Every finding on record at Rotary Senior Living

Based on clinical record review, written statement, staff interview and policy review, the facility failed to ensure a resident was treated with dignity for 1 of 3 residents reviewed (Resident #26). The facility reported a census of 27 residents. Findings include:Resident #26's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The MDS included diagnoses of progressive neurological conditions (gradual brain disorders), Alzheimer's disease (progressive memory loss disorder), and depression (mood disorder). Resident #26's Care Plan revised 6/24/26 included an activities of daily living (ADL) self-care performance deficit, noting Resident #26 depended on staff for eating. Additionally, the Care Plan instructed staff Resident #26 depended on staff to meet emotional, intellectual, physical, and social needs related to cognitive deficits. The Interventions instructed staff to converse with Resident #26 while providing care. An undated written statement completed by Staff B, Certified Nursing Aide (CNA) documented she worked on 7/2/26 with Staff C, CNA. During suppertime, Staff B and Staff C fed several residents needing extra meal assistance. At this time, Staff C fed Resident #26, who usually struggled with meals, noting Resident #26 didn't eat or drink. Staff C placed a plastic straw to Resident #26's mouth and stated, come on, suck it like your husbands, referring to genitals. Staff C looked at Staff B, saw Staff B felt taken aback by the comment, and stated to Staff B, I could totally say something about you and your boyfriend too. Staff B documented feeling very uncomfortable from the comment. On 7/22/26 at 2:15 PM Staff B stated working the 2:00 PM to 10:00 PM shift with Staff C on 7/2/26. At dinner time, Staff B and Staff C assisted four residents needing meal help at the back dining room table. Staff C assisted Resident #26 with eating and drinking, while Staff B assisted another resident across the circle table from Staff C. Staff C attempted giving Resident #26 orange juice from a blue cup with a straw, placed the straw up to Resident #26's mouth, and stated, come on [Resident #26's name], suck it like your husbands. Staff B stated believing Staff C referred to genitals. Staff B stated Resident #26 stayed predominantly non-verbal and didn't respond. Staff C looked at Staff B, who appeared wide-eyed and taken aback, and stated to Staff B he could say something about Staff B and Staff B's boyfriend too. Staff B stated feeling uncomfortable and didn't say anything. Staff C chuckled after making the comment to Resident #26 and looked at Staff B with an expression asking if Staff B thought the comment felt funny. Staff B stated no other staff stood nearby, and Staff C didn't speak loudly enough for the whole dining room to hear. Staff B stated completing the written statement on 7/13/26. A review of the facility staffing schedule showed Staff B and Staff C both worked on 7/2/26 from 2:00 PM to 10:00 PM. On 7/23/26 at 9:47 AM Staff D, Licensed Practical Nurse (LPN), stated working a 6:00 AM to 6:00 PM shift on 7/2/26. Staff D stated they entered the dining room at times if a resident required medication during mealtime, but spent most of the time charting at the nurse's station or passing medications in a hallway. Staff D stated 2 staff members usually sat at the back table with residents needing assistance, and Staff D couldn't hear speech at the table. On 7/23/26 at 10:15 AM Staff E, Administrator, stated expecting staff to treat residents with dignity and respect, and expecting staff not to speak in an offensive or inappropriate manner to a resident. The Residents' [NAME] of Rights policy dated November 2016 instructed each resident held a right to a dignified existence. The policy directed the facility to treat each resident with respect and dignity, caring for each resident in a manner and environment promoting maintenance or enhancement of quality of life.

Based on clinical record review, written statement review, policy review, and staff interviews, the facility failed to ensure staff immediately reported an allegation of verbal and sexual abuse for 1 of 1 resident reviewed for abuse reporting (Resident #26). Staff B, Certified Nursing Aide (CNA), witnessed Staff C, CNA, make a sexually offensive comment to Resident #26 on 7/2/26, but didn't report the allegation until 11 days later on 7/13/26. The facility reported a census of 27 residents. Findings include:Resident #26's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Resident #26's medical diagnoses included progressive neurological conditions (gradual brain disorders), Alzheimer's disease (progressive memory loss disorder), and depression (mood disorder). An undated written statement completed by Staff B documented they worked on 7/2/26 with Staff C, assisting residents needing extra meal help during suppertime. Staff C fed Resident #26, who usually struggled with meals and didn't eat or drink. Staff C placed a plastic straw to Resident #26's mouth and stated, come on, suck it like your husbands, referring to genitals. Staff C looked at Staff B, saw Staff B felt taken aback by the comment, and stated to Staff B, I could totally say something about you and your boyfriend too. Staff B documented feeling very uncomfortable from the comment. The Nursing Progress Note dated 7/13/26 reflected a staff member reported to the nurse feeling uncomfortable following comments made by another staff member several weeks prior. Staff B stated sitting at the dining table with a male staff member, assisting Resident #26 with eating and drinking. Staff B stated when Resident #26 wouldn't drink from the cup offered, the male staff member commented, Suck it like your husband. The Nursing Progress Note dated 7/13/26 indicated the staff member completed a head-to-toe assessment following the verbal abuse allegation. Vital signs measured within normal limits. Resident #26 stayed alert to self only and remained unaware of the verbal abuse allegation due to advanced dementia (memory loss). Staff notified Resident #26's family by telephone and notified the Primary Care Provider (PCP) of the reported incident. On 7/22/26 at 1:47 PM Staff A, Administrator, acknowledged making a facility self-report to the Iowa Department of Inspections, Appeals and Licensing (DIAL) on 7/13/26 regarding alleged violations to Resident #26 occurring on 7/2/26. Staff A stated Staff B received a disciplinary write-up for failing to report in a timely manner, noting the incident occurred on 7/2/26 and Staff B didn't report it until 7/13/26. On 7/22/26 at 2:15 PM Staff B stated working the 2:00 PM to 10:00 PM shift with Staff C on 7/2/26. At dinner time, Staff B and Staff C assisted four residents needing meal help at the back dining room table. Staff C assisted Resident #26 with eating and drinking, while Staff B assisted another resident across the circle table from Staff C. Staff C attempted giving Resident #26 orange juice from a blue cup with a straw, placed the straw up to Resident #26's mouth, and stated, come on [Resident #26's name], suck it like your husbands. Staff B stated believing Staff C referred to genitals. Staff B stated Resident #26 stayed predominantly non-verbal and didn't respond. Staff C looked at Staff B, who appeared wide-eyed and taken aback, and stated to Staff B he could say something about Staff B and Staff B's boyfriend too. Staff B stated feeling uncomfortable and didn't say anything. Staff B stated completing the written statement on 7/13/26 after reporting the incident to Staff D, Director of Nursing (DON). Staff B stated working again on 7/4/26, taking the week off, and returning on 7/13/26. Staff B stated thinking about the incident while off duty, deciding to report it to Staff D on 7/13/26, 11 days after the incident. Staff B stated receiving a disciplinary write-up for failing to report the incident right away. Staff B acknowledged needing to report the incident right away and confirmed completing Dependent Adult Abuse Mandatory Reporter Training prior to 7/2/26. A record review of Staff B's employee file showed a certificate of completion for Dependent Adult Abuse Mandatory Reporter Training dated 6/4/25. Staff B received a written disciplinary write-up on 7/15/26 for failing to report suspected abuse on 7/2/26. On 7/23/26 at 10:15 AM Staff A stated expecting staff members to report suspected abuse within required timeframes and acknowledged Staff B didn't report suspected abuse in a timely manner. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 10/19/22 instructed procedures include screening and training employees, protecting residents, and preventing, identifying, investigating, and timely reporting abuse. The policy instructed staff to report all allegations of resident abuse to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation.

Based on observations, staff interview, and policy review, the facility failed to provide appropriate textured food and appropriate serving sizes for 3 of 4 residents on an altered textured diet. The facility reported a census of 27. Findings include: 1. The puree hot lunch offered on 7/22/26 consisted of a hot beef sandwich, mashed potatoes, green beans, and a cherry bar. The facility had a total of 3 residents on a puree diet. Staff A, dietary cook, voiced they typically prepare a total of 4 serving of puree items. This is to ensure an extra serving is available for any last minute needs or mishaps.On 7/22/26 at 9:35 AM during a continuous observation, Staff A, Dietary Cook, pureed 4 cherry bar servings to correct consistency and measured 2.5 cups total volume for a lunch menu offering a hot beef sandwich, mashed potatoes, green beans, and a cherry bar for 3 residents on a pureed diet. Staff A checked the Puree Diet Portion Sizes/Scoop Chart and stated needing a #6 scoop size. Staff A dished 3 portions of cherry bar, using all product among 3 bowls. While placing items in the cooler, Staff A stated dishing only 3 portions instead of 4 and determined it felt too late to adjust. After preparing 4 servings of pureed roast beef, Staff A pureed 3 servings of green beans from a can offering 3.5 total servings. Staff A stated a final volume of 1 cup required a #16 scoop size. Staff A covered and labeled both roast beef and green beans with the scoop size for service, placing items in the steamer until lunch.On 7/22/26 at 12:00 PM lunch service began with Staff A preparing resident plates. Staff A used a #16 scoop for pureed green beans for 2 of 3 residents on a pureed diet.A record review of the Puree Diet Portion Sizes/Scoop Chart showed the following:a.With a final volume measurement of 2.5 cups, pureed cherry bar requires equal portioning between 4 servings with #12 and #16 scoops.b.With a final volume measurement of 1 cup, pureed green beans require equal portioning between 3 servings with a #12 scoop.On 7/22/26 at 3:00 PM Staff B, Certified Dietary Manager (CDM), acknowledged incorrect pureed servings for cherry bar and green beans. Staff B stated staff need to refer to and read the pureed serving size chart correctly for correct scoop sizes.2. Resident #26's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Resident #26's MDS documented diagnoses including Alzheimer's dementia (memory loss) and dysphagia (swallowing difficulties). Resident #26 depends on staff for feeding.A record review of Resident #26's Order Summary report dated 7/22/26 listed Resident #26's diet order as Mechanical Soft textures (ground meat with food cut into bite-sized pieces).On 7/22/26 at 9:35 AM Staff A stated residents on a mechanical soft diet receive green beans instead of peas offered on regular textured diets.On 7/22/26 at 12:00 PM Staff A prepared Resident #26's lunch plate with peas, ground roast beef, and mashed potatoes. Dietary staff delivered the plate to the table where nursing staff initiated feeding assistance. Approximately 5 to 7 minutes later, Staff B approached staff assisting Resident #26 and instructed staff not to feed peas to Resident #26. Staff B provided a bowl of green beans and explained to offer green beans instead. Nursing staff acknowledged.On 7/22/26 at 3:00 PM Staff B acknowledged staff shouldn't have served peas to Resident #26 because mechanical soft diets don't allow peas.The policy titled Simplified Diet Manual, 12th Edition, instructed whole kernel corn and peas require avoidance on a mechanical soft diet.

Based on observation, interviews, and document review, the facility's administrative staff failed to ensure the nursing staff adequately monitored the INR level (international normalized ratio, a test measured how quickly blood clots) for 1 of 1 resident on warfarin (Resident #2), including after Resident #2's physician prescribed medications which could increase Resident #2's INR. Resident #2's physician started Resident #2 on an antibiotic (which can increase the INR) on 1/21/26, and added another antibiotic on 1/22/26. The nursing staff discovered a large bruise on Resident #2's mons pubis (the fatty area surrounding the penis) on 1/24/26. The nursing staff did not begin increased monitoring of Resident #2's bruising or check Resident #2's INR upon discovery of the bruise. The nursing staff reported they relied on the Pharmacist to notify them of drug interactions, such as a medication which would increase a resident's INR. Resident #2's wife checked Resident #2's INR on 1/26/26 (2 days after staff discovered the bruise), which showed Resident #2's INR as 7.3 (therapeutic range is 2.0 - 3.0). The nursing staff received orders from the clinic monitoring Resident #2's INR and adjusting the warfarin, but before the staff could implement the orders, Resident #2's condition changed and required emergent hospitalization. The hospital staff identified Resident #2's INR was greater than 13 (a critical level) and had a large internal bleed in the abdominal muscles. The hospital staff had to transfuse 2 units of blood due to Resident #2's internal bleeding. Due to the location of the bleeding, the hospital staff could not stop the bleeding, which resulted in the hospital staff placing Resident #2 on hospice. Resident #2 died at home on 1/31/26. The facility's administrative staff reported a census of 29 residents with 7 residents taking blood thinning medication.The Department of Inspections, Appeals, and Licensing notified the facility staff on 3/13/216 at 4:30 PM that the situation rose to the level of Immediate Jeopardy (a situation where the safety of residents is at risk for serious injury, serious harm, serious impairment, or death). The Immediate Jeopardy situation began on 1/24/26 when the nursing staff failed to implement increased monitoring for Resident #2's bruising while Resident #2 was on medications that increased the risk for bleeding. The facility staff removed the immediacy on 3/14/26 by taking the following actions:a. 3/14/26: The Administrator and the Director of Nursing (DON) began educating all nurses on the facility's High Risk Medications Anticoagulant policy.b. On 3/14/26: The Administrator and DON started staff education for all nurses on the facility's Risk Management process. This process included proper assessment and intervention. Staff would complete a head-to-toe assessment if a resident's condition changed, complete a risk management assessment, when necessary, notify the resident or the resident's representative and physician, and add the resident to their hot chart list for further follow-up and assessment.c. On 3/14/26: Current agency nurses received education or completed it before starting their next shift.d. All nursing staff would receive education on the two policies on 3/14/26 or before starting their next shift.e. On 3/13/26: The DON and Nurse Specialist audited all residents who received anticoagulant medications to ensure no one was experiencing adverse side effects related to the medications. The audit noted no additional concerns with the medication regimens.Findings include:Resident #2's Minimum Data Set (MDS) assessment, which the facility completed on 12/2/25, showed a Brief Interview for Mental Status (BIMS) score of 6, meaning Resident #2 had severe cognitive impairment. Resident #2 also had limited range of motion on one side of his upper and lower arms and legs. Resident #2 required substantial/maximal assistance—meaning the caregiver provided more than half the effort, lifting or holding the body or limbs—with personal care activities, including toileting hygiene, managing footwear, personal hygiene, and dressing his upper and lower body. The MDS also confirmed Resident #2 received an anticoagulant medication during the lookback period. The Care Plan Focus, which the facility revised on 6/6/25, noted Resident #2 received anticoagulant therapy (blood thinners) because he had a history of a stroke. A stroke is when blood flow to the brain is blocked or a blood vessel in the brain ruptures. The goal stated Resident #2 would be free from discomfort or bad reactions from using the blood thinner. The Interventions directed staff to do the following:a. 9/9/25: Check INR according to physician orders.b. 6/25/25: Monitor, document, and report adverse reactions to the blood thinner as needed (PRN)—meaning as the situation required. Adverse reactions included blood-tinged or red blood in the urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle/joint pain, lethargy (extreme sleepiness), bruising, blurred vision, loss of appetite, sudden changes in mental status, or sudden significant changes in vital signs. The plan also directed staff to make sure the Certified Nurse Aides (CNAs) knew Resident #2 used a blood thinner and had a risk for bruising, requiring them to protect his skin during transfers and clothing changes. The Care Plan did not include instructions on how to monitor Resident #2's INR or interactions with the use of antibiotics with the blood thinner. Resident #2's January 2026 Medication Administration Record (MAR) included these orders:a. 1/20/26: Warfarin Sodium (a blood thinner) oral tablet 3 mg. The order was to give one tablet by mouth every evening shift for blood thinning. Documentation showed Resident #2 received warfarin every evening from 1/20/26 through 1/25/26.b. 1/21/26: Rocephin (antibiotic), 1 gram (GM). The order was to inject 1 GM intramuscularly (IM)—meaning injected into the muscle—one time only for bronchitis, until 1/21/26.c. 1/22/26: Metronidazole (antibiotic also known as Flagyl) oral tablet 500 mg. The order was to give one tablet three times a day for Clostridium difficile (C. diff)—an infection in the bowels—for 10 days. Resident #2's January 2026 Treatment Administration Record (TAR) included an order dated 5/3/25 to monitor for discolored urine, black tarry stools, sudden severe headache, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status, vital signs, shortness of breath, and nose bleeds. Staff documented 'N' if they monitored and observed none of these symptoms. They documented 'Y' if they monitored and observed any of these symptoms, requiring a progress note with findings twice a day. The documentation showed 'N' on 1/24/26 and 1/25/26, with a 'Y' noted on 1/26/26. The MAR and TAR did not include an order for an INR. The Nursing Note dated 1/19/26 at 11:00 AM Resident #2's wife showed the nurse Resident #2's INR of 3.9. The nurse received a call from Staff C, who was the Anticoagulant Provider. Staff C gave a new order to hold the warfarin night and begin 3 mg of warfarin once daily. The Nursing Note dated 1/21/26 at 8:00 AM The nurse informed the Medical Doctor (MD)—the primary physician—about Resident #2's changes in condition. The MD gave new orders to administer Rocephin 1 GM IM day and the following day for bronchitis. The MD directed staff to schedule Resident #2 for rounds on Friday, 1/23/26. The Nursing Note dated 1/23/26 at 6:11 PM The nurse received signed orders from the MD to give Rocephin 1 GM IM for five days total. The Nursing Note dated 1/24/26 at 6:40 AM documented the nurse found a 7 cm by 5 cm bruise on Resident #2's mons pubis/penis area. When asked if the area hurt, Resident #2 stated he felt no pain. Resident #2 reported he did not know what happened when the nurse asked. The Nursing Note dated 1/26/26 at 8:00 AM documented staff identified Resident #2 as lethargic extremely sleepy and unable to follow commands. Resident #2's head hung low with his chin resting on his chest, he was drooling, and staff found him difficult to wake up. The Nursing Note dated 1/26/26 at 12:45 PM documented Resident #2's wife showed the nurse an INR reading of 7.3. The nurse spoke with Staff C at the anticoagulation clinic, who managed Resident #2's warfarin plan. Staff C recommended Resident #2 eat cooked spinach or take 1-2 mg of Vitamin K once, hold the warfarin for three days, and recheck the INR on Thursday (1/29/25). Staff C explained the medications Rocephin, metronidazole, and his recent upper respiratory illness would severely affect his INR levels. Staff members tried unsuccessfully to help Resident #2 eat lunch. Resident #2 appeared lethargic, unable to follow commands, had his head hanging low with his chin resting on his chest, and drooled. The nurse saw a noticeable muscle twitching in his left upper arm. When the nurse listened to his lungs, she heard abnormal sounds and observed him cough. Resident #2's condition quickly declined. After the assessment, the nurse sent Resident #2 to the hospital by ambulance. The ED Provider Notes dated 1/26/26 at 2:42 PM reflected Resident #2 arrived at the hospital from the nursing home because of an altered mental status. Resident #2's wife reported he had been sick with a cough and congestion for about one week and started on Rocephin injections a few days prior, along with prednisone. The provider also gave him Flagyl to prevent C. diff. Resident #2's wife reported his condition significantly worsened, and he would not even drink from a straw the day before. On day, he would not respond to her at all. The provider could not complete a full assessment because of Resident #2's change in mental status. Lab results showed a glucose level of 668, while the healthy range was 70 to 100 mg/deciliter (dL)—a measurement of concentration—and an INR of greater than 13.0. Because of the bruising, the Emergency Department (ED) completed an abdomen/pelvis Computed Tomography (CT) Scan—a detailed form of imaging. The CT Scan revealed an uneven, bumpy, thick mass (density) along the lower left rectus sheath, which is the tissue surrounding the abdominal muscle. This finding suggested an acute or subacute hematoma—a large collection of blood under the skin from larger blood vessels. The mass measured 12.3 cm long by 7.8 cm across by 5.3 cm from front to back (AP dimension). Adjacent to this was poorly defined, dense fluid in the left lower section of the abdomen/pelvis, which suggested hemoperitoneum/hematoma—bleeding in the lining of the abdomen, which doctors considered a medical emergency because the large volume of blood the abdomen could hold could lead to hemorrhagic shock. Because Resident #2 lost a large volume of blood, the hospital gave him 2 units of packed red blood cells (PRBC)—meaning blood—and 10 mg of Vitamin K. The provider spoke extensively with Resident #2's wife and son. They decided against pursuing surgery or an interventional radiology procedure. They felt comfortable keeping him in the hospital. Per the Cleveland Clinic article titled Hemoperitoneum updated 12/11/23, hemoperitoneum is blood in the abdominal or pelvic cavity. This condition occurs when something inside the cavity breaks or ruptures, representing an emergency. While it can result from an injury, it can also happen spontaneously, meaning without injury. The Nursing Late Entry Note dated 1/27/26 at 7:32 AM documented the facility called the hospital for an update on Resident #2. The hospital reported Resident #2 received a blood transfusion and a diagnosis of a rectus sheath hematoma an accumulation of blood in the stomach lining surrounding the muscle, usually due to a rupture of the epigastric arteries or a tear in the muscle itself likely caused by a chronic cough. On 2/27/26 at 1:30 PM, Staff E, Registered Nurse (RN), reported Resident #2 went out to breakfast and managed okay. Staff members needed to feed him and ensure he swallowed his food. He needed more help eating but could still chew and swallow. Staff E heard he was well over the weekend and fairly alert. After making sure she could assist him with eating, staff helped him eat lunch. When staff members went to his room, they noticed he was not doing well while in bed. Liquids and food came out of his mouth. His wife approached Staff E and reported Resident #2 had an INR of 7. His wife stated she already contacted the anticoagulant clinic about the INR, and they would provide orders on what to do. Staff E said she knew something was wrong with Resident #2 and urged his wife to send him to the emergency room (ER). When the ambulance arrived, Resident #2 became increasingly lethargic. Staff E described him as a sick person and later learned he passed away at home. On 3/3/26 at 2:20 PM, Staff F, Certified Nurse Aide (CNA), reported staff found the bruise on Resident #2 on 1/24/26. Staff F said she helped Staff D, Licensed Practical Nurse (LPN), care for Resident #2 night. When she went in to do the final rounds, they found the area. When asked about how she provided care, including whether she picked up the penis shaft and placed her hand on the pubis area to hold up the penis while doing care, Staff F stated she did not. She picked up the penis to perform care and then placed it back down. When she and Staff D did rounds between 3:00 AM and 4:00 AM, Resident #2 did not have a bruise there. Staff F stated Resident #2 did not get out of bed night and did not complain anything bothered him or anyone hurt him. Both staff members were shocked when they saw the bruise on his pubis area. Staff F was unsure where the bruise came from and did not believe staff caused this type of bruise. On 3/3/26 at 4:00 PM, Staff D said around 6:30 AM on 1/24/26 Staff F reported Resident #2 had an unusual bruise she had not seen when she performed rounds earlier. Staff D then went in, saw the bruise, and documented it in the progress notes. She told the day shift nurse the area needed watching and monitoring. She asked Resident #2 if someone hurt him and he said no. She asked if someone abused him and he said no. She asked if he had pain and he said no. She asked if he knew what happened and he said no. Staff D faxed a note to the doctor and informed Resident #2's wife about the area. Staff D reported the Medical Examiner (ME) (a public official who investigates deaths) called her about the bruise found in the pubis area and asked what she thought happened. Staff D told the ME she did not know what happened. When Staff D returned to work, she asked about his bruise, but no one knew anything at the time and Resident #2 was already in the hospital. Staff D was not certain how the bruise got there. She recorded it in the progress notes but did not complete a skin sheet. Staff D described the bruise as quite large and deep purple. On 2/27/26 at 2:20 PM, the Advanced Registered Nurse Practitioner (ARNP) stated after she reviewed Resident #2's chart, she determined the abdominal sheath likely caused the bruising to the groin area. She explained the sheath was probably shifting and rupturing, and the blood then moved down to area, which was common. The bruising resulted from the rupture of the membranes and the bleeding followed down to the pubis area. She confirmed the bruise was dark purple. The ARNP explained there was no cure or treatment other than giving Vitamin K and observing him. No local hospital would accept him because they could not treat specific kind of bleeding and its location. Because of this, his family chose to enroll him in hospice care. He left the hospital and went home. On 3/3/26 at 3:10 PM the DON stated the progress notes for Resident #2 described a 7 cm by 5 cm bruise on his mons pubis/penis area. Staff members notified the doctor but did not include follow-up documentation in the progress notes on 1/24/26. Resident #2 went to the hospital on 1/26/26. Staff attributed the bruise to the high INR sent him to the hospital. The nurse who found the area did not take a picture or complete an investigation. On 3/3/26 at 4:15 PM the DON explained Staff D knew about the bruise but did not follow up with staff on an investigation. The DON stated on 1/26/26, the risk management team reviewed the situation and felt Resident #2's bruise resulted from his high INR Monday morning. When questioned about finding the bruise on 1/24/26 but not drawing an INR until 1/26/26, and how one correlated the bruise to a high INR when the INR was not drawn until Monday, the DON admitted she had not considered it that way. The risk management team believed the high INR caused the bruise. The DON acknowledged a bruise could signal abuse and staff needed to investigate any injury of unknown source to find the cause and analysis. She stated staff failed to do this with Resident #2 and would learn from it moving forward. On 3/12/26 at 1:36 PM Resident #2's wife reported she monitored his INR through the hospital. She checked his levels every Monday and they were generally fine until that week. His level increased to 8, which was very high. She immediately took the monitoring machine to the nurses because the result was high, and they called the nurse. She did his testing because the anticoagulant clinic told her they received the results right away if she performed the test. When asked about the bruise on his penis, she reported she learned about it at the hospital. Resident #2's wife stated she usually visited him twice a day but stayed home sick for a few days before he went to the hospital. When she returned, she learned he did not eat well over the weekend. She attempted to help him eat three times that day, but he refused, so they decided to send him to the hospital. Once he arrived at the hospital, they immediately gave him three small bags of blood. They told her he needed the blood due to his significant blood loss and did not expect him to survive the night. He survived from Monday until he passed away at home on Saturday. On 3/12/26 at 2:25 PM, Staff A, CNA, explained a few days before Resident #2 went to the hospital, he felt unwell and did not get out of bed. The morning he went to the hospital he got up and fed himself, had more energy, and ready to get out of bed. Staff A stated she saw his bruise, noting it was not black when she saw it. When she told the nurse, they said they had already documented it. On 3/12/26 at 2:25 PM, Staff I, Licensed Practical Nurse (LPN) reported she had not worked with Resident #2 recently because she worked on the south side. She explained the facility did not have anyone on Coumadin, except veteran patients. The facility typically changed residents from Coumadin because it was difficult to monitor and was an older drug. They did not change the veteran residents because it was their right, and the Veterans Administration (VA) would only pay for Coumadin. On 3/13/26 at 11:25 AM, Staff G, RN, explained Resident #2's wife performed his INRs using her own machine. She would show the nurse the machine, which sent the information directly to the anticoagulant clinic. Staff G assumed the facility had a standing order from the anticoagulant clinic for his INR. She recalled the reading was clearly off, approximately 7. That was the only time Resident #2's wife showed her the number; otherwise, she did not show the number. Staff G assumed the numbers were in the normal range during those other times. Resident #2's wife would tell staff they should receive orders based on his number. She only told them the 7.1 number one time. The anticoagulant clinic worked through his wife, and staff needed to get the orders from her. That day, Resident #2's wife gave Staff G her personal phone to speak with one of the nurses at the clinic, who gave verbal orders. After receiving those orders, staff contacted the local provider for orders, who then confirmed them. Staff tried to get him spinach, but the kitchen did not have any. His wife offered to get some for the kitchen to cook. At lunch, Resident #2 refused to eat because he was very lethargic. He could not follow simple commands to eat; the food stayed in his mouth, and he would not eat. After this, she contacted the DON, and they all agreed to send him to the emergency room (ER). Although they had Vitamin K in an ampule in the Emergency Kit (Ekit)—a supply of medications and equipment for urgent use—they did not give it to him because of how much his condition deteriorated. At that point, they needed to send him to the hospital. Staff G stated they did not have an INR tracking sheet to her knowledge and did not know how frequently they should have monitored his INR. Staff G explained they had other residents on anticoagulant medications, like Xarelto and Eliquis. They performed weekly checks and routine lab work for those residents but had no specific requirements to check for them. They documented the assessments in the TAR. If they found anything abnormal, they documented it in the progress notes; otherwise, everything was fine. Staff G did not see Resident #2's bruise herself. She saw it after an order came back from the physician. Staff D sent a note to the physician, who acknowledged it. When Staff G reviewed the order, she learned of his bruising. By time, Resident #2 was already in the hospital. On 3/13/26 at 12:30 PM the DON explained they rarely saw people on Coumadin because most switched to Eliquis or newer blood thinners. However, the VA was holding off and did not yet cover the newer blood thinners. Resident #2 used Coumadin and had a machine to check his INR. His wife performed the finger poke and showed staff the machine. She would call the anticoagulant clinic to report the result and receive an order. Staff would then document it and get the physician to sign off on the official order. The DON reported they documented the INR in the progress notes and thought they had an INR log but said she would check the progress notes. If his wife was not at the facility to check his INR, they would choose another day to check it, as she visited daily unless she was sick. The DON reported when residents used Coumadin, staff regularly helped them avoid Vitamin K in their diet and watched them closely if they started an antibiotic. If they started antibiotics, the pharmacy typically alerted them. They needed to watch the resident if they took Coumadin because antibiotics effected the INR rate. The DON explained Resident #2 was very ill with a respiratory issue, and the physician ordered an antibiotic for him. Resident #2 had weekly INR orders. The DON did not know if they should have ordered more frequent INR checks. They should monitor for bruising or bleeding gums, which indicated an elevated INR. If staff saw bruising, they needed to report all bruising to the nurse. The nurse should then investigate the cause of the bruise. The DON explained this happened with Resident #2; he got a bruise over the weekend. Staff D was his nurse. Staff reviewed the bruise morning during risk management. Since Resident #2 had a bruise, staff figured it resulted from his high INR. She explained Resident #2 started on an antibiotic Thursday because he saw the physician Friday. The physician added Flagyl because of a history of C. diff. With an order for antibiotics and INR, the physician placed the orders and decided how often to check. The facility did not have a standard order, but they would have to call and check. The DON acknowledged in hindsight, they did not have a standing order for an INR when someone started an antibiotic or an expectation for how often to check the INR. The DON stated she did not know if she would have thought about it if the pharmacy did not flag them. During a follow-up interview on 3/13/26 at 1:25 PM, Staff A reported she did not remember who helped Resident #2 get out of bed. She explained she did not see his bruise herself but knew he had bruises on his lower body. She noted he was diabetic and thought the bruises could have resulted from insulin injections. Staff A stated if she had seen a skin problem, which she did not, she would have talked to the nurse as soon as possible (ASAP) meaning immediately. She believed she helped transfer him with Staff H, CNA. On 3/13/26 Staff H reported she possibly helped Resident #2 get out of bed because she charted on him, but she was not sure. She explained he had bruises on his stomach area and his buttocks were always purple. When asked about the abdominal bruises, she stated he normally had a small amount, but the progress notes should contain everything, as she always reported all her findings to the nurses immediately. Staff H did not remember any private bruising; his penis was eventually black. Staff H added she would have noticed that. On 3/13/26 at 3:10 PM Staff D reported she learned of his bruise sometime after 5:00 AM because that was when she checked blood sugars. He had a HI blood sugar—a high reading exceeded the meter's capacity—and she received orders for 10 units of Novolog (insulin). Staff D did not know how Resident #2 got the bruise. She told the day nurse, Staff J, to monitor him because Staff D had many things happening and was working to lower his blood sugar to a readable number. After this, Staff D did not work for several days. When she returned Tuesday night, she received a report from Staff G about Resident #2 being in the hospital. Staff G explained everything about his INR, but Staff D had no idea about his bruise. On a different night, Resident #2's son called to report he passed away. Staff D reported she asked Staff J to call Resident #2's wife about the bruise that day because his wife was home sick. During the interview Staff D questioned the cause of his high INR and wondered if Flagyl interacted with the Coumadin. She explained if she had placed the order, she would have inquired because staff fax the physician if they receive any alerts and ask questions. Staff D stated they relied on the pharmacist for education. On 3/13/26 at 2:15 PM, the Administrator and the DON reported the facility found the bruising on Resident #2's abdomen during the overnight shift from 1/23/26 to 1/24/26. He had a new bruise, and the nurse created an Incident Report. They explained approximately 36 hours passed between the time the nurse found the bruise and the time Resident #2's wife received the elevated INR result. They stated a bruise would not automatically require the nurse to notify the provider immediately. The record showed the nurse documented finding the bruise on 1/24/26 at 6:40 AM. The nurse also called the doctor for a high blood sugar level on 1/24/26 at 5:59 AM because the Accu-Chek was HI at 5:26 AM. If they had Resident #2 on increased monitoring, staff would have documented it in the progress notes. They noted approximately 36 hours passed between the time staff notified the provider about the high INR and when they found the bruise. When asked about the requirement for shift monitoring and the side effects of blood thinners, they responded staff performed monitoring in some way. The CNAs reported anything abnormal. The nurse did not perform an assessment on everyone every shift. The nurse documented assessing the resident for side effects every shift in the TAR. The documentation in the TAR did not show the nurses identified any signs or symptoms of side effects. They assumed staff would document finding a new bruise. Staff G documented 'Y' (yes to side effects) on 1/26/26. The other entries showed an 'X' on 1/23/26 did not match a code, and on 1/24/26, staff documented an 'N' (indicating no side effects) on the TAR. On the Sunday (1/25/26) shift, the TAR did not contain documentation of the bruising or any other documents. They added the identification of the bruise and the realization of a high INR occurred within a short timeframe, only 24-36 hours. They did not have any photos or documentation of the pelvic bruising in any other part of the system. The Administrator and the Director of Nursing (DON) reported that the facility discovered bruising on Resident #2's abdomen during the overnight shift spanning 1/23/26 – 1/24/26, leading a nurse to create an Incident Report. They noted that approximately 36 hours elapsed between the discovery of the bruise and the time Resident #2's wife was notified of the elevated INR result. They argued that a bruise does not automatically mandate immediate provider notification. According to the record, the nurse documented finding the bruise at 6:40 AM on 1/24/26. Earlier that morning, at 5:59 AM on 1/24/26, the nurse had already contacted the doctor regarding a high blood sugar level, as the Accu-Chek reading was HI at 5:26 AM. Facility representatives indicated that if the resident required increased monitoring, it would have been documented in the progress notes. They reiterated that about 36 hours separated the notification to the provider about the high INR and the initial bruise discovery. When questioned about the requirement for shift monitoring and the side effects of blood thinners, they stated that monitoring was performed in some manner, with CNAs reporting anything abnormal. They clarified that the nurse did not perform a full assessment on every resident every shift, but the nurse documented assessing the resident for side effects every shift in the Treatment Administration Record (TAR). The documentation in the TAR, however, did not show nurses identifying any signs or symptoms of side effects. Staff assumed that finding a new bruise would be documented. On the TAR, Staff G documented 'Y' (yes to side effects) on 1/26/26. Other entries included an 'X' on 1/23/26, which did not correspond to a code, and an 'N' (indicating no side effects) documented on 1/24/26. Crucially, the TAR for the Sunday (1/25/26) shift contained no documentation of the bruising or any other related documents. Finally, they asserted that the identification of the bruise and the realization of a high INR occurred within a short timeframe, only 24-36 hours apart, and confirmed they had no photos or documentation of the pelvic bruising in any other part of the system. On 3/13/26 at 2:50 PM, the Physician reported he could look up the information but did not recall being told about Resident #2's 5 cm by 7 cm pelvic bruise on 1/24/26. He stated he could look it up but did not remember being told. He saw Resident #2 on 1/23/26 and completed a note on him day. He had no way of knowing if staff called him on 1/24/26 and could not remember if he gave a verbal order. On 3/17/26 at 9:50 AM, Staff J explained she arrived the morning after staff found Resident #2's bruise. Staff D reported in rounds she found a bruise, so they went and looked at it together. The bruise appeared as if something, like a pad or brief, had rubbed or pinched his skin. Resident #2 used blood thinners, so they said they would watch the area. They did not notify the doctor or Resident #2's wife. Staff J explained the bruise was not large and looked like the brief sat incorrectly. When she returned to work a few days later, Resident #2 was in the hospital. Resident #2's wife performed his INRs, and Staff J was not involved in process. They recorded the information related to his INRs in the progress notes. For other residents who needed INR checks, the facility drew their blood for INR and sent it to the lab. If they received an abnormal result, they would call the physician and document it in the electronic health record within the lab information.

Based on clinical record review, facility investigation, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, including injuries of unknown source, were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for a resident who sustained a left hand middle finger fracture (Resident #3). The facility failed to conduct a thorough investigation to determine the cause of the fracture. During the interviews, the staff reported they didn't know how his injury occurred and even added they didn't think of abuse. The facility reported a census of 29 residents.Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impaired cognitive decisions. Resident #3 sometimes could understand others and others understood them. They had adequate hearing, and vision with no behaviors or rejection of cares documented. Resident #3 required substantial to maximal assistance with all aspects of daily living (dressing, personal hygiene, transfers, oral hygiene and positioning). The MDS included diagnoses of Non-Alzheimer's Dementia, Polyneuropathy (widespread damage of peripheral nerves, causing numbness, tingling, burning pain, and muscle weakness, starting in the feet and hands), and macular degeneration (common eye disease that destroys sharp, central vision). The MDS lacked documentation of falls since the previous assessment.The Care Plan Focus initiated dated 2/17/23, indicated Resident #3 had self-care deficit related to activity intolerance, Alzheimer's, dementia and paranoid schizophrenia. The Interventions instructed the following:a. Resident #3 required 2 staff for transfers with the full-body mechanical lift, turning and repositioning, movement between surfaces, and a quarter inch bed rail to be used to promote independence with bed mobility. b. Protect Resident #3's arms with long sleeve shirts, place pillows on their side when in bed to protect from bumping arms and feet on the bed. Observe and report any changes to the physician as needed.The Nursing Note dated 1/27/26, labeled late entry at 6:35 AM, documented, the staff notified the nurse of Resident #3's swollen arm. The nurse observed significant non-pitting (a type of swelling where the skin does not indent after pressure is applied) edema (swelling caused by excess fluid trapped in the body tissues) to Resident #3's left-hand with no pain or discomfort when touched. The nurse removed the left arm protector due to circulatory restriction on the arm and elevated on a pillow.The Nursing Note dated 1/27/26 at 11:05 PM, indicated the nurse sent a facsimile with the following communication, noticeable significant edema to left-hand, no pain with movement, and range of motion. No edema elsewhere. Please advise. The facility received the following order from the physician, raise arm above the heart every couple of hours. With a question about the ability to get an X-Ray? Resident #3's swelling decreased per the overnight staff. The X-Ray report dated 1/28/26 at 4:18 PM, documented the impression as an acute non-displaced (a bone break where the pieces remain in their proper alignment) fracture noted through the 3rd middle phalanx (between the proximal and distal).The Nursing Note dated 1/28/26 at 5:31 PM, reflected nursing received a verbal report Resident #3 had a 3rd middle finger fracture. The physician would call the facility with orders. At 7:25 PM, the nurse and physician placed a splint on Resident #3's left-hand middle finger. Resident #3 didn't cooperate during the application of the splint.On 2/26/26 at 3:40 PM, observed Resident #3 lying in bed on their right side wearing a splint on their middle finger of the left-hand. On 3/3/26 at 12:45 PM the Interim Director of Nursing (DON) brought a one-page investigation of Resident #3's fracture, adding in retrospect they could have done a better investigation and looked at all of the possibilities of the fracture of his middle finger. However, the staff said they didn't know what happened and he would get his fingers caught in his shirt. With that information, the Administrator, the Corporation, and her felt they didn't need to report it since the staff didn't know how it happened. They didn't call it in or do further investigations as they thought it was due to his geri-sleeve being too tight. They were shocked the Advanced Registered Nurse Practitioner (ARNP) ordered an x-ray and then it turned up as a fracture. The Interim DON added they should have done more of an investigation since he had a fracture, and no one knew how it happened. She added she couldn't make the decision on whether or not they would notify DIAL. The Interim DON explained she didn't think staff abuse/neglect, she said the staff wouldn't come forward and tell her the truth. Something happened to his finger; they just don't know what.The undated, untitled facility investigation pertaining to Resident #3's fractured left middle finger, documented no staff witnessed anything happen. The investigation reflected Resident #3 constantly rubbed his fingers together, and putting his hands in his shirt. The X-Ray noted degenerative changes. The facility determined the cause of the broken finger as the combination of Resident #3 rubbing his fingers together and his degenerative changes. On 3/3/26 at 1:00 PM Staff A, Certified Nurse Aide (CNA), and Staff B, CNA, reported Resident #3 grabs onto the rails to assist with rolling so they can change him. They both said he had days when he will grab his fingers and pull or twist them. They added they didn't know how his left middle finger got broke but they know he had days with him awake and other days with him sleepy. They said he could have possibly got his middle finger stuck in the top half of his side rails or maybe by twisting his fingers. They added he liked to swing out some days, while other days he remained perfectly content.On 3/3/26 at 1:35 PM the Interim DON acknowledged the facility didn't do a thorough investigation on Resident #3 and understood how thought of abuse could occur due to the fracture of a middle finger. She learned the facility needed to do a better investigation and look at everything that could have possibly happened to his finger and have a file ready. She added she learned something new every day, especially with abuse rising in the facilities it is easy to understand how and what DIAL is looking for to determine abuse didn't occur to any of the residents. On 3/3/26 at 4:45 PM, the Administrator interrupted the regulation as the fracture did not meet the criteria of reporting for injury of unknown origin and disagreed it was a reportable incident. Review of the Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/19/22, all allegations of Resident injuries of unknown origin shall be reported to the Iowa Department of Inspection and Appeals, not later than 2 hours after the allegation is made. Following the investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections and Appeals. This written report shall be forwarded to the Department within 5 days of the initial report.

Based on observation, clinical record review, resident and staff interviews, and facility policy, the facility failed to do document weekly skin location and measurements for 1 of 3 resident reviewed with skin impairments. (Resident #4). The facility reported a census of 29 residents. Findings include:Resident #4's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no impaired cognitive decisions. Resident #4 could understand others and others understood them. They had adequate hearing, and vision. Resident #4 required substantial to maximal staff assistance with dressing and toileting hygiene and partial to moderate assistance with repositioning and total dependence with transfers. The MDS included diagnoses of hypertension (a condition where blood consistently pushes hard against artery walls), diabetes mellitus, pneumonia and non-pressure ulcer of the skin.The Care Plan Focus initiated dated 10/15/25, indicated Resident #4 had a potential/actual impairment to skin integrity, due to an itchy rash on their skin. The Interventions instructed the following:a. Ensure Resident #4 had adequate footwear on at all times, at least non-skin socks. b. Monitor/document location, size and treatment of skin injury.c. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces.d. Weekly treatment documentation to include measurement of each area of skin break downs (width, length, depth, type of tissue and exudate) and any other notable changes or observations.The Skin Observation Tool dated 1/25/26 at 6:41 PM, documented the left and right toes had a skin tear. The documentation lacked measurements. The notes indicated the big toe on the left foot got the skin tear from footboard on the bed. The 5th digit on the right foot, indicated the skin tear resulted from the foot board on the bed. The Skin Observation Tool dated 1/28/26 at 1:44 PM, documented in the notes section, fading bruising to left forearm, Resident #4 continued to have multiple different areas of scratches and small scabs from scratching self. No documentation of location or measurements.The Skin Observation Tool dated 2/4/26 at 10:51 AM, included only the documentation in the notes section. The note indicated Resident #4 continued to have abrasion/skin tears to the bottom of his right foot. The note included Resident #4 had multiple areas of scratches from scratching himself.The Skin Observation Tool dated 2/11/26 at 7:56 AM, included only the documentation in the notes section. The note indicated Resident #4 continued to have abrasion/skin tears to the bottom of his right foot. The note included Resident #4 had multiple areas of scratches from scratching himself.The admission Assessment note dated 2/23/26 at 3:52 PM documented Resident #4 returned from the hospital. The note described his skin as warm and dry. He had normal skin turgor (the skin ability to change shape and return to normal the faster response usually shows adequate fluid intake) with no alteration in skin condition.The re-admission assessment dated [DATE] at 3:52 PM, in the skin section, documented Resident #4's skin as warm, dry, with no alteration in skin noted.The re-admission Braden Scale for Predicting Pressure Sore Risk dated 2/23/26 at 1:26 PM, identified Resident #4 as a high risk for developing pressure sores.The Skin Observation Tool dated 2/25/26 at 4:17 PM, documented Resident #4's right toe skin tear measured 0.5 centimeters (cm) in length by 0.5 cm, and continued to have scabs to the bottom and side of the 5th digit of his right foot. The Skin Issues Note dated 3/2/26 at 11:42 AM, documented the staff evaluated Resident #4's skin issue of the right lateral foot skin tear, wound acquired in-house, it is unknown how long the wound has been present. The wound measured 1.18 cm length by 0.76 cm with no depth and noted as improving.On 2/26/26 at 2:15 PM, observed Resident #4 lying on his back with the bottom of his feet resting against the foot board on his bed. On 2/26/26 at 2:15 PM, Resident #4 stated his feet rest against the foot board at the end of his bed and felt that caused the sores on the bottom of his right foot and toes.On 2/27/26 at 10:24 AM, observed Resident #4 lying in bed with the bottom of his right and left foot resting against the foot board.On 3/3/26 at 11:00 AM, the Director of Nursing acknowledged the clinical record lacked documentation of the locations and size of the areas on the bottom of Resident #4's right foot. The DON reported they expected the nursing staff to follow the facility policy on documenting weekly skin locations and measurements.The Weekly Skin Assessment and Documentation Process dated 1/20/23, instructed the facility wound nurse to address all skin ulcers and non-ulcers and document them weekly. The nurse who initially identified the skin issue would complete the appropriate skin assessment. They would complete a separate skin assessment for each identified skin/wound alteration. The staff would update and review the Care Plan to ensure it included the identification of the skin/wound alteration and appropriate.

Based on observation, clinical record review, policy review, resident, family, and staff interviews, the facility failed to provide needed services in accordance with professional standards by not assessing, intervening and documenting for a resident with a wound for 1 of 3 resident reviewed (Resident #1). In addition, the facility failed to assess his lower legs when applying or removing his ankle, foot brace (AFO) as ordered by the physician. Resident #1 had a wound on their right shin, that went unidentified until dermatology observed while at his appointment for a different situation. The clinic took a sample of the wound while at the dermatology appointment and ordered an antibiotic along with a culture of the drainage of the wound. The lab results grew Methicillin resistant Staphylococcus aureus (MRSA a type of staph bacteria that is resistant to many antibiotics use to treat infections). The facility identified a census of 31 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required dependent assistance for activity of daily living (ADL) and no skin issues. The MDS included diagnoses of hypertension (high blood pressure), cerebrovascular accident (stroke), hemiplegia (inability to control one side of the body), hemiparesis (weakness of one entire side of the body), anxiety and depression. The Care Plan Need revised 12/27/24 indicated Resident #1 had an ADL self-care performance deficit related to hemiplegia, impaired balance, limited mobility, limited range of motion (ROM), and stroke. The Interventions directed: a. Revised 10/31/24: Resident #1 wore an ankle, foot brace (AFO) on his right foot, staff to inspect his skin before and after applying the AFO. b. Revised 4/26/23: Resident #1 required skin inspection once a week. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. The Care Plan Need revised 2/7/25 indicated Resident #1 had an infection of infected skin area on his right lower extremity, mid shin. He received antibiotics for treatment of the infection. The Interventions directed to give antibiotics as ordered and report any signs of adverse reactions to the nurse and physician. Interview on 2/18/25 at 2:45 PM, Resident #1, stated the staff come in the morning and put on his AFO and then at night they take off the AFO to his right lower extremity, but has no knowledge if they check his skin. Resident #1 stated that during a routine dermatology appointment, the dermatologists looked at his skin underneath his pant leg and found the wound on his right shin, pushed on the wound and a white substance started to drain out from underneath a dark scab. The Dermatologists suggested to get a culture of the wound and started him on an antibiotic until the results of the wound culture came back. Interview on 2/19/25 at 10:00 AM, Resident #1 family, stated that during a routine dermatology appointment, the dermatologists wanted to take a look at Resident #1 legs. The dermatologists proceeded to pull up the right pant leg and noticed a blackened area underneath the Velcro strap, the dermatologist saw a white substance oozing out of the scab and started to squeeze and more white substance started to drain. The dermatologists decided to order a culture of the white substance and put Resident #1 on an antibiotic until the results came back from the culture. The Certified Nursing Assistant (CNA) Shower Skin Report dated 2/4/25, included a section regarding skin issues observed. The section of the form remained blank. The instructions indicated if no skin concerns noted please indicated no skin concerns. The Nursing Communication form dated 2/6/25, signed by the physician, directed to get a culture of the sore on Resident #1's right shin, add Mupirocin (antibiotic) ointment twice daily for 10 days and leave open to air, no bandages. Can apply to all open areas on lower extremities. Add cephalexin (antibiotic) 500 milligrams three times a day for 10 days. The Skin and Wound Evaluation V7.0 form dated 2/6/25 at 3:14 PM, documented a skin tear to Resident #1's front right lateral (side) lower leg, in house acquired. The area measured 2.2 centimeters (cm) area, 2.0 cm length by 1.5 cm width. The form described the wound as a scab (a hard-dried crust that forms over a cut or wound) with erythema (redness that may be intense bright red to dark red or purple) of the area around the skin. Resident #1's February 2025 Treatment Administration Record (TAR) listed an order dated 12/7/21 to complete a head to toe skin audit weekly on Tuesdays. The order included instruction to please take photos and measurements as directed by the skin and wound application. The order lacked documentation for the date of 2/4/25. The Nursing note dated 2/6/25 at 3:04 PM indicated Resident #1 returned from his dermatologist appointment with new orders for cephalexin 500 milligrams three times a day for 10 days due to the infected skin area on his right lower extremity, mid shin. The orders directed to leave open to air and no bandages. Apply topical Mupirocin ointment (to treat skin infections) twice daily for 10 days to all 3 areas. Resident #1 had 2 areas on the right lower extremity and one on the left knee. The provider cultured the wound on the right shin. The Nursing note dated 2/7/25 at 2:38 AM, indicated Resident #1 began an antibiotic for his skin. The note reflected Resident #1's areas to his shin and legs remained open to air, without drainage noted. The wound had redness observed on his right shin. The Nursing Note dated 2/7/25 at 11:28 AM reflected Resident #1 received cephalexin as ordered for skin infection. The facility waited for culture of the fluid to return. The nurse cleaned the area on the right lower extremity well and top softened to remove the scabbed area, no drainage observed at the time. Peri wound (skin surrounding a wound) is red and warm. Some discomfort noted with pressure and treatment of topical antibiotic ointment applied to all areas in need of treatment. No adverse issues noted with oral antibiotic. The Order Note dated 2/10/25 at 5:34 PM documented cephalexin as discontinued by Dermatologist/prescriber. The Nursing Note dated 2/11/25 at 3:18 PM reflected Resident #1 continued to take doxycycline (oral antibiotic to treat infections caused by bacteria) for skin infection to right lower leg. Resident tolerated medication well with no adverse reactions noted. Resident #1's lower legs had scabs present with the surrounding skin pink to all areas. The areas appeared improved and healing. They would continue to observe. The Nursing Note dated 2/12/25 at 12:38 AM, identified Resident #1 took doxycycline for MRSA (infection that doesn't respond to certain antibiotics) leg wounds. He denied pain in his wounds and had areas on his legs left open to air. The Infection Note dated 2/12/25 at 10:13 AM indicated Resident #1 continued to take an antibiotic, but specific antibiotic changed due to culture and sensitivity. His wounds didn't show erythema or discharge. He denied pain and no adverse effects observed due to change in antibiotic at the time. The clinical record lacked documentation of completed skin assessments after removing or applying Resident #1's AFO before and after the identification of the infection in his lower legs. Interview on 2/17/25 at 4:45 PM, Staff C, Certified Nursing Assistant (CNA), stated the staff removed Resident #1's AFO from his right lower extremity at night. Staff C confirmed his clinical record didn't have documentation of completed skin checks after removing the AFO at night or when put on in the morning. Interview on 2/18/25 at 9:03 AM, Staff D, Licensed Practical Nurse (LPN), verified Resident #1's clinical record didn't have documentation of the completed skin after they removed Resident #1's AFO at night or put on in the morning. Interview on 2/18/25 at 10:15 AM, Staff E, LPN, confirmed Resident #1's clinical record didn't have documentation of completed skin checks when removing the AFO at night or put on in the morning. Interview on 2/19/25 at 1:00 PM, the Director of Nursing verified Resident #1's clinical record lacked documentation of the completed skin checks before or after removing the AFO or putting it on him. The facility failed to check Resident #1's skin per his Care Plan. The undated Weekly Skin Assessment Policy listed the purpose as to ensure timely identification, prevention, and management of skin conditions, including pressure ulcers, in residents at the facility. a. Frequency: i. A comprehensive skin assessment must be conducted weekly for all residents. ii. Additional assessments may be required based on changes in the resident's condition, such as new wounds, health decline or hospitalization . b. Assessment Components: i. Visual inspection of the entire body, focusing on high risk areas ii. Palpations to assess for skin temperature, moisture and texture. iii. Documentation of the findings including: A. any areas of concern, redness, open area, moisture related skin damage B. any signs of pressure ulcer or wounds C. Interventions provided for existing wounds, such as dressings or treatments D. Changes in skin condition compared to the previous assessment. c. Communication and Reporting: i. Weekly skin assessment findings must be communicated to the interdisciplinary team for care planning and coordination. ii. Any notable changes in the resident's skin condition should be promptly escalated to the appropriate healthcare provided for further evaluation.

Based on clinical record review, staff interview, policy and procedure review, the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 3 resident reviewed (Resident #2). The facility identified a census of 31 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severe memory impairments. Resident #2 displayed physical behaviors (hitting, kicking, scratching and grabbing) towards others. Resident #2 required substantial to maximal assistance with all activities of daily living (ADL) including ambulation. The MDS included diagnoses of Alzheimer's disease and non Alzheimer's dementia. The Care Plan Focus initiated 1/7/25 reflected Resident #2 required help with cares. The Interventions directed the following: a. He can become aggressive and combative with staff during care. He resists changing, toileting, bathing. Approach him calmly and have assistance present during his care. b. Resident #2 did better with peri care if someone held his hands while the other person assisted with washing him. It also helped if they talk to him to help keep him distracted. The Care Plan Focus initiated 1/9/25 indicated Resident #2 had a potential to be physically aggressive. The Interventions directed the following: a. Give Resident #2 as many choices as possible about care and activities. b. When he becomes agitated: Intervene before agitation escalates; guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. An undated, untitled, and unsigned form provided by the facility reflected Staff A, Certified Nurse Aide (CNA), reported on 1/22/25 they assisted Staff B, CNA, provide evening care to Resident #2. Upon entering the room, the staff found Resident #2 with his eye closed resting in his recliner. Staff B told Staff A to Resident #2's hands as she had the other hands, then she yanked him and acted very rough during the process of undressing and completing peri-cares. As Resident #2 received help, he became physically aggressive towards the staff. Staff A explained he attempted to comfort Resident #2 during his care by placing his hand lightly and gently on Resident #2's shoulder. Resident #2 continued to have physical aggression, as common behavior with dementia. The facility corrected the action by suspending Staff B pending the internal investigation. The facility initiated the investigation while including resident and staff interviews. The facility educated staff on timely reporting. The Summary of Findings dated 1/23/25 written by the Director of Nursing (DON), documented on 1/22/25, Staff A reported a concern regarding the cares provided by Staff B during the evening of 1/16/25. Subsequent interviews with residents indicated they felt safe and treated with respect and dignity, with no concerns about their care. Staff members who work closely with Staff B described them as helpful and attentive, with no concerns about the quality of care provided. Resident #2 had a history of physical and aggressive behaviors and mood related to his dementia. He is Care Planned to have staff assist times two with all cares to protect him and staff. The Nursing note dated 1/14/25 at 5:38 AM described Resident #2 as more cooperative with cares assist times 3. After the last rounds Resident #2 got up two times wandering around in the hallway in a T shirt and brief. Staff able to redirect with minimal difficulty. Resident #2 sat in the lounge chair at that time, as he enjoyed a Pepsi. Resident #2 remained calm. The Nursing note dated 1/22/25 at 12:45 PM indicated the staff attempted multiple times to get Resident #2 up for the day. Resident #2 refused to allow staff to assist him out of bed. The staff changed Resident #2's incontinent briefs, he continued to lay in bed at that time. The Nursing note dated 1/22/25 at 1:53 PM Resident got out of bed and sat at the table eating lunch. No behaviors noted. The Clinical Record lacked documentation of the 1/16/25 incident. Interview on 2/17/25 at 10:00 AM, the Facility Administrator confirmed all resident are to be treated with respect and dignity from staff at all times. Interview on 2/17/25 at 3:00 PM, the facility Director of Nursing (DON), verified all staff are expected to treat residents with dignity and respect per the policy/procedure. An Education form dated 1/31/25, given to surveyor by the Administrator on 2/19/25 at 4:15 PM, documented: Handling a combative resident requires a careful and compassionate approach. a. Stay calm and professional, maintain a calm demeanor, your body language and tone can influence the resident's behavior. b. Assess the situation: determine the cause of the combative behavior. It could be due to pain, confusion, fear or frustration. c. Use De escalation Techniques, speak softly and use simple language, offer reassurances, avoid physical confrontation, give the resident space to reduce feeling of being trapped. d. Redirect Attention, change the focus of the conversation or activity, introduce a calming activity or a favorite topic. e. Involve other staff, if the situation escalates, seek help from other staff members, teamwork can provide additional support and safety, ensure that the care plan identifies these behaviors and interventions. f. Implement safety measures: ensure the environment is safe for both the resident and staff, remove any potential hazards, if necessary, follow protocols for managing aggressive behavior, including calling for additional help. The Resident Rights policy updated 12/16/22, defined its purpose as that all resident have their rights guaranteed to them under Federal and State laws and regulations. This policy is intended to outline resident rights requirements in long term care communities. a. All resident have the right to be cared for with respect, enhancing self esteem and self worth while incorporating the resident unique goals, preferences, and choices. Staff will value a resident's preferences and honor their input during altercations. b. Care for all residents will be done with respect and dignity in an environment that promotes quality care coupled with recognition of each resident's individuality. c. All resident will be treated with dignity and respect. d. All staff will engage in activities with residents with respect, enhancing self esteem and self worth while incorporating and honoring the resident's unique goals, preferences, and choices.

Based on clinical record review, the Resident [NAME] of Rights, facility investigation, staff interview, and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents (Resident #2) were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours. See F550 for additional information regarding Resident #2. The facility reported a census of 31 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severe memory impairments. Resident #2 displayed physical behaviors (hitting, kicking, scratching and grabbing) towards others. Resident #2 required substantial to maximal assistance with all activities of daily living (ADL) including ambulation. The MDS included diagnoses of Alzheimer's disease and non Alzheimer's dementia. The Care Plan Focus initiated 1/9/25 indicated Resident #2 had a potential to be physically aggressive. The Interventions directed the following: a. Give Resident #2 as many choices as possible about care and activities. b. When he becomes agitated: Intervene before agitation escalates; guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. An undated, untitled, and unsigned form provided by the facility reflected Staff A, Certified Nurse Aide (CNA), reported on 1/22/25 they assisted Staff B, CNA, provide evening care to Resident #2. Upon entering the room, the staff found Resident #2 with his eye closed resting in his recliner. Staff B told Staff A to Resident #2's hands as she had the other hands, then she yanked him and acted very rough during the process of undressing and completing peri-cares. As Resident #2 received help, he became physically aggressive towards the staff. Staff A explained he attempted to comfort Resident #2 during his care by placing his hand lightly and gently on Resident #2's shoulder. Resident #2 continued to have physical aggression, as common behavior with dementia. The facility corrected the action by suspending Staff B pending the internal investigation. The facility initiated the investigation while including resident and staff interviews. The facility educated staff on timely reporting. The Summary of Findings dated 1/23/25 by the Director of Nursing (DON), documented on 1/22/25, Staff A, CNA, reported a concern regarding the cares provided by Staff B, CNA, during the evening of 1/16/25. Subsequent interviews with residents indicated that they feel safe and treated with respect and dignity, with no concerns about their care. Staff members who work closely with Staff B described as helpful and attentive, with no concerns about the quality of care provided. Resident #2 has a history of physical and aggressive behaviors and mood related to his dementia. He is care planned to have staff assist times two with all cares to protect him and staff. Resident #2's Clinical Record lacked documentation of the 1/16/25 incident. Interview on 2/17/25 at 10:00 AM, the facility's Administrator confirmed the facility failed to notify DIAL of the incident between Resident #2 and Staff B within the 2-hour time frame. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated May 2023, instructed all allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made.

Based on observations, interviews, and record review, the facility failed to provide proper interventions to ensure doctor's orders reflected the current need of residents for 1 out of 5 residents reviewed (Resident #11). During a meal observation, Resident #11 was served a mechanical soft textured diet. The doctor's order for Resident #11's diet was pureed textured diet. The pureed diet textured order was obtained without ensuring this was the correct diet for him after a nursing trial was completed. The facility reported a census of 32 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that Resident #11's diagnoses included . A Brief Interview for Mental Status for this resident revealed a score of 9 out of 15, which indicated moderately impaired cognition. This resident was independent for eating. A physician's order dated 4/25/24, documented that Resident #11's was to have a mechanical soft textured diet. A physician's order revised 7/15/24, documented that Resident #11's was to have a pureed textured diet. On 7/17/24 at 12:51 p.m., lunch service began at 12:00 p.m Staff A, [NAME] dished up ground hamburger over buttered bread, mixed vegetables and mashed potatoes for Resident #11. It was noted that Resident #11's diet order was for pureed texture. Staff A was preparing to hand the meal off to a server who would bring the tray to Resident #11. The cook was stopped after dishing the food up but prior to her serving and inquired about this. Staff A stated Resident #11's did not have an order for pureed texture, his diet order is for mechanical soft'. She served the meal. After the meal service, the order was checked in this resident's electronic health record and it showed he was to receive pureed textured food. The Certified Dietary Manager (CDM), was asked about the diet discrepancy. This CDM also said that Resident #11's doctor's order was for mechanical soft textured food. The CDM added that they only trialed pureed textured food for Resident #11. The CDM stated that Resident #11 had a stroke and nursing wanted to trial pureed consistency to see how Resident #11 tolerated it. The CDM stated that she and Staff B, Licensed Practical Nurse (LPN), just had a discussion about Resident #11's diet and it was decided that they would stay with the mechanical soft diet as Resident #11 did much better with the diet. Staff B was asked about the diet and Staff B concurred with the CDM. Staff B stated they never got an order for pureed textured food for Resident 11. When told the order was for pureed, Staff B asked who got that order?. Staff B stated they had just trialed the pureed diet for a day or so to see if Resident #11 would eat more food and it was found that he actually did better with mechanical soft textured, so they kept the diet at mechanical soft textured. Observation of Resident #11 during the meal revealed that he was chewing and swallowing the food and did not have any coughing episodes or difficulty swallowing the food. This observation revealed that Resident #11 ate approximately 80% of what was on his plate. On 7/17/24 at 1:48 p.m., Staff B stated that on Friday 7/12/24, one of the caregivers asked if they could try pureed textured diet for Resident #11 due to drowsiness in the afternoon. Staff B stated they could try for supper. Staff B stated they did try a pureed texture diet for supper and Resident #11 was holding his liquid supplement in his mouth and reaching for his food. Staff B stated she was off for the weekend and the plan was to continue with the trial of the pureed textured diet for three days per nursing judgement for the downgrade of Resident #11's diet. Staff B stated she had worked 6 a.m. to 6 p.m., that day and talked to the night nurse and together they decided to try it for the weekend. Staff B returned to work on Monday 7/15/24. Staff B stated the CDM asked Staff B what the plan was for Resident #11's diet. Staff B stated she told the CDM to serve mechanical soft texture and Staff B would observe how Resident #11 tolerates the food. Staff B stated that Resident #11 had become more alert over the weekend and wanted regular food. He was really sleepy since his ER visit. No documentation over the weekend. Staff B, after the observation, told the kitchen to continue on with the mechanical soft textured diet, and they wouldn't be changing his diet to pureed. Staff B stated there was not a doctor's order obtained for the pureed by her as she was downgrading the diet per nursing judgement. The Director of Nursing (DON), stated that she talked with the Registered Dietitian (RD) on 7/15/24. The DON said the RD talked with the DON about the pureed food trial for Resident #11. The DON stated she went ahead and obtained a doctor's order for pureed textured diet on 7/15/24 without talking to Staff B because it was so busy. The DON stated she was just trying to help Staff B out. So [NAME] told [NAME] that we needed to decide either to continue it or change it back to mech soft either way we needed an order for it. The DON stated she should not have changed Resident #11's diet order without assessing the outcome of the pureed textured diet trial. An Assessment/Reassessment Change of Condition policy revised on 5/30/23, directed the staff as follows: RESPONSIBILITY: Director of Nursing, Licensed Nurses PURPOSE: To complete a comprehensive assessment of a resident, ensuring the resident receives treatment and care in accordance with professional standards of practice while taking into consideration an individual's unique cultural, spiritual, and physical needs. Documentation and verbalization (report) of pertinent data collected will ensure continuity of care amongst other members of the health care team. Documentation is a verifiable written record of events identifying that effective nursing care was provided. PROCEDURE: The licensed nurse assessment identifies current and future care needs of the resident by identifying normal and abnormal human physiology and helps to prioritize interventions and care. The Licensed Nurse will document observations, action taken and responses to interventions/orders, recording at consistent time intervals. The resident will be added to the Hot Charting list upon admission and when a change of condition is identified. Assessment/reassessment will address pertinent subjective, objective and physical assessment information regarding the resident's condition. Any licensed nurse, on any shift, may place a resident on the Hot Charting list. The list will identify residents requiring follow-up assessment/reassessment and documentation during each shift. The charge nurse will monitor residents with conditions requiring re-assessment, until the condition is resolved/stabilized. As a general guide, residents will remain on the Hot Charting list in accordance with the facility Guidelines for Documentation of Changes in Condition. The physician and POA/ responsible party, will be kept informed of the resident's condition/status.

Based on nursing schedule review, staff interview and policy review, the facility failed to have 8 hours Registered Nurse (RN) coverage. The facility reported a census of 32 residents. Findings include: Review of the nursing schedule dated 4/1/24 lacked documentation of RN coverage. Review of facility policy titled, Nursing Coverage and Compliance, updated 3/12/21 revealed the purpose was to define the requirements for nurse coverage in the facility to ensure the health and safety of residents. The policy further revealed an RN is scheduled to include 8-hour coverage per day. During an interview 7/16/24 at 12:23 PM, the Administrator revealed the facility did not have 8 hours of RN coverage on 4/1/24 as the Director of Nursing (DON) had been scheduled to work and did not. The Administrator further revealed a minimum of 8 hours of RN coverage a day is a regulation.

Based on interview and record review, the facility failed to notify of changes in benefit coverage for 2 out of 3 residents reviewed (Residents #87 and #88). The facility reported a census of 32 residents. Findings include: The facility did not provide the Notice of Medicare Non-Coverage (NOMNC) for Resident #87 and Resident #88 when they were requested during the survey. Both residents received Medicare Part A services and the services were ending . On 7/17/24 at 11:12 a.m., the Administrator acknowledged the facility did not issue the NOMNC for Resident #87 and Resident #88. The Administrator stated the facility has since provided education to the Social Services Designee (SSD). The Administrator stated that the SSD didn't realize she needed to fill out 2 forms, therefore the NOMNC was not filled out nor was it given to Residents #87 and #88. The administrator updated the policy to reflect the use of the NOMNC. A Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 policy dated 7/17/23, directed the following: A Medicare provider or health plan (Medicare Advantage plans and cost plans , collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Note: The two day advance requirement is not a 48 hour requirement.

Based on clinical record review, staff interview and policy review, the facility failed to notify the Long Term Care Ombudsman (LTCO) of a discharge/transfer to the hospital for 1 of 1 residents reviewed for hospitalization (Resident #13). The facility reported a census of 32 residents. Findings include: Clinical census review revealed Resident #13 discharged from the facility to the hospital on 3/18/24 and returned to the facility 3/25/24. Review of the clinical record lacked Long Term Care Ombudsman (LTCO) notification documentation that Resident #13 had been discharged to the hospital on 3/18/24 as required by federal regulation. Review of undated facility policy titled, Ombudsman Notice of Transfer or Discharge, documented copies of notices for emergency transfers must be sent to the Office of the State LTCO on a monthly basis. During an interview 7/17/24 at 10:08 AM, the Administrator revealed they were unable to locate documentation regarding notification of the LTCO for Resident #13's 3/18/24-3/25/24 hospitalization . The Administrator further revealed it is an expectation the LTCO is notified when a resident is discharged from the facility to the hospital.

Based on clinical record review, staff interview and policy review, the facility failed to notify the resident or resident representative of the facility's bed hold policy for 1 of 1 residents reviewed for hospitalization (Resident #13). The facility reported a census of 32 residents. Findings include: Clinical census review revealed Resident #13 discharged from the facility to the hospital on 3/18/24 and returned to the facility 3/25/24. Review of Resident #13's clinical record lacked documentation of the resident or resident representative being notified of the facility's bed hold policy with the 3/18/24-3/25/24 hospitalization . Review of facility policy titled, Bed Hold Policy, revised 7/27/15 revealed a resident's bed will be held when he/she needs to be transferred to a hospital or for therapeutic leave. This policy will be presented to each Resident or Responsible Party upon admission and again when hospitalization or therapeutic leave has been confirmed. During an interview 7/17/24 at 10:08 AM, the Administrator revealed they were unable to locate bed hold documentation for Resident #13's 3/18/24-3/25/24 hospitalization . The Administrator further revealed it is an expectation the resident or resident representative is notified of the facility's bed hold policy when a resident is discharged to the hospital.

Based on observation, clinical record review, policy review and staff interview the facility staff failed to do the scheduled controlled medication shift counts as directed by facility policy. In addition, the facility failed to destroy a discontinued narcotic medication for 1 out of 3 residents reviewed (Resident #1). The facility census was 31 residents. Finding include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS included diagnoses of arthritis, osteoporosis, recent hip fracture, Alzheimer's dementia, and anxiety. Resident #1 received an opioid (pain medication) in the 7-day lookback period. The After-Visit Summary dated 11/6/23 included an order for Oxycodone (pain medication) 5 milligrams (mg) immediate release tablets. The order directed to give 0.5 tablets, (2.5 mg total) by mouth every 6 hours as needed for pain. Resident #1's November 2023's Medication Administration Record (MAR) listed the order for Oxycodone 5 mg, give 0.5 tablet by mouth every 6 hours as needed. - Documentation indicated Resident #1 received a dose for a pain level of 10, indicating severe pain on 11/6/23 at 5:59 p.m. The Nursing Note dated 11/7/23 at 10:19 a.m., indicated Resident #1 saw the provider who discontinued her Oxycodone order. The Physician telephone orders dated 11/7/23, included an order to discontinue Oxycodone. The Progress Notes dated 11/8/24 at 8:21 a.m., documented new orders to start Oxycodone 2.5 mg by mouth every 4 hours as needed for pain. The Facility's Self-Report dated 11/8/23, included the following Description of Alleged Occurrence: The provider discontinued Resident #1's Oxycodone order on 11/7/23 at 10:15 a.m. The facility discovered the Oxycodone medication card with the remaining 37, (half tabs), and narcotic count sheet missing on 11/8/23 at 8:45 a.m. On 4/10/24 at 11:30 a.m., Staff A, Registered Nurse (RN), stated that on 11/7/23, the primary care physician (PCP) came to the facility to do rounds, as Resident #1 appeared more lethargic and didn't track. The PCP discontinued the Oxycodone; however, Staff A didn't destroy the Oxycodone as directed by the facility policy/procedure when a narcotic is discontinued. Staff A left the medication card and the narcotic sheet in the medication narcotic box and binder. Staff A and Staff B, licensed practical nurse (LPN), did the narcotic count at 6:00 p.m., on 11/7/23. Staff A and Staff B failed to do the narcotic count per the facility's policy/procedure. On 11/8/23 at 6:00 a.m., Staff A and Staff B proceeded to do narcotic count again. They continued to not follow the facility policy and procedure for counting narcotics. Staff A stated that when the staff gave Resident #1 a shower, she complained about hip pain. Staff A called the physician and received orders to re-start the Oxycodone for Resident #1. Staff A, knowing no one destroyed the Oxycodone after the PCP discontinued the order on 11/7/23, she went to the narcotic box. When she looked in the narcotic box, she discovered Resident #1's Oxycodone card and narcotic sheet missing. Staff A went to the facility's Director of Nursing (DON) and Administrator and explained what happened, then they started an investigation. On 4/10/24 at 2:30 p.m., Staff B, confirmed they didn't complete the narcotic count as directed by the policy and procedures with Staff A on 11/7/23 at 6:00 p.m., and on 11/8/23 at 6:00 a.m. Staff B couldn't confirm if the narcotic box contained Resident #1's Oxycodone. On 4/11/24 at 2:10 p.m., the Administrator verified they expected the nursing staff to count the medications per facility policy/procedure. If the provider discontinued a narcotic medication, the facility must waste the medication right away with another nurse. On 4/11/24 at 11:00 a.m., narcotic controlled count completed by Staff C, LPN, and Staff D, RN. Both nurses verified the count as accurate. They followed the facility policy and procedure for counting narcotics. The Narcotic Count Policy dated 5/2/23, Purpose: The purpose of this policy is to ensure that all narcotic medications are safely and securely stored, administered, and accounted for in accordance with state and federal laws and regulations. A narcotic count will be completed by two employees within 60 minutes prior to the end of each shift. Any unresolved discrepancies/errors will be reported to the director of nursing for follow-up. Narcotics wasted will be witnessed and cosigned by two employees, including the RN, LPN or CMA. Narcotic wasted will be witnessed and cosigned by two employees.

Based on observations, record review, policy review, and staff interview the facility failed to complete proper hand hygiene during cares for two of three residents reviewed (Resident #23 and Resident #33) and failed to cover residents' personal laundry and linen during delivery rooms and halls to maintain standard precaution for infection control. The facility reported a census of 37 residents. Findingd include: 1. The Minimum Data Set (MDS) assessment for Resident #28 dated 5/11/2023, included diagnoses of Non-Traumatic Brain Dysfunction, Non-Alzheimer's Dementia, Anxiety Disorder, and depression. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, personal hygiene and was always incontinent of bladder and bowel. The MDS documented no Brief Interview for Mental Status (BIMS) completed, indicating severe cognitive impairment for decision-making. During an observation on 8/1/23 at 5:20 PM, the Director of Nursing (DON), Staff B, Certified Nurse Aide (CNA), and Staff C, CNA transferred Resident #28 from the recliner to a wheel chair, and was taken to the shower room. All 3 staff washed hands, applied gloves, and transferred the resident to the toilet with the DON holding the resident's hands. Staff B and Staff C removed the resident's pullup, with a large amount of bowel movement (BM) in the pull-up, front peri area, and between/on buttocks. Staff C cleansed the front peri area folding the cloth for each wipe, removed gloves, washed hands and applied new gloves. Staff C cleansed the buttocks and buttock area, removing a large amount of BM, with visible BM on Staff C's gloves. Staff C proceeded to remove gloves, did not complete hand hygiene, applied new gloves, and with gloved hands pulled up resident's pants, and touched resident's arm and hands. 2. The MDS assessment for Resident #33 dated 7/4/2023, included diagnoses of Alzheimer's Dementia and Adult Failure to Thrive. The MDS documented the resident required limited assistance of 1 staff for dressing, toilet use, personal hygiene and was frequently incontinent of bladder and bowel. The MDS documented no BIMS, indicating severe cognitive impairment for decision-making. During an observation on 8/2/23 at 8:34 AM, Staff D, Certified Medication Aide (CMA) entered Resident #33's room, did not complete hand hygiene, and applied gloves. With Resident #33 sitting on the toilet, Staff D removed the resident's pull-up, which was damp and with BM smear. Staff D proceeded to remove her gloves (did not complete hand hygiene), applied new gloves, removed the resident's shoes and pants, and proceeded to cleanse and dry the resident's peri area. Staff D then removed her gloves, washed hands, applied new gloves, and assisted resident to the recliner. 3. Observations on 7/31/23 at 12:36 PM, 8/1/23 at 2:05 PM, and 8/3/23 at 3:01 PM revealed laundry cart with clean clothing being distributed to residents. The cart was being pushed down the hallways uncovered. Review of facility policy titled Essential Infection Control Hand Hygiene updated 5/2/23, documented employees shall use waterless hand rub or soap and water to clean hands before donning gloves and after removing gloves and when moving from a contaminated body site to a clean body site during resident care. During an interview on 8/03/23 at 10:47 AM, the Director of Nursing stated expectation to wash hands before applying gloves to assist residents and wash hands after removing gloves after providing cares and before applying new gloves.

Based on record review, staff interview, and policy review the facility failed to ensure the code status was correct in the electronic health record and the Iowa Physician Orders for Scope of Treatment (IPOST) for 1 of 16 residents' charts reviewed (Resident #5). The facility reported a census of 37. Findings include: The Minimum Data Set (MDS) assessment for Resident #5 dated [DATE], included diagnoses of heart failure and diabetes. The assessment indicated the resident had a Brief Interview for Mental Status score of 15, no cognitive impairment for decision making. Resident #5's electronic health record documented a Physician's Order dated [DATE], for Cardiopulmonary Resuscitation (CPR)/ Attempt Resuscitation (person has no pulse and is not breathing). Resident #5's IPOST, signed by the resident and the physician on [DATE], documented Do Not Attempt Resuscitation (DNR). Resident #5's Medication Review Report signed by the physician on [DATE], documented an order for CPR/Attempt Resuscitation (person has no pulse and is not breathing). Facility policy titled CPR Policy/Resuscitation Policy/Code Status Policy, revised [DATE], documented physician orders will be followed up to the point that new (different) orders are received and if preferences change, new orders will be obtained from the physician. During an interview on [DATE] at 3:15 PM, the Director of Nursing confirmed the resident had changed her IPOST to DNR, that was the resident's preference, and the expectation for the physician's order and IPOST to match and be correct.

Based on clinical record review, policy review, and staff interviews, the facility failed to notify the physician of a significant weight loss of 1 of 15 resident's reviewed (Resident #4). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed diagnoses of heart failure, Non-Alzheimer ' s dementia, paranoid schizophrenia, anxiety and depression. The same MDS documented a Brief Interview for Mental Status (BIMS) of 09, which indicated moderate cognitive impairment. Residents' functional status documented in the MDS indicated that she needed extensive assistance for bed mobility, dressing, toileting, and personal hygiene. Resident #4 ' s Care Plan, with a revision date of 4/15/23, documented that resident had nutritional risk due to difficulty self-feeding, and that she had a history of variation in appetite. Clinical record review of resident weights revealed that on 6/24/23, the resident weighed 156.0 lbs. On 7/30/23, the resident weighed 147.7 pounds which was a -5.32 % Loss. The clinical record lacked documentation of notification of the physician regarding the weight loss. Review of undated document titled Weight Loss, stated that the Director of Nursing (DON), or designee was to identify any weight loss or gain weekly and notify physician and family of severe weight change. In an interview on 8/2/23 at 1:10 PM with the DON, she stated that the weight loss should have been caught and the physician notified.

Based on clinical record review, and staff interview, failed to meet professional standards of quality by failing to report low blood glucose findings to the physician as ordered for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #3, documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had moderately impaired cognition. The MDS identified that the resident required extensive assistance of one staff for bed mobility, transferring, ambulation, dressing, toileting, and personal hygiene. The MDS also documented diagnoses of heart failure, diabetes, depression, asthma and chronic obstructive pulmonary disease. Clinical record review with order date of 3/17/21 and revision date of 2/19/23, revealed Accu-Chek orders with parameters to call the physician if blood sugars are < 60 mg/dl or > 300 mg/dl. Clinical record review revealed that on 4/8/23 at 1:15 PM, Resident #3' s blood glucose was 56 mg/dl, and on 7/14/23 at 11:46 AM, it was 53 mg/dl. The clinical record lacked documentation of the physician being notified of blood sugars outside of parameters. The clinical record also lacked documentation of resident ' s condition or interventions performed. In an interview on 8/3/23 at 2:50 PM, the Director of Nursing (DON) stated that her expectation was that the physician be notified and documentation be placed in the clinical record.

Based on record review and staff interview, the facility failed to complete a discharge summary for 1 of 1 residents reviewed (Resident #36). The facility reported a census of 37 residents. Findings include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 9 indicating moderately impaired cognition. The clinical record indicated that Resident #36 was admitted to the facility on [DATE] for skilled nursing services after falling at home, and discharged to a Residential Care Facility (RCF) on 5/25/23. The clinical record lacked documentation of the Resident's complete discharge summary while residing in the facility. In an interview on 8/3/23 1:10 PM, the Director of Nursing (DON) stated they are just starting a new recapitulation program that summarizes the resident stay.

Based on clinical record review, policy review and staff interviews, the facility failed to initiate cardiopulmonary resuscitation (CPR) as ordered by the physician after he was found expired in his room [DATE] at approximately 3:00 AM for 1 of 1 residents reviewed (Resident #1). The Licensed Practical Nurse (LPN) working during the incident stated she would have initiated CPR had she known Resident #1 was a full code. The facility also failed to communicate physician's orders accurately related to CPR and Do Not Resuscitate (DNR) orders for 3 of 6 residents sampled (Residents #9, #10 and #11). Those situations constituted Immediate Jeopardy to resident health and safety. The facility reported a census of 38 residents. The State Agency notified the facility of the Immediate Jeopardy that began as of [DATE] on [DATE] at 12:15 PM. The facility abated the Immediate Jeopardy situation on [DATE] through the following actions: a. Updating and providing education to staff on the CPR policy. b. Review of all residents code status to include order, iPOst, Care plan and Point Click Care. The scope was lowered from a J to a D at the time of the survey after ensuring the facility implemented their education and completed audits. Findings include: 1.The Minimum Data Set (MDS) dated [DATE] documented Resident #1 admitted to the facility [DATE] and had diagnoses including hypertension and atrial fibrillation. The MDS further documented the resident required extensive assistance of 1 for transfers, bed mobility and toilet use. The admission orders dated [DATE] documented Resident #1 had a diagnosis of sepsis due to Covid-19 and was a full-code. The clinical record lacked a Care Plan for Resident #1. Review of Resident #1's Durable Power of Attorney for Health Care Decisions form dated [DATE] revealed the resident wanted CPR tried in the event of cardiac arrest. The clinical record lacked an incident report following the [DATE] incident for Resident #1. The Progress Notes dated [DATE] at 3:10 AM revealed Staff G, LPN documented she was called to Resident #1's room by a Certified Nurse Aide (CNA) and after assessment noted no apical pulse, blood pressure or respirations. The documentation lacked further assessments related to the resident's expiration. During an interview on [DATE] at 2:08 PM, Staff E, CNA revealed she began her shift at 10:00 PM on [DATE] and the nurses were busy so she didn't get report. Stated she went to Resident #1's room after the shift had started and introduced herself and was joking with the resident and he acted fine. Staff E stated while doing rounds a couple hours later the call light for Resident #1's roommate went off and she went to answer the light and that is when she saw that Resident #1 had expired but she did not touch him. Staff E stated she did not know the resident's code status and that is something she would learn during report but since it was busy with call lights and the nurse was busy, she didn't get report. During an interview on [DATE] at 3:05 PM Staff F, LPN reported after midnight on [DATE] she was working at the nurse's station when Staff E came and reported to her that she thought Resident #1 had passed away. Staff F stated she did an assessment on the resident and based on his positioning and pale color he didn't look alive. Staff F further revealed she did not know the resident was a full code and didn't inquire about his code status. Staff F stated had she known the resident was a full code she would have performed CPR and she did not recall if there was a code status on his name plate outside his room. Personnel record review revealed Staff F had a current CPR certification dated [DATE]. Review of facility policy titled, CPR Policy Resuscitation Policy, revised [DATE] revealed the following: 1. Upon determination that a resident is in cardiopulmonary or respiratory arrest, CPR will be immediately initiated by nursing staff and 911 called for advanced cardiac life support unless one of the exceptions applies: a. When the resident or surrogated indicated that resuscitation is not desired and the attending physician has issued a do not resuscitate (DNR) order that is maintained in the facility's clinical record; or b. When there is the presence of obviously clinical signs or irreversible death (defined as rigor mortis or dependent lividity); or c. When attempts to perform CPR would place the rescuer at risk of personal injury. 2. Each resident's resuscitation status will be maintained in the clinical record as follows: CPR or DNR. 3. If CPR is required it will be immediately initiated by any staff member currently certified to perform CPR, pursuant to current American Heart Association guidelines. 4. If a nurse's assessment concludes that the resident exhibits signs of irreversible death leading to nursing judgment not to initiate CPR, complete and contemporaneous documentation of the nursing assessment shall be documented in the clinical record. During an interview on [DATE] at 9:30 AM the Administrator revealed on [DATE] the Director of Nursing (DON) did not give report to the day nurse regarding new admission Resident #1 including his code status. The Administrator revealed the Power of Attorney (POA) wasn't at the facility upon the resident's admission to discuss code status so the expectation would be to follow the order from the hospital which was a full code order. The Administrator further revealed the DON never gave report to anyone on [DATE], there was not a code status in the computer as expected for the resident and she wasn't sure if the resident even had a name plate outside his room in place. The Administrator stated she would expect staff to look for the code status if they didn't know it which should have been on the resident's face sheet, in the orders and on the resident's door with a red or green dot. During an interview on [DATE] at 9:29 AM, Staff G, CNA stated there are green dots on the resident's door next to their name which indicated full code status and they have a resident roster and if there is a heart next to the resident's name it indicated they were a full code. Staff G further stated the red dot on the resident's door next to their name indicated they were a fall risk but, don't quote me I may be wrong. During an interview on [DATE] at 9:35 AM, Staff H, CNA stated there is a sheet of paper they get during report with the resident's names and if there is heart next to their name it indicated the resident was a full code and if they didn't have a heart next to their name it indicated DNR. Staff H stated she didn't know what it meant if there was a red dot on the resident's name plate next to their room because she doesn't pay attention. During an interview on [DATE] at 9:39 AM, Staff I, LPN stated red dots on names outside of resident door meant they were DNR status and code status is also in the computer. Staff I further stated code status is also in the computer and if there is not a red dot on the resident's name plate it meant the resident was a full code but would check in the computer to make sure a red dot didn't get missed. Staff I revealed she would check with the DON if nothing was on the door or in the chart. During an interview on [DATE] at 10:00 AM the DON revealed to check code status they used a daily room roster and they also had code status indicators on resident name plates. The DON stated they used red dots on resident's name plates indicating DNR status and if there is not a red dot on the name plate it indicated full code status. The DON further revealed if there is a heart next to the resident's name on the daily room roster it indicated the resident was a full code and if there is not a heart next to the resident's name it indicated DNR status. 2. The MDS dated [DATE] documented Resident #9 admitted to the facility [DATE] and had diagnosis including pelvis fracture, chronic obstructive pulmonary disease (COPD) and hallucinations. The MDS further documented the resident required extensive assistance of 2 for bed mobility, transfers and toilet use. The Care Plan revised [DATE] documented Resident #9 wished to have her advance directives followed and directed staff to not perform CPR. Clinical record review revealed Resident #9 had an Iowa Physician Orders for Scope of Treatment (IPOST) dated [DATE] indicating an order for CPR. During a walk-thru of the unit [DATE] at 10:05 AM with the DON and a copy of the current daily room roster revealed Resident #9 had a heart on the room roster indicating full code status and a red dot on her name plate indicating DNR status. The DON acknowledged the inconsistency between the daily room roster with the red heart which indicated full code status and the red dot on her name plate which indicated DNR status. 3.The MDS dated [DATE] documented Resident #10 had diagnosis including cirrhosis, Alzheimer's disease and osteoporosis. The MDS further documented the resident was independent with transfers and bed mobility and required limited assistance of 1 with toilet use. The Care Plan revised [DATE] documented Resident #10 wished for her advanced directives to be followed and directed staff to not perform CPR. Review of Resident #10's face sheet indicated she had an IPOST in place indicating DNR. During a walk-thru of the unit [DATE] at 10:05 AM with the DON and a copy of the current daily room roster revealed Resident #10 did not have a red dot on her name plate indicating full code status and she did not have a heart next to her name on the room roster indicating DNR status. The DON acknowledged the inconsistency between the daily room roster which indicated DNR and the lack of red dot on name plate which indicated full code status. 4.The MDS dated [DATE] documented Resident #11 had diagnosis including schizophrenia, legal blindness and anxiety. The MDS further documented the resident required extensive assistance of 2 with bed mobility, transfers and toilet use. The Care Plan revised [DATE] documented Resident #11 wished for his advanced directives to be followed and directed staff to not perform CPR. Clinical record review revealed Resident #11 had an IPOST dated [DATE] indicating DNR. During a walk-thru of the unit [DATE] at 10:05 AM with the DON and a copy of the current daily room roster revealed Resident #11 did not have a red dot on his name plate indicating full code status and the resident did not have a heart next to his name on the daily room roster indicating DNR status. The DON acknowledged the inconsistency between the daily room roster which indicated DNR and the lack of red dot on his name plate indicating full code status.

Based on record review and staff interviews, the facility failed to ensure that residents who have not used antipsychotic drugs did not receive these drugs unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who used antipsychotic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 3 residents reviewed (Resident #1). The facility identified a census of forty-one (41) residents. Findings include: 1. According the Minimum Data Set (MDS) assessment tool dated 5/25/16, Resident #1 had a [DIAGNOSES REDACTED]. The resident had behavior symptoms of rejection of care and wandering one to 3 days a week. The MDS identified the resident's behavior symptoms worsened since the previous assessment. The resident required limited staff assistance with transfers and ambulation (walking) in the corridor, and required supervision with ambulation in room, toilet use and personal hygiene. The resident was continent of bowel and bladder. The MDS did not identify that the resident received psychoactive medications. The Resident Progress Notes (RPN) dated 5/16/16 at 10:25 a.m. documented staff observed the resident in the activity area near the exit doors. The resident stated he/she wanted to go across the street to the suite in the residential building where he/she lived prior to admission to the nursing facility. Staff easily redirected the resident who returned to their room without further incident. The RPN dated 5/17/16 at 7:55 a.m. documented the physician saw the resident on routine rounds with no new orders. The RPN dated 5/19/16 at 4:52 p.m. documented the facility received a facsimile (fax) from the physician. The fax contained an order for [REDACTED]. Review of 4/2016 and 5/2016 RPN prior to the 5/16/16 entry failed to identify any behaviors to justify the initiation of the [MEDICATION NAME] antipsychotic drug. On 10/6/16 at 9:48 a.m. the resident's responsible party stated he/she spoke with the physician on 5/19/16 after the facility gave him/her a verbal notice to move the resident to another facility. The resident's responsible party reported the physician offered [MEDICATION NAME] as an option to assist with the resident's stay at the facility. The physician also ordered a hospice consultation on that date. A hospice agreement dated 5/24/16 identified the resident began receiving hospice services for a liver mass diagnosed in September of 2015. The agreement revealed the nursing facility would follow their protocols and standing orders as appropriate, and communicate changes in condition to physician and hospice. The facility undated and untitled time documented on 5/23/16, the facility made a Hospice referral, admitting [DIAGNOSES REDACTED]. Hospice notes dated 6/8/16 at 10:25 a.m. identified fatigue and documented the resident slept through the visit. When awakened, the resident appeared groggy. Staff reported the resident lay in bed more frequently now. Following the initiation of [MEDICATION NAME] RNP notes revealed the following: 6/12/16 at 1:50 p.m. Staff documented the resident appeared highly agitated with constant pacing and verbalizing nonsensical events. 6/15/16 at 4:20 a.m. Staff observed the resident sitting on the floor with their legs out in front of them. The resident did not sustain injury. 6/20/16 at 12:37 a.m. Staff documented an unwitnessed fall without injury. 6/30/16 at 7 p.m. Staff observed the resident sitting on the arm of a chair. The entry also identified the resident walked with a more shuffled gait recently. The resident stated his/her feet were heavier. 7/4/16 at 3:10 p.m. Staff identified the resident as extremely restless and driven to get somewhere, but didn't remember where. 7/4/16 at 9:43 p.m. Staff documented the resident as extremely restless, constantly going from dining area and lobby to room. The resident stated several times his/ her legs felt weak and gave out. Staff initiated one staff assistance for the resident for the rest of the shift and a motion alarm at bedtime. 7/5/16 at 7:19 a.m. Staff observed the resident with a very unsteady gait. At 5:07 p.m. on the same date, staff documented the resident was very restless. 7/6/16 at 1:10 p.m. Staff documented the resident was very restless like he/she was driven and unable to get comfortable. 7/7/16 at 12:21 p.m. Resident yelled at the motion sensor frequently and continued to be restless and active that shift. 7/8/16 at 2:37 p.m. Staff observed the resident self-transferred multiple times and became agitated. 7/10/16 at 5:12 a.m. Resident agitated and setting off motion alarm numerous times. At 10:25 a.m., the resident required one to one staff assist due to setting off alarms and moving from one place to another. After sitting for one minute he/she got up and was on the move again. The RPN dated 7/11/16 identified the resident continued to transfer themselves. At 11:32 a.m., the physician ordered [MEDICATION NAME] (an anti-anxiety) 0.25 mg. every 6 hours as needed. On the same date, a telephone order document the physician discontinued the [MEDICATION NAME]. During an interview on 10/6/16 at 3:03 p.m., the Director of Nursing stated the physician discontinued the [MEDICATION NAME] due to resident declines. Hospice notes dated 7/11/16 revealed the physician discontinued the [MEDICATION NAME] to see if it was related to the resident's recent decline. The resident's functional status declined after the resident started [MEDICATION NAME]. According to http://www.rxlist.com/[MEDICATION NAME]-drug/patient-images-side-effects.htm, [MEDICATION NAME] side effects included restlessness and anxiety. During an interview on 10/6/16 at 8:52 a.m., the MDS/care plan nurse stated there was an incident in February 2016 when the resident started to open the door to go outside. After the second incident on 5/16/16, the DON at the time called the family about other placement due to the 2 incidents. The facility met with the family and the family called the physician, who then ordered [MEDICATION NAME], some blood work and a UA (urinalysis). She stated the physician discontinued the [MEDICATION NAME] because they wondered if it had caused the resident's shuffling gait. The RPN dated 7/12/16 throughout day and evening shifts identified the resident as restless and attempting to transfer themselves. An entry the same day at 6:29 p.m. revealed the resident started [MEDICATION NAME] (antibiotic) for a urinary tract infection [MEDICAL CONDITION]. Record review revealed no further documentation of restlessness. On 7/14/16 at 10 a.m., the facility placed a call to the physician to update him on the resident's anxiety and status since the discontinuation of [MEDICATION NAME]. At 11:55 a.m., the physician returned the call and the DON informed him that the resident's anxiety had increased over the last week and the resident appeared motor driven. The physician ordered [MEDICATION NAME] (antianxiety) 30 mg. BID (twice a day) and [MEDICATION NAME] (antianxiety) 0.25 mg. every 4 hours PRN (as needed). The Resident Progress Notes identified the resident as restless on the following dates and times: On 7/14/16 at 1:45 p.m., 2:30 p.m., 2:45 p.m., 3 p.m., 3:30 p.m., 3:33 p.m., 5 p.m. and 6:30 p.m. On 7/15/16 at 12:25 a.m., 4:20 a.m., 5:47 p.m., and 11:50 p.m. On 7/16/16 at 8 a.m., and 7:39 p.m. RNP notes dated 7/18/16 at 3:22 p.m. identified the resident wanted to pour their coffee on tablemate's. Staff intervened. At 6:30 p.m., identified the resident as restless. RNP notes dated 7/19/16 at 9:15 a.m. revealed the resident stated he/she felt tired. At 9:55 a.m., the resident required assistance while ambulating to rest in hall and sit in a chair. Staff assisted the resident back to their room and to bed. At 11:45 a.m. and 2 p.m., staff documented the resident attempted to self transfer. Hospice notes dated 7/20/16 revealed hospice increased their visits to 3 times a week due to the resident's increased need for assistance. On 7/21/16 at 8:55 a.m. the facility sent a fax to the physician with updates on behavior since the initiation of the [MEDICATION NAME]. Review of the fax revealed the facility informed the physician the resident continued to be restless with complaints of the inability to urinate. They informed the physician that a side effect of [MEDICATION NAME] was restlessness and added the resident required one to one staff due to restlessness. The facility asked the physician if he would consider a low dose of Klonopin (benzodiazepine). The physician replied on the same date with an order to discontinue the [MEDICATION NAME] and start Klonopin 1 mg. at bedtime for anxiety and UA next week. The RPN dated 7/22/16 at 3:47 a.m. identified the resident as confused and groggy. The RPN dated 7/25/16 at 10 a.m. revealed the facility sent a UA to the clinic. At 12:02 p.m., the resident did not respond to verbal or tactile stimuli. The resident's arms were flaccid. The facility notified hospice at 12:09 p.m., but did not notify the physician. At 12:28 p.m., the UA results revealed no UTI. At 1:29 p.m., the resident required two staff for assistance. The resident could not follow verbal commands and kept their eyes closed. The resident responded when staff called his/her name. The resident ambulated bent over almost directly at the waist. On the same date at 8:50 p.m., the resident couldn't follow commands when awake and required the assistance of 2 staff for ambulation into the bathroom. The resident remained bent at the waist and unable to stand up straight. He/she opened his/her eyes when spoken to but did not verbalize much. When the resident did verbalize, he/she did not answer appropriately. Hospice notes dated 7/25/16 revealed the resident showed decline and needed 2 staff to assist with ambulation and transfers due to bilateral lower extremity weakness. Resident Progress Notes dated 7/26/16 at 5:50 a.m. identified the resident demonstrated decreased weight bearing ability and required 2 staff for assistance. The resident kept their eyes closed with cares and remained bent at the waist when standing or sitting. The resident opened their eyes when asked questions and responded appropriately to questions. At 9:57 p.m., the resident spoke more, but remained bent forward with a shuffled gait. The resident fed themselves a small amount, but refused the rest. Resident Progress Notes dated 7/27/16 at 5:35 a.m. revealed the resident required 2 staff for transfers. The resident took a few steps with a shuffled gait and remained bent forward at the waist. Hospice notes dated 7/27/16 revealed the resident slept 20 plus hours a day and occasionally the resident tried to get up. Hospice documented last week the resident only used a wheelchair with staff propelling it as the resident did not walk on his/her own anymore. The RPN dated 7/28/16 at 2:53 a.m. revealed the resident was very sleepy and appeared to grab at things in the air. At 12:31 p.m., staff documented the resident slept for long periods of time. At 8:06 p.m., the resident could not follow simple commands. The RPN dated 7/29/16 at 1:11 p.m. revealed the resident did not open his/her eyes and did not bear weight well. The resident slept for long periods. At 8:50 p.m., the resident could not sit up. Review of the resident's July 2016 Medication Administration Record [REDACTED]. The RPN dated 8/1/16 at 3:07 a.m. identified the resident as unable to sit up in bed unassisted. The resident bore weight poorly and continued to lean forward with transfers or when sitting in chair. At 2:22 a.m., the resident repeatedly requested that staff get that snake out of his/her room. Resident Progress Notes dated 8/3/16 at 7:57 p.m. documented the resident laid in bed asking about his/her babies and my twins. According to http://www.rxlist.com/Klonopin-drug.htm, the physician should be called at once if there was a serious side effect such as confusion, hallucinations, unusual thoughts or behavior. There was no evidence the facility notified the physician of unusual behavior, confusion, and hallucinations. RNP notes dated 8/5/16 at 2:10 a.m. revealed the resident hit the nurse and and stated they wanted to go to California. Hospice notes dated 8/5/16 revealed the resident slept through the visit. RNP notes dated 8/7/16 at 6:30 a.m. revealed the resident hit and yelled at staff. RNP notes dated 8/8/16 at 4:45 a.m. revealed the resident hit and kicked at staff and spoke of the girls stranded in Fort Dodge.' RNP notes dated 8/9/16 at 5:10 a.m. revealed the resident called staff names and said he/she was [AGE] years old. RNP notes dated 8/22/16 at 7:00 a.m. revealed the physician conducted a desk review and changed the Klonopin to 1 mg QID (four times a day) and [MEDICATION NAME] (antidepressant) 20 mg. daily. Orders revealed the physician ordered both medications for anxiety. Hospice notes dated 8/22/16 documented the resident as very lethargic. The resident woke briefly to answer a question and within minutes was snoring. Hospice discussed the medication change with the DON and informed the DON the resident may experience increased lethargy with the Klonopin increase. The note identified a decline in the resident's condition. The resident displayed increased weakness, poor balance, and became fatigued more quickly. The RPN dated 8/22/16 at 5:46 p.m. identified the resident as very restless so far that shift. The RPN dated 8/23/16 at 4:30 a.m. revealed staff observed the resident had more difficulty feeding themselves. The resident bent forward and when staff cued him/her to sit up straight, it was not effective. The RPN dated 8/24/16 at 5:05 a.m. identified the resident as sleepy with more difficulty feeding themselves. The RPN dated 8/24/16 at 8:56 a.m. revealed the facility received a fax to increase [MEDICATION NAME] from 0.5 mg to 1 mg to every 4 hours PRN. At 9:09 a.m., the facility received an order from the physician to add [MEDICATION NAME] (for [MEDICAL CONDITION] mania) 500 mg. every bedtime. The physician also ordered [MEDICATION NAME] (an anti-psychotic) 2.5 mg. four times a day PRN for anxiety and behaviors. On the same date at 7:22 p.m., staff documented the resident ate with his/her eyes closed and made very little response. The entry also identified the resident continued with the increased Klonopin and increased sleepiness. The RPN notes dated 8/25/16 at 12:53 a.m. revealed the resident demonstrated poor to no weight bearing and leaned forward when seated on the commode. The entry identified the resident as sleepy. At 2 a.m., staff documented the resident's speech sounded garbled and unintelligible. The resident could not get a banana to his/her mouth without staff assistance. At 7:46 a.m., the facility received orders to begin an antibiotic for a UTI. On 8/25/16 at 1:40 p.m., documentation identified the resident as very sleepy. The RPN dated 8/26/16 at 1 a.m. revealed the resident continued to look very sleepy and his/her eyes remained closed. At 5 a.m., the resident remained sleepy in bed, and at 1:09 p.m., staff could not awaken the resident for his/her noon Klonopin. At 4:15 p.m., notes identified Hospice called and asked the facility if they gave the resident their medications. Staff told hospice the resident was unresponsive since taking their morning medications and also had trouble swallowing water. On the same date at 9:35 p.m., staff documented the resident as unresponsive that shift. Staff attempted to awaken the resident to administer medications but could not get the resident to wake up; he/she did not open their eyes or respond to verbal stimuli. Hospice notes dated 8/27/16 revealed the resident had no oral intake the past 24 hours other than 2 bites of toast and was weak and difficult to arouse. The resident did not respond to verbal or active stimuli without 10 minutes of heavy verbal and tactile stimulus and was very weak and unable to move his/her extremities. The hospice note identified the change of condition was due to medication changes. The RPN dated 8/27/16 at 1:50 p.m. revealed Hospice phoned the facility with orders from the Hospice physician to hold psychoactive medications for 48 hours. Review of appetite records revealed the resident did not eat meals on 8/25/16, 8/26/16, 8/27/16 and 8/28/16 other than 26 to 50% of breakfast on 8/27/16. Review of the RPN dated 8/29/16 at at 5:55 p.m. revealed the physician discontinued the Klonopin and [MEDICATION NAME]. Review of the August 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The RNP identified the resident became more responsive following the discontinuation of the psychoactive medications with minimal behaviors. The RNP revealed the following entries: 9/4/16 at 3:55 a.m. Resident pleasant and cooperative. No combative behavior. 9/5/16 at 5:20 a.m. Resident transferred with assistance of 1 staff and arouses easily to name. Pleasant and cooperative. 9/6/16 at 2:10 a.m. Arouses easily. Transfers without difficulty with 1 to 2 staff. No combative behavior. A progress note dated 9/9/16 and written by the ARNP revealed the resident had recent medication changes with improvement in behaviors. Interviews: On 10/5/16 at 3:10 p.m. the Hospice manager stated the facility made medication changes and did not notify hospice. The facility added 2 to 3 medications at a time even though the resident had a UTI during that period. She stated when the family found the resident unresponsive in August, Hospice stepped in and the Hospice physician stopped the psychoactive drugs for 48 hours. From that point on, Hospice went to the facility daily to check on the resident. She stated the DON made recommendations to the physician who signed the orders. The resident suffered, but when he/she went off the medications, the resident thrived. On 10/6/16 at 11 a.m. Staff A RN (registered nurse) stated regarding the 8/2016 change of condition that the resident had not been awake for 48 hours. Staff A was with the resident the evening of 8/26/16 when the family arrived. The next day 2 Hospice workers arrived. Hospice called the Hospice physician and wanted to change the Klonopin orders. Staff A informed them they needed to go through the facility DON to change medications. The DON felt changes should not be made without her input. Staff A stated the resident would have a day where he/she did not respond but when it was over a day and became 48 hours that was unusual. On 10/6/16 at 12:15 p.m. Staff B CNA (certified nurse aide) stated she got along well with the resident. The resident had a reaction to medication changes. Once the resident's medication changed, the resident was zombified and confused. The resident wanted to get up, but didn't have the strength. Before the medication change, the resident ate 2 to 3 breakfasts. After that change, staff was lucky to get the resident to eat 1/2 banana.`The resident was like that the whole month of August. Before the medication change, the resident walked with a gait belt and after the medication change, the resident couldn't walk. The resident would move forward holding onto the walker but his/her feet wouldn't move so the resident stayed in one spot. On 10/5/16 at 4:16 p.m. Staff C CNA stated she began employment 7/8/16. When she first started employment, the resident was a sweet, sassy person and only needed 1 assist. Then the resident got ornery and yelled and the facility kept putting the resident on medications. The resident was drowsy all the time and trying to get up. The facility started one to one care and alarms. The resident got drowsier and drowsier, so Hospice took over the resident's medications, got them straightened out, and the resident went back to his/her sweet self. On 10/5/16 at 3:55 p.m. Staff D CMA (certified medication aide) stated when she first met the resident, the resident walked by him/herself or with supervision, but the resident declined and then they used 2 staff to assist the resident. She stated the resident was really sleepy sometimes and other times, wide awake. On 10/5/16 at 4:03 p.m. Staff E CNA stated at the point the resident seemed sleepy, Hospice got in the picture. When the resident came to the facility, staff transferred him/her with one assist and when the resident left (to go to another facility), he/she had one to one care and required a pivot transfer.

Based on record review and staff interview, the facility failed to plan for and direct nursing services to ensure Resident #13 received adequate supervision to prevent accidents. Record review identified the facility staff utilized a mobility monitor (alarm) to alert staff of Resident #13 ' s safety needs with self-transfers after the resident sustained [REDACTED]. On [DATE] a nurse removed the mobility monitor and Resident #13 attempted to self-transfer and fractured his/her right hip. The resident required surgical repair and comfort care measures until the resident ' s death on [DATE]. Staff interviews and record review identified the resident had impaired balance and intermittent confusion which affected his/her ability to make safety decisions. The sample consisted of six (6) residents and the facility identified a census of 36 (thirty six) residents. Findings included: Resident #13's Admission Assessment documented the resident admitted to the facility on [DATE] (to the last room at the end of the 200 hallway). Staff documented on the resident's [DATE] Fall Assessment Tool and Guidelines for Use the resident had a history of [REDACTED]. The resident scored 17 points on the form which stated a score of 10 or above indicated a risk for falling. Physical Therapy and Occupational Therapy initiated treatment on [DATE]. The Initial Physical Therapy Evaluation documented the resident had been hospitalized from [DATE] to [DATE]. On [DATE] at 12:55 p.m. staff documented in the Nurses' Bedside Record the resident admitted to the facility and was alert and oriented. Staff assisted the resident with ambulation with a gait belt and a walker. Staff documented the resident had a slow gait which was unsteady at times with body jerking. Staff showed the resident the call light and the resident demonstrated he/she could use it. At 7:30 p.m. staff described the resident as alert and oriented. Staff encouraged the resident to use the call light. Two staff assisted the resident with ambulation using a gait belt and a walker. Staff described the resident's gait as slow and unsteady with jerky movements of the arms and legs. Staff documented in the Nurses' Bedside Record the following: On [DATE] at 8:00 a.m. staff described the resident as alert and oriented. Two staff assisted the resident with ambulation using a gait belt and a walker. Staff described the resident's gait as slow and steady with involuntary jerking of body and limbs. The resident demonstrated use of the call light. At 1:30 p.m. staff found the resident in the bathroom without the walker. The resident stated he/she had gone to the bathroom independently. Staff encouraged the resident to use the call light and the resident demonstrated its use. At 7:45 p.m. staff described the resident as alert and oriented. Two staff assisted the resident with ambulation using a gait belt and walker. Staff documented the resident continued with involuntary jerking of the body and limbs. On [DATE] at 9:30 a.m. staff documented the resident alert and oriented to self and time of year, but confused to place. One staff provided extensive assistance in transfers and ambulation with a gait belt and walker. Staff described the resident's gait as unsteady and noted the resident continued to be weak. At 7:50 p.m. staff documented the resident alert to self with confusion to place and time. Two staff assisted the resident with toileting and ambulated the resident with a gait belt and walker. Staff described the resident's gait as slow and unsteady at times due to jerking movements of the limbs. Staff documented the call light in reach. On [DATE] at 3:00 p.m. Physical Therapy staff faxed to the resident's physician stating, after working with the resident the PT had concerns that the resident had a neurodegenerative disorder. The resident displayed choreic and ataxic involuntary movements with activity, was depressed and displayed confusion and word finding difficulty. PT recommended a consultation to rule out Huntington's or ALS. The physician responded in agreement and stated the family would consider a neurology consultation after the first of the year. On [DATE] at 1:10 a.m. staff found the resident in the bathroom having transferred him/herself there without a walker. Staff documented the call light within reach but the resident had not used it. Staff checked the call light and it worked. Staff "strongly" encouraged the resident to use the light and wait for staff. At 9:00 a.m. staff documented the resident alert to self but confused to place and time. Two staff assisted the resident with transfers, ambulation and toileting with the use of a walker and gait belt. Staff documented the resident's gait unsteady and the resident with involuntary, erratic, dance like movements that were more pronounced in the upper extremities. At 8:15 p.m. staff documented the resident alert to self with confusion to place and time. Staff documented two staff assisted the resident with transfers and ambulation using a walker and gait belt. Staff documented the resident's gait slow and unsteady with involuntary dance like movements of the extremities. Staff documented the call light in reach. At 8:45 p.m. staff documented the resident self transferred to the bathroom without assistance or a walker. Staff documented that was the second time that shift staff had found the resident self transferred. The nurse spoke with the resident about the importance of using the call light and waiting for assistance. On [DATE] at 7:30 a.m. staff documented the resident oriented to self only The resident unsure of the month, season or time of day. Two staff provided extensive assistance with transfers and ambulation using a gait belt and walker due to the resident's unsteady gait. At 7:40 p.m. staff documented the resident alert to self with confusion to place and time. The resident continued with involuntary movements of the extremities. Two staff assisted the resident with transfers using a gait belt and walker. Staff described the resident's gait as slow and unsteady. On [DATE] at 8:15 a.m. staff documented the resident alert to self and time, but confused to place. Staff documented the resident continued with involuntary movements of the extremities. Two staff provided moderate assistance with ambulation in the room and facility using a walker and gait belt. Staff documented the resident's gait as slow and steady. At 7:30 p.m. staff documented the resident oriented to self but not place and time. Two staff assisted the resident with ambulation using a walker. Staff described the resident's gait as slow and steady, however the resident continued with involuntary movements of the extremities. The resident's [DATE] Minimum Data Set (MDS) documented the resident had severely impaired cognitive function. On [DATE] at 6:40 a.m. staff documented the resident oriented to self and time but confused to place. Staff assisted the resident with ambulation using a gait belt and walker. Staff described the resident's gait as slow and steady. At 7:50 p.m. staff documented the resident oriented to self but not place. Two staff assisted with transfers and ambulation using a gait belt and walker. Staff described the resident's gait as slow and steady. On [DATE] at 7:10 a.m. staff documented the resident oriented to self but confused to place and time. Two staff provided extensive assistance with ambulation using a gait belt and walker. Staff described the resident's gait as slow and unsteady and noted the resident continued with erratic dance like movements. At 7:10 p.m. staff documented the resident alert to self with confusion to place and time. Two staff assisted the resident with toileting and transfers using a gait belt and walker. Staff described the resident's gait as slow and steady with dance like movements of the extremities. On [DATE] at 12:35 p.m. staff documented the resident confused to place and time. Two staff provided extensive assistance with transfers and ambulation using a gait belt and walker. Staff described the resident's gait as slow and unsteady. The resident continued with erratic dance like movements. At 8:20 p.m. staff documented the resident alert to self but confused to place and time. Staff documented the resident continued with dance like movements and two staff assisted the resident with transfers and ambulation. Staff documented the call light in reach. At 10:05 p.m. staff documented the resident found on the floor in his/her room. Staff immediately noted blood on the floor under the resident's head and noted on the resident's hands. The resident had a 2.5 by 0.4 centimeter laceration to the back of the head and observed the left knee swollen. The resident stated he/she needed to go to the bathroom. Staff documented the call light had been in reach but the resident had not used it. Staff subsequently sent the resident via ambulance to the hospital where the laceration was closed with staples. The record lacked any documentation indicating staff initiated any new interventions after repeatedly finding the resident in the bathroom alone considering the resident's cognitive impairment and unsteady gait. During interview on [DATE] at 12:51p.m., Staff J1 and Staff K1 Co-Directors of Nursing reviewed the care plan and reported they could not find other interventions besides encouraging the resident to use the call light until the [DATE] fall resulting in the head laceration. The DONs reported they would review the resident's record regarding any intervention put in place when the resident's mobility alarm had been removed. At 1:22 p.m., the DONs stated they would write a rational for why the mobility alarm had been discontinued on [DATE], and confirmed no new interventions had been initiated to minimize the resident's risk for falls. A hand written addition to the resident's Care plan dated [DATE] directed staff to toilet the resident every night between 9:30 and 10:00 p.m. and to leave the over bed night light on. On [DATE] at 1:17 a.m. the resident returned to the facility. The resident thought it was afternoon. Staff counted seven staples closing the head laceration. Staff initiated a motion sensor alarm per nursing judgment. At 8:17 a.m. staff documented the resident alert to self but confused to place and time. Two staff assisted the resident with ambulation using a gait belt and a walker. At 8:15 p.m. staff documented the resident oriented to self only. Physical Therapy staff discharged the resident from their services because the resident did not show any signs of improvement. They documented the resident very fatigued and confused. On the same date Occupational Therapy also discontinued their services because little gain had been made secondary to the resident's unwillingness to participate in skilled tasks. On [DATE] at 12:17 a.m. staff documented two staff assisted the resident with ambulation using a gait belt and walker. They described the resident's gait as slow and slightly unsteady. At 8:15 a.m. staff documented the resident disoriented to place and time. Two staff assisted the resident with ambulation. At 8:00 p.m. staff documented the resident oriented to self and place. Two staff assisted the resident with ambulation using a gait belt and walker. They described the resident's gait as slow and at times unsteady. On [DATE] at 7:05 a.m. staff documented the resident alert and oriented to all spheres. On [DATE] at 6:50 a.m. staff documented the resident oriented to self only and confused to place and time. At 8:10 p.m. staff documented the resident alert to self and confused to place and time. On [DATE] at 7:40 a.m. staff documented staff assisted the resident with care and toileting needs. On the same date staff completed another Fall Assessment Tool and Guidelines for Use form. The assessment described Resident #13's mental status as intermittent confusion. The assessment revealed the resident's gait and balance as follows: loss of balance while standing, balance problems when walking and decrease in muscular coordination. The assessment identified Resident #13 had a history of [REDACTED]. A score of ten or above indicates a risk of falling. On [DATE] at 8:30 p.m. staff documented the resident alert and oriented to person, place and time. On [DATE] at 7:00 a.m. staff documented the resident alert and oriented to person, place and time. At 8:00 p.m. staff documented the resident alert and oriented to person, place and time. On [DATE] at 6:50 a.m. staff documented the resident alert and oriented to self only and confused to place and time. At 8:10 p.m. staff documented the resident alert to self only. Staff documented the resident walking with a more stable gait. On [DATE] at 8:45 p.m. staff documented one staff assisted the resident to the bathroom. On [DATE] at 11:05 a.m. staff documented the resident oriented to self and confused to place and time. At 8:15 p.m. staff documented the resident alert to self only. On [DATE] at 8:00 p.m. staff documented the resident alert and oriented to person, place and time. Two staff assisted the resident with transfers using a gait belt and walker. On [DATE] at 2:00 a.m. staff documented the resident rested well that evening and had been up a few times to the bathroom. The nurse documented no self transfers, the monitor remained in place per nursing judgment. At 11:00 a.m. staff documented the mobility monitor removed from the resident's room due to no further reports of self transfer. At 10:35 p.m. staff found the resident on the floor in his/her bathroom. The call light had been in reach but had not been turned on. They noted the resident displayed the usual dance like movements of the upper and lower extremities. Staff observed the resident had shortening of the right leg and subsequently transferred the resident to the hospital for further examination. On [DATE] at 1:45 a.m. staff received a call informing them the resident had a hip fracture. On [DATE] at 10:30 a.m. staff were informed the resident had surgery the previous day and had been transferred to ICU. At 3:00 p.m. staff were informed the resident had been admitted to Hospice for comfort care. On [DATE] staff were informed the resident had died on [DATE]. The resident's hospital Discharge Summary, Death Summary identified the [AGE] year old had multiple medical problems, severe [DIAGNOSES REDACTED], CHF (congestive heart failure), had been admitted with a working [DIAGNOSES REDACTED]. The resident had a difficult extubating and required intubation for a while. The family chose hospice care and the tube was removed. The resident's medical condition rapidly deteriorated with multi-organ dysfunction. The resident died on [DATE] at 2:45 a.m. During interview on [DATE] at 1:22 p.m. Staff J1 and Staff K1 confirmed no additional interventions had been implemented when they discontinued the mobility monitor. The DONs stated they would write a rational for discontinuing the resident ' s mobility alarm on [DATE]. During interview on [DATE] at 10:31 a.m. Staff J1 and Staff H stated prior to removing the alarm they reviewed the resident's record and talked to staff. Staff J1 stated they did not document the interviews or assessed safe to remove the resident's alarms. The Administrator, also present, stated there had been two CNAs and a nurse on duty when the resident fell . The record lacked any documentation indicating staff had implemented any new interventions when they removed the resident's mobility monitor. The record lacked any documentation indicating staff performed any assessment or risk/benefit analysis when they removed the mobility monitor. During interview on [DATE] at 10:36 a.m. Staff U, CNA stated she had worked with the resident various times since admission. She stated the resident was one you really had to watch. She stated the resident had continued to get up independently even after the fall with the head laceration. She said this did not occur every shift but it did occur frequently. She stated she usually attached the resident's call light cord to the resident's pajamas as well. She stated the resident didn't really use the call light. She says when she came to work the day of the last fall she found out the alarm had been discontinued. She says she told the nurse, "you know she's a fall risk." She stated no one had asked her if she thought it was safe to remove the alarm. During interview on [DATE] at 1:26 p.m. Staff J, CNA stated she had taken care of the resident at various times after the resident's admission. She stated the resident frequently set off the motion sensor alarm. She couldn't say for sure the resident had gotten up independently after the fall with the head laceration but the resident did set off the motion sensor alarm. She stated the resident did sometimes use the call light, but not consistently. She stated when she found out the alarm had been discontinued she thought it wasn't a good idea. Staff J stated there was a reason Resident #13 had the motion senior alarm.

Based on observation, record review and staff interviews, the facility failed to ensure that Resident #1 received adequate supervision to prevent accidents and the health service supervisor failed to ensure staff were aware of the expectations of the BRPR flow sheet for the resident ' s toileting needs. After the fall, the facility educated the staff as to the expectation of " offering " the toilet. The sample consisted of 4 residents and the facility identified a census of 40 residents. The facility staff failed to follow the bathroom flow sheet. They did not offer the resident the toilet at 10 p.m. and 12 a.m. At 2 a.m. the resident got up to use the toilet per self and fell resulting in a major injury to the elbow and pelvis. Staff identified the resident did not always use the call light and would attempt to self ambulate. Findings include: 1. A Minimum Data Set (MDS) with observation end date of 3/28/12 assessed Resident #1 with a brief interview for mental status (BIMS) score of 12 (moderate cognitive impairment). A resident mood interview identified the resident with trouble concentrating on things such as reading a newspaper or watching television. The resident had trouble falling asleep or staying asleep or sleeping too much. The resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and bathing. A "balance during transitions and walking" test identified the resident as not steady and only able to stabilize with human assistance when moving from seated to standing position and walking. The resident was continent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The resident did not have pain or a history of falls. A fall assessment tool, dated 3/28/12, identified the resident with a score of "12". A score of 10 or above indicates high risk A BRPR (bathroom/toileting) flow sheet dated 4/24/12 10 p.m. to 6 a.m. shift directed staff to "offer" the resident the toilet at each round (12 a.m., 2 a.m. 4 a.m.) A care plan dated 4/4/12 identified the resident as up ad lib with 4 wheeled walker between morning and night time care. During the night, the resident was encouraged to use the call light for staff assistance. The toileting plan directed staff to encourage bathroom before leaving room and rest periods and per request. On 5/16/12 at 8:12 a.m. when asked what the care plan intervention meant, Staff H (Director of Nursing) stated the care plan entry meant the resident was "per request" at night but staff needs to follow the BRPR flow sheet which does not say per request but "offer". When it says "offer" staff should wake the resident and ask if the resident wants to get up to the bathroom. An incident/accident report dated 4/25/12 at 2 a.m. identified Staff A (registered nurse) standing by the nurses ' station and hearing someone yell for help. She ran towards the direction of the yelling and found Resident #1 lying on the right shoulder and hip with head at the head of the bed on the floor. She observed the walker at the foot of the bed. The call light was in reach prior to the fall and the resident wore nonskid slippers. Observation revealed the bed locked but not in the lowest position. When Staff A asked the resident what he/she tried to do, the resident stated he/she tried to go to the bathroom. The resident denied feeling dizzy or light headed prior to the fall. The resident did not think he/she hit head. The resident complained of elbow pain. Staff stood the resident and the resident slowly and steadily ambulated to the toilet. Observation showed the resident favored the right hip and the resident identified it as "sore". After the resident got back in bed, Staff A assessed the following skin issues to the right elbow: Dark purple bruises measuring 2 centimeters (cm.) by 1.2 cm., 4.2 cm. by 1 cm., 3 cm. by 1 cm. with a 4 cm. by 2 cm. skin tear, bruise 3 cm. by 1 cm., bruise 1 cm. by 2 cm., bruise 2 cm. by 2.3 cm. with 2 cm. by 0.4 cm. skin tear. Staff administered Tylenol (analgesic) and placed the right upper extremity on a pillow. Staff last checked the resident at 12 a.m. rounds. A nurses' bedside record dated 4/25/12 at 3 a.m. identified the resident as lying in bed. The resident stated the hip was a little sore and moved the right arm and shoulder with complaints of pain. Staff readjusted the pillow under the arm and the resident stated that helped. At 4:20 a.m. staff phoned Wright Medical Center (WMC) and updated them on the resident's fall and complaints of pain. WMC directed staff to transfer the resident to the hospital via ambulance/ At 4:50 a.m. paramedics arrived and the resident stated he/she wanted to use the toilet before leaving the facility. Staff attempted to ambulate the resident who then voiced complaints of hip pain and only able to take a few steps. The resident used the commode and then transferred to WMC. The resident returned on 4/26/12 at 6:25 p.m. with the right arm in a splint and sling. A Trimark Family Practice note dated 4/27/12 documented the resident sustained [REDACTED]. A fracture at the right elbow proximal ulnar metaphysis was noted. One x-ray said there was no pelvic fracture and another suggests a subtle and stable fracture of the pelvis. The physician identified the resident with a probable pelvis fracture and would receive conservative management from physical therapy (PT) and surgical intervention for the right elbow on 5/2/12. The orthopedic physician note dated 4/30/12 documented the resident required open reduction and internal fixation (ORIF) of the right olecranon fracture and weight bearing as tolerated to the lower extremities due to right superior pubic rami fracture. A nurses' bedside record dated 5/3/12 at 1:45 p.m. documented the resident returned to the facility following surgery to right elbow. The resident had a return appointment on 5/14/12. A report of consultation, dated 5/14/12 identified failure of fixation of right olecranon fracture. The resident required another surgery to repair the right elbow fracture. Observation showed on 5/8/12 at 6:10 p.m. the resident up in a wheelchair. Observation showed the resident's right arm bandaged and swollen above the bandage and in a sling. When asked if he/she would visit with the surveyor, the resident stated we would have to talk another time because "they are having a party and I need to be there" At 6:20 p.m., of the same date, observation showed the resident in the lounge area. At that time staff stated the resident could not be left alone in his/her room. The resident stated, "This is my birthday party". Staff identified the resident as confused and attempted to orient the resident who did not accept reorientation. Observation showed, on 5/16/12 at 4:55 a.m., the resident in bed with motion alarm and pressure alarm in place. Staff asked the resident if he/she wanted to use the toilet. The resident initially stated he/she did not need the toilet and then a minute later stated he/she did need the toilet. Two staff transferred the resident from the bed to the commode. The resident complained of pain with movement of the right arm. At that time, Staff B (licensed practical nurse) stated the resident would go to surgery that morning to have the right elbow "redone". Staff Interviews: On 5/8/12 at 6:24 p.m., Staff A stated as she charted at the nurses ' station on the night of the incident, she heard hollering. She ran to the resident's room and found the resident on the floor. Staff A stated the resident is not supposed to walk on their own at night. The resident is supposed to have assistance. Staff A stated sometimes the resident uses the call light. The bathroom (BRPR) flow sheet says to offer the bathroom. Staff A stated at 12 a.m. rounds nurse aides visualized the resident but did not offer the toilet. Staff A stated she did not think the nurse aides looked at the flow sheet the night of the incident. Staff did not offer the toilet at 10 p.m. or 12 a.m. They "breath checked" the resident only. Staff A stated "breath check" is visualizing the resident to ensure they are breathing and in no distress. When asked if anything could have prevented the incident, Staff A stated staff should have offered the resident the bathroom as the BRPR flow sheet directed. On 5/8/12 at 7 p.m., Staff C (nurse aide) stated she worked the night of the incident. She stated at first rounds (10 p.m.) staff checked on the resident. The resident just got into bed prior to that time and had just used the toilet. At that time, staff applied the resident's gripper socks but did not toilet the resident. At the 12 a.m. round, the resident was sound asleep and snoring so they didn't wake the resident. 1.5 to 2 hours later they heard the resident scream and found the resident on the floor. The resident stated she was going to the bathroom. Staff C stated they did not use the BRPR flow sheet that night. Staff C stated she is sure the flow sheet was available. Staff C thought the resident would use the call light. After that, Staff C was informed she should have awakened the resident for bathroom. When asked if anything would have prevented the incident, Staff C stated if they would have awakened the resident and helped the resident to the bathroom at rounds. Staff C stated she just filled in that night to help and does not usually work the overnight shift. On 5/8/12 at 6:45 p.m. Staff D (nurse aide) stated he saw the resident at 12 a.m. and the resident was asleep. He stated the usual routine on rounds was to let the resident sleep and not awaken the resident if he/she was asleep. Staff D stated the resident usually used the call light. He worked at the facility for 9 months and only saw the resident walk up the hall at night a couple times. He stated staff looks at the BRPR flow sheet and if it said "offer" they would not wake up the resident. If the resident was asleep they would let the resident sleep and if the resident was awake then they would offer the toilet. He stated now staff wakes up every resident that has "offer" written on the sheet. On 5/16/12 at 6:12 a.m. Staff E (nurse aide) stated prior to the resident's injury, the resident would pull the call light and staff would ask the resident if he/she needed the bathroom on rounds if the resident was awake. Staff E stated now they ask the resident every round. Staff E stated the resident did get up a lot on his/her own prior to the fall on 4/25/12 but the resident did not have prior falls. On 5/16/12 at 6:05 a.m. Staff F (nurse aide) stated prior to the resident's fall staff would offer the resident the toilet but the resident would refuse. Staff F stated the resident got up at night and that was not supposed to happen. The resident did not have prior falls. On 5/16/12 Staff G (Administrator) stated the only two staff that got written up was Staff C and Staff D because all the other staff said they were following the BRPR flow sheet correctly. The facility educated everyone and had them sign the education sheet. The facility self correction form, dated 5/8/12 stated during the investigation, the facility discovered that two CNAs misunderstood what "offer" meant and the facility gave them a written counseling regarding the expectations of each round during night shift, bathroom flow sheet documentation requirements and definition of the term offer on the bathroom flow sheet. The facility in-services all nursing staff on all of the terms on the bathroom flow sheet so there are no future misunderstandings on any of the terms. The facility also instructed staff to speak to the charge nurse or a nurse manager if they have any questions in the future or if any residents request a change in the flow sheet. For example, if a resident requests to not be awakened on every round, this issue will be referred to the nurse managers for evaluation, change in care plan, etc. A copy of the definitions of the items on the bathroom flow sheet will be placed in the front of the bath binders for each hall. All new staff will be responsible for reading and understanding these terms prior to working on the floor. Observation during 4 a.m. rounds on 5/16/12 identified bathroom flow sheets in use and definitions available for staff.

Based on record review and staff interview, the facility failed to plan for and direct nursing services to ensure one (1) of five (5) residents received adequate supervision against hazards. Resident #1 fell after staff left him/her unattended in the bathroom. Resident #1 sustained an acute head injury and intracranial bleed and expired from the injury 3 days later. While the care plan directed staff to not leave the resident alone in the bathroom; the pocket care guide that staff relied upon to provide care lacked any directives to remain with Resident #1 in the bathroom. The majority of staff reported they normally left Resident #1 unattended in the bathroom and the director of nursing failed to ensure care plan interventions intended to prevent falls were implemented. The facility identified a census of forty-five (45) residents. Findings include: 1. A Minimum Data Set (MDS) with an assessment reference date of [DATE], assessed Resident #1 with a brief interview for mental status (BIMS) score of "8". A score of "8" identified moderate impairment. The MDS documented the resident transferred and ambulated in room with staff assistance (staff provide weight bearing support). The resident required extensive staff assistance with toileting. A "balance during transitions and walking" test identified the resident as not steady and only able to stabilize with human assistance with moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfers. The resident had functional range of motion limitations of both upper extremities. The resident utilized a wheelchair and walker for mobility. The resident had [DIAGNOSES REDACTED]. Nurses bedside records dated [DATE] at 7 a.m. documented the nurse aide summoned Staff D (charge nurse) to the resident's room. Staff D documented she observed Resident #1 on the bathroom floor on the left side between toilet and sink facing door. The nurse documented she witnessed a large amount of blood coming from the left side of the resident ' s head. Resident #1 was unresponsive and staff called 911. The resident was transported to the emergency room (ER) and he/she returned to the facility on the same date at 10 a.m. with orders for "palliative care" and a Hospice consult order. The [DIAGNOSES REDACTED]. The resident entered Hospice care on [DATE] and the resident's condition continued to decline. A pain management medication log identified the resident with pain after the incident as evidenced by restlessness, grimacing and twitching. Staff administered Roxanol (narcotic) for the pain. A Mortician's form documented the date of death as [DATE] and time of death as 2:20 p.m. The physician documented the cause of death as "Intracranial bleed" on the form. Fall history for Resident #1: a). A major injury determination form, identified the resident with a fall with injury on [DATE] at 2:30 p.m. Staff assisted the resident to the bathroom and the resident attempted to self transfer and fell . An incident/accident report regarding the [DATE] incident documented the steps taken to prevent reoccurrence as "not to leave alone on toilet". An investigation narrative of the [DATE] fall stated the resident transported to the emergency room (ER) for evaluation and x-ray. An x-ray identified a left pelvic fracture. The physician did not believe this was a major injury. b.) A major injury determination form, identified the resident with a fall with injury on [DATE] at 4:35 p.m. Staff found the resident lying on the floor near the foot of the bed. The resident attempted to self transfer. An incident/accident report dated [DATE] at 4:35 p.m., documented a 2.5 by 1.2 centimeter (cm.) bruise to the left side of head with 2 cm. by 2 cm. bump. A 1 cm. by 1.5 cm. skin tear to right ring finger with 0.5 cm. bruise, 6 cm. by 1 cm. bruise to right outer elbow, 7 cm. by 5 cm. red area to right knee, 7 cm. by 0.5 cm. red area to left knee. The resident transported to the ER for a CT scan of the head showed no evidence of acute intracranial hemorrhage. The physician did not identify the fall as a major injury. An incident/accident report regarding the [DATE] incident documented the steps taken to prevent reoccurrence as "closer observation." c.) An incident/accident report dated [DATE] at 5:25 p.m. documented staff found the resident on the floor. The resident slid down to floor and hit back of head on bed frame. The resident complained of a sore back and staff assessed a 4 cm. by 2 cm. hematoma to the back of the head and a 1 cm. by 2 cm. red area to the middle back. Steps to prevent reoccurrence listed on incident report as "Non skid strips on floor beside bed". d.) An incident/accident report dated [DATE] at 4 p.m. documented staff heard "Help!" coming from the resident room. When staff arrived, they observed the resident on the floor between the bed and chair. The resident attempted to self transfer and put self to bed. The resident did not sustain injury. Care Plan/Pocket Care Guide: The [DATE] care plan identified the resident with impaired mobility and chronic pain related to osteoporosis, osteoarthritis, history of compression fracture, chronic headache, occipital neuralgia and polymyalgia rheumatica manifested by unsteady gait, weakness routine pain management, fatigue, low back/shoulder pain, history of falls and requires increased assist with mobility. The care plan contained an addendum dated [DATE] that stated the resident requires supervision and staff should not leave the resident alone in the bathroom. A pocket care plan guide, that staff relied upon to provide care and dated [DATE] did not contain the directive to not leave Resident #1 alone in the bathroom. The pocket guide did not address how staff should toilet the resident other than the resident is toileted per request and offer toilet with rounds at night. (In comparison, the pocket care plan guide for two other residents on the same list had special instructions provided to staff to not them unattended in their room or in the lobby area.) Staff Interviews: On [DATE] at 1:33 p.m., Staff E (nurse aide) stated and documented in her written statement the following: she assisted the resident to the bathroom on [DATE]. Staff E usually gets clothes out first but the morning of [DATE], the resident sat up at the bedside and expressed an urgent need for the toilet. Staff E assisted the resident into the bathroom and sat the resident on the toilet. Staff E then went to the closet and got clothes for the resident while the resident sat on the toilet. Staff E stated she did not have the resident in view when she obtained clothes from the closet. Staff E stated she then heard the resident say something and headed back to the bathroom and on the way, Staff E heard a noise. Staff E rushed in to find the resident on the floor. Staff E called for help with the call light and yelling for assistance. Staff E stated when she stepped out of the bathroom, prior to the fall, she did not intentionally break any rules. She knew staff should not leave the resident alone but thought that meant leaving the bedroom area. She did not know she needed to stay in the bathroom right by the resident. Staff E stated she relied on pocket care guides when caring for residents. On [DATE] at 9:33 a.m., Staff A (housekeeper) stated around 7 a.m. on [DATE] she heard Staff E yell for her to get a nurse because Resident #1 fell off the toilet. Staff A then looked for the nurse. Another nurse aide Staff J, arrived and asked Staff A to assist with moving the resident out of the bathroom. Staff A held the resident's neck and head so it remained stable while staff moved the resident out of the bathroom. Staff A stated she had seen other staff leave the resident unattended in the bathroom to obtain clothing or make a bed. She did not report this because she is not familiar with care plans. On [DATE] at 1:20 p.m., Staff J (nurse aide) stated on [DATE] at 7:15 a.m., she observed Staff A trying to find a nurse. Staff J asked what was wrong and found out the resident was on the floor. Staff J entered the room and observed the resident under the sink face down in blood. She then left and found the nurse (Staff D). Staff D arrived and stated she better call 911 and left. Staff J then thought she needed to get the resident off his/her face so she phoned an off duty nurse for advise. That nurse advised her to stabilize the resident's head and neck so they could turn the resident over. Staff did this and then stayed with the resident holding the resident's neck and applying pressure to the head to control bleeding. Staff J stated in the past she would leave the resident unattended in the bathroom for about 10 seconds to grab a wheelchair. Staff J stated she relied on the pocket care plans to know what to do for the residents. The pocket guides are found in the bath books. On [DATE] at 9:40 a.m., Staff D (registered nurse) stated on [DATE] at 7 a.m., she arrived at Resident #1's room after another staff informed her "It's bad". She observed the resident on left side between toilet and sink with copious amounts of red blood on the floor coming from the left side of the head. The resident was unresponsive. Staff D then called 911. On [DATE] at 1:10 p.m., Staff I (nurse aide) stated when staff toilets the resident they get him/her in the bathroom and then leave for a couple minutes. While waiting, Staff I sits or stands outside the door keeping an eye on the resident. Staff I is aware of what to do for residents through the pocket care guides located in bath books. The guides give general directions for resident care. On [DATE] at 10:20 a.m., Staff H (nurse aide) stated when she toilets the resident she keeps the resident in view at all times. Staff H knew not to leave the resident because of care plans that are always available. On [DATE] at 10 a.m. Staff G (nurse aide) stated she would take the resident to the toilet during the day. If the resident appeared alert and sitting Ok then Staff G would leave the door cracked open and watch the resident. If the resident appeared sleepy then Staff G would stay in the bathroom with the resident. Staff knows what to do for residents through care guides. On [DATE] at 1 p.m., Staff F (nurse aide) stated she would walk the resident to the rest room and then sit the resident down and stand outside the bathroom door with the resident not really in view. The resident would tell staff when he/she finished. Staff F stated staff has pocket care guides to use to know what to do for residents. Staff F stated it could have happened to any of us because she did not know that staff were to stay in the bathroom with Resident #1. On [DATE] at 12:42 p.m. Staff B (Co Director of Nursing) stated care plan information is available to nurse aides through the pocket care guides. Staff B stated when the care plan states not to leave resident alone in bathroom that staff needs to be in the bathroom with the resident. The surveyor showed Staff C the pocket care plan guide use by the aides. When asked if the [DATE] care plan guide was the guide in place when Resident #1 fell (on [DATE]) Staff C stated on [DATE] at 3:10 p.m. that she did not know. On [DATE] at 3:20 p.m., Staff C (Co Director of Nursing) stated when the care plan says do not leave unattended in the bathroom that staff needs to have the resident in the field of vision and they can step out of the bathroom as long as the resident remains in the field of vision. The DON stated she did not find an in-service where it was explained (to staff) what unattended actually means prior to the incident ([DATE]). On [DATE] at 3:33 p.m., the Administrator stated she held meetings following the incident but did not specify to staff what "do not unattended" actually meant. She stated in her opinion do not leave unattended means staff needs to visualize the resident at all times.

Based on observation, record review and staff interviews, the facility failed to ensure that a resident who enters the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for three (3) of seven (7) residents identified with sores (Resident #1, Resident #2 and Resident #3). The facility reported a census of 35 (thirty-five) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 11/10/10, assessed Resident #1 with a BIMS (Brief Interview for Mental Status) score of 0 (severe impairment). The resident required extensive assistance of staff with bed mobility, transfers, ambulation in hall, dressing, eating, toileting, personal hygiene and bathing. The resident had functional limitations of upper and lower extremities. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident on scheduled pain medication regimen and also received PRN (as needed) pain medication for daily pain evidenced by non verbal sounds and facial expressions indicating pain. The MDS indicated the resident not at risk for pressure sore development and identified the resident without sores or foot problems at that time. A Braden Scale for predicting pressure sore risk identified the resident with a score of 17. A pain assessment form dated 11/4/10 identified the resident to receive [MEDICATION NAME] 50 milligrams (mg.) three times per day and Tylenol 650 mg. three times per day. The pain assessment identified the resident with a recent onset of left leg and foot pain noted primarily at night. The form documented the question: if new, what had changed? The facility staff documented the following: possible caused by foot turning out more and increased difficulty with ambulation program. The pain assessment identified the resident's pain interfered with the resident's quality of life in the following ways: sleep disturbance, mood/behavior and concentration. Resident #1 saw the podiatrist on 9/27/10 for routine nail care. At that time, the podiatrist identified a need for high risk foot care secondary to ASO ([MEDICAL CONDITION] obliterans). The podiatrist documented nonpalpable pulses in the feet as well as thin, atrophic and shiny skin on the feet. At that time, the podiatrist identified the feet as free of ulcers, open [MEDICAL CONDITION] or evidence of bacterial infection. The podiatrist did not identify pain present. Review of nurses bedside records identified the resident began to complain of pain in bilateral feet on 10/21/10. Documentation identified the resident as screaming with pain. Staff repositioned the resident's feet on a pillow and administered [MEDICATION NAME] (for pain) 50 milligrams (mg.). Staff did not assess the feet. According to nurses bedside records and the P.R.N. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 10/22/10 at 11 p.m. [MEDICATION NAME] given. 10/23/10 at 2:30 a.m. Shouting "It hurts" Tylenol given. 10/25/10 at 2:30 a.m. Complains of left foot pain. No sign of skin irritation or breakdown. [MEDICATION NAME] given. 10/26/10 at 11 p.m. Yelling crying states left leg hurts. [MEDICATION NAME] given. 10/27/10 at 12:10 a.m. Continues to cry identifies "ankle" Tylenol given. 10/27/10 at 10:40 p.m. Crying and shouting "It hurts" [MEDICATION NAME] given. 10/28/10 at 12:45 a.m. Continues to scream and cry. States left foot hurts. 10/29/10 at 1:35 a.m. Shouting crying "It hurts" Tylenol given. 10/29/10 at 11:35 p.m. Screaming crying "Ow ow" Says left foot hurts. [MEDICATION NAME] given. 10/30/10 at 12:35 a.m., Continues to scream and cry. Complains of pain in the left foot. Tylenol given. Reminded other residents are sleeping. Resident stated, "I can ' t help it". 10/30/10 at 10:35 p.m. Complains of left foot and leg discomfort. [MEDICATION NAME] given. 10/31/10 at 1 a.m., Nurse faxed the physician to update on increased use of PRN pain medications due to complaints of left leg and foot discomfort. 10/31/10 at 10 p.m. Complains of left leg and foot discomfort. Increased yelling and tearfulness [MEDICATION NAME] given. 10/31/10 at 11 p.m. Tylenol given for left leg pain No injury noted to affected area. No swelling or redness. Physician order [REDACTED]. 11/1/10 at 10:45 p.m. Awake crying and screaming. "Ow Ow" and "It hurts". 11 p.m. Continues to shout and cry. Tylenol given. 11:15 p.m. Continues to scream loudly. 11:45 p.m. Continues to scream and cry loudly. Brought to dining room for monitoring 11/2/10 at 11:20 p.m. Tylenol given for left foot and leg pain. 11/3/10 at 11:20 p.m. Tylenol given for pain in both feet 11/4/10 at 12:30 a.m. Awake and screaming "My feet". Tylenol given. 11/4/10 at 10:20 p.m. Nurse refaxed physician to inform of resident's increased pain medication use despite [MEDICATION NAME] three times daily started on 11/1/10. 11/4/10 at 3 p.m. Yelling "My feet". [MEDICATION NAME] given. 11/5/10 Doctor at facility with new orders for pain management. The physician nursing home note identified the resident with "chronic unexplained leg pain". The physician identified the resident with pain with movement and touch. The physician changed the resident's [MEDICATION NAME] (for depression) to [MEDICATION NAME] for pain relief. Under "skin" the physician identified "no rashes" The ABN (abnormal) area was blank. There is no notation that the physician examined the resident's foot. 11/5/10 at 10:30 p.m., In bed shouting "Where am I?" and crying. Brought to lobby area. 11/6/10 at 10:10 p.m. Tearful and yelling Brought out to lobby. 11/7/10 at 2 a.m. Yelling complains of left leg and foot discomfort. Stops yelling when transferred into wheelchair and brought to lobby. 11/9/10 at 12:15 a.m. States, "Oh it hurts". States left foot hurts. [MEDICATION NAME] given. 12:30 a.m. Continues to scream and shout. Brought to lobby for supervision. 11/11/10 at 1:35 a.m. Shouting "Oh my legs". Tylenol given. 11/13/10 at 6 a.m. Crying States, "Something is wrong with my feet". Given scheduled Tylenol. 11/16/10 at 1:30 a.m., Yelling "It hurts" reports leg pain. [MEDICATION NAME] given. 11/17/10 at 2:50 p.m. Yelling that left foot hurts. [MEDICATION NAME] given. 11/18/10 at 2:50 p.m. Yelling and reports left foot hurts. [MEDICATION NAME] given. 11/26/10 at 11:20 p.m. Shouting and crying. States leg hurts. Nurse visually inspected leg with no skin issues noted. Tylenol given for leg pain. 12/1/10 at 12:10 a.m. Tylenol given for calling out and crying due to leg pain. 12/14/10 at 2:15 a.m. Complains of pain in feet Tylenol given 12/16/10 at 2 a.m. Awake and screaming for help. Complains of pain in both feet. Tylenol given. 12/17/10 at 12:40 a.m. Shouting crying and states feet hurt. [MEDICATION NAME] given. 12/19/10 at 12:45 a.m. Complains of both feet hurting. [MEDICATION NAME] given. 12/20/10 at 12:30 a.m. Complains of left leg discomfort. Increased yelling out. [MEDICATION NAME] given. 12/21/10 at 2:50 a.m. Shouting, crying intermittently. States, "My feet hurt". [MEDICATION NAME] given. 12/28/10 at 12:30 a.m. Given [MEDICATION NAME] for complaints of feet hurting. 12/30/10 at 1:05 a.m. Continues to cry out and shout. Complains of foot pain. Brought out to lobby area. 1/1/11 at 3:30 a.m. Screaming loudly. States, "it ' s my feet" Tylenol given. 1/4/11 at 12:15 a.m. Screaming. States has pain in left foot. Tylenol given. On 1/7/11 the physician saw the resident. There is no assessment of pain or the left leg/foot noted. 1/13/11 at 5 p.m. Yelling when left foot touched. [MEDICATION NAME] given. On 1/22/11 at 1:15 a.m. Resident in bed screaming "help me" states she hurts all over. Tylenol given at 1:45 a.m. the resident continued to scream loudly so staff got the resident up in wheelchair and took resident to lobby area. Quiet after gotten up from bed. At 2:15 a.m., Resident resting quietly in dining room in wheelchair. At 6:05 a.m. Staff M arrived on duty, Staff C informed her the resident had possible gangrene to the left foot. Staff C stated she reported this several times to Staff A L.P.N. (licensed practical nurse) in the past. The last time Staff C reported this was yesterday (1/21/11). Upon inspection, Staff M observed a 3.8 centimeter (cm.) by 2.2 cm. black eschar area on the right medial great toe next to nail bed and a Stage 4 area 2.2 cm. by 2 cm. by 0.2 depth with black eschar slough attached to dry intact skin located at the base of the left little toe medial posterior aspect. A third area at the surface of the left upper sole of foot where little toe touches surface is a red linear line abrasion measuring 2.4 cm. by 0.2 cm. A 4th area 3 cm. by 0.3 cm. on the surface sole of the left foot light purple linear line running below middle toe towards heel, superficial and intact. On 11/26/10 at 11:20 p.m., staff documented they visually inspected the left leg. The entry did not specify inspection of the foot. Review of nurse ' s bedside records failed to identify an assessment of the left foot documented since 10/25/10, even though the resident continued to complain. The wound nurse saw the resident on 1/24/11. The wound nurse identified the left great toe as: puffy, deep pink and tender to firm pressure. Area of brown eschar on medial edge of nail 0.9 cm. by 0.5 cm. No apparent active drainage. Scant bloody drainage on previous dressing. Wound surrounded with 0.2 cm. line of maceration. Left 4th toe: dusky with no apparent open wound. Not tender to movement. Left 5th toe: red, dusky, tender to touch with wound on medial plantar surface 1 cm. by 1.2 cm. by 0.2 cm. 80% slough on dorsal edge of wound. Previous dressing partially saturated with bloody drainage. Wound bed not probed but appears to be near bone. No open areas or discoloration on plantar surface. Impression: Non stageable wound on left great toe. Stage 4 wound on 5th toe. Each wound covered with PolyMem secured with rolled gauze; change daily. Assessment of the right foot did not identify open areas. Assessment showed a bruise on the proximal anterior 5th toe 0.8 cm. by 0.4 cm. on right foot The physician saw the resident on 1/24/11 for the left foot 1st and 5th toe ulcerations. The physician identified the resident with limited weight bearing and wearing shoes. He documented he may feel dorsal pedal pulse faintly. He assessed shallow ulcers on the medical great toe and the inferior 5th toe of the left foot. On that date, the physician wrote: "I saw the patient on 1/24/11 for foot ulcerations. I do not believe the wounds are infected. For treatment plan, I agreed with the current wound care dressings, advised no wearing of shoes and consulted the wound care nurse. The patient's situation with regards to the foot is not critical. If there was a delay in nursing staff evaluation, my evaluation or in the wound care nurse evaluation, it was not a critically meaningful delay and the patient's care has not been compromised." Staff Interviews: On 1/27/11 at 11:53 a.m., Staff C (Certified Nurse Aide/CNA) stated she reported the resident's left foot looked red on 12/21/10. Staff A (License Practical Nurse/LPN) looked at the foot noting the foot did not feel warm and Staff A did not identify any sores. On 1/11/11 Staff C reported to Staff A observations of a tinge of blood on the bath towel when drying the left foot. Staff C stated she did not see any sores and did not know if Staff A looked at the foot. On 1/21/11 Staff C informed Staff A the resident's foot looked worse. Staff C stated she did not know if Staff A checked the foot. On 1/22/11 the resident sat at the nurse ' s station when she arrived at work that morning. Staff discussed the resident yelling at night and that is why the resident sat at the nurse ' s station at that time. Staff informed Staff M (Registered Nurse/RN) she should check the resident's foot because the foot troubled the resident. Staff M checked the foot right away and asked if anyone reported the impaired skin areas before. Staff C stated she informed Staff A. On 1/27/11 at 11:20 a.m. Staff B (CNA) stated she reported the resident's foot to Staff A on 12/24/10. According to Staff B, Staff A assessed the foot and stated it looked red but there was no open areas. Staff B stated she observed a cream colored "gunk" on the towel after she tried between the resident's toes on the left foot. On 1/26/11 at 4:08 p.m., Staff A (LPN) confirmed Staff C reported a small amount of blood on towel after drying between the resident's 4th and 5th toes. She stated she inspected between the toes and saw no abnormality. She also confirmed Staff B reported drainage when drying between the toes. Staff A observed the towel and thought the drainage might be a combination of lotion and dry skin. During the assessment. the resident yelled "Stop it". On 1/21/11 Staff A stated Staff C informed her the resident's toe looked worse. Staff A stated she forgot to go back and check the foot. Staff A identified the facility cut staff and she had more responsibilities and that contributed to her forgetting to check the foot before she left for the day. On 1/27/11 at 4:27 p.m., Staff L (Director of Nursing/DON) stated Staff A is overwhelmed with the work load and it could be a contributing factor to the incident. She identified when staff reports a skin concern to the charge nurse that the charge nurse is expected to inspect the area and document findings in nurses notes, initiate a skin sheet and incident report, call the physician and family and treat the area as ordered. Observation showed, on 1/26/11 at 1:08 p.m., Staff B and Staff C transfer the resident to bed. Once in bed, staff removed the resident's gripper socks. Observation showed a bandage on the left foot. Observation of the left foot showed a red area between the 4th and 5th toes of the right foot and a small brown area on the top of the 5th toe. Staff B stated, I haven't seen that before". Observation showed, on 1/27/10 at 9:15 a.m., Staff P perform a treatment to the left foot. The resident screamed and opened her eyes wide as Staff P performed the treatment. Observation showed a brown area slightly larger than pea size on the underside of the 5th toe on the left foot. When Staff P manipulated the toe, observation showed a horizontal open area where the toe joins the plantar surface of the foot and a brown area on the left outer big toe. At that time, the surveyor asked Staff P to check the area between the 4th and 5th digit of the right foot. Observation showed redness between the toes and no open areas. At 9:35 a.m. Staff P stated she would start a skin sheet for the area between the 4th and 5th toes of the right foot. At 11 a.m. Staff P stated she placed gauze between the toes. Observation showed the area much less red since staff P placed the gauze. A skin condition record dated 1/27/11 identified the red area between the 4th and 5th digit of the right foot as 4 cm. by 3 cm. On 1/27/11 at 11:20 a.m. Staff B stated she did not report the red area on the right foot that she observed with the surveyor on 1/26/11 because it appeared " to be a normal redness". On 1/27/11 at 4:27 p.m. Staff L stated when staff observes a skin issue they are to report the finding to the charge nurse. The facility has initiated a new procedure to write the finding down and give it to the charge nurse so they have something in writing. The care plan, dated 1117/10 identified the resident at risk for impaired skin integrity. The resident utilized a pressure reduction mattress on bed, bilateral lower extremities elevated while in bed, reposition per facility policy. Addendums to the care plan included: 1/27/11 foot cradle to foot of bed and 1/31/11 foam heel protectors on for comfort. On 1/31/11 the wound nurse reassessed the areas on the left foot as follows: Wound on medial edge of left great toe eschar 1.1 cm. by 0.8 cm. with scattered scabbing and deep redness in area 2 cm. by 1.5 cm. that includes eschar. Most of great toe is deep pink. Wound on medial plantar surface of left 5th toe 1.1 cm. by 0.8 cm. 60% covered with dry black eschar remainder moist pink. Very small amount of bloody drainage on previous dressing on 5th toe. resident finches and cries out frequently to light touch. The wound nurse did not identify open areas on the right foot and identified PolyMem present between each toe on right foot. On 2/6/10, weekly pressure ulcer records identified the area on underside of the 5th toe as a "Stage 4" measuring 2 cm. by 2 cm. with a depth of 0.2-0.3. Comments indicated the area "improved". On the same date, weekly pressure ulcer records identified the left great toe area as "Stage 4" measuring 3.2 cm. by 2.2 cm. and no depth. Comments indicated the area "improved". A skin condition report, on 2/5/11 identified the purple linear line running inferior of 3rd digit of left foot as 3 cm. by 0.3 cm. (no change in size) A skin condition report, dated 2/5/11 identified the red linear area where 5th toe meets surface of upper sole of foot as 1.6 cm. by 0.1 cm. (smaller). A skin condition report regarding the right foot area between the 4th and 5th toes did not contain documentation since 1/27/11 (when the area showed 4 cm. by 3 cm. redness). 2. A Minimum Data Set with an assessment reference date of 12/01/10 assessed Resident #2 with a BIMS score of 5 (severe cognitive impairment). The resident required extensive assistance of staff with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. The resident required human assistance for surface to surface transfers (transfer between bed and chair or wheelchair) and moving on and off toilet. The resident had [DIAGNOSES REDACTED]. The MDS did not identify the resident with pressure sores. A Braden Scale for pressure sore risk, dated 121/10 identified the resident with a score of 19. According to nurses bedside records dated 11/15/10, the resident had a history of [REDACTED]. Staff observed a 5 cm. by 6 cm. red area on the left buttock with a 0.2 cm. superficial open area. This area healed on 2/14/10. Weekly pressure ulcer records identified the area as on the right buttocks and not the left. A nurses bedside record dated 1/23/11 at 7 a.m. indicated Staff B informed Staff M that the resident has a hard dark area to the mid medial right buttock. At that time, Staff B stated she reported the area to staff A earlier in the week. Staff M found no skin condition records and no documentation in the chart. Staff M measured the area 1.2 cm. wide and 1.4 cm. long and identified it as a Stage 4 pressure area. Staff Interviews: On 1/27/11 at 11:20 a.m., Staff B stated on 1/20/11 she noticed a small darkened area hard to the touch on the resident's right buttock. Later that morning she reported the area to Staff A. It appeared the same on 1/22/11. When she heard nothing about it by 1/23/11, she reported to Staff M. Staff B stated prior to the development of the sore on the resident's buttock, the resident sat in a glider chair by the bird cage. Staff B stated there was no special cushion in the chair when the resident sat in it. On 1/26/11 at 4:08 p.m., Staff A stated sometime during the week of 1/17/11 Staff B reported the resident had a hard spot on his/her bottom. Staff A stated she assisted the resident to the bathroom later that day and did not observe any abnormalities on the resident's bottom. The wound nurse saw the resident on 1/24/11 and removed a small dry scab from the resident's right medical buttock. This left a small pink slightly moist wound 0.6 cm. by 0.4 cm. by 0.1 cm. with 2 cm. [DIAGNOSES REDACTED] surrounding. The resident complained of pain to touch. No apparent active drainage. the wound nurse covered the area with a transparent dressing. A care plan, dated 12/9/10 identified the resident at risk for impaired skin integrity. The care plan directed staff to implement interventions that included: pressure reducing cushion in wheelchair, waffle cushion in recliner. On 1/27/11 at 12:52 p.m., Staff N stated prior to pressure sore development, the resident sat in a chair by the bird cage with no special cushion. On 1/26/11 at 4:55 p.m., Staff D stated the resident sat in the chair with no special cushion. On 1/26/11 at 3:08 p.m. Staff G stated the last time she assisted the resident, she observed the resident with a red bottom "which it always is because she sits up in a recliner chair in the afternoons". She stated she did not report the redness because it is always red from sitting on it all afternoon. She stated she observed the resident seated on a pillow a couple times because the resident complained of his/her bottom being sore, otherwise the resident just sits on the recliner with no cushion. On 1/27/11 at 3:20 p.m., Staff H stated the resident does not use cushions in the chair. On 1/27/11 at 3:07 p.m., Staff I stated the resident does not use a special cushion when she sits in the glider chair in the lobby. Observation showed, on 1/26/11 at 12 p.m., Staff E toileted the resident. The resident had a transparent dressing on the buttock covering a very small open area. When asked if the resident uses a special cushion in his/her chair, Staff E stated the resident is not care planned for a special cushion but he tries to "throw one in the chair". He then added, "The resident doesn't like to lay down. The resident likes to sit in the lobby chairs. I think that's what getting his/her bottom". Staff then transported the resident to a wooden dining room chair that did not contain a pressure reduction cushion. The resident remained in the chair until 1:28 p.m. when observation showed staff walking the resident from the dining area. On the same date at 5:20 p.m., the resident again sat in the wooden dining room chair that did not contain a pressure reduction cushion. Observation showed, on 1/27/11 at 8:25 a.m. in a wheelchair having breakfast. The wheelchair did not contain a pressure reduction device. Observation showed the resident still in the wheelchair at 9:10 a.m. At that time, the surveyor summoned Staff P to verify there was no pressure reduction cushion in the wheelchair. At 9:11 a.m. Staff P confirmed no pressure reduction present. At 10 a.m., Staff L informed the surveyor that the resident is usually not in the wheelchair but (s)he was late to breakfast so the resident rode to the dining area. Observation showed, on 1/31/11 at 3:10 p.m. to 4:30 p.m. the resident in the glider/recliner chair in the lobby by the bird cage with no cushion present. On 2/6/11 the weekly pressure ulcer record identified improvement in the area. The record identified the area as "Stage 1" and measuring 0.6 cm. by 0.4 cm. 3. Resident #3 admitted to the facility on [DATE]. Skin condition reports, at the time of admission, identified the resident with a stage one 1 centimeter (cm.) by 1 cm. red raised area on the left 4th toe. Observation showed, on 1/27/11 at 2:55 p.m., the resident in his/her room. The resident agreed to allow examination of the 4th toe. Observation showed some redness present around a corn on the toe. The resident stated the area just "stays the same" and it is "sore all the time". The resident exhibited pain and extreme tenderness when any manipulation of the toe or the toe covering occurred. The record lacked evidence the facility made the physician aware of the condition/assessment of the 4th toe area until 1/28/11. Nurses bedside records identified the physician examined the 4th toe on 1/28/11 at 7:15 a.m. The physician directed staff to continue using the toe protective sleeve and have the podiatrist assess with next visit. A weekly pressure ulcer record, dated 2/1/11, identified the left 4th toe area as 1 cm. by 1 cm. intact and dark pink.