Every finding on record at Sheffield Care Center

Based on facility record review, staff interviews, and policy review, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours a day, 7 days a week. On 2/1/25 and 8/1/25 the facility failed to ensure they had an RN on duty for at least 8 hours for the entire 24 hours. The facility reported a census of 37 residents. Findings include: Review of the Nursing schedules and Timecards lacked a RN on 2/1/25 and 8/1/25.On 8/19/25 at 3:00 PM, the Director of Nursing (DON) verified she didn't work on 8/1/25. She said she didn't think about needing RN coverage. She said if she could get a day off, she takes it. On 8/19/25 at 3:56 PM, the Administrator verified the facility didn't have RN coverage on 8/1/25. She reported the DON did the best she could with RN coverage. She said the facility only had 3 RNs on staff and used agency staff for RN coverage as needed. On 8/19/25 at 6:26 PM, the Administrator reported she expected the facility to have 8 hours of RN coverage, 7 days per week. On 8/20/25 at 8:30 AM, the Administrator verified the facility didn't have RN coverage on 2/1/25. The facility's undated policy titled Registered Nurse defined the purpose of the policy as to ensure the facility had an RN available for supervision in the facility. The policy directed the facility must use the services of a RN for at least 8 consecutive hours a day, 7 days a week.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies for 2 of 2 areas of concern. Findings include: The survey identified the following concerns at the current survey, previously cited at surveys in the past year:a. Abuse, Neglect, and Exploitation Trainingb. Infection Prevention and ControlThe facility's QAPI Plan revised April 2014 instructed the facility shall develop, implement, and maintain an ongoing facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. In addition, the QAPI plan included the following objectives:a. Provide a means to identify and resolve present and potential outcomes related to resident care and services.b. Reinforce and build upon effective systems and processes related to delivery of quality care and services.c. Provide structure and processes to correct identified quality and/or safety deficiencies.d. Establish systems and processes to maintain documentation relative to the QAPI programs, as a basis for demonstrating the facility had an effective ongoing program.On 8/21/25 at 10:30 AM, the Administrator reported she didn't know of the concerns with the repeated deficiencies until identified during this survey. The Administrator reported the facility would review their current process for each area of concern and provide staff education/training. She said the concerns would be reviewed and monitored through the facility's QAPI program.

Based on personnel file reviews, facility policy review, and staff interviews, the facility failed to provide dependent adult abuse certification training within 6 months of hire for 2 of 5 employees reviewed (Staff C, Dietary Aide, and Staff D, Housekeeper). The facility identified a census of 37 residents.Findings include: 1. Staff C's personnel file documented a hired date of 12/2/24. The personnel file lacked documentation Staff C had completed Dependent Adult Abuse Mandatory Reporter Training within 6 months of hire. 2. Staff D's personnel file documented a hired date of 10/7/24. The personnel file included a Dependent Adult Abuse Mandatory Reporter Training Certificate completed 5/30/25.On 8/19/25 at 1:42 PM, the Business Office Manager (BOM) verified Staff C didn't complete the Dependent Adult Abuse Mandatory Reporter Training and acknowledged Staff D completed their Dependent Adult Abuse Certification late. The BOM said the facility expected new hires to complete Dependent Adult Abuse Mandatory Reporter Training within 6 months of hire. On 8/19/25 at 1:50 PM, the Administrator reported she expected the staff to complete Dependent Adult Abuse Mandatory Reporter Training within 6 months of hire.The facility policy titled Abuse Prevention Policy revised December 2016 documented the facility required staff training/orientation programs that include such topics as abuse prevention, identification and reporting abuse, stress management, and handling verbally or physically aggressive resident behavior. On 8/19/25 at 4:20 PM, the Administrator reported the facility didn't have a specific policy related to dependent adult abuse training. She said they always followed the State mandated within 6 months of hire.

Based on clinical record review, observations and staff interviews the facility failed to implement care plan interventions related to not locking smoking materials for one resident (Resident #27). The facility reported a census of 37 residents.Findings include: 1. Resident #27's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of cerebrovascular accident (CVA or stroke), anxiety and depression. The Care Plan Focus initiated 5/7/24 related to smoking. The Focus reflected Resident #27 smoked for a long-time but recently decided to quit due to the cost of cigarettes however, he did occasionally smoke. Resident #27 had a history of extinguishing his cigarettes on his wheelchair, then keeping the cigarette butts, and storing them in his wheelchair bag. The Interventions directed to store Resident #27's smoking supplies in the north nurses' station. The Smoking - Safety Screen dated 7/26/25 indicated Resident #27 needed the facility to store lighter and cigarettes. On 8/18/25 at 12:03 PM Resident #27 stated he smoked and rolled his own cigarettes in his room. Resident #27 explained he went outside to smoke around 20-30 times a day. He added he could go unsupervised. On 8/20/25 at 9:45 AM observed Resident #27 go outside to smoke. Resident #27 lit his own cigarette and distinguished it in the proper container. Resident #27 didn't stop at the nurses' station to get his smoking materials and didn't drop them off at the nurse's station after he finished smoking. On 8/20/25 at 10:00 AM, Resident #27 stated he kept his cigarettes and lighter in his bag on his wheelchair, so he didn't forget to take them with him when he went outside. On 8/20/25 at 10:40 AM Staff G, Certified Nurse Aide (CNA), reported Resident #27 kept his lighter and cigarettes on him.The Care Plans, Comprehensive Person-Centered policy revised December 2016 instructed to develop and implement a comprehensive, person-centered Care Plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional for each resident. a. The Care Plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 2. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care. 3. The resident will be informed of his or her right to participate in his other treatment. 4. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's Care Plan is determined to not be practicable. The care plan process will: a. Facilitate resident and/or representative involvement b. Include an assessment of the resident's strengths and needs c. Incorporate the resident's personal and cultural preferences in developing the goals of care.5. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.6. Assessments of residents are ongoing, and Care Plans are revised as information about the residents and the residents' condition change.7. The Interdisciplinary Team must review and update the care plan: a. When a resident had a significant change in their condition b. When the resident didn't meet the desired outcome8. The resident has the right to refuse to participate in the development of his/her Care Plan, medical, and nursing treatments. The nurse would document the refusals in the resident's clinical record in accordance with established policies. An interview on 8/20/25 at 3:30 PM the Director of Nursing (DON) acknowledged she missed updating Resident #27's Care Plan related to locking his smoking materials.

Based on clinical record review, staff interview, and facility policy review the facility failed to update a resident's Care Plan to accurately reflect the resident's needs for 2 of 2 residents reviewed (Residents #8 and #32). The facility reported a census of 37 residents.Findings include:1. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS included diagnoses of non-Alzheimer's dementia, depression, and hypertension (high blood pressure). The Nurse Progress Note dated 6/27/25 at 4:44 PM reflected Resident #8 fell and complained of left hip and leg pain. The Intervention listed the facility sent him to the emergency room for evaluation. The Fall Investigation dated 6/27/25 at 4:31 PM indicated Resident #8 had an unwitnessed fall. The facility sent him to the emergency room (ER) for evaluation. The Intervention reflected the facility would update his Care Plan upon return from the hospital.The Skilled Note dated 7/6/25 at 2:38 AM identified Resident #8 used a seat alarm. The Fall Investigation Report dated 7/25/25 at 5:04 AM indicated Resident #8 had an unwitnessed fall in his room. The previous fall interventions in place at the time of the fall listed grippers socks and seat alarm. The Intervention directed to change Resident #8's scenery if he appeared restless, and move him to the north dining room in the recliner to watch TV. The Care Plan Focus revised 5/14/24 reflected the last revised Intervention as 5/14/24. The Care Plan lacked information related to changing his scenery and an Intervention related to the 6/27/25 fall.2. Resident #32's MDS assessment dated [DATE] identified a BIMS score of 2, indicating severe cognitive impairment. The MDS included diagnoses of benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that commonly occurs in older men), Alzheimer's disease, and Parkinson's disease.On 8/19/25 at 10:30 AM, observed Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA, provide Resident #32 perineal (peri) care and catheter care. The Clinical Physician Orders reviewed 8/20/25 included an order dated 8/4/25 to change his catheter every month and as needed (PRN).Resident #32's Care Plan lacked documentation of use of an indwelling urinary catheter.The Care Plans, Comprehensive Person-Centered policy revised December 2016 instructed to develop and implement a comprehensive, person-centered Care Plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The Policy directed the following:a. The Care Plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. b. Care Plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.c. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.d. The Interdisciplinary Team must review and update the care plan:i. When a resident had a significant change in condition.iii. When the resident readmitted to the facility from a hospital stay.An interview on 8/20/25 at 3:30 PM the Director of Nursing (DON) acknowledged she missed updating the Care Plan to identify Resident #32's catheter and Resident #8's fall with fracture.

Based on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents for 1 of 3 residents reviewed (Resident #13) for falls. The facility failed to complete a thorough root cause analysis (RCA) and failed to implement new and/or effective fall interventions after a fall occurred. The facility reported a census of 37 residents.Findings Include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5 indicating severely impaired cognition. Resident #13 required partial/moderate assistance with bed mobility and transfers. The MDS documented Resident #13 used a walker and wheelchair for mobility. The MDS included diagnoses of cerebrovascular accident (CVA) (stroke), non-Alzheimer's dementia, hemiplegia (muscle weakness or partial paralysis on one side of the body), repeated falls, unsteadiness on feet, transient alternation of awareness, dizziness and giddiness, low back pain, and muscle spasm of back. The MDS identified Resident #13 had one fall since the prior assessment which resulted in an injury. The MDS coded Resident #13 used a chair alarm and bed alarm on a daily basis.The Care Plan Focus revised 7/23/25 identified Resident #13 had a risk for falls. The Care Plan directed the following Interventions:a. 6/20/22: Staff to assure fall interventions in place, clear environment, adequate lighting, and proper footwearb. 7/7/25: Staff to ensure fall mat under Resident #13 when in bed or chair, make sure the alarm worked and if not to notify the charge nursec. 7/7/25: Resident #13 to wear gripper socks when in bed. The Care Plan documented Resident #13 would remove socks when in bed - 7/7/25d. 1/6/25: Resident #13 to use a motion sensor to alert staff of movementsResident #13's Fall Risk Assessment Scored documented the following scores:a. 10/27/24 = 13b. 1/26/25 = 27c. 5/10/25 = 20d. 7/30/25 = 20The Fall Report Note dated 11/30/24 at 12:20 AM, reflected the staff found Resident #13 lying on her left side in front of the bathroom door with her walker by her side. The note documented Resident #13 did not have gripper socks on and the staff found them in her bed. Resident #13 said she was going back to bed after using the bathroom. Resident #13 complained of slight discomfort to her head without abnormalities. The note documented the new intervention as for staff to assure Resident #13 had gripper socks on throughout the night. The Fall Investigation form dated 11/30/24 documented the root cause of Resident #13's fall as she didn't have on proper footwear. The Fall Report Note dated 2/12/25 at 3:57 PM indicated when Resident #13 stood up unassisted, she fell to the floor in the dining room, and sat on her buttocks with her legs out in front. The note documented Resident #13 had a 10 centimeter (cm) by (x) 14 cm bruise that started to form. The note listed an intervention to educate staff to assure Resident #13 had the alarm under her at all times. The facility form titled 5 Why's Root Cause Analysis dated 2/12/25 identified the root cause of the fall as Resident #13 had impaired cognition, got up unassisted and didn't ask for help. In addition, it indicated Resident #13 had shoes on and had her alarm in place.The Report Note dated 3/30/25 at 5:36 AM reflected the staff found Resident #13 on the floor in her room lying on her right side near the top of her bed with both of her lower extremities extended out away from the bed. The note documented the bed alarm didn't sound and Resident #13's roommate alerted staff of her fall. The note listed the intervention as to apply gripper socks at bed time and for staff to check bed alarm placement when in bed.The facility form titled 5 Why's Root Cause Analysis dated 3/30/25 documented the root cause of the fall as Resident #13 being cognitively impaired and got up unassisted. In addition, the root cause documented Resident #13 had her gripper socks on with gripper strips on the floor in front of her bed.The Progress Note dated 7/6/25 at 12:09 AM identified the staff found Resident #13 lying on the floor on her right side in her room. She had a bed alarm in place but, it didn't work. The note documented Resident #13 had bare feet, because she removed her gripper socks in bed because her feet got too hot. The note documented Resident #13 sustained the following injuries from the fall:-right side of the head: 3 cm x 2.1 cm red raised area -right upper arm: 4 cm x 2.5 cm reddened area with 4 bruises in the proximal area of bruise. -top of the right foot: 4.4 cm x 4.1 cm bruise -left shin: 7.8 cm x 3.2 cm reddened bruise -distal area of the right elbow: 1.8 cm x 2.8 cm abrasion The note documented the intervention as staff to ensure that the bed alarm worked. If the alarm didn't work they needed to arrange for her to have a different resting place for close supervision. The facility form titled 5 Why's Root Cause Analysis dated 7/6/25 listed the root cause of the fall as Resident #13 had impaired cognition, she required assistance with mobility, and she got up unassisted without using her call light. The Fall Report Note dated 7/20/25 at 9:00 AM reflected the found Resident #13 sitting on her bottom with her legs extended and arms resting at her side in the common area in front of the TV console. The note documented Resident #13 had a skin tear to her right wrist that measured 3 cm x 2 cm. The nurse applied steri-strips. The note listed the fall intervention as to put the alarm under Resident #13 at all times and not just at bedtime. The facility form titled 5 Why's Root Cause Analysis dated 7/20/25 documented the root cause analysis of the fall as Resident #13 had impaired cognition and tried to transfer herself unassisted. The note indicated the staff didn't know why she tried to get up.On 8/20/25 at 12:10 PM, Staff H, Certified Nursing Assistant (CNA), reported Resident #13's alarm went into use at all times about a month or so ago because she continued to try and get up by herself. Staff H reported the staff transfer the alarm pad from her chair to her bed or to the couch. She said when the light started flashing on the alarm pad the battery needed to be changed. Staff H stated the facility had older alarms that didn't work, but they recently got new ones and she thought Resident #13 had one of the new alarms. During the interview with Staff H, the alarm monitor sounded at the nurses' desk. The alarm volume sounded very low, Staff H increased the volume on the alarm monitor.On 8/20/25 at 12:15 PM, the Director of Nursing (DON) acknowledged she completed the fall documentation for Resident #13 on 2/12/25 and verified she didn't have the alarm in place at the time of the fall. The DON reported they discussed resident falls and root cause analysis at a weekly meeting. When asked how they monitored Resident #13's alarm, the DON replied she thought they had the alarm on the Treatment Administration Record (TAR). She reviewed Resident #13's TAR and acknowledged it didn't contain Resident #13's bed alarm to be signed off by the nursing staff. She said that was her fault, and she would take one for the team. The DON described Resident #13 as difficult due to her cognitive impairments and that's why she had the alarm to prevent falls. She said the facility only had so much they could do. The DON acknowledged they attempted other fall interventions besides the bed alarm. On 8/20/25 at 3:12 PM, the Administrator reported the facility didn't have an alarm policy in place. On 8/20/25 at 3:14 PM, the DON reported she reviewed Resident #13's falls. She didn't find any additional fall interventions. She acknowledged the facility didn't conducted a thorough root cause analysis and the staff could have dug deeper into the falls. She said a resident always had a reason to try to get up. The Administrator was present and said they didn't like to use alarms, and the DON described alarms as a crutch for the staff. When asked regarding the fall risk assessment score, the DON responded the higher the score, the higher the risk for falls.On 8/20/25 observed Resident #13's cordless sensor had an alarm pad life good for 45 days. The pad lacked a start date and end date filled in. The warning label on the sensor pad documented the manufacturer didn't claim the device would stop elopements and/or falls.On 8/21/25 at 9:30 AM, the Social Worker reported herself as the person responsible for programming the alarms. She reported if a pad malfunctioned, the aides brought her the pad and she would replace it. The Social Worker acknowledged the facility didn't replace the alarm pad every 45 days per the manufacturer directions. She said she just changed the pads when they stopped working. The Social Worker acknowledged the sensory alarm pad had life of 45 days. She reported the facility used some of the alarm pads for over a year without issues, and some of the pads malfunctioned after 1 week of usage. She stated she educated the nursing staff that the alarms are not a fall intervention and wouldn't prevent a fall. The Social Worker said she expected the nurses to have additional fall interventions in place. She acknowledged the staff shouldn't use the alarms as interventions, and should try to figure out why the resident attempted to get up. She reported she had these types of conversations with the nursing staff, but didn't know for sure what the staff documented. The Fall Risk Assessment Policy revised December 2007 directed the staff to identify environmental factors that may contribute to falling. The staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.The Falls - Clinical Protocol policy revised September 2012 directed the staff to attempt to define the possible causes of a resident's fall within 24-hours of the fall. The policy further directed if they had an unclear cause of a fall, if the fall may have a significant medical cause, or if the resident continued to fall despite attempted interventions, a physician would review the situation, and help identify contributing causes. The policy instructed if the facility couldn't identify or correct underlying causes, the staff would try various relevant interventions, based on an assessment of the nature or category of the fall, until their falls reduces, stops, or until the facility identified a reason the falls continued.

Based on observations, facility record review, staff interviews, and the facility policy, the facility failed to provide adequate care for a urinary catheter for 1 of 1 resident reviewed (Resident #32). The facility reported a census of 37 residents.Findings include: Resident #32's MDS assessment dated [DATE] identified a BIMS score of 2, indicating severe cognitive impairment. The MDS included diagnoses of benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that commonly occurs in older men), Alzheimer's disease, and Parkinson's disease.The Nurse Progress Note dated 8/1/25 at 5:14 AM identified Resident #32 had a urinary catheter.The Clinical Physician Orders reviewed 8/20/25 listed an order dated 8/4/25 to change Resident #32's urinary catheter every month and as needed (PRN).On 8/18/25 at 10:22 AM, observed Resident #32's urinary catheter bag lying on the floor underneath his bed. On 8/19/25 at 1:45 PM witnessed Resident #32's urinary catheter bag hanging on the bed, lying on the floor without a dignity bag. The Catheter Care policy revised September 2014 defined the purpose of the procedure as to prevent catheter-associated urinary tract infections. The policy directed to make sure to keep the catheter tubing and drainage bag off the floor.On 8/19/25 at 2:35 PM the Director of Nursing (DON) reported they expected the catheter bag to be in a dignity bag and not touching the floor.

Based on observation, policy review, and staff interviews, the facility failed to keep the medication cart locked or under direct observation of authorized staff for a minimum of 7 minutes in an area where residents could access it. The facility reported a census of 37 residents. Findings include:Findings include: On 8/18/25 at 12:26 PM, observed the south side medication cart in the hallway near the nurse's station unlocked and unsupervised. During that time, witnessed the following:a.12:26 PM - 1 housekeeper walked past the unlocked medication cart. b.12:27 PM - 1 housekeeper walked past the unlocked medication cart. c.12:30 PM - 2 housekeepers walked past the unlocked medication cart. d.12:33 PM - Staff B, Licensed Practical Nurse (LPN), approached the medication cart. Staff B verified the medication cart was unlocked. Review of the undated facility policy titled, Storage of Medications, directed compartments containing medication are locked when not in use. Trays or carts used to transport such items are not to be left unattended. Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes. During an interview 8/21/25 at 8:27 AM, the Director of Nursing confirmed they expected medications to be locked when unsupervised.

Based on observations, interviews and policy review, the facility failed to ensure infection control practices were followed during 3 resident observations (Resident #1 and Resident #32). Staff A, Registered Nurse (RN) failed to disinfect her hands between changing gloves while completing Resident #1's wound treatments. Staff F, Certified Nurse Aide (CNA), failed to complete hand hygiene between changing gloves during Resident #32's catheter and perineal (peri). In addition, the facility staff reused the same 2 personal protective gowns when caring for Resident #32 on enhanced barrier precautions (EBP) for one week before washing. The facility reported a census of 37 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. The MDS included diagnoses of diabetes mellitus, cellulitis of left toe and non-pressure ulcer to left lower leg. The MDS reflected Resident #1 had applications of ointments/medications other than to his feet and applications of nonsurgical dressings to his feet in the lookback period. Resident #1's Clinical Physician Orders included the following: a. 8/19/25: Iodosorb and gauze to the left second toe only, soak wound for 10 minutes with Vashe or saline soaked gauze. Change 3 times per week. Clean right first toe with Vashe or saline with dressing only (no longer doing Iodosorb to R first toe) one time a day every Tuesday, Wednesday, Friday, Sunday for wound healing and every 24 hours as needed for wound healing. b. 7/22/25: Cleanse and apply a Mepilex to the left leg wound on bath days and as needed one time a day every Tuesday, Friday and Sunday for wound 3 times per week. On 8/19/25 at 11:21 AM observed Staff A, Registered Nurse (RN), complete wound treatment to Resident #1's right first toe and left leg. Staff A changed their gloves after removing the dirty dressing from Resident #1's left second toe. Staff A failed to completed hand hygiene before she applied new gloves. After completing the wound treatment to the first toe, Staff A changed gloves but failed to complete hand hygiene before applying the new gloves. The facility policy revised August 2015 and titled, Handwashing/Hand Hygiene, documented the following: a. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water after removing gloves. b. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. c. Perform hand hygiene before applying non-sterile gloves. During an interview on 8/19/25 at 11:30 AM, the Director of Nursing (DON) reported they expected staff to complete hand hygiene when changing gloves. 2. Resident #32's MDS assessment dated [DATE] identified a BIMS score of 2, indicating severe cognitive impairment. The MDS included diagnoses of benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that commonly occurs in older men), Alzheimer's disease, and Parkinson's disease. On 8/19/25 at 10:30 AM, observed Staff E, CNA, and Staff F, CNA, provide Resident #32 peri care and catheter care. Both CNA's performed hand hygiene and applied gloves to their hands. Staff E removed the front of the brief and performed Resident #32's front peri care and catheter care. Staff E removed their gloves and applied a new pair, without completing hand hygiene, before pulling up the front of Resident #32's brief. On 8/19/25 at 10:30 AM watched Staff E and Staff F apply a black gown that hanged on the back of Resident #32's door. Staff F stated they used the gowns for the EBPs for Resident #32. Staff F stated when they finished, they hang the gown back on the door, as they reused the gowns. Staff F stated they did that for all the residents who needed EBPs. On 8/19/25 at 1:30 PM witnessed Staff B, Licensed Practical Nurse (LPN), remove a black gown from the back of Resident #32's door and put it on to provide g-tube (a type of feeding tube) care. When Staff B completed the care, she placed the black gown on the back of the door. Interview on 8/19/25 at 11:50 AM the Director of Nursing (DON) stated the staff did reuse the gowns. The DON stated the staff reuse the gowns for the same resident, not for other residents. The DON stated she needed to contact housekeeping to see how they are cleaned. Interview on 8/19/25 at 12:10 PM the DON stated housekeeping changed the gowns on Monday mornings. Interview on 8/19/25 at 2:00 PM Staff I, Housekeeper, stated she took them to laundry and washed them separately on Monday morning and replaced them in the room. Interview on 8/19/25 at 2:15 PM Staff J, Environmental Services, described the black gowns as disposable. Staff J stated housekeeping collected them on Monday mornings and threw them away, then replaced them with new gowns. Staff J stated they had the gowns in the laundry room so if the staff needed a new one, they went to the laundry room to get a new one. Staff J stated she didn't know why they did it that way, that is just what they told her to do. Interview on 8/19/25 at 2:35 PM the DON shrugged her shoulders and stated she didn't know, they just did it that way. She stated her and the Administrator discussed it and thought it would be okay, but she was open for ideas. The undated website Iowa Health and Human Services described the one and done as the best practice for limiting the spread of hospital acquired infections. With routine use, one person used personal protective equipment (PPE), one time for one patient encounter, discard or fully cleans the equipment, as directed.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (Fiscal Year Quarters 1, 2, and 3, 2024) review, facility staffing review, policy review, and staff interviews, the facility failed to submit staff reports for the PBJ Staffing Data Report. The facility reported a census of 56 residents. Findings include: The PBJ Staffing Data Reports for Fiscal Year 2024, Quarters 1, 2, and 3 all triggered for the following: a. Failed to Submit Data for the Quarter b. One Star Staffing Rating c. Excessively Low Weekend Staffing d. No RN hours d. Failed to have Licensed Nursing Coverage 24 Hours/Day Review of nursing staffing schedules for August and September 2024 revealed appropriate nursing staffing, 8-hour daily RN coverage, and 24 hours/day Licensed Nursing coverage. Interview on 9/26/24 at 11:51 AM, the Administrative Assistant/Office Manager acknowledged the facility didn't successfully submit the staffing data for quarters 1, 2, and 3 as they had changes to the facility's time clock system that she didn't know about. The submitted reports ran with the new time clock system had an incorrect format for the PBJ reporting. As a result, the facility didn't successfully submit the data. Once the Administrative Assistant/Office Manager knew of the formatting problem, she learned CMS's application for submitting the data had changed. Since then, she has no access for this program and had worked with CMS to try to correct this. Review of facility provided Staffing policy, revised October 2017 revealed the following: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation a. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. b. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. c. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are also staffed to ensure that resident needs are met. d. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll based journal system on the schedule specified by CMS, but no less than once a quarter.

Based on interviews, observations, and record review, the facility failed to initiate Enhanced Barrier Precautions (EBP) and they facility didn't know what they were. At the time of the survey 1 resident had a catheter (Resident #23) and didn't have EBP set up in his room. In addition, the facility failed to handle laundry from isolation rooms while wearing the appropriate Personal Protective Equipment (PPE). The facility reported a census of 35 residents. Findings include: Resident #23's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #23 had an indwelling catheter. The MDS included a diagnosis of retention of urine. On 9/23/24 at 11:50 AM, Resident #23 stated he had a catheter and it drained into a leg bag inside of his pant leg. His room didn't have an EBP sign or cart with PPE set up. An email from the Administrator dated 9/26/24 at 1:26 PM documented the facility would initiate EBP for Resident #23 due to his catheter. An additional email from the Administrator dated 9/26/24 at 1:32, documented that the facility didn't have any residents with chronic wounds. On 9/26/24 at 10:37 AM, when questioned about EBP, the Director of Nursing (DON) and the Administrator responded they didn't hear or know about it, nor did they remember getting information about it. They looked over EBP information off the website. They stated they would initiate EBP right then. On 9/26/24 at 11:01 AM during a walk-through the laundry room, Staff C, Laundry Aide, stated she didn't wear a gown nor has she ever worn a gown when handling isolation laundry in red bags. She stated she put on a mask, gloves, and face shield before, but never put on a gown. She stated she washed the isolation red bags last and she sits the bag on the ground. Then she grabbed the bag at the bottom after opening it up at the top, then tipped and shake the contents out of the red bag into the washing machine. Afterwards, she disposed of the red bag into a biohazard container. On 9/26/24 at 12:50 PM, the Administrator stated they understood the concerns with the staff not wearing a gown when handling isolation laundry bags and the facility not having EBP in place. A Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Reference: QSO 24 08 NH dated 3/20/24, documented the following: Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs) Background: Multidrug resistant organism (MDRO) transmission is common in long term care (LTC) facilities (i.e., nursing homes), contributing to substantial resident morbidity and mortality and increased healthcare costs. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. In 2019, CDC (Center for Disease Control) introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP) as a strategy in nursing homes to decrease transmission of CDC targeted and epidemiologically important MDROs when contact precautions do not apply. The approach recommended gown and glove use for certain residents during specific high contact resident care activities associated with MDRO transmission and did not involve resident room restriction. As described in the Healthcare Infection Control Practices Advisory Committee (HICPAC) white paper, Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021, more than 50% of nursing home residents may be colonized with an MDRO. This report noted that the use of contact precautions to prevent MDRO transmission involves restricting residents to their rooms, which may negatively impact a resident's quality of life and psychosocial well being. As a result, many nursing homes only implemented contact precautions when residents are infected with an MDRO. Memorandum Summary In July 2022, the CDC released updated EBP recommendations for Implementation of PPE Use in nursing homes to prevent spread of MDROs, and therefore, CMS is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC targeted or other epidemiologically important MDRO when contact precautions do not apply. This new guidance related to EBP is being incorporated in F880 Infection Prevention and Control to assist LTC surveyors when evaluating the use of enhanced barrier precautions in nursing homes. We note that facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. Memorandum Summary of CMS is issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. o EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their multidrug resistant organism status. o The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control. An undated Linen, laundry, textile handling policy, directed the following: The facility staff should handle all used laundry as potentially contaminated and use standard precautions (e.g., gloves, gowns when sorting and rinsing). The facility should use the following practices: Policy Interpretation and Implementation a. Staff should handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces and persons. b. Employees should perform hand hygiene and wear appropriate PPE for sorting and handling contaminated laundry.

Based on employee's file review, facility policy, and staff interview, the facility failed to assure 2 of 5 employees met the requirements for Mandatory Adult Abuse Training (Staff A and Staff B). The facility reported a census of 35 residents. Findings include: A review of Staff A's, Dietary Aide, employee file listed a hire date of 1/29/24. The file listed a due date of the two-hour Dependent Adult Abuse Mandatory Reporter Training as 7/29/24. The file lacked a certification of completion. A review of Staff B's, Dietary Aide, employee file listed a hire date of 2/2/24. The file indicated a due date of the two-hour Dependent Adult Abuse Mandatory Reporter Training as 8/29/24. The file lacked a certification of completion. Review of facility Abuse Prevention Policy, revised December 2016, stated: As part of the resident abuse prevention, the administration will: require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. In an interview on 9/26/24 at 11:50 AM, the Administrator acknowledged the employees should have completed the Dependent Adult Abuse Mandatory Reporter Training within six months of their hire date. In an interview on 9/26/24 at 12:06 PM, the facilities Administrative Assistant/Office Manager acknowledged the employees didn't complete the required Dependent Adult Abuse Mandatory Reporter Training.

Based on observation, clinical record review, staff interview and policy review, the facility failed to follow standard practices and protocol for infection prevention during wound care for 1 of 2 residents reviewed (Resident #28). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #28 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognitive response. The MDS further documented the resident had diagnoses including medically complex conditions, cancer, anemia, coronary artery disease, heart failure, renal insufficiency, diabetes mellitus and cellulitis of right axilla (armpit). The Care Plan for Resident #28 revised 10/9/23 with a focus for the area to the right axilla documented under interventions and tasks to follow wound protocol per order and treatment to the area at right axilla per order. Clinical record review of Physician Orders for Resident #28 revealed an order for Aquacel Ag Foam External Pad (Silver) to apply to right axilla topically one time a day every Monday, Wednesday and Friday for wound healing related to cellulitis of right axilla, cleanse area with normal saline or wound cleanser, apply Aquacel, and cover with 4X4 Mepilex. During an observation on 11/15/23 at 8:55 AM, Staff A, contracted Registered Nurse (RN), conducted wound care to Resident #28 ' s right axilla. The facility Director of Nursing (DON) was present during the wound care. Staff A brought supplies to the resident's room with bare hands, placed the supplies on the tray table in the resident's room, washed her hands, applied gloves, and then removed tools from a backpack and placed the tools on the tray table. Staff A did not place a barrier down on the table and did not sanitize the table. Staff A sprayed Dermal (antimicrobial) on clean gauze that had been placed in a plastic cup, removed the new dressing from the wrapper, dated the dressing, then cut a square off the Aquacel with scissors that had been placed directly on the tray table. Staff A then removed the previous dressing from the resident, placed the dressing in a trash can and then cleaned the wound bed with Dermal spray on the gauze. Staff A then removed a curettage (tool used to remove tissue) and used this tool in the wound area. Staff A then measured the wound and put the square of Aquacel on the wound. Staff A then removed the new dressing from the package, touching the inside of the clean dressing with the same gloved hands used to clean the wound and touch supplies on the table. Staff A did not wash or sanitize hands or change gloves in between removing the previous dressing, cleaning the wound and applying the new dressing. Staff A then removed gloves, washed hands, put on new gloves, and cleaned the scissors and the pen with an alcohol wipe. During an interview 11/15/23 at 12:10 PM, the DON acknowledged concerns with the wound care of Resident #28 conducted by Staff A. The DON verified Staff A did not have a clean field prior to setting down supplies on the tray table and did not change gloves after cleaning the wound. The DON stated she expected staff to have a clean field prior to setting down supplies for wound care. She verbalized she expected staff to change gloves after cleaning the wound and before applying a new dressing. The DON acknowledged the facility wound care policy was not followed and this is a concern for infection control. The facility policy titled Wound Care revised October 2010 instructed staff to use a disposable cloth to establish a clean field prior to wound care. It further instructed staff to wash and dry hands thoroughly and put on exam gloves to remove the dressing, then apply clean gloves to cleanse the wound with a no touch technique.

Based on clinical record review, staff interviews and policy review the facility failed to ensure assessments before and after outpatient hemodialysis treatments were completed for 1 of 1 resident reviewed for dialysis, (Resident #4). The facility reported a census of 30 residents. Finding include: Resident #4 ' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 13, indicating intact cognition. The MDS identified Resident #4 required extensive assistance of two persons with bed mobility and limited assistance of one person with transfers, ambulation in room and toilet use. The MDS included diagnoses of hypertension (high blood pressure), cancer, anemia, coronary artery disease, diabetes mellitus, chronic kidney disease with dependence on renal dialysis (running blood through an external machine to rid the blood of toxins). The Care Plan with a revised date of 6/27/23 identified a need for hemodialysis on Tuesday, Thursday, and Saturday. The Care Plan directed staff to do the following: -Monitor, document and report as needed any signs and symptoms of infection to the access site: redness, swelling, warmth or drainage. -Monitor, document and report as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. -Monitor, document and report as needed new or worsening peripheral edema (swelling on legs). A Physician Progress note dated 7/24/23 revealed Resident #4 had a right chest port for dialysis treatments. The August 2023 Medication Administration Record (MAR)/Treatment Administration Record (TAR) failed to direct staff to complete pre/post hemodialysis assessments on Tuesday, Thursday, and Saturday or a daily assessment for Resident #4. Review of August 2023 calendar revealed Resident #4 should have attended hemodialysis on the following dates: 8/1, 8/3, 8/5, 8/8, 8/10, 8/12, 8/15, 8/17, 8/19, 8/22, 8/24, 8/26, 8/29 and 8/31. The clinical record lacked documentation pre and post dialysis assessment for Resident #4 were completed for the month of August 2023. The documentation lacked assessments regarding status of the resident, the dialysis port, and complete/full set of vital signs before and after dialysis. The clinical record revealed no dialysis evaluations/assessments on non-dialysis days for the month of August 2023. An undated facility policy titled Policy and Procedures for Dialysis Services documented the purpose of the policy was to ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the residents' goals and preferences. The policy directed coordination and collaboration between the facility and the dialysis facility to assure the following: 1. The resident's needs related to dialysis treatments are met. 2. The professional standards of practice are met including: a. The ongoing monitoring for complications related to dialysis treatments received at a certified dialysis facility including but not limited to the port site with cares, blood pressure and weight changes and informing the attending practitioner and dialysis facility of the changes. b. The nursing home staff must be aware and identify changes in the resident's behavior that may impact the safe administration of dialysis, including, resistance to care, and pulling on tubes, access sited and inform the attending practitioner and dialysis facility of the changes. The policy further directed the facility staff to contact and communicate with the practitioner, resident/resident representative, and designated dialysis staff regarding any significant changes in the resident's status related to the clinical complications or emergent situation that may impact the dialysis portion of the care plan. These situations may include but are not limited to changes in condition or sudden unexpected decline in condition, dialysis complications such as bleeding, hypotension or adverse consequences to a medication or therapy, or other situations. On 8/31/23 at 11:50 AM, Staff A, Licensed Practical Nurse (LPN) reported Resident #4 had a port for dialysis. Staff A stated she would obtain a blood pressure after Resident #4 returned from dialysis and would document the reading in the medical record. Staff A stated there was not an assessment form to fill out. Staff A reported she does not complete any other vital signs or an assessment after Resident #4 returned from dialysis. On 8/31/23 at 12:05 PM, the Director of Nursing (DON) acknowledged and verified pre and post dialysis assessments have not been completed. The DON stated she would start the assessments right away.

Based on observations, interviews, and record reviews, the facility failed to keep the kitchen clean. An ice machine had a layer of calcium or lime, broken tile in front of the dishwasher and wooden cupboards storing kitchen equipement were tacky to the touch during the initial kitchen walk through. The facility reported a census of 27. Findings include: On 5/17/21 at 11:00 AM, an initial walk through was done with the Dietary Manager (DM) present. The following was observed: a. broken floor tile in the dishwashing area. b. wooden cabinets were sticky to touch. c. a line of hard build up was on the ledge above where door opens on a ice machine. In an interview at the time of the walk through, the DM stated: a. They were in the works for the floor tile to be replaced and all new stainless steel walls were put in dishwasher room. b. The cupboards are difficult to clean. Kitchen staff in the area agreed with the DM. c. The build up on the ice machine needed to be cleaned off. An undated copy of a construction note which was provided by the Nursing Home Administrator (NHA), documented that a review of the kitchen floor tile to be replaced was completed and possible repair options were being looked into. The NHA left to get confirmation of date the note was written. On 5/20/21 at 2:00 PM, the NHA provided the same construction note with the date Febrruary 8th, 2021 written on it. The NHA stated she got the date from looking at when the stainless steel walls were put into the kitchen as it was the same day the kitchen tile was looked at for possible repair options. A Sanitzation policy dated 2017, documented the food service area shall be maintained in a clean and sanitary manner. It directed that ice machines will be cleaned and sanitized and that kitchen surfaces that are not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.

Based on observations, interviews and record review, the facility failed to address pain in the resident's comprehensive plan of care for 1 of 12 residents reviewed, ( Resident #23). The facility did not include or address in the comprehensive care plan the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required related to pain. The facility reported a census of 27. Findings include: In a Minimum Data Set (MDS) with an Assessment Reference Date of 4/10/21, Resident #23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) was scored at 13 out of 15 indicating intact cognition. Resident #23 required extensive assist of 1 for bed mobility, transfer, dressing, and toilet use. The MDS documented the resident had rated her pain on a scale of 0-10 at a 5 over the prior 5 days. Resident #23 had received scheduled and prn pain medication but had not received non-medication interventions for pain. A Progress Note dated 5/18/21, documented [MEDICATION(S)] (pain medication) was discontinued but clarification would be sought from the Physician's Assistant the following day as the order was just started and resident does have chronic back pain. An Order Summary Report dated 5/20/21, directed nurses and medication staff that Biofreeze Colorless Gel was to be applied to back two times a day for back pain, to left back thigh as needed at HS (hour of sleep) for pain, and to left back thigh once a day for left back thigh pain. Acetaminophen 650 mg three times a day and Acetaminophen 650 mg every 4 hours as needed were to be administered for pain. A Care Plan provided by the facility and printed on 5/20/21, revealed pain, pain medications, and/or pain interventions were not addressed or included in Resident #23's comprehensive care plan. On 5/18/21 at 10:16 AM, Resident #23 stated she was in pain. The resident was dozing in and out of sleep. Resident #23 stated her pain was at an 8 or 9 in two places. When asked if it was at an 8 or 9 on a scale of 1 to 10, she answered not now. On 5/20/21 at 11:19 AM, the Director of Nursing (DON) and the MDS Nurse reviewed Resident #23's Care Plan and concurred pain was not on the care plan. The DON stated [MEDICATION(S)] was ordered as the pain was new. When asked about frequent pain, the MDS Nurse concurred pain was coded as being frequent on the MDS. On 5/20/21 at 1:18 PM, the MDS Nurse stated that this resident was not care planned for pain and should have been. The MDS Nurse was going to amend the care plan to address frequent pain.

Based on interviews and record review, the facility failed to document the weekly progress of care for a pressure ulcer consistent with professional standards of practice for 1 of 3 residents reviewed, (Resident #23). The facility did not provide 2 weeks of the required weekly documentation of a pressure ulcer status from 2/18/21 to 5/19/21. The facility reported a census of 27. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. In a Minimum Data Set (MDS) with an Assessment Reference Date of 4/10/21, Resident #23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) was scored at 13 out of 15 indicating intact cognition. Resident #23 required extensive assist of 1 for bed mobility, transfer, dressing, and toilet use. The MDS documented Resident #23 had one Stage 3 pressure ulcer present upon admission and was at risk of developing pressure ulcers On 5/17/21 at 2:59 PM, Resident #23 stated it was okay for surveyor to watch dressing change to her pressure ulcer the following day. Resident #23 was in bed. On 5/18/21 at 10:12 AM, Resident #23 stated she would allow a few questions but did not want an observation of her wounds. She stated she had been told that morning that her bottom sores were looking better. Resident #23 was in her room sitting in her recliner. During a review of Resident #23's records, the Wound/Skin Record was looked over for the coccyx wound. The record documented on 2/18/21 this resident had an unstageable pressure ulcer. This record revealed the next entry was documented on 3/3/21 which showed a lack of weekly assessment and documentation. Furthermore, the record showed an assessment was done on 3/10/21, then not again until 3/24/21, which revealed another weekly assessment with documentation was missing. On 5/20/21 at 1:18 PM, the MDS Nurse stated the assessments needed to be done weekly and acknowledged the absence of the two assessments identified in the above paragraph. On 5/20/21 at 3:00 PM, the Director of Nursing (DON), stated she was disappointed in her Nurses as she had repeatedly gone over with them the need for the weekly assessments and documentation of pressure ulcers. The DON acknowledged the documentation was missing 2 weeks of assessments. On 5/20/21 at 5:45 PM, the DON provided documentation of one of the two missing assessments and stated she found one of the two anyway. In a copy of a fax dated 2/22/21 that was provided by the DON as further documentation of the coccyx pressure ulcer, revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 5/24/21 at 12:43 PM, the DON stated the documentation was from the Wound Nurse and the DON thought the documentation was for the coccyx pressure ulcer. She acknowledged the fax was for a right heel ulcer and would not apply to the missing coccyx pressure ulcer documentation.

Based on observations, interviews and record review, the facility did not provide respiratory care consistent with professional standards. The facility failed to administer oxygen per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 27. Findings include: In a Minimum Data Set (MDS) with an Assessment Reference Date of 4/10/21, Resident #23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) was scored at 13 out of 15 indicating intact cognition. Resident #23 required extensive assist of 1 for bed mobility, transfer, dressing, and toilet use. An Admission Record form with a print date of 5/20/21, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/21 at 2:58 PM, observed Resident #23 with oxygen(O2) on per nasal cannula(nc). On 5/18/21 at 10:14 AM, observed Resident #23 with O2 on at 2 L(liters) per nasal cannula from oxygen concentrator. On 5/18/21 at 10:37 AM, Resident #23 had a harsh, wet cough. It was noted the cough was present the day before as well. On 5/19/21 at 9:59 AM, Resident #23 was sitting in a common area reclined in a recliner. The resident was greater than 6 feet apart from the other resident in the room. A wet cough noted. Resident #23 stated the cough had not gotten worse. The resident stated she was comfortable and had O2 on per concentrator. On 5/19/21 at 12:10 PM, Resident #23 was in the dining room with the O2 concentrator by her side and the nc in her nose. On 5/19/21 at 1:10 PM, the resident was in her bed with O2 on. On 5/19/21 at 2:57 PM, Resident #23 was in her room in bed with O2 on at 2L per n/c. A Care Plan with focus and intervention date of 3/4/21, documented Resident #23 was at a risk for a self-care deficit related to weakness and [CONDITION(S)]. It directed nursing to check oxygen saturation shiftly and that this resident uses oxygen if the oxygen saturation was below 90% on room air. A Treatment Administration Record (TAR) dated 5/1/21-5/31/21, directed staff that oxygen at 1-2 liters to keep oxygen saturation above 90% was to be used as needed for [CONDITION(S)]. The TAR showed one instance of the oxygen being used on 5/15/21. This entry did not record the resident's oxygen saturation level. The TAR nor the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/20/21 at 11:19 AM, the Director of Nursing (DON) and the MDS Nurse reviewed Resident #23's Care Plan and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . They acknowledged the order for oxygen was a PRN order and was Care Planned to be used on a PRN basis. They further acknowledged that oxygen saturation checks had only been done one time in May and that these checks were to be done prior to applying oxygen. Both the MDS Nurse and the DON concurred that observations of Resident #23 had been correct and Resident #23 had been on continuous oxygen during the week of the survey without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on document review and staff interview the facility failed to ensure staff certified in Cardiopulmonary Resuscitation (CPR) was scheduled 24 hours per day. The facility reported a census of 27 residents. Findings: During a review of the facility document titled Schedule Sheet dated ,d+[DATE] and ,d+[DATE], the document failed to show scheduled staff certified in CPR coverage for any complete 24 hour day for the dates from [DATE] through [DATE]. During an interview on [DATE] at 2:47 PM, the Director of Nursing (DON) confirmed the facility only had 3 CPR certified nurses. The DON acknowledged she had 4 nurses complete the on-line exam portion of a CPR course on [DATE], after surveyors had entered on [DATE] for the facility's annual recertification survey. The DON confirmed the 4 nurses had not completed the skills portion of the CPR certification, so certification was not complete. The DON acknowledged the facility failed to have 24 hour certified CPR coverage for any days from [DATE] through [DATE]. The DON stated expectation for all facility nurses to be CPR certified to ensure the facility had 24 hour CPR coverage.

Based on observations, interviews and record reviews, the facility failed to assure food was prepared and appropriate to meet resident's need according to their assessment and care plan in 1 of 27 residents, (Resident #11). During lunch service on 5/19/21 Resident #11 required a mechanical soft diet and was served a regular consistency goulash which contained corn. The facility reported a census of 27. Findings include: A Minimum Data Set with an Assessment Reference Date of 3/10/21, documented Resident #11's diagnoses included [CONDITION(S)], [CONDITION(S)] or [CONDITION(S)] bowel disease; anxiety disorder and gastro-[CONDITION(S)] reflux disease without esophagitis. The Brief Interview for Mental Status (BIMS) was scored at an 11 out of 15 indicating a mild cognitive deficit. The resident required supervision with assist of 1 to dine. Resident #11's diet was documented as mechanically altered, requiring change in texture of food. An Admission Record printed on 5/20/21 at 4:42 PM, documented further diagnoses of depression and unspecified mood (affective) disorder. An Order Summary Report dated 5/20/21, documented Resident #11's diet as Mechanical soft/cut meat texture, regular consistency, alternate bites/sip/ no straws, crush pills in sauce, sit up 90 degrees, slowly feed small bites/sips. The start date of this diet was dated 2/5/21. A Care Plan with last review date of 3/10/21, directed staff this resident was to have meat cut into bite size pieces and to serve diet as ordered. On 5/19/21 during lunch service that started at 12:02 PM, it was noted Resident #11 received regular goulash with corn in her goulash. During the lunch service on 5/19/21, Staff C, Cook, pulled goulash out of oven and said this is the goulash for mechanical soft diets as it has no corn. Staff C saw one corn kernel in the goulash and removed it. Staff C had already served Resident #11 goulash with corn in it from the regular diet goulash pan prior to getting the goulash made for residents who require a mechanical soft diet. Staff C had gotten the mechanical soft goulash out for another resident who required a mechanical soft diet. A Diet Type Report dated 5/17/21 and provided by the facility, documented Resident #11's diet was regular diet mechanical soft/cut meat with additional directions of alternate bites/sip, no straws, crush pills in sauce, sit up 90 degrees, slowly feed small bites/sips, 1800 cc fluid restriction. A Week #3 Wednesday Diet Spreadsheet dated 5/26/21, documented for a regular diet 6 ounces of grandma's goulash was to be served. It documented for a mechanical soft diet 6 ounces of grandma's goulash, no corn was to be served. On 5/20/21 11:35 AM, the Dietitian stated that for residents on mechanical soft diets- the menu said goulash, no corn. The goulash should not have had corn in it. The Dietitian agreed with the menu. If the menu says no corn, then there should not have been corn in it. The Dietitian said she approved and signed the menus. She added the menus are also approved by Martin Brothers Dietitians. On 5/20/21 at 3:02 PM, the Dietary Manager (DM), stated residents on a mechanical soft diet should have received the mechanical soft goulash.

Based on observation, clinical record review and staff interviews, the facility failed to follow door alarm procedures to ensure each resident received adequate supervision to prevent elopement for one of four residents reviewed that were at risk for elopement, which resulted in an immediate jeopardy to resident health and safety. (Resident #1) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had no wandering and was independent with ambulation in the room and corridor, and required supervision for off unit activities. A care plan dated as initiated 4/5/18, identified a focus area titled Wandering, elopement risk related to impaired cognition and confusion. A goal with a target date of 4/2/19, established the expectation the resident would not leave the facility unattended and directed staff to place Wanderguard (alarm monitoring device) on her walker, staff to check functioning every shift, and when resident heading in the direction of exit doors, provide distractions by offering pleasant diversions. A document titled Wandering Risk Scale dated 1/1/18 identified the resident scored an 11, which indicated high risk for wandering. A document titled Elopement Form dated 5/28/19, identified the resident was last seen by facility staff at 6:20 p.m. and was found outside by an Assisted Living employee, Staff A, Licensed Practical Nurse, LPN at 6:34 p.m. walking around and looking for kids, and was returned to the facility unharmed. 10 minute checks were initiated to prevent the resident from eloping the building again. An undated administrative note titled Timeline, reviewed with the Administrator on 6/5/19 at 3:20 p.m., revealed on 5/28/19 4:30 p.m., the resident attempted to exit the front main entrance, breeching the interior exit door to the foyer. Was returned to the unit by the Administrative Assistant, who alerted staff the resident was more confused and required increased monitoring. The Administrator confirmed no formal monitoring was initiated. On 5/28/19 at 6:20 p.m., staff observed the resident in the main dining room. At 6:34 p.m., the main front door alarm sounded. Staff B, LPN silenced the alarm at the keypad and returned to the main dining room. From the main dining room Staff B, LPN and Staff C, Certified Nurse Aide, CNA visually checked the front entrance door, witnessed two unidentified visitors leaving. Staff B, LPN returned to the keypad and reset the alarm system. At 6:38 p.m., the Administrative Assistant notified by Staff A, LPN the resident was found outside by a visitor at the Assisted Living building. The Administrator confirmed staff was unaware the resident had exited the building and was not looking for her. Review of an undated facility document titled, Employee Orientation Checklist outlined the review of emergency procedures, specifically walk away residents. The Administrator confirmed during interview on 6/5/19 at 3:20 p.m., staff was trained as a new employee and routinely with emergency preparedness in-service education and understood the following protocol labeled as Alarm System. The Administrator clarified they would have expected staff to follow alarm policy and proceed to the door when the alarm sounded and check for exiting residents. Review of a documented titled Alarm System, dated as last reviewed on 5/29/19, revealed the following expectations to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. If an alarm sounds, alarm will be silenced, and opened door will be announced over intercom pager system. Staff will proceed to open door and check perimeters of door for exiting resident. The Alarm System policy was labeled as amended on 5/29/19 to clarify: If visitors set off alarms, staff will still proceed to check perimeters for residents potentially following visitors outdoor. During interview on 6/5/19 at 4:00 p.m., Staff B, LPN stated on 5/28/19 at 6:34 p.m. they heard the door alarm and went immediately to the North alarm keypad and silenced it. Staff B returned to the main dining room where she and Staff C, CNA observed a man and a woman leaving the exterior door at the main entrance. Staff B confirmed the people leaving had exited the interior door and visualized through the window on the wood interior door. Staff B admitted they did not recognize the individuals, which was unusual, and could not clearly see. Staff B did not think it was a resident, and admitted they failed to go the entrance door to visualize the perimeter. Staff B acknowledged she probably should have gone to the entrance. Staff B returned to the North keypad, even though the South keypad was adjacent to the alarmed door, and reactivated the alarm. Staff B confirmed being unaware the resident had exited the building and was not actively looking for them. Staff B was made aware the resident was more confused after an outing with the daughter and had made an attempt to exit earlier that day. During interview on 6/6/19 at 9:40 a.m. Staff C, CNA stated on 5/28/19 they were in the main dining room when the alarm sounded. Staff B, LPN silenced the alarm and returned to the main dining room. Staff C looked from where they were standing in the main dining room and saw a man and a woman leaving, it was not a resident. Staff C admitted they could not see that well as the individuals were already through the interior door, could have been wrong and did not recognize the individuals. Staff C acknowledged the expectation was to see who set off the alarm and they should have gone down to the door. During interview on 6/6/19 at 9:20 a.m., Staff A, LPN stated on 5/28/19 they were working in the assisted living building and was notified by a visiting family member that a resident from the nursing home was outside. Staff A stated they immediately went outside and found the resident in front of the entrance to the assisted living building, with a walker, looking for her car. Staff A stated they called the Administrative Assistant at nursing home at 6:38 p.m., as determined by the telephone call log. Staff A confirmed expectation when alarm sounded to go to the alarmed door and check the area for resident. During an environmental tour on 6/6/19 at 10:30 a.m., the Administrator demonstrated the actions the staff had taken and route the resident took on 5/28/19 after exiting the facility and assisted to measure the distances as described below: The distance from the main dining room to the front entrance was 96 feet. The doors Staff B and Staff C visualized the man and women leaving was at this distance. The exit doors were made of wood with a window in each door that measured 19 inches tall by 9 inches wide. The front entrance leads to a sidewalk with a 5 ½ inch curb, that leads to a parking lot (Bennet Drive), with parking for 45 or more cars that was accessed by a busy street (Gilman Street) that semi-tractor trailers were noticed to be traveling with a 35 mile per hour speed limit. The resident walked approximately 95 surveyor paces to the assisted living on the sidewalk. Gilman Street measured 100 surveyor paces through the parking lot. Gilman Street intersects with Highway 65 in approximately ½ mile at a busy intersection. The weather on 5/28/19 was 61 degrees Fahrenheit and cloudy. IMMEDIATE CORRECTIVE ACTION was completed on 5/28 & 5/29/19 by implementing every fifteen minute resident checks and the alarm policy was changed to include when visitors set off the alarm staff will proceed to check the perimeters for residents. Training of all staff was completed on 5/28-29/19 regarding the alarm policy and changes of the alarm policy. Therefore, this will be considered a past non-compliance IJ.

Based on clinical record review and staff interview the facility failed to ensure safety equipment worked properly for one of three residents who sustained a fall with a fracture (Resident #4). The facility census was 36 residents. Findings include: 1. According to Resident #4 ' s MDS (Minimum Data Set) assessment dated [DATE] for a significant change in condition. The MDS reflected Resident #4 ' s Brief Interview for Mental Status as 7 that indicated severe cognitive impairment. According to the MDS Resident #4 required extensive assistance of two staff members for bed mobility, transfers, dressing, walking in the room and corridor, toilet use and personal hygiene. Resident #4 ' s [DIAGNOSES REDACTED]. The MDS documented Resident #4 experienced a fall with an injury except for major injury. A facility policy/procedure titled Transfer/Gait Belts/Ambulation and Use of Safety Straps/Belts, revised on 11/08, directed the staff will use gait belts on residents who require assistance with transfers and/or ambulation when mechanical lifting devices are not used. The policy/procedures included directives to always keep one hand on the resident's gait belt and the other hand on the resident's walker. The staff members are directed to grasp the gait belt firmly and walk about a half step behind the resident. The staff members are to ambulate or transfer the resident to the shower or whirlpool chair following applicable guidelines. Resident #4 ' s Care Plan initiated on 8/19/15, included a focus area of resident needs extensive assistance from staff with activities of daily living. Resident #4 changes his/her mind about staff assisting or not assisting with dressing. Resident has a history of falls at home roughly 6 in the past year , also has glaucoma and takes medications to treat hypertension, [DIAGNOSES REDACTED] and depression that does put at risk for fall. Reside has pin in shoulders and spine and also has had lung cancer in the past and still sees the oncologist at the VA, these concerns do put Resident #4 at risk for skin impairment and altered comfort. On 11-20-15 resident had a CAT scan that identified a compression fracture in sacrum, and is having increased pain. As of 12-2-15 pain medication has been increased twice to control pain. Resident #4 has not had a functional decline from compression fracture. The problem included the following Fall reduction interventions: 1. Rearrange room to have a clear path in room. 2. Follow Physical and Occupation Therapy recommendations. 3. Smart alarm in bed and chair to alert staff of transferring unassisted. 4. After meals and returning to room offer toilet and transfer to recliner of bed for comfort. 5. Place a large sign on walker to use the call light and ask for assistance. 6. Room moved closer to the nurse ' s station. A Tinetti Assessment Tool for Balance dated 7/31/15, documented resident unable to perform test. Alarm placed on resident for safety. Will use 2 person transfer until therapy assessment. A Fall Nurses Notes and Fall Scene Investigation form dated 11/5/15 at 11:30 a.m., documented resident sitting on floor beside bed with legs bent, resting on left hip. Walker out in front of resident. Resident facing the television. Resident states I was going to go to the bathroom and my foot slipped out. I fell hitting my head (pointing to left temple) on the foot board. I then landed on my knees then my tailbone. Noted chair alarm failed to sound. A Fall Nurses Notes and Fall Scene Investigation form dated 10/13/15 at 1:20 p.m., documented staff entered room and found resident lying on back attempting to reach for foot board of empty bed to pull self-up. Resident #4 reports attempting to get to bed, got up out of wheelchair and lost balance. Alarm failed to sound. Alarm checked later and was working. A Physician communication sheet dated 11/5/15, documented resident fell - did not use call light, will place large sign on walker with reminder to use call light and wait for assistance. Doctor responded OK-observe for any problems. A Physician communication sheet dated 11/9/15, documented resident complains of coccyx pain has bruise on right buttocks. Do you want x-rays due to Resident #4 ' s 11/5/15 fall. Doctor responded-OK to get sacrum/coccyx X-rays for pain after a fall. A Physician communication sheet dated 11/18/15 documented staff assessed tailbone (coccyx) pain today Resident #4 reports. Pain medications help decrease pain some but always present at a 4 or 5 out of a pain scale of 10. Pain can get up to 9 out of 10. Order after X-ray was if pain persists could do CT of pelvis. Questioned Resident #4 regarding CT and resident would like to have done. Doctor responded OK for CT of pelvis. A Computed Tomography dated 11/19/15 at 2:10 p.m., documented CT pelvis without contrast of sacral pain due to fall. Impression: a. Acute to subacute appearing misplaced and slightly angulated fracture involving the mid sacrum at the junction of S 3 and S 4. A Physician note dated 11/20/15 at 12:55 p.m. on the 11/19/15 CT Scan acknowledged the results and identified pain relief is all that can be done for Resident #4 related to the fractured sacral pain. Interview on 12/7/15 at 9:44 a.m., during the initial tour of the facility with the facility director of nursing, confirmed and verified that the facility is at fault that the alarm failed to sound and that the alarm system in the facility is 70-80% non-effective. II. Based on observation, interview and record review, the facility failed to provide adequate nursing supervision for one resident with swallowing difficulties (Resident #1) and failed to ensure harmful chemicals were stored in a secured area. The facility census was 36 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 11/25/15, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required no assistance or supervision with eating, but required a mechanically altered diet. The care plan dated 8/30/13, documented the resident as on a mechanically altered diet due to swallowing evaluation showing silent aspiration. The care plan directed staff to provide a mechanical soft diet, provide cues to alternate food and liquids and use a double swallow technique. The care plan also directed the resident to continue eating and drinking at a slow rate, eat and drink upright at 90 degrees during and 20-30 minutes, take small bites and drinks, no straws. During observation on 12/8/15 at 12:15 p.m., Resident #1 sat alone in his/her room in a recliner with a lunch tray. The resident ate a bowl of soup and ham salad sandwich independently, although the care plan directed staff to provide cues. The resident did not use a double swallow technique and did not alternate food and liquids. On 12/9/15 at 2:30 p.m., the Director of Nursing stated the resident should not have been eating unsupervised in their room. 2. On 12/8/15 at 11:00 a.m., observation revealed an unlocked cupboard in an unlocked soiled utility room on the 200 hall with the following items: a. An aerosol spray can labeled disinfectant spray with a warning label to keep out of reach of children. b. A large jug of pink liquid labeled Mikro Quat Germicide with a warning label hazardous to humans. c. A large jug of Clorox bleach with a warning to keep out of reach of children, danger corrosive. A sign on the cupboard read doors have to be locked a t all times. At 11:07 a.m., the Surveyor notified Staff E, Licensed Practical Nurse. Staff E stated they had not known the cupboard had been unlocked and proceeded to lock it. On 12/10/15 at 8:30 a.m., the facility Administrator reported the facility had 6 residents with wanderguards. Based on observation, clinical record review and staff interview, the facility failed to follow the plan of care for one of six residents reviewed. (Resident #1 ) The facility census was 36 residents.

Based on observation, clinical record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment and the health service supervisor failed to follow the plan of care by following the therapy recommendations (Resident #1) and placement of dycem in the wheelchair (Resident #2). The sample consisted of 4 residents reviewed. The facility reported a census of 44 residents. Findings include: 1. The Admission Record for Resident #1 identified the resident had [DIAGNOSES REDACTED]. The Physical Therapy assessment and signed by the therapist on 6/11/12, noted the resident's summary of barriers to function included safety, endurance and cognition. The assessment noted the resident required assistance for transfers and walking. The therapist documented the resident's static balance when standing as fair and dynamic balance while standing as poor. A Therapy Alert dated 5/6/12, written by the physical therapist noted the resident required contact guard assistance to walk to the dining room with a walker. The alert directed staff to please instruct him/her to take long steps, stay close to the walker and look straight. If he/she fails ask him/her to stop and get closer to walker. The resident will need assistance to steer the walker. During interview on 10/22/12 at 8:45 a.m., the Physical Therapist stated contact guard assistance required staff to maintain physical contact with the resident throughout transfers/walking. The therapist stated when she/he ordered contact guard assistance, it was expected staff to maintain a grip on the resident's gait belt at all times throughout the transfer and/or walking. A Therapy Alert dated 5/17/12, instructed staff to tell the resident to keep his/her feet between walker legs when he/she walks. His/her feet should be near the tennis balls. He/she tends to push walker way too far out in front. The Restorative Recommendations dated 5/29/12, noted the resident's problems included decreased strength and difficulty with walking and transfers. The Resident Care Plan dated 7/10/2012 identified a problem with difficulty walking and transfers which required assistance from staff. The resident had a history of [REDACTED]. Interventions included: the resident would benefit from assistance with transfers, however at times, he/she transferred self. Falls interventions included: a sign in the bathroom reminding resident to sit on the toilet, staff to assist the resident in the morning and take directly to the dining room, at times of confusion have resident sit in the bird room or other common areas so staff could visually check on him/her more frequently, and use a pressure alarm when unattended and pressure alarm at bedtime. The plan of care included Therapy Alert from 5/4/12, noting resident required contact guard assist to walk to dining room, instruct resident to take long steps, stay close to walker and to look straight, if resident failed, ask resident to stop and get closer to walker. Resident would need assistance steering the walker. A September 2012, Walk to Dine report instructed staff to ambulate the resident 100 to 150 feet with a wheeled walker and contact guard assistance, staff and gait belt. A Physician report dated 8/29/12, noted the resident lived at the care center due to dementia, falls, coronary artery disease and depression. The physician noted the resident still had a tendency to get up without assistance and the resident utilized alarms. The physician noted the resident's poor short-term memory and tendency to forget to ask for assistance. The "Changes to current care plans or short term care plans" noted on 9/6/12, the pressure alarm was removed while awake due to resident dignity, resident will get up on own. The resident had the right to get up unassisted if he/she chose. The report noted the resident's bathroom door was closed, stated tripped over feet while opening bathroom door. Intervention was to keep bathroom door open. During interview on 10/15/12 at 3:20 p.m., the Director of Nursing stated they could not keep the resident down. The alarms were not keeping the resident from falling and they wanted to keep the resident happy so they removed the alarms and allowed the resident to get up independently in his/her room and began 30 minute checks on the resident. A Fall Risk assessment dated [DATE], documented the resident as at a high risk for falls due to disoriented, a history of three or more falls, balance problems while standing/walking, change in gait pattern when walking, required assistive devices, the use of medications and medical diagnoses. A Minimum Data Set (MDS) assessment dated [DATE], documented the resident had short term memory loss/impairment and as independent with transfers, toileting and walking while in bedroom. Nurse Notes dated 9/23/12 at 9:45 p.m., documented staff heard the resident call out for assistance. Staff found the resident on the floor in his/her bedroom with his/her head up against the closet. The resident complained of hip pain. The resident was unable to state what had happened. The resident complained of pain in the right hip extending to the knee, "It hurts pretty well." The resident remained on the floor with staff until the ambulance personnel arrived. New intervention: have pajamas on and covers on bed pulled back by 8:00 p.m. An Orthopedic Discharge Summary dated 9/28/12, documented the resident had a fractured hip and treatment included a right hip hemi-arthroplasty. During interview on 10/16/12 at 11:15 a.m. the Care Plan Coordinator stated the resident's care plan instructed staff to utilize an alarm for the resident and included the Physical Therapist Alert. Staff changed the resident's care plan sometime between 9/18/12 and 9/24/12 and discontinued the use of the alarm while in the chair. Staff left the Physical Therapist Alert that instructed staff to provide assistance for the resident while ambulating in the hallway and to use an alarm while in bed. The staff intent was for the resident to be independent while in his/her room, including getting up from the recliner and using the bathroom independently. During interview on 10/16/12 at 12:20 p.m., Staff A, Licensed Practical Nurse, LPN stated sometime prior to the resident's most recent fall, the Director of Nursing decided to remove the resident's personal alarm, initiated 30 minute checks and they were to see how the resident did. The resident had previously utilized a pressure alarm that alerted staff when he/she attempted to get up unassisted. Staff A had assisted the resident to the bathroom in the past and noted the resident would walk with his/her back bent way over and required frequent reminders to stand up straight and stay close to the walker. The resident would follow Staff A's verbal cues and would bend over again and walk too far back from the walker. The resident would often fall asleep in his/her recliner. The resident would forget he/she required assistance for safe transfers/walking. The resident was pretty laid back and would allow staff to assist him/her. The resident would forget to use the call light to summon assistance. The evening of the fall, Staff A witnessed the resident in his/her recliner with his/her eyes closed. The nursing assistants reported the resident refused a shower that evening. Staff A heard the resident crying out for assistance and went to the resident's room. Staff A found the resident on the floor. The resident told the nurse felt like had hurt hip. During interview on 10/16/12 at 3:35 p.m., Staff B, Registered Nurse, RN stated the resident had a history of [REDACTED]. The facility had utilized an alarm to alert the staff when the resident would attempt to get up out of a chair. The resident would set off the alarm and staff responded to the alarm. Sometimes staff would respond in time to assist the resident with the transfer/walking and sometimes the resident would already be up when staff arrived. The resident was not steady on feet and was not safe to be up independently due to at times was unsteady. When the facility staff went to the 30 minute room checks the resident was allowed to be independent in his/her room. The resident did not ask for assistance and did not use the call light due to dementia. The resident was forgetful and even now staff have to frequently remind the resident not to cross his/her legs due to the hip surgery, however, the resident continued to cross his/her legs due to forgetfulness. During interview on 10/16/12 at 10:10 a.m., Staff C, Certified Nurse Aide, CNA stated staff used to use a pressure alarm for the resident that would alert them when the resident attempted to stand up unassisted. Staff was able to get to the resident when the alarm sounded and assist the resident to the bathroom. The resident would unfasten a personal/clip alarm at times and would fold the pressure alarm in half to silence the alarm. They took the alarms away and allowed the resident to be independent in his/her bedroom. Observation on 10/22/12 at 10:20 a.m. revealed the Physical Therapist assisted the resident with walking with the use of a gait belt and a front wheeled walker. The therapist held onto the gait belt throughout the transfer and walking. The therapist instructed the resident to stand up straight, look forward and to walk/stay close to the walker. The resident would take a few steps and then would stoop over and begin to walk far behind the walker using poor posture. The therapist would frequently remind the resident to stand upright and walk close to the walker. The resident required frequent reminders to maintain a safe posture and to use the walker correctly in a safe manner. 2. The plan of care dated 8/28/12, documented Resident #2 had a problem with self-care deficit, at risk for falls and altered comfort related to the need for extensive assistance with cares and transfers. The approaches directed staff to use Dysom in the wheelchair seat. Observation on 10/16/12 at 9:51 a.m., revealed Staff C, CNA and Staff D, CNA assist the resident to the bathroom. Staff transferred the resident from a wheelchair to the toilet. Observation revealed no Dysom in the wheelchair as planned. Staff transferred the resident from the toilet into a different wheelchair with no Dysom in the wheelchair. Observation on 10/16/12 at 4:35 p.m., revealed no Dysom in the resident's wheelchair. The Director of Nursing checked the resident's wheelchair by lifting the cushion in the seat of the wheelchair revealing no Dysom in the chair.

Based on observation, clinical record review and staff interview, the facility failed to provide adequate assistance during a transfer for one of seven residents reviewed with a history of falls. The facility also failed to utilize safety devices for two of seven residents reviewed with fall histories (Residents #1 & #7). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS also documented the resident required extensive assistance of one staff for locomotion on the unit The Resident Care Plan dated 7/19/12, included a problem of mobility/ambulation/transfers/continence. The problem included the following fall reduction approaches: a. Staff will assist resident in the morning and take directly to the dining room. b. Resident likes to sit in the bird room. c. Provide 30 minute checks. d. Alarm on when in bed, wheel chair or recliner. e. Remove foot pedals from wheel chair when in bird room. f. Offer toileting every hour. During an observation on 12/11/12 at 2:24 p.m., Staff A, Certified Nurse Aide (CNA) and Staff B, (CNA) assisted the resident from a recliner to a wheel chair. Staff A pushed the resident from a lounge area to a shower room down the hall in the wheel chair. The wheel chair contained no foot pedals. The resident wore soft shoes with his/her feet close to the floor during the transport. During interview on 12/12/12 at 10:30 a.m., the facility Administrator stated the resident's wheel chair pedals were in the lounge area earlier on the previous day, but did not know who had taken them. She stated the resident needed to urinate before being pushed with no pedals, and stated the resident had said he/she could hold their feet up. The Administrator stated staff would have had to go to the other side of the building if they wanted to get a different wheel chair that had pedals on it. 2. The MDS for Resident #7 dated 10/22/12 documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one staff for locomotion on the unit. The Resident Care Plan updated 11/14/12, revealed the resident with a self-care deficit and directed staff to provide extensive assistance and two staff members with a wheeled walker for transfers. The same care plan identified the resident at risk of falls related to dementia. The approach section documented the resident did have a history of falls, and included the following fall reduction approaches: a. Anti-tip wheels/bars on wheel chair. b. Dycem in wheel chair. c. Wedge cushion in wheel chair. d. Will participate in restorative program. A Fall Nurse's Note dated 11/26/12 at 7:15 a.m., documented a staff person transferred the resident to a wheel chair after a shower and the resident slipped and fell to the floor, hitting their head. The note documented the resident found on his/her left side on a tile floor. The note also documented the resident hit his/her head and sustained a five centimeter open area over the left eye. On 12/11/12 at 3:48 p.m., the resident laid in bed. Staff A and Staff B transferred the resident to a wheel chair. The resident wore soft shoes. Staff A pushed the resident from his/her room up the hallway to the dining room with no wheel chair pedals as the residents feet hung close to the floor. The resident had a fading yellow bruise near the left eye. Staff B stated the bruise was from a fall in the shower when he/she transferred the resident. Staff B stated the resident was doing really well so he/she transferred the resident alone, because it did not seem like the resident needed assistance of two. Staff B stated the resident usually held a grab bar in the shower room during transfers, but stated he/she knew the resident required the assistance of two staff and that he/she should have used a gait belt. Staff C, CNA, stated on 12/11/12 at 4:00 p.m., the resident always required assistance of two for a transfer with a gait belt and he/she would never transfer the resident alone. Staff C stated he/she had never given the resident a shower. Staff D (CNA) stated on 12/11/12 at 4:05 p.m., he/she had never given the resident a shower before, but the resident always required assistance of two for transfers. Staff D reported he/she always used a gait belt. During an interview on 12/12/12 at 8:12 a.m., the facility Director of Nursing (DON) stated the expectation would be for staff to place wheel chair pedals on a wheel chair if any resident needed to be pushed. She stated Resident #7 usually self-propelled his/her wheel chair. The DON reported she witnessed Staff B pushing Resident #7 without wheelchair pedals and scolded the CNA afterwards. She also reported Staff B was counseled regarding the incident when the resident fell in the shower room, and verified the resident should have been transferred with the assistance of two staff. The DON also verified a gait belt was not used when the resident fell , however, staff were expected to use a gait belt with all resident transfers.

Based on observation, clinical record review and staff interviews, the facility failed to plan for and direct nursing services to ensure residents received adequate supervision. Resident #5 left the nursing home without being noticed and his/her safety interventions failed to alert staff of his/her supervision needs. After this incident on 11/21/11, the facility documented staff supervised Resident #5's location every ten minutes due to the wanderguard alarm system not consistently working. On 11/30/11 Resident #5 left the nursing home without being noticed and no provisions were implement to supervise his/her needs. In addition, the facility relied upon the wanderguard alarm system to alert staff of supervision needs for Residents #1, #2, #3 and #4 and failed to implement provisions until directed by the Department. The findings constituted an immediate jeopardy situation to residents health and safety. The facility identified a census of 38 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE], documented he/she had cognitive loss/dementia. Record review for Resident #5 identified the following: Resident #5's Initial Wandering assessment dated [DATE] determined staff would apply a wanderguard to Resident #5 since he/she exhibited signs of restlessness and or agitation. A physician's progress note dated 10/12/11 noted the resident was seen as a new admission. The resident had fairly severe dementia and continued to have decline in mental abilities. The resident had a history of [REDACTED]. A physician's progress note dated 11/16/11 assessed this resident with profound dementia. The physician noted this resident walked around the facility all day long. The resident had virtually no short-term memory. Review of this resident's Treatment Administration Record revealed the facility first began documenting their checks of Resident #5's wanderguard on 10/16/11 and completed checking the wanderguard each shift (three times a day) from 10/16/11 to 11/30/11. Daily Notes documented the following: On 10/4/11 at 3:00 p.m. resident admitted to the facility. Resident alert and confused. Resident wandered and was verbally aggressive. Wanderguard placed on resident's left wrist. Resident was given an as needed Ativan due to agitation. On 10/4/11 at 2:00 p.m. resident uncooperative with assessment. The resident removed wander guard and staff replaced on ankle. On 10/5/11 at 1:00 p.m. resident up about in facility, resident alert and confused. Resident required multiple reminders and cues on direction. Due to the resident's dementia the resident was unable to remember where his/her room was or any of the daily routines. On 10/10/11 at 12:30 p.m. resident attempted to leave building, non-cooperative & pacing. Ativan administered for increased anxiety. Will continue to monitor. The social service progress notes dated 10/10/11 revealed another resident reported to the social service designee (SSD) that Resident #5 had walked outside the front doors and the wander guard did not activate the alarms. The SSD documented the wander guard was on the resident's ankle at the time. The SSD indicated she found Resident #5 outside and was able to redirect the resident back into the nursing home. The SSD documented the resident wanted to leave so he/she could go home to milk the cows. When interviewed on 1/3/12 at 12:15 p.m. the social service designee stated on 10/10/11 she was in the back of the building when another resident came to her and told her he/she did not want to get anyone in trouble, however he/she wanted to know if she knew Resident #5 just walked out the front door. The social service designee then walked to the front of the building and asked the nurse if she knew that Resident #5 left the building at which time the nurse told her no and stated the alarm did not sound. She then went to the Administrator and asked her if she knew that Resident #5 exited the building, at which time she stated no and stated the alarm did not sound. The social service designee then went out the front door and looked for the resident. She found Resident #5 outside by the assisted living building. The resident was alone. She asked the resident where he/she was going. The resident reported he/she was going to do chores. The social service designee then brought the resident back to the facility. Observation throughout this investigation revealed the assisted living building was located approximately one forth mile from a highway, with speed limit 55 miles per hour. The nursing home is surrounded by farm ground. The facility is approximately one half mile from town. The road located in front of the facility is posted 35 miles per hour. When interviewed on 1/4/12 at 11:04 a.m. the Administrator stated on 10/10/11 Resident #5 eloped from the facility without staff knowledge and the wanderguard system did not sound due to the staff had failed to activate this resident's wanderguard bracelet when they put the bracelet on the resident. The administrator stated the staff must push a button in on the bracelet to activate the alarms system. She stated once the bracelet is activated it cannot be turned off or deactivated. Daily Notes documented the following: On 10/11/11 at 9:15 p.m. resident exited the building, setting off the alarm. On 10/13/11 at 10:00 a.m. resident made two attempts to exit through the northeast (NE) door. The resident was unable to comprehend direction. The resident continues to wander around the facility. The resident stated, " Where do I go to get going north?" This resident's Plan of Care dated 10/25/11 noted this resident had a tendency to wander around the facility and into other residents rooms and had tried to leave the building on occasion. The approaches included when resident is wandering engage him/her in a conversation about where he/she is going and what he/she might need. This plan of care directed the staff if the resident did try to leave try to redirect the resident back into the facility. The following daily notes documentation showed frequent attempts of Resident #5 attempting to exit the nursing home as illustrated by: a. On 10/22/11 at 1:15 p.m. resident wandered the facility with one attempt to leave the facility through the front door, the alarm sounded. b. On 10/23/11 at 11:05 a.m. noted NE door alarm sounding, found resident walking along sidewalk, headed for the assisted living. Resident was easily redirected back into the facility. c. On 10/25/11 12:15 p.m. resident exited building through the south exit setting off the wander guard system. d. On 10/25/11 at 7:00 p.m. resident exited building through NE exit. Set off wander guard system. The nurse was able to keep resident in her sight until she was able to redirect the resident back into the building. e. On 11/4/11 at 3:00 p.m. resident exited through the NE door, setting off the alarm. Nurse was able to keep resident within sights until could reach the resident and redirect back into the building. f. On 11/7/11 2:15 p.m. resident attempted to go out front door. g. On 11/7/11 at 7:30 p.m. resident attempted to go out the SE door. h. On 11/12/11 at 3:30 p.m. resident trying to go out exit doors. i. On 11/13/11 at 1:40 p.m. resident went out NE door. Alarm sounded. j. On 11/21/11 at 1:15 p.m. resident was seen by dietary staff outside in the back parking lot by a staff car with the back door open. Temperature outside 36 degrees. The wander guard door alarm did not sound when resident exited the building. An Unusual Occurrence Report dated 11/21/11 at 1:05 p.m. noted Resident #5 was seen by the kitchen staff out of the kitchen window, in the back parking lot next to an employee vehicle with the back passenger door open. The staff then went outside and directed this resident back into the facility. The outside temperature at the time was 36 degrees. The resident was last seen at 12:45 p.m. The wander guard did not alarm when the resident exited the building. The staff began doing 10 minute checks on this resident. The daily notes documented on 11/23/11 at 9:00 a.m. wandering and wander guard bracelet not working at times. The facility documented staff checked on Resident #5's whereabouts every 10 minutes on 11/21/11; and on 11/22/11 with the exception of 7-9PM when nothing was documented. The facility continued to document they checked on Resident #5's whereabouts every 10 minutes from 11/23/11 to 3:20 p.m., on 11/28/11. The Unusual Occurrence Report dated 11/30/11 at 1:20 p.m. noted by Staff A documented a physical therapist found Resident #5 standing outside the assisted living front door. The therapist re-directed the resident back inside the building. The nurse assessed Resident #5 and documented the resident was noted to have increased anxiety and pacing around. Staff A documented, "10 minute checks - started in the AM, resident last seen at 1:10p.m. (1310). Staff A documented Resident #5 now on 1:1 with staff. The daily notes dated 11/30/11 at 2:00 p.m. documented by Staff A identified Resident#5 found by the physical therapy staff outside in front of assisted living door. Staff A documented the wander guard intact, however the door alarm malfunction. Staff A documented Resident #5 on 10 minute checks since am; and since the elopement, now on 1:1 with staff. Staff A documented Resident #5 had been dressed in long sleeve light jacket with a T-Shirt underneath and wearing jogging pants, tennis shoes, socks and baseball hat. Staff A documented the temperature outside at 35 degrees F (Fahrenheit). Staff A noted Resident #5 had an increased anxiety, pacing and wandering a lot more than usual. When interviewed on 1/3/12 at 12:08 p.m. the physical therapist stated when he drove up to the facility he saw this resident outside, walking towards the assisted living building. The resident told the therapist he/she was looking for his/her tractor. The therapist assisted Resident #5 back into the building. The alarm did not sound when they re-entered the building. The nurse told the therapist they had problems with the alarm system that day. When interviewed on 1/4/12 at 11:40 a.m. nurse, Staff A stated she was Resident #5's nurse on 11/30/11. She stated they had not been doing the 10 minute checks on Resident #5 until after he/she had eloped on 11/30/11. She stated they started the 10 minute checks after the physical therapist assisted the resident back to the building. Staff A stated she had then been given the 10 minute location check list and it was marked with the time she was to begin her documentation of the 10 minute checks. There was no documentation on the 10 minute location sheet from 3:30 p.m., on 11/28/11 until 11/30/11 at 12:20 p.m. The 10 minute location sheet for 11/29/11 was without the resident ' s name and had no documentation recorded for staff knowing his/her whereabouts every ten minutes. The daily notes documented on 11/29/11 (no time given) as needed Ativan given at 2:30 p.m. and 8:30 p.m., increased anxiety and restlessness. In room was plugging/unplugging all electrical items, trying to put call light cord into outlet. Carrying large amount of books.The notes did not reflect 10 minute checks were completed. The 10 minute location sheet dated 11/30/11 documented by Staff A identified blanks from 6 a.m. until 12:20. p.m.; and Staff A documented she checked on Resident #5 from 12:20 p.m. to 1:00 p.m. ; however no 10 minute checks were documented for 20 minutes from 1:10 p.m. to 1:30 p.m. On 11/30/11, after the elopement, the Unusual Occurrence Report documented Resident #5 would receive 1 to1 with Staff. The facility reported the incident to the Department; and was notified by the Department to begin monitoring for other residents that utilized the wanderguard alarm system. When interviewed on 1/3/12 at 10:17 a.m. the maintenance supervisor stated nurses would inform him of when the wanderguard system was not working properly. He stated multiple times the nurses would report the wanderguard system was not working when they checked it and then when he went and checked it was working. In the past they had found there were different things which interfered with the wandergaurd system. He stated they found out if they plugged the vacuum cleaner into a certain outlet then the wandergurad system would not alarm. They also found it they stored certain items such as wheelchairs too close to the exit then the system would not alarm. He stated for the last two to three years, they knew the wanderguard system was not working properly, however they could not determine why. They attempted multiple things, such as changing batteries and trying to fine tune the system but nothing seemed to help. After Resident #5 eloped on 11/21/11 he told the Administrator they needed to replace the system. They found out the system was old and beyond its life expectancy. The maintenance supervisor installed the new wanderguard system, however he left the old system hooked up as well, due to the new system also did not work properly. After Resident #5 eloped again on 11/30/11 a representative from the wanderguard company came to the facility and determined they were having electrical interference from their electronic laundry washing machine. When the washer was in the spin cycle, the wanderguard system would not work. This washing machine was approximately two to three years old, and therefore explained why they were having trouble with the wanderguard system for the last couple of years. They ordered a filter for the washing machine which was then installed on 12/7/11. When interviewed on 1/3/12 at 1:45 p.m. a laundry staff member, Staff C stated they routinely ran the clothes washing machine from 7:00 a.m. through 3:00 p.m., and the night shift nursing staff also ran the washing machine every night for one to two loads. When interviewed on 1/4/12 at 8:45 a.m. a staff nurse, Staff A stated there were times when she was checking the wander guard alarm system that it did not work. She stated when it did not work, she would inform the maintenance supervisor when he came to work. She stated she never received any directive on what to do when the system did not work. When interviewed on 1/4/12 at 8:50 a.m. a staff nurse, Staff B stated when she performed the checks of the wanderguard system there were times it did not work. She stated the system normally worked approximately 99% of the time. She stated she normally checked the system at 6:00 a.m. and would tell the maintenance supervisor when he came to work. She would also go and check to make sure all residents were in the building. The facility reported approximately 5 residents with the Wander guard elopement/alarm system. The Administrator reported the facility was not providing additional supervision to the other five residents at risk for elopement due to it would be so difficult for someone in a wheelchair to exit through the employee exit. Clinical record review for Residents #1, #2, #3 and #4 revealed no 10 minute monitoring started until 11/30/11. Resident #1's MDS dated [DATE] identified he/she used a walker and a wheelchair for mobility. Resident #2's MDS dated [DATE] identified he/she used a walker and was independent with walking on and off the unit. Resident #3's MDS dated [DATE] identified he/she used a walker and wheelchair, and was independent on and off the unit. Resident #4's MDS dated [DATE] identified he/she used a walker and was independent in walking on and off the unit. The monitoring record for Residents #1,#2, #3 and #4 showed blanks in the monitoring system as follows: Resident #1's every 10 minute location sheet showed no documentation on 12/4/11 from 11 a.m. through 11:30 a.m. Resident #2's every 10 minute location sheet showed no documentation on 12/4/11 from 11 a.m. through 11:30 a.m. Resident #3's every 10 minute location sheet for 12/3/11 was blank at 2PM and was also blank on 12/5/11 at 5:30 p.m. Resident #4's every 10 minute location sheet dated 12/4/11 from 5:40 p.m., to 5:50 p.m., was blank. Review of the facility's Wander guard Alarm System policy and procedure instructed the staff to test the wander guard exit door panels every shift, record the results and report their concerns to the maintenance department. Review of the Door Check lists for November 2011 revealed the staff did not document the results of their checks. Review of these documents also revealed the facility failed to document these checks consistently on each shift and on each day. The policy and procedure also failed to instruct the staff to ensure resident safety when they found the system to malfunction. The Elopement Prevention Policy instructed the facility to analyze all elopements/exits from the facility. When interviewed on 1/4/12 at 9:05 a.m. the Administrator stated when residents eloped from the facility they did try to determine how and why the residents eloped, however this was not a formal analysis and they did not document their assessment of how or why the resident eloped as directed in their policy. The facility abated the immediate jeopardy situation on 12/7/11 when the wanderguard company determined an electrical interference with the electronic laundry washing machine. The facility installed a filter to address the interference on 12/7/11. The facility provided training to staff on 11/30/11 to supervise resident ' s at risk and updated their policy. These factors lowered the severity from a J to a G level. As of the exit date the facility did not establish a frequency to monitor the effectiveness of the new filter system and the designated staff.