Every finding on record at Savannah Heights

Based on record review, staff interviews, and the facility policy, the facility failed to ensure the chair/bed alarms worked properly one resident (Resident #3) and failed to implement new interventions in an effort to limit falls for 3 of 3 residents (Resident#1, Resident #2, and Resident #3) reviewed for supervision related to re-occurring falls The facility reported a census of 30 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated resident used a manual wheelchair and walker and independent with mobility. The MDS revealed medical diagnoses for acute respiratory failure, anxiety disorder, and depression. The MDS revealed resident took antidepressant and opioid medications. The Care Plan revealed a focus area dated 10/17/24 for resident had an actual fall due to sleeping on the edge of bed. The interventions dated 4/4/25 indicated educated to not sit on the side of the bed. The Nurses Note dated 12/7/25 at 8:34 PM, revealed this nurse was called into residents' room by CNA (Certified Nurse Aide). Resident was laying on the floor next to his bed on his side. When asked what had happen resident stated that he was reaching for something on his table and slid out of the bed.The Nurse Note (late entry) dated 12/9/25 at 7:50 PM, revealed at 7:50 PM, called to resident room, upon arrival resident noted to be laying on floor. parallel to bed, body positioned on left side facing bed, head pointing to television, feet pointing to CPAP (continual positive airway pressure - a device used to treat sleep apnea) machine, resident reports he was sitting on edge of bed, leaning on right elbow watching television when his sheets started sliding off of bed, resident was unable to catch himself before he fell, bed appears less than 2 feet from ground, resident reports he fell on right shoulder, denies hitting head, bruising noted to right posterior upper back near armpit area, laceration noted to left lateral foot, no other injuries r/t (related) his fall noted at this time, resident does have old bruising from fall 48hrs (hours) prior.The Nurses Note dated 12/14/25 at 4:44 PM, revealed this nurse was walking resident 108 up to dining room for supper when resident 101 called out help. This nurse saw resident laying on left side with head towards feet of the bed on the floor, parallel with bed. The Nurses Note dated 12/17/25 at 7:19 AM, revealed at 00:10 AM called to resident room, prior to being called to resident room this nurse overheard loud bang and resident yell aw shit, upon arrival, resident found to be laying parallel to bed, head at foot of bed, feet facing head of bed, resident lying on left side. Denies hitting head, reports he bumped his chin on wheelchair, bruising starting to form on chin, reports he also bumped feet on bedside table. skin tears noted to 2nd and 3rd right toes. When inquiring about what happened resident reports he was about to stand up to go to the bathroom when he slipped in something wet upon further inspection of surroundings, appeared water was spilled on floor at bedside, resident has multiple bruising noted from prior falls including bruising to right hip, bruising to left chest under breast, bruising to left flank and bruising to right upper back near axilla that are in various healing stages. The Nurses Note dated 12/19/25 at 00:30 AM, revealed at 00:30 called to resident room, upon arrival, resident laying on back on floor, parallel to bed, with head at foot of bed, top of head facing television, feet facing head of bed, gripper socks noted to feet, resident reports he was going to get up to his wheelchair when he dozed off and rolled out of bed, denies hitting head, reports scarping left knee when rolling out of bed, upon inspection, scab to left knee from prior fall was reponed, area cleansed xeroform applied, padded gauze applied and taped, scab to right knee from prior fall remains intact, no other new injuries noted, continues to have various stages of bruising to chin, and thoracic from prior falls. The Nurse Note dated 12/19/2025 at 8:46 PM, revealed at 7:45 PM, called into Resident room, upon arrival resident sitting on floor, with body perpendicular to bed, watching TV. Resident had socks on both feet, resident reports that he slid out of his bed and onto the ground. The Nurse Note dated 12/21/25 at 00:45 PM, revealed at 00:20 AM called into resident's room, upon entering the room, resident was found sitting on the floor in an upright position on the floor next to the bed. Resident reports he was going to get up to his wheelchair and slid out of bed. Resident denies hitting his head, and no new injuries were located upon assessment. Resident has various stages of bruising to his chin, stomach, and extremities all due to prior falls.The Incident Reports reviewed for the falls above and lacked documentation of interventions put in place at the time of the fall. The Care Plan reviewed and lacked documentation of the falls or for any new/revised interventions for Resident #1. 2. The MDS assessment dated [DATE] revealed Resident #2 scored a 12 out of 15 on the BIMS exam, which indicated cognition moderately impaired. The MDS indicated resident used a walker and wheelchair and needed partial/moderate assistance with sit to standing; and chair/bed to chair transfer. The MDS revealed medical diagnoses for stroke, non-Alzheimer's dementia, and traumatic brain injury (TBI). The MDS indicated resident had 2 or more falls with no injury and 1 fall with injury, but not major injury since last assessment. The MDS indicated resident received insulin 7 out of 7 days and an anticonvulsant. The Care Plan revealed a focus area dated 1/17/25 for risk of falls related to gait/balance problems and ataxia. The interventions dated 1/17/25 indicated anticipate and meet the resident's needs; be sure the resident's call light within reach and encourage to use for assistance; and ensure resident wore appropriate footwear. The interventions revised on 10/16/25 revealed resident can be taken by staff for more supervision due to frequent falls and noncompliance to nurse station, around the building. The electronic health record (EHR) revealed the following Physician Order: Document behavior during shift r/t self-transfers, turning off alarms, etc.- two times a day dated 10/15/25The Nurses Note dated 12/11/25 at 6:02 PM, revealed at approximately 6:55 AM resident was standing in hallway waving at this nurse, with no wheelchair or walker. RN (Registered Nurse) requested assistance from NOC (night) nurse, who stood by resident while this nurse obtained WC (wheelchair). Resident was seated in WC and responded yes when asked if he was ready for breakfast. This nurse and NOC nurse then turned around, facing away from resident. This nurse then looked back at resident and witnessed him lying on LT (left) side, having active seizure. Upon reviewing camera footage, it is notable that resident began seizure while seated in wheelchair, causing resident to fall from chair and hit head.The Nurses Note dated 12/13/25 at 10:34 AM, revealed this nurse was notified by ADON (Assistant Director of Nursing) [name redacted] that resident was on the floor. upon entering room resident was sitting on the floor with his legs in front of him.The Nurses Note (late entry) dated 12/15/25 at 9:45 AM, revealed this nurse was called to resident's room by staff. Upon entering room, resident was seated on floor parallel to bed, with his head underneath bedside table. Upon assessment, it was noted that resident hit LT side of head AEB (as evidenced by) laceration to LT eyebrow. Steri strips applied. The Nurses Note dated 12/18/25 at 2:35 PM, revealed this nurse was notified by CNA [name redacted] that resident was on the floor. resident sitting in front of desk with legs stretched out in front of him. his wheelchair a few feet away from him flipped backwards.The Nurses Note dated 12/21/25 at 11:35 AM, revealed this nurse was called to resident room by CNA [name redacted], stating that resident was on the floor. Upon entering room resident was sitting on the floor in front of his closet, with his feet out in front of him, and back resting on the closet door with CNA at his side. Resident denies hitting head, no new injury noted, resident denies pain, does however have scattered bruising and scabbing amongst his legs/arms from numerous falls over the last two weeks. The Nurses Note dated 12/26/25 at 10:24 AM, revealed this nurse was called to residents' room by CNA [name redacted]. Resident was sitting on the floor with back against bed, feet out in front of him. Wheelchair facing towards bed on the right side of resident.The Nurses Note (late entry) dated 1/1/26 at 8:30 AM, revealed this nurse was exiting room [ROOM NUMBER] when I heard a crash from country kitchen. RN went into country kitchen to find resident seated on floor next to recliner, with alarm sounding. Resident stated he was attempting to get into WC when the chair tipped over. Recliner was sitting upright at this time.The Nurses Note dated 1/4/26 at 7:50 PM, revealed nurse got called to 100 Dining Room/Country Kitchen at 7:28 PM by CNA, Resident was found sitting on the floor. Resident states he was trying to get to his wheelchair, which was too far away. Resident attempted to get out of the chair in the dining room to walk to his wheelchair which was approximately 5 feet from the chair at the time.The Nurse Note (late entry) dated 1/12/26 at 7:40 PM, revealed at 7:40 PM called to resident room, upon arrival resident parallel to bed, back facing tv, front facing call light box on wall, resident standing on 2 feet pushing hands off of floor to stand up, CNA stating wait for the nurse she's coming resident continued to stand self-up and get back into bed while this nurse was walking into room, resident noted to only have pull up and socks on, upon assessment skin tear noted to right elbow, hematoma and swelling also noted to area, resident denied any pain to area, bruising noted to right buttock, wheelchair noted to be unlocked and up against recliner with shoes in wheelchair.The Nurses Note dated 1/20/26 at 5:57 PM, revealed this nurse was called to the Country Kitchen on 100 Hall. Resident was sitting on buttocks with back against recliner.The Nurses Note dated 1/26/2026 at 4:10 AM, revealed resident had unwitnessed fall in resident room at 4:10 AM, resident was found by CNA sitting on floor next to bed perpendicular to bed. Resident denies immediate pain or discomfort from the fall. Resident states he was trying to get to the bathroom.The Nurses Note dated 2/8/26 at 10:02 AM, revealed this nurse heard alarm sounding, upon entering room resident was sitting on the floor with feet facing the East wall. parallel with the bed. Bed was raised all the way up, resident stated he did that. This nursed called for help to assist resident to wheelchair.The Nurses Note dated 2/8/26 at 5:50 PM, revealed resident was sleeping at the start of this shift. This nurse was coming back from the dining room and heard alarm sounding. Upon entering the room resident was sitting on the floor.The Nurses Note dated 2/13/26 at 9:45 PM, revealed this nurse was called into resident room by CNA, resident found on floor below his TV sitting upright. Resident's bed alarm was going off, but unable to be heard by staff due to resident turning TV and [NAME] to unacceptable levels, resident did change bed height from low so he could get up by self.The Medication Administration Note dated 2/14/26 at 5:08 AM, revealed . resident was found in bed during shift change, where resident resided until around 9:30 PM last night, when CNA called this nurse into residents' room. Resident had unwitnessed fall d/t (due to) not utilizing call light, raising bed to unsafe level, TV and [NAME] at unacceptable levels, which muffled the bed alarms beeps, and transferring without the assistance of staff. The Nurses Note dated 3/1/26 at 6:45 AM, revealed this nurse was exiting room [ROOM NUMBER] when I heard an alarm sounding, resident was standing in the country kitchen between his recliner and wheelchair. resident started to grab his wheelchair before falling and landing on his right shoulder.The Nurse Note dated 3/1/26 at 2:50 PM, revealed this nurse was at the nurse's station when alarm started sounding, this nurse and CNA [name redacted] ran to resident's room. resident was sitting on the floor in front of his bed with his legs out in front of him.The No Type Specified dated 3/8/26 at 1:38 PM, revealed resident found sitting on floor next to bed, with resident's shoes on. with resident stating that he slowly sat down on the ground.The Nurses Note dated 3/13/26 at 9:21 PM, revealed this nurse was called to resident room by CNA, upon entering resident room resident was laying on his back on the floor, next to his bed. Resident denies having any pain, but is actively bleeding from a laceration on the back/top of his head d/t hitting head on bedside table.The Care Plan lacked new/revised interventions for all the falls noted above. 3. The MDS assessment dated [DATE] revealed Resident #3 scored a 6 out of 15 on the BIMS exam, which indicated that cognition severely impaired. The MDS indicated resident used a walker and needed supervision/touching assistance with sitting to stand and chair/bed to chair transfer. The MDS indicated medical diagnoses for Type I diabetic mellitus, non-Alzheimer's dementia, anxiety disorder, and depression. The MDS indicated 2 or more falls with no injury since last admission. The MDS revealed resident took insulin 7 out of 7 days, antidepressant, antipsychotic, antianxiety. The Care Plan revealed a focus area revised on 5/2/25 for risk for falls related gait/balance problems. The interventions dated 4/18/24 indicated make sure alarm is in place and functioning properly. The EHR revealed the following Physician Orders - check to make sure alarms are in place and working four times a dayThe Nurses Note dated 12/7/25 at 2:07 PM, revealed this nurse called to residents' room by a member of housekeeping stating that the resident was sitting on the floor next to bed. Upon entering the room resident was sitting on her bottom with her back against the bed.The Nurses Note dated 2/8/26 at 7:16 PM, revealed resident had witnessed fall in resident room, by CNAs. Resident was ambulating by self to door to close her door and fell when she let go of her walker to close the door. Resident did hit back of head on bedstand, had a laceration to back of head.The Incident Report dated 2/8/26 at 6:05 PM, revealed resident's chair alarm was not going off at the time of the fall.The Nurses Note dated 3/21/26 at 00:15 PM, revealed this nurse found the resident found sitting upright on floor beside bed, with emesis all over resident's clothes and ground in front of resident. Resident denies hitting head and refers to getting out of bed via sliding instead of standing and falling. Resident's bed alarm was plugged in and working but wasn't going off when resident was found on the floor. Resident unable to state when emesis or fall occurred.During an interview on 4/1/26 at 9:26 AM, the MDS Coordinator/RN queried on Resident #1 and fall interventions and the MDS Coordinator stated Resident #1 was not always compliant and was able to transfer himself into his wheelchair at one point. The MDS Coordinator stated Resident #1 would scoot himself over in bed and then would be on the floor. The MDS Coordinator stated the facility used education, call light in place and an appropriate mattress as fall interventions. During an interview on 4/1/26 at 9:26 AM, the MDS Coordinator/RN queried on what the process is after a fall occurred and the MDS Coordinator stated the nurse did the report and intervention for the incident report and assessed the situation. The MDS stated a lot of time the intervention was reeducation. The MDS Coordinator queried on who can update the care plan and the MDS Coordinator stated she used one day a week and updated care plans for the residents who had MDS coming up and had triggered items. The MDS asked if she attended the morning meetings and the MDS Coordinator stated she worked part time and not the person who addressed the falls on the care plan to see if the residents needed new interventions. The MDS Coordinator stated she did not go back and see how many falls residents had or if they had interventions in place. During an interview on 4/1/26 at 9:26 AM, the MDS Coordinator/RN queried on Resident #3 fall interventions and the MDS Coordinator stated Resident #3 had the call light within reach, alarms, and everything Resident #3 needed around her. During an interview on 4/1/26 at 9:26 AM, the MDS Coordinator/RN queried on Resident #2 multiple falls and the MDS Coordinator stated Resident #2 was an interesting soul. The MDS Coordinator stated Resident #2 was pretty much a 1:1 and not compliant with a lot of anything. The MDS Coordinator stated there was not a lot the facility could do for him. The MDS Coordinator stated she worked a couple of evening shifts and pretty much sat at his door. The MDS Coordinator stated the staff would sit Resident #2 in the country kitchen and give him a bell, make sure he had food and drink to keep an eye on him. The MDS Coordinator stated she didn't know what else the facility could do for Resident #2 except for what they have already done. During an interview on 3/31/26 at 4:26 PM, Staff A, Licensed Practical Nurse (LPN) queried on any issues with alarms with Resident #3 and Staff A stated yes, a few times. Staff A stated the alarms were plugged and the facility used two different alarms. Staff A stated one alarm was white and the other one brown. Staff A stated the white alarm had a red light that told you it was working and the brown one would beep, but had a tendency to have a delayed response or doesn't go off. Staff A stated he tried replacing the brown alarms with the white box. Staff A stated the Director of Nursing (DON) aware and told him to use the white box. Staff A queried on the interventions for Resident #3 and Staff A stated using alarms and Resident #3 room was near the nurse's station. During an interview on 3/31/26 at 4:26 PM, Staff A, LPN queried on Resident #2 fall interventions and Staff A stated Resident #2 was usually a 1:1 with med pass. Staff A stated Resident #2 confused at baseline and thinks he can walk by himself. Staff A stated staff kept Resident #2 wheelchair close to the bed so he didn't have to walk along with the urinal and call light. Staff A stated Resident #2 usually got up between 2-3 AM and then didn't have a good explanation on why Resident was on the floor.During an interview on 4/1/26 at 10:02 AM, Staff B, LPN queried on what the nurse does after the fall and Staff B stated the staff tried to figure out the cause or an intervention. Staff B queried how an intervention was relayed to other staff and Staff B stated through spot charting in the progress note and passed on in report. During an interview on 4/1/26 at 10:02 AM, Staff B, LPN queried on fall interventions for Resident #2 and Staff B stated redirection, sitting Resident #2 in the recliner in the country kitchen to keep closer eye on him, engage in an activity. Staff B asked if Resident #2 needed 1:1 supervision and Staff B stated not necessary a lot and it depended on the day. Staff B stated sometimes Resident #2 had great days and other days, Resident #2 up and down a lot. During an interview on 4/1/26 at 10:02 AM, Staff B, LPN queried on where the fall interventions were found and Staff B stated she was sure there was a spot for interventions. Staff B asked if floor nurses could update the care plans and Staff B stated she was not 100% sure. Staff B stated the nurses could go into risk management and review the incident reports, but wasn't sure about the care plans. Staff B stated she thought the facility said something about nurses adding to the care plan if needed.During an interview on 4/1/26 at 10:25 AM, Staff C, CNA queried on where to find the fall interventions and Staff C stated usually with communication with the nurses or the Kardex. During an interview on 4/1/26 at 10:39 AM, Staff D, CNA queried on where to locate fall interventions and Staff D stated she spoke to the other CNAs and the nurses who had more interactions with the residents. Staff D stated she was the bath aide and did not do rounding and didn't know when residents fell unless other staff told her. During an interview on 4/1/26 at 11:02 AM, the Director of Nursing (DON) queried on the management process after a fall and the DON stated her and the Administrator read through the incidents and signed off on them. The DON stated the MDS Coordinator reviewed care plans every week and interventions. The DON asked when the care plan needed updated for falls and the DON stated ideally when the fall occurred. The DON queried on interventions with Resident #2 and the DON stated they tried everything under the sun like activities, alarms, and sign in his room for reorientation. During an interview on 4/1/26 at 11:07 AM, the Administrator stated they talked about falls at the daily meetings and if any issues and interventions. The Administrator stated it was hard to find interventions for resident who fell all the time. The Administrator stated recently the facility supervised Resident #2 at a higher level and educated staff to check on him more often. During an interview on 4/1/26 at 11:07 AM, the Administrator queried on the chair alarms not working properly for 2 falls with Resident #3 and the Administrator stated on the Medication Administration Record, it showed the alarms working properly. The Administrator stated she wasn't sure why they didn't go off and staff needed to be checking them. The Administrator queried if the facility did a root cause analysis and the Administrator stated no, not on paper. The Administrator stated they went through and talked about it. The Administrator stated the facility stepped up their game and reviewed 2 months of Resident #2 falls and seen who was working and the time of day and if that was the root cause analysis, they did do that. During an interview on 4/1/26 at 12:17 PM, the ADON queried if she attended morning meetings and the ADON stated yes. The ADON stated they review the falls and try to find the root cause but Resident #2 was so unpredictable. The ADON asked where the conclusion of the root cause was found and the ADON stated she felt the most of the falls happened at night and the staff couldn't get to Resident #2 fast enough. The ADON asked about fall interventions for Resident #2 and the ADON stated she didn't know what else the facility could do except for a 1:1 at all times. During an interview on 4/1/26 at 12:35 PM, the DON stated they did review the falls and see if any patterns and she wasn't sure if interventions like being in a more common place, bell he can ring were on the care plan or not. The DON stated she had not personally put interventions in for falls, but should be done when the fall happens. The DON asked what she did after reviewing the fall on the risk management and the DON stated she didn't have a solid answer for that. During an interview on 4/1/26 at 12:35 PM, the DON asked what conclusion did they have for the alarms not going off and the DON stated she couldn't tell me 100%. The DON stated she didn't know the immediate action and the nurses were supposed to put an immediate intervention. The DON stated she was confused because the checking the alarms were checked off every day. The DON stated she did not go and personally check the alarms or ask if someone shut it off, or maybe the resident slid off the bed with the pad. The DON stated she didn't specifically interview the nurse after it happened. During an interview on 4/1/26 at 12:35 PM, the DON stated the nurses on the floor can add to the care plan and were supposed to update the care plans after the falls. The Facility Resident Fall Procedure (no date identified) revealed:Resident Fall Procedure.post fall intervention in your progress notes within 1 hour of the fallPost Fall Intervention Suggestions .Make sure these are resident specific and appropriate

Based on staff interview, clinical record review, and facility policy review, the facility failed to provide notification of resident discharge/readmission status to a Long Term Care Ombudsman for 3 of 3 residents (Resident #2, Resident #8, and Resident #38) reviewed for discharge process. The facility reported a census of 34 residents. Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 7/25/25, revealed Resident #2 was unresponsive, or unable to complete Brief Interview for Mental Status (BIMS). Resident #2 required full dependance on staff assistance for care needs. The list of diagnoses included anoxic brain damage, quadriplegia (loss of movement to all extremities), and epilepsy. Review of Resident #2's Electronic Health Records (EHR) revealed a list of MDS assessment completed, in part: a. On 4/13/25, a Discharge- return anticipated, assessment was completed. b. On 4/23/25, an Entry assessment was completed. c. On 5/18/25, a Discharge- return anticipated, assessment was completed. d. On 5/24/25, an Entry assessment was completed. 2. Review of the MDS assessment, dated 7/11/25, revealed a BIMS score of 15 out of 15, which indicated intact cognition. The list of diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, chronic respiratory failure with hypoxia, and seizure disorder. Review of a General (nursing) note, dated 8/01/25 at 4:46 PM, revealed that a verbal order was received from provider to send Resident #8 to the emergency department to evaluate hypoxia (low oxygen levels) and at 7:29 PM, the family was notified that Resident #8 returned to the hospital. Review of a Long Term Care (LTC) Evaluation note, dated 8/04/25 at 10:56 PM, documented the reason for evaluation was for 72 hour post hospital stay. Review of Resident #8's Electronic Health Records (EHR), lacked MDS assessment completed for discharge to the hospital on 8/01/25, and further lacked completion of an entry assessment upon return to the facility, from the hospital, on 8/04/25. Review of Resident #8's EHR revealed a list of completed clinical nursing assessments, which included a Transfer Form, dated 8/01/25, for discharge to the hospital. 3. The MDS assessment, dated 6/10/25, revealed Resident #38's list of diagnoses included congestive heart failure (CHF), acute respiratory failure with hypoxia, and atrial flutter. Review of Resident #38 EHR, revealed an admission date of 5/30/25 and a discharge date of 6/10/25. Review of Resident #38's EHR revealed a list of completed clinical nursing assessments, which included a Transfer Form, dated 6/10/25, for discharge to the hospital. Review of a General (nursing) note, dated 6/10/25 at 7:16 PM, documented that Emergency Medical Services (EMS) left facility with Resident #38 at 7:15 PM and were given Transfer Form, resident's order summary, and face sheet. The note revealed that physician was made aware of resident's transfer to the hospital. Review of a General note, dated 6/17/25 at 5:06 PM, revealed hospital updated facility that Resident #38 would be transferring to another facility. Review of an electronic mail (email), sent by facility administrator on 8/20/25 at 3:19 PM, stated that the only Ombudsman notification list of residents discharged for the year 2025, had been completed for April 2025. Review of an email, sent by facility administrator on 8/20/25 at 3:27 PM, stated that the April 2025, Ombudsman notification list was found to be blank. During an interview on 8/25/25 at 10:03 AM, the Business Office Manager confirmed she sent the Ombudsman Notifications and she forgot to do them this year. The Business Office Manager stated she knew they needed to be done and it was her fault the notifications did not get completed. Review of the facility policy, titled Discharging a Resident Procedure, revised on 8/06/2018, lacked step for Ombudsman notification of resident discharge.

Based on clinical record review, facility policy review, resident family and staff interview, the facility failed to notify a family member prior to a chest x-ray being performed and failed to notify the physician a resident returned to the facility after hospitalization in a timely manner for 2 of 2 residents (Resident #18 and Resident #8) reviewed for notifications. The facility reported a census of 34 residents. Findings include: 1. The Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #18 scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The MDS listed a medical diagnosis of traumatic brain injury. Review of the electronic health record (EHR) Nurse Note dated 8/8/25 at 8:32 AM, revealed [name redacted] provider in house, gave verbal orders for chest X-ray due to residents increased coughing and congestion. Review of the X-Ray Report dated 8/8/25 at 11:02 AM indicated: a. Impressions: 1. Exam: 2 views of the chest; 2. Indication: Increased cough; 3. comparison: no prior radiograph; 4. Findings/Impression: Chronic fracture at the posterior aspect of the right fourth and fifth ribs. No cardiomegaly. No pneumonia. No definite pleural effusion. Calcification thoracic aorta. Streaky opacity at the left lung base representing infiltrate versus atelectasis. Mild increase in bilateral interstitial opacities. Review of a Provider Progress Note dated 8/11/25 at 8:44 AM revealed an order for a Z-pak (azithromycin- antibiotic). A Provider Progress Notes dated 8/12/25 at 11:07 AM, documented Z-pak ordered. Review of a Nurse Note dated 8/16/25 at 11:19 AM, revealed spoke with daughter [name redacted], wants Z pack DC (discontinued) as she states resident doesn't need it, will notify provider During an interview on 8/18/25 at 2:30 PM, the family representative stated the facility had not called her and updated her on a few things concerning Resident #18. The family member stated 2 weeks ago Resident #18 had a cough and the facility did a chest x-ray and the family member did not become aware of the chest x-ray until the facility called to inform her of the order for antibiotics after the antibiotics were started. During an interview on 8/21/25 at 12:24 PM, Staff E, Licensed Practical Nurse (LPN) queried on who conducted family notifications and Staff E stated the nurse who puts in the order. Staff E asked about Resident #18 chest x-ray order and Staff E stated the daughter came in and told Staff E the daughter did not get notification of her dad's chest x-ray and didn't want Resident #18 on antibiotics. Staff E stated the facility policy was to notify the family with any new medication orders or changes. During an interview on 8/21/25 at 3:00 PM, Staff F, LPN queried on family notifications and Staff F stated the nurse on shift made the calls to the families. Staff F stated she typically stayed over to make her family notification calls and documented them. Staff F stated she received the order for Resident #18 chest x-ray as she walked out the door in the morning because Staff F saw the provider. Staff F stated the day nurse was supposed to notify the family because Staff F was ending her shift. During an interview on 8/25/25 at 9:49 AM, the Director of Nursing (DON) queried on which staff notified the family of changes and the DON stated she notified the family as she put the orders in. The DON stated the nurse needed to document family notification and the facility was working on educating the nurse to do more documentation. The DON stated she expected nursing staff to notify the families of changes and document when completed. During an interview on 8/25/25 at 11:01AM, the Administrator confirmed Resident #18 family was not notified of the chest x-ray. The Administrator stated the night shift nurse received the order and the day shift nurse was supposed to call the family and the task was not completed. 2. Review of the MDS assessment, dated 7/11/25, revealed Resident #8 with a BIMS score of 15 out of 15, which indicated intact cognition. The list of diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, chronic respiratory failure with hypoxia, seizure disorder, and anxiety disorder. Review of a the EHR revealed a Nurses noted entered on 8/1/25 at 5:03 PM Late Entry: Verbal orders received from [name redacted, provider] to send resident to ED (emergency department) to evaluate for hypoxia (low oxygen). EMS (emergency medical services) en route to the facility at this time. Review of a LTC Evaluation note, dated 8/04/25 at 10:56 PM, documented the reason for the evaluation was for 72-hour post hospital stay. The note revealed that Resident #8's lung sounds were diminished in the front and back lobes and identified that Resident #8 had a small pneumothorax (collapsed lung) to the left lung, without placement of chest tube, due to small size. The note revealed that Resident #8 had a displaced rib fracture to the left chest and had complaints of pain in left ribs, was given narcotic (oxycodone) medication due to non-pharmacological pain relief. The note documented that Resident #8 also received treatment in the hospital for pneumonia (lung infection). Review of a LTC Evaluation note, dated 8/05/25 at 11:40 PM, revealed that Resident #8 had difficulty breathing, shortness of breath, and used abdominal muscles to breath. The note documented that Resident #8 had a moist, loose cough with moderate amount of secretions produced. Review of a General (nursing) note, dated 8/06/25 at 5:01 AM, documented that discharge orders were found in Resident #8's bag from the hospital with new orders received to start azithromycin (antibiotic) two tablets for one day, cefuroxime (antibiotic) one tablet twice a day for one day, Prednisone (anti-inflammatory) 20 milligrams (mg), 1 tablet for 3 days, and ipratropium-albuterol nebulizer treatment 4 times daily. The note documented that Resident #8 was made aware of these orders. Review of a hospital discharge summary, printed on 8/04/25, revealed the following instructions listed, in part: a. Patient to return to nursing facility. b. Start to take oral cefuroxime 500mg, with instructions to give 1 tablet two times a day, for one day, to be taken on 8/05/25. c. Start to take oral azithromycin 250mg, with instructions to give 2 tablets one time a day, for one day, to be taken on 8/05/25. d. Start to take oral prednisone 20mg, with instructions to give 1 tablet one time a day for 3 days, to be started on 8/05/25. e. Start to take Ipratropium Albuterol 0.5mg-2.5mg per 3 milliliters (mL) inhalation solution, with instructions to inhale 3mL four times each day, to be started on 8/04/25. The hospital discharge summary revealed a handwritten nursing signature, dated 8/06/25, which noted when the new orders were received. Review of Resident #8's Medication Administration Record (MAR), dated between 8/01/25 and 8/21/25, documented, in part: a. Azithromycin 250mg: Date of administration recorded on 8/06/25. b. Cefuroxime 500mg: Date of administration recorded on 8/06/25. c. Prednisone 20mg: Dates of administration recorded on 8/06/25, 8/07/25, and 8/08/25. d. Ipratropium-Albuterol inhalation solution 0.5mg-2.5mg per 3mL: Order start date: 8/06/25. Review of Resident #8 EHR's lacked physician notification of hospital discharge orders not started on 8/05/25, as ordered, but instead started and administered on 8/06/25. During an interview, on 8/21/25 at 3:05 PM, Staff F, Licensed Practical Nurse (LPN), confirmed working with Resident #8 on 8/06/25 and recalled Resident #8's hospital discharge orders were found in a bag in his room. Staff F stated she entered in the discharge orders to start right away and was unable to recall if the orders had any specific start date. Staff F denied notification sent to Resident #8's primary care provider eue to the orders that were found, were from a hospital provider. During an interview, on 8/21/25 at 3:55 PM, Staff G, Registered Nurse (RN), confirmed working with Resident #4 on 8/04/25, and recalled assessing Resident #8's respiratory status following return from the hospital but denied completing any re-admission paperwork or assessments upon his return to the facility. Staff G stated resident admissions were typically completed by office staff, but that recently floor nursing staff were being trained on how to complete admissions. Review of the undated facility policy titled, Routine Documentation directed, in part: Complete and thorough documentation is key to providing quality patient care. All important information needs to be documented in [name redacted] as a Progress Note (Nurse Note) so that it can be pulled to the 24 hour/72 hour report for shift report, supervisory review, and overall patient care review. Many instances justify documentation, whether it be something out of the norm, new/changed/worsening condition, monitoring, conversation with provider or family, etc. Below you will find a list of some things that should be documented, though this is not inclusive. If you didn't document it, it didn't happen and it's not realistic to think you will be able to remember 5 months (or years) from now. If in doubt, put a note in! a. Communication with provider (and outcome, orders, etc.) b. Communication with family (and questions or concerns addressed, needing to be addressed, follow up needed, etc.)

Based on staff interviews, record review, and the facility policy, the facility failed to care for a resident in a dignified manner by not emptying her bedside commode after providing toileting assistance for 1 of 3 residents reviewed for dignity. The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated Resident #40 dependent with toileting hygiene and chair/bed to chair transfer. The MDS revealed Resident #40 occasionally incontinent of bladder and always continent of bowel. Review of the Care Plan revealed a Focus area dated 11/7/24 for needed assistance with Activities of Daily Living (ADL's) related to Chronic Obstructive Pulmonary Disease (COPD) which places me at risk for falls/injury. The Interventions dated 10/23/24 included Resident #40 used a mechanical lift with a 2 assist with all transfers and dependent with assist x 1 with wheelchair mobility . During an interview on 8/21/25 at 10:46 AM, Staff A, Certified Nurse Aide (CNA) queried if she ever noticed the bedside commode in Resident #40 room not emptied after use and she stated sometimes she noticed it in the mornings. Staff A explained she would empty it after third shift. Staff A stated she didn't know if the Director of Nursing (DON) or the Administrator knew about it. During an interview on 8/21/25 at 10:59 AM, Staff B, CNA queried if she ever noticed the bedside commode in Resident #40's room not emptied after use and she stated at least one time when she came into work in the morning. Staff B stated Resident #40 had the call light on and when Staff B walked in the room and noticed. Staff B stated Resident #40 aware of the bedside commode not been emptied and commented about it, so Staff B made sure to take care of it. During an interview on 8/21/25 at 2:23 PM, Staff C, CNA queried about Resident #40 bedside commode not being emptied and she stated when she came into work, the bedside commode would still have urine and bowel in it. Staff C stated she told the nurses at least 3 times, but didn't remember which ones. During an interview on 8/25/25 at 9:36 AM, the DON queried if she knew about Resident #40 bedside commode not being emptied and the she stated she had never been told it was an issue. The DON stated she didn't see it happening because the DON and Administrator made frequent trips in the hall and they would smell it. The DON stated it is the expectation that after a bedside commode is used, it is removed and immediately cleaned. During an interview on 8/25/25 at 10:10 AM, Staff D, CNA queried on Resident #40 bedside commode not being emptied and she stated yes. Staff D explained the bedside commode had been used and not cleaned multiple times by different staff members. She stated she did not tell a nurse as in the past when she told a nurse of a concern nothing was done. Staff D stated two out of the three days in a week Staff D worked, she noticed the bedside commode not being emptied when she worked Resident #40 hall. Staff D stated she never told the DON or Administrator. During an interview on 8/25/25 at 11:04 AM, the Administrator informed of the interviews concerning the bedside commode and the Administrator stated she didn't remember anyone telling her about the issue. The Administrator stated if it happened, she didn't understand why the staff didn't report it to her so she could address the issue. The Facility Resident Rights Policy dated 12/12/16 revealed: a. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, policy review, and staff interviews, the facility failed to address the use of anxiolytics(medications used to treat anxiety) on the Care Plan, and the use of non-pharmacological interventions staff should attempt prior to administration for 1 of 5 residents reviewed for medications (Resident #31). The facility reported a census of 32 residents. Findings: The Minimum Data Set(MDS) assessment tool, dated 6/4/24, listed diagnoses for Resident #31 included generalized anxiety disorder, chronic pain, and hypertension(high blood pressure). The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. The undated facility policy PRN (as needed) Medication Use, directed staff to document non-pharmacological interventions prior to administration such as relaxation, repositioning, and food/beverages. The July and August 2024 Medication Administration Records(MARS) listed a 7/25/24 order for lorazepam (an anxiolytic) 0.5 milligrams(mg) every 8 hours as needed for anxiety. The MAR documented the resident received the medication at the following times: 7/25/24 10:45 p.m. 7/26/24 9:23 p.m. 7/27/24 2:25 p.m. 7/27/24 10:32 p.m. 7/28/24 1:30 p.m. 7/30/24 7:15 a.m. 7/30/24 8:55 p.m. 7/31/24 8:19 p.m. The facility lacked documentation of non-pharmacological interventions carried out prior to the above administrations. The resident's Care Plan, as of 8/28/24, did not address the resident's anxiolytics or direct staff to attempt non-pharmacological interventions prior to the administration of prn anxiolytics. On 8/28/24 at 2:51 p.m. the Administrator stated staff should document 3 non-pharmacological interventions prior to the administration of an anxiolytic. On 8/29/24 at 7:52 a.m., Staff A Registered Nurse(RN) stated staff attempted three interventions prior to the administration of a PRN anxiolytic. On 8/29/24 at 12:00 p.m., the Administrator stated they worked on Care Plans this week and inquired as to which medications needed to be included.

Based on observation, clinical record review, and staff interview, the facility failed to ensure only residents able to safely self-administer medications had access to medications for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 32 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 6/7/24, listed diagnoses for Resident #5 included traumatic brain dysfunction, anxiety, and morbid obesity and listed the resident's Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. A 4/8/21 Care Plan entry stated the resident had impaired thought processes due to traumatic brain injury. The August 2024 Medication Administration Record(MAR) listed a 5/7/22 order for chlorhexidine gluconante solution (a physician ordered medicated oral rinse used to prevent infections) one time per day. The resident's clinical record lacked documentation the resident could safely self-administer her medications. During an observation on 8/26/24 at 2:13 p.m., a bottle of chlorhexidine gluconate solution sat on the sink in the bathroom while the resident was in her room. A label on the bottle directed staff to keep out of the reach of children. On 8/26/24 at 2:13 p.m. the acting Director of Nursing(DON) stated the mouthwash should be in a lock box and stated she would lock it up. She stated staff most likely took it out and used it and forgot to put it back in. Via email correspondence on 8/29/24 at 1:05 p.m., the Administrator stated she could not locate a policy regarding the self-administration of medications.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to respond to call lights in a timely manner for 1 of 2 residents reviewed for staffing concerns(Resident #135). The facility reported a census of 32 residents. Findings: The 8/15/24 Brief Interview for Mental Status(BIMS) evaluation listed Resident #135 score as 15 out of 15, indicating intact cognition. An 8/12/24 Care Plan entry stated the resident required assistance with activities of daily living(ADLs). The facility All Alarms Report for the time period of 8/21/24 to 8/28/24 revealed call light response times for Resident #135 which exceeded 15 minutes: 8/21/24 24 minutes 8/21/24 22 minutes 8/22/24 17 minutes 8/23/24 26 minutes 8/24/24 41 minutes 8/24/24 23 minutes 8/25/24 17 minutes 8/25/24 22 minutes 8/26/24 17 minutes 8/27/24 19 minutes On 8/26/24 at 2:51 p.m. Resident # 135 stated it too staff 20 minutes to respond to her call light when she had to go to the bathroom. On 8/29/24 at 11:41 a.m., the resident stated she had a clock on the wall to time staff call light response time. On 8/29/24 at 12:00 p.m., the Administrator stated staff should respond to call lights as close to 15 minutes as possible. The undated facility policy Answering the Call Light, directed staff to answer call lights within 15 minutes.

Based on clinical record review, policy review, and staff interviews, the facility failed to document non-pharmacological interventions carried out prior to the administration of as needed (PRN) anxiolytics(medications used to treat anxiety) for 1 of 1 residents reviewed with PRN anxiolytics(Resident #31). The facility reported a census of 32 residents. Findings: The Minimum Data Set(MDS) assessment tool, dated 6/4/24, listed diagnoses for Resident #31 which included generalized anxiety disorder, chronic pain, and hypertension(high blood pressure). The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 12 out of 15, indicating moderately impaired cognition. The July and August 2024 Medication Administration Records(MARS) listed a 7/25/24 order for lorazepam(an anxiolytic) 0.5 milligrams(mg) every 8 hours as needed for anxiety. The MAR documented the resident received the medication at the following times: 7/25/24 10:45 p.m. 7/26/24 9:23 p.m. 7/27/24 2:25 p.m. 7/27/24 10:32 p.m. 7/28/24 1:30 p.m. 7/30/24 7:15 a.m. 7/30/24 8:55 p.m. 7/31/24 8:19 p.m. The facility lacked documentation of non-pharmacological interventions carried out prior to the above administrations. The resident's Care Plan did not address the resident's anxiolytics or direct staff to attempt non-pharmacological interventions prior to the administration of PRN anxiolytics. On 8/28/24 at 2:51 p.m. the Administrator stated staff should document 3 non-pharmacological interventions prior to the administration of an anxiolytic. On 8/29/24 at 7:52 a.m., Staff A Registered Nurse(RN) stated staff attempted three interventions prior to the administration of a PRN anxiolytic. The undated facility policy PRN Medication Use, directed staff to document non-pharmacological interventions prior to administration such as relaxation, repositioning, and food/beverages.

Based on clinical record review, staff interview, facility policy review, the facility failed to offer the pneumococcal vaccine at the recommended times for 2 of 5 residents reviewed for Pneumococcal vaccinations (Residents # 13, #26). The facility reported a census of 32 residents. Findings include: 1. Resident #26's Immunization record stated the resident received the PCV13 (Pneumococcal conjugate vaccine) on 10/18/2016 and the PPSV23 (Pneumococcal polysaccharide vaccine) on 10/31/2012. The record stated the resident was [AGE] years old. 2. Resident #13's Immunization record stated the resident received the PCV13 Pneumococcal vaccine on 12/16/2018 and the PPSV23 Pneumococcal vaccine on 9/8/2010. The record stated the resident was [AGE] years old. The facility showed no documentation they offered the Pneumococcal vaccine. The Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, retrieved from https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf on 8/29/2024 contained the following guidance: For adults [AGE] year or older who: a. Shared clinical decision-making for those who already completed the series with PCV13 and PPSV3: b. Prior Vaccines: Completed series: PCV13 at any age and PPSV23 at greater or equal to 65 yrs. c. Shared clinical decision-making option: For greater or equal to 5 years PCV20. Together, with the patient, vaccine providers may choose to administer PCV20 to adults equal or greater [AGE] years old who have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. During an interview on 8/29/2024 at 11:00 AM, the Administrator stated she did not realize, Iowa Immunization Registry Information System (IRIS), had two Pneumococcal 23 vaccination listed for the same date on both of the residents, resulted with completion of series according to IRIS. The facility policy Policy and Procedure: Subject: Influenza, Pneumococcal, and COVID Immunization, reviewed 2/8/24, stated Residents will be offered the influenza vaccine and education yearly during the flu season and the Pneumococcal and COVID vaccination will be offered on admission, following the current CDC or Iowa Department of Public Health. Education for all vaccination's will be provided.

Based on staff interviews, record review, and the facility policy, the facility failed to complete the neuro assessments after an unwitnessed fall for 1 of 3 residents reviewed for assessment and intervention (Resident #1). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed resident dependent with toileting hygiene, and partial/moderate assistance with bed to chair transfer. The MDS revealed diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety. The MDS revealed the resident took opioids and used bed and chair alarms daily. The Care Plan revealed a focus area dated 1/10/24 that the resident had moderate risk for falls related to unaware of safety needs. The interventions dated 3/25/24 revealed fall intervention for a fall on 3/23/24 the resident will have physical therapy/occupational therapy evaluation and treat. The Physician Orders revealed the following medication orders: a. Tramadol HCL oral tablet 50 mg - Give 0.5 mg tablet by mouth three times a day for pain, give with Tylenol 500 mg at 7 AM/1 PM/6 PM - ordered on 10/6/23 and discontinued on 3/27/24 b. per [name redacted] on call provider- send the resident to emergency room (ER) for evaluation of pain with transfers following fall yesterday- start date 3/24/23 c. Tramadol HCL oral tablet 50 mg- give 1 tablet by mouth every 6 hours for pain- ordered on 3/26/24 with start date of 3/27/24 d. Calcitonin nasal solution - 1 spray alternating nostrils one time a day for pain alternate nostrils with each dose- ordered on 3/26/24 with start date of 3/27/24 The Progress Note dated 3/23/24 at 4:20 PM (late entry-documented on 3/24/24 at 12:18 PM) revealed the following information: a. Fall Details: Date/Time of fall: 3/23/24 at 4:20 PM: b. Fall not witnessed. The fall occurred in the resident's room. c. Activity at the time of fall: Resident moved self from piano bar into room without staff assistance and attempted to toilet self. d. Reason for the fall was evident. e. Did an injury occur as a result of the fall: No. f. Did fall result in an ER (emergency room ) visit/hospitalization : No. g. Provider: [name redacted] Time notified: 03/23/2024 h. Notified of Fall: Fall Details Note:Resident previously been in piano bar watching peers play cards. She proceeded to wheel self to room, closed door and attempted to transfer self to toilet. CNA (Certified Nurse Aide) [name redacted] found resident on floor with alarm sounding, sat in the middle of the room upright. This nurse called to room and resident laughed, sat upright in the middle of the floor. When asked what happened resident laughed and said I was hanging onto the bed, then I was on my butt. i. Contributing Factors: 1. Recent change in environment: No. 2. Was fluid spilled on floor: No. 3. Clutter present on the floor: No. 4. Floor mat was on floor: No. 5. Poor lighting in the area: No. 6. Bed was at an improper height: No. 7. Other furniture involved: Yes. Wheelchair was involved in the fall. Wheelchair unlocked at time of fall. Wheelchair footrest(s) were not in the way at the time of fall. 8. Wearing glasses at the time of the fall: Yes. 9. Footwear at time of fall: Shoes. Resident didn't use cane/walker as instructed. Resident used incontinence supplies at the time of the fall. 10. Incontinent at time of fall: No. 11. Bedside call light on when resident found: No. 12. Bathroom call light on when resident was found: No. 13. Personal alarm sounding when resident found: Yes. 14. Other residents were not involved in fall. j. Contributing factors note: 1. Resident utilized bed as support rather than walker. The Progress Note dated 3/23/24 at 4:20 (late entry- documented on 3/24/24 at 12:30 PM) revealed this nurse called to resident's room by CNA. This nurse entered room and resident sat upright in the middle of the room laughing. When asked what happened, resident laughed and stated I was hanging onto the bed, then I was on my butt. The resident denied pain, ROM (Range of Motion) intact following incident. Resident denied hitting head, no evidence indicating otherwise, but neuro's initiated per protocol. Resident assisted back to chair and had no further problems through the shift. The Neuro Assessment V3-V2 report revealed the following dates and times the neuro assessment not completed for the unwitnessed fall on 3/23/24 at 4:20 PM : a. second 15 minute check- resident not available for assessment due to resident at supper eating b. third 15 minute check- resident not available for assessment due to resident at supper eating c. fourth 15 minute check- resident not available for assessment due to resident at supper eating d. second 30 minute check- lacked documentation e. first hourly check- lacked documentation f. second hourly check- lacked documentation g. third hourly check- lacked documentation h. fourth hourly check- lacked documentation i. first 4 hour check- lacked documentation j. second 4 hour check- lacked documentation k. third 4 hour check- lacked documentation l. fourth 4 hour check- lacked documentation m. first 8 hour check- resident not available for assessment due to resident dined at breakfast n. third 8 hour check- dated 3/24/24 at 8:00 PM- lacked additional documentation o. fourth 8 hour check- dated 3/24/24 at 4:00 AM- resident not available due to resident in bed rested peacefully. During an interview on 4/1/24 at 10:54 AM, Staff B, LPN (Licensed Practical Nurse) queried on the neuro check assessment and she stated the neuro's charted under the assessments. Staff B stated when the resident at supper she didn't complete the neuro checks because nothing indicated she hit her head and didn't complain of a headache and nothing by her when the resident sat on the floor after the fall. During an interview on 4/1/24 at 1:52 PM, Staff A, LPN queried on the neuro checks for Resident #1 after the fall on 3/23/24 and she stated she knew about the fall and was told the resident didn't hit her head. Staff A stated she planned on doing the neuro checks but they didn't happen. She stated she looked at the times and was on the other side of the building administering medications and the times passed. She stated she thought only one or two of the neuro assessments needed during her shift. During an interview on 4/2/24 at 11:57 AM, Staff D, LPN queried on the protocol for an unwitnessed fall and she stated she looked at the resident's BIMS and if the BIMS low they started neuro assessments whether or not they thought the resident hit their head. Staff D asked if she conducted neuro checks when the resident was at meals and she stated yes she did unless the resident refused and she charted the resident refused. Staff D stated she woke the resident up for neuro checks unless she received an order not to wake them. During an interview on 4/2/24 at 3:28 PM, the DON (Director of Nursing) queried on the process for an unwitnessed fall and she stated if the BIMS less than 13, the nurses automatically started neuro assessments. The DON confirmed she reviewed the neuro assessment for the fall on 3/23/24 and saw all of neuro assessments not completed. The DON queried on her expectation of the neuro assessments and she stated the neuro assessments offered to the residents, but not pulled away from meals and if the assessment can wait to do it after the meal, and if the results were not normal, notify the provider. The Facility Neurological checks for head injuries policy/procedure dated 1/22/18 revealed the following information: a. Assess resident for changes in level of consciousness immediately after striking the head, then frequently throughout the shift for at least 72 hours. b. Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions; confusion, memory loss, difficulty speaking, gait or balance problems, pupils of unequal size or reactions, headache, vomiting, visual disturbances, or periods of coherence, alternating with periods of confusion or lethargy. c. Perform frequent neurological assessment every: 1. 15 minutes for 1 hour 2. 30 minutes for 1 hour 3. 1 hour for 4 hour 4. 4 hours for 16 hours 5. 8 hours until 72 hours elapsed and resident stable d. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure; assessment of pupil size and reactivity, equality of hand grip strength, lower extremity motor functions, and pain level. The Facility Resident Fall Procedure (no date included) revealed the following information: a. If unwitnessed and/or resident hit their head, initiate neuro checks 1. A neuro check schedule sheet placed in the bottom filing drawer in Nurse Station B that helped establish time schedule for neuro checks, but they needed to be documented in EMR (Electronic Medical Record) also 2. Open up the Neuro Assessment under the assessment tab on the EMR for documentation of the vitals/assessments.

Based on interviews, record review, and the facility policy, the facility failed to ensure the resident was supervised in her room while in a wheelchair which resulted in a fall for 1 of 4 residents reviewed for inadequate nursing supervision (Resident #1). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed resident dependent with toileting hygiene, and partial/moderate assistance with bed to chair transfer. The MDS revealed diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety. The MDS revealed the resident took opioids and used bed and chair alarms daily. The Care Plan revealed a focus area revised on 3/22/24 for assistance with ADLs (Activities of Daily Living) related to dementia, incontinence, pain, medication use that placed the resident at risk for falls/injury. The intervention dated 12/6/23 revealed due to a fall the resident won't be left in her wheelchair in her room unsupervised and would be transferred to her bed or recliner. The Care Plan revealed a focus area dated 1/10/24 that the resident had moderate risk for falls related to unaware of safety needs. The interventions dated 3/27/24 revealed following all activities, staff to assist the resident to her room and transferred her to bed or recliner to avoid resident assisting self to bed/recliner. The Progress Note dated 3/23/24 at 4:20 PM (late entry-documented on 3/24/24 at 12:18 PM) revealed the following information: a. Fall Details: Date/Time of fall: 3/23/24 at 4:20 PM: b. Fall not witnessed. The fall occurred in the resident's room. c. Activity at the time of fall: Resident moved self from piano bar into room without staff assistance and attempted to toilet self. d. Reason for the fall was evident. e. Did an injury occur as a result of the fall: No. f. Did fall result in an ER (emergency room ) visit/hospitalization : No. g. Provider: [name redacted] Time notified: 03/23/2024 h. Notified of: Fall Fall Details Note:Resident previously been in piano bar watching peers play cards. She proceeded to wheel self to room, closed door and attempted to transfer self to toilet. CNA (Certified Nurse Aide) [name redacted] found resident on floor with alarm sounding, sat in the middle of the room upright. This nurse called to room and resident laughed, sat upright in the middle of the floor. When asked what happened resident laughed and said I was hanging onto the bed, then I was on my butt. i. Contributing Factors: 1. Recent change in environment: No. 2. Was fluid spilled on floor: No. 3. Clutter present on the floor: No. 4. Floor mat was on floor: No. 5. Poor lighting in the area: No. 6. Bed was at an improper height: No. 7. Other furniture involved: Yes. Wheelchair was involved in the fall. Wheelchair unlocked at time of fall. Wheelchair footrest(s) were not in the way at the time of fall. 8. Wearing glasses at the time of the fall: Yes. 9. Footwear at time of fall: Shoes. Resident didn't use cane/walker as instructed. Resident used incontinence supplies at the time of the fall. 10. Incontinent at time of fall: No. 11. Bedside call light on when resident found: No. 12. Bathroom call light on when resident was found: No. 13. Personal alarm sounding when resident found: Yes. 14. Other residents were not involved in fall. j. Contributing factors note: 1. Resident utilized bed as support rather than walker. The Progress Note dated 3/23/24 at 4:20 (late entry- documented on 3/24/24 at 12:30 PM) revealed this nurse called to resident's room by CNA. This nurse entered room and resident sat upright in the middle of the room laughing. When asked what happened, resident laughed and stated I was hanging onto the bed, then I was on my butt. The resident denied pain, ROM (Range of Motion) intact following incident. Resident denied hitting head, no evidence indicating otherwise, but neuro's initiated per protocol. Resident assisted back to chair and no further problems through the shift. The Incident Report #429 dated 3/16/24 at 4:20 PM titled unwitnessed revealed the following information: a. Nursing Description: This nurse called to resident's room by CNA. This nurse entered room the resident sat upright in the middle of the room and laughed. Pressure alarm sounded. Appropriate footwear on. When asked what happened, resident laughed and stated I was hanging onto the bed, then I was on my butt. Resident denied pain, ROM intact following incident. Resident denied hitting head, no evidence indicating otherwise, but neuro's initiated per protocol. Resident assisted back to chair and no further problems through the shift. b. Resident Description: Resident helped up off of floor, toileted, and removed from room. Staff not to leave resident unattended in 300 hall common area, only in country kitchens where staff is often near. c. Mental Status: oriented to person, place, and time d. Injuries report post incident: no injuries observed post incident e. predisposing environmental factors: fall alarm f. predisposing situation factors: ambulated without assist Reviewed the camera footage with the Administrator on 4/1/24 at 11:30 AM for the fall that occurred on 3/23/24 which showed the following timeline: a. 3/23/24 at 1:48 PM- resident self propelled in the 300 Hall b. 3/23/24 at 1:53 PM- resident turned the corner into the 200 Hall, c. 3/23/24 at 1:57 PM- resident at the other end of the 200 Hall d. 3/23/24 at 2:05 PM- resident self propelled into her room e. 3/23/24 at 4:10 PM- CNA took linen barrel into the resident's room. f. 3/23/24 at 4:15 PM- Staff B, LPN (Licensed Practical Nurse) came down the 300 Hall pushed her computer cart and went into the resident's room. During an interview on 4/1/24 at 11:38 AM, the Administrator stated Staff B texted her while in the room with Resident #1. The Administrator stated she received report that Resident #1 door shut. The Administrator confirmed the resident in her room alone until 4:10 PM before someone went into her room. The Administrator stated they generally shut the resident's door when the resident not in her room. During an interview on 4/1/24 at 11:55 AM, the Administrator queried on how often the CNAs do rounding and she stated they should do it every 2 hours and not more than 3 hours. The Administrator stated the resident ate at 4:30 PM and that was probably the reason the CNA went into her room. During an interview on 4/1/24 at 10:09 AM, Staff E, CNA stated she started doing rounds after her break on 3/23/24 and found the resident's door shut. She stated she went in her room and saw the resident fell and stayed with her until the nurse came into the resident's room and they got the resident up off the floor into her wheelchair. During an interview on 4/1/24 at 10:54 AM, Staff B, LPN (Licensed Practical Nurse) confirmed Resident #1 fell on [DATE] and she went into her room and assessed her and filled out the paperwork the following day. During an interview on 4/1/24 at 3:11 PM, Staff F, CNA queried on Resident #1 fall and she stated she worked that day and heard over the walkie the resident was on the floor in her room. Staff F stated if the resident was in her room she needed to be in her bed or recliner and the door needed to be open for the alarms. During an interview on 4/2/24 at 11:26 AM, Staff G, CNA confirmed Resident #1 cannot be in her room in her wheelchair by herself and that the resident's door should be open unless doing cares. During an interview on 4/2/24 at 3:10 PM, Staff H, CNA confirmed Resident #1 couldn't be in her room alone in her wheelchair and if she saw the resident in her wheelchair in her room she would bring her out to the into dining room area. During an interview on 4/2/24 at 3:28 PM, the DON (Director of Nursing) queried on if Resident #1 was allowed in her room unattended in her wheelchair and she stated they told the staff the resident couldn't be in her wheelchair in her room unattended and if they saw her in her room to ask if she needed toileted and then transfer her to the bed or recliner. The DON stated she expected staff to take the resident back to her room after meals and transfer her to the bed or recliner. The Facility Fall Risk Policy dated 2/12/17 revealed the following information: a. Procedure: 1. Upon admission, residents had a comprehensive assessment, including fall risk assessment tool within 14 days of admission. The MDS instrument identified specific resident problem areas or needs. Other criteria taken into consideration as followed: resident fallen in past week; or/and resident with underlying pathology causing falls. Resident had a recent decline in physical functioning or lacked insight into their limitations. Appropriate approached and interventions addressed on care plans. The Care Planning Policy dated 5/8/18 revealed the following information: a. Care Plan interventions designed after careful consideration of the relationship between the resident's problem area and their causes. When possible, interventions address the underlying source of the problem areas.

Based on resident record review, resident and staff interview, and facility policy review, the facility failed to obtain physician orders to address advance directives in a timely manner for 1 of 2 residents newly admitted to the facility (Resident #85). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #85 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Renal insufficiency, thyroid disorder, and anxiety disorder. It also identified her to be independent with most activities of daily living. A review of the census tab in the Electronic Medical Record (EMR) revealed she had been admitted to the facility on [DATE]. On [DATE]nd, 23rd, & 24th, 2024 a review of the medical record revealed no orders to address the Advance Directives/code status of the resident. In an interview on [DATE] at 8:12 AM, Resident #85 reported if her heart stopped beating, she would not want CPR (cardiopulmonary resuscitation) and thought she had signed a form to address that issue. In an interview on [DATE] at 8:08 AM, Staff A, LPN, reported Advance Directives would be in the resident's paper chart and addressed in the electronic medical record. Upon review of the electronic medical record, Staff A verified it did not address Resident #85's code status and may be waiting for the doctor to sign the IPOST and if something happened Resident #85 would be a full code. In an interview on [DATE] at 8:41 AM, the administrator reported that she would expect the nurse to try to get the order for Advance Directives as soon as the resident was admitted . The nurse did get an order for DNR (do not resuscitate) yesterday.

Based on record review, staff interview, and facility policy review, the facility failed to provide the correct information to residents being discharged from skilled services for 2 of 3 residents reviewed (Residents #1 and #86). The facility reported a census of 35 residents. Findings include: 1. A review of the Notice of Discontinue Therapy (Key Rehab form) for Resident #1 revealed the date for the end of therapy would be 1/15/24. A review of the ABN (Advanced Beneficiary Notice) form CMS- R 131 did not have documentation to indicate when services will be discontinued and did not have documentation on which option the resident chose. The form did not provide information on the option to request an appeal to the QIO (Quality Improvement Organization). 2. A review of the Notice of Discontinue Therapy (Key Rehab form) for Resident #86 revealed the end date of therapy would be 11/8/23. A review of the ABN form CMS- R 131 did not have documentation to indicate when services would be discontinued, none of the options were marked to show which the resident chose. The form did not provide information on the option to request an appeal to the QIO (Quality Improvement Organization). In an interview on 1/24/24 at 10:00 AM, the Business Office/Human Resources Manager reported the following when asked what the process was when she issued ABN's to residents coming off skilled services: She took over the process to issue ABNs in May 2023 and received training from the former administrator. She received a form from therapy to inform her that the resident would be discharged from skilled services. She is supposed to review the ABN form with the resident 48 hours before their therapy ended. However, she also reported the new form did not include the dates when therapy had been started and when therapy was due to end. The former administrator showed her how to fill out Form R131 She verified this new form did not have a place to put dates when services began and due to end. She did not have any instructions or policy to refer to when she first started issuing ABNs. In an interview on 1/25/24 at 8:45 AM, the administrator reported the facility's corporate office informed them that the new form they used was obtained directly from the CMS website and that was what the staff were instructed to have the residents sign. A review of the undated facility policy titled: Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) revealed documentation of the following: Completing the Notice ABNs may be downloaded from the CMS website. Instructions for completion of the form are set forth below: The following should be completed, the header, the resident's name, reason why Medicare may not pay, estimated cost, options regarding payment, signature and date of resident/POA. The policy did not address the need to provide information on the option to request an appeal to the QIO.

Based on employee record review, facility policy review, and staff interview, the facility failed to complete a background check for the potential history of abuse and criminal charges for 1 of 6 employee files reviewed (Staff C). The facility reported a census of 35 residents. Findings include: A 1/25/24 employee record review of Staff C, Certified Nursing Assistant, revealed a lack of a completed background check for child abuse, dependent adult abuse, sexual offender registry, and criminal history. Facility payroll records confirmed Staff C worked in the facility on the following dates: a. August 2023: 8/21/23, 8/22/23, 8/23/23, 8/24/23 b. September 2023: 9/5/23, 9/6/23, 9/7/23, 9/19/23, 9/20/23, 9/21/23, 9/26/23, 9/27/23, 9/28/23, 9/29/23 c. October 2023: 10/3/23, 10/4/23, 10/5/23, 10/11/23, 10/12/23, 10/13/23 d. January 2024: 1/6/24 During an interview on 1/25/24 at 1:45 PM, the Business Office Manager (BOM) stated she did not complete a background check for Staff C. The BOM stated she had the staff sign a Criminal History Record Check form, but failed to complete the necessary background checks. An undated facility form, titled New Hire Checklist, directed staff to complete the following background checks: a. OIG (Office of Inspector General - checks for individuals who are barred from participating in federal healthcare programs) check on all names b. SAM (System for Award Management - checks for individuals that have been excluded from participating in federal contracts of any type, including those involving federal healthcare programs) on all names c. Sex Offender registry on all names d. Background completed in SING (Single Contact License & Background Check)

Based on observation, record review, resident and staff interview, the facility failed to document assessments of the resident's fistula before and after dialysis for 1 of 1 residents reviewed on dialysis (Resident #3). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #3 had been admitted to the facility on [DATE] and identified as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14. The MDS also identified Resident #3 had the following diagnoses: Heart Failure, End Stage Renal Disease requiring dialysis, and Diabetes Mellitus. The MDS also identified Resident #3 required partial/moderate staff assistance with toilet use, showers, and personal hygiene. On 10/26/22 the Care Plan identified Resident #3 with CKD (Chronic Kidney Disease) stage IV and went to Dialysis on Monday, Wednesday, and Friday. He had a dialysis fistula in his left forearm. The Care Plan had documentation of the following interventions: Monitor for bleeding and document. Notify provider if bleeding occurs. Date Initiated: 10/26/2022 Monitor pulse, numbness, tingling, in left hand before and after dialysis and document Date Initiated: 10/26/2022 Monitor thrill before and after return from dialysis and document. Date Initiated: 10/26/2022 A review of Resident #3's paper chart and electronic medical record revealed the nurses failed to document assessments of the fistula before and after dialysis. In an interview on 1/24/24 at 3:45 PM, the administrator/RN reported the only documentation the facility had was from the dialysis center. The facility nurses do not document assessments of the fistula when Resident #3 leaves for or when he comes back from dialysis. A review of the undated policy provided by the facility had documentation of the following: The general nurse should document: a. Location of the catheter b. Condition of the dressing c. If the dialysis was done during the shift and what resident's condition was when they return d. Any report that was received from the dialysis nurse e. Observation of the resident post dialysis

Based on observations, facility policy review, and staff interviews, the facility failed to post daily nursing staff information as required. The facility reported a census of 35 residents. Findings include: During an observation on 1/22/24 at 12:45 PM, the facility posted daily nursing staff information in a public location for the following dates: a. 1/6/24 b. 1/7/24 c. 1/8/24 d. 1/14/24 e. 1/15/24 f. 1/16/24 g. 1/20/24 During an observation on 1/23/24 at 8:00 AM, the nurse staffing information postings remained unchanged, During an observation on 1/24/24 at 7:35 AM, the nurse staffing information postings included 1/24/24. During an interview on 1/25/24 at 9:03 AM, the Director of Nursing (DON) stated the missing days identified on 1/22/24 were located at a nurses station. She stated the third shift nurse is to complete the staff nursing information form and post at the end of their shift. The DON stated she expects staff to post the daily staff nursing information daily in the public area designated. The facility lacked a policy on posting nursing staff information daily.

Based on record review and staff interviews, the facility failed to report an injury of unknown origin within 24 hours to the State Survey Agency and provide the results of their investigation within five days The facility reported census was 37. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] documented that Resident#2 had the diagnoses including stroke, seizure disorder, and dementia. The MDS revealed that the resident required total assistance of two staff for transfers, bed mobility and toilet use. The MDS documented that the resident had severely impaired cognitive skills for daily decision making. Lifting Machine, Using a Mechanical Policy with revised date of July 2017, directed staff as follows; - to use at least two nursing assistants to safely move a resident with a mechanical lift. -Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. In an interview on 3/2/23 at 2:30 p.m. the Administrator stated she was notified of a bruise found on Resident #2's chest on 10/8/21. The Administrator stated she initiated an investigation into the bruise and discovered that on the evening before, Resident #2 was transferred using the Hoyer lift by Staff C, Certified Nurses Aide (CNA). During the transfer the battery failed and Staff C lowered Resident onto her bed using the emergency button, which dropped Resident #2 quickly and caused the lift arm to lower into Resident #2's chest. The Administrator stated the family was notified and provided an explanation for the bruises. The Administrator stated she did not notify the State Survey Agency of the incident or provide the State Survey Agency with the results of their investigation within 5 days of the incident. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019 directed staff as follows under the Reporting sub-title; 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 two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24 hours) if the events that cause the allegation involve neglect exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections and Appeals. This written report shall be forwarded to the Department with five days of the initial report. The Facilities Self Reports document dated September 18, 2019 to February 20, 2023 lacked documentation that the facility had reported an injury of unknown origin for Resident#2.

Based on record review and staff interviews, the facility failed to provide adequate supervision using a mechanical lift to ensure a safe transfer in accordance with facility policy. (Resident #2) The facility reported census was 37. Findings include: According to the Minimum Data Set (MDS) with an assessment reference date of [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated a severely impaired cognitive status. Resident #2 required total dependence on others with transfers, ambulation, dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included Non-Alzheimer's dementia, cerebrovascular accident (stroke), hemiplegia, aphasia and seizure disorder. In an interview on [DATE] at 2:30 p.m. the Administrator stated she was notified of a bruise found on Resident #2's chest on [DATE]. The Administrator stated she initiated an investigation into the bruise and discovered that on the evening before, Resident #2 was transferred using the hoyer lift by Staff C. During the transfer the battery failed and Staff C lowered Resident onto her bed using the emergency button, which dropped Resident #2 quickly and caused the lift arm to lower into Resident #2's chest. The Administrator stated the family was notified and provided an explanation for the bruises. According to the facilities investigation summary dated [DATE], the investigation found that Staff C had put Resident #2 to bed by herself on [DATE]. Staff C reported that during the transfer the battery died , so she had to use the emergency button to lower Resident #2 down onto the bed. Staff C further reported that she was unable to stop the lift from lowering into Resident #2's chest. At the time of the incident there were no immediate bruising or injury noted. Staff C was provided verbal education regarding following care plans, safe transfers and utilizing two people with all mechanical lift transfers. According to the facilities Using a Mechanical Lift policy, the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device. General Guidelines included that at least two staff are needed to safely move a resident with a mechanical lift.

Based on clinical record review, observations and interviews the facility failed to maintain a catheter drainage bag in a sanitary manner and failed to provide incontinence care in a manner to prevent the spread of potential pathogens for 2 of 4 sampled (Residents #14 and #20). The facility reported a census of 22. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #14 had [DIAGNOSES REDACTED].#14 required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. Resident #14 had severe cognitive impairments. During an observation on 10/02/19 at 7:57 a.m., revealed Staff B (Nurse Aide) and Staff C (Nurse Aide) assisted Resident #14 with incontinence cares on the toilet. Staff B donned gloves and wiped stool off the toilet seat. Staff B's glove contained stool. Staff B and Staff C assisted Resident #14 to stand and transfer to the wheelchair. Staff B touched Resident #14's clothing with the soiled gloves. Staff B and Staff C removed their gloves and washed their hands. During an interview on 10/2/19 at 9:15 a.m., the Director of Nursing stated she expected the staff to remove their gloves and wash their hands after providing incontinent care. Review of the facility policy and procedure for incontinent care review date 8/26/19, #10 documented remove soiled gloves, cleanse hands and apply new gloves with rationale of infection prevention by maintaining clean versus dirty procedure. 2. The MDS dated [DATE] revealed Resident #20 had [DIAGNOSES REDACTED]. Resident #20 required extensive assistance of two staff for bed mobility, transfers, and toileting. Resident #20 had no cognitive impairments. The MDS documented Resident # 20 had an indwelling catheter. During an observation on 9/30/19 at 11:51 a.m., revealed resident #20's catheter drainage bag attached to the side of the bed. The uncovered drainage bag touched the floor. The Procedure for Catheter Care reviewed on 8/26/19 documented the bag and tubing should not contact the floor. During an interview on 10/02/19 at 03:29 p.m., the Nurse Consultant reported an expectation of the staff to keep the catheter drainage bags off the floor.

Based on clinical record review, observations and interviews the facility failed to provide proper incontinence care for 1 of 4 sampled (Resident #8) who was unable to carry out activities of daily living. The facility reported a census of 22. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], included [DIAGNOSES REDACTED]. Resident #8 required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS identified Resident #8 had bowel and bladder incontinence. Resident #8 had severe cognitive impairments. During an observation on 10/02/19 at 12:31 p.m., revealed Staff A (Nurse Aide) and Staff B (Nurse Aide) removed Resident #8's wet brief. Staff A used disposable wipes to perform anterior perineal care. Staff A wiped multiple times without folding the wipe to a clean area. Staff A used another wipe and wiped multiple times without folding the wipe to a clean area. Staff A and Staff B rolled Resident #8 on her right side. Staff A cleansed Resident #8's posterior perineal area. Staff A again wiped multiple times without folding the wipe to a clean area. Staff A used another wipe, and wiped multiple times without folding the wipe to a clean area. Staff A failed to cleanse Resident #8's right hip area. Staff A failed to change the wipe or wipe surface with each contact with Resident #8' skin. Review of the Incontinent Care Policy and Procedure reviewed on 8/26/19 revealed a procedure to cleanse the perineal area from front to back with washcloth and Tena cream cleanser, changing cloth or cloth surface with each swipe. Then turn the resident to one side, cleanse buttocks, hips and thighs. Turn resident to opposite side and repeat. During an interview on 10/2/19 at 3:29 p.m., the Administrator and Nurse Consultant stated an expectation of the staff to cleanse both hips when performing incontinence care and change wipe or wipe surface with each swipe.

Based on record review, and staff interviews, the facility failed to follow fall interventions for 1 of 3 sampled (Resident #1). The Care Plan directed the staff to transfer the resident from the wheelchair when in her room. The staff left the resident in the wheelchair in her room unattended. The resident fell and sustained a fractured femur. The facility reported a census of 24. Findings include: The Minimum Data Set (MDS) Assessment tool dated 5/7/19 revealed Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had severe cognitive impairment with symptoms of [MEDICAL CONDITION] present. The MDS dated [DATE] revealed Resident #1 required extensive assistance of one staff with bed mobility, transfers, walking, dressing, bathing, toilet use and personal hygiene. Resident #1 had one fall without injury since the previous assessment on 2/7/19. The Care Plan initiated on 5/8/18 directed one staff to do provide a walker and a gait belt for transfers and walking, transfer to a recliner after each meal or/and activity, provide call light and a blanket. The Care Plan initiated on 1/14/19 and revised on 5/7/19 directed the staff to use the wheelchair for transport only, place in a standard chair for meals and activities, transfer to recliner in the morning, transfer to recliner or bed 30 to 40 minutes after meals, and do not leave in wheel chair. The COMS - Fall Risk Evaluation - V 2 sheet dated 5/7/19 revealed Resident #1 scored 13. A score of 10 or greater indicated a HIGH RISK for falls. The Background sheet revealed on 5/28/19 at 6:57 p.m., the Registered Nurse found Resident #1 on the floor. The staff transported Resident #1 to her room at 6:22 p.m. (after supper) and she remained upright due to reflux. Resident #1 stated she was going to the bathroom. Resident #1 complained of severe left hip pain. At 7:55 p.m., Medics transported Resident #1 to the Emergency Department. Resident #1 admitted to the hospital due to left [MEDICAL CONDITION] related to the fall. The sheet revealed the staff did not act perfectly in this matter since Resident #1's Care Plan specifically stated the wheelchair is for transport only. The intervention is due pain but also to prevent falling forward out of the wheelchair. The staff found Resident #1 on her back with the wheelchair parallel to her (3 - 4 feet away). Resident #1 readmitted to the facility on [DATE]. The Diagnostic Radiology report dated 5/28/19 revealed Resident #1 sustained a displaced fracture through the neck of the left femur. The report dated 5/29/19 at 2:08 p.m. revealed Resident #1 had surgical repair of the left hip without postoperative complications. The Care Plan revised on 5/23/19 directed two staff to transfer Resident #1 with a sit to stand lift. During an interview on 9/18/19 at 9:02 p.m., Staff A (Certified Nurse Aide) stated Resident #1 asked to return to her room. Staff A transported Resident #1 to her room and left her seated in the wheelchair next to her bed with the call light. Staff C, informed the assigned aide that she left Resident #1 in her room. Staff A stated at that time it was okay to leave Resident #1 in her wheel chair in her room. During an interview on 9/18/19 at 6:35 p.m., Staff B (Registered Nurse) stated the staff knew not to leave Resident #1 in the wheelchair in her room. The staff needed to transfer her to the recliner or in bed. The staff could also leave Resident #1 in her wheelchair by the nurse for observation until they could transfer her to bed. Staff B walked by Resident #1's room and observed her on the floor near the bathroom. Resident #1's wheelchair had the braked on and sat near Resident #1. Staff B reported Resident #1 did not have the ability to unlock the brakes. Staff B called for help and Staff C responded. Staff C reported she did not know who put Resident #1 in her room. During an interview on 9/19/19 at 8:02 a.m., Staff C (Certified Nurse Aide) stated Resident #1 usually returned to her room after supper and the staff assisted her to bed. Staff C reported Resident #1 did not like to sit in the wheel chair. Staff C reported the care plan directed the staff not to leave Resident #1 in the wheelchair in her room. Staff C reported she had Resident #1 on her assigned section the evening of the fall. Staff C did not know that Resident #1 was in her room until she responded to Staff B's call for help and saw Resident #1 on the floor in her room. During an interview 9/18/19 at 5:40 p.m., Staff D (Certified Nurse Aide) stated Resident #1 required two staff for transfers. Staff D reported being surprised when she heard staff left Resident #1 in her room in her wheelchair. During an interview on 9/18/19 at 6:21 p.m., Staff [NAME] (Licensed Practical Nurse) stated Resident #1 remained seated for 20 to 30 minutes after supper and then the staff assisted her to bed. Resident #1 remained in the common area for observation until the staff had time to assist her to her bed or recliner. Staff [NAME] reported they staff knew not to leave Resident #1 in the wheelchair in her room. During an interview on 9/18/19 at 7:58 p.m., Staff F (Certified Nurse Aide) stated the resident was a fall risk, she was not supposed to be left alone in her wheel chair in her room, she was supposed to be transferred to the recliner if she wanted to stay up, or to bed. During an interview on 9/19/19 at 8:58 a.m., Staff G (Certified Nurse Aide) and Staff H (Certified Nurse Aide) stated the resident was a fall risk and had an alarm because she attempted to self-transfer. Staff G and Staff H reported the staff did not leave Resident #1 in her room in the wheelchair. The staff transferred her to the recliner or to bed. During an interview on 9/19/19 at 9:34 a.m., the Director of Nursing stated she would not have wanted or directed staff to leave the resident in her wheelchair alone in her room. The facility's undated Certified Nurse Aide (CNA) Job Description revealed a nursing care function and duty that directed the CNA's to review the care plans daily.

Based on record review, resident and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices for 1 of 4 residents reviewed. Resident #4 admitted to the facility 8/10/18 with a history of falls and a left [MEDICAL CONDITION]. The facility implemented fall alarms in an attempt to alert staff when the resident attempted to stand unassisted and/or was on the move. However, Resident #4 removed his alarm and they did not sound. Staff noted the resident removed his alarms, but failed to implement additional supervision or other measures to mitigate the risk of the alarm(s) not sounding. On 9/15/18, Resident #4 removed his tab safety alarm and fell , which resulted in a fractured right wrist, pain, a 2 day hospital stay, and a wrist splint. The facility reported a census of 36 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 09/07/18, Resident #4 admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4 out of 15 indicating severely impaired cognitive ability. The MDS documented the resident required extensive assist of one staff for bed mobility, ambulation (walking), dressing, and toilet use. The MDS also documented the resident required limited assist of one staff for transfers, ambulation in room, and personal hygiene, although ambulation did not occur. The MDS revealed the resident used a wheelchair and walker for mobility devices and had a functional limitation in range of motion to one side of his lower extremity that interfered with daily function or placed the resident at risk of injury. The care plan with focus start date of 08/10/18 identified Resident #4 needed assist with ADL's (activity of daily living) related to recent fall prior to admission with fracture to left hip and weakness, which placed him at risk for falls/injury. The care plan indicated resident had a fall on 9/16/18 and injured his right wrist. The care plan included approaches/interventions that directed staff: a) Initiated on 8/10/18: Staff to assist the resident with bed mobility and put bilateral upper side rails in place to assist resident with bed mobility. b) Initiated on 8/10/18: staff to assist resident with one to two staff members for dressing. c) Initiated on 8/21/18: staff to stand with resident at sink with gait belt and four wheeled walker for hand washing, oral cares, combing hair, and shaving. d) Initiated 9/18/18: resident to use a platform walker for transfers and ambulation and resident is to wear a Velcro adjustable wrist splint to right wrist. e) Initiated on 9/18/18: resident had a personal alarm and bed alarm, but resident disconnected them at times. f) Initiated on 9/18/18: staff to place a monitor for safety in the resident's room so they could hear if the resident stood unassisted while staff was at the nurse's station. Review of the facility's Capstone Fall Screener dated 8/10/18 documented Resident #4's fall scoring as 55. A score of 4 or higher represented a resident at high risk. Review of the resident's progress notes revealed the following: a. On 8/15/18 at 11:49 PM: Documentation revealed the resident displayed restless behavior and the 2nd shift nurse initiated a clip alarm due to safety concerns. b. On 8/16/18 at 1:11 PM, staff contacted the resident's family to inform them of resident attempting to transfer by himself and to notify family regarding the use of the clip alarm for safety. On 8/21/18 at 12:36 AM: Staff documented the resident experienced confusion and wanted to do everything on his own. The alarms remained in place because the resident attempted to stand unassisted. c. On 8/22/18 at 1:37 PM: The RN wrote that therapy verbalized concerns regarding the resident's cognition during the Medicare Meeting. During the meeting, therapy reported the resident could transfer with assist of 1 or 2 staff and ambulated for short distances with assistance. d. On 8/25/18 at 4:52 AM: The LPN documented summoned to the resident's room by CNA. The resident sat in his recliner with the bed alarm on the bedside table, turned off and folded neatly. The resident had transferred himself from the bed to the recliner and removed his clip alarm. Staff encouraged the resident to use the call light to ask for assistance. e. On 8/27/18 at 4:33 PM: Documentation showed a visitor found the resident in the bathroom and had not used the call light to ask for assistance. The resident had transferred on his own and walked to the bathroom alone. Staff encouraged the resident to call for help for transfers. f. On 9/15/18 at 7:13 PM: A CNA (Certified Nurse Aide) called Nurse into the resident's room and observed resident on the floor on his back. Resident agitated and denied hitting his head, but reported he had a broken wrist. The notes described the resident as confused. The nurse's assessment revealed the resident's right wrist was painful, swollen, and had the appearance of a possible dislocation; the resident also complained of back pain. The notes indicated the nurse attempted to call family and left a message, and also notified the resident's physician. The physician ordered staff to transfer Resident #4 to the emergency room for further evaluation and treatment. The ambulance transported the resident from facility to the emergency room . g. On 9/15/18 at 10:17 PM: Staff spoke with Resident #4's family member and family reported awareness of resident's admission to the hospital for pain control. h. On 9/17/18 at 2:30 PM: The nurse documented the resident returned to facility. Review of report of Date of Incident 9/15/18 documented staff found Resident #4 on the floor via unwitnessed fall. The report noted the resident was known to take alarms off. Interventions in currently in place: alarms, nonskid footwear, signs in room for reminders for resident to use his call light, walker nearby, and adequate lighting. New interventions initiated include alarms are not able to be heard unless close to resident's room, resident is also known to take alarms off, baby alarm to be placed if not defective, maybe move closer to nurses station. Review of Resident #4 hospital Radiology Report dated 9/15/18 at 7:57 AM documented history of resident with a fall and subsequent right wrist pain. The report's impression included diffuse osteopenia, impacted and angulated horizontal fracture through the distal metaphysis of the radius, displaced ulnar styloid fracture, and no definable carpal bone fracture. An interview was conducted on 9/28/18 at 10:30 am with the Administrator. The Administrator's documentation dated 9/19/18 indicated CNA found Resident #4 on the floor in his room on 9/15/18. Resident immediately complained of right wrist pain; resident transferred to the emergency room via ambulance and was admitted to the hospital for observation until 9/17/18 for pain control. Resident's family decided to not pursue surgical treatment. Resident returned to the facility with a wrist splint on. Resident is temporarily using a platform walker at this time. Administrator stated the resident had had no previous falls during his skilled care. The Administrator indicated due to the resident's impaired cognitive ability, staff provided cueing, reorientation, reminders, and provided supervision as possible. Staff also sat with the resident during periods of restlessness and provided 1:1 with staff. The Administrator indicated upon return to the facility an audio monitor was placed in resident's room with the base stationed at the nurses' station to alert staff of resident's movement and alarms sounds of resident. Interview was conducted on 9/28/18 at 10:48 PM with Staff A, Certified Nurse Aide (CNA), along with her written statement regarding Resident #4. Staff A stated she came into work at 2 PM on 9/15/18 and was assigned in the hallway of Resident #4. Staff A stated she first saw Resident #4 shortly after 2 PM while she passed snacks to residents. Staff A stated at that time the resident sat in his chair reading a book had a bag of books on the floor beside him, a tab alarm in place, and his walker and call light within reach. Staff A stated she came out of a resident's room close to Resident #4's room and heard a noise. Staff reported another coworker was in the hallway assisting residents at the same time Resident #4 fell . Staff A stated she found Resident #4 lying on his back on the floor in his room, in front of his closet/desk. Staff A stated the resident was holding his wrist and he stated he fell . Staff A stated no alarm was sounding and reported she found his tab alarm on top of his desk and his bed pressure alarm in a dining room chair in his room that she had not seen when she checked the resident earlier. Staff A stated the resident's call light was not on, gripper socks on remained on the resident's feet, and floor dry. Staff A stated she immediately summoned the nurse via walkie-talkie. Staff A reported the resident was known to remove his alarms or transfer by himself, carrying the alarms with him. Staff A stated therapy is working with the resident, and staff does education with resident he is found up unassisted, and there are signs in his room to remind him not to get up without using call light and waiting for assist. Interview was conducted on 9/28/18 at 10:11 am with Staff B, Registered Nurse (RN). Staff B stated she was assigned to care for Resident #4 on 9/15/18 when he fell . Staff B indicated she had seen the resident 10 to 15 minutes prior to his fall as she administered medications. Staff B stated the resident sitting in his chair reading a book, tab alarm in place and call light in reach, and resident voiced no needs or wants at that time. Staff B stated she was in another hall when she was summoned to resident's room by staff and found the resident on the floor on his back. Staff B stated the resident complained of wrist pain and back pain. The resident's wrist was swollen and looked dislocated. Staff B stated she contacted the resident's physician who instructed to send resident to the emergency room for further evaluation and treatment. Staff B stated the resident was admitted to the hospital for a fractured wrist and for pain control. Staff B reported the resident appeared to have removed his tab alarm and placed it on his desk in his room. Staff B indicated the resident has a history of frequently removing his alarms, including tab alarm and pressure bed alarm or carrying the alarm with him. Staff B stated staff attempted to provide frequent checks on the resident when possible, but there was nothing documented. Interview was conducted on 9/28/18 at 9:47 am with Staff C, Registered Nurse (RN), Assistant Director of Nursing (ADON) and Care Plan and MDS nurse. Staff C stated Resident #4 did have a bed alarm and a pressure alarm with a history of removing them. He also had signs in his room that reminded him to use his call light for assist. Staff C stated the alarms, his history of removing his alarms or his signs in the room to remind him to use call light were not placed on the care plan until 9/18/18. Staff C stated she is not sure when the alarms or the signs were implemented but that should have been on the care plan. Staff C stated after the resident's fall on 9/15/18, staff placed a baby monitor in the resident's room with the monitors in two of the nurses stations so staff can hear movement of resident or his alarms. Staff C stated this was not on the care plan until 9/18/18. Staff C stated the resident needs 1 to 1 supervision by staff at times, but this is not on the care plan.

The following deficiency relates to facility self report incident -I. Based on record review, interviews with resident, staff and facility policy, the facility failed to ensure one of four residents received adequate supervision to protect against abuse/hazards from others. Record review identified on 9/17/16, Resident #2 got upset with Resident #1 and threw hot scolding coffee on him/her. Resident #1 had no [MEDICATION NAME] injury but reported it hurt having hot coffee thrown on him/her. The facility reported a census of 35 residents. Findings include: According to the Minimum Data Set (MDS) assessment with assessment reference date of 9/1/16, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognitive skills. Resident #1 required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. Resident #1 used a wheelchair for mobility. Resident #1's [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment with assessment reference date of 8/25/16, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognitive skills. Resident #2 required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. Resident #2 used a wheelchair for mobility. Resident #2's [DIAGNOSES REDACTED]. Care Plan dated 4/21/16 noted Resident #2 with occasional episodes of anger and impulse control that may affect others and interventions to direct Resident #2 to his/her room when displaying episodes of anger and if angry episodes involve another resident, separate immediately. Progress notes dated 7/5/16 noted Resident #2 at 1:51 p.m. had threaten to physically harm resident (Resident #1) and throw radio if resident doesn't move radio across the room. Staff educated resident not to physically harm resident or touch resident's radio and the conversation had been reported to the Director of Nursing. The Progress Notes dated 9/1/16 at 10:30 a.m., identified Resident #2's team met and staff reviewed his/her care plan for occasional episodes of anger and interventions in place to prevent/decrease agitation. Resident #2 was no longer on Antidepressant medication, and the resident transfers him/her(self) per wheelchair. Staff documented a goal for the resident to understand staff members 50% of the time due to impaired cognition. Progress Notes date 9/17/16 at 1:09 p.m. documented Resident #1 had been leaving the dining room after lunch when his/her bumped into Resident #2 ' s table. Resident #2 got very upset and started saying Resident #1 had bumped into him/her on purpose and then proceed to throw hot coffee on Resident #1. The report documented the incident had been witnessed by the Director of Nursing and she immediately started removing Resident #1 ' s shirt to keep the coffee off his/her skin. Two staff assisted with separating residents and getting cold towels to put on Resident #1 ' s stomach. Resident #1 ' s skin where the coffee had spilled was bright pink in color and after ice packs were applied his/her skin had no increase in redness, or no blister had formed. Resident #1 reported it did not hurt anymore. The redness is almost completely gone after 30 minutes. Incident report dated 9/17/16 at 12:30 p.m. stated Resident #1 was leaving the dining room area and bumped into Resident #2's table. Resident #2 began yelling at Resident #1 and threw his/her coffee onto Resident #1's chest. Staff immediately responded and separated the residents. Resident #1's shirt was removed and cool wet clothes applied to his/her abdomen. Resident #1 was taken to his/her room and an ice pack applied to his/her abdomen. Within 30 minutes Resident #1 was not complaining of any pain and there was no noted blistering or redness related to the hot coffee poured on Resident #1. During an interview with Resident #1 on 10/25/16 at 2:20 p.m., he/she reported on 9/17/16, he/she passed by another (resident's) table and accidently bumped into the table. Resident #1 reported the resident sitting at the table got upset and then threw a cup of hot coffee onto his/her chest/stomach. Resident #1 stated it (coffee) was really hot, scolding and it hurt. Resident # 1 reported staff quickly removed his/her shirt and put cold water on him/her. Resident #1 reported no further incidents with Resident #2 since this incident. In an interview on 10/3/16 at 2:43 p.m. the Director of Nursing (DON) stated she was in the dining room during lunch on 9/17/16 helping residents when she heard a holler and turned as Resident #1 was passing by Resident #2. Resident #2 was agitated and before the DON could get to them, Resident #2 threw his/her coffee onto Resident #1's chest/abdomen. The DON immediately started removing Resident #1's clothing and other staff got cool wet wash clothes and placed them on Resident #1's abdomen. Resident #1 was taken to his/her room and provided further first aid. The DON stated there was no lingering injury to Resident #1. The DON stated Resident #2 had expressed his/her dislike for Resident #1 in the past, but had never been physically aggressive towards him/her. Facility Reporting Suspected Dependent Adult Abuse to the Administrator and other Officials policy stated Facility staff will ensure that all alleged violations involving mistreatment, neglect or abuse (including suspicious injuries), and misappropriation of resident property are reported immediately to the Administrator or their designee and the Iowa Department of Inspections and Appeals as required to be accordance with state law.

Based on clinical record review and staff interviews, the facility failed to provide adequate supervision to protect one of six residents from hazards during transfer. Review established Resident #1 fell during transfer and staff transferred the resident from floor to wheelchair before a full nursing assessment was completed. The resident was later identified with two fractures (clavicle and ankle) and a finger dislocation. The facility reported a census of 33 residents. Findings include: The quarterly Minimum Data Set ((MDS) dated [DATE] identified Resident #1 with an intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 (the BIMS scale for cognitive impairment states a score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates the resident is not cognitively impaired). Resident #1 required extensive physical assist of 2 staff members with ambulation, transfers, and toileting. Resident #1 utilized a walker and wheelchair for mobility. The [DIAGNOSES REDACTED]. The MDS revealed Resident #1 exhibited functional limitations in range of motion for bilateral lower extremities. MDS assessment balance during transitions section revealed Resident #1 was not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking and moving on and off the toilet. The MDS indicated Resident #1 experienced no falls in the three month period since the prior MDS assessment. Resident #1's weight was recorded on the MDS as 256 pounds. The care plan revised 10/12/15 identified Resident #1 had self-care deficits related to CVA and right knee pain related to degenerative joint disease (DJD) and staff was directed to transfer and ambulate Resident #1 with one staff member with gait belt and walker as tolerated. The care plan noted Resident #1 received physical therapy for his/her knee pain 3-5 times a week. Review of Progress Notes (narrative nurse ' s notes) revealed the following entries: 12/4/15 at 5:40 a.m. by Staff K, Licensed Practical Nurse (LPN): Resident was with two staff refused to ambulate to the bathroom had to lower to the floor had trouble getting up times two use wheelchair then placed in bed, V/S: 134/68, temperature 97.8, 99 pulse regular, respirations 20, O2 sat/R A 93%. Range of motion done complains legs hurt staying in bed at this time faxed report to Dr.'s office at 7:20 a.m. called spouse at 7:25 a.m. 12/4/15 at 2:23 p.m. by Staff J, Registered Nurse (RN): Resident this a.m. stayed in bed for breakfast. About 10:45 a.m. went in to get resident up for shower and he/she wanted to stay in bed. Assisted to shower chair with the EZ-stand (mechanical lift that assists resident with transfer- requires resident to bare weight) resident did not bare weight with the transfer and turned bluish color during the transfer. Given a shower noted bruising on right side front part of neck, right chest area some bruising, upper back, part of both arms, left hand thumb area, left ring finger, upper part of back, left shin, and right hip fold has an open slit. Resident eyes while in the shower not focused. Doctor called to see about transfer to the emergency department for evaluation. After shower put back to bed using Hoyer (mechanical lift that utilized a sling for resident transfers) resident color was grayish at that time. Ambulance here at 11:40 a.m. and resident loaded on ambulance at 11:45 a.m. Review of the incident report dated 12/4/15 at 5:40 a.m. revealed Resident #1 assisted by two staff members to ambulate and then refused to continue. Staff lowered Resident #1 to the floor. Staff documented difficulty getting Resident #1 up off the floor and into bed via the wheelchair. Day shift follow up documentation revealed attempt to transfer Resident #1 using an EZ Stand mechanical lift. Staff noted bruising on Resident #1 and complaints of pain. The facility notified primary care physician regarding a transfer for an evaluation and treatment. Order received for the transfer. Review of the Patient Transfer Form undated revealed Resident #1 experienced shortness of breath, color bluish at times with new bruising noted on Resident #1 ' s neck, left hand and leg. Staff documented during the night shift Resident #1 ' s legs gave out while transferring. Review of an emergency room Visit Summary dated 12/4/15 at 2:48 p.m. noted Resident #1 was admitted to acute care hospital with a right clavicle fracture, hypoxia (low oxygen in blood), and a urinary tract infection. Review of the discharge summary from the acute care hospital dated 12/15/15 revealed subsequent X-rays taken during Resident #1's hospital stay revealed the following additional radiology findings: 1. Left ring finger: Fracture to base of middle finger along with mild dislocation of the left fourth finger with osteopenic bone and mild-moderate degenerative changes. 2. Right ankle: mildly displaced fractures involving the right fibular shaft and medial malleolus (ankle) with prominent osteopenic changes. 3. Skeletal survey X-rays revealed rib and femoral neck fractures which were old fractures with different ages in healing and age-indeterminate. During an interview on 1/8/16 at 6:20 a.m. Staff B, Certified Nursing Assistant (CNA), stated on 12/4/15 at 5:30 a.m. he went to Resident #1 ' s room to provide morning cares and ambulate him/her to the bathroom. Staff B CNA stated Resident #1 ambulated with assist of one staff, the gait belt, and the wheeled walker. Staff B held the gait belt and assisted Resident #1 to stand and walk approximately 5 steps with the wheeled walker. According to Staff B CNA, Resident #1 went down without warning. Staff B put his knee under Resident #1 to attempt to break the fall. Staff B CNA stated he was unable to keep Resident #1 on his/her feet because of the resident's larger size. As Resident #1 was on Staff B's knee almost down to the floor Staff D CNA, entered the room and assisted lowering Resident #1 completely to the floor. Staff B CNA stated when Resident #1 was lowered to the ground the resident did not indicate that he/she was injured in any way. Staff B CNA, stayed with Resident #1 and Staff D CNA, went to tell the nurse. Staff D CNA returned to the room with Staff F certified occupational therapy aide (COTA), and stated the nurse, Staff K, Licensed Practical nurse (LPN), was busy and she instructed the CNA's to assist Resident #1 to stand up and transfer the wheelchair and she would come to the room to assess Resident #1 as soon as she could. Staff F COTA, held the wheelchair steady while Staff D CNA and Staff B CNA attempted to lift Resident #1 by the gait belt. Staff B stated the gait belt slipped up under Resident #1's armpits during the transfer to the wheelchair. Staff B stated it was difficult to get Resident #1 up into the wheelchair. Staff B stated once in the wheelchair they transferred Resident #1 to the bed. Staff B stated Staff K LPN, was in the room within one or two minutes. Staff B stated when a resident falls the resident is to stay on the floor until the nurse can assess the resident. Staff B stated he did not consider lowering a resident to the floor a fall so when the nurse instructed them to get the resident up he did. During an interview on 1/12/16 at 6:15 a.m. Staff D CNA, stated he and Staff B assisted residents up in the morning. Staff D CNA stated he entered Resident #1 ' s room and observed Staff B lowering the resident to the ground. Staff D CNA went to assist Staff B and after Resident #1 was on the floor. Staff D exited the room he to tell the nurse Staff K about the incident. Staff D stated Staff K LPN was busy with another resident and he cannot recall if Staff K said to get Resident #1 up or not. Staff D stated upon returning to the room he saw Staff F COTA and asked her to assist standing Resident #1 up. Staff D stated he and Staff B worked hard to get Resident #1 into the wheelchair. Staff D stated they considered using a Hoyer lift but decided it was harder on Resident #1 to place a sling under him/her prior to transfer. Staff D stated after Resident #1 was in bed Staff K came to the room to assess Resident #1. Staff D stated he and Staff B, used a gait belt to assist Resident #1 to stand. Staff D commented the gait belt could have slipped under Resident #1's arms but he was unable to recall if it did. During an interview on 1/8/16 at 7:25 a.m. Staff F COTA, stated she was asked by Staff D to accompany him to Resident #1's room to assist with standing Resident #1 up. Staff F stated she held the wheelchair steady while the two CNAs assisted Resident #1 up into the wheelchair from the floor. Staff F COTA stated she was concentrating on steadying the wheelchair and was unable to recall how the CNA ' s lifted the resident up. Staff F stated she noted something up high on Resident #1 ' s chest but she could not state definitively that it was a gait belt. Staff F stated Resident #1 looked scared but did not indicate by facial expression or gesture that he/she was in pain. Staff F stated she thought Staff K LPN already assessed Resident #1 otherwise she would not have allowed the CNA ' s to transfer Resident #1 until after a head to toe assessment was completed by the nurse. Staff F stated at the time she did not suggest the CNA ' s use a Hoyer lift to get Resident #1 up but does think it would have been more appropriate given Resident #1's size. During an interview on 1/12/16 at 3:30 p.m. Staff K LPN, stated around 5:40 a.m. she was ambulating another resident to the bathroom when Staff D approached her and stated Resident #1 was lowered to the floor during ambulation. Staff K stated she told Staff D to go ahead and get Resident #1 up and into bed and she would be there as soon as she possibly could to assess Resident #1. Staff K stated she had the CNA's transfer Resident #1 because she did not want him/her lying on the floor until she got there. Staff K stated she did not consider lowering Resident #1 to the floor to be a fall so she did not assess the resident before the transfer. Staff K stated she arrived in the room within 5 minutes and assessed Resident #1 for injuries. She was told by the CNA ' s it took all three of them to get Resident #1 up off the floor using the gait belt. Staff K stated range of motion on Resident #1 ' s arms and legs failed to identify any limitations. Staff K stated Resident #1 was not verbal but could make his/her needs known by gestures. When the nurse asked Resident #1 if she was hurt Resident #1 failed to identify any pain. Staff K stated all staff have been re-educated and instructed lowering a resident to the ground required full nursing assessment prior to assisting a resident up. During an interview on 1/8/16 at 8:30 a.m. Staff A CNA and shower aide stated she used the EZ-Stand lift to transfer Resident #1 into the shower room because Resident #1 indicated to Staff A he/she was unable to stand. Staff A transferred Resident #1 without difficulty using the stand. Staff A stated she noticed multiple areas of bruising on Resident #1 during the shower including bruising on the neck, shoulder, finger and back. Staff A notified the nurse and staff used the Hoyer lift to transfer Resident #1 back to bed to avoid further injury. Staff A stated Resident #1 was transferred to the emergency room for evaluation. Staff A stated she was aware if you lowered a resident to the floor the nurse had to assess the resident before getting them up. During an interview on 1/8/16 at 8:25 a.m. the Administrator stated originally he thought Resident #1 was having a stroke and this was why he/she was sent to the emergency room . The Administrator was not aware of a [DIAGNOSES REDACTED].#1 until 12/7/15. During an interview on 1/12/16 at 9:00 a.m. with the Director of Nursing (DON) stated staff should have identified the incident as a fall and the nurse should have done a total assessment prior to getting the resident up off the floor. She stated the policy on Resident Accident/Incident Policy has been revised to include specific steps for staff to take when a resident falls. All staff have been re-educated regarding the changes to the policy. She acknowledged the old policy was vague and failed to specify when the nursing assessment should be completed after a resident incident or accident.