Every finding on record at Sanford Senior Care Sheldon

Based on observation, infection control policy and staff interview the facility failed perform proper hand hygiene during toileting for 1 of 3 residents observed (Resident #2) The facility reported a total census of 42 residents.Findings include:Observation on 6/1/26 at 10:48 a.m., with Staff A, Certified Nursing Assistant (CNA) and Staff B, Licensed Practical Nurse (LPN) assisting Resident #2 to the bathroom. Staff A applied gloves with no hand hygiene prior to applying gloves after assisting the resident to sit on the toilet. Staff A then touched her hair and pulled up her own pants with gloves on and proceeded to lean her hand on the mechanical lift. Staff A picked up the wet wipes package and laid it within reach of the toilet. Staff A then with the soiled gloves on touched the residents incontinent brief she was wearing and with the soiled gloves on adjusted the residents shirt. Staff A with the soiled gloves still on again touched the lift and pulled out 3 wet wipes and rested her right hand on the lift with the soiled gloves still on. Staff B raised the mechanical lift with resident to a standing position and Staff A with the soiled gloves still on performed perineal care for Resident #2. Staff A with the soiled gloves still on pulled the resident's incontinence brief back up, followed her pants. Staff A took over the lift for Staff B and pushed the mechanical lift with the resident back to her wheelchair and lowered her into her wheelchair. Staff A released the leg strap and mechanical lift sling and removed the sling from the resident and hung the sling up for the next use in the residents bathroom. Staff A with the soiled gloves still on pushed the mechanical lift into the hallway and came back into the residents room. Staff A then removed her gloves and performed hand hygiene. Review of the facility provided policy titled Hand Hygiene with a revised date of 11/13/25 revealed the following information:All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene.1. Entering Room2. Before Clean Task3. After Bodily Fluid/Glove Removal4. Exiting Room5. Zones: Patient zone and Health-care zones.Hand hygiene should be performed after Gloves should be utilized whenever contact with blood, body fluid or other potentially infectious matter is present, contact with non-intact skin or as part of transmission-based precautions, and when using chemicals during cleaning activities. Change gloves when moving from a dirty to a clean or sterile activity performing hand hygiene in between changing gloves. Gloves are single use and should not be washed or sanitized for reuse. Hand hygiene must be performed after removal regardless of task. Patients who are in isolation requiring gloves upon entry to room, staff should access health-care zone first and then perform tasks. If staff need to re-access health-care zone, gloves are to be removed, hand hygiene should be performed and then apply gloves.Interview on 6/1/26 at 1:17 p.m., with the Director of Nursing (DON) revealed she expected staff to be changing gloves and doing proper hand hygiene during cares with the residents.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse within 2 hours of an allegation of abuse for 1 of 5 residents reviewed for abuse (Resident #1). The facility staff removed the deficiency prior to the surveyor entering the facility on March 4, 2026 through the following actions:On 12/18/25 the facility placed education related to no cell phones in resident care areas, and if staff see or hear anything that could be suspected abuse or neglect or an infringement of resident dignity on the scheduling app for all staff. On 12/19/25 the facility implemented all staff receive education on resident dignity, photography, abuse or suspected abuse reporting, abuse definitions and follow up quiz for understanding. The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of depression, hypertension and psychomotor defect following cerebral infarction (disturbances in the link between cognitive brain function and physical movement following stroke). The MDS showed the Brief Interview for Mental Status (BIMS) score of 8 indicating severe cognitive impairment. Interview on 3/4/26 at 2:04 p.m., with Staff A, Certified Nursing Assistant (CNA) revealed she was in the hallway with Staff B, CNA and Staff B stated you will never believe what happened and showed Staff A a photo of Resident #1 laying on the floor after a fall with a brief and a tshirt on and Staff B was in the background of the photo. Staff A asked Staff B why she had the photo and Staff B replied oh it is in our work group chat that we have. Staff A did not know for sure when she saw the photo but it was approximately a week later she turned it into the administration. Staff A explained she sat on it and thought about it for a while and knew it wasn't right for Staff B to have the photo and that is why she decided to turn it in to the administration. Interview on 3/4/26 at 2:23 p.m., with Staff C, CNA revealed she had some time off and when she came back to work she was talking with Staff A and Staff D, CNA about how things were when she was gone. Staff A and Staff D asked if Staff C had heard about the picture. Staff C asked about the picture. Staff A and Staff D explained Staff B had a picture of Resident #1 after he had a fall and was laying on the floor wearing a brief and his shirt and Staff B was in the background of the photo. Staff C did not see the photo. Staff C went and found the Director of Nursing (DON) and reported it to her right away. Staff C stated that Staff A and Staff D were nice girls and Staff C thought they were afraid of the other girls and that is why they did not report it to administration. Interview on 3/4/26 at 2:50 p.m., with the DON revealed Staff A, Staff C and Staff D came to her and said that approximately a week before Staff B showed them a photo of Resident #1 laying on the floor the night he had a fall. Staff described the photo to her as Resident #1 laying on the floor with his brief down to his ankles and a pillow underneath his head. Staff B was in the photo. Staff explained to her she had shown them the photo as they were talking about Resident #1's fall. The DON explained staff A and Staff D had stewed on it awhile and then mentioned it to Staff C and she suggested to them they needed to report it to administration. Review of facility provided investigation dated 12/18/25 revealed the following information:Interventions included Staff A, Staff C and Staff D will be receiving corrective action for not reporting allegations in a timely manner. Review of the facility intake information the facility submitted a self report on 12/18/25 at 6:52 p.m Review of the facility provided policy titled Abuse and Neglect with a reviewed date of 4/7/25 revealed the following:Alleged or suspected violation involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency. If there is an allegation of abuse, neglect, exploitation or mistreatment, then it will be reported immediately, but not later than 2 hours after the allegation is made. Interview on 3/4/25 at 4:39 p.m., with the DON revealed the staff should have reported it to the administration right away.

Based on observations, clinical record reviews, staff interviews and policy review the facility failed to prepare and serve food in a form designed to meet individual needs and according to their assessments and care plans for 5 of 9 residents (Resident #4, #9, #30, #117 and #217) reviewed. The facility failed to prepare and serve 5 meals according to the residents' prescribed diet orders. The facility reported a census of 46 residents.Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment. The document revealed the resident received a mechanically altered diet during the last 7 days of the assessment period. The resident's Care Plan contained a problem area dated 10/15/25 of receiving a mechanically altered diet related to dysphagia. The approach dated 10/15/25 revealed a Level 6 Soft and Bite Sized Diet with moist meat or gravy/mildly thick liquid and no straws. The resident's diet order dated 8/26/25 revealed regular bite sized food, dry meat to be cut in small bites with thin liquids - no straws. 2. Resident #9's MDS dated [DATE] revealed a BIMS of 15/15 score indicating normal cognition. The document revealed the resident received a mechanically altered diet during the last 7 days of the assessment period. The resident's Care Plan contained a problem area of a mechanically altered diet related to poor dentition with a last reviewed date of 10/15/25. The approach for the intervention included a Level 6 Diet (Soft and Bite Sized) with ground meats per resident choice with a start date of 2/6/22. The resident's diet order dated 3/15/22 revealed Level 6 (Soft and Bite Sized) with ground meats. 3. Resident #30's MDS dated [DATE] revealed a BIMS of 6/15 indicating severe cognitive impairment. The document revealed the resident did not receive any alterations to her diet during the reporting period. The resident's Care Plan contained a problem area dated 10/15/25 of mechanically altered diet due to swallowing difficulty with an approach of Level 6 Soft and Bite Sized Diet with meals. The resident's diet order dated 10/16/25 revealed a Soft and Bite Sized Diet. 4. Resident #117's MDS dated [DATE] revealed a BIMS score of 3/15 indicating severe cognitive impairment. The document revealed the resident received a mechanically altered diet during the last 7 days of the reporting period. The resident's Care Plan contained a problem area dated 10/16/25 with a requirement of mechanically altered diet related to esophageal constriction with an approach of Level 6 Soft and Bite Sized Diet. The resident's diet order dated 10/22/25 disclosed a mechanical soft diet. 5. Resident #217's MDS dated [DATE] revealed a score of 0/15 indicating severe cognitive impairment. The document revealed the resident did not receive any alterations to her diet during the reporting period. The resident's Care Plan contained a problem area dated 10/15/25 of requiring a mechanically altered diet with an intervention of Soft and Bite Sized. The resident's diet order dated 10/2/25 disclosed National Dysphagia Diet (NDD)6 - Soft and Bite Sized with meals. During an observation on 10/4/25 at 10:10 AM the Dietary Manager (DM) prepared diet modifications for the #4 Pureed Diet and #5 Minced and Moist Diet. The DM stated she was preparing a total of 4 #4 Pureed Diet servings (3 for residents and 1 extra) and 3 #5 Minced and Moist Diet (2 for residents and 1 extra). The staff prepared noodles, beef and broccoli and egg rolls for both consistencies. The Diet Spreadsheet for the noon meal on 11/4/25 disclosed the following was to be served to the residents on modified diets:#6 Soft and Bite Sized Diet: bite sized beef and broccoli stir fry with thick gravy, soft and bite sized buttered fettuccine noodles, pureed egg roll, Smooth and Thick Sweet and Sour Sauce and pureed brownie.#5 Minced and Moist Diet: minced beef and broccoli stir fry with thick gravy, minced fettuccine noodles with thickened broth, pureed egg roll, Smooth and Thick Sweet and Sour Sauce and pureed brownie.#4 Pureed Diet: pureed beef and broccoli stir fry, pureed soft fried noodles, pureed egg roll, Smooth and Thick Sweet and Sour Sauce and pureed brownie. During a continuous observation on 10/4/25 beginning at 11:42 AM Staff A, Dietary Aide, and Staff B, Dietary Aide, began the meal service. Staff A prepared Resident #30's plate with Minced and Moist noodles, beef and broccoli and a regular egg roll. The resident's plate was transferred to an unidentified staff who served the resident. The resident picked up a utensil and was prepared to initiate eating when the serving was stopped. Staff A when questioned about the Resident #30's diet order and what was served, admitted the resident should have been served a pureed egg roll versus a regular egg roll. Staff A prepared a corrected egg roll serving for the resident and provided it to the staff for Resident #30. The DM entered the kitchenette and reviewed Resident #30's dietary order and confirmed the resident should have received a pureed egg roll with her meal not the regular egg roll that had been provided. Staff B continued serving the meal. During the meal service observation Staff A and Staff B prepared and served #6 Soft and Bite Sized diets for Resident's #4, #9, #117 and #217 brownies cut into bite sized pieces. On 11/4/25 at 12:20 PM the Registered Dietitian acknowledged awareness of a resident who was ordered a #5 Minced and Moist Diet being provided a regular egg roll. The staff stated if a resident was on a #6 Soft and Bite Sized Diet their egg roll should have been cut up. On 11/4/25 at 12:22 PM the DM stated Resident #30 was recently discussed during the Morning Meeting and the decision was made to downgrade to a #5 Minced and Moist Diet due to spitting foods out and exhibiting some coughing during meals. The staff stated they were waiting for the official order to come down for the change of diet consistencies. When asked what the consistency should be for the egg roll for the Soft and Bite Sized Diet, the Kitchen Supervisor initially stated it would be chopped, then stated would like to refer to the menu. When referring to the Diet Spreadsheet for 11/4/25, the staff acknowledged the document stated the residents were to receive a pureed egg roll. When counting the number of residents with #4 Pureed, #5 Minced and Moist and #6 Soft and Bite Size diets there were 9 residents who should have received pureed egg rolls. The Dietary Manager conceded that she did not prepare pureed egg rolls for 9 residents; she only prepared pureed egg rolls for the 5 residents on the #4 Pureed and #5 Minced and Moist diet consistencies, not the 4 residents on the #6 Soft and Bite Sized Diets. On 11/5/25 at 10:05 AM the DM reviewed the Diet Spreadsheet for 11/4/25 noon meal and acknowledged the residents receiving a #6 Soft and Bite Sized Diet should have received a pureed brownie, not a brownie that had been cut into bite sized pieces. The staff stated she was not aware neither Staff A nor Staff B provided a Smooth and Thick Sweet and Sour Sauce for residents receiving a #4 Pureed Diet, #5 Minced and Moist Diet and #6 Soft and Bite Sized Diet. The DM stated a Diet Spreadsheet was available in the kitchen and kitchenette and expected staff to utilize it when preparing and serving meals. The facility's Texture-Modified Diets-Food and Nutrition Services Policy, reviewed 5/12/25, revealed its purpose is to ensure the safe consumption of food/fluids for residents who have difficulty chewing or swallowing. The document disclosed that the food and nutrition services department alter the texture and consistency of foods that are prescribed by the resident's attending physician and all diet orders, including texture modifications, must have a physician's order.

Based on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards by not practicing accepted hygiene practices. The facility reported a census of 46 residents. Findings include: During a continuous observation on 10/4/25 beginning at 11:42 AM Staff A, Dietary Aide, and Staff B, Dietary Aide, began the meal service. Staff A left the kitchenette area and moved into the main dining room. Staff B requested Staff A's assistance in the kitchenette preparing 3 special request meals. Staff A entered the kitchenette, went to the stove top and initiated making scrambled eggs. The staff did not complete hand hygiene upon entry into the kitchenette. The staff cracked the eggs and proceeded to don a single glove on the left (L) hand. With the gloved L hand Staff A opened the bread wrapper, removed the bread and placed it in the toaster. The staff continued to monitor scrambled eggs until complete, transferred the eggs to the plate, carried the plate with the L gloved hand, placed a cover over the food, placed it on the steam table, and returned to the toaster. Staff A continued with the single gloved L hand to hold bread while buttering with the right. The toast was transferred to the plate and provided to the serving staff. Staff B worked at the steam table, washed her hands and moved to the food prep area, donned a single glove, placed a pre-assembled grilled cheese sandwich on a skillet, obtained bread from the wrapper and placed 2 slices of bread in the toaster. The gloved hand touched the wrapper as well as the bread. Staff B returned to the steam table with one gloved hand when Staff A indicated the sandwich had burned on the skillet and a new one would need to be started. Staff A cracked an egg into the skillet for making a fried egg sandwich using the gloved and ungloved hands. Staff A obtained new bread from the package using the same gloved hand, obtained cheese from the refrigerator, and used the gloved hand to place the cheese on the sandwich. The grilled cheese was removed from the skillet and placed on a plate for serving. Staff A obtained the bread from the toaster using the same gloved hand and placed it on a plate, stabilized the toast with the L gloved hand while the right buttered, and then added the egg for serving. On 11/6/25 at 12:15 PM the Dietary Manager stated it was the expectation that hands should be washed when entering the kitchenette area prior to touching any food items, as well as prior to donning gloves and glove removal. The Dietary Manager stated serving/preparatory staff should not be touching non ready to serve food items with a gloved hand and returning to ready to eat food items without changing gloves and hand hygiene. The facility's Glove Use in NFS Department, reviewed 3/4/25, revealed staff would utilize single use gloves as needed to avoid direct contact with ready to eat foods. The document further revealed fresh gloves were to be used if staff change tasks, hands must be washed and replaced with clean gloves and when possible use utensils rather than the gloved hand to handle food. The facility's Wash Hands document revealed hands should be washed before starting work, after touching raw poultry, meats or fish and during food preparation as necessary.

Based on record review and staff interview, the facility failed to notify the physician and the resident's representative of a significant weight loss for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 46 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #11 had long and short term memory problem, and severely impaired cognitive skills for daily decision making. The resident required supervision or touching assist with eating. The resident's diagnoses included non-Alzheimer's dementia. The resident weighed 125# and did not have a weight loss of 5% or more in a month, or 10% or more in 6 months. The Care Plan dated 10/15/25 identified the resident at nutritional risk related to dementia. The weight record documented the resident weighed: a. 129 on 9/2/25, b. 125.4 on 9/16/25, c. 120.7 on 10/7/25, a 6.4% loss, (5% in 1 month is significant). d. 117.5 on 10/14/25, e. 116.9 at 10/21/25, a 9.4% loss in 50 days, (7.5% in 90 days, and 10% in 180 days is significant). The clinical record lacked any documentation the facility notified the physician or Resident #11's representative of the significant weight change. On 11/6/25 at 8:40 a.m. the Director of Nursing (DON) stated she found no notification of the physician or family of the significant weight loss. The facility Weight and Height policy reviewed/revised 9/30/25 identified the purpose to ensure residents maintained acceptable parameters of nutritional status regarding weight and to report changes in a resident's clinical condition (significant weight change) to the physician and family and/or resident. The location would immediately inform the resident, consult with the resident's physician and, notify the resident's legal representative when there was a significant change in the resident's weight. Significant weight change was defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days.

Based on record review and staff interview, the facility failed to update a resident's care plan with an intervention to prevent further falls for 1 of 2 residents reviewed with falls (Resident #4). The facility reported a census of 46 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated 7/325, Resident #4 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident demonstrated independence in ambulation. The resident required set up assist with transfers. The resident's diagnoses included cerebral infarction or stroke. The Care Plan with a start date of 4/17/25 identified the resident at risk for falling related to weakness and use of medications. Interventions included encouraging the resident to assume a standing position slowly, ensuring the resident wore eyeglasses, giving the resident verbal reminders not to ambulate/transfer without assistance, keeping in lowest position with brakes locked, keeping the call light in reach at all times, keeping personal items and frequently used items within reach, providing, well maintained footwear, and providing an environment free of clutter (all dated 4/17/25). The Progress Notes dated 7/29/25 at 2:05 a.m. documented the nurse was called to the residents room at 11:30 p.m. and observed the resident laying on the floor, on her back with her legs straight down and arms straight down to her sides, with a large amount of bright red blood under and around her her head. Range of Motion (ROM) done with her upper and lower extremities without difficulty or discomfort. No shortening of a leg or leg turned outward. No other injuries noted. The resident stated her head hurt. She said she was going to peek out into hallway to see if anything was going on. The next thing she was laying on the floor. They were under a thunderstorm watch and warning, most of the evening shift. Used a total mechanical lift and 3 staff members to get the resident up off floor and seated into her wheelchair. They pushed the resident to the emergency room (ER). In the fall packet dated 7/28/25 at 11:30 p.m. the nurse documented she believed the resident sat in a locked wheelchair and could not get the brakes unlocked, so she climbed over the foot pedals and lost her balance and fell. There were no witnesses to the fall. The form indicated documentation would include updating the care plan. There must be an immediate intervention, and notification of leadership if unable to find a long term intervention. These 2 items were not checked they were done. The Care Plan failed to identify any new interventions. On 11/6/25 at 8:20 a.m. the DON stated after a fall, Care Plans should be updated to include new interventions to try to prevent any further falls.

Based on observation, record review, and staff interview, the facility failed to ensure a resident received services to maintain or improve Range of Motion (ROM) for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 46 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had no limitation in functional Range of Motion (ROM) of the upper or lower extremities. The resident's diagnoses included cerebral infarction or stroke. According to the MDS assessment dated [DATE], Resident #4 scored 9 on the BIMS indicating moderate cognitive impairment. The resident had limitation in functional ROM of both upper extremities. The clinical record lacked documentation the facility consulted the physician about the noted declines for a therapy evaluation. The Care Plan dated 4/17/25 identified Resident #4's limited ability to transfer herself related to weakness from cerebral infarction. Interventions included Physical Therapy (PT)/Occupational Therapy (OT) for strengthening per the physician's order, and following PT/OT recommendations. On 11/5/25 at 1:20 p.m. Staff C Licensed Practical Nurse (LPN) took the resident to the bathroom. She asked the resident to put her left arm up to the grab bar. The resident could not do it. Staff C tried to help her put the arm up and the resident cried out to go slower. Staff C tried again and able to get her arm up to the bar and she grabbed on. Using the gait belt Staff C lifted the resident to a standing position. After toileting, Staff C again got the resident to a standing position. When back in the wheelchair the resident said when she had the stroke she laid on the affected side awhile, the right side. She said she thought the left side was a problem from that side having to do everything. Staff C said it had been getting worse. On 11/4/25 at 4:44 p.m. the MDS coordinator stated she started in July and she coded the (9/25/25) MDS for ROM as impairment both sides upper because the resident had difficulty raising her arms and they had to maneuver her arms into clothing. She did not feel that was a change for the resident (she did not do the previous assessment). The resident attended exercise class when she wanted to. The CNA's did some ROM when they assisted with care. The MDS Coordinator reported the resident only attended exercise class 5 times in October. She said there were no staff at exercises to assist with the exercises. Residents did what they were able to do. She said they had some residents on restorative, but mostly walking programs. On 11/5/25 at 8:30 a.m. (when asked about restorative), the Director of Nursing (DON) stated they did not have a restorative aide. The facility Restorative Walk and Dine Program revised 7/30/25 identified the purpose to assist a resident to maintain ability to ambulate independently or with limited assistance. Responsible employees included Certified Nursing Assistant's (CNA's) and Restorative Nursing Assistant's (RNA's). A resident capable of ambulating to and from the dining room would be placed on the Walk and Dine Program. The facility's restorative program did not address a resident's ROM.

Based on record review and staff interview, the facility failed to ensure a resident received dietary supplements as planned to maintain or increase weight for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 46 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #11 had long and short term memory problem, and severely impaired cognitive skills for daily decision making. The resident required supervision or touching assist with eating. The resident's diagnoses included non-Alzheimer's dementia. The resident weighed 125# and did not have a weight loss of 5% or more in a month, or 10% or more in 6 months. The Care Plan dated 10/15/25 identified the resident at nutritional risk related to dementia. The interventions included a regular diet with boost supplementation 3 times a day (TID). The weight record documented the resident weighed: a. 129 on 9/2/25, b. 125.4 on 9/16/25, c. 120.7 on 10/7/25, a 6.4% loss, (5% in 1 month is significant). d. 117.5 on 10/14/25, e. 116.9 at 10/21/25, a 9.4% loss in 50 days, (10% in 180 days is significant).The record lacked a weight the last week in October.The resident's weight obtained per request on 11/5/25 of 119.8#. The clinical record lacked any documentation the facility notified the physician or Resident #11's representative of the significant weight change. The diet sheet utilized by dietary showed Resident #11 on a regular diet with Boost TID. The Dietary flowsheet for October 2025 showed documentation the resident received supplement with breakfast and dinner. It lacked documentation the resident received a supplement 3 times a day. On 11/5/25 at 8:22 a.m. Staff D Dietary Aide (DA) stated the supplement was Boost and how much she took. On 11/5/25 at 8:45 a.m. the Director of Nursing (DON) looked at the weights and the last weight recorded on 10/21/25. She thought they had the supplement taken care of. She would see about a weight, and the supplement. On 11/5/25 at 5:20 p.m. the DON and Dietary Supervisor (DS) stated they were to give the resident Boost 3 times a day. The DS said she couldn't say why it was not documented on the evening shift. The DON stated they talked about the resident in the weight meeting, so they knew about the loss. In an email on 11/6/25 at 9:23 a.m. the DON wrote she didn't have specific notes, but they talked about Resident #11's weights at the 10/21 and 10/28/25 weight meetings. The facility Weight and Height policy reviewed/revised 9/30/25 identified the purpose to ensure residents maintained acceptable parameters of nutritional status regarding weight and to report changes in a resident's clinical condition (significant weight change) to the physician and family and/or resident, to accurately measure weight and height, and to monitor weight loss or gain in a resident. Residents at nutritional risk would be weighed weekly. The location would immediately inform the resident, consult with the resident's physician, and notify the resident's legal representative when there was a significant change in the resident's weight. Based on a resident's comprehensive assessment, the location ensured that a resident maintained acceptable parameters of nutritional status, such as body weight, unless his/her clinical condition demonstrated it was not possible. If weight varied by more than three percent, reweigh the resident and document. Significant weight change was defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days.

Based on observations, record review, staff and family interviews, the facility failed to complete accurate assessments and implement interventions for a resident to prevent the development of a Stage 4 pressure sore for 1 of 3 residents reviewed (Resident #1). Certified Nursing Assistant (CNA) staff identified a reddened area on a resident's coccyx in [DATE] and reported it to nursing staff. The record lacked assessments of the area, notification to the physician and treatment orders. On [DATE] an open area on the coccyx was identified and measured 1cm x1 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] the open area to the coccyx measured 1cm x 0.8 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] Resident #1 was admitted to the ER with a diagnosis of sacral decubitus ulcer, stage 4. The resident expired on [DATE] the Death Certificate showed immediate cause of death MRSA Cellulitis, buttock, due to sacral ulcer Stage 4. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 3:52 p.m The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: a. All residents received a full body skin review by RN Nurse Supervisor and no additional concerns were identified. b. All nursing staff were reminded of the importance of skin observations and following process on [DATE]. Additional education was provided on [DATE] and [DATE]. Notifications to physicians and family were included in this education and are on skin checklist packets. This was done by the Director of Nursing and or designees. c. Skin processes and status were reviewed at each huddle beginning [DATE] and this will continue using the huddle checklist. This was initiated by the Director of Nursing Services. d. All care plans were reviewed and updated as appropriate on [DATE] by RN supervisors. This was reviewed again on [DATE] by RN supervisors, Social Worker and Activity Director. e. A tracking tool was initiated that will be completed weekly to show all ulcers and surgical wounds. This will be reviewed at the weekly Risk meeting. This will be completed by the RN supervisor after wound rounds are completed. f. A weekly Risk meeting has been established. This meeting will include Administrator, Director of Nursing, RN Supervisors, Social Services, Activity Director, Quality Director, and Infection Preventionist. Residents with skin impairments will be reviewed to assist in identifying further interventions needed. Care plans will be updated with any changes noted. g. Reviews for each resident with ulcers and or surgical wounds will be reviewed daily for signs and symptoms of pain and infection. This will be noted on the residents treatment sheet. h. The Director of Nursing and or RN Supervisors will review the Matrix Even each day to review tasks and assessments that were completed as necessary. i. Audits to ensure skin observations are complete will be conducted weekly for 3 months by the Director of Nursing or designee. j. The tracking tool will be completed weekly going forward to track measurements, treatment and care plan updates. This will be done by an RN supervisor or designee. The scope was lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 48 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The MDS assessment dated [DATE]showed Resident #1 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The diagnoses included non-Alzheimer's Dementia, diabetes mellitus and hypertension. The MDS included Resident #1 required partial to moderate assistance from staff for toileting hygiene, bathing, lower body dressing, putting on and taking off footwear, and personal hygiene. The Resident was at risk of developing pressure ulcers or injuries and did not currently have a pressure ulcer or injury and had a pressure reducing device for bed. Review of the Progress Notes revealed the following: On [DATE] at 8:25 a.m., Skin Observation on coccyx done, see observation. On [DATE] at 2:28 p.m., Resident wound on coccyx was bleeding a bit today. Review of the Care Plan dated [DATE] revealed the resident was at risk for pressure ulcer due to moisture. The Care Plan lacked information about any redness or open areas. Review of Bath Sheets revealed the following information: On [DATE]- completed with skin tears written on the sheet with a circle and line drawn to the coccyx area on the body diagram. Reddened areas noted to the buttocks and coccyx area with skin barrier cream applied to buttocks. On [DATE]- completed with reddened areas noted to the buttocks area. On [DATE]- completed with skin tears written on the sheet with a circle and line drawn to the coccyx area on the body diagram. Reddened areas noted to the buttocks and coccyx area with skin barrier cream applied to buttocks. On [DATE]- completed with reddened area noted to buttocks with circle and 2 x's on the buttocks/coccyx area hand written very red and sore. On [DATE]- completed with a reddened area noted to the buttocks with asterisk over the coccyx area. On [DATE]- completed with a reddened area noted to the buttocks and coccyx area with a circle around the coccyx area. On [DATE]- completed with no reddened area noted. Review of Skin Integrity Conditions assessment dated [DATE] at 10:12 a.m., completed by Staff R, Registered Nurse (RN) revealed a pressure sore to Resident #1's coccyx area that measured 1 centimeter (cm) x 1cm. Interventions listed were pressure reducing device in chair, pressure ulcer care and applications of ointments or medications. Review of the clinical record lacked any documentation of the pressure ulcer or pressure ulcer care started on [DATE] and notification of the physician or family. Review of the Care Plan lacked any new interventions for the care of the identified pressure ulcer. Review of the Skin Integrity Conditions assessment dated [DATE] at 8:22 a.m. revealed a pressure ulcer to Resident #1's coccyx area measuring 1cm x 0.8cm. No further details listed on the assessment. Review of the clinical record lacked any documentation of the pressure ulcer, pressure ulcer care and notification of the physician or family. Review of emergency room Encounter note dated [DATE] at 1:28 p.m., revealed exam of Resident #1 who presents to the emergency room with concerns of hypotension. Initial blood pressure ,d+[DATE]. Fluids were ordered. Diagnosis included pressure injury of buttock, Stage 3 unspecified laterally. The assessment patient is minimally responsive. Findings included: wound present. Large sacral pressure wound characterized by redness, tenderness and purulent drainage. This morning when the staff attempted to get him up, the patient pointed to his bottom and they noticed a sore in the sacral area. Review of hospital Admission History and Physical dated [DATE] at 8:33 a.m., under Assessment Plan Principle Problem with active diagnosis including sacral decubitus ulcer, Stage 4. On the day he was brought to the ER 1 day ago the staff noted sore on his bottom that he pointed to a complaint of pain. Unsure when that was initially noted or felt. Review of the hospital Discharge Summary dated [DATE] at 8:35 p.m., revealed death summary diagnosis included sacral decubitus ulcer, Stage 4. The patient was admitted 2 days earlier for altered mentation and found to have decubitus ulcer and suspected of having sepsis likely from that. The family opted for keeping him comfortable. He was admitted in the care of his pain and discomfort and he died peacefully. The Death Certificate for Resident #1 showed immediate cause of death was MRSA Cellulitis, buttock, due to sacral ulcer Stage 4. Interview on [DATE] at 2:26 p.m., with Staff D, CNA revealed she knew Resident #1 had something on his coccyx area but was not sure what it looked like as there was always white cream on the area when she took care of him. Staff D expressed Resident #1 would complain about pain in his buttocks area. Interview on [DATE] at 2:47 with Staff E, CNA revealed she had seen the area on Resident #1's bottom and reported it to her medication aide that was working that day and she put a cream on the area. Interview on [DATE] at 2:50 p.m., with Staff A, RN revealed she had worked with Resident #1 and had received disciplinary action for a note she started in the Progress Notes and never followed up on the area. Staff A revealed she had seen a red area on Resident #1's buttocks area and had not done any interventions or a skin packet when she observed the area. Approximately a week and half to 2 weeks ago the CNA's told Staff A that Resident #1 had bright red blood on the toilet seat. Staff A had the CNA's give him a bath and when he was done she assessed his buttocks area and no areas were noted at that time. Interview on [DATE] at 3:05 p.m., with Staff F, RN revealed she had not seen the wound on Resident #1's buttocks but staff had reported it to her. Staff F revealed whoever the nurse working the hallway is responsible for the dressings and treatments on the hallway. Staff F had told another nurse to do the treatment but had not followed up with her to ensure the treatment and documentation was completed. Staff F further revealed she passed on to the next shift the concerns with Resident #1's coccyx area. Interview on [DATE] at 9:08 a.m., with Staff B, RN revealed she had cared for Resident #1 and had seen his coccyx area for the first time when it was red and not open but did not document the information. Staff B revealed she had seen the area when it was open and did not document it as she was under the understanding the nurse prior to her was aware of it and was going to document the area. Interview on [DATE] at 9:29 a.m., with Staff C, CNA revealed on [DATE] Staff A, RN had been in the room with the CNA's assisting with transfer and was unable to look at his coccyx area at that time due to resident transferring poorly. Staff C stated she had reported on [DATE] to the nurse the area looked like hamburger but the area was covered in cream and you could see the blood spots in the slits of the cream when she assisted with pulling up Resident #1's pants. Interview on [DATE] at 10:12 a.m., with Staff G, CNA revealed she had seen Resident #1's buttocks area and reported it to superior that day. Staff G described the area as a red openish area on the upper left buttock and on the upper right buttock there were 2 open areas and it was bleeding. The staff came and looked at it but was unsure if she measured the area and applied a duoderm dressing to the area. Interview on [DATE] at 10:21 a.m., with Staff H, CNA revealed Resident #1's buttocks area when he came wasn't very big at all but he did voice concerns of pain in the buttocks area and the area had been progressively getting worse. The last time she had assisted Resident #1 she stated the area on his buttocks looked absolutely awful. Staff H had reported to the nurse on duty the resident's color was off and he looked grey and purple. Staff H described the area was from the coccyx area where there were 2 blisters. On the way down there was bloody skin on both sides of the buttocks and continuing down looked like hamburger and went all the way down to the scrotum. Staff put cream on it as they were not sure what else to do. Staff H explained Resident #1 was incontinent towards the end and when the staff would change his brief it would stick to the area and when removed the resident would moan in pain. Interview on [DATE] at 10:30 a.m., with Staff I, RN revealed she was unaware of the area but wishes she would have known about it sooner. Interview on [DATE] at 10:35 a.m., with Staff J, RN revealed she was unaware of any skin areas on Resident #1 but was aware of the area now. Staff J revealed she understands he had an open area to the buttocks coccyx area and his groin was red and sore. Staff J denied ever seeing the open area to Resident #1 but the CNA had reported it looked like hamburger to her. Staff J revealed when it was reported to her the resident was in his recliner and staff had not cared for him yet and the meals were being served in the hallways so when staff went into assist him she was unable to go as she was assisting other residents. Staff J denied looking at the area when it was reported to her during her shift. Staff J reported she did not report the area to the next shift coming on. Staff J revealed looking back she wished she would have gone in and looked at the area or at least had someone go in and look at the area when it was reported to her. Interview on [DATE] at 1:58 p.m., with the Director of Nursing revealed the facility had nursing staff that received disciplinary action and some were suspended due to not following through with the skin. We are trying to do everything possible to prevent this from occurring again. Review of facility provided policy titled Pressure Ulcers with a reviewed date of [DATE] revealed; A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Residents will receive appropriate assessments and services to promote and maintain skin integrity. Review of facility provided policy titled Skin Assessment Pressure Ulcer Prevention and Documentation Requirements reviewed [DATE] revealed if a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The licensed nurse records the location of the area, the measurements, and the ulcer/wound characteristics. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for a treatment. Notify resident and/or family/representative of the pressure ulcer, orders and planned interventions.

Based on record review, staff and physician interview, the facility failed to notify the physician and family of significant weight loss for 2 of 3 residents reviewed (Resident #14 and #27) and for 1 resident with a choking incident (Resident #27). The facility reported a census of 49 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #14 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident fed herself. The resident had diagnoses including gastroesophageal reflux disease, diabetes, non-Alzheimer's dementia, anxiety and depression. The resident had a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months, and was not on a physician prescribed weight loss regimen. The clinical record lacked documentation the physician or resident representative were notified of the significant weight loss. On 10/2/24 at 11:15 AM the Dietician stated when a resident had a significant weight loss he would do a dietary assessment and make recommendations if necessary. The DON or MDS Coordinator should notify the physician. On 10/2/24 at 3:13 p.m. the Director of Nursing (DON) stated she couldn't say if the physician or family were notified of the significant weight loss. They met with the dietician for recommendations. The resident did not require a change in dietary interventions at that time. The facility Weight and Height policy dated 9/18/23 identified the purpose included to report changes in a resident's clinical condition (significant weight change) immediately to the physician, the family and to the resident. The policy included the location would immediately inform the resident, consult with the resident's physician and, if known, notify the resident's legal representative when there was a significant change in the resident's weight. The licensed nurse should notify the director of food and nutrition (dietician) within 24 hours regarding any significant weight change. Significant weight change was defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days. The licensed nurse should immediately notify the medical provider regarding any significant weight change (as defined above). 2) According to the MDS assessment dated [DATE] Resident #27 scored 9 on the BIMS indicating moderate cognitive impairment. The resident required partial/moderate assistance with eating. The resident had diagnoses including a stroke, anxiety and depression. The resident had a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months, and was not on a physician prescribed weight loss regimen. a. The Progress Notes dated 7/18/24 at 2:09 p.m. documented the Dietician held a meeting with the MDS nurse and the Director of Nursing (DON) to discuss the resident's weight loss. The resident had a 9# loss for the previous 60 days. Protein supplement 3 times a day. The clinical record lacked documentation the physician or resident representative were notified of the significant weight loss. On 10/2/24 at 3:13 p.m. the DON stated she couldn't say if the physician or family were notified of the significant weight loss. They met with the dietician for recommendations. b. The Progress Notes dated 9/7/24 at 9:42 a.m. documented a staff member put on the Staff Emergency light in the resident's room and went and found another nurse. The nurse entered the resident's room and found the resident struggling to breathe due to aspiration. The resident's face was turning blue, with lips blue as well. The nurse brought the resident to her side and cleared her airway of saliva and mucus. The resident followed commands throughout the the process. Assessment completed after the resident's airway cleared included crackles in the lung fields and vital signs were checked. At 11:25 a.m. the resident assessed again after the episode of aspiration. The resident alert and oriented to name, and no signs of confusion noted. The resident communicated with clear speech. Vital signs were taken. Lung sounds were clear. The resident's clinical record lacked documentation the facility notified the physician or the resident representative of the incident. On 10/2/24 at 3:13 p.m. the DON stated she did not feel the physician or family needed to be notified of the choking incident. The nurses took care of the situation and followed up a couple hours later and the resident was fine. She did not feel it indicated any further follow up. The resident had trouble swallowing, that's why she had a modified diet. On 10/3/24 at 8:40 a.m. the resident's Physician stated she would expect notification of the significant weight loss and the episode of choking/aspirating. The facility Physician - Family Notification policy dated 9/8/23 identified it would establish a consistent process for notification of resident's family members and resident's attending physician of specific events/situations. It directed a staff member would immediately contact a resident's emergency contact person and the attending physician in the situations including a significant change in physical, mental or psychosocial status.

Based on record review and staff interview, the facility failed to notify the long term care (LTC) Ombudsman of resident hospitalization s for 2 residents reviewed (Resident #4 and #8). The facility reported a census of 49 residents. Findings include: 1) The Resident Census page showed Resident #4 was hospitalized [DATE] and returned 5/29/24, 7/21/24 and returned 7/25/24, and 8/19/24 and returned 8/27/24. The monthly Transfers/Discharges forms provided by the facility for ombudsman notification, lacked the resident's transfers to the hospital. 2) The Resident Census page showed Resident #8 was hospitalized [DATE] and returned 8/18/24. The monthly Transfers/Discharges forms provided by the facility for ombudsman notification, lacked the resident's transfer to the hospital. On 10/3/24 at 9:05 a.m. the Social Worker stated she did not include transfers to the hospital on the monthly notification to the ombudsman. She was not instructed to include those. The facility Ombudsman policy dated 12/6/23 included the ombudsman was an advocate whose goal was to promote the highest quality of life for residents by serving as a communication bridge between the resident and the location. For information regarding state-specific regulations, see website: www.ltcombudsman.org. Navigating the link brought up the National Long Term Care Ombudsman Resource Center CMS S&C Memo, and another a link to the Explanation of Notice of Transfer-Discharge and SQC (May 12, 2017.) The memo documented when a resident was temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, according to 42 CFR 483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.

Based on record review and staff interview, the facility failed to assure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 of 17 residents reviewed (Resident #4). The facility reported a census of 49 residents. Findings include: According to the MDS assessment dated [DATE] Resident #4 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS documented the resident was not considered by the state Level 2 Preadmission Screening and Record Review (PASRR) to have serious mental illness. The resident had diagnoses including non-Alzheimer's dementia and bipolar disorder. A PASRR Notice of Nursing Facility Approval dated 12/11/18 directed Resident #4 needed the level of services provided in a nursing facility, and specialized services for behavioral health were required. The resident met the criteria for having a diagnosis of mental illness as defined by PASRR. The resident had depressive disorder, bipolar disorder, and dementia. On 10/3/24 at 8:35 a.m. Staff A Registered Nurse (RN) MDS Coordinator stated she did MDS's, as did Staff B RN. Staff A said if a resident had a level 2 PASRR she would answer yes (to the question on the MDS). If they had a level 1 without need for level 2 she would answer no. At 9:40 a.m. Staff A stated the resident did have a level 2 PASRR, and the answer to the question about PASRR would be yes. The facility MDS 3.0 RAI (Resident Assessment Instrument) policy dated 8/27/24 directed each discipline would be responsible for completing its section(s) of the MDS. The MDS coordinator would submit the MDS.

Based on record review and staff interviews the facility failed to provide professional standards of care by not repositioning a resident with spinal cord dysfunction per provider orders for 1 of 17 residents reviewed (Resident #49). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #49 documented diagnosis of traumatic spinal cord dysfunction and an unhealed pressure ulcer. The MDS showed a BIMs score of 15, which indicated no cognitive impairment. The Provider Order for Resident #49 dated 9/4/24 instructed staff to reposition every one hour while in the chair and every two hours while in bed. The Care Plan for Resident #49 instructed staff to turn and reposition the resident every two hours. If the resident refused repositioning, document the refusal. The Care Plan failed to show the most current provider order to reposition every one hour while in the chair and every two hours while in bed. The Repositioning Records for Resident #49 showed the facility failed to change the repositioning schedule to match the providers orders from 9/4/24. The look back period included 9/4/24 through 9/30/24. The following dates showed the facility failed to reposition Resident #49 as ordered: 9/15/24 9/16/24 9/17/24 9/18/24 9/19/24 9/20/24 9/21/24 9/22/24 9/23/24 9/24/24 9/25/24 9/26/24 9/29/24 9/30/24 The Repositioning Records for Resident #49 showed the facility failed to provide repositioning documentation for the following dates: 9/4/24 9/5/24 9/6/24 9/7/24 9/8/24 9/9/24 9/10/24 9/11/24 9/12/24 9/13/24 9/14/24 9/27/24 9/28/24 The Provider Order policy last revised 2/14/24 specially covered medications, the policy failed to include instructions for orders regarding additional care, treatments and services. In an interview on 10/2/24 at 10:14 AM, Staff C, Registered Nurse (RN) reported she followed up with Certified Nursing Assistants about failing to turn and reposition Resident #49 as ordered. When asked if staff are required to document Resident's #49 refusals to turn or reposition, Staff C replied, yes. Staff C reported Resident #49 often left the building for doctor ' s appointments, wound vac dressing changes and spent one to eight hours per day out with family. When asked if absences should be documented on the Repositioning Record, Staff C replied, yes. In an interview on 10/3/24 at 10:05 AM, the Director of Nursing (DON) reported staff had room to improve compliance for repositioning orders and documentation. When asked about expectations regarding repositioning orders, the DON replied, Yes. The staff should reposition the resident and document it.

Based on clinical record review, staff interviews, and policy the facility failed to complete assessments as ordered by the physician for the necessary care and services. Clinical record review revealed the nursing staff failed to complete all required skin assessments for 1 out of 17 residents reviewed (Resident #49) and failed to follow physican orders for administration of oxygen for 1 of 1 resident reviewed, (Resident #6). The facility reported a census of 49 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #49 documented diagnosis of traumatic spinal cord dysfunction and an unhealed pressure ulcer. The MDS showed a BIMs score of 15, which indicated no cognitive impairment. The Care Plan for Resident #49 identified a risk for skin breakdown related to immobility due to a spinal cord injury. Conduct a systematic skin inspection daily. The Provider Order for Resident #49 dated 9/4/24 instructed staff to assess skin daily. The Skin Assessments Record for Resident #49 showed the facility failed to complete daily skin assessments during the look back period from 9/4/24 through 9/30/24: a. 9/5/24 b. 9/7/24 c. 9/8/24 d. 9/10/24 e. 9/11/24 f. 9/13/24 g. 9/14/24 h. 9/15/24 i. 9/17/24 j. 9/18/24 k. 9/19/24 l. 9/20/24 m. 9/21/24 n. 9/22/24 o. 9/24/24 p. 9/25/24 q. 9/26/24 r. 9/28/24 s. 9/29/24 The Skin Assessment Pressure Ulcer Prevention and Documentation Requirement identified in-services for nursing and other disciplines will be held as necessary and will include the following: a. Pressure ulcer protocols and guidelines b. Etiology and risk factors for skin breakdown c. Use of the Braden Scale for Predicting Pressure Sore Risk UDA d. Skin observation and assessment e. Selection and use of pressure redistribution devices f. Demonstration of positioning g. Instruction on accurate documentation In an interview on 10/3/24 at 10:05 AM, the Director of Nursing (DON) reported upon prior review of skin assessment documentation, the DON noted staff failed to complete skin assessments daily as ordered. The DON stated, I already followed up with the nurses. 26527 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #6 scored 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had diagnoses including coronary artery disease. The resident received oxygen (O2) therapy. The current Care Plan dated 3/4/21 identified the resident required oxygen therapy related to post covid complications. Interventions included administering oxygen per physician orders, may increase to 2-5 liters as needed to maintain saturations >90%, from 2 liters continuous. Written on the care plan date 8/19/24 the resident with O2 sat 82% on 2 liters. Increased to 3 liters per order, O2 sat 91%. The Director of Nursing (DON) signed. On 9/2, O2 sat 88% on 2 liters, increased to 3 liters and O2 sat 92%, signed by the DON. On 9/30 O2 sat 89% on 2 liters, increased to 3 liters, O2 sat 96%, signed by the DON. On 9/30/24 at 2:22 p.m. the resident sat in her recliner with her eyes closed, oxygen on per nasal cannula at 3 liters. On 10/1/24 at 10 a.m. the resident slept in her recliner with her O2 set at 3L. A General Order with a start date of 3/5/21 showed the resident had an order for O2 at 2 liters continuous. The Medication Administration History for 8/1/24 to 8/31/24, 9/1/24 to 9/30/24, and 10/1/24 to 10/2/24 lacked the order or a place to initial the O2 administered. The Medication Administration History for 8/1/24 to 8/31/24, 9/1/24 to 9/30/24, and 10/1/24 to 10/2/24 included the order for Oxygen 2-5 liters as needed (PRN) to keep sats >90%. The medication record lacked any documentation the resident had her oxygen increased. The Progress Notes lacked documentation regarding the low O2 saturation on 8/19/24, 9/2/24, and 9/30/24, or assessment of the resident's vital signs and lung sounds. The O2 Sats for the resident documented O2 sats 8/5/24/ 8/12/24, 8/19/24, 9/2/24, 9/16/24, and 9/30/24. The sats page lacked followup O2 sats, even when the sats were documented low. The sats were only documented every 2 weeks since 8/19/24. Despite the Oxygen being at 2 liters each time the sats were low there was no documentation in the resident's clinical record of an assessment of the resident's respiratory status. The clinical record lacked documentation of how long the resident required increased oxygen, assessment after she had the oxygen decreased back down to 2 liters, and who monitored and made changes to the resident's O2. On 10/2/24 at 3:15 p.m. the DON stated the Certified Nursing Assistant's (CNA's) checked the O2 sats and documented. The resident's (O2 sats) should be checked 1x/week. She said they would need to address it. The facility policy Oxygen Administration, Safety, Mask Types dated 7/8/24 documented oxygen administration was carried out only with a medical provider order. A licensed nurse or other employee trained according to state regulations in the use of oxygen would be on duty and was responsible for the proper administration of oxygen to the resident. The procedure included assessing the resident for at least first 15 to 30 minutes after beginning of therapy and at regular intervals depending on the resident's condition.

Based on record review and staff interview, the facility failed to assure the physician evaluated for a dose reduction of a psychotropic medication for 1 of 5 residents reviewed (Resident #8). The facility reported a census of 49 residents. Findings include: Resident #8's Physician Order Report dated 9/3/22 to 10/3/24 documented the resident's diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. With a start date of 11/20/2023, for Anti-Depressant Medication Use: observe resident closely for significant side effects (sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity, excess weight gain), twice a day. The resident's medications included Amitriptyline 50 mg at bedtime with a start date of 11/20/23. A facility Antidepressant Drug Report dated 6/1/24 documented the resident received Amitriptyline 25 mg, 2 tabs at bedtime (hs) for Alzheimer's dementia with psychotic disturbance/visual hallucinations with a start date of 11/20/23. The resident had not had a dose reduction failure and due for a dose eval 5/2024. A Consultant Pharmacist Communication to the Physician dated 5/30/24 included: The resident had a current dose of Amitriptyline 50 mg at hs for dementia with behavioral symptoms. If tricyclic antidepressant (TCA) drugs were used to manage behavior, stabilize mood, or treat a psychiatric disorder, it was recommended they be reviewed for a possible gradual dose reduction (GDR) in an attempt to find the lowest effective dose. If a dose reduction was not possible at the time, please state the reasoning below, and the risk vs the benefit of continuing the drug at the current dose. The Physician response to the recommendation/finding, please check one of the following: Agree: Please write order(s). Other: (Please write a brief statement concerning the rationale for your response to the recommendation). The resident's clinical record lacked a response to a possible GDR. On 10/2/24 at 3:20 p.m. the Director of Nursing (DON) stated she couldn't speak to whether there was a GDR for the resident's Amitriptyline, she would have to look into it. On 10/3/24 at 11 a.m. during the exit conference with facility staff, the DON confirmed they did not have a response from the physician for evaluation of the resident's Amitriptyline for GDR.

Based on observation, clinical record review, resident and staff interviews, the facility failed to appropriately perform assessments and interventions for the necessary care and services to maintain the residents' highest practical physical well- being for 5 out of 45 residents reviewed with signs and symptoms of COVID-19 (Residents #2, #3, #4,#5 and #6). Records showed 3 residents required hospitalization after emergency room (ER) visits, (Residents #2, #4 and #5). The failure to assess and test for COVID when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 4:49 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. All residents with respiratory infection symptoms will be evaluated by the charge nurse. B. Any resident exhibiting any signs of symptoms of respiratory infection will be tested for COVID-19 and treated per physician directions. C. An evaluation of residents with respiratory symptoms and/or testing positive for COVID-19 will be conducted at least daily until symptoms have resolved. With updates to the physician as appropriate. D. All nurses were educated beginning [DATE] and completed on [DATE] related to the requirements for testing for COVID-19 and isolation of any resident with new respiratory symptoms. E. Audits on residents to ensure they are free of respiratory infection symptoms and completion of COVID-19. The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnosis of stroke, hemiplegia and diabetes. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderately impaired cognition. Review of Progress Notes revealed the following: A. On [DATE] at 8:33 PM, Resident #2 reported he coughed all day like crazy, and requested cough medicine. Staff A Registered Nurse (RN) noted the resident presented with upper respiratory congestion with expiratory wheezing and rhonchi. No documented nursing assessments related to respiratory symptoms occurred from [DATE]-[DATE]. No test conducted to assess for COVID-19. B. On [DATE] the following Progress Notes revealed: a. At 5:02 AM Staff B, Licensed Practical Nurse (LPN), documented Resident #2 sounded horse and nasally. At 10:55 PM ([DATE]) guaifenesin with codeine administered per resident ' s request for cough and congestion. No respiratory assessment completed. No test conducted to assess for COVID-19. b. At 2:16 PM Staff C, LPN, documentation revealed Resident #2 reported not feeling good today, failed to eat breakfast or lunch, and stayed in his room all day. Staff C administered robitussin and acetaminophen at 10:58 AM. No respiratory assessment completed. No test conducted to assess for COVID-19. c. At 3:48 PM Staff D, RN, documented they were called to Resident #2 ' s room, resident unresponsive. The nurse noted drool in large amounts, incontinent of urine and oxygen saturation at 82%. Resident transported to the ER. The Hospital Discharge Summary dated [DATE] for Resident #2 showed on admission the Principal Problem documented as pneumonia due to COVID-19 and Active Problem included hypoxia. 2. The MDS assessment dated [DATE] for Resident #3 documented diagnosis of dementia and diabetes. The MDS showed a BIMS score of 7 which indicated severe cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 3:04 PM, Staff E, RN, documented Resident #3 asked for a bottle of Listerine for a sore throat that started to hurt. The nurse explained Listerine is not used for a sore throat. Assessment completed. Resident #3 reported nasal congestion, a sore throat, and a headache. Lung sounds clear to auscultation bilaterally. Vital sign documented to be within normal limits. The nurse informed the resident that it is probably best for the resident to eat supper in their room. B. No documented nursing assessments related to symptoms occurred on [DATE]. No test conducted to assess for COVID-19. C. On [DATE] documentation revealed: a. At 8:40 AM, Staff E, RN, documented Resident #3 appeared to not feel well. Resident #3 reported a sore throat and a cold. The resident ' s family requested an appointment be made for Resident #3 to see their PCP. A clinic appointment made for 9:00 AM. b. At 12:48 PM, Staff B, LPN, reported the PCP notified the facility Resident #3 tested positive for COVID-19, and needed to be quarantined for 14 days. The PCP reported Resident #3 ' s symptoms started on [DATE]. 3. The MDS assessment dated [DATE] for Resident #4 documented diagnosis of diabetes. The MDS showed a BIMS score of 15 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 5:29 PM, Staff B, LPN, documented Resident #4 spent the afternoon in his room due to cold symptoms, mostly congestion, very little cough and hoarse voice. The nurse administered acetaminophen and congestion/cough medication. B. No documented nursing assessments related to respiratory symptoms occurred during the overnight hours on [DATE] or during the morning hours of [DATE]. No test conducted to assess for COVID-19. C. On [DATE] at 4:54 PM, Staff G, RN, documented Resident #4 continued to have cold symptoms, considerable upper respiratory congestion present with aches and chills. Resident #4 stated he felt terrible. D. On [DATE] Progress Notes revealed: a. At 4:33 AM Resident #4 continued to have cold symptoms, and a hoarse voice. At 3:45 AM requested and was given PRN Tylenol and PRN cough liquid. Resident requested assistance getting up and being walked to/from the bathroom. b. At 12:51 PM Resident #4 ' s family did not wish for residents to be seen in the clinic or ER would like to continue with cough medicine and pain medication if needed. c. No documented nursing assessments related to symptoms occurred after 4:33 AM on [DATE]. No test conducted to assess for COVID-19. d. At 4:00 PM Resident #4 taken to the ER per resident request due to increased weakness, family aware and agreed. Resident #4 was admitted to the hospital. The Hospital Records dated [DATE] for Resident #4 showed diagnoses COVID-19 and hypoxia present on admission. 4. The MDS assessment dated [DATE] for Resident #5 documented diagnosis of renal disease and Alzheimer ' s Disease. The MDS showed a BIMS score of 13 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] resident consents received for flu and RSV vaccines. Flu shot administered in left deltoid and RSv vaccine administered in right deltoid. B. On [DATE] at 2:20 AM Resident #5 requested cough medicine. Staff A, RN, documented Resident #5 heard coughing violently while walking and using the bathroom. Lungs are congested. Oxygen saturation at 93%. a. At 3:15 AM Resident #5 coughed occasionally but the cough was less severe than before the medication. Lungs continued to be congested. b. No documented nursing assessments related to respiratory symptoms occurred during the overnight hours from [DATE] at 3:15 AM to [DATE] at 10:30 PM. No test conducted to assess for COVID-19. C. On [DATE] at 10:30 PM, Resident #5 ' s family called the facility stating that her mother just called her and that she is not feeling good. On assessment resident alert and oriented, vitals and blood sugar within normal limits. D. No documented nursing assessments related to symptoms occurred during the overnight hours from [DATE] at 10:30 PM to [DATE] at 4:00 PM. No test conducted to assess for COVID-19. E. On [DATE] at 4:00 PM, Resident #5 found to be lethargic while sitting on the toilet that lasted approximately 1.5 minutes. Resident ' s pulse 131, and oxygen saturation 85%. Resident #5 taken to the ER then hospitalized . The Hospital Discharge Summary dated [DATE] for Resident #5 showed pneumonia due to COVID-19 present on admission. 5. The MDS assessment dated [DATE] for Resident #6 documented diagnosis of non-traumatic brain disorder and Alzheimer ' s Disease. The MDS showed cognitive skills for daily decision making to be severely impaired. Review of Progress Notes revealed the following: A. On [DATE] at 6:45 PM, family of Resident #6 notified of the COVID-19 outbreak. Resident tested negative. B. On [DATE] at 10:54 AM, Resident #6 tested negative for COVID-19. C. On [DATE] at 4:54 PM, Resident #6 with a fever of 101.1. D. No documented nursing assessments after a known fever that developed during an COVID-10 outbreak occurred from [DATE] at 4:54 PM to [DATE] at 12:44 PM. No test conducted to assess for COVID-19. E. On [DATE] at 12:44 PM, the family of Resident #6 informed the resident test positive for COVID-19. The State of Iowa Certificate of Death showed Resident #6 expired on [DATE]. The immediate cause of death for Resident #6 documented as respiratory failure due to or as a consequence of COVID-19. In an interview on [DATE] at 9:14 AM, the facility PCP was asked if the COVID-19 vaccine caused a positive COVID test result, the provider replied, No, that has not been indicated. The PCP explained that the COVID vaccine and other vaccines, such as the flu and RSV could lower the immune system, making people more susceptible to contracting COVID. The PCP reported that she expected testing to occur when there are a combination of respiratory symptoms or any COVID symptom if the facility is in outbreak status. When asked if she expected staff to test a resident that reported coughing like crazy all day, had upper respiratory congestion with expiratory wheezing and rhonchi, the provider stated, Yes. I would have expected testing for that one. When asked if the PCP expected staff to test a resident that received cough medicine for a violent cough and congested lung sounds, the provided replied, yes. When asked if during a COVID outbreak would the provider expect a resident with a fever of 101.1 and sleepiness to be tested for COVID, the provider replied, I would expect a resident with any COVID symptom to be tested during an outbreak. In an interview on [DATE] at 10:27 AM, the Director of Nursing (DON) was asked to explain the assessment and testing expectations for respiratory signs and symptoms. The DON replied, we follow the policy. When asked what the policy stated, the DON replied, Don ' t you know the regulations? In an interview on [DATE] at 12:17 PM, Staff B, LPN, reported herself and other nurses stopped reporting respiratory symptoms because nothing was done about it. Staff B explained, Nurses could not test residents, instead they were supposed to report signs and symptoms to the DON and Clinical Manager. The DON and Clinical Manager would then decide which residents to test. When asked if this impacted resident assessments, Staff B replied, Yes. The residents with symptoms weren't tested for COVID anyways. Leadership didn ' t want to be in outbreak. When we did report symptoms nothing was done. We were told to leave it alone. When asked what would happen if leadership wasn ' t present when a resident developed respiratory symptoms, Staff B replied, then staff would wait until morning to notify leadership. When asked if nurses were expected to complete ongoing assessments with the presence of respiratory symptoms or abnormal findings, Staff B replied, We didn ' t do anything about respiratory symptoms. Nothing was being done. The DON and Clinical Manager told us to leave it alone. In an interview on [DATE] at 12:39 PM, Staff A, RN, reported nursing staff could not assess the residents with a COVID-19 assessment unless the DON or Clinical Manager approved it. Staff A stated, They told us to ignore when residents had respiratory symptoms. Leadership didn ' t want the facility in outbreak status for COVID-19. Staff A further explained, when the nurses reported residents were getting sick, the DON and Clinical Manager would tell us to leave it alone because we weren't going to test for COVID. The Clinical Manager would say things like shh, no he's not sick and to leave it alone. When asked if nursing staff were expected to complete ongoing respiratory asssessments with the start of symptoms Staff A replied, we became desensitized to respiratory symptoms. We weren ' t allowed to test residents and couldn ' t test ourselves until after the shift ended. When Resident #2 first showed symptoms he was not tested , isolated or moved to a quarantined area. When Resident #4 first showed symptoms, I did not report it, because we were told to leave it alone and shh. We became desensitized to it. Everyone was desensitized. In an interview on [DATE] at 1:13 PM, the Infection Preventionist (IP) reported that she would have definitely tested Resident #2 on [DATE] for COVID because they were in a community outbreak as well. The IP stated, we talk about things like that in the daily safety briefing- all leadership meetings for the entire facility. That's where I shared things like that. The IP reported that she would have definitely tested Resident #3 on the first day of symptoms, [DATE]. The IP reported that she also would have tested Resident #4 on [DATE] and Resident #5 on [DATE]. The IP reported she would have tested Resident #6 on [DATE]. In an interview on ,d+[DATE]/ 24 at 1:36 PM, Staff E RN, reported she asked the DON to assess Resident #3 after the resident reported congestion and a sore throat. Staff E reported, the DON decided not to test for COVID. When asked if the DON gave ongoing assessment instruction or if the symptoms prompted further assessments. Staff E stated, no. In an interview on [DATE] at 4:49 PM, the DON was informed of IJ concern. The DON replied, I figured that. When asked if she expected the IJ, the DON replied, Oh ya. When asked if she knew what the IJ was related to, the DON replied, COVID. In an interview on [DATE] at 9:32 AM, the Nurse Consultant reported the policy for assessment of respiratory symptoms is located in the Emerging Threats-Acute Respiratory Syndrome Coronavirus. In an interview on [DATE] at 1:15 PM, Staff A, RN, reported that starting today daily risk assessments are now completed on all residents. When asked what the assessment included, the nurse replied, we have to check the resident ' s pulse, lung sounds, and for other signs and symptoms of COVID. The nurses now test for COVID if the daily risk assessment is positive. In an interview on [DATE] at 1:46 PM, the Infection Preventionist reported that she expected nursing staff to complete ongoing assessments and documentation of all abnormal findings, including respiratory symptoms or signs and symptoms of COVID. The Emerging Threats-Acute Respiratory Syndrome Coronavirus policy last revised on [DATE] indicated for long term care facilities that residents are monitored for signs and symptoms of COVID-19 per routine practice. Residents with symptoms of COVID-19 will be isolated and tested immediately.

Based on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses by failure to test and isolate residents with respiratory signs and symptoms for 5 out of 45 residents reviewed (Residents #2, #3, #4, #5 and #6). Records showed three residents required hospitalization after emergency room (ER) visits, ( Residents #2, #4 and #5). The failure to test for COVID and isolate when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 5:09 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. All residents who exhibit signs or symptoms of respiratory infection will be immediately evaluated by the charge nurse and isolated in their room in transmission-based precautions under suspicion of COVID-19 or other respiratory illness. A COVID-19 test will be performed to assist in diagnosing of COVID-19. 2 negative tests, 48 hours apart, will be required to rule out COVID-19 and other respiratory pathogens along with symptoms will be considered prior to discontinuing precautions. B. All COVID-19 positive residents will be treated according to physician ' s orders and placed in isolation in a private room, if able. If no private room is available, the resident will remain in their room with their roommate; the privacy curtain will be pulled. C. Whenever there is a COVID-19 positive staff member or resident, close contacts (residents) and higher risk exposures (staff) will be identified. The Director of Nursing/Designee and the Administrator will determine if exposed staff and residents can be determined through contact trace testing or if Broad based testing is warranted. D. Identified staff and residents will be tested on days 1, 3 and 5 following their exposure. E. Testing may be expanded based on results on additional testing. When additional residents and staff are testing positive with each round of testing, close contact exposures cannot be identified, or an outbreak is present on more than one unit or hallway, expanded outbreak testing will be implemented. All facility staff and residents will then be tested every 3 to 7 days until the facility has gone 14 days with no additional positive cases. F. Staff will be expected to test at the beginning of their shift. G. Staff use of PPE per policy (Emerging Threats) and Surveillance and Mitigation guide will be required, to include masks, N95s, gowns and eye protection based on location of Covid-19 positives in the facility and area of facility staff is assigned to work. Education to all staff began on the evening of [DATE] and completed on [DATE]. H. Any staff member that has not completed the education by the end of [DATE] will have education completed at the beginning of their next shift and will not be allowed to work until this has been completed. I. Audits on residents to ensure they are free of respiratory infection symptoms and completion of COVID- 19 testing if symptoms noted will be completed by the Director of Nursing or designee daily x 5 working days and then weekly x 4 weeks. Audits for appropriate use of PPE will be conducted daily during any time frame there are residents with suspected or confirmed Covid-19. J An Ad Hoc Quality Assurance meeting was held on [DATE] with Administrator, Director of NursingServices, Nurse Manager, Social Services, Medical Director and Region Clinical Director. IJ templates reviewed, discussion of removal plan and acceptance of plan by all team members present at Ad Hoc Quality Meeting. The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnosis of stroke, hemiplegia and diabetes. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderately impaired cognition. Review of Progress Notes revealed the following: A. On [DATE] at 8:33 PM, Resident #2 reported he coughed all day like crazy, and requested cough medicine. Staff A Registered Nurse (RN) noted the resident presented with upper respiratory congestion with expiratory wheezing and rhonchi. Nursing staff failed to test for COVID and isolated the resident if needed. B. On [DATE] the following Progress Notes revealed: a. At 5:02 AM Staff B, Licensed Practical Nurse (LPN), documented Resident #2 sounded horse and nasally. At 10:55 PM ([DATE]) guaifenesin with codeine administered per resident ' s request for cough and congestion. Nursing staff failed to test for COVID and isolated the resident if needed. b. At 2:16 PM Staff C, LPN, documentation revealed Resident #2 reported not feeling good today, failed to eat breakfast or lunch, and stayed in his room all day. Staff C administered robitussin and acetaminophen at 10:58 AM. No respiratory assessment completed. Nursing staff failed to test for COVID and isolated the resident as needed. c. At 3:48 PM Staff D, RN, documented they were called to Resident #2 ' s room, resident unresponsive. The nurse noted drool in large amounts, incontinent of urine and oxygen saturation at 82%. Resident transported to the ER. The Hospital Discharge Summary dated [DATE] for Resident #2 showed on admission the Principal Problem documented as pneumonia due to COVID-19 and Active Problem included hypoxia. 2. The MDS assessment dated [DATE] for Resident #3 documented diagnosis of dementia and diabetes. The MDS showed a BIMS score of 7 which indicated severe cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 3:04 PM, Staff E, RN, documented Resident #3 asked for a bottle of Listerine for a sore throat that started to hurt. The nurse explained Listerine is not used for a sore throat. Assessment completed. Resident #3 reported nasal congestion, a sore throat, and a headache. Lung sounds clear to auscultation bilaterally. Vital sign documented to be within normal limits. The nurse informed the resident that it is probably best for the resident to eat supper in their room. B. No documented nursing asessments related to symptoms occurred on [DATE]. No test conducted to assess for COVID-19. C. On [DATE] documentation revealed: a. At 8:40 AM, Staff E, RN, documented Resident #3 appeared to not feel well. Resident #3 reported a sore throat and a cold. The resident ' s family requested an appointment be made for Resident #3 to see their PCP. A clinic appointment made for 9:00 AM. Nursing staff failed to test for COVID and isolate the resident as needed. b. At 12:48 PM, Staff B, LPN, reported the PCP notified the facility Resident #3 tested positive for COVID-19, and needed to be quarantined for 14 days. The PCP reported Resident #3 ' s symptoms started on [DATE]. 3. The MDS assessment dated [DATE] for Resident #4 documented diagnosis of diabetes. The MDS showed a BIMS score of 15 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 5:29 PM, Staff B, LPN, documented Resident #4 spent the afternoon in his room due to cold symptoms, mostly congestion, very little cough and hoarse voice. The nurse administered acetaminophen and congestion/cough medication. Nursing staff failed to test for COVID and isolate the resident as needed. B. On [DATE] at 4:54 PM, Staff G, RN, documented Resident #4 continued to have cold symptoms, considerable upper respiratory congestion present with aches and chills. Resident #4 stated he felt terrible. Nursing staff failed to test for COVID and isolate the resident as needed. C. On [DATE] at 4:33 AM Resident #4 continued to have cold symptoms, and a hoarse voice. At 3:45 AM had requested was given PRN Tylenol and PRN cough liquid. Resident requested assisstance with getting up and being walked to/from the bathroom. a. At 12:51 AM Resident #4 ' s family did not wish for residents to be seen in the clinic or ER would like to continue with cough medicine and pain medication if needed. b. No documented nursing assessments related to symptoms occurred after 4:33 AM on [DATE]. No test conducted to assess for COVID-19. c. At 4:00 PM Resident #4 taken to the ER per resident request due to increased weakness, family aware and agreed. Resident #4 was admitted to the hospital. The Hospital Records dated [DATE] for Resident #4 showed diagnoses COVID-19 and hypoxia present on admission. 4. The MDS assessment dated [DATE] for Resident #5 documented diagnosis of renal disease and Alzheimer ' s Disease. The MDS showed a BIMS score of 13 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 2:20 AM Resident #5 requested cough medicine. Staff A, RN, documented Resident #5 heard coughing violently while walking and using the bathroom. Lungs are congested. Oxygen saturation at 93%. Nursing staff failed to test for COVID and isolate the resident as needed. a. At 3:15 AM Resident #5 coughed occasionally but the cough was less severe than before the medication. Lungs continued to be congested. B. On [DATE] at 11:20 AM nurse assisted resident to doctor appointment to clean ears. C. On [DATE] at 2:50 PM nurse assisted resident to to behavioral health appointment. Resident's daughter also at the visit. D. On [DATE] at 10:30 PM, Resident #5 ' s family called the facility stating that her mother just called her and that she is not feeling good. On assessment resident alert and oriented, vitals and blood sugar within normal limits, PRN Tylenol given. Nursing staff failed to test for COVID and isolate the resident as needed. E. On [DATE] at 4:00 PM, Resident #5 found to be lethargic while sitting on the toilet that lasted approximately 1.5 minutes. Resident ' s pulse 131, and oxygen saturation 85%. Resident #5 taken to the ER then hospitalized . The Hospital Discharge Summary dated [DATE] for Resident #5 showed pneumonia due to COVID-19 present on admission. 5. The MDS assessment dated [DATE] for Resident #6 documented diagnosis of non-traumatic brain disorder and Alzheimer ' s Disease. The MDS showed cognitive skills for daily decision making to be severely impaired. Review of Progress Notes revealed the following: A. On [DATE] at 6:45 PM, family of Resident #6 notified of the COVID-19 outbreak. Resident tested negative. B. On [DATE] at 10:54 AM, Resident #6 tested negative for COVID-19. C. On [DATE] at 4:54 PM, Resident #6 with a fever of 101.1. Nursing staff failed to test for COVID. D. On [DATE] at 12:44 PM, the family of Resident #6 informed the resident test positive for COVID-19. The State of Iowa Certificate of Death showed Resident #6 expired on [DATE]. The immediate cause of death for Resident #6 documented as respiratory failure due to or as a consequence of COVID-19. In an interview on [DATE] at 10:27 AM, the Director of Nursing (DON) was asked to explain the assessment and testing expectations for respiratory signs and symptoms. The DON replied, we follow the policy. When asked what the policy stated, the DON replied, Don ' t you know the regulations? In an interview on [DATE] at 12:17 PM, Staff B, LPN, reported herself and other nurses stopped reporting respiratory symptoms because nothing was done about it. Staff B explained, Nurses could not test residents, instead they were supposed to report signs and symptoms to the DON and Clinical Manager. The DON and Clinical Manager would then decide which residents to test. When asked if this impacted resident assessments, Staff B replied, Yes. The residents with symptoms weren't tested for COVID anyways. Leadership didn ' t want to be in outbreak. When we did report symptoms nothing was done. We were told to leave it alone. When asked what would happen if leadership wasn ' t present when a resident developed respiratory symptoms, Staff B replied, Then staff would wait until morning to notify leadership. When asked if nurses were expected to complete ongoing assessments with the presence of respiratory symptoms or abnormal findings, Staff B replied, We didn ' t do anything about respiratory symptoms. Nothing was being done. The DON and Clinical Manager told us to leave it alone. In an interview on [DATE] at 12:39 PM, Staff A, RN, reported nursing staff could not assess the residents with a COVID-19 unless the DON or Clinical Manager approved it. Staff A stated, They told us to ignore when residents had respiratory symptoms. Leadership didn ' t want the facility in outbreak status for COVID-19. Staff A further explained, When the nurses reported residents were getting sick, the DON and Clinical Manager would tell us to leave it alone because we weren't going to test for COVID. The Clinical Manager would say things like shh, no he's not sick and to leave it alone. When asked if nursing staff were expected to complete ongoing respiratory symptoms with the start of symptoms Staff A replied, We became desensitized to respiratory symptoms. We weren ' t allowed to test residents and couldn ' t test ourselves until after the shift ended. When Resident #2 first showed symptoms he was not tested , isolated or moved to a quarantined area. When Resident #4 first showed symptoms, I did not report it, because we were told to leave it alone and shh. We became desensitized to it. Everyone was desensitized. In an interview on [DATE] at 1:13 PM, the Infection Preventionist (IP) reported that she would have definitely tested Resident #2 on [DATE] for COVID because they were in a community outbreak as well. The IP stated, we talk about things like that in the daily safety briefing- all leadership meetings for the entire facility. That's where I shared things like that. The IP reported that she would have definitely tested Resident #3 on the first day of symptoms, [DATE]. The IP reported that she also would have tested Resident #4 on [DATE] and Resident #5 on [DATE]. The IP reported she would have tested Resident #6 on ,d+[DATE]. In an interview on ,d+[DATE]/ 23 at 1:36 PM, Staff E RN, reported she asked the DON to assess Resident #3 after the resident reported congestion and a sore throat. Staff E reported, the DON decided not to test for COVID. When asked if the DON gave ongoing assessment instruction or if the symptoms prompted further assessments. Staff E stated, no. In an interview on [DATE] at 4:49 PM, the DON was informed of IJ concern. The DON replied, I figured that. When asked if she expected IJ, the DON replied, Oh ya. When asked if she knew what the IJ was related to, the DON replied, COVID. In an interview on [DATE] at 9:32 AM, the Nurse Consultant reported the policy for assessment of respiratory symptoms is located in the Emerging Threats-Acute Respiratory Syndrome Coronavirus. In an interview on [DATE] at 1:15 PM, Staff A, RN, reported that starting today daily risk assessments are now completed on all residents. When asked what the assessment included, the nurse replied, we have to check the resident ' s pulse, lung sounds, and for other signs and symptoms of COVID. The nurses now test for COVID if the daily risk assessment is positive. In an interview on [DATE] at 1:46 PM, the Infection Preventionist reported that she expected nursing staff to complete ongoing assessments and documentation of all abnormal findings, including respiratory symptoms or signs and symptoms of COVID. The Emerging Threats-Acute Respiratory Syndrome Coronavirus policy last revised on [DATE] indicated for long term care facilities that residents are monitored for signs and symptoms of COVID-19 per routine practice. Residents with symptoms of COVID-19 will be isolated and tested immediately.

Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #18). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 49 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 9:30 a.m The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A staff member is to monitor the door at all times until the Wanderguard servicing agent arrives to assess the system. Maintenance also increased the distance for alarm to activate to 8 feet instead of 6 ,d+[DATE] feet that it was previously set at. Increased to 10 feet on [DATE]. Maglock installation completed to the doors on [DATE]. Added an alarm speaker closer to the Nurse's Station. The resident was placed on 15-minute placement checks until reviewed by IDT and assess plan to decrease or discontinue. Care plan updated. Stopped 15 min checks [DATE] as all door and alarm adjustments have now been completed. All staff educated and return quiz completed upon clocking into their next scheduled shift on resident elopement policy/drills. Charge nurse on duty at time of event provided education along with review of incident, plan of correction, and if any learning opportunities resulted. When staff are unable to identify a person that is entering/exiting the door alarms including non-wanderguard alarms staff must physically go to the alarming area to investigate who passed through the door and if unable to identify the source of the alarm they must do a resident count immediately to ensure all residents are accounted for. Missing resident drill will be conducted over the next three shifts, starting on the evening shift on [DATE]. All residents will have an elopement risk assessment completed by [DATE] to ensure the current risk is current and wanderguard in place if identified need for one. All door wanderguard alarms were checked after the resident returned to the facility to ensure they were working. All doors alarms appropriately. Checking wanderguard placement and that it is working daily which is already in place and documented by the nurse. Activities will provide 1:1 visit with resident four times weekly. likes to fold clothes, sweep floors, and wipe tables. Care conference with daughter was held on [DATE] and discussed with daughter if she agrees to a 30-day trial of not taking resident out of the facility to monitor if anxious and agitated behaviors have fewer episodes. Family agrees. SBAR communication sent to the Doctor on [DATE] asking if lab work would be appropriate to rule out infection. Lab workup completed on [DATE]. Reviewed by primary care physician and no new orders received. Video camera views were reviewed, and it was determined that some screens could be removed from the monitor and replaced with more outside areas that would be better to monitor more sidewalks and outside areas around the facility. The North most door (closest to the exit doors) to the dining room to be closed all the time to divert residents to the two dining room doors to the south. Signage added to the door. The facility identified a census of 49 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 18 documented diagnoses of Non-Alzheimer ' s dementia, hypertension and hyperlipidemia. The MDS showed the Brief Interview for Mental Status (BIMS) score was not assessed. Review of the MDS dated [DATE] revealed the following information: Under assessment for mental status short term memory seems to appear or recall after 5 minutes indicates memory problem. Under assessment for mental status for long term memory seems to appear or recall after 5 minutes indicates memory problem. Under behavior revealed the following; Wandering presence and frequency- behavior of this type occurred daily Wandering- impact Does the wandering place the resident at a significant of getting to a potentially dangerous place- Yes Does the wandering significantly intrude on the privacy or activities of others- Yes Review of Resident #18 ' s Progress Notes revealed the following: On [DATE] at 8:58 p.m., resident has been wandering up and down the halls today. She was given some towels to fold and was easy to redirect today. Staff assisted her to go to bed and she has not got up since. On [DATE] at 5:44 p.m., resident has wandered up to the nurse ' s desk a few times. States she just didn ' t feel good but is very vague as to why she doesn ' t feel well. On [DATE] at 3:39 p.m., resident has been wandering and has been to the door multiple times trying to get out. Wanderguard has sounded multiple times as the resident has crossed towards the exit. Redirection has been unsuccessful. Resident is finally taken outside with the activity director to enjoy the weather. On [DATE] at 11:45 p.m., hall nurse notifies that resident is not found to be able to give the resident her medications. Staff nurse has started to look in areas that the resident is noted to be seen in as she is often wandering or found in the bed of other residents. All staff that are currently available have started looking for the resident. Two other staff members were outside the building to walk the perimeter of the building. Call received from an officer with the police department stating that they were with the resident and asked if someone could go to the address to pick her up. Two staff members were sent to the location to pick the resident up. Call made by nurse to the daughter to notify of the incident. Nurse stated she will keep her updated. On arrival at the facility the nurse started the resident on 15 minute checks. Resident was wearing a light sweater and her church clothes, pants and a t-shirt. Complete head to toe assessment completed. Primary Care Physician notified by fax and on-call physician notified by phone. Interview on [DATE] at 12:53 p.m., Staff B, Licensed Practical Nurse (LPN), revealed she was working the day Resident #18 left the building. She went to give the resident her medication at approximately 10:30 a.m., and the resident was not in her room. Staff B revealed this is not uncommon as she normally wanders around the facility. Staff B revealed she did not tell anyone else right away but after she was unable to locate Resident #18, she alerted other staff that were working. Staff began looking around the facility as well as outside and were unsuccessful finding the resident. The facility received a phone call from the police department stating they had a confused resident. Staff B revealed a nurse and Certified Nursing Assistant (CNA) went to Resident #18 ' s location and picked her up and brought her back to the building. Interview on [DATE] at 12:57 p.m., Staff C, CNA, revealed she had seen Staff A looking around and asked her what she was doing. When Staff C was alerted Resident #18 was missing, she began searching the facility. Staff C revealed her and Staff H, LPN started at the end of the south hallway with one staff on each side of the hallway, looking in rooms, bathrooms, closets, linen closets, anywhere a person could get into. Staff C revealed her and Staff H moved over to the east hallway and looked in rooms, bathrooms and closets with no success. Staff C revealed she felt like they searched the facility for 45 minutes. Staff C and Staff G then moved to the outside of the facility. Staff C went around to the east and Staff H went around to the west and they met in the middle on the backside of the facility. Staff C revealed she was looking around corners and in and under bushes with no success in locating Resident #18. Staff C revealed when her and Staff H came into the building the police were on the phone and had Resident #18. Staff C revealed prior to knowing Resident #18 was missing, she had heard a faint alarm which was turned off quickly but was unable to verify which alarm had sounded. Staff C revealed Resident #18 does wander around the facility quite often and she has seen her get agitated and beat her hands on the east side doors stating she does not belong here and to let her out. Resident #18 does wander around the facility quite often and sets off the wanderguard alarm on a regular basis. Interview on [DATE] at 1:07 p.m., with Staff D, CNA revealed she was on break when the staff made her aware Resident #18 was unable to be located. Staff D revealed she clocked back in and immediately began looking for Resident #18. Staff D verified staff were not able to locate her within or around the facility. Staff D further revealed the police department called and had located Resident #18. Staff D revealed Staff H, LPN and Staff E, CNA went and got Resident #18 and brought her back to the building. Interview on [DATE] at 1:39 p.m., with the Director of Nursing (DON) revealed she had received a call from the facility that Resident #18 had eloped from the facility and the police found her approximately a half mile from the facility around a place where she used to live. She was told Resident #18 was sitting under a tree with a couple ladies and came back to the building with no concerns. The DON revealed Resident #18 went out the north doors and the wanderguard did not sound when Resident #18 exited the building but the door alarm did and the staff turned it off without checking the door. The DON further revealed the wanderguard was set to 6 ,d+[DATE] feet and sometimes it would catch the wanderguard and sometimes it would not and this is what the door had been set at since installation. The facility did extend the sensor feet after the incident. Interview on [DATE] at 1:49 p.m., with Staff E, CNA revealed she had been on lunch break and when she came back she found out Resident #18 was unable to be found. Staff E revealed she immediately began looking for Resident #18. The facility received a phone call from the police station regarding Resident #18 and they needed someone to come and pick her up. Staff E and Staff H left the facility to pick her. Staff E revealed when they arrived to pick up Resident #18 she was sitting under a tree with some ladies having a glass of water. She smiled at the staff when she was addressed. Staff E confirmed Resident #18 was wearing her wanderguard. Resident #18 returned to the facility with Staff E and Staff H with no incident. Upon entering the facility the wanderguard alarm sounded when Resident #18 entered the facility. Staff E revealed she had given Resident #18 a bath earlier in the day and she was agitated during the bath to the point she tried to crawl out of the bathtub. Staff E confirmed she was wearing her wanderguard during her bath. Staff E further revealed Resident #18 does wander around the facility towards the doors and watches the doors but usually is easy to redirect away from the door. Interview on [DATE] at 1:59 p.m., with Staff F, Registered Nurse (RN), revealed she was the charge nurse on the day of the incident. Stated she was made aware when Staff A went to Resident #18 ' s room to give her medications. Staff A was unable to locate Resident #18 and alerted the other staff. All staff immediately began looking for Resident #18 inside the facility and around the facility premises. Staff F received a phone call from the police department that they had Resident #18 and needed someone to pick her up. Staff E and Staff H went and brought Resident #18 back into the building. Staff F was unsure how Resident #18 exited the building. When Resident #18 re-entered the building and the wanderguard alarm sounded. Staff F assessed the resident with no concerns noted. Staff F noted the resident was a little more anxious than usual and wanted to get out of the building after returning. Staff F notified the family of the incident, primary care physician, on-call physician and received no new orders. Resident #18 was placed on 15 minute checks for her safety. Staff F revealed she took direction from the leadership on the interventions put into place. The facility immediately began educating staff after the incident. Interview on [DATE] at 2:05 p.m., with Staff G, CNA, revealed they didn ' t know much about the situation. Stated that Resident #18 does walk around the facility a lot and she got out the back door. Staff G further revealed you can just push the doors open and they will alarm but you can just walk out. Interview on [DATE] at 2:38 p.m., with Staff H, LPN revealed Staff A came down her hallway asking if she had seen Resident #18 and she told Staff A she had not seen her recently. Staff H revealed all the staff began looking around the facility and then they headed outside. Staff H revealed her and Staff C went to look outside on the grounds. Staff H revealed she headed west around the grounds and Staff C headed east around and they met at the back of the building unable to locate Resident #18. Staff H revealed when she came back in from outside Staff F was on the phone with someone and they revealed Resident #18 was with them and they needed someone to pick her up. Staff H and Staff E went to where Resident #18 was. Staff H stated when the staff arrived Resident #18 was sitting under a tree with a couple of ladies having a glass of water and smiled at them and said hello. Staff H and Staff E returned to the building with Resident #18 with no concerns. Staff H confirmed Resident #18 was still wearing her wanderguard and the alarm sounded upon re-entering the building. Review of Resident #18 ' s Care Plan with a revision date of [DATE] revealed the following information: Potential for elopement from the facility related to dementia, wanderguard placed on left ankle Watch resident closely throughout the day especially when family and staff are leaving the facility. Wanderguard program. Redirect resident when attempting to go out the doors. Dated [DATE] Resident is more anxious and upset when she is looking for her deceased family members or the girls. Looking at the front door more often for her family to pick her up. Resident resists care related to her dementia. Resident is unable to participate in BIMS related to diagnosis of dementia. Resident is at risk for falling related to wandering and dementia. Review of facility provided untitled and undated information revealed the following regarding the incident: Resident #18 received her bath around 9:30 a.m., on [DATE] given by Staff E, CNA, and was noted to be agitated and anxious and at one point attempted to climb out of the tub and made statements about her family coming to pick her up. The wanderguard was also noted to be on her left ankle at this time. Upon leaving the tub/shower room Resident #18 started to wander about the facility which is normal for her. Staff on shift stated that the wanderguard alarm did alarm once by the front door where they found Resident #18 and redirected her away from the door. According to video footage at 10:00 a.m., Resident #18 was at the front door and the wanderguard alarm sounded and CNA and Staff F, RN responded and redirected Resident #18 away from the door then reset the alarm. Staff F stays at the front door as she saw visitors approaching and let them enter the facility. The wanderguard alarm at the front door alarmed again at 10:01 a.m., by Resident #18 and staff responded and redirected Resident #18 a second time. Resident #18 then goes toward East Hall then turns back and goes into the dining room and leaves the dining room from the north dining room door, turns left to the alarmed double doors exiting out and turns right exiting outside at 10:05 a.m The North double doors alarmed that it opened. Staff F had just approached the nurse's desk and simultaneously turned to reset the alarm and then she looked up at the camera to monitor door activity. The wanderguard alarm did not activate at that time as no staff responded to manually reset code to turn off the alarm when viewing the video. The Maintenance Director entered the nursing home through those same doors at 10:13 a.m., and he stated there was no alarm going off at that time. The Wanderguard Log from that door and the first alarm that activated was at 11:34 a.m., which was after the time resident returned (returned at 11:26 per video) and staff took Resident #18 to the North door to test the wanderguard alarm and it did activate the alarm at that time. Review of facility provided policy titled Elopement with a revision date of [DATE] revealed the following information: The location will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents at risk for elopement. These include identifying environmental hazards and resident risks; evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. All residents will be assessed for risk of elopement through the pre-admission and/or admission process and as needed. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented and follow-up will be completed as required by state and federal regulations. Interview on [DATE] at 1:39 p.m., with the DON revealed the staff working should have physically checked the alarm instead of resetting it.

Based on clinical record, facility policy, and staff interview, the facility failed to include side effects of high risk medications and psychotropic medications and revise a care plan to include a non-pressure related wound on care plans for 4 of 16 residents reviewed (Residents #15, #22, #25, #40). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #15 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of type 2 diabetes mellitus and hyperlipidemia (high cholesterol). The MDS revealed the resident was administered diuretic medication 7 of the last 7 days and was administered antidepressant medication for 7 of the last 7 days. The Skin Integrity Condition assessment on 6/18/23 revealed the resident had an open area to the right lower shin. The Progress Note on 6/18/23 at 2:08 PM revealed resident was noted to have a 4.7 by 2.0 cm (centimeter) open area on the right lower shin on the area. Resident stated that the area was a fluid filled blister prior to her bath but that during the bath the blister had broken. The area was cleansed and a mepilex has been applied to the area. Resident stated that the area had been weeping like a sieve on the overnight. Call has been placed to notify the family of the status of the wound. The Orders signed by a physician directed that furosemide 80 (milligrams) be administered twice daily. The Orders signed by a physician directed that sertraline 50 mg was administered daily. The Orders signed by a physician directed that spironolactone 25 mg was administered daily. The Orders signed by a physician directed that tramadol 50 mg was administered every 6 hours as needed (PRN). The resident's Care Plan lacked the issue with this open area of skin as well as the side effects of furosemide, tramadol, sertraline, and spironolactone. The Comprehensive Care Plan and Care Conferences-Rehab/Skilled with a revision date of 10/21/22 directed: 1. To provide an ongoing method of assessing, implementing, evaluating and updating the resident ' s care plan to help maintain the resident ' s highest practicable level of function, including culturally competent and trauma informed care. 2. The interdisciplinary team will ensure that the care plan is comprehensive by incorporating care plan interventions for box warnings can be found in the eMAR (electronic Medication Administration Record) and physician orders. 3. In addition to updates during a care plan review, care plans must be revised as the resident ' s needs/status changes. If a change is made to the care plan between review dates, documentation of this may be made in the PN - Care Plan Change. In an interview on 6/28/23 at 9:28 AM, Staff A, Registered Nurse (RN) reported that the resident refuses to wear edema wear, is non compliant with cares, and that skin issues are a chronic problem due to her lower extremity edema. The MDS Coordinator reported that her annual care plan update occurred last week and that she would expect issues with open skin to be on the care plan. Staff A confirmed specific side effects of high risk and/or psychotropic medications should be listed on care plans. 2. The MDS dated [DATE] for Resident #22 revealed the resident had short and long term memory problems. The MDS revealed the resident had atrial fibrillation or other dysrhythmias and non-Alzheimer's dementia. The MDS revealed the resident was administered an antipsychotic and a diuretic in the past 7 days. The Physician Order Report signed by a physician on 3/31/23 revealed orders for: 1. Lasix (furosemide) 29 mg once a day. 2. Risperidone 0.25 mg at bedtime. The Medications Administration History for June 2023 revealed that furosemide and risperidone were administered to the resident from 6/1/23 to 6/27/23. The resident's Care Plan lacked interventions that identify the specific side effects of Lasix and risperidone. In an interview on 6/28/23 at 9:28 AM, the Staff A, Registered Nurse (RN) reported that specific side effects of high risk and/or psychotropic medications should be listed on care plans. 3. The MDS dated [DATE] for Resident #25 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS revealed the resident had a diagnosis of hypertension (high blood pressure) and was administered a diuretic medication in the past 7 days. The Physician Order Report signed by a physician on 4/4/23 revealed an order for Lasix furosemide 20 mg once a day. The Medications Administration History for June 2023 revealed that furosemide was administered to the resident from 6/1/23 to 6/28/23. The resident's Care Plan lacked specific side effects of Lasix. In an interview on 6/28/23 at 9:28 AM, the Staff A, Registered Nurse (RN) reported that specific side effects of high risk and/or psychotropic medications should be listed on care plans. 44474 4. The MDS assessment dated [DATE] for Resident #40 documented diagnoses of heart failure and hypertension.The MDS showed a BIMS score of 11 indicating moderate cognitive impairment. Review of the June 2023 Medication Administration Record (MAR) revealed the following orders: Bumetanide tablet (diuretic medication) daily with an order date of 5/19/23, Spironolactone tablet (diuretic medication) daily with an order date of 4/12/23. Review of the MDS dated [DATE] revealed diuretic medication was taken 7 out of 7 days in the look back period. Review of the Physician order report signed 6/5/23 revealed the following orders: Bumetanide tablet (diuretic medication) daily with an order date of 5/19/23, Spironolactone tablet (diuretic medication) daily with an order date of 4/12/23. Review of the current Care Plan undated lacked information regarding the usage and side effects of diuretic medication. Interview on 6/28/23 at 12:58 p.m., Staff A, RN revealed the diuretic medication should be on the care plan.

Based on clinical record, Resident Assessment Instrument (RAI) Version 3.0 Manual, and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 16 residents reviewed (Resident #36). The facility reported a census of 49 residents. Findings include: The MDS for Resident #36 dated 3/30/23 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of peripheral vascular disease (PVD) or peripheral arterial disease (PAD) and hyperlipidemia (high cholesterol). The MDS revealed the resident took an anticoagulant in the past 7 days. The Physician Order Report signed by a physician on 6/5/23 revealed an order for Plavix (clopidogrel) 75 milligrams (mg) once a day. The report lacked an order for an anticoagulant medication. The Medications Administration History for June 2023 revealed the resident received Plavix 6/1/23 to 6/28/23. The Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual directed do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel (Plavix) here. In an interview on 6/28/23 at 2:12 PM, Staff A, Registered Nurse (RN) reported that the resident was ordered an anticoagulant when he was first admitted to the facility and shortly after the medication was discontinued. In the same interview, Staff A reported that Plavix has always been coded on MDS as an anticoagulant since it is a blood thinner and was not aware that Plavix should not be coded as an anticoagulant.

Based on record review, staff interview, schedule review and abuse policy, the facility failed to follow their abuse policy and immediately separate the alleged perpetrator from the resident for 2 of 9 residents reviewed (Resident #3 & Resident #1). In addition the facility failed to notify the Department of alleged abuse immediately not greater than 24 hours for 1 of 9 residents reviewed (Resident #1). The findings constitute an immediate jeopardy to the residents health and safety. The facility identified a census of 61 current residents. Findings include: 1. Resident #3's Minimum Data Set assessment dated [DATE], revealed he/she had short and long term memory problems; and had moderately impaired cognitive skills for daily decision making. Resident #3 had behavioral symptoms directed towards staff. Resident #3 had a history of [REDACTED].#3 required extensive assistance of 1 staff for bed mobility, transfers, ambulation, dressing and toilet use. Resident #3 is able to ambulate with assistance of staff with the use of a gait belt and wheeled walker. Record review identified Resident #3 had lived in the facility since 12/1/14. Resident #3 had [DIAGNOSES REDACTED]. Review of the Skin Risk Assessment with Braden Scale dated 9/1/16 revealed the resident had a score of 21. A total score of 19 or above indicated not at risk. Review of the Progress Notes dated 11/14/15 at 8:01 p.m., revealed the resident in his/her room yelling for someone to get his/her paints and pictures then began having a coughing spell. Nebulizer treatment given and resident given his/her coloring pages and [MEDICATION NAME]. At 9:03 p.m. the resident sleeping soundly in his/her recliner. The Incident Notification dated 11/15/16 revealed Resident #3 was noted to have 2 bruises measuring 4.5 cm (centimeters) by 2.5 cm and 6 by 2.5 cm. Undated pictures of Resident #3's right arm revealed bruising to the right hand and right forearm. The medical record did not contain documentation of a history of bruising or injuries for Resident #3. Staff Z's written statement included the following information: She had been working 2-10:30 p.m. shift on 11/14/16 and at 10:15 p.m. and completing the end of the shift rounds. When she got to Resident #3's room Staff V stated the resident needed to go to bed and attempted to stand Resident #3 up with Staff J. Resident #3 refused again and Staff J released her/his upper arm and said she was not going to force the resident to do something he/she did not want to do. Staff U, the nurse stepped in and they needed to get the (expletive) out. Staff J left the room. Staff U and Staff V held Resident #3's arm down and slightly behind his/her buttocks and then made the resident stand. Staff U and Staff V removed the resident's clothes forcefully while Resident #3 cried for them to stop. Staff Z did not respond to the surveyor's call/s for an interview. Interview with Staff J, CNA on 3/8/17 at 2:55 p.m., she stated she worked with Resident #3 and toileted him/her around 8:30 p.m Staff J asked Resident #3 if he/she wanted his/her pajamas on and he/she said no. Resident #3 wanted in his/her recliner. Staff J asked Resident #3 again at 9:00 p.m., if he/she wanted to go to bed, and he/she said no. At 10:00 p.m., Staff Z and she were doing rounds in another resident's room. Staff V, CNA came in and told them to finish and she would go to Resident #3's room. Staff J walked into Resident #3's room and he/she was seated in the recliner. Staff V was in the room. Resident #3 was refusing to get up. Staff J went to get the bed alarm and went back to the room. Staff U, LPN walked into the room. Staff V tried to undress Resident #3 and Resident #3 said No, No, No. Staff V put a gait belt on and Staff J said she was going to help. Resident #3 said No, get away and started hitting. Staff J reported she backed away and Staff U told Staff J If you're not going to help her (Staff V), she will. Staff U went to help. Staff J reported she left and called the DON. While calling the DON, she could hear Resident #3 say No leave me alone and he/she repeated it. The DON said she would take care of it. The next day, 11/15/17 staff J she came to work at 2:00 p.m. at the facility asked for statements. Interview with Staff N, CNA on 3/9/17 at 7:20 AM revealed on 11/14/16, Staff N worked the 10:00 PM to 6:30 AM shift. Staff N went looking for Staff U at 10:15 PM and she went to Resident #3's room. Staff V was on one side and Staff J was on the other side of the resident. Resident #3 said No, I don't want to. Staff J stopped and did not want to get him/her up, since the resident was refusing. Staff U came in the room too. Staff V said we have to get the resident up because he/she's wet. Staff J was uncomfortable with this and Staff U said If you're not going to help, move so I can. Staff J left the room after this. Staff U went to the resident's right side. Staff U and Staff V did a normal transfer with a gait belt and told Resident #3 to grab the walker. Resident #3 started slamming the walker and still saying leave me alone. Staff U held the walker and ambulated with Resident #3 to the bed. The got his/her pants and brief down which were both wet. They got him/her to bed as Resident #3's pants were down and brief off. Staff V wiped/cleaned Resident #3. Resident #3 sat and then laid on the bed. Resident #3 started to hit Staff V. They rolled Resident #3 to the wall to put a clean brief on and he/she continued to hit Staff V. Staff V held Resident #3's hands down. Resident #3's hands were crossed and Staff V's hands were on top of the resident's hands and (right) wrist. Staff V told Resident #3 You can't hit me, it's not nice to hit. Staff V continued to hold Resident #3's hands down on the side and when they rolled him/her back. Resident #3 said leave me alone and was fighting under his/her hands. Staff N got the brief on and Staff V let go. They covered Resident #3 and told him/her good night. Within 5 minutes Resident #3 was asleep. Staff N remembers Staff Z coming into the room at some point earlier and said you can't do that, the Residents have the right to say no. Interview with Staff F, LPN on 3/8/17 at 11:05 a.m. revealed she worked with Resident#3 the next day from 6:00 AM to 6:00 p.m. (11/15/16). Staff F got a report form Staff U and she reported nothing out of the ordinary. Around 2:00 p.m., Staff Z (Agency Staff) stated she had worked they evening prior on 11/14/16. Staff Z stated she witnessed an incident and stated Resident #3 had been up for 3 days, which is normal for him/her. Staff Z said Staff U and Staff V started to get Resident #3 up. Resident #3 said No, No, I don't want to go to bed. Staff F stated Staff Z reported they (Staff U and Staff Z) held Resident #3 down and made him/her lay in bed (during cares). Staff F told Staff Z she needed to sit down and write everything out. Staff F went to Resident #3's room and she could see bruising in the shape of a hand. She stated she should have done a head to toe assessment but she was so upset. Staff F worked the day before from 6:00 AM to 6:00 p.m. on 11/14/16 and she saw no bruising and staff did not report bruising. Interview with Staff D, RN on 3/7/17 at 4:40 p.m., she stated she did not work at the time of the incident but worked the following day (11/15/16). She heard report that Resident #3 had been sleeping at all night. She heard a report that staff forced Resident #3 to go to bed. Staff D went to look at Resident #3 and he/she had bruises on both of his/her forearms. The DON told her these were old bruises. Staff D stated it had been the 1st times she had seen the bruises. The Administrator took over the investigation. Interview with Staff W, RN on 3/7/17 at 4:00 p.m. revealed she was not at the facility the time of the incident and had left her shift prior that night. She came to work at 2:00 p.m. and left around 9:00 to 9:30 p.m., on 11/14/16. The next day (11/15/16) Staff Z came to her and stated the DON had threatened her to change her witness statement. Staff W contacted the Director and she contacted the CEO. The DON stated they were old bruises and to quit worrying about it. Staff W felt uncomfortable and they reported it and talked to the Director and CEO. The facility did a thorough investigation and the DON was suspended. Interview with Staff U, LPN on 3/14/17 at 2:10 p.m. at 10:00 p.m. the evening and night CNAs completed their rounds. At approximately at 10:10 p.m. CNAs were in Resident #3's room working with him/her. Staff J (or another agency staff) also went into Resident #3's room and heard the resident say she/he did not want to (get up.) Staff U stated Resident #3 was in his/her recliner. Staff V was on the left of Resident #3 with the walker in front of him/her. According to Staff U, Staff J said she did not want get the resident up. Staff U stated then just put Resident #3 in bed. Staff U stated Staff V told Resident #3 we need to stand you up. Staff U also stated Staff V put her hands on Resident #3 gently while Resident #3 had been in the recliner. Staff U reported they also took Resident #3's brief off. She stated they did pull the slacks down 1st to put him/her in bed. Staff U clarified she did not see Staff V put her hands on Resident #3. According to Staff U, when they were done caring for Resident #3, Staff V told her she had put her hands on Resident #3 due to the resident hitting. Once they stood Resident #3 up he/she may have said, No but he/she did not fight. Staff U stated Staff J was not present at this time. They put Resident #3 to bed and he/she went to find Staff J. Staff U stated she left Staff V and another CNA to finish with Resident #3. Staff U called the DON to tell her Staff J left (the room and did not assist) and she told her to write it up and she would take care of it tomorrow. Staff U went to Resident #3's room to check and Resident #3 was asleep. Resident #3 slept all night. Interview with Staff V, CNA on 3/14/17 at 3:30 p.m., revealed when she came to work at 10:00 p.m. the staff do rounds with the shift going off duty. She went into Resident #3's room with possibly 2 other CNAs. Resident #3 was fully clothed. Staff V stated Resident #3 can go in cycles and can be up for days. Resident #3 was wet and they wanted to make sure he/she had alarms and was dry. Resident #3 was upset at first. Staff V does not think Resident #3 was asleep and would not have awakened him/her. Staff V encouraged Resident #3 to get up to check him/her. Staff V asked Resident #3 if he/she wanted to use the restroom and he/she wasn't happy. Staff V stated she tried to tell Resident #3 she wanted him/her to be safe and to toilet him/her. Staff V stated Resident #3 was somewhat combative. Staff V stated 1 CNA (cannot remember who) said she was not going to help. Staff U, the nurse said If you're not going to help, I will. Staff V stated the resident did not want to go to the bathroom and the nurse said let's just get him/her to bed then. Staff V and Staff U stood Resident #1 up. Staff V stated Resident #1 didn't fight and didn't say anything. Staff V further stated Resident #1 did not fight when he/she was in bed. Staff V stated staff changed Resident #3 when they put him/her in bed. Staff V stated at that point Resident #3 was not fighting and there was no need to hold his/her hands. Staff V said Resident #3 had not been resistive before. Staff V stated the remainder of the night, she checked and changed Resident #3 every 2 hours. She stated Resident #3 was exhausted and slept through the checks and changes. Review of the Daily Staff Assignment Sheet dated 11/14/16 revealed Staff U, LPN worked on the South hall from 6:00 PM to 10:00 PM and also scheduled on the South and East hall 10:00 PM to 6:30 AM. The daily staff assignment sheet also revealed Staff V, CNA worked 10:00 PM to 6:30 AM on the East hall. According to the Daily Assignment Sheet Staff U and Staff V assigned as the caregiver for the resident's hall on the remaining worked shift. During an interview with The Administrator on 3/8/17 at 3:30 PM he stated staff brought the incident to the nurses attention on Tuesday afternoon (11/15/16). He stated the DON did not think it had been a big issue. The facility investigated and reported the incident to the Department within 24 hours. Staff were suspended and did not work following the incident. He stated the DON had been terminated following the investigation. He further stated in November the facility implemented orientation and sign the Abuse policy and procedure form for new agency staff. The facility also had an in-service on 12/8/16 and went through the policy and procedure for abuse to ensure staff understood the requirements. The facility will continue to complete on an annual basis. 2. According to the MDS (minimum data set) dated 11/24/16 Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision making. According to the MDS the resident had behavioral symptoms which included physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others and rejected evaluation or care 1 to 3 days of the assessment period. According to the MDS the resident required extensive assistance of 2 person physical assist with bed mobility, transfers, dressing, toilet use and personal hygiene. The care plan dated 11/28/16 directed staff to handle resident with care during direct care. Review of the Incident Notification dated 2/21/17 revealed it had been reported Resident #1 had been combative with cares. A CNA (Staff S) then hit the resident. No injury noted. Review of the Daily Staff Assignment Sheet revealed Staff S, CNA (certified nursing assistant) scheduled and worked on 2/14/17, 2/16/17, 2/17/17, 2/18/17 and 2/19/17. According to the Daily Assignment Sheet Staff S assigned as the caregiver for the resident's hall on all worked shifts. Interview with Staff T, CNA on 3/15/17 at 6:00 p.m. she stated she was working with Staff S. She stated Staff S can have a bad attitude and Resident #1 can be combative at times. Resident #1 swatted at Staff S. Staff S slapped Resident #1 and the resident did get upset and seemed to have increased confusion. Staff S said I think my patience with them is gone and stated maybe it is time for a different career. Staff S also stated You abuse you're F(expletive) spouse like that? No wonder, you're here. Staff T stated she did not get to report it in time and it occurred approximately 8:00 to 8:30 PM. Staff T stated she did hear a slap sound skin to skin and the slapped was to Resident #1's right arm/wrist area. Staff T reported Resident #1 was more upset. Staff T changed the subject and calmed Resident #1 down and finished changing him/her on her own. Staff T reported Staff S left the room and did not believe she went back into Resident #1's room, and that shift ended at 10:30 p.m Review of the Certificate of Completion for Dependent Adult Abuse Training for Mandatory Reporters revealed the following completion dates: a. Staff K, RN (Registered Nurse) 7/12/12. b. Staff P, CNA 8/16/16. c. Staff S, CNA 6/3/13. d. Staff T, CNA 7/27/12. Review of the Verification of the Abuse Prevention, Identification, Investigation and Reporting Policy revealed the staff acknowledge that they have received and read the abuse prevention, identification, investigation and reporting policy. They are responsible for reviewing and applying the contents while at Sanford Sheldon Medical Center & Sanford Sheldon Senior Care. The form dated as follows: a. Staff S, CNA on 2/4/17. b. Staff T, CNA on 2/9/17. During an interview with Staff K, RN on 3/8/17 at 5:30 PM she stated on 2/20/17 at approximately 11:00 PM Staff P, CNA told her he had worked with Staff T, CNA on a previous shift. Staff T had told Staff P she worked with Staff S (CNA) to assist Resident #1. Staff T said she saw Staff S slap Resident #1. Staff T had felt uneasy about it being Agency staff and should have said something. Staff K stated she told the Director the next day. The next day, Staff K told the Director. Staff K said she worked with Staff S while for a different resident and Staff S had a tone in her voice with the resident. Staff K told her not to do that. Staff K stated Staff S did leave and stated she had an inappropriate attitude. She stated it was not reported as it was not abusive just an attitude. She further stated neither Staff S nor Staff T had been in the facility when this was reported to her. During an interview with Staff P, CNA on 3/10/17 at 10:15 AM he stated he worked with Staff T, CNA on an overnight shift (2/18/17). Staff T told him Staff S had worked with her recently and she saw her slap the resident on the hands. He asked if she had reported it and said no. She said it occurred about 5 days prior and he told her she had to report in 24 hours. He stated he thought she would report it then. He reported it to Staff K when they worked together (2/20/17) at 10:00 PM to ensure it had been reported. During an interview with Staff T, CNA on 3/15/17 at 6:00 PM she stated she assisted the resident with Staff S, CNA. The resident swatted at Staff S. Staff S slapped the resident on the right arm wrist area. Staff S also said you abuse your spouse like that, no wonder you're here. She stated it happened approximately 8:00 to 8:30 PM and she did not get to report it. She further stated the resident became upset and she changed the subject and calmed him/her. She had Staff S leave the room and she finished changing him/her on her own. During an interview with the Director on 2/23/17 at 12:20 PM she stated she on 2/21/17 Staff K had told her that during the night shift, Staff P reported to her Staff T told him she saw something and should have reported and did not know why she didn't but now had been so long she can't say anything. Staff T told Staff P she saw Staff S hit the resident. The Director also stated Agency staff are given orientation 2 hours prior to their 1st shift worked in the facility. The orientation includes abuse policy. They are given a copy of the abuse policy. She further stated Staff S worked on 2/19/17 and went home ill at 9 PM. Review of the Abuse Training dated 8/6/16 revealed Staff J, CNA, Staff K, RN, Staff U, LPN and Staff V, CNA had attended. Review of the Monthly All Staff Meeting dated 12/20/16 revealed review of the Abuse Policy as follows: a. Please note the change in the reporting guidelines as now only have 2 hours to report abuse to DIA versus the 24 hours had prior. Review the attached policy. Review of the Policy and Procedure titled Abuse Prevention, Identification, Investigation and Reporting dated 1/6/17 directed staff to do the following: a. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. b. All allegations of Resident abuse should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Director of Nursing, Administrator or designated representative. c. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than 2 hours after the allegation is made. d. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse and result in serious bodily injury, or not later than 24 hours if the events that cause the allegation involve abuse but do not result in serious bodily injury. The Abuse Policy identified residents had the right to be free from verbal, mental, and any physical abuse. The Federal defintion of abuse defined as: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility abated the IJ on 3/10/17 when they completed the following: On 3/10/17, the facility abated the Immediate Jeopardy when they re-educated all employees and all employees from the temporary staffing agency on abuse prevention, abuse identification investigation, and reporting based on their Abuse Policy. All the employees received 1-1 training from a member of the leadership team on the abuse policy. The leadership staff will address the abuse policy point by point individually with each employee and upon completion the employee will sign an acknowledgement to establish their understanding. Each employee received a copy of the Abuse policy as well. This lowered the severity of the IJ at K level to a D severity level.

Based on record review, policy review and staff interviews, the facility failed to ensure Resident #3 remained free from abuse. Record review identified Resident #3 obtained bruises on his/her wrist/arms after staff forcefully held the resident's hands behind his/her back during cares. Record review identified Resident #3 did not have a history or bruising or bruising prior to the incident. The facility reported a census of sixty one (61) residents. Findings Include: Record review identified Resident #3 had lived in the facility since 12/1/14. Resident #3 had [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set assessment dated [DATE], revealed he/she had short and long term memory problems; and had moderately impaired cognitive skills for daily decision making. Resident #3 had behavioral symptoms directed towards staff. Resident #3 had a history of [REDACTED].#3 required extensive assistance of 1 staff for bed mobility, transfers, ambulation, dressing and toilet use. Resident #3 is able to ambulate with assistance of staff with the use of a gait belt and wheeled walker. Review of the Skin Risk Assessment with Braden Scale dated 9/1/16 revealed the resident had a score of 21. A total score of 19 or above indicated not at risk. Review of the Progress Notes dated 11/14/15 at 8:01 p.m., revealed the resident in his/her room yelling for someone to get his/her paints and pictures then began having a coughing spell. Nebulizer treatment given and resident given his/her coloring pages and [MEDICATION NAME]. At 9:03 p.m. the resident sleeping soundly in his/her recliner. The Incident Notification dated 11/15/16 revealed Resident #3 was noted to have 2 bruises measuring 4.5 cm (centimeters) by 2.5 cm and 6 by 2.5 cm. Undated pictures of Resident #3's right arm revealed bruising to the right hand and right forearm. The medical record did not contain documentation of a history of bruising or injuries for Resident #3. The care plan in place at the time of the incident (11/14-15/2016) did not identify behaviors/power struggles/ or any directive to address Resident #3 when he/she became resistant with cares or safety concerns related to Resident #3 sleeping in his/her recliner. The care plan dated 11/28/16 directed staff to avoid power struggles with Resident #3. The care plan directed staff to maintain a calm environment and when Resident #3 begins to resist care, stop and try the task later and do not force Resident #3 to do the task. The care plan also directed staff to respect Resident #3's rights to make decisions. Staff Z's written statement included the following information: She had been working 2-10:30 p.m. shift on 11/14/16 and at 10:15 p.m. and completing the end of the shift rounds. When she got to Resident #3's room they explained Resident #3 had (already) went to the bathroom and was napping in his/her chair since about 9 p.m. Staff V stated the resident needed to go to bed and attempted to stand Resident #3 up with Staff J. Resident #3 refused again and Staff J released her/his upper arm and said she was not going to force the resident to do something he/she did not want to do. Staff U, the nurse stepped in and they needed to get the (expletive) out. Staff J left the room. Staff U and Staff V held Resident #3's arm down and slightly behind his/her buttocks and then made the resident stand. Staff U and Staff V removed the resident's clothes forcefully while Resident #3 cried for them to stop. Staff Z did not respond to the surveyor's call/s for an interview. Interview with Staff J, CNA on 3/8/17 at 2:55 p.m., she stated she worked with Resident #3 and toileted him/her around 8:30 p.m Staff J asked Resident #3 if he/she wanted his/her pajamas on and he/she said no. Resident #3 wanted in his/her recliner. Staff J asked Resident #3 again at 9:00 p.m., if he/she wanted to go to bed, and he/she said no. At 10:00 p.m., Staff Z and she were doing rounds in another resident's room. Staff V, CNA came in and told them to finish and she would go to Resident #3's room. Staff J walked into Resident #3's room and he/she was seated in the recliner. Staff V was in the room. Resident #3 was refusing to get up. Staff J went to get the bed alarm and went back to the room. Staff U, LPN walked into the room. Staff V tried to undress Resident #3 and Resident #3 said No, No, No. Staff V put a gait belt on and Staff J said she was going to help. Resident #3 said No, get away and started hitting. Staff J reported she backed away and Staff U told Staff J If you're not going to help her (Staff V), she will. Staff U went to help. Staff J reported she left and called the DON. While calling the DON, she could hear Resident #3 say No leave me alone and he/she repeated it. The DON said she would take care of it. The next day, 11/15/17 staff J she came to work at 2:00 p.m. at the facility asked for statements. Interview with Staff N, CNA on 3/9/17 at 7:20 AM revealed Resident #3 had fallen asleep in the recliner before and staff left him/her sleep until last rounds if needed. Resident #3 is normally incontinent on some of the rounds, probably 2:00 AM and 4:00 AM rounds. Staff will ask Resident #3 if she needs the restroom and he/she can refuse. On 11/14/16, Staff N worked the 10:00 PM to 6:30 AM shift. Staff N went looking for Staff U at 10:15 PM and she went to Resident #3's room. Staff V was on one side and Staff J was on the other side of the resident. Resident #3 said No, I don't want to. Staff J stopped and did not want to get him/her up, since the resident was refusing. Staff U came in the room too. Staff V said we have to get the resident up because he/she's wet. Staff J was uncomfortable with this and Staff U said If you're not going to help, move so I can. Staff J left the room after this. Staff U went to the resident's right side. Staff U and Staff V did a normal transfer with a gait belt and told Resident #3 to grab the walker. Resident #3 started slamming the walker and still saying leave me alone. Staff U held the walker and ambulated with Resident #3 to the bed. The got his/her pants and brief down which were both wet. They got him/her to bed as Resident #3's pants were down and brief off. Staff V wiped/cleaned Resident #3. Resident #3 sat and then laid on the bed. Resident #3 started to hit Staff V. They rolled Resident #3 to the wall to put a clean brief on and he/she continued to hit Staff V. Staff V held Resident #3's hands down. Resident #3's hands were crossed and Staff V's hands were on top of the resident's hands and (right) wrist. Staff V told Resident #3 You can't hit me, it's not nice to hit. Staff V continued to hold Resident #3's hands down on the side and when they rolled him/her back. Resident #3 said leave me alone and was fighting under his/her hands. Staff N got the brief on and Staff V let go. They covered Resident #3 and told him/her good night. Within 5 minutes Resident #3 was asleep. Staff N remembers Staff Z coming into the room at some point earlier and said you can't do that, the Residents have the right to say no. Staff N had never seen it before. Staff N stated the Resident #3 was so upset. After the incident happened, Resident #3 went through a stage and got upset over things. If staff tried to assist the resident to sit, Resident #3 would say you're trying to kill me and get upset. She had not seen anything like that since. Interview with Staff F, LPN on 3/8/17 at 11:05 a.m. revealed she worked with Resident#3 the next day from 6:00 AM to 6:00 p.m. (11/15/16). Staff F got a report form Staff U and she reported nothing out of the ordinary. Around 2:00 p.m., Staff Z (Agency Staff) stated she had worked they evening prior on 11/14/16. Staff Z stated she witnessed an incident and stated Resident #3 had been up for 3 days, which is normal for him/her. Staff Z said Staff U and Staff V started to get Resident #3 up. Resident #3 said No, No, I don't want to go to bed. Staff F stated Staff Z reported they (Staff U and Staff Z) held Resident #3 down and made him/her lay in bed (during cares). Staff F told Staff Z she needed to sit down and write everything out. Staff F went to Resident #3's room and she could see bruising in the shape of a hand. She stated she should have done a head to toe assessment but she was so upset. Staff F worked the day before from 6:00 AM to 6:00 p.m. on 11/14/16 and she saw no bruising and staff did not report bruising. Staff F stated the resident slept all day on 11/15/16. Interview with Staff D, RN on 3/7/17 at 4:40 p.m., she stated she did not work at the time of the incident but worked the following day (11/15/16). She heard report that Resident #3 had been sleeping at all night. She heard a report that staff forced Resident #3 to go to bed. Staff D went to look at Resident #3 and he/she had bruises on both of his/her forearms. The DON told her these were old bruises. Staff D stated it had been the 1st times she had seen the bruises. The Administrator took over the investigation. Interview with Staff W, RN on 3/7/17 at 4:00 p.m. revealed she was not at the facility the time of the incident and had left her shift prior that night. She came to work at 2:00 p.m. and left around 9:00 to 9:30 p.m., on 11/14/16. The next day (11/15/16) Staff Z came to her and stated the DON had threatened her to change her witness statement. Staff W contacted the Director and she contacted the CEO. The DON stated they were old bruises and to quit worrying about it. Staff W felt uncomfortable and they reported it and talked to the Director and CEO. The facility did a thorough investigation and the DON was suspended. Interview with Staff U, LPN on 3/14/17 at 2:10 p.m. revealed she came on duty at 6:00 p.m., and around 9-9:30 p.m., Staff U got report from Staff W (nurse) that Resident #3 had been on a cycle and can be up for 3-4 possible days. At 10:00 p.m. the evening and night CNAs completed their rounds. At approximately at 10:10 p.m. CNAs were in Resident #3's room working with him/her. Staff U stated 1 person could (normally) get Resident #3 up from his/her recliner. Staff J (or another agency staff) also went into Resident #3's room and heard the resident say she/he did not want to (get up.) Staff U stated Resident #3 was in his/her recliner. Staff V was on the left of Resident #3 with the walker in front of him/her. According to Staff U, Staff J said she did not want get the resident up. Staff U stated then just put Resident #3 in bed. Staff U stated Staff V told Resident #3 we need to stand you up. Staff U also stated Staff V put her hands on Resident #3 gently while Resident #3 had been in the recliner. Staff U reported they also took Resident #3's brief off. She stated they did pull the slacks down 1st to put him/her in bed. Staff U clarified she did not see Staff V put her hands on Resident #3. According to Staff U, when they were done caring for Resident #3, Staff V told her she had put her hands on Resident #3 due to the resident hitting. Once they stood Resident #3 up he/she may have said, No but he/she did not fight. Staff U stated Staff J was not present at this time. They put Resident #3 to bed and he/she went to find Staff J. Staff U received a written note from the facility that she went against their wishes and she felt they are being targeted. Staff U stated normally she would leave a resident and go back later. She did not leave Resident #3 due to his/her safety at the change of shift. Staff U stated she left Staff V and another CNA to finish with Resident #3. Staff U called the DON to tell her Staff J left (the room and did not assist) and she told her to write it up and she would take care of it tomorrow. Staff U went to Resident #3's room to check and Resident #3 was asleep. Resident #3 slept all night. Staff checked and changed her and at times could be dry all night. Staff U did not think they were excessive with Resident #3. Staff U reported Resident #3 had been having several falls, and staff started a chair, tab and bed alarm. Staff U stated the alarms were not under him/her and the cord not hooked up. There was no bed alarm on the bed. Interview with Staff V, CNA on 3/14/17 at 3:30 p.m., revealed when she came to work at 10:00 p.m. the staff do rounds with the shift going off duty. She went into Resident #3's room with possibly 2 other CNAs. Resident #3 was fully clothed. Staff V stated Resident #3 can go in cycles and can be up for days. Resident #3 was wet and they wanted to make sure he/she had alarms and was dry. Resident #3 was upset at first. Staff V does not think Resident #3 was asleep and would not have awakened him/her. Staff V encouraged Resident #3 to get up to check him/her. Staff V asked Resident #3 if he/she wanted to use the restroom and he/she wasn't happy. Staff V stated she tried to tell Resident #3 she wanted him/her to be safe and to toilet him/her. Staff V stated Resident #3 was somewhat combative. Staff V stated 1 CNA (cannot remember who) said she was not going to help. Staff U, the nurse said If you're not going to help, I will. Staff V stated the resident did not want to go to the bathroom and the nurse said let's just get him/her to bed then. Staff V and Staff U stood Resident #1 up. Staff V stated Resident #1 didn't fight and didn't say anything. Staff V further stated Resident #1 did not fight when he/she was in bed. Staff V stated staff changed Resident #3 when they put him/her in bed. Staff V stated at that point Resident #3 was not fighting and there was no need to hold his/her hands. She stated the Charge Nurse (Staff U) and evening CNAs were with her. Staff V said Resident #3 had not been resistive before. Staff V stated the remainder of the night, she checked and changed Resident #3 every 2 hours. She stated Resident #3 was exhausted and slept through the checks and changes. Staff V stated Resident #3 did not fight the remainder of the night. Staff V stated she did not get a call that night from the DON. Staff V stated they just instituted tab alarms, and Staff U told her the alarms started that afternoon. Staff V stated she was following Staff U's instruction. Staff V stated management later told her they should have gone in later to check on Resident #3. Interview with the Director on 3/8/17 at 11:00 a.m. she revealed she took pictures of Resident#3's bruises after the incident. The bruises in the pictures are in the same areas noted after the incident. She did get statements from Staff J, CNA and Agency CNA (Staff Z). Staff J had been upset staff was forcing Resident #3 left to call the DON. The Director got the statements on Tuesday 11/15/17 and on 11/15/17 Staff V and staff U were suspended. Interview with the CEO on 3/8/17 at 3:30 p.m., he stated on the afternoon of Tuesday 11/15/16, staff alerted the nurse on Monday night 11/14/16 of the incident. The DON thought it had not been a big issue. They interviewed Staff J and the Director called him and though it had been a big deal. The CEO reported they suspended Staff V and Staff U and they did not work after their shift. The CEO stated then they got the DON's report that she sent to DIA. The following Monday, he suspended the DON. The CEO stated there was no reason to hold Resident #3 down and change him/her. Resident #3 was already changed. He stated it was not appropriately handled and the DON did not feel it was urgent. The DON was terminated after the investigation was completed in December 2016 (12/2/16). The Abuse Policy identified resident must not be subject to abuse by anyone, including but not limited to facility staff. All residents had the right to be free from verbal, mental, and any physical abuse. The policy identified acts by a caretaker taking into the totality of the circumstances. A physical injury to or which is at a variance with the history given the injury or unreasonable confinement, unreasonable punishment and or assault of a dependent adult which involves a breach of skill or care exercised by a caretaker in similar circumstances. Assault of a dependent adult meant the commission of any act which is generally intended to result in physical contact which will be painful, injurious, insulting, or offensive, couple with the apparent ability to execute the act. The Federal defintion of abuse defined as: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

Based on record review, observations, staff interviews, and review of the facility policy/procedures, the facility failed to provide adequate supervision in order to prevent resident to resident altercations (Resident #16, #7, #17, #18, #19) and to prevent a fall (Resident #8). Record review revealed Resident #16 displayed aggressive behaviors towards other residents in the CCDI (Chronic Confusion and Dementing Illness). The facility failed to ensure the resident's environment remained free of accident hazards when using a mechanical lift (Resident #4) and transporting a resident in a wheelchair without the use of foot pedals (Resident #4, Resident #6). The sample consisted of 7 residents and the facility reported a census of 61 residents. Findings included: 1. Resident #16 had a Minimum Data Set (MDS) assessment with a reference date of 2/12/15. The MDS reflected the resident had short and long term memory impairments, severely impaired skills for daily decision making, continuous inattention and disorganized thinking without fluctuation, without delusions and hallucinations, and physical behavior such as hitting 1 to 3 days of the assessment period. Resident #16's behaviors put the resident at significant risk for physical illness or injury and significantly interfered with the resident's care. The resident's behaviors put others at significant risk for physical injury and significantly disrupted care or the living environment. Resident #16's wandering intruded significantly on the privacy or activities of others and behaviors had worsened. The MDS identified the resident required supervision with ambulation, and eating, required extensive staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing, and the resident used a walker for mobility. Resident #12's [DIAGNOSES REDACTED]. The Care Plan for Resident #16 identified a problem start date on 3/19/13 which identified the resident had a memory problem due to dementia. The goal dated 2/20/15 reflected the resident would have positive experiences in the daily routine without experiencing overly demanding tasks and without becoming overly stressed. The approaches included and directed staff to provide consistent care givers, cue and supervise ADLs (Activities of Daily Living) and activities, and use touch and gestures. The Care Plan identified a problem on 3/19/13 with the resident resisting care for obtaining blood work (for tests), taking medications, and ADL assistance. The approaches included and directed staff to avoid power struggles with the resident, maintain a calm environment, make simple requests, praise positive behavior, and reproach when the resident resisted cares. The Care Plan identified on 3/20/13, the resident an elopement risk and directed staff to observe the resident closely especially when family and staff left the SCU (Special Care Unit) and to redirect the resident when needed. The Care Plan documented the resident received psychotropic medications related to Alzheimer's dementia and depression. The approaches dated 3/20/13 directed staff to assess the resident for behaviors that present a danger to self and/or others, assess effectiveness and side effects of drug treatment, monitor behaviors, and follow up with psychiatric services every 4 to 6 months and when needed. The Nursing Resident Progress Notes reflected the following: On 6/9/14 at 4:40 p.m., a possible resident to resident contact, unwitnessed by staff, but staff heard a commotion and the other resident held Resident #16's face. On 6/26/14 at 11:46 a.m. staff documented Resident #16 became angry with another resident (Resident #18) due to Resident #18's continuous vocalization. Resident #16 hit Resident #18 in the right upper arm, the nurse felt the hit not hard enough contact to cause injury, and the staff planned to monitor. During an interview on 5/14/15 at 12:45 p.m., the DON (Director of Nursing) stated the record lacked an event report and investigation. The Care Plan lacked documentation of any new behaviors and interventions. On 8/15/14 at 5:58 p.m., the staff documented Resident #16 sat at a table with another resident (Resident #7), Resident #7 got up from the table, Resident #16 pushed Resident #7 to the floor. The intervention documented the staff would try to keep the residents separated. On 5/14/15 at 12:45 p.m. a meeting with the DON verified Resident #16 pushed Resident #7. An MDS dated [DATE] documented Resident #7 with short and long term memory impairment, severely impaired cognitive skills for daily decision making, continuous inattention and disorganized thinking without fluctuation, delusions, and wandered daily. The MDS identified the resident required staff supervision with bed mobility and walking in the corridor and limited staff assistance with transfers and walking in own room. Resident #7's Care Plan with a problem start date of 10/17/13 identified the resident wandered, problem start dates of 10/18/13 for potential elopement and psychotropic drug use, and a problem start date of 10/19/13 for wandering. The Care Plan identified the resident's [DIAGNOSES REDACTED]. An Event Report dated 8/15/14 at 6:01 p.m. documented Resident #7 fell in the dining room when pushed by another resident (Resident #16). The report documented Resident #7 sat at the dining room table with another resident (Resident #16) and Resident #16 stood up and pushed Resident #7 to the floor and the push witnessed by staff. Resident #7 received a 4 centimeter laceration to the middle of the forehead, staff applied pressure, ice, steri-strips, and Bacitracin ointment. Staff completed neurological assessments that resulted in normal findings. The event sheet documented the resident had head pain rated a 2 on a scale of 0 to 10. The interventions included first aid, rest, ice, cold and direct pressure to the wound. The Incident Investigation Note dated 8/15/14 at 3:45 p.m. documented the staff separated Resident #7 from Resident #16 at the time. Leadership Review/Recommendations included to keep the residents separated, this may be difficult due to dementia diagnosis, and the resident's Care Plan updated with changes. On 9/18/14 at 8:15 p.m., staff documented Resident #16 yelled at and hit Resident #17 (sitting in a recliner) in the face with an open hand, went after Resident #19 and hit him/her with a walker, and hit a staff member in the face with a closed fist when staff attempted to intervene. Staff documented neither the staff or resident injured and Resident #16 apologized and returned to own room. A Behavior and Mood Events Aggressive/Combative Behavior sheet documented the altercation and that Resident #16's physician notified of the altercation and staff planned to notify Resident #16's family in the morning. The record lacked documentation the resident's family notified of the altercation. The behavior/mood events form lacked documentation of any immediate or new pharmacy or non pharmacy interventions. The resident's Care Plan lacked documentation of any new interventions. On 11/3/14 at 5:45 p.m., staff documented Resident #16 hit an unidentified resident with a closed fist to the left cheek. The staff separated the residents. A Behavior and Mood Events-Aggressive/Combative Behavior sheet documented the incident and lacked the name of the resident hit by Resident #16. On 12/10/14 at 8:30 p.m., staff documented Resident #16 combative with staff and other residents, used wheeled walker to ram into others, hit residents and staff members, redirection not successful, resident refused medications, and the resident had calmed down by bedtime. During a meeting with facility staff 5/14/15 at 12:45 p.m., the DON verified the nurse on duty at the time of the 12/10/14 resident to resident altercations, was unable to remember the name of the residents hit by Resident #16 and the record lacked documentation of resident names. On 12/26/14 at 2:35 p.m. reflected the resident seemed irritable and paced often. The resident rammed walker into objects and even peers. The resident redirects briefly. On 12/26/14 at 2:35 p.m., staff documented the resident more irritable, paces often, observed ramming walker into objects and peers, the resident redirected briefly, and tried to swing at a staff member. On 2/2/15 at 11:53 p.m., staff documented Resident #16 hit another resident (Resident #2) when Resident #2 got too close and neither resident obtained injuries. Staff notified Resident #16's family and not the physician of the altercation. On 2/25/15 at 10:41 p.m., staff documented the resident as irritable when bothered by other residents, yelled at the residents to leave him/her alone, slammed walker into a resident if that resident too close to Resident #16, and staff redirected the resident to own room. On 2/26/15 at 12:19 p.m., staff documented the resident irritable, resistive with medications when given, slapped at staff a couple times, and calmer by noon. A psychiatric ARNP visit report dated 3/24/15 documented staff reported the resident continued to be mean spirited, made attempts to hit other residents with wheeled walker, frequently angry, attempted to pinch and swing at staff and attempted to swing out and assault peers, and difficult to redirect. The ARNP increased the resident's Risperdal to 1.5 mg. twice daily. During an interview on 5/14/15 at 9:10 a.m., Staff K (Unit Manager for SCU) stated the facility completed incident reports and investigations for falls, bruises, and skin impairments, and not for resident to resident altercations. Staff K stated she found event reports for resident to resident altercations on 9/18/14 and 11/3/14 and the reports lacked investigations. Staff K verified Resident #16's Care Plans lacked documentation of any new interventions related to the resident hitting/pushing staff and residents. On 5/14/15 at 12:45 p.m. Staff K stated the Daily Nursing Report to the DON (used by nursing staff to document resident behaviors, elopements, staff issues, and other events) were given to the DON until October or November 2014 and then given to Staff K and Staff J. Staff K verified the events discussed at daily stand up meetings, behaviors with Resident #16 were discussed and not documented anywhere. Staff threw the sheets away and no longer have sheets for the above resident to resident altercations. 2) Resident #8 had a MDS assessment dated [DATE] which reflected the resident with intact cognition, required extensive staff assistance with bed mobility, transfers, dressing, toilet use, had not ambulated, and used a wheel chair for mobility. The MDS identified the resident not steady, but able to stabilize without staff assistance when moved from a seated to standing position, moved on and off the toilet, and with surface to surface transfers. The MDS documented the resident had 2 or more falls without injury during the previous assessment period and had bilateral one sided range of motion impairment. A CAA (Care Area Assessment) dated 11/17/14 documented the resident liked independence, very stubborn, and wanted to remain independent. A CAA Summary Report dated 11/19//14 documented the resident very proud and independent. The resident's Care Plan documented the resident with [DIAGNOSES REDACTED]. The Care Plan identified a start date of 11/5/09 for a problem with falls related to Paget's, many past fractures, and scored 15 on a fall assessment completed 2/18/15. The approaches directed staff to assist the resident per request and as tolerated, not always compliant with requesting staff assistance, kept urinal and other personal items close by, wears gripper socks at night, trapeze on the bed for independence and strength, perimeter mattress on bed, sticky tape in front of bed and toilet, and to keep call light nearby. Safety Event reports documented the following falls: a. On 6/2/14 at 9:10 a.m., the staff found the resident on the floor in the bathroom. The resident fell when his/her foot slipped during a transfer. The resident did not have injury and did not call for help to go to the bathroom. The investigation note completed 6/4/14 revealed the resident had felt dizzy earlier in the day, the resident's Meclizine (used to treat dizziness) frequency had been decreased. b. On 7/10/14 at 6:45 p.m. the staff found the resident on the floor in the bathroom after the resident lost balance and used the bar to lower self to the floor. The resident did not have an injury, and the nurse encouraged the resident to call for staff assistance to toilet. The investigation note dated 7/11/14 documented the resident as alert and the original intervention appropriate for the resident. c. On 9/14/14 at 5:50 a.m. the staff found the resident on the floor beside the bed. The resident had a gripper sock on the right foot and not the left foot because the foot got hot during the night. The resident did not have an injury. The resident educated to keep both gripper socks on. The investigation report completed on 9/16/14, documented the resident alert and the original intervention appropriate. d. On 12/14/14 at 1:00 p.m. staff found the resident on the bathroom floor after the resident self transferred and eased self to floor. The resident did not have an apparent injury and the nurse showed the resident the sign that reminded him/her to use the call light. The investigation report completed on 12/15/14 documented at the time of the fall, the nurse educated the resident to use the call light and the staff planned to discuss the resident's change in continence with the physician at the next visit. e. On 12/18/14 at 9:42 a.m. the staff found the resident on the floor. The resident hit his/her head after falling backwards in the wheel chair. The resident had a foot on the stool. The resident did not have an injury and the staff educated the resident about safe practices. The investigation report dated 12/22/14 documented the nurse offered anti-tippers on the wheel chair, and the resident refused stating he/she would not elevate legs in the same manner again. A Care Plan entry dated 12/19/14 documented the resident refused to allow anti tip bars on wheel chair. f. On 1/9/15 at 1:16 p.m. staff documented the resident lowered self to the floor in their room when attempted a self transfer from the bed to the wheel chair, without injury. The resident had a gripper sock on the left foot and shoe on the right foot, and the resident educated to call staff and wait for assistance with transfers/needs. On 1/11/15 at 2:36 p.m. staff documented the resident had used the call light that shifted to request assistance. The investigation report dated 1/12/15 documented the original intervention appropriate and the staff updated the Care Plan. Care Plan review revealed the resident received education on 1/9/15. g. On 2/18/15 at 10:39 p.m. staff documented the resident found on the floor by the bed after the resident stated he/she attempted to transfer from the bed to the wheel chair, lost balance, slid to floor, without injury, and the resident reminded of safe practices. The investigation report dated 2/19/15 documented the original intervention appropriate and the care plan updated. A 2/18/15 Care Plan entry documented the resident educated to use call light. h. On 3/2/15 at 2:00 p.m. the resident lowered self to knees during a transfer from the bed to wheel chair. The resident had no injury. The staff educated the about safe practices and to use the call light. The resident stated he would try to do better. The investigation report dated 3/4/15 documented the original intervention as appropriate and the Care Plan updated. A 3/2/15 Care Plan entry documented the fall and gripper strips in place. During a meeting with the staff 5/13/14 at 4:00 p.m., the DON stated the facility staff wanted to help the resident, the resident refuses interventions, refuses restorative, the resident had intact cognition and wants to remain independent. Review of incident reports and investigations of falls back to 6/2/14 lacked documentation of any type of therapy evaluations and treatment for [REDACTED]. 3. Resident #13 had a MDS assessment with a reference date of 2/22/15 which identified the resident had short and long term memory impairments, severely impaired cognitive skills for daily decision making, continuous inattention, hallucinations, delusions, daily physical, verbal, and other behaviors directed towards others. The MDS reflected Resident #13 rejected care 1 to 3 days of the assessment period, and wandered daily. The behaviors put the resident at significant risk for illness or injury, interfered with care and participation in activities or social events, intruded on the privacy of others, and significantly disrupted care or the living environment. The MDS identified the resident required extensive staff assistance with ambulation, dressing, eating, toilet use, and hygiene at the time of the MDS completion. The Care Plan with a start date of 2/26/15 identified the resident had problems with impaired decision making related to dementia and physical behavior symptoms toward others that included hitting, kicking, pushing, and scratching. The approaches directed staff to supervise the resident, avoid power struggles, provide a calm environment, offer simple directions for cares and allow extra time, consistent staff when possible, and when the resident becomes physically abusive keep the resident away from staff, other residents, and visitors and try tasks again later. A nursing Resident Progress Notes entry dated 2/16/15 at 3:00 p.m. documented the resident had an admission to the facility from a behavior health unit. A Resident Progress Notes entry dated 2/22/15 at 9:00 p.m. documented at 8:00 p.m. the resident became combative towards staff and another resident, hitting, screaming, and yelling profanity. The staff attempted unsuccessfully with attempts to fold laundry, gave the doll to the resident to care for, ambulated the resident, and all unsuccessful. The staff administered a PRN (as needed) Seroquel (antipsychotic). During an interview on 5/13/15 at 3:00 p.m., Staff P, RN (Registered Nurse), stated at the time of the 2/22/15 incident, the resident in the day room upset about something, swearing, and hit Staff P. Staff P stated the resident hit another resident, possibly Resident #7, had no memory of a resident injury at the time, and told the staff to notify her if the resident developed any redness or bruising. Staff P believed Resident #13 hit the other resident on the face with an open hand, non pharmacy interventions attempted without relief. The resident received Seroquel, and believed the Seroquel helped the resident calm down. Staff P stated nursing staff had a report sheet at one time to document skin tear, incidents, and other events. Now, the staff documented events on a DON report sheet the Unit Managers do not keep. Staff P stated she asked for the sheets to help her recall the incident. Staff P stated a minimum of 2 staff work in the SCU (Special Care Unit) on the day and evening shift and 1 staff worked the night shift. Staff P stated the resident (Resident #13) seemed very pleasant after medication changes and had not paced as did when first admitted . 4) Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 04/02/15. The MDS reflected the resident demonstrated long and short term memory problems and moderately impaired skills for daily decision making. Resident #4 required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use and personal hygiene. The Care Plan identified Resident #4 at risk for falls. The approaches included Hoyer (total mechanical) lift as needed (prn), and wheelchair for locomotion. During an observation on 05/11/15 at 4:10 p.m. staff provided care to Resident #4 and transferred the resident with a total mechanical lift. Staff did not cross the straps between Resident #4's legs, and his/her legs spread apart during the transfer. During an observation on 05/12/15 at 6:30 a.m., staff placed the (mechanical) lift sling under Resident #4. The back of the sling was below Resident #4's shoulders, and Resident #4's right arm was out over the side of the sling when staff transferred Resident #4 to the bath chair. Staff wheeled Resident #4 to the whirlpool room without putting the pedals in a down position so the resident's feet could be placed on the pedals. During an interview on 05/13/15 at 12:40 p.m. the Director of Nursing (DON) stated she had watched the (lift) video also and the 2 ways to attach the (leg) straps were criss crossed between the legs or under the legs. She stated based on the information the lift sling should be up at the shoulders so an arm could not be out over the sling. The Lift Operating Instructions directed to position the sling underneath the resident, making sure the sling was centered under the resident. Lift the resident's left thigh and pull the left wing of the sling under the resident's thigh. Then place the excess wing over the top of the resident's left thigh. Repeat the same for the right thigh. Position the lift over the resident. Attach the loops by the resident's shoulders to the lift using the shortest loops. Take the wing laying over the left leg and hook it on the right hook. Take the wing laying over the right leg, criss cross it over and hook it on the left hook. 5) Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of 02/19/15, which identified the resident with a BIMS (Brief Interview of Mental Status ) score of 2. A score of 2 determined the resident had a severe cognitive impairment. Resident #6 used a wheelchair and walker and required extensive assistance with transfers. The Care Plan dated 06/13/13 identified Resident #6 at risk for falls. The approaches included Resident #6 used his/her wheelchair independently, and to assist as necessary. During an observation on 05/12/15 at 1:27 p.m. Staff F CNA wheeled Resident #6 to his/her room without the foot pedals placed on the chair. During an interview on 05/13/15 at 4:10 p.m. the DON stated the staff were to use the foot pedals when they pushed the resident. A facility policy/procedure titled Proper Use of Foot Pedals (undated)directed foot pedals to be used on wheelchairs at all times unless the resident was independent with wheelchair mobility. If staff pushed an independent resident, pedals must be put on prior to staff assistance.