S &C (Survey and Certification) 09-20. In addition, the facility presented a copy of page 27 from a CMS Medicare Coverage of Skilled Nursing Facility Care booklet. Page 27 documented, "if you request to have a claim submitted, you are not required to pay for your SNF stay until you are informed of Medicare's decision (you do have to pay any coinsurance charged and for services and supplies not covered by Medicare). The resident was responsible for the cost of the stay if Medicare determines they did not meet Medicare criteria. During the same interview, the Administrator called the corporate billing office. The office stated if Medicare agreed the resident needed to remain on Part A Skilled Care, the resident's own insurance would pay the coinsurance for skilled care. S & C 09-20 (Center for Medicaid and State Operations/Survey and Certification Group), dated 1/9/09, documented facilities were unable to charge the resident for Medicare covered Part A services while a Demand Bill was pending. During interview 10/2/14 at 9:30 a.m., the Corporate Nurse stated they found the published date of the Medicare Coverage of Skilled Nursing Facility Care the facility cited in their 2/22/12 letter to WPS. The Corporate Nurse presented documentation the booklet's most recent revision date 2/1/14.

Based on observation, clinical record review and staff interview, the facility failed to ensure gradual dosage reduction and failed to document indications for the use of an antipsychotic medication for two of seven residents reviewed. ( Resident #12 & #11) The facility census was 63 residents. Findings include: 1. The plan of care documented Resident #12 had [DIAGNOSES REDACTED]. The Medication Review Report dated 7/31/14, documented the resident had received the antipsychotic medication [MEDICATION NAME] 1 milligram (mg) daily at bed time since 7/19/13 and [MEDICATION NAME] 0.25 mg twice daily since 8/1/14. On 5/13/14, a Request for Gradual Dose Reduction form was checked by the physician with a statement "Do not attempt to taper the dose of this drug. In my professional opinion, and/or by diagnosis, to do so is clinically contraindicated. Target symptoms are under control." The clinical record lacked any documented clinical rationale why a dosage reduction would be contraindicated or why a dosage reduction would impair the resident's function or increase distressed behavior. During interview on 10/2/14 at 9:23 a.m., Staff A, Co-Director of Nursing confirmed there was no documentation of a dosage reduction or clinical rationale written by the physician in the resident's record. 2. An Admission Record sheet documented Resident #11 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had disorganized thinking that fluctuated, comes and goes and changes in severity, minimal depression and without hallucinations and delusions. The Medication Review Report, signed by the physician 8/12/14, documented the resident received [MEDICATION NAME] (an antidepressant) 25 mg for a sleep disturbance with a start date of 12/12/13, [MEDICATION NAME] 1 mg 3 times daily for anxiety with a start date of 11/8/13 and when needed to promote relaxation related to anxiety with a start date of 10/25/13 and Quetiapine (an antipsychotic) 25 mg for senile dementia with delusional features with a start date of 6/13/14. The September 2014 Medication Administration Record [REDACTED]. The care plan revised 2/11/14, documented the resident's mood varied from day to day, the resident showed little facial emotion, tended to be calm, and voice with little fluctuation. Interventions directed staff to assist with and provide activities, monitor mood, signs and symptoms of depression, staff to speak clearly and slowly to the resident to enable understanding, able to make needs and preferences known, more confused at times, uses call light more at times, and sits in the lobby during periods of increased confusion to maintain safety. The care plan identified a [MEDICAL CONDITION] medication related to dementia with behavior disturbances. Interventions directed staff to monitor for medication side effects that included unsteady gait, tardive dyskinesia, extra pyramidal symptoms that included shuffling gait, difficulty swallowing, dry mouth suicidal ideation's, social isolation, [MEDICAL CONDITION], loss of appetite, and behavior symptoms not usual to the person. An electronic nursing Progress Note dated 6/6/14 at 9:30 a.m., documented the resident's physician visited via Telemed with 3 family members and the resident's status discussed. The notes documented all parties present felt the resident had a progression in dementia, hospice not currently appropriate, obtain a urine specimen, and if the resident without a urinary tract infection, start a low dose of [MEDICATION NAME]. The Interdisciplinary Progress Notes dated 6/13/14 at 11:00 a.m., documented a physician order [REDACTED]. daily at bedtime. At 6:00 p.m., staff documented plans to begin [MEDICATION NAME] that night. The May 2014 Behavior Monthly Flowsheet documented the resident had 10 plus episodes of anxiety 5/3/14, 5/18/14, and 5/26/14, interventions provided and the resident's anxiety remained unchanged. The June and July 2014, Behavior Monthly Flowsheet lacked documentation the resident had any [MEDICAL CONDITION], anxiety or health complaints. Observation on 10/1/14 at 11:55 a.m., documented the resident in the room asleep in the chair. Observation on 10/2/14 at 7:15 a.m., revealed the resident in lobby/living room area by the nurse's station awake and quiet. During interview 10/2/14 at 8:40 a.m., Staff B, Co DON (Director of Nursing) stated the [MEDICATION NAME] was started after a teleconference with a Palliative Care physician involved in the resident's care. Staff B stated the resident sat at the nurses station and repeatedly asked for his/her mother, the resident believed he/she had a physician appointment every day, made frequent telephone calls to family about physician appointments, and on 6/16/14 (after [MEDICATION NAME] began) the resident believed he/she having a baby. Staff B stated staff and family believed the resident's increase in confusion was due to a [MEDICATION NAME] dose increase and after the [MEDICATION NAME] dose was decreased on 5/21/14 the confusion continued.

Based on observation and staff interview, the facility failed to repair marred plaster walls in three resident rooms Room #1, Room #20, Room #26. The facility reported a census of 58 residents. Findings included: On 6/25/13 at 9:58 a.m. observation revealed the lower portion of the plaster wall going into the bathroom of Resident Room #26 had badly chipped/scraped plaster with the base trim missing. On 6/25/13 at 10:03 a.m. Resident Room #1 also had the lower wall near the bathroom entrance badly scraped of plaster and the base trim missing. On 6/25/13 at 10:05 a.m. Resident Room #20 had the lower wall near the entrance to the bathroom had badly scraped plaster with the base trim missing. During the Environmental Tour of the facility on 6/26/13 which began at 10:00 a.m. the facility administrator did not disagree when shown the chipped/scraped plaster in Resident Room #20.