Every finding on record at Solon Nursing Care Center

Based on clinical record review, facility policy review, and staff interview, the facility failed to ensure staff accurately completed Minimum Data Set (MDS) assessments for 4 of 4 residents (Resident #19, Resident #10, Resident #48, Resident #4) reviewed for assessment accuracy. The facility reported a census of 83 residents. Findings include:1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed diagnoses of prostate cancer (prostate gland cancer) and Lewy Bodies dementia (progressive brain disease affecting thinking and movement). The MDS assessment lacked identification Resident #19 received hospice services. The Care Plan Focus dated 6/17/26 identified Resident #19 required comfort cares at end of life. Resident #19 started hospice services on 1/15/26. On 8/5/26 at 1:40 PM Staff O, Registered Nurse (RN), reported Staff A, Licensed Practical Nurse (LPN), taught them how to complete a MDS assessment completion from Staff A. stated taking over MDS assessments in June 2026, with the Director of Nursing (DON) signing off. Staff A reported they completed Resident #19's MDS assessment dated [DATE] and explained they missed identifying hospice services for Resident #19. 2. Resident #10's Minimum Data Set (MDS) admission assessment dated [DATE] revealed an admission date of 6/25/26 and listed diagnoses of heart failure (heart pumping weakness) and Alzheimer's dementia (progressive memory loss disorder). The MDS assessment lacked identification Resident #10 received hospice services. The Care Plan Focus dated 6/25/26 identified Resident #10 required comfort cares at end of life. Resident #10 started hospice services on 6/25/26. On 8/5/26 at 1:40 PM Staff A reported they completed Resident #10's MDS assessment dated [DATE]. Staff A reported Resident #10 entered the facility on hospice services and confirmed they failed to identify hospice services on Resident #10's MDS assessment dated [DATE]. On 8/5/26 at 1:48 PM the DON reported they held the responsibility for signing off on MDS assessments. The DON explained the facility previously contracted with a nurse consultant to review MDS assessments for accuracy before notifying the DON to sign off. The DON reported they audited the MDS assessments the prior week with a list to correct, but didn't identify concerns with MDS assessments for Resident #19 and Resident #10. The DON agreed to provide the facility policy on MDS assessments. On 8/5/26 at 3:32 PM the DON stated they used an MDS assessment checklist as facility policy. On 8/5/26 an undated and untitled document identified by the facility as the MDS assessment checklist revealed categories related to hospice services and high-risk medications. 3. Resident #48's Minimum Data Set (MDS) Quarterly assessment dated [DATE] showed Section N0415E (Anticoagulant) coded with a 1 indicating Resident #48 received an anticoagulant (blood thinning medication), while Section N0415I (Antiplatelet) remained uncoded. Resident #48's Physician Order Sheet and Medication Administration Records (MAR) spanning October 2025 through August 2026 revealed no active or past orders for anticoagulant medication. Active medication orders confirmed Resident #48 received daily baby aspirin therapy, an antiplatelet (clot prevention medication), which staff omitted from the MDS assessment. The Care Plan revised 6/4/26 documented Resident #48 received antiplatelet therapy for chronic systolic heart failure and cardiomyopathy, not anticoagulant therapy. On 8/5/26 at 11:20 AM a clinical record review confirmed Resident #48's MDS assessment dated [DATE] triggered for an anticoagulant even though staff never ordered or administered an anticoagulant to Resident #48, and staff didn't properly mark antiplatelet therapy. On 8/5/26 at 11:21 AM Resident #48 stated not receiving an anticoagulant medication. On 8/5/26 at 1:41 PM Staff A stated they managed the MDS process after the previous coordinator left, noting the DON signed off on MDS work prior to submission. Staff A confirmed Resident #48's MDS assessment dated [DATE] contained incorrect coding regarding anticoagulant and antiplatelet medications. On 8/5/26 at 1:48 PM the DON confirmed they signed Resident #48's MDS assessment dated [DATE] as complete and verified they failed to identify the discrepancy prior to submission. The DON noted an Staff E, external auditor, didn't catch the discrepancy during auditing, acknowledging facility management previously held no knowledge of the inaccuracy. 4. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified they received an antipsychotic (mood and behavior stabilizer) medication on a routine basis only during the lookback period. Resident #4's August 2026 Medication Administration Record (MAR) revealed Resident #4 didn't receive antipsychotic medications during the look-back period. On 8/5/26 at 11:00 AM the DON reported they expected the staff to not document on the MDS a resident received antipsychotics if they didn't receive them.

Based on observation, record review, facility policy review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent potential contamination during pureed meal preparation for 3 residents receiving pureed diets, and failed to maintain a clean drinking water faucet free from mineral buildup located in the main dining room. The facility reported a census of 83 residents. Findings include:1. A record review of a document titled Altered Diets revealed three residents received a pureed diet. On 8/3/26 at 10:26 AM during an interview in the main dining room kitchen, the Dietary Manager reported three residents received a pureed diet, noting pureed meal preparation occurred around 10:00 AM. On 8/4/26 at 9:55 AM an observation showed Staff N, Cook, knock a spatula and an oven mitt onto the kitchen floor. Staff N picked up both items off the floor with bare hands and handed the spatula to the Dietary Manager. Staff N continued using the oven mitt during pureed meal preparation without washing hands. Staff N used the soiled mitt to open a steamer oven, pull back aluminum foil on a pan while touching the underside of the foil, remove a smaller pan containing cooked peppers and pepper steak, recover the larger pan containing cooked sliced carrots with the foil, and empty the pan containing peppers and pepper steak into a Robot Coupe (machine used to puree food). While emptying the peppers and pepper steak into the Robot Coupe, Staff N touched the top inside edges of the pan with the soiled mitt. After pureeing the peppers and pepper steak, Staff N poured the pureed mixture into a large measuring cup. Staff N walked to another counter, put on eyeglasses, and touched her face without washing hands. After determining the measurement, Staff N opened a drawer, retrieved a spatula, and scraped the contents of the measuring cup into an oven pan without washing hands after opening the drawer. Staff N used the soiled mitt to open the steamer oven, pull back foil off the larger pan containing cooked sliced carrots, place the pureed pepper steak mixture into the larger pan, and remove the smaller pan containing cooked carrots. Staff N handled the pan of carrots with the soiled mitt while placing the carrots into the Robot Coupe. After pureeing the carrots, Staff N measured and placed the pureed carrots into a smaller oven pan. Staff N grabbed the soiled mitt to open the oven, removed the foil covering the pureed pepper steak mixture, placed the pureed carrots in the larger pan next to the pepper steak mixture, and applied a new sheet of foil to cover both dishes. On 8/4/26 at 11:29 AM an observation showed Staff N begin food service in the main dining room, serving pureed pepper steak and carrots to three residents. On 8/4/26 at 12:09 PM during an interview, Staff N and the Dietary Manager explained staff shouldn't use an item dropped on the floor, such as an oven mitt. Staff N reported failing to realize she continued using the oven mitt after dropping it on the floor and confirmed she should've washed her hands after picking up the mitt prior to continuing food preparation. 2. On 8/5/26 at 9:22 AM an observation showed Staff H, Certified Nursing Assistant (CNA), filling individual resident drinking cups from a drinking water faucet located at the sink in the main dining room. An observation of the drinking water faucet revealed a buildup of white and green crusty deposits around the water faucet opening. On 8/5/26 at 10:44 AM Staff H stated filling water mugs for all residents on the South Hall using the drinking water faucet. On 8/5/26 at 10:45 AM an observation showed 19 residents resided on the South Hall. On 8/5/26 at 12:21 PM the Dietary Manager stated housekeeping staff held responsibility for cleaning the sink area and water faucet in the main dining room. On 8/5/26 at 12:22 PM Staff I, Housekeeper, stated holding responsibility for cleaning resident rooms and the smaller side of the main dining room (which excluded the sink and drinking water faucet) due to assignment to the East Hall. Staff I reported housekeepers on the South and [NAME] halls split the larger side of the main dining room. On 8/5/26 at 12:25 PM Staff J, Housekeeper, stated assignment to the [NAME] Hall and holding responsibility for cleaning chairs and floors in the main dining room on the larger side alongside the housekeeper assigned to the South Hall. Staff J reported dietary staff held responsibility for wiping counters and the sink in the main dining room, noting housekeeping staff would clean the area if dietary staff didn't. On 8/5/26 at 12:27 PM Staff K, Housekeeper, stated assignment to the South Hall and holding responsibility for cleaning chairs and floors in the main dining room. Staff K reported dietary staff held responsibility for cleaning counters and the sink area in the main dining room, noting housekeeping staff would clean the area if dietary staff didn't. On 8/5/26 at 3:06 PM the Maintenance Director stated replacing the faucet in the main dining room. On 8/5/26 at 3:32 PM an observation showed the drinking water faucet in the main dining room continued exhibiting a buildup of white and green crusty deposits. On 8/6/26 at 9:44 AM the Maintenance Director stated a misunderstanding resulted in replacing only the hand faucet in the main dining room and attempting calcification (crusty mineral build-up) cleanup on the drinking water dispenser. The Maintenance Director reported calcification remaining inside the drinking water faucet and noted ordering a replacement water faucet. The Food Preparation and Service Sanitation Policy undated instructed staff to prepare, store, transport, and serve all food under safe and sanitary conditions to prevent contamination and foodborne illness. The policy directed employees to wash hands before handling food and whenever contamination occurred. The policy instructed staff to properly clean and sanitize equipment, utensils, preparation surfaces, food carts, and serving areas.

Based on clinical record review, observation, resident interview, staff interview, and facility policy, the facility failed to provide care and treatment in accordance with professional standards of practice for 2 of 2 residents reviewed for quality of care (Residents #9 and #4). The facility failed to ensure a resident experiencing symptomatic hypoglycemia (low blood sugar) was properly monitored, assessed, and reported to the physician (Resident #9), and failed to thoroughly assess, monitor, and notify the physician of ineffective interventions for a resident experiencing persistent constipation (Resident #4). The facility reported a census of 83.Findings include:Based on observation, record review, and interview, the facility failed to ensure staff monitored, documented, and reported low blood sugar levels to the primary care provider for 1 of 1 resident (Resident #9) reviewed for diabetes management, and failed to document bowel movements, monitor constipation, and notify the provider when laxative interventions proved ineffective for 1 of 1 resident (Resident #4) reviewed for bowel management. 1. Resident #9's Minimum Data Set (MDS) assessment recorded a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS coded Resident #9 with diabetes mellitus (high blood sugar condition). The MDS identified Resident #9 received insulin injections during the assessment reference period. The Care Plan Focus updated 4/22/26 identified Resident #9 had diabetes mellitus type 2 and took insulin. The Interventions directed staff to report and document signs or symptoms of hypoglycemia (low blood sugar) including sweating, tremor, nervousness, confusion, and slurred speech to the nurse or physician, and administer diabetes medication as ordered by the primary care physician. Physician Orders contained active orders for: a. Insulin degludec (diabetes medication), inject 10 units subcutaneously (under the skin) every day at 12:00 PM (ordered 5/18/26). b. Blood Glucose Level (BGL) Sensor, check blood sugars three times a day at 8:00 AM, 12:00 PM, and 4:00 PM (ordered 5/8/26). c. True Metrix Glucose Test Strip, As Needed (PRN) (ordered 5/26/26). On 8/3/26 at 3:42 PM Resident #9 stated her blood sugar recently dropped to 50 and staff brought her a sandwich. Resident #9 reported waking up the previous night with a BGL of 53, activating her call light, and receiving orange juice from staff. On 8/4/26 at 2:10 PM Resident #9 stated her BGL dropped low again the previous night, causing her to feel shaky and sweaty while calling for assistance. Resident #9 stated the nurse asked if she wanted to go to the emergency room, but Resident #9 felt unable to make that decision. On 8/4/26 at 2:19 PM Resident #9 showed her BGL reader displaying readings of 54 milligrams per deciliter (mg/dL) on 8/3/26 at 2:55 AM, 53 mg/dL on 8/4/26 at 1:26 AM, and 54 mg/dL on 8/4/26 at 1:41 AM. A review of Progress Notes and vital signs on 8/4/26 at 2:19 PM showed the clinical record lacked documentation pertaining to low BGL events, assessments, or interventions on the night shifts for 8/3/26 or 8/4/26. On 8/4/26 at 1:48 PM Staff E, Oral Medication Technician (OMT), stated she couldn't find progress notes or recorded vital signs regarding low BGL events. Staff E confirmed the facility used reporting guidelines for low BGL. On 8/4/26 at 3:44 PM Staff F, Registered Nurse (RN), stated they worked the night shift on 8/2/26 and 8/3/26. Staff F acknowledged Resident #9 called due to low BGL and confirmed they gave her orange juice. Staff F confirmed she didn't see the 54 mg/dL reading on the sensor and acknowledged failing to document the incident in the clinical record. On 8/4/26 at 3:47 PM the Director of Nursing (DON) stated they expected the nurses to notify the physician for low blood sugar events and administer orange juice. On 8/4/26 at 5:01 PM an observation showed the DON reviewed the daily graph on Resident #9's BGL reader application, confirming low BGL readings from the previous two nights. The DON stated staff should send a fax to the physician requesting further instructions. The DON acknowledged staff should've sent a fax or notification to the physician when hypoglycemia occurred, but the nurse failed to do so. The undated Blood Glucose Policy instructed staff to: a. Notify the Primary Care Provider (PCP) if blood glucose measures greater than 400 mg/dL or below 70 mg/dL. b. Create an event for hypoglycemia or hyperglycemia (high blood sugar). c. Check blood glucose twice when receiving a high or low reading. 2. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified diagnoses of unspecified dementia (memory loss disorder), Congestive Heart Failure (CHF) (heart pumping weakness), and Chronic Kidney Disease (CKD) (kidney damage), and indicated they had constipation. The MDS recorded a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. A Care Plan entry dated 7/29/26 identified potential for constipation related to CKD, hyperlipidemia (elevated blood fats), CHF, and dementia, setting a goal to maintain a bowel movement at least every 3 days. The Interventions dated 2/12/26 directed staff to document the frequency and character of bowel movements and monitor for signs and symptoms of constipation. Resident #4's Vitals Results: Output Bowel Movement lacked documentation indicating whether Resident #4 had a bowel movement from 7/23/26 through 8/1/26. Documentation showed Resident #4 had a bowel movement on 7/22/26 at 5:36 PM. Resident #4's July 2026 Medication Administration Record (MAR) listed the following PRN medication: a. Stimulant Laxative Plus (sennosides-docusate sodium) (stool softener and laxative) tablet 8.6-50 milligrams (mg) daily PRN, started 6/2/26. MAR entries showed staff administered PRN medication on 7/23/26 (proved effective), 7/28/26 (ineffective), 7/29/26 (lacked documentation of effectiveness), 8/3/26 (ineffective), and 8/4/26 (ineffective). A review of Progress Notes from 7/21/26 through 8/1/26 lacked documentation regarding assessments and interventions staff performed for Resident #4's bowel movements. The record review lacked notification to the provider. On 8/5/26 at 9:37 AM Staff C, Certified Nursing Assistant (CNA), stated they documented the resident's bowel movements in the computer. On 8/5/26 at 9:40 AM Staff B, Licensed Practical Nurse (LPN), stated night shift nurses ran daily bowel movement audits and printed the reports. On 8/5/26 at 9:41 AM Staff A, LPN, stated CNAs they documented bowel movements, and the night shift nurses printed reports for residents with no bowel movements. On 8/5/26 at 10:04 AM Staff D, CNA, stated they documented bowel movements in the computer. On 8/5/26 at 11:00 AM the DON stated they expected the staff to administer PRN medications after 3 days without a bowel movement, re-administer PRN medication if ineffective, and notify the provider by phone or text message. On 8/5/26 at 11:35 AM Staff B stated staff wrote bowel movements on paper kept on the cart and shredded the paper at shift end. Staff B stated Resident #4 typically had a bowel movement every 2 to 3 days. Staff B stated she didn't know which days Resident #4 had bowel movements between 7/23/26 and 8/1/26. The undated Bowel Movement List Protocol policy directed the third shift staff to print a daily bowel report and administer PRN constipation medication after 3 days without a bowel movement. The policy instructed staff to administer prune juice and request a PRN order if a resident lacked PRN orders. The policy instructed staff to write a progress note detailing effectiveness after administering PRN medications. The policy directed staff to notify the provider if no results occurred after 4 days.

Based on observation, record review, facility policy review, resident, family, and staff interviews, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) by wearing a gown when performing urinary catheter care for 1 of 1 resident (Resident #58) reviewed for infection control. The facility reported a census of 83 residents. Findings include:Resident #58's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment identified Resident #58 maintained an indwelling urinary catheter (tube inserted into the bladder to drain urine) and listed active diagnoses including benign prostatic hyperplasia (BPH) (enlarged prostate gland) with lower urinary tract symptoms (urinary blockage symptoms) and urine retention (inability to empty the bladder). The Care Plan Focus revised 7/31/26 identified Resident #58 required an indwelling urinary catheter related to BPH with lower urinary tract symptoms and obstructive uropathy (blocked urine flow). The Care Plan included interventions for Enhanced Barrier Precautions (EBP) (infection prevention measures requiring personal protective equipment). On 8/3/26 at 11:45 AM observed a sign posted on the exterior door of Resident #58's room identifying a resident in the room required EBP. Resident #58 remained in his room and reported using a urinary catheter. On 8/3/26 at 2:07 PM witnessed Staff M, Certified Nursing Assistant (CNA), stop at the doorway of Resident #58's room while Resident #58 and his spouse occupied the room. Resident #58 requested Staff M empty his catheter. Staff M sanitized her hands, applied gloves, and retrieved a graduated cylinder (measuring container), paper towels, and alcohol pads. Staff M placed paper towels on the floor near Resident #58 and set the graduated cylinder on top of the paper towels. Resident #58 raised his right pant leg to expose the urinary catheter leg bag. Staff M cleaned the port (drainage valve) of the leg bag with an alcohol pad, emptied urine from the bag into the cylinder, and attempted port closure. The port didn't fully close, dripping urine onto Resident #58's compression hose (elastic support stocking) and floor. Staff M closed the port, cleaned the port with an alcohol pad, wiped the floor with paper towels, emptied cylinder contents into the toilet, and rinsed the cylinder. Staff M removed gloves and washed her hands. Staff M applied gloves, removed Resident #58's right leg compression hose and sock, reapplied his sock, and washed and rinsed the compression hose in the bathroom sink. An observation of Resident #58's bathroom door showed personal protective equipment (PPE) (protective gowns, gloves, and face shields) supplies available including gowns, gloves, and face shields. Staff M failed to wear a gown during the procedure. On 8/3/26 at 2:07 PM Resident #58 and his spouse reported staff never wore a gown when emptying Resident #58's catheter. On 8/5/26 at 1:48 PM the Director of Nursing (DON) stated staff implement EBP whenever a resident maintains a urinary catheter, an indwelling medical device with external access, or a wound requiring dressing changes. For residents placed on EBP, staff post a sign on the resident's door, maintain PPE available in the room, and wear a gown and gloves at a minimum. The DON explained staff wear PPE when anticipating contact with a resident's body and clothing. The DON reported staff receive monthly training regarding EBP. On 8/5/26 at 2:17 PM Staff N, Certified Nursing Assistant (CNA), stated always working the same hall Resident #58 resided on. Staff N explained Resident #58 maintained EBP due to catheter use. Staff N reported staff must wear gloves, gown, mask, and goggles when assisting Resident #58 with dressing, showering, toileting, bed linen changes, and urinary catheter care. The Enhanced Barrier Precautions policy undated instructed examples of residents requiring EBP included residents with a catheter, directing staff to follow precautions specifically when anticipating close physical contact.

Based on observation, clinical record review, facility investigation report, and staff interviews, the facility failed to supervise one of four residents reviewed in order to prevent a fall with major injury (Resident #2). The facility reported a census of 67 residents. Findings include: The MDS (Minimum Data Set) dated 10/19/2023 revealed Resident #2 had moderately impaired cognitive abilities, required moderate assistance to transfer from one surface to another, use the toilet, and dress. The resident required supervision with eating, had urinary and bowel incontinence, and a fall resulting in a fracture. The MDS reported the resident had diagnoses including stroke, coronary artery disease, hypertension, dementia, and repeated falls. The MDS dated [DATE] revealed Resident #2 had moderate cognitive impairment, required extensive assistance of one staff for transfers and ambulation, unsteady balance, and had two falls without injury. The Care Plan identified the resident had a risk for falls due to impaired cognition initiated on 11/12/2022 and updated. The Care Plan instructed staff to provide stand and pivot transfer assistance with two staff and the use of a gait belt. Fall interventions included: green pool noodle behind the pummel cushion in chair to prevent cushion from moving, keep tray table within reach of resident at all times, encourage resident to lay in bed at night, Velcro remote to stand beside chair, medication reviews, gripper socks, lipped mattress, moved to assisted dining table, low bed, non skid strips in front of chair, restorative program, and staff education. The Fall Risk assessment dated [DATE] revealed Resident #2 had a high fall risk. A nursing Progress Note dated 10/9/2023 at 6:28 P.M. included: Patient was yelling in her room for help, and observed patient lying on the floor in supine position (on her back), near the roommate's bed. Patient was bleeding from her forehead, nose and mouth. A 7 x 2 cm (centimeter) injury noted and bleeding, covering the face. Patient stated: I was taking myself to check my closet, and go to the bathroom and I felt dizzy, and lost balance and went down. Staff called 911 and patient taken to UIHC ER (University of Iowa Health Care emergency room ) for further evaluation. A Progress Note dated 10/04/2023 at 5:00 A.M. included: Resident observed on the floor next to the bathroom door, laying on her left side on 10/4/23 at 5:00 A.M. Range of Motion within normal limits, moves all extremities without pain and discomfort. Resident is alert and oriented to self per baseline. Resident failed to use the call light to call for help. Call light and personal belonging are within reach. A Progress Note dated 10/03/2023 2:00 A.M. included: Resident observed on the floor laying on her left side at 10/3/23 at 2:00 A.M. Resident reported I climbed off the recliner to see what's happening out there. Resident is alert and oriented to self, reported no pain, able to communicate needs but did not use the call light to call for help. Range of Motion within normal limits, and moved all extremities without pain. Observation on 3/26/2024 at 9:15 A.M. revealed the resident in her room, in the recliner with the foot rest up. The alert resident watched television, had call light available and had no signs of bruises or injury, and wore gripper socks. The resident appeared restless, concerned with dirt in her recliner. At 11:30 A.M., two staff transferred the resident from the recliner to the wheel chair and transported her to the dining room. The resident refused to use the bathroom. On 4/1/2024 at 10:20 A.M. the resident rested in the recliner, covered with a blanket, had eyes shut and restless legs. At noon, the resident sat at the assisted dining room table with staff present. She stated she did not want to eat the food on her plate and waited for a peanut butter sandwich. At 12:25 P.M., observation revealed the resident ate 100% of her sandwich. She remained alert and verbal with staff. The Resident's UIHC History and Physical report dated 10/10/2023 included: The resident admitted on [DATE] and patient states she fell while going to the restroom to get her walker. Assessment: fall with frontal scalp hematoma, multiple fractures face bones, nausea likely due to pain. Right 5th metacarpal (finger) fracture. Recommend resident return to care facility when medically appropriate with hospice services. Findings: no acute intracranial (within the skull) findings, right inferior wall frontal lobe hematoma extending inferiorly along the nasal bridge, comminuted right nasal bone fracture, left nasal bone fracture, fracture of the right frontal process of the maxilla (jaw bone), fracture of the zygomatic arch (bone beneath the eye), likely fracture anterior nasal septum. The Resident's fall history revealed she had 15 falls from 6/30/2023 - 11/26/2024. The fall on 10/9/2024 resulted in a major injury. The facility Post Fall/Incident assessment dated [DATE] revealed Resident #2 fell in her room at 5:20 P.M. Staff found the resident laying supine with a 7 cm. (Centimeter) by 2 cm. forehead laceration. The resident reported she attempted to go to the closet and then the bathroom, felt dizzy and fell The resident yelled from her room for help. Staff E, RN (Registered Nurse) went in and observed her lying on the floor near the roommate's bed. Patient was bleeding from her forehead, nose and mouth. Staff called 911 for help and the resident transferred to the emergency room for evaluation. The facility Device Activity Report dated 10/9/2023 revealed room [ROOM NUMBER]'s call light was activated from 4:57 P.M. until 5:27 P.M. The facility investigation revealed the resident activated her call light at 4:57 P.M. and was shut off at 5:27 P.M. Cameras revealed Staff E, RN stood in the middle of the hallway directly in front of the call light board from 4:30 P.M. until the resident called out for help shortly before 5:30 P.M. Staff E reported during that time, he checked his MAR (Medication Administration Records) to be sure medications were signed off. He heard someone yelling for help, entered room [ROOM NUMBER], and saw Resident #2 on the floor with copious amounts of blood coming from a forehead laceration, and her nose and mouth. Staff E reported he forgot to check the call light board, and blamed the CNA's (Certified Nurse's Aides) for not getting her out to dinner by that time. On 4/1/2024 at approximately 2 o'clock P.M., Staff A, Administrator reported the facility used the current call light system for about three years and never really had any issues with it. Staff used pagers in the past and they decided to stop using them because staff either lost them or forgot to charge them. A couple of months ago, they upgraded the call light system, reintroduced wireless pagers for staff to carry that alert them when a call light is on and when a exit door alarms. When Resident #2 fell on [DATE], video footage showed Staff E, RN standing in front of the hall monitor on East hall for 30 minutes and did not respond to the resident's call light. They terminated Staff E because he failed to take his job seriously. Staff F, CNA received a discipline for not working on East hall that evening from 5 - 6 P.M. The resident presented a challenge, you could have your eyes on her one minute and the next, she would fall. The facility tried several interventions such as room change, alarms, and medication changes involving hospice, the medical director and the nurse practitioner. The resident seemed calmer and clearer recently and had no fall since November. The resident prefers to sleep in the recliner and does occasionally use the call light. When the resident first admitted , she ambulated independently, and moved to the first room on East hall for closer supervision due to falls. On 3/26/2024 at 2 P.M., Staff B, DON (Director of Nursing) reported Resident #2 occasionally used the call light and on October 9, 2023, she did put her call light on. Call light records revealed the call light was on for about 30 minutes before staff found her on the floor. The resident said she intended to go to her closet to get something when she fell . The resident had a history of falls and this was the only fall that resulted in a major injury. When she returned from the hospital, she had one on one supervision until 10/24/2023 and then staff checked on her every fifteen minutes until 2/8/2024. Currently staff check on her every hour, and her room is the first on the hall with staff frequently passing by. The resident's room door is kept open so staff can visualize her as they pass by. The fall investigation revealed Staff E stood near the call light monitor in the middle of East hall and failed to respond to her light during the 30 minutes it was on. Two CNA's also worked on East hall and were assisting residents to the dining room during that time. Staff E reported he checked the MARS during that time, and he failed to check the call light monitor. When he heard the call for help, he responded. The call light monitor shows all activated call lights. Currently, staff also carry pagers that are hall specific. Staff F, CNA arrived at 5 o'clock P.M. and was supposed to help out on East from 5-6 P.M. Staff F failed to work on her assigned hall during that hour, leaving one CNA assigned to East hall. The resident graduated from hospice services. On 4/1/2024 at 1:45 P.M., Staff C, CNA reported working on East hall on 10/9/2023 from 2 - 10 P.M. Staff C assisted Resident #2 to the bathroom earlier in her shift, prior to her falling around 5:30 P.M. After the resident fell , Staff C observed the resident on the floor with another staff present. Staff C worked alone on the hall from 5 - 6 P.M., however another staff came at some point and assisted with getting residents to dinner. Staff C worked at getting residents to dinner and had no recall if call lights were on. On 4/1/2024 at 10:35 A.M., Staff D, CNA reported working on 10/9/2024 from 2 - 10 P.M. on [NAME] hall. When Staff D finished assisting residents to dinner, he went to East hall to help. When he walked passed Resident #2's room, he observed her on the floor, bleeding, and near the roommate's bed with Staff E present. Staff D stayed with the resident while Staff E assessed her and called for the ambulance. The fall occurred during the one hour juncture when there was only one staff on East hall. When Resident #2 resided on the end of [NAME] hall, she frequently thought she could self transfer and sustained falls. The resident moved to the first room on East hall for closer supervision. The resident preferred to sleep in the recliner and is able to use the call light. The resident had no recent falls and seemed calmer with no complaint of pain. The resident now required the assistance of two staff for transfers. The facility's new hire Orientation Packet included: Call lights appear on screens in every hall and must be answered in 15 minutes. The facility's Registered Nurse job description and requirements signed by Staff E on 10/26/2022 included: General job summary: The registered nurse assists in the supervision and administration of the quality of nursing care for the facility. The Registered Nurse assists in maintaining a physical, social and psychological environment which will be conducive to the best interest and welfare of the residents. Job Descriptions: Ability to use good judgment in determining the needs of residents. Ability to exercise initiative in resident care, directing the work of subordinates and fulfilling other required duties assigned by the supervisor. Capacity to be supportive of and adaptable to change.

Based on clinical record review, observations, staff interviews, and manufacturer's user recommendations, the facility failed to ensure wander guards (a monitoring bracelet with activated alarm when exiting) were monitored for placement and functioning for resident safety for 4 of 4 resident's reviewed (Resident #58, #28, #59, and #14) for wandering and risk for elopement. The facility also failed to assess 1 out of 4 residents (Resident #14) with the removal of a wander guard. The facility reported a census of 62. Findings include: 1. The Minimum Data Set Assessment (MDS) dated [DATE] for Resident #58 identified a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating severely impaired cognition. The MDS identified Resident #58 had signs and symptoms of delirium with inattention and disorganized thinking with behavior present and fluctuates. The MDS identified the resident was independent with transfers and ambulation with no assistive devices. The MDS documented diagnoses that included Alzheimer's dementia, anxiety, and depression. The Care Plan revised 5/23/23 identified Resident #58 had a wander guard. The care plan lacked documentation on the location of the wander guard device. The care plan lacked direction on when and how often to check for placement and functioning. The Elopement Risk Assessments for the resident documented the following: On 12/9/22= 5. A score of 5 or greater indicated risk On 2/28/23= 5. On 5/23/23= 15. On 5/22/23 at 11:22 AM observed Resident #58 with a wander guard device to her left wrist. The resident stated she does not want to live at the facility and her daughter had dumped her at the facility. On 5/23/23 at 5:30 PM the Administrator reported a restorative aide checks the wander guards for placement and functioning daily. A review of the forms titled Daily Wandergard Check dated December 2022, January 2023, February 2023, March 2023, April 2023 and May 2023 lacked documentation the wandergard had been checked daily for Residents #58. On 5/24/23 at 9:30 AM the Director of Nursing (DON) reported the Restorative Aide checked the wander guards for placement and functioning. The DON stated when the Restorative Aide was off there was not another staff member assigned to check the wander guards. On 5/24/23 at 10:14 AM Staff E, the Restorative aide reported she checked the wander guards for placement and functioning when scheduled Monday through Friday. 25855 2. The Minimum Data Set, dated dated dated [DATE] identified Resident #28 as cognitively impaired with a BIMS of 0 out of 15 possible points. The MDS documented diagnoses to include coronary artery disease, depression and repeated falls. The MDS documented he had a history of two falls without injury and two falls with minor injury. It identified the resident required limited staff assistance with dressing, toileting and personal hygiene and totally dependent on staff for baths. It also identified the resident with a wander/elopement alarm used daily. On 5/24/23 at 2:36 PM observed the resident standing by the exit door by the private dining room off South hall. He pushed on the safety bar of the door which triggered the alarm to sound as he had on a wandergard bracelet. Staff C, Licensed Practical Nurse (LPN), re-directed the resident away from the door and walked with him to sit on the sofa at the end of the hall. The resident then began to ambulate down the hall using his wheeled walker with steady gait with a Certified Nursing Assistant (CNA) walking beside him. On 11/15/22 the Care Plan identified the resident with the problem of being at risk for falls and on 11/16/22 the intervention of a wandergard placed on the resident had been added. It did not direct the staff to document checks on the wandergard daily. 3. The MDS dated [DATE] identified Resident #59 as cognitively impaired with a BIMS score of 3 out of 15 possible points. The MDS documented the following diagnoses to include atrial fibrillation (an abnormal heart rhythm), coronary artery disease and heart failure. The MDS identified the resident required staff supervision only with dressing and personal hygiene and required extensive staff assist with bathing. It also identified the resident with a wander/elopement alarm used daily. On 5/23/23 at 6:59 AM observed the resident ambulated independently from her table to the next table without using her walker. Staff D, Registered Nurse (RN) reminded the resident to use her walker when she walked. The resident wore a wandergard bracelet to her right wrist. Observed the resident to return to sit in a dining room chair. On 3/30/23 the Care Plan identified the resident with the problem of history of wandering in the hallways and will exit seek. The Care Plan did not direct the staff to document checks on the wandergard daily. A review of the forms titled Daily Wandergard Check dated December 2022, January 2023, February 2023, March 2023, April 2023 and May 2023 lacked documentation the wandergard had been checked daily for Residents #28 and #59. In an interview on 5/25/23 at 10:07 AM, Staff D, RN reported the Restorative Aide checks the wandergards daily. She brings a wrist bracelet to check the exit doors and will check each of the residents who have a wandergard. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported once a day, the Restorative Nurse checks every morning the wandergard alarms daily. She will check all the exit doors with a wrist bracelet wandergard and open the door and checks batteries in the resident's bracelets. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported the Restorative Aide checks wandergards every day. She will test the door to make sure the alarm works. She also check the resident's bracelet to make sure the batteries are working. 4. The MDS Assessment for Resident #14 dated 2/23/23, documented diagnoses that included Alzheimer's dementia and heart failure. The MDS included a BIMS score of 8 out of 15 possible points indicating moderately impaired cognition. The MDS documented the resident as independent for transfers and set up with ambulation. The Care Plan dated 3/3/23, revealed Resident #14 verbally expressed her intent to leave the facility unsupervised. The goal documented the resident will not exit seek. The Care Plan directed staff to equip the resident with a device that alarms when wanders and to provide reassurance and redirection when the resident experiences paranoia or other symptom/reason that may be causing exit seeking behavior. The Elopement Risk assessment dated [DATE], revealed Resident #14 may be at risk of elopement. The Elopement Risk assessment dated [DATE], revealed the resident may be at risk of elopement. The Elopement Risk assessment dated [DATE] for the resident is incomplete. A review of the forms titled Daily Wandergard Check dated February 2023, March 2023, and April 2023 lacked documentation the wandergard had been checked daily for Resident #14. On 5/24/23 at 9:10 AM, Staff H, CNA reported Resident #14 wandered all over the place and does go outside to sit in the locked area. Staff H, reported Resident #14 wore a wander guard and the Restorative Nurse checked it first thing in the mornings. Staff H, revealed she is unaware who checks the wander guards on the weekends. On 5/25/23 at 11:40 AM, the DON confirmed at the time the facility discontinued Resident #14's wander guard she didn't expect the facility to complete an assessment. The DON revealed now she expected an assessment done before the removal of a wander guard. The undated wander guard manufacturer's user manual directed the facility to test the wander guard bracelets daily and to record the test results in the resident's records. The user guide further documented that it was important to test the wander guard bracelet before putting it into use and daily thereafter. The user guide documented failure to do so could result in injury or death. The undated facility policy titled Missing Resident Policy lacked documentation regarding the Wanderguard system. On 5/24/23 at 10:25 AM, the Administrator and DON acknowledged the manufacturer's user manual recommendations and verified the wander guards were not checked daily and should have been.

Based on observations, clinical record review, resident and staff interviews, the facility failed to maintain the residents' dignity for two of three residents reviewed. (Residents #11 and #17) The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a Brief Interview of Mental Status (BIMS) of 12 out of 15 possible points. The MDS documented diagnoses to include heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. It also identified the resident to be totally dependent on staff for locomotion on and off the unit and for bathing. During an observation and interview on 5/22/23 at 10:32 AM, as the resident sat up in her wheelchair in her room, she pointed to her bed (which did not have side rails) and reported she is not happy that side rails were removed from her bed as she used to use them to help her out of bed. She stated now she has to hold the window frame to help her get out of bed. She also stated she has to wait long as an hour to get her call light answered and she wets her pants every night. She stated she wakes up every morning soaking wet and is not happy about it. In an interview on 5/24/23 at 9:10 AM, Staff C, Licensed Practical Nurse (LPN) reported staff are made aware when a resident turns on their call light because call lights show up on screens that appear to be a monitors. She stated there is one in each hallway and staff would know when call lights are on if they stand in front of a monitor. The call lights are not audible. In an interview on 5/24/23 at 9:11 AM, Staff D, Registered Nurse (RN) reported Resident #11 did not have side rails on her bed as therapy had been evaluating her to develop a baseline as she is receiving therapy for positioning and strengthening. She also reported staff are made aware when a resident turns on their call light when the computer monitor in each hall makes a sound. She stated the staff should answer them within 10 minutes. In an interview on 5/25/23 at 6:00 AM, Staff F, Certified Nurse Aide (CNA) reported staff are made aware when a resident turns on their call light when the screen makes a noise. She stated there is one screen per hallway and if the light shows up on the screen and it is red this means it is a bathroom light. She stated staff should answer call lights within 15 minutes. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported he did not know why Resident #11 did not have side rails on her bed and could not recall if she had complained to him about it. He also reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported Resident #11 used to have side rails on her bed. Staff G reported she had been told that state said it would be considered a restraint and they had just removed them the week before state walked in the building. The resident had complained to Staff G about it every day she worked with her. She really wants to use them to help her get in and out of bed. Staff G also reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported she did not know why Resident #11 did not have side rails on her bed and that the resident complained to her that she would like the side rails to help her sit up in bed. She also reported staff should answer call lights within 3 minutes. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing (DON) reported she would expect staff to answer call lights as soon as possible. She stated the call lights are not audible. She would expect staff to make rounds hourly to check on the residents and check the monitors. 2. The MDS dated [DATE] identified Resident #17 as cognitively impaired with a BIMS of 7 out of 15 possible points. The MDS documented diagnoses to include renal insufficiency, neurogenic bladder and non-Alzheimer's dementia. It also identified the resident required extensive staff assistance with most activities of daily living and had an indwelling urinary catheter. The Care Plan identified Resident #17 with the for need assistance with activities of daily living due to impaired mobility and impaired cognition from encephalopathy, Parkinson's, dementia, and autonomic dysfunction. It did not direct staff to ensure the resident's privacy during provision of personal cares. During an observation of catheter care on 5/23/23 at 9:47 AM, Staff A, CNA and the Assistant Director of Nursing (ADON), entered the room. Staff A informed the resident of the need to change the catheter bag. The ADON pulled the privacy curtain, however, it did not provide 100% coverage as there was a gap from the end of the curtain to the wall which measured approximately 24 inches. At 9:43 AM, the housekeeping supervisor entered the room and started working on a soap dispenser in the bathroom. The ADON did not tell the housekeeping supervisor to leave the room and return later. Staff A had then pulled down the resident's pants while the housekeeper remained in the bathroom. At 9:57 AM the housekeeping supervisor left the room. In an interview on 5/25/23 at 6:00 AM, Staff F, CNA reported if a non-nursing staff entered the room while giving cares, she would cover up the resident, tell that person she was doing patient cares and if still doesn't leave the room, she would tell her to leave the room In an interview on 5/25/23 at 10:07 AM, Staff D, RN reported if a non-nursing staff entered the room while giving cares, she would cover up the resident, and she would have that person leave the room. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported if a non-nursing staff entered the room while giving cares, he would tell that person he is doing cares and to come back later. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported if a non-nursing staff entered the room while giving cares, she would pull the privacy curtain and tell them to leave the room until cares are done. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported if a non-nursing staff entered the room while giving cares, she would tell that person to step out until she was finished with cares. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing reported if a non-nursing staff entered the room while giving cares, she would expect the staff to ask that person to step out. In an interview on 5/25/23 at 7:32 AM, the Administrator reported the facility did not have a policy related to dignity. A review of the Resident's [NAME] of Rights dated as last revised November 2016 revealed in pertinent part: The resident has a right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observation, clinical record review, resident and staff interviews, the facility failed to ensure the resident's call light had been placed within the resident's reach for one of one residents reviewed (Resident #11). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 12 out of 15 possible points. The MDS documented diagnoses to include heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. The MDS documented the resident required minimal assist of one person for bed mobility, transfers, dressing, toileting and hygiene. Observations revealed the resident lying in bed without her call light in reach on the following dates and times: On 5/22/23 at 10:32 AM, as the resident sat up in her wheelchair in her room, the call light was on top of the other nightstand out of her reach. She stated she could scoot up to the call light, but it would not be so easy. On 5/22/23 at 2:10 PM, as the resident sat up in her wheelchair watching TV, the call light remained on top of nightstand out of her reach. On 5/22/23 at 4:44 PM, as the resident slept in her bed, the call light remained out of reach on top of nightstand behind her. On 5/24/23 at 8:52 AM, as the resident laid in bed, the call light was on top of nightstand out of her reach. On 11/28/21 the Care Plan identified the resident with the problem of being at risk for falls due to impaired cognition, impaired mobility, and right rotator cuff injury. The Care Plan directed staff on 9/10/22 to post a sign in her room to remind her to use the call light for needs. The care plan did not address the need to place the call light within her reach. In an interview on 5/25/23 at 6:00 AM, Staff F, Certified Nurse Aide (CNA) reported before leaving a resident's room, she should ensure the resident had her call light in reach. In an interview on 5/25/23 at 10:07 AM, Staff D, Registered Nurse (RN) reported before leaving a resident's room, she should ensure the the call light is in reach. In an interview on 5/25/23 at 10:18 AM, Staff C, Licensed Practical Nurse (LPN) reported before leaving a resident's room, he would ensure they are comfortable, if their needs are met and make sure the call light is reach. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported before leaving a resident's room, she would make sure the resident is laying properly and the call light is near the resident. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported before leaving a resident's room, she would make sure the call light is in reach. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing stated she would expect staff before leaving a resident's room to make sure the call light is in reach.

Based on clinical record review, staff interview, and the MDS 3.0 Resident Assessment Instrument Manual (RAI), the facility failed to complete and transmit a discharge assessment for 1 of 1 resident (Resident #42) reviewed. The facility reported a census of 62 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 identified a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderately impaired cognition. The Resident Census for Resident #42 documented the resident admitted to the facility on [DATE] and discharged from the facility on 12/29/22. Review of the clinical record for the resident revealed the discharge MDS assessment was not completed and not transmitted. On 5/24/23 at 9:40 AM the Director of Nursing (DON), verified and acknowledged the discharge assessment was not completed. The DON reported the facility follows the MDS 3.0 RAI guidelines for completing and submitting MDS.

Based on clinical record review, staff interviews and facility policy review the facility failed to ensure the accuracy of the Pre Admission Screening and Resident Review (PASRR) for 1 out of 1 resident reviewed (Resident # 30). The facility reported a census of 62 resident. Findings include: The Minimum Data Set (MDS) Assessment for Resident # 30 dated 3/16/23, listed diagnoses of non-Alzheimer's dementia, and bipolar disorder. The MDS included a Brief Interview for Mental Status score of 13 out of 15 possible points indicating intact cognition. The MDS revealed Resident #30 rejected care 4-6 days in the 7 day look back period of the MDS. The Care Plan for Resident #30 dated 10/31/2022, listed he took psychotropic's (antidepressant, anti-psychotic) related to major depressive disorder and bipolar disorder. The Continuity of Care Document from the previous healthcare facility dated 10/20/22, included quetiapine 12.5 milligrams (mg) (anti-psychotic medication). The document revealed the Problem list included a diagnoses of bipolar disorder. The PASRR dated 03/16/21, included diagnoses major depressive disorder (MDD) and listed antidepressant medication. The PASRR failed to include Resident # 30's diagnoses of bipolar disorder and the anti-psychotic medication. On 05/25/23 at 11:10 AM, the Social Service Staff stated, she reviews the PASRR for accuracy before admission. If something is not correct on the PASRR, she will complete a new PASRR. On 05/25/23 at 11:19 AM, the Assistant Director of Nursing, (ADON) report it is the expectation the PASRR are accurate. She denied a policy or procedure directing to ensure PASRR accuracy. On 05/25/23 at 11:45 the Director of Nursing (DON) confirmed she expected the PASRR correct.

Based on observations, clinical record review, staff interviews, and facility record review the facility failed to follow proper infection prevention techniques with indwelling catheters for two of two residents reviewed (Residents #17 and #23). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #17 as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 7 out of 15 possible points. The MDS documented the resident had diagnoses to include renal insufficiency, neurogenic bladder and non-Alzheimer's dementia. It also identified the resident required extensive staff assistance with most activities of daily living and had an indwelling urinary catheter. On 8/16/22, the Care Plan identified Resident #17 with the problem of requiring a suprapubic urinary catheter related to neurogenic bladder. The Care Plan directed staff to not allow tubing or any part of the drainage system to touch the floor, store collection bag inside a protective, dignity pouch and use a catheter strap. Observations of Resident #17 included the following: On 5/22/23 at 11:41 AM, as resident sat in his wheelchair outside the main dining room, the Foley tubing was on the floor. On 5/23/23 at 9:38 AM, the resident asleep in bed and the urinary bag had not been placed in a dignity bag and the bottom of the bag touched the floor. On 5/23/23 at 9:47 AM, Staff A, CNA entered the resident room with the ADON (Assistant Director of Nursing). After Staff A pulled down the resident's pants, the resident did not have a thigh strap to prevent the tubing from being pulled. On 5/23/23 at 9:50 AM, after Staff A emptied the urinary bag, she clamped the spigot and placed the bag on the floor with the spigot side on the floor and proceeded to empty the graduate into the toilet. A review of a urine culture collected 2/9/22 revealed greater than 100,000 colony forming units of Proteus Mirabilis. The form included a new order to treat with Bactrim DS one tablet twice daily for seven days. 2. The MDS dated [DATE] identified Resident #23 as severely cognitively impaired with a BIMS of 5 out of 15 possible points. The MDS documented diagnoses to include traumatic subdural hemorrhage (stroke), osteoporosis and retention of urine. The MDS documented the resident required extensive staff assistance with dressing, toileting and totally dependent on staff for bathing. It also identified the resident with an indwelling catheter. On 10/14/22, the Care Plan identified Resident #23 with the problem she required an indwelling urinary catheter related to urinary retention and directed staff to position the bag below the level of the bladder, manipulate tubing as little as possible during care, use a catheter strap, and do not allow tubing or any part of the drainage system to touch the floor. Review of the residents clinical record revealed the following: On 3/8/23 at 1:15 PM the urinalysis revealed 3+ protein, 1+ ketones, 3+ blood and 4+ bacteria. Observations of Resident #23 revealed the following: On 5/23/23 at 6:30 AM asleep in bed with the foley (urinary drainage system) tubing on the floor. On 5/23/23 at 6:45 AM assessment unchanged. On 5/23/23 at 7:08 AM assessment unchanged with foley tubing on the floor. No staff observed in hall or near room. On 5/23/23 at 7:20 AM assessment unchanged with foley tubing on the floor. On 5/23/23 at 7:30 AM assessment unchanged with foley tubing on the floor. In an interview on 5/25/23 at 6:00 AM, Staff F, CNA reported before she leaves a resident with an indwelling catheter, she would make sure to never leave the bag or tubing on the floor. In an interview on 5/25/23 at 10:07 AM, Staff D, RN reported before she leaves a resident with an indwelling catheter, she would make sure make sure it's in place, should be in a dignity bag below bladder level. The tubing should be placed as much as you can in the dignity bag and should not be dragging on the floor. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported before he leaves a resident with an indwelling catheter, make sure it's below bladder level, off the floor and in a privacy bag, make sure the tubing is not kinked. The tubing should not be on the floor. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported before she leaves a resident with an indwelling catheter, she would make sure the bag is in the privacy bag. The catheter bag and tubing should not touch the floor. There should also be a thigh strap on the leg to keep it from pulling and verified Resident #17 did not have one. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported before she leaves a resident with an indwelling catheter, she would make sure it's in the privacy bag and that there is a leg strap for the tube. The bag and tubing should not be touch the floor. In an interview on 5/25/23 at 1:48 PM, DON (Director of Nursing) reported before staff leave a resident with an indwelling catheter, she would expect staff to make sure the bag and tubing is not touching the floor and below bladder level. She would also expect drainage bag to be in a dignity bag. A review of the undated facility policy titled Catheter and Perineal Care for the Catheterized Resident documented it is the policy of the facility to conduct catheter and perineal care for catheterized resident in order to accomplish the following objectives: a. to prevent infections, b. to prevent inflammation and/or facilitate healing of reddened perineal area, c. to enhance the resident's comfort. The policy lacked interventions to direct the staff to prevent infections.

Based on clinical record review, observations, and staff interviews, the facility failed to provide oxygen according to the physician orders for 1 of 1 resident reviewed for respiratory services (Residents #4). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) for Resident #4 dated 4/13/23 documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severely impaired cognition. The MDS identified Resident #4 required oxygen while a resident at the facility. The MDS documented diagnoses to include heart failure, hypertension, pulmonary fibrosis and dependence on supplemental oxygen (O2). The Care Plan revised on 4/19/23 documented Resident #4 to have oxygen as needed. The Care Plan directed staff to follow the doctor orders for liter flow and to provide assistance with the oxygen concentrator and portable oxygen tank. The Physician Order dated 3/2/2023 directed staff to administer oxygen at 2 liters per nasal cannula (NC) as needed for comfort. Review of resident vital sign records for oxygen saturation (oxygen level in the blood) revealed the following documentation: On 5/13/23 at 2:11 a.m.- O2 on at 3 liters. On 5/13/23 at 11:47 p.m.- O2 on at 3 liter. On 5/17/23 at 6:09 p.m- O2 on at 3 liters. On 5/20/23 at 3:35 p.m.- O2 on at 3 liters. On 5/21/23 at 7:06 p.m.- O2 on at 3 liters. On 5/23/23 at 10:20 a.m. observed the resident sitting in her room in a wheelchair with oxygen on at 4 liters per NC. On 5/24/23 at 7:29 a.m. observed the resident sitting in the dining room with oxygen on at 2.5 liters per NC. On 5/24/23 at 10:42 a.m., the Director of Nursing (DON) reported the facility does not have a oxygen policy. The DON reported oxygen was administered per physician orders. On 5/24/23 at 1:19 p.m., the DON stated she would expect staff to follow physician orders for oxygen administration.

Based on observations, clinical record review, resident and staff interviews, the facility failed to answer resident call lights in a timely manner for three of three residents reviewed (Residents #11, #25 and #55). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 cognitively intact with a BIMS (brief interview for mental status) of 12 out of 15 possible points. The MDS documented diagnoses to inclue heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. The MDS documented the resident required limited assitance of one person for transfers, dressing, toileting and hygiene and did not walk. The MDS documented the resident was occasionally incontinent of urine. The Care Plan dated 11/28/21 identified the resident with the problem of being at risk for falls due to impaired cognition, impaired mobility, and right rotator cuff injury and directed staff on 9/10/22, to place a sign in the room to remind resident to use her call light for needs. On 5/22/23 at 10:32 AM, observed the resident up in her wheelchair in her room with a digital clock radio on her nightstand that is highly visible from her bed. She stated she's waited as long as an hour to get her call light answered and she wets her pants every night. She stated she wakes ep every morning soaking wet and is not happy about it. In an interview on 5/24/23 at 9:10 AM, Staff C, Licensed Practical Nurse reported staff are made aware when a resident turns on their call light because the call lights show up on screens. She stated there is one in each hallway and staff would know when call lights are on if they stand in front of a monitor. She stated the call lights are mot audible. In an interview on 5/24/23 at 9:11 AM, Staff D, Registered Nurse stated staff are made aware when a resident turns on their call light when the computer monitor on each hall will make a sound. She stated the staff should answer them within 10 minutes. In an interview on 5/25/23 at 6:00 AM, Staff F, Certified Nurse Aide (CNA), reported staff are made aware when a resident turns on their call light when the screen on a computer monitor makes a noise. She stated there is one screen per hallway and if the light shows up on the screen and it is red this means it is a bathroom light. She stated staff should answer call lights within 15 minutes. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported staff should answer call lights within 3 minutes. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing (DON) reported she would expect staff to answer call as soon as possible. She stated she would expect staff to make rounds hourly to check on the residents and check the monitors. A review of the Device Activity Report (which shows time frame it took for staff to answer call lights) revealed the following: On 5/21/23 at 2:47 PM call light answered after 17 minutes 44 seconds. On 5/21/23 at 6:28 AM call light answered after 47 minutes and 43 seconds. On 5/19/23 at 1:37 PM call light answered after 24 minutes and 43 seconds. On 5/18/23 at 6:17 PM call light answered after 25 minutes 23 seconds. On 5/17/23 at 12:00 AM call light answered after 43 minutes and 44 seconds. On 5/16/23 at 11:05 PM call light answered after 24 minutes and 14 seconds. On 5/15/23 at 9:05 PM call light answered after 21 minutes and 38 seconds. On 5/16/23 at 2:40 PM call light answered after 23 minutes and 29 seconds. On 5/16/23 at 9:11 AM call light answered after 24 minutes 46 seconds. On 5/16/23 at 2:09 AM call light answered after 47 minutes 44 seconds. On 5/15/23 at 2:55 PM call light answered after 45 minutes 38 seconds. On 5/14/23 at 8:52 AM call light answered after 22 minutes and 5 seconds. On 5/13/23 at 3:38 AM call light answered after 33 minutes and 34 seconds. 34821 2. The MDS assessment for Resident #55 dated 5/11/23, documented diagnoses to include stroke and weakness. The MDS revealed Resident #55 scored a BIMS of 12 out of 15 possible points indicating moderate cognitive impairment. The MDS documented the resident required extensive assist of 2 staff for toileting and extensive assist of 1 staff for personal hygiene. The Care Plan for Resident #55 dated 8/2/22 documented she needs assistance with toileting due to impaired mobility from a stroke. The Care Plan listed a goal that she will be kept clean, dry and odor free. The Care Plan also identified the use of a diuretic medication related to fluid volume overload. On 5/22/23 at 1:05 PM, Resident # 55, stated she can wait sometimes for help. She pointed out she has a clock and knows how long it takes them. She revealed at times she can wait up 45 minutes for staff to help her. Review of the Device Activity Report for Resident # 55's room revealed the following: On 5/25/23 the call light on over 15 minutes and over 45 minutes. On 5/24/23 the call light on over 15 minutes 1 time. On 5/23/23 the call light on 2 times over 15 minutes. On 5/21/23 the call light on over 25 minutes. On 5/20/23 the call light on 2 times over 15 minutes. On 5/19/23 the call light on one time over 25 minutes. 3. The MDS assessment for Resident #25 dated 5/4/23, included diagnoses of edema. anemia, and cervical (neck) disc disorder. The MDS documented a BIMS of 15 out of 15 indicating intact cognition. The MDS revealed she needed extensive assist of 1 staff for bed mobility, transfers, dressing and toileting. The Care Plan for Resident #25 dated 8/24/22 documented the need for assistance with toileting due to impaired mobility from deconditioning and coordination deficit. The Care Plan listed a goal that she will be kept clean, dry and odor free. The Care Plan also identified the use of diuretic medication related to her edema (swelling). On 05/22/23 at 4:29 PM, Resident # 25 revealed she waited over an hour for the staff to come help her. She reported she ordered out food and they delivered the food before the staff answered her call light. Resident #25 stated she waits over 15 minutes almost daily. Review of the Device Activity Report for Resident # 25's room revealed the following: On 5/25/23 the call light on over 15 minutes three times. On 5/24/23 the call light on over 15 minutes one time. On 5/23/23 the call light on over 15 minutes six times. On 5/22/23 the call light on over 15 minutes three times In an interview on 5/25/23 at 1:30 PM, the Maintenance Supervisor reported when reading the device activity report which shows how long it took for staff to answer the call light, the rows that show the event locator showed alarm will show how long it took for the call light to be answered. In an interview on 5/25/23 at 7:32 AM, the Administrator reported the facility did not have a policy on call lights.

Based on clinical record review, facility staff, Nurse Practitioner, Wound Clinic Doctor and family member interviews, the facility failed to prevent the development of a pressure ulcer to the right heel for one of one residents reviewed which resulted in a serious infection and partial amputation of the heel (Resident #4). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15, and with the following diagnoses: Deep Vein Thrombosis (DVT - blood clots), renal insufficiency (kidney failure) and arthritis. The MDS also identified Resident #4 required extensive staff assist with bed mobility, dressing, toileting, bathing and totally dependent for locomotion on and off the unit On 8/12/22 the Care Plan identified Resident #4 with the problem of being at risk for skin breakdown and directed staff to: a. Apply offloading boots while in bed. b. Monitor skin with cares and report any signs of skin breakdown. c. Skin treatments as ordered for any areas of impaired skin integrity. A review of the Nurse's Notes revealed the following: a. On 7/19/22 at 2:49 PM, documented the Resident #4 admitted to the facility without any pressure ulcers to the right heel. b. On 8/2/22 at 1:48 PM, documented the resident readmitted from the hospital with a blister on the right heel considered to be a pressure area and lacked documentation to show the resident had heel protectors on. The Non-Pressure Skin Condition Report revealed the following: a. An area first identified to the right heel of Resident #4 on 8/2/22. b. On 8/2/22, the area measured 6.2 centimeters (cm) long x 7.2 cm wide, no depth, with a fluid filled blister intact and a Mepilex treatment requested from the Hospital in place. The report showed the Doctor and family notified (no documentation that the resident had Prevalon boots (heel protective boots) on) c. On 8/10/22, the area measured 6.8 cm long x 7.2 cm wide and no depth. Remains with boggy, fluid filled blister intact. d. On 8/17/22, the area measured 8.0 cm long x 10.2 cm wide, no depth and marked as deteriorated with the Mepilex treatment to change every 7 days. e. Assessments continued documented weekly. Review of further Nurse's Notes revealed the following: a. On 8/10/22 at 2:01 PM, has a fluid filled blister and a discolored spongy area to to the right foot. No documentation until 5 days later 8/15/22 that the resident had bilateral heel protectors on. Consistent documentation showed the Resident #4 with 3+ pitting edema to the right lower leg. b. On 8/16/22 at 9:29 PM, right leg with 3+ pitting edema and pressure areas on heel and ball of foot. Bilateral heel protectors placed on at bedtime. The September 2022 Treatment Administration Records (TAR's) revealed an order written on the TAR (no date when ordered) for offloading boots on at bed time (HS) or when in bed. The TAR failed to have documentation on following dates: September 15 and 29 to show the boots had been applied. The last week of the September Non-Pressure Skin Condition Report revealed on 9/30/22, the area measured 1.8 cm long x 2.5 cm wide x 0.1 cm deep. Small amount serous drainage, granulation tissue with black/brown eschar. Review of the Nurse Practitioner (NP) Notes documented the following: a. On 10/7/22, identified the resident with a stage 2 pressure ulcer to the right heel which measured 1.7 cm long x 2.4 cm wide x 0.2 cm deep with some eschar. No surrounding erythema (redness). b. On 10/13/22, Stage 2 non-pressure ulcer to the right heel which measured 2 cm long x 2.7 cm wide x 0.2 cm deep with some eschar. A review of the October 2022 TARs revealed Order for offloading boots at HS and when in bed not signed out as applied on 10/17/22. Review of the Wound Clinic Notes described the following: a. On 10/18/22, the resident with a pressure ulcer to the right calcaneous (heel bone) acquired 8/18/22 which measured 2.4 cm long x 1.7 cm wide x 0.2 cm deep with a large amount of necrotic/dead tissue). b. On 10/25/22, the wound has been in treatment x 1 week, classified as stage 3 wound with etiology of pressure ulcer and located on right calcaneous. Measurements 3.3 cm long x 2.4 cm wide x 0.2 cm deep. There is subcutaneous tissue exposed and a foul odor after cleansing the area was noted. Large amount of necrotic tissue in the wound bed including eschar. There is, however, no periwound erythema, edema, increase in local temperature or induration. There is bogginess underneath the lesion. Had a long discussion with his wife that it is best to for him to have more care than the Wound Clinic can provide on a somewhat urgent basis. Review of more Nurse's Notes showed the following: a. On 10/24/22 at 10:02 PM, dressing to right heel dated 10/22. Removed large amount of dead skin when completing dressing change as ordered. (No documentation that the Physician had been notified) b. On 10/25/22 at 7:39 PM, resident sent to the Emergency Department (ED) from the Wound Clinic. admitted for intravenous (IV) antibiotic for a wound infection c. On 10/26/22 at 6:49 PM, called hospital for an update. The resident reported to be septic and will need to be on several IV antibiotics. Family considering surgical intervention. The Hospital Records from hospitalization which began 10/25/22, documented the following: a. On 10/25/22, ED Physician Note: Patient comes from the Wound Clinic with chief complaint of right lower leg pain, swelling and warmth. Right foot and heel swollen, red with pitting edema. Foley catheter in place. The Wound Clinic Physician became concerned with infection as the wound appeared to be boggy with surrounding erythema with significant swelling and odor to the right lower leg. The right lower leg wound appears to be severe. b. On 10/26/22, Orthopedic Consult showed right heel ulceration began while he was hospitalized . Developed increasing cellulitis of the limb and undergoing IV antibiotic treatment. Cellulitis improved but has a necrotic ulcer of the heel which measured 8 cm long and 8 cm wide c. On 10/28/22, Orthopedic Consult for right posterior heel ulcer that has been worsening. Patient now has a severely infected right heel with redness, drainage and foul smell. The right heel is quite tender with redness, significant necrosis with exposed bone and obvious infection. Spoke to his wife and recommended partial calcenectomy and may have to consider below knee amputation. In an interview on 11/2/22 at 7:15 PM, the resident's family member reported he had his heel that amputated which started out as a small wound. The hospital sent him back to the Nursing Home with special boots to prevent it from getting bigger so there isn't any pressure and they never put them on him. In an interview on 11/3/22 at 12:28 PM, Staff A, Licensed Practical Nurse (LPN) reported Resident #4 was supposed to wear heel protectors while in bed. The Night Nurse reported the resident would kick them off and spent a lot of time in the recliner. Staff A did not recall if he wore heel protectors on while in the recliner. When Resident #4 went to the Wound Clinic before he went to the hospital, he had a foul odor to his right heel. At that time his wound was open, with a moderate amount whitish yellow drainage. The edges of the wound bed were a little bit red, edges were rough around the circumference and the wound bed was more of a white color. Resident #4 didn't complain of any pain to it unless they changed the dressings. In an interview on 11/3/22 at 1:01 PM, Staff C, Certified Nurse Assistant (CNA) reported when Resident #4 arrived, he had an open area to his right heel which had been treated with the boots. He was so tall that when he laid in bed, lots of times his feet would touch the foot board. He had a nickel sized open area to his right heel. One time he went to the doctor and when he came back, it started to have an odor. In an interview on 11/8/22 at 9:18 AM, Staff A, LPN reported the following: a. When asked if a resident has a pressure ulcer, how often should the ulcer be assessed, measured, documented on, she reported daily at minimum and they changed the dressing twice a day. It should be measured daily, not sure. b. When asked who is responsible for assessing pressure ulcers at the facility, she reported the nurses caring for the resident. The MDS Coordinator/ LPN had been assigned to measure wounds and do skin sheets, she assesses them weekly. c. Documentation on the wound are recorded on paper in a notebook in the Medication Room. d. Resident #4 had a spot to his right heel and supposed to wear heel protectors while in bed. If he sat in his recliner, he had his slippers or shoes on. In an interview on 11/8/22 at 9:32 AM, Staff D, LPN reported the following: a. When asked who is responsible for assessing pressure ulcers at the facility, she reported usually the doctor will diagnose it as pressure, the nurse who is caring for the resident is responsible for assessing. On Fridays, the MDS Coordinator will measure the wounds and document on a paper form which gets scanned into the electronic record. b. When asked when a resident has a pressure ulcer, how often should the ulcer be assessed, measured, she explained documented on once a week and could not recall if the paper form is scanned into the electronic record. c. She could not recall what had been Care Planned for Resident #4 to prevent the pressure ulcer from growing. In an interview on 11/8/22 at 11:15 AM, the Nurse Practitioner reported she could not recall how the pressure ulcer to his heel occurred, but Resident #4 had poor mobility, in decline and had problems with edema which all may have contributed to his skin breakdown. In an interview on 11/8/22 at 12:02 PM, the Director of Nursing (DON) reported the following: a. The resident did not have an open area to his right heel when he had first been admitted to the facility. And could not recall if there had been formal documentation that classified it as pressure sore, however, she thought it had been identified as a pressure sore. b. In September, Resident #4 had been sent to the hospital and diagnosed with COVID and had the wound debrided (treatment to remove dead tissue from a wound). The resident had an area which started out as a blister. The facility treated the area with Mepilex dressings and the blue and black Prevalon boots that the hospital sent with him In an interview on 11/10/22 at 9:03 AM, Staff F, Wound Care Physician reported the following: a. When asked what she felt caused the pressure ulcer to his right heel, it had developed while the resident hospitalized for a Pulmonary Embolism (PE - blood clot in the lung) in September. She could not report how it developed. She did order the Prevalon boots which he had at the facility. b. Pressure ulcers can always be prevented because the just needs to be rotated/repositioned. In an interview with the 11/10/22 at 1:54 PM, the resident's spouse reported the following: a. When he first arrived to the facility, the area to his right heel had not opened. It became infected and turned black. She recalled one day she visited him and he had his bare foot on the floor with drainage underneath it and an odor. A week later, he went to the Wound Clinic and by then it really had a definite odor. The Doctor at the Wound Clinic sent him to the emergency room from there. b. Upon arrival to the hospital, a surgeon informed her that gangrene had set in and needed surgery that day. The infection had went to the heel bone and he removed the heel bone. c. The resident did have a footboard on his bed the Nursing Staff never removed it from his bed and he was tall enough that his heel would rest against on the footboard. In an interview on 11/14/22 at 1:51 PM, Staff N, Registered Nurse (RN) reported the nurses had been putting Mepilex dressing and the boots on at night. Resident #4's dressings should have been changed twice a day, once on first shift and once on 2nd shift. When she came to work on the October 24th, his dressing had moved up his leg and dated 10/22 with no initials on it. When she saw the wound, it appeared macerated. Staff N thought the combination of trying to exert the walking and couldn't keep the pressure relieving devices on because he crossed his legs so much. In an interview on 11/15/22 at 4:08 PM, Staff G, Wound Care Physician reported he had sent the resident to the hospital as the wound required more attention and more workup than they could provide at the clinic. He also reported every pressure ulcer is preventable and that he probably had not been repositioned enough.

Based on record review, family and staff interviews, the facility failed to follow facility processes and state rules related to an Involuntary Discharge for one of three residents reviewed (Resident #6). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set assessment dated [DATE] identified Resident #6 as severely cognitively impaired and unable to complete a Brief Interview for Mental Status (BIMS) test. It also identified her with the following diagnoses: Alzheimer's Disease, mood disorder and repeated falls and totally dependent on staff for toileting, personal hygiene and bathing. A review of the Care Plan identified the resident on 3/5/21 with the problem of needing long term nursing care with the following interventions: Per resident representative request, only ask the resident about his/her desire to return to the community, as well as making referrals to local contact agencies during comprehensive assessments, encourage verbalizations of fears and concerns with care. Provide reassurance when necessary and arrange for quarterly care conference with resident and family. Allow resident to make independent choices as able. A review of the Nurse's Notes revealed the following: a. On 5/29/22 at 9:41 PM, this aggressive resident had been observed in person by Unit Certified Nurse Aide's (CNA) and on cameras present in unit wrapping hands around anterior neck of another resident. This incident was unprovoked by other resident. Aggressive resident was removed from situation and redirected. This writer did not observe this incident in person. b. On 5/31/22 at 11:36 AM, called placed to resident's family member with the Director of Nursing (DON) , Assistant Director of Nursing (ADON), Social Worker and Administrator to inform of facilities' inability to provide placement for the resident based on notes from the hospital on restraints and requirements for one on one care. c. On 5/31/22 at 2:52 PM, Involuntary Discharge Notice issued to the resident and her representative via certified mail. A review of the proposed decision by the Iowa Department of Inspections and Appeals Division of Administrative Hearings regarding the Basis for Involuntary Discharge: Continuing Threat to Welfare of Other Residents and Staff, the title implies the Administrative Law Judge (ALJ) did not find Resident #6's physical aggression towards residents and staff justified an Involuntary Discharge. However, reading the paragraph it appears the ALJ is ruling that she found the facility failed to follow the Involuntary Discharge requirements and that Resident #6's continuing threat to the welfare of others is time and fact sensitive and based on the type of discharge issued by the facility. Other than the headline, the ALJ did not rule on whether or not Resident #6's behaviors were a continuing threat to the welfare of other residents and staff. Because finding number one's title is misleading and findings two through four better explain the issues with the discharge, the first finding is not adopted. 11/14/22 8:20 AM interview, the resident's family member reported the state ALJ had already made a decision regarding the Involuntary Discharge and provided documentation as such. In an interview on 11/29/22 at 11:22 AM, the Social Worker reported a. The process when issuing an Involuntary Discharge would be notify the family usually, not sure what the time frame is to issue it. b. Resident #6 had been discharged from the facility because she had an altercation with a male resident in the Memory Care Unit. Her daughter did not agree with our choice to do so. We felt the other residents were at a significant risk for injury. c. We issued the notice about her discharge the day she left here before she went to the hospital. d. The reason she had not been allowed to return to the facility from the hospital had been due to her aggressive behaviors with other residents. She had strangled another male resident. In an interview on 11/29/22 at 12:13 PM, the DON reported she had been unsure of the process when issuing an Involuntary Discharge. When asked about the discharge for Resident #6, she reported the resident had aggressive behaviors and sent out to the hospital. The DON had been off on medical leave when the resident had been discharged .

Based on observation, record review and staff interview, the facility failed to update Care Plans for two of three residents reviewed (Resident #2 and #9). The facility reported a census of 57 residents. Findings Include: A review of the Minimum Data Set, dated dated dated [DATE] identified Resident #2 as severely cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS). It also identified her with the following diagnoses: Alzheimer's Disease and seizure disorder and required extensive staff assistance with toileting, dressing and hygiene and completely dependent on staff for bathing. It also identified she had problems with inattention and disorganized thinking on a continual basis without fluctuation. A review of the Incident Report dated 8/27/22 revealed a description of an incident where a male resident (Resident #1) fondled the chest of a female resident (Resident #2) in her room, the resident was fully dressed and incident lasted approximately one to two minutes. A review of the statement provided by the Director of Nursing (DON) revealed the following: a. On 8/27/22 she had been notified by Staff J, Licensed Practical Nurse (LPN) about an incident where resident Resident #1 found fondling the breast of Resident #2. This had been initially reported by Staff T, Housekeeper who had been in Resident #2's bathroom changing out the paper towels and witnessed Resident #1 caressing Resident #2's breast. A Certified Nurse Aide (CNA) had been called in immediately and removed Resident #1 from the room. A self report was initiated with Department of Inspections & Appeals (DIA) at the time of notification by the DON. Care Plans updated and staff notified of treatment plan for Resident #1. A review of the Care Plan dated as last reviewed 11/15/22 did not include new interventions to address the above incident on Resident #2's Care Plan. A review of the Nurse's Notes revealed the following entries: a. On 8/27/22 at 2:30 PM, resident resting in her recliner. No signs/symptoms of distress related to the groping incident. b. On 8/29/22 at 1:30 AM, no concerns with resident related to the inappropriate touching event. Observations of the resident revealed the following: a. On 11/2/22 at 1:06 PM, sitting up in dining room chair, wearing clean clothing and non-skid shoes. Resident #1 sat at another table and did not have any interactions with her. b. On 11/2/22 at 1:31 PM Staff C, CNA held resident's hand and assisted her to walk to her room, Resident #1 not in the hallway. c. On 11/2/22 at 2:01 PM, resident currently sitting in her recliner in her room, Resident #1 not in the hallway or in her room. d. On 11/3/22 at 8:30 AM, sitting up in dining room chair with both feet resting on the floor, Resident #1 not in the hallway or in her room. c. On 11/3/22 at 10:34 AM, ambulating in hallway with steady gait with her son holding her left hand and her daughter-in-law holding her right hand. Resident #1 not in the hallway. d. On 11/3/22 at 1:39 PM, sitting up in her recliner Resident #1 not in the hallway or in her room. e. On 11/9/22 at 7:30 AM, Sitting in main dining room (MDR) chair Resident #1 sat at another table without interacting with her. f. On 11/9/22 at 8:43 AM, Staff E, CNA held back of the gait belt around the resident's waist as resident ambulated without devices from the MDR in the hallway to her room. Resident #1 not in the hallway or in her room. g. On 11/9/22 at 9:40 AM sitting up in recliner in her room, Resident #1 not in the hallway or in her room. In an interview on 11/9/22 at 8:20 AM, Staff T, Housekeeper reported she had witnessed Resident #1 fondle Resident #2's breast in August 2022 and that he had a history of being inappropriate behavior with females. In an interview on 11/14/22 at 1:04 PM, Staff J, LPN reported an incident that involved Resident #1 fondled Resident #2's breast, that Resident #1 had a history of inappropriate behavior to females, after the incident they had been immediately separated. Staff J reported he would expect that to be addressed on Resident #2's Care Plan and that the Care Plans in the rooms did not address inappropriate behaviors and interventions. In an interview on 11/14/22 at 10:29 AM interview with Staff V, CNA reported in August 2022, she witnessed Resident #1 touching Resident #2's breast and that she had no idea what had been care planned for Resident #2 if the incident occurred again. She also reported there are care plans in the room, but they don't address behaviors. In an interview on 11/29/22 at 10:46 AM, Staff D, LPN reported she could not verify the exact date when the above incident occurred, but it had been more than a few months ago. She also reported the MDS Coordinator had been responsible for updating Care Plans which should occur with any changes and that after the above incident, typical interventions that should have been added to the care plan include: Separate them immediately if it happened, report it to the nurse, the nurse would assess the resident In an interview on 11/29/22 at 11:02 AM, Staff Y, Registered Nurse (RN) reported Care Plans should be updated when there are any changes at all in their mentation, medical condition, etc. She thought the MDS Coordinator with help from the DON and the Assistant Director of Nursing (ADON). She also reported the MDS Coordinator had been working the floor a lot. In an interview on 11/29/22 at 12:13 PM, the DON reported the following: a. When asked when she would expect Care Plans to be updated, it would depend on the situation, but with changes on the resident's condition. When the changes are made, these are can be found in the computer. The CNAs have access to the computers to look at the plans. Every room has a Care Sign posted for all staff, how they transfer, assistive devices, etc. b. The MDS coordinator is responsible for updating the care plans. The DON and ADON can also update. c. The incident between Resident #1 and #2 occurred in August 2022. d. Interventions she would expect to be added to Resident #2's care plan after that incident would include: separate the two residents, provide emotional support, continue to monitor, report it to the Charge Nurse who would then complete an incident report e. When asked to explain why Resident #2's Care Plan had not been updated, she reported she updated Resident #1's Care Plan, but did not think to update Resident #2's care plan. Upon request for a policy on Care Plans, the Administrator reported the facility did not have one. 46874 2. The Minimum Data Set (MDS) Assessment identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 upon admission on 8/2/22 and Then re-scored at 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction and had required a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The Admission MDS identified Resident #9's skin conditions as a surgical wound (left hip) and moisture associated skin damage (MASD) of the coccyx area. The Care Plan dated as last revised 8/11/22 stated Resident #9 had needed staff assistance with management of the bowel colostomy to include assistance with emptying the colostomy bag, monitor the stoma and surrounding area and to notify the physician with concerns. The resident Care Plan lacked being updated to include colostomy stoma skin issues, resident pain incurred during colostomy bag changes, and lacked updating the changed process of colostomy stoma wafer, bag changes and Provider ordered colostomy products to be used. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. Admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now every 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR had shown Resident #9 had been administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the residents November 2022 EMAR shown the resident had been administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward there had been a total of six times the resident had been administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration.

Based on observation, record review and staff interviews, the facility failed to follow physician orders for two of three residents reviewed (Residents #8 and #9). The facility reported a census of 57 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #8 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 11 out of 15 and with the following diagnoses: heart failure, peripheral vascular disease and diabetes mellitus. The MDS also identified the resident as independent with most activities of daily living except bathing which she required extensive staff assist with. The Care Plan identified the resident with the problem of potential for skin breakdown on 6/20/22 due to peripheral vascular disease. Interventions included: 10/5/22 tubigrips to both legs, high-low bed with pressure reduction mattress and half rail to inner side of bed and grab bar to outside of bed. to help with repositioning, check her skin with cares & bathing. She needs assist with repositioning. On 11/15/22 at 8:47 AM, attempted to complete an observation of the resident in the dining room, Staff Y, Registered Nurse (RN) reported the resident is currently in the hospital and had problems with her toe and being diabetic. In an observation on 11/21/22 at 8:00 AM, the resident asleep in bed lying on right side with two one half side rails up. Dressing dry and intact to right foot. Call light in reach. Bed alarm in place and activated. Properly positioned and appears comfortable. A review of the Progress Notes revealed the following: a. On 10/25/22 at 2:25 PM, resident has an area on the right great toe with scabbed areas on the right 2nd and 5th toes. Recently took antibiotic to treat cellulitis to the right foot b. On 11/04/22 at 12:18 PM, area to right second toe resolved. New order to discontinue treatment. c. On 11/11/22 at 1:39 PM, right foot swollen, red and warm to touch. Odor coming from area to right fifth toe. Call placed to doctor to notify of changes to foot. Order to send to emergency room (ER) for evaluation. d. On 11/11/22 at 6:09 PM, this nurse received call from resident's family to notify the facility of resident being admitted to hospital for infection in fifth toe of right foot. e. On 11/14/22 at 10:06 AM, spoke with resident's family who informed that the resident's Orthopedic Doctor recommended amputation of the right small toe. Tentative plan for surgery is tomorrow. f. On 11/18/22 at 7:51 PM, resident admitted right 5th toe amputee, refused to have dressing changed as she said they just changed it at the hospital earlier that day. A review of the Physician Orders and November Treatment Administration Record (TAR) revealed an order dated 6/20/22 - Menarin cream apply to legs and feet daily (scheduled for 2nd shift) No doses signed out to show the treatments had been completed. A review of the Hospital Wound Nurse Assessment note dated 11/18/22 documented the resident had a right 5th toe amputation on 11/15/22. In an interview on 11/15/22 at 7:35 AM, Staff A, Licensed Practical Nurse (LPN) reported Friday, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) called and asked me about Resident #8's little toe and told me they saw a Mepilex foam bandage which she dated and put her initials on it. They informed they could not find orders for it. Staff A reported there had been an order and that it had not been discontinued and it had not been scanned into the electronic record. The DON and ADON are responsible for scanning orders into Electronic Medical Record (EMR). In an interview on 11/29/22 at 10:46 AM, Staff D, LPN reported the following: a. The Pharmacy had the responsibility of adding new orders to the Medication Administration Records/Treatment Administration Record's (MARs/TARs). They would have to call the Pharmacy if orders came in after hours or on the weekend. b. The double check system in place to ensure the orders were transcribed correctly is new orders are reviewed by the next shift and noted on the 24 hour report and it gets noted on the 24 hour report sheet. Any new orders should be addressed on the nurse's progress note with follow-up after new medications are started. c. The process she follows when administering medications is to find out who the patient is, what the medication is, make sure the order is correct, make sure the order is matching the medications in the unit dose envelopes d. She could not explain why the treatments for Resident #8 had not been signed out for the month of November. In an interview on 11/29/22 at 11:02 AM, Staff Y, RN reported the following: a. The DON and ADON will process new orders, fax the order to the pharmacy and call the nurse if something needs to be started right away. She could not remember who entered the new orders, thought the Pharmacy entered the new orders on to the MARs/TARs. b. There had not been a double check system to ensure the orders had been transcribed directly. Most of the nurses will check the original order to make sure it's been transcribed directly. c. The process she takes before she gives medications is: check the medication against the MAR to make sure they match, mark off each medication that she had checked, make sure it's the right dose, time and day, give medication then sign off the medications on the MARs and TARs. d. She admitted sometimes medications are not signed out because nurses will forget to do this. She gives medications to at least 20 residents, some take an extreme amount of time to take their medications and sometimes this causes the nurses to forget to sign out the medications. In an interview on 11/29/22 at 12:13 PM, the DON reported the following: a. When asked who is responsible for adding new orders to the MARs/TARs, she reported the nurse receiving the order, however, any nurse can verify the order. After a new order is received, it is sent to the Pharmacy by fax. All orders are entered on the Pharmacy end and they populate into the chart at the facility. The facility began using Electronic Medication Administration Records (EMAR) on 10/26/22. Problems arose when orders came over had to be corrected as the scheduled times had not been included. She had to add all the correct times to all the MARs. b. When a new order comes in, Pharmacy checks it and it is double checked by the DON and verified by a nurse. c. The process she expected the nurses to follow when administering medications is to use the 5 rights, right resident, right medication, right dose, right time and compare what they have to what is documented on the MAR. d. When asked why the order dated 6/20/22 for Menarin cream apply to legs and feet daily (scheduled for 2nd shift) for Resident #8 had not been signed out for the month of November, she reported the order had not been entered into the EMAR. e. When there are parentheses around initials on the MARS, she thought it meant the medications had not been administered or not charted. Every PRN medication given should have an assessment documented in the Nurse's Notes. Upon request for the facility policy regarding following Physician Orders, the Administrator reported they did not have one. 46874 2. The Minimum Data Set (MDS) Assessment identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 upon admission 8/2/22 and then rescored a 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction and had required a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The Admission MDS identified Resident #9's skin conditions as a surgical wound (left hip) and moisture associated skin damage (MASD) of the coccyx area. The Care Plan dated as last revised 8/11/22 stated Resident #9 had needed staff assistance with management of the bowel colostomy to include assistance with emptying the colostomy bag, monitor the stoma and surrounding area and to notify the physician with concerns. The resident's Care Plan lacked being updated to include colostomy stoma skin issues, resident pain incurred during colostomy bag changes, and lacked updating the changed process of colostomy stoma wafer, bag changes and Provider ordered colostomy products to be used. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. Admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now every 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR shown Resident #9 administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the resident's November 2022 EMAR shown the resident administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward a total of six times the resident administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration.

Based on observation, record review and staff interviews, the facility failed to document assessments per the facility fall protocol for one of two residents reviewed (Resident #5) and failed to document assessments of a resident's skin surrounding the stoma after the colostomy bag had been changed four times in a day (Resident #9). The facility reported a census of 57 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 4 out of 15. The MDS also identified her with the following diagnoses: cerebrovascular accident (a stroke), Non-Alzheimer's Dementia and spinal stenosis, and she required extensive staff assistance with locomotion off the unit and with bathing. A review of the Incident Report dated 10/9/22 at 10:00 AM, documented the resident with a hematoma to the right side of her head which measured 5 centimeters (cm) by 5 cm. Fall not witnessed and occurred in her room. On 8/7/22 the Care Plan identified the resident with the problem of being at risk for falls due to impaired mobility and impaired cognition from spinal stenosis, chronic pain, and dementia. The Care Plan directed the staff to follow these interventions: a. Regarding the fall on 10/1/22: sign in room to remind resident to use her call light for help and high-low bed with bilateral grab bars to assist me with repositioning myself. b. Needs the assist times one staff with gait belt and walker for transfers and ambulation. c. Use a wheelchair that staff propel her in when her back pain is limiting her ambulation or for off unit i.e.: scale as needed, appointments, etc. d. Regarding fall on 3/18: Lyrica discontinued. e. Staff are to not put a chux on resident's recliner. f. Staff to remind resident to walk closer to her walker when ambulating as needed to help her maintain better balance. A review of the Nurse's Progress Notes revealed the following: a. On 10/9/22 at 2:01 PM, this nurse called to this resident's room, upon entry noted resident lying on her right side facing the bathroom. Grips equal. This nurse rolled resident onto her back no shortening of either leg and no rotation noted to either foot. Resident sat in sitting position and she says her leg hurts. This nurse palpated both hips and noted no difference at this time. Gait belt placed on resident and this nurse and a Certified Nurse Assistant (CNA) stood resident up and the resident expressed that her leg hurts and this nurse noted outward rotation to right foot. Resident placed in bed and pillow placed between legs. Physician called and received orders to transport to the emergency room (ER). b. Ambulance left with resident around 11:30 AM. c. At 1:31 PM the hospital called and reported fracture to right hip. A review of the Neuro Flow Sheet revealed only one assessment with vital signs and a neuro check completed at 10:00 AM. No documentation noted for 10:15, 10:30, 10:45 and 11:00 AM as per fall protocol of every 15 minutes 4 times after fall occurred. In an interview on 11/14/22 at 1:20 PM, Staff J, Licensed Practical Nurse (LPN) reported after a resident experiences an unwitnessed fall, the nurse should check vital signs, do neuro checks, check for any rotation to any of the extremities, check for injury and should be done every 15 minutes four times, every 30 minutes four times and hourly four times then every 4 hours twice and once a shift for 72 hours. In an interview on 11/14/22 at 1:34 PM, the MDS Coordinator/LPN reported the following: a. After a resident has an unwitnessed fall and there is a hematoma noted to the head, the nurse should check neuros and vital signs every 15 minutes four times, every 30 minutes four times, hourly four times, every 4 hours twice then once a shift for the next 72 hours. These should be documented on the Neuro Flow Sheet. b. When Resident #5 fell on [DATE] in the morning, before lunch in the morning. The aide notified her of the fall and when she assessed the resident, the resident laid on the floor and complained of pain. She did have a hematoma above her right eyebrow. c. When asked why the Neuro Flow Sheet did not have any documentation of vitals, neuro checks, etc after 10:00 AM, she reported she had been preparing for the resident to be taken to the hospital. That it happened on a weekend where only one other nurse and an aide worked the Care Center (where the long term residents reside). In an interview on 11/16/22 at 10:37 AM, Staff R, LPN reported when a resident has an unwitnessed fall, the nurse should assess, get vital signs, find out if it was unwitnessed, any injuries, check the area to see if there is a safety concern, do the neuro checks every 15 minutes for an hour, hourly after the first hour for 4 hours and after that she could not recall how often. These should be documented on a Neuro Assessment/Post Fall Form, this is recorded on a paper form, then gets scanned into the Electronic Medication Record (EMR), but don't know who is responsible. She also reported the MDS Coordinator did not call her for help to complete some of those assessments. And the only reason she could think of as to why it was not done was they were short staffed. On the weekends, it would be common for one nurse to be responsible for 30 residents. Staff often call in sick on the weekends. She could not recall any other details regarding Resident #5's fall as she had cared for residents in the opposite hall. Staff R did recall the hospital called later to report the resident had a fracture of the hip. Upon request for a policy on assessment/intervention, the Administrator reported the facility did not have one. 46874 2. The MDS identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 upon admission 8/2/22 and then rescored a 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction and required a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The Admission MDS identified Resident #9 skin conditions as a surgical wound (left hip) and Moisture Associated Skin Damage (MASD) of the coccyx area. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. Admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now every 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR had shown Resident #9 had been administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the residents November 2022 EMAR shown the resident had been administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward there had been a total of six times the resident had been administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration.

Based on clinical record review, Hospice Nurse, Pharmacist and facility staff interviews, the facility failed to failed to assess and intervene for residents with pain for one of three residents reviewed. The facility reported a census of 57 residents. Findings Include: The MDS had identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 upon admission 8/2/22 and then rescored a 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction requiring a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The Admission MDS identified Resident #9's skin conditions as a surgical wound (left hip) and Moisture Associated Skin Damage (MASD) of the coccyx area. The Care Plan dated as last revised 8/11/22 stated Resident #9 had needed staff assistance with management of the bowel colostomy to include assistance with emptying the colostomy bag, monitor the stoma and surrounding area and to notify the physician with concerns. The resident Care Plan lacked being updated to include colostomy stoma skin issues, resident pain incurred during colostomy bag changes, and lacked updating the changed process of colostomy stoma wafer, bag changes and Provider ordered colostomy products to be used. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. Admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now very 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR had shown Resident #9 had been administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the residents November 2022 EMAR shown the resident had been administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward there had been a total of six times the resident had been administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration.

Based on observations, record review, family and staff interviews, the facility failed to properly maintain heat registers in the residents rooms to prevent any possible injuries to occur for two of three residents (Resident #3 and #4). The facility reported 57 residents. Findings Include: Observations of Resident #3's room revealed the following: a. On 11/2/22 at 2:35 PM, the heat register with metal pieces that appear bent. b. On 11/29/22 at 10:00 AM, heat register remains unchanged with bent pieces of metal and unrepaired. Observations on 11/8/22 at 11:29 AM with the Maintenance Director of Resident #4's room, revealed the heat register had one end still bent up. A review of Resident #4's Nurse's Notes revealed the following: a. On 10/2/22 at 12:34 PM, the resident observed with both feet hanging over edge of the bed with small abrasions noted to tips of great, 2nd and 3rd toes. Areas cleaned with NS and wrapped with gauze. In an interview on 11/2/22 at 7:15 PM, the Resident #4's family member reported there had been an incident where his foot fell over the side of the bed and hit the heat register which caused lacerations to his toes. In an interview on 11/3/22 at 12:28 PM, Staff A, Licensed Practical Nurse (LPN) reported the resident's spouse reported the resident's left leg fell off the bed and hit his foot on the foot register and got caught in between the metal parts. Staff A could not recall if the heat register had been repaired. In an interview on 11/8/22 at 11:29 AM, the Maintenance/Housekeeping/Laundry Supervisor reported when there are problems identified in resident's rooms, Nursing Staff are responsible for sending him requests for repairs. He reported he never received a request to repair the heat register in Resident #4's room. One of his Housekeepers reported that one of the heat register's covers popped off and they straightened it back up and put it back on. In an interview on 11/8/22 at 12:02 PM, the Director of Nursing (DON) reported she had not been informed of the heat register in the resident's room being in need of repair. She thought the family had reported it to the Social Worker. In an interview with the 11/10/22 at 1:54 PM, the resident's spouse reported underneath the windows are heat registers and there is one sheet of metal that goes across there. She had straightened up the sheets on his bed and noticed one of the panels from the heat register on the floor and a puddle of blood on the floor. She reported the problem to one of the nurse's and informed her that they required maintenance. No one ever came to fix it. Several days went by and that piece of the heat register still laid on the floor. The resident had been able to push the bed away from the wall enough that one of his legs dropped down in to the coil of the heater. He ended up getting some cuts to his toes to the left leg which the nurse cleaned up and put band aides on. In an interview on 11/29/22 at 11:22 AM, the Social Worker reported Resident #4's family informed her that his foot had fallen off the bed onto the register and the heat register caused him to have a scrape on his foot. She reported her follow-up for that had been that she contacted the Maintenance Director who informed her that it had already been fixed by that point. She did not have any documentation of this request. When asked if the facility had a policy regarding maintenance repairs, the Administrator reported they did not have one.

Based on clinical record review, observations, family and staff interviews, the facility failed to administer the pain medication as ordered for one of one residents reviewed for pain (Resident #9), resulting in episodes of uncontrolled pain for the resident. The facility reported a census of 51 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10, and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also identified the resident received a scheduled pain medication regimen and at the time of the Pain Assessment Interview, the MDS documented should not be conducted as resident is rarely/never understood. A review of the Care Plan identified the resident with the problem of chronic pain due to [CONDITION(S)] (date initiated 11/16/21 and goal target date of 4/30/22) with the following interventions: a. Encourage non-pharmacological interventions to assist with pain control, i.e.: ice, repositioning, wheelchair ride, visit, activity, distraction, snack, music, touch/massage, etc. b. Monitor my pain level. c. Report unrelieved or unacceptable pain to my doctor. A review of the Clinical Admission Documentation Form dated 3/29/22 and completed at 5:32 PM by Staff G, Registered Nurse (RN), the following noted: a. Marked as no verbal/non-verbal expressions of pain. b. Intensity of pain documented as moderate pain. c. Rated as a 4 on the Pain Scale of 0 to 10 with 10 being the most pain. d. No documentation to show the frequency of pain had been assessed. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. Received at the facility on 3/29/22 at 12:19 PM. b. Orders included: [MEDICATION(S)] 50 milligrams (mg), one tablet orally 3 times a day and twice daily (BID) as needed (PRN). c. Acetaminophen (Tylenol) 325 mg two tablets three times daily (TID)- also handwritten in beside this order was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/7/22 at 1:00 PM, Staff B, Licensed Practical Nurse (LPN) reviewed the Narcotic Record for the Resident #9 and verified a bottle of [MEDICATION(S)] 50 mg tablets accounted for. Staff B stated the resident had scheduled doses of [MEDICATION(S)] ordered and that the first dose not signed out until 3/30/22 at 6:40 PM, over 30 hours after the medication order first received from the hospital. The Narcotic Medication Sheet noted dated as received on 3/29/22 by Staff F, LPN. Review of the Narcotic Medication Sheet of doses given had been signed out at: a. On 3/30/22 at 7:45 AM. b. On 3/30/22 at 12:00 PM. c. On 3/30/22 at 5:40 PM. d. **No doses signed out for 3/31/22. e. On 4/1/22 at 8:00 AM. On 4/7/22 at 1:10 PM, Staff K, LPN/acting Director of Nursing (DON) and Staff A, LPN reviewed the Emergency Medication Kit (E-Kit) in the Medication Storage Room and revealed the E-Kit contained [MEDICATION(S)] 50 mg tablets stocked. On 4/11/22 at 1:08 PM, Staff G, RN reviewed the West Medication Cart with the surveyor and revealed it contained a large bottle of Tylenol 500 mg pills. A review of the Progress Notes revealed the following: a. On 3/29/22 7:02 PM, Resident arrived at 3:45 PM by wheelchair from the hospital. Had been hospitalized with severe hip pain, and had a sacral fracture. Rated pain at 5 out of 10 and given PRN order of Tylenol 650 mg. b. On 3/30/22 6:00 AM, (nearly 12 hours after the resident arrived from the hospital), Resident complained of a lot of pain last night. The nurse unable to locate the Discharge Medication Orders and failed to document she contacted the Admitting Physician or Physician On-Call for orders. She called the Hospital for orders and still had not received prior to her shift ending. She offered ice packs to help relieve pain. A Certified Nurse Aide (CNA) walked with the resident to help alleviate the pain. c. On 3/30/22 9:54 PM, 6:00 PM, dose of [MEDICATION(S)] given from bottle d. On 3/31/22 8:42 PM, during 8:00 PM Medication Pass, the resident stated she would like to have PRN at 3:00 AM. Given 7:30 PM scheduled Tylenol. e. On 4/1/22 8:47 PM Resident reported pain when she sat. Pain management with [MEDICATION(S)] effective as reported by the resident. f. On 4/2/22 10:31 AM Reported pain management effective. A review of the Medication Administration Records (MAR's) revealed the following for the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. An order dated 3/29/22 [MEDICATION(S)] Hcl tab 50 mg one tablet TID scheduled at 8:00 AM, 12:00 PM and 6:00 PM. b. No doses signed out on 3/29/22, the resident did not receive a scheduled dose at 6:00 PM as ordered. c. No doses signed out on 3/30/22 for 8:00 AM or on 3/31/22 at 6:00 PM. d. An undated order (handwritten in) Tylenol 1000 PO TID scheduled for 10:00 AM, 3:00 PM and 8:00 PM. e. No doses signed out as given at 8:00 PM on 3/29/22 The PRN MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. Order for [MEDICATION(S)] Hcl 50 mg one tab BID PRN for severe pain, no doses signed out as given at all. b. The PRN MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 3/29/22 at 10:30 PM APAP (Tylenol) 650 mg PO given for complaint of hip pain at a 5out of 10. b. Result charted 3/30/22 at 3:30 AM as not effective. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. Tylenol 100 mg TID per day for pain scheduled at 10:00 AM, 3:00 PM and 8:00 PM no doses signed out as given. b. [MEDICATION(S)] 50 mg TID per day scheduled at 8:00 AM, 2:00 PM and 10:00 PM with only one dose signed out on 3/30/22 at 8:00 AM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of PRN MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 4/3/22 at 1:13 AM for pain level of 6 out of 10, evaluated again 4/3/22 (no time documented) results charted as resident sleeping. b. On 4/4/22 at 1:00 AM - no pain level documented - no documentation of re-evaluation. c. On 4/6/22 at 2:30 AM - for pain level 9 out of 10, result documented as re-evaluated 4/6/22 at 4:00 AM with pain level 4/10 and helpful. d. On 4/7/22 3:45 AM - for pain level of __ out of 10 (unable to read the pain level) for complaint of right hip/back pain, result documented as re-evaluated on 4/7/22 at 4:00 AM. A review of the record revealed no documentation on a Pain Assessment Flow Sheet. Observations of the resident during the investigation survey (4/5/22 - 4/12/22) revealed the resident had been properly positioned and appeared comfortable. During an interview on 4/5/22 at 5:41 PM, the resident's family member reported it upset him greatly when the resident would call him crying in pain after she had a pelvic fracture and reported she had not received her pain medication. On 4/11/22 at 7:27 AM Staff F, LPN reported the following: a. The process is for obtaining orders and medications when getting ready to receive a resident coming from the hospital, would be to ask if the family had any discharge papers or medications. b. If she did not have the medications ordered, the process would be to ask the family to bring the medication or she could pull the medication from our E-Kit. c. When the resident returned to the facility from the hospital she had received paperwork from the previous shift that the resident had been in a lot of pain. Every time she asked her to rate it, she would rate it as 10 out of 10. d. When asked if she had the [MEDICATION(S)] that was ordered for her, Staff F reported she did not have the orders, she called the Discharge Planner at the hospital who requested documents with the facility letterhead. She had not received any documents from the hospital and looked at the MARs in the book and gave her Tylenol and an ice pack. There were no orders for [MEDICATION(S)] as she had looked at the MARs the resident had before she had been sent out to the hospital. Before her shift ended, Staff F still had not heard back from the hospital. On 4/11/22 at 8:45 AM, the Consultant Pharmacist reported the Pharmacy received the faxed discharge instructions from the facility on 3/29/22 at 12:45 PM and on 3/29/22 at 2:25 PM the Pharmacy sent a packing slip to the facility with the medications. On 4/11/22 at 9:45 AM, Staff G, RN reported the Pharmacy would send the new MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When she first arrived from the hospital, the resident said she was in pain in both hips and when she walks it's worse. Staff G could not recall if the resident's medications arrived prior to her shift ending. On 4/11/22 at 10:10 AM, Staff A, LPN reported she did not take care of the resident when she arrived from the hospital and that when a new admit is coming from a hospital, the Charge Nurse will send the orders to the Pharmacy and the nurse taking care of the resident is responsible for checking the orders against the medications when they arrive from the Pharmacy. On 4/11/22 at 2:00 PM, Staff D, CNA reported when she took care of the resident, she would cry, she would sit in her chair, and say she was in so much pain. The resident would sit in the chair screaming, she put her hands on her hips. She seemed to scream out more throughout the shift more than she did not. The nurses gave her pain medication, but it did not seem to help. On 4/11/22 at 3:12 PM, Staff K, LPN/acting DON reported when she spoke to Staff F, LPN she reported she did not have a signed order. Staff K verified the medications and MARs had been delivered on 2nd shift on 3/29/22. The medications were in the resident's drawer in the med cart and MARs were on the counter in the Medication Room. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy would not have sent the medication without a signed prescription. Staff F had the orders on the clipboard, she had the MARs that the Pharmacy sent. She called the hospital to get the orders, but failed to call the doctor and nurse on call and failed to follow the Doctor's Order. On 4/12/22 at 6:05 AM, Staff I, RN reported when she took care of the resident after she returned from the hospital, the resident did have a lot of pain, she could rate her pain, and had facial grimacing. Staff I gave her the pain medication and returned later to recheck to see if it worked and it had been effective. Nurses should check residents usually 30 minutes to an hour after giving pain medication. On 4/12/22 at 9:21 AM, Staff L, CNA reported when he saw the resident after she returned from the hospital, she would say she was in pain and would yell out frequently. On 4/12/22 at 1:03 PM, Staff K, LPN/acting DON reported no Pain assessment Flow Sheet for the resident on the date she returned from the hospital noted. A review of the undated disciplinary action provided by Staff K, LPN/acting DON revealed the following: Staff F, LPN had been called regarding Staff F's failure to provide pain medication to Resident #9 when the resident stated she had been in pain and requested pain medication and had not been given any medications. Staff F reported did not have a signed order to give the medication and explained that the resident returned from the hospital with an order on the discharge paperwork. Staff F stated it had not been a signed order that the medication had been delivered from Pharmacy and in the cart. When asked why she did not call the Nurse-On-Call or Doctor-On-Call, she explained she felt she did not have an order, and called the hospital and had been unable to obtain an order from the hospital. When asked why she did not follow the Facility Protocol and call the Nurse-On-Call or the resident's doctor, she reported she did not. Staff K explained it had been unacceptable to leave a resident in pain and not follow Doctor's Orders and the Orders had been printed on the MAR. Staff K later verified the disciplinary action had been taken on 3/30/22. A review of the undated facility policy titled: Pain Assessment documented the following: a. Each resident will be assessed upon admission, quarterly when significant medication changes occur and at any time resident returns from the hospital. b. The nurse will determine which scale to use, depending on the cognitive status of the resident. c. A Pain Assessment Flow Sheet will be used to determine the effectiveness of the pain management and the resident's chart will be flagged. A professional nurse will review this after 3 days when any changes are made in the medication regiment and if changes in a resident's level of pain occur. d. All interventions for pain will be implemented in a timely manner. e. The physician will be notified any time an assessment reveals inadequate pain control despite implementation of an appropriate plan of care.

Based on clinical record review, staff interview and physician interview, the facility failed to regularly test staff and 2 of 2 residents who tested positive for COVID-19 and expired (Residents #42 and #258). The failure included not conducting routine testing of unvaccinated staff members per Community Transmission Levels which would have required twice a week testing from [DATE] thru [DATE]. The failure included not conducting Broad Based, Facility Wide Testing of all staff and residents in lieu of sufficient evidence of close contact tracing when positive cases arose on [DATE] and [DATE]. The failure to conduct routine testing of staff and residents resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 55 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #42 identified the resident as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of a 3. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus Area initiated and revised [DATE], documented a problem of COVID-19. The Nurse's Notes revealed the resident tested positive for COVID-19 on [DATE] at 2:32 PM and expired on [DATE] at 9:52 AM. The Record of Death documented the date of death as [DATE] with the immediate cause of death as COVID-19 and [CONDITION(S)]. An Untitled Facility Form documented names of residents with dates they tested positive for COVID-19 and dates they had been removed from isolation (transmission based precautions) revealed the resident had been removed from isolation on [DATE]. On [DATE] at 12:26 PM, the resident's Primary Care Physician reported that the resident's primary cause of death as COVID-19 and dementia. 2. The MDS dated [DATE] for Resident #258 identified a BIMS score of 3 which indicated severe cognitive impairment. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus Area initiated and revised [DATE], documented a problem of COVID-19. The Nurse's Notes revealed the resident tested positive for COVID-19 on [DATE] at 2:08 PM and expired on [DATE] at 5:31 PM. The Record of Death documented the date of death as [DATE] and the immediate cause of death as COVID-19. On [DATE] at 12:27, the resident's Primary Care Physician reported COVID-19 as the resident's primary cause of death was COCID-19 with secondary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 10:32 AM, the DON also reported that the MDS Coordinator is responsible for updating the Care Plans quarterly, that the Care Plans should not have necessarily been addressed as a specific problem of COVID versus a facility protocol issue. On [DATE] at 12:14 PM, the Director of Nursing (DON) reported he would expect the issue related to COVID-19, be addressed on residents' Care Plans. 3. A review of the facility COVID-19 Testing Results Form titled LTC Data Collection Tool for Residents and Staff revealed the lack of documentation of tests completed from [DATE] through [DATE]. In an interview on [DATE] at 10:13 AM, the Director of Nursing (DON) reported there may not be documentation of COVID testing from [DATE] through [DATE] but that does not mean testing not completed and results are elsewhere in the facility. He also reported that COVID testing kits were in short supply in October and the unvaccinated staff (who work part time as needed) had been monitored by symptomology. A review of the facility form titled LTC Data Collection Tool for COVID-19 documented the following on the Unvaccinated staff and resident list: a. Staff J, Licensed Practical Nurse (LPN) had been tested on ly on [DATE]. b. The Activity Aide had been tested on [DATE], [DATE], [DATE], [DATE], and [DATE]. c. Staff U, Certified Nurse Aide (CNA) noted no documentation to show testing completed. d. Staff V, Weekend Clerical no documentation to show testing completed. e. Staff W, Dietary Aide tested positive on [DATE]. The [DATE] Dietary schedule revealed Staff W taken off the schedule from [DATE] through [DATE]. f. Unvaccinated Resident #53 had been tested on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ans [DATE]. Record review of Staff Schedules for October and [DATE] revealed unvaccinated staff in the sample worked the following days: a. Staff J, LPN: For [DATE]: On 3 and 4, 9 and 10, 16 and 17, 23 and 24, and 30. For [DATE]: On 6 and 7, 13 and 14, 20 and 21, 27 and 28 b. Activity Aide: For [DATE]: On 1, ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE]. For [DATE]: On ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] c. Staff U, CNA: For [DATE] on 4,-6, 8,-11, ,d+[DATE], ,d+[DATE],,d+[DATE], and ,d+[DATE]. [DATE]: On ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] d. Staff V, Weekend Clerical Staff (Start date [DATE]): For [DATE]: On 8, 15, 22, and 29. e. Staff W, Dietary Aide For [DATE]: On 1, ,d+[DATE], 6, 8, ,d+[DATE], 13, 18, 20, 22, 24, 27, 29, and 31. [DATE]: On 1, 3, 5, 8, 10, 15, 17, 19, 22, 24, 26, and 29. In an interview on [DATE] at 12:59 PM, the Director of Nursing (DON) reported that COVID testing from [DATE] through [DATE] had been completed at odd times and the results had not been forwarded to him and could not produce any testing information from [DATE] to [DATE]. He also reported that testing kits have often arrived late. In an interview on [DATE] at 3:26 PM, Staff J, LPN reported she had been tested weekly since testing started. She worked two sixteen hour shifts on the weekends and had been tested when she goes into the facility. She also stated that test results get documented on a sheet of paper with the names of staff who need to be tested and then placed in the DON's mailbox. A review of the COVID tests Shipping Confirmation Sheets revealed the following: a. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . b. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON could not provide Shipping Confirmation Sheets for [DATE]. On [DATE] at 1:23 PM, the DON/Infection Control Preventionist reported the following Community Positivity Rates: a. On [DATE] as 9.5%. b. On [DATE] as 9.2%. c. On [DATE] as 8.6%. d. On [DATE] as 8.0%. e. On [DATE] as 8.1%. f. On [DATE] at 8.7%. g. On [DATE] at 9.5%. h. On [DATE] at 10.3%. i. On [DATE] at 10.8%. A review of the Center for Disease Control (CDC) website revealed the community positivity rates For October through [DATE] ranged from a low of 5.43% to a high of 11.74% . CDC testing guidelines state unvaccinated staff should be tested on ce weekly when Community Positivity Rate is above 5% and twice per week when above 10%. In an interview on [DATE] at 9:50 AM, the Administrator stated they used an information pamphlet from their Consulting Pharmacy. In an interview on [DATE] at 11:06 AM, the Administrator reported the facility educated all staff on the COVID vaccination using a pamphlet, however, could not provide documentation of the education or Declination Forms for the unvaccinated staff, and unvaccinated Resident #53. On [DATE] at 1:30 PM, Staff AA, Activity Aide reported when there is COVID in the building that the employees should be tested three times a week. She also reported there had been a time when staff not tested on a regular basis, but could not recall the exact time frame. On [DATE] at 1:37 PM, Staff C, CNA reported the staff had been getting tested on ce a week, however, in November and December they had not been tested as he had been informed the CDC said testing should be completed once a month. On [DATE] at 1:47 PM, Staff BB, Dietary Aide reported when COVID had been in the building, the staff tested for COVID twice a week. She also reported in December she had not been tested for three weeks as there had been no COVID in the building. On [DATE] at 2:46 PM, Staff CC, Environmental Aide reported when the facility had an outbreak, the staff had been tested daily on days worked. She also reported she had not been vaccinated and signed a declination form and after she tested positive, no one asked her about who she had close contact with. On [DATE] at 7:09 AM, Staff O, CNA reported she did not know how often she should be tested and the last time she had been tested had been 4 weeks ago when she tested positive. She also reported sometimes they had been tested on ce a week, other times there would be a month or two without being tested . After she tested positive on [DATE], no one asked her who she had close contact with. On [DATE] at 1:42 PM, Staff EE, Dietary Aide reported he had been tested on ce every 2 weeks, that there had been a time for approximately one to two months where staff had not been tested . After he had tested positive, no one asked who he had close contact with. He had not been vaccinated, had not had any education on the risks/benefits of the COVID vaccine and had not had a Declination Form reviewed. On [DATE] at 2:04 PM, Staff FF, Dietary Aide reported he had been tested for COVID twice a week since the facility had an outbreak, now it's once a week. Before the outbreak, staff had been tested on ce every 2 or 3 weeks. He also reported he had the first dose of the COVID vaccine, however, had been informed by the pharmacy he had the initial dose at that there had been a shortage and never had the additional doses. He also reported he had not been educated on the risks/benefits of the vaccine. On [DATE] at 12:12 PM, Staff BB, Dietary Aide, stated the facility did not provide education regarding the COVID vaccination nor did the facility call her on [DATE] regarding COVID vaccination education as reported. On [DATE] at 12:45 PM, Staff F, Agency CNA stated that she did not receive education from the facility on COVID testing, that since she had been employed by an Agency, the Agency provided her with COVID education. On [DATE] at 12: 50 PM, Staff FF, Agency CNA stated that she did not receive education from the facility on COVID testing. On [DATE] at 1:19 PM, Staff V, Weekend Clerical Staff stated she had not received any education regarding COVID testing either by a call or email. On [DATE] at 3:29 PM, Staff U, CNA reported she had not received education on the risks/benefits of the COVID vaccine, had not been vaccinated and not given a Declination Form for her to sign. Previously she had been tested on ce a week, then twice a week and testing had not been scheduled regularly. The State Agency informed the facility of the Immediate Jeopardy (IJ) on February 10, 2022 at 9:00 AM, as the facility failed to test staff and residents according to the CMS QSO-,d+[DATE]-NH memo revised [DATE]. Facility staff removed the Immediate Jeopardy on February 16, 2022 at 3:00 PM through the following actions: a. Implementing testing measures according to the CMS QSO-,d+[DATE]-NH Memo. b. The facility provided education to all the staff about the need for testing according to the CMS QSO-,d+[DATE]-NH Memo. c. Staff will be tested twice a week for COVID-19 and documented, unless COVID-19 positive in the last 3 months until further notice. d. All staff notified via email, Facebook and a Memo that is posted and will be added to paychecks on Friday of testing requirements. e. Staff testing- will do all shifts and document results. f. Staff not working in the next 24 hours will be called to come in and test. g. As needed (PRN) staff that are in college, ex. not planning to work until this summer will be excluded. h. Administrator has a list of these staff members. i. Routine testing of symptomatic residents. The scope lowered from L to F at the time of the survey after ensuring the facility implemented education and their policy and procedure.

Based on observations, clinical record review, and staff interviews, the facility failed to appropriately supervise and intervene to prevent one of three resident reviewed from eloping from the facility (Resident # 18). The facility staff failed to ensure the location of the residents in the Chronic Confusion Dementing Illness (CCDI) unit before turning off the door alarms. This failure resulted in an Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 55 residents. Findings Include: Resident #18's Minimum Data Set (MDS) Assessment completed 12/9/21, identified diagnoses of non-Alzheimer's dementia, and heart failure. The MDS reflected the resident's Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severely cognitively impaired. The MDS listed Resident # 18 as independently ambulatory in the Unit, and that he required limited staff assist with moving off the Unit. The Care Plan dated as reviewed 12/15/21, failed to identify the resident as at risk for elopement, and identified he needed assistance with Activities of Daily Living (ADL's) due to dementia. The Care Plan reflected the resident ambulated independently. The Elopement Risk assessment dated [DATE], asked the question, does the resident pace, wander, try to get out a door, find family of friend, or perceive they need to be doing something other than what they are doing, such as - go to work, get home, fix supper, do the chores? The staff documented yes. Review of the Nurse's Progress Notes revealed the following: a. On 12/30/21 at 10:54 AM, Resident walking around in his coat exit seeking. b. On 1/21/22 at 5:55 PM, Resident found on hands and knees in parking lot by oncoming staff, dressed in a flannel shirt, blue jeans, and tennis shoes and found to have a laceration above his left eyebrow and vomiting. The staff assisted the resident into a wheelchair and into the facility at 6:00 PM and several blankets placed on resident. 911 called and Emergency Medical Services (EMS) arrived at approximately 6:05 PM. The resident's temperature documented as 95.5 Fahrenheit. EMS then transported the resident to the hospital. The Event Report for Resident # 18 dated 1/21/22, documented an unwitnessed fall outside of the facility on the sidewalk. The report reflected Resident # 18 lethargic, weak, abrasion to his face and pain to the face at a level of 5 on a 0-10 scale. The Hospital Report dated 1/21/22, reflected facial contusions, facial and bilateral knee abrasion. The report also identified Resident # 18 on aspirin and [MEDICATION(S)] (blood thinner). The Physician's Order Sheet dated 12/28/21, reflected [MEDICATION(S)] (antiplatelet) 75 milligrams (mg) daily. The Facilities' Summary dated 1/21/22, reflected the Resident # 18 exited the facility on 1/21 22 at approximately 5:30 PM. The Summary revealed the resident pushed on the locked door of the Unit for the 15 seconds and the door opened. The resident sustained a fall on the side walk outside the facility. Observation at 1/31/22 at 9 AM, revealed the speed limit on the road to the East of the building 30 miles per hour (mph) and the speed limit on the road north of the building 25 mph. On 2/1/22 at 4:00 PM, the Memory Care Coordinator reported she left the facility at 4:30 PM on 1/21/22. On 2/2/22 at 10:28 AM, the Maintenance Supervisor, revealed the Administrator directed him on Monday 1/24/22, to add a the Wanderguard Alarm system to the Palliative Care Building Door in the vestibule. The Maintenance Supervisor explained the CCDI unit door alarm beeps here at the door, the call light station, Nursing Desk and pager. The CCDI unit alarms beeps when the door bar is touched. If pressure is held on the door bar, the lock disengages after 15 seconds, and the beep changes to consistent bell to alert the staff in the CCDI. The notification goes to a pager as well. On 2/3/22 at 9:20 AM, Staff H, RN, reported on 1/21/22, Staff I came into the building and told him there is a man on his knees on the side walk. Staff H stated he ran outside, found Resident # 18 on his hands, and knees, with a head injury. Staff H revealed as soon as he and Staff I attempted to stand Resident # 18 he vomited, Staff I left to get a wheel chair to take the resident inside to provide first aid while they waited for the ambulance to arrive. Staff H confirmed his role as Charge Nurse for the West hall, and the CCDI unit on 1/21/22. Staff H indicated he failed to hear the alarms sound when Resident # 18 exited the facility. Staff H confirmed, Staff Z as the only staff in the CCDI unit at the time Resident # 18 exited. Staff H verified he received direction to move the Aviary in front of the Palliative Care Door where Resident #18 exited from to prevent further exiting. On 2/3/22 at 10:10 AM, Staff Z, CNA, revealed she was the one staff on duty in the CCDI unit at the time Resident # 18 exited the facility. Staff Z reported she heard the alarm sound, but was in a room with another resident. Staff Z stated she checked on the residents that normally wandered around, they were okay, so she turned the off the alarm. Staff Z revealed the alarm went off for a few minutes before she got to it. On 2/3/22 at 4:30 PM, review of the video surveillance footage of the exit doors and the front of the facility showed on 1/21/22 at 6:05 PM, Resident # 18 walked out the CCDI Unit got to the front sidewalk near the sign, fell , and remained on the ground for 30 minutes. On 2/3/22 at 4:30 PM, the Director of Nursing (DON), reported the times on video surveillance are inaccurate, the actual time the resident left the building was about 5:30 PM and Staff I, Certified Nursing Assistant (CNA) found Resident # 18 outside on the sidewalk as he came into work. The 2/4/22 at 3:49 PM, the State Climatologist revealed the weather conditions on 1/21/22 between 5:30-6 PM, at the location Resident #18 left the facility are recorded as: 12 degrees, with a -1 degree wind chill, 10 miles per hour (mph) [NAME] winds, and the sunset at 5:02 PM. On 2/7/22 at 5:52 AM, Staff I, CNA, stated he pulled in the front driveway on 1/21/22 for the 6 PM shift, saw a man without a coat on, on his knees, on the front sidewalk by the sign. Staff I mentioned he failed to recognize the man, as he attempted to help the man get up and he saw the blood coming from the man's head. Staff I reported the man said he was cold, so he put his coat around the man. Staff I explained he ran inside the building, told the nurse to call 911, and the Registered Nurse went outside with him to help the man. Staff I revealed the temperature as below zero and windy. Staff I stated as he and the nurse tried to get the man up, the man started to vomit. He went back into the facility and retrieved a wheel chair to get the man in the building and wait for the ambulance. On 2/7/22 at 3:14 PM, Resident #18 sat in his room on the sofa and noted with a Wanderguard on his right wrist. The policy titled Wanderguard Alarm Sounding dated 9/21/09, directed staff will investigate every time the Wanderguard System goes off to ensure all residents are accounted for. The Procedure Section of the Wanderguard Policy continued to at point: a. Staff will visualize what resident who set off the Wanderguard Alarm System. If staff is able to confirm what resident activated the alarm it may be reset. b. If staff is not able to confirm why the Wanderguard System was activated they will proceed outside to visually view any resident who might have gone out the door. c. If a resident is visualized they will be brought back in the facility by staff. The alarm will be reset. The incident will be reported to the Charge Nurse. d. If no resident is visualized by staff the Charge Nurse will be notified the Wanderguard System alarm was sounding with no one visualized with a bracelet to have set it off. The alarm will be reset. e. The Charge Nurse will initiate a head count to verify all the residents are accounted for. The State Agency informed the facility of the Immediate Jeopardy (IJ) on February 9, 2022 at 8:30 AM. Facility staff removed the Immediate Jeopardy on January 21, 2022 prior the start of the Survey through the following actions: a. The facility removed the the IJ by placing an Aviary in front of the door the resident walked out of preventing anyone else to exit the building out that door. b. A Wanderguard Alarm placed at the door on 1/24/22 and all mobile residents on the CCDI Unit had Wanderguard bracelets applied. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and their policy and procedure.

Based on clinical record review, facility record review, and staff interview, the facility failed to develop and implement any policies or procedures related to staff receiving a COVID-19 vaccination and failed to identify additional precautions to be taken by unvaccinated staff. The facility failed to ensure 100% of staff received the vaccine as the facility reported an overall vaccination rate of 95.6%. The facility experienced an outbreak of COVID-19 infection during the month of [DATE] which resulted in 2 resident deaths with the primary cause of death documented as COVID-19 (Resident #42 and #258). This failure led to an immediate jeopardy situation. The facility reported a census of 55 residents. Findings Include: 1. The facility information provided on [DATE] to complete the Staff Matrix for F888 report identified the following statistics related to staff COVID-19 vaccinations: a. 4 partially vaccinated staff members (this means staff received at least 1 dose of a primary series of COVID-19 vaccination) b. 74 fully vaccinated staff members (this means staff received all primary doses of a COVID-19 vaccination series) c. 1 staff member granted or pending medical exemption d. 7 staff members granted or pending non-medical exemption e. 0 temporary delays (vaccination not recommended based on CDC guidelines) f. 90 total staff members Four out of 90 staff members had no vaccination status documented nor did they have evidence of an approved exemption or temporary delay. This calculates to 95.6% of all staff members vaccinated; less than 100% equals non-compliance. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #42 identified a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus Area initiated and revised [DATE], documented a problem of COVID-19. The Nurse's Notes revealed the resident tested positive for COVID-19 on [DATE] at 2:32 PM and expired on [DATE] at 9:52 AM. The Record of Death documented the date of death as [DATE] with the immediate cause of death as COVID-19 and [CONDITION(S)]. An Untitled Facility Form documented names of residents with dates they tested positive for COVID-19 and dates they had been removed from isolation (transmission based precautions). The form revealed the resident removed from isolation on [DATE]. On [DATE] at 12:27 PM, the resident's Primary Care Physician reported the resident's primary cause of death was COVID-19 with a secondary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 3. The MDS dated [DATE] for Resident #258 identified a BIMS score of 3 which indicated severe cognitive impairment. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus Area initiated and revised [DATE], documented a problem of COVID-19. The Nurse's Notes revealed the resident tested positive for COVID-19 on [DATE] at 2:08 PM and expired on [DATE] at 5:31 PM. The Record of Death documented the date of death as [DATE] and the immediate cause of death as COVID-19. On [DATE] at 12:26, the resident's Primary Care Physician reported the resident's primary cause of death was COVID-19 infection with secondary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Observations of unvaccinated facility staff revealed the following: a. On [DATE] at 2:00 PM, Staff F, Certified Nurse Aide (CNA), wore a standard surgical mask and provided resident care. b. On [DATE] at 2:00 PM, Staff F wore a standard surgical mask and entered and exited resident rooms. c. On [DATE] at 3:55 PM, Staff CC, Environmental Aide in the East hall, wore a standard surgical mask and entered and exited resident rooms. d. On [DATE] at 4:22 PM, Staff CC, wore a standard surgical mask and entered and exited resident rooms. e. On [DATE] at 11:49 AM, Staff F wore a standard surgical mask and entered and exited resident rooms. f. On [DATE] at 2:07 PM, Staff F wore an N-95 mask as she walked down the East hall and passed a group of residents. On [DATE] at 12:14 PM, the Director of Nursing (DON) verified he made a few errors entering data on staff vaccinations as he had two different lists and the information on the website is a few weeks old. He received information regarding vaccination status from vaccination cards. The DON voiced unvaccinated staff have to sign a Religious or Medical Exemption Form which then gets placed in the employee ' s Human Resource (HR) file. He also reported precautions he would expect unvaccinated staff to follow would be to wear a standard surgical mask, eye protection, and for the staff to avoid work in the COVID-19 unit. He would not expect them to work in any other departments other than Nursing. On [DATE] at 1:33 PM, the DON reported his plan was to have 100% of all employees vaccinated and he informed staff if they were not vaccinated they would not work. In a follow up interview on [DATE] at 1:48 PM, the DON reported the Facility's Contingency Plan regarding unvaccinated staff, effective [DATE], was that all unvaccinated staff should not work. He again reported he made errors when he provided the list of unvaccinated staff to the surveyors. On [DATE] at 4:13 PM, the Administrator reported she did not write up a policy related to staff vaccinations and the new F888 regulation. The Administrator commented she notified all staff and did not realize she had to write a policy. She stated all staff have been notified that no matter how many hours they work, they had to test twice a week or they would be terminated. She also reported they would need to decide what the additional requirements were going to be. In a follow up interview on [DATE] at 4:20 PM, the Administrator responded she had a plan to achieve 100% of staff vaccinations within 60 days of the new memo related to F888 ([DATE]), however, she had not written the plan up. The undated facility policy provided on [DATE] documented the following: The CMS staff COVID-19 Vaccination Rule requires facilities to take additional precautions for staff who remain unvaccinated due to a medical/religious exemption or newly hired staff who only have the first dose of the two-dose series. The facility requires all staff that meets the above criteria to test prior to each shift for COVID-19 and document the results. On [DATE] at 11:49 AM, Staff F (identified as unvaccinated) reported her job duties that day had been to provide showers and after 2:00 PM she would work as a CNA on the floor. Staff F said she had not been instructed on wearing different Personal Protection Equipment (PPE) other than the standard surgical mask she wore. On [DATE] at 11:59 PM, Staff AA, Activity Aide (identified as unvaccinated) reported she had been tested daily for COVID-19 since the week she started, that her job duties entailed working with residents in activities, that she had been informed of the need to wear an N-95 mask just that morning, and that she could not come in to close contact with residents listed as the most compromised residents. On [DATE] at 1:19 PM, Staff II, CNA (identified as unvaccinated) verified she had an exemption from obtaining the covid vaccination. Staff II said she worked at the facility third shift [DATE] as a CNA and she wore a standard surgical mask. Staff II stated she did not receive any education on the need to wear a different mask or to stay away from certain residents. On [DATE] 11:22 AM, the Administrator reported Staff HH, Agency CNA, was tested for covid in [DATE] and the Agency informed them she actually had COVID-19 infection on [DATE]. In a follow up interview on [DATE] at 11:47 AM, the Administrator reported Staff HH tested positive for COVID on [DATE]. A review of the Agency Staff COVID testing log revealed: a. Staff F, CNA tested negative on [DATE], [DATE], [DATE] and [DATE]. b. Staff HH, CNA tested negative on [DATE] and confirmed positive on [DATE]. On [DATE] at 1:00 PM, the Administrator provided the following Action Plan: a. Notified by DIA of IJ for Infection Control. b. Reviewed the CMS QSO Memo ,d+[DATE]-NH. c. Staff Education: COVID-19 Testing. d. All staff that are not fully vaccinated or have an approved exemption for religious or medical reasons will be tested for COVID-19 prior to the start of each shift they work unless they have had COVID-19 confirmed in the last three months. e. All staff that are under-vaccinated or have an approved exemption were notified by the Administrator of testing prior to each shift policy on [DATE]. f. Highly compromised residents have been identified and will not have interaction with staff that are under-vaccinated or have an approved exemption. g. Staff that are under-vaccinated or have an approved exemption will be instructed on the additional precautions including testing prior to each shift, wearing an N-95 mask and avoiding identified highly compromised residents. On [DATE] at 3:51 PM, the Administrator submitted the following additions to the Action Plan: a. Staff members who needed to take additional requirements due to vaccination status were contacted in person or via phone on [DATE]. b. Agency staff members were identified who had an exception or were not fully vaccinated. The staff names are located in the facility COVID-19 Testing Book and those staff need to wear an N-95 mask and what resident's they cannot have interaction with. The COVID-19 Book contains: a. Staff lists to document testing. b. List of facility staff who need additional precautions. c. List of agency staff who require additional precautions (identified by their agency). d. Current list of residents who are identified as highly compromised. e. Policy on additional precautions for not fully vaccinated staff or that have an approved exemption. Also added: a. Any staff that do not have an approved exemption or at least one dose of the COVID-19 and doing additional precautions will not be working. b. Staff that are under-vaccinated or have an approved exemption will be instructed on the additional precautions including testing prior to each shift, wearing an N-95 mask and avoiding identified highly compromised residents. c. As of [DATE] any staff that is not fully vaccinated or has an approved exemption for medical or religious will be terminated. According to QSO memo ,d+[DATE]-ALL, the facility needed policies and procedures in place related to F888 by [DATE] for the State of Iowa. The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 8:00 AM, when the facility failed to have policy or procedures in place in regards to unvaccinated staff and the extra precautions needed when working with the residents as of [DATE]. The facility removed the Immediate Jeopardy on [DATE] at 3:36 p.m. through the following actions: a. Developed policies and procedures in regards to unvaccinated staff and the extra precautions needed when staff work with the residents. b. Identified highly compromised residents and extra precautions needed. c. Identified what staff are unvaccinated and have a Religious or Medical Exemption. d. Educated facility and Agency staff on the new Policy and Procedures. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure.

Based on observation, staff interviews, and clinical record review the facility failed to assess residents' pain and provide pain interventions for 2 of 2 residents reviewed (Resident # 44, and #158). The facility reported a census of 55 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident # 158 dated 1/7/22 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating significant cognitive impairment The MDS listed the resident required extensive assist of 2 for transfers, and toileting, and extensive assist of 1 for bed mobility, dressing , and personal; hygiene. The MDS reflected the no reports of pain during the look back period. The Care Plan for Resident # 158 dated 4/30/21, identified a goal of pain will be managed within acceptable levels. The Care Plan approach directed Nursing Staff to encourage non pharmacological intervention to assist with pain control i.e.: repositioning, wheel chair ride, visit, snack, activity, distraction, music, touch/massage, etc. Also instructed staff to monitor pain level and report unrelieved or unacceptable pain to the Physician. The Medication Administration Record (MAR) dated 1/25/2022, reflected [MEDICATION(S)] (treat nerve pain)100 milligrams (mg's), give three times a day and noted the medication marked as administrated on 1/26/22 three times. The as needed (PRN) Medication Record dated 1/25/22, reflected acetaminophen (Tylenol) 650 milligrams (mg) given at 8 AM and noon. The record lacked other doses of pain medication administered to Resident # 158. Noted on the MAR [MEDICATION(S)] (muscle relaxant) 5 mg three times a day with a start date of 1/22/22. The medication administered on 1/25/22 at 8 AM and noon. Review of the Physical Therapy Treatment Encounter Note dated 1/18/2022, read Resident #158 in visible discomfort. Right lower extremity (RLE) due to frequent spasms, Resident is unable to shift own position in chair. Discussed changes in tone RLE with Nursing and will discuss with Nurse Practitioner/Physician for assistance with medical management. Nursing provided acetaminophen. A Facsimile (fax) dated 1/20/22, identified Resident # 158 with a lot of muscle spasms and tightness causing severe pain behind the right knee. The fax reflected a suggestion for a muscle relaxant or pain medication for the resident. The fax continued to read Resident #158 refused to move in bed or get out of bed due to the amount of pain. Review of the Physical Therapy Treatment Encounter Note dated 1/24/2022, read Resident # 158 now has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempted passive stretch to right hamstring and adductors but this set off abnormal tone and spasms in RLE with significant complaints of discomfort. The Pharmacist Note dated 1/25/2022 at 10:09 AM, read no changes to Resident # 158's scheduled medications with /no PRN use documented. New order for as needed [MEDICATION(S)] 5 mg noted with/ additional details unavailable at this time. The Nurses Progress Note dated 1/25/2022 at 8:30 PM, read Resident confused this evening. Calling out for help but resident does not know what she wants help with. Resident also called out for someone to call 911 because she needed help. Does not know what she wants help with, when asked. Review of Resident # 158's clinical record failed to document a Pain Assessment completed. Review of X-Ray results dated 1/26/22, reflected impression: a. Suspected non-displaced intertrochanteric [CONDITION(S)]. There is a subtle linear lucency (a clear or translucent area) involving the lesser trochanter on both views. If a higher level of confidence is clinically necessary, then a cat scan (CT) could be considered. b. Acute comminuted and mildly displaced distal femoral metadiaphysis fracture (corner fractures). c. Severe osteopenia (reduced bone mass of lesser severity than [CONDITION(S)]) by subjective assessment. Observation on 2/07/22 at 4:23 PM, Resident # 158 laid on her low bed with her legs extended. On 2/2/22 at 9:17 AM, Staff S, Licensed Practical Nurse (LPN), reported the Physician ordered [MEDICATION(S)] for the resident's pain. Staff S revealed the resident's pain level had changed and she called got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff S continued to report, she talked to the Director of Nursing (DON), and the sent the resident to the hospital. On 2/2/22 at 9:45 AM, Staff O, Certified Nurses Aide (CNA), stated for about a week before Resident # 158 went to the hospital her right hip appeared swollen, and she displayed a lot of pain. The resident screamed as we moved her, we told the Nurses 2-3 times a day about Resident # 158's pain. On 2/2/22 at 11:13 AM, Staff GG, CNA, described Resident # 158's pain as severe pain on Monday before she went to the hospital, the resident didn't want to be touched. Staff GG said the week before on Monday she seemed fine. She reported over the weekend the pain went up. On 2/2/22 at 10:48 PM, the Physical Therapist (PT), indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PT reported she worked with Resident #158 on Tuesday 1/18/22, and Wednesday 1/19/22, the week before the resident went to the hospital. PT revealed she talked with the nurse that week about Resident #158's leg spasm and pain after treatment on 1/18/22. PT explained, she planned to see Resident #158 on Friday 1/21/22, but waited until Monday 1/24/22, so the resident could get the order for pain medications. PT said the resident's right leg spasm worsened and with touch she was uncomfortable. PT reported on 1/26/22 the resident went to the hospital with a potential fracture. Interview on 2/3/22 at 9:20 AM, Staff H, Registered Nurse (RN), reported Resident # 158 complained of pain quit a lot, 2 or 3 times per shift. He stated the CNA's and the resident reported the pain to him. He explained he gave acetaminophen a few times at the end of the shift. He said he thought the pain worsened at least 2 weekends before she was sent to the hospital. On 2/3/22 at 11:35 AM, Staff FF, CNA, stated Resident #158 seemed in a lot of pain with movement in the week of 1/17/22, before she went to the hospital, grabbing at her leg with movement. Staff FF, revealed she asked the resident how her pain ranked on a 0-10 scale, and the resident reported her at a 10. Staff FF, reported she told the Nurses about the resident's reported pain. On 2/3/22 at 12:55, Staff L, CNA, reported Resident # 158's pain started about 1/15/22, and continued into the next weekend she worked on 1/23/22. She revealed the resident didn't want to get out of the bed for meals because her leg hurt so bad. The Resident yelled out in pain when staff placed a blanket over her. Staff L, reported telling the Nurses about her pain. On 2/07/22 at 11:12 AM, Staff O, CNA, confirmed Resident # 158, reported a lot of pain over the past few weeks before she went to the hospital. On 2/08/22 at 11:07 AM, Staff D, Oral Medication Aide (OMT), reported if a resident complained of pain she would tell the Charge Nurse, so she could give some medication if directed to. On 2/08/22 at 11:11 AM, Staff X, RN, reported the documentation of resident complaints/reports of pain, are on the PRN MAR and in the Progress Note. On 2/08/22 at 11:15 AM, Staff P, LPN, reported the documentation of residents Pain Assessments are located on the PRN Medication Sheets and in the Progress Notes. On 2/09/22 at 1:13 PM, the Director of Nursing (DON), reported the facility lacked policies or procedures directing staff how, and when to complete Pain Assessments. The DON continued to report his expectation is Pain Assessments are documented in the Progress Note and on the MAR. On 2/08/22 4:47 PM, the Medical Director, reported his expectation is the facility to call him if a resident is in pain and needed a medication to treat the pain. He continued to report the expectation for the staff at the facility to administer as needed medications to treat the resident's pain. 2. The Minimum Data Set, dated dated dated [DATE] identified Resident #44 as cognitively impaired with a BIMS of 7. The MDS also documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan focus area initiated 11/28/21 and revised 1/5/22, documented a problem the resident had been at risk for falls and did not direct the staff to assess and treat for pain after a fall occurred. A review of the Nurse's Notes revealed the following entry dated 12/26/21 at 1:01 PM: Noted swelling from a skin tear from A previous fall. Swelling noted to be around undereye and upper eyelid. The resident complained of pain to the area and pressure. A review of the Neurological Assessment Flow Sheet revealed the following documentation on 12/15/21 with no documentation if the resident had pain or if the resident assessed for pain: a. At 3:00 PM - Blood Pressure (BP) = 176/72, Heart Rate (HR) = 93. b. At 3:15 PM - BP 168/84, HR 93. c. At 3:30 PM - BP 147/78, HR 88. d. At 3:45 PM - BP 141/71, HR 93. e. At 4:15 PM - BP 139/73, HR 93. f. At 4:45 PM - BP 144/72, HR 93. g. At 5:15 PM - BP 141/84, HR 93. h. At 5:45 PM - BP 136/81, HR 93. g. At 6:45 PM - BP 117/76, HR 76. A review of the December 2021 Medication Administration Record (MAR) revealed the resident did not receive any Tylenol on 12/15/21 when it had been ordered to give 650 milligrams (mgs) every 4 hours as needed. In an interview on 2/2/22 at 12:42 PM, Staff A, LPN reported the resident's skin tear scabbed over and had a piece that came out of it like some coagulated piece which measured one centimeter. Staff A tried to relieve the pain or pressure as the resident complained of a headache and she tried to relieve the pressure as the bump was pretty big protruding approximately about one centimeter out from the resident's forehead. Staff A reported she tried to push around on it a little bit just seeing if she could get anything to come out. In an interview on 2/2/22 at 2:24 PM, the resident's Primary Care Physician reported he had been made aware of the area on the resident's forehead and afterward, the resident became hemodynamically unstable. His expectation of treatment to the site would be to use ice and observe. He would not expect staff to poke or manipulate the area and if the resident had increased pressure or pain he would have expected to be notified. In an interview on 2/8/22 at 2:52 PM, the Director of Nursing (DON) reported on the Neuro Sheet, the pain addressed in documentation of the resident's response to pain. The form does not address how much pain the resident is having. When charting pain in the Nurse's Notes, the DON would expect the nurse to document where the resident was having pain, behavior, use the pain scale to determine the level of pain and what they did to treat the pain.

Based on facility and hospital record review and staff interview, the facility failed to ensure that each resident received adequate supervision and assistance when transferred with a mechanical lift (Hoyer Lift) to prevent accidents. Concerns were noted for one out of six residents (Resident #1). Staff failed to safely transfer Resident #1 in accordance with the individual plan of care which resulted in the resident falling and sustaining an injury which required hospitalization . The facility reported a census of 61 residents. Findings include: According to documentation in the Medical Record/Face Sheet, Resident # 1 had diagnoses which included [CONDITION(S)] (MS), nutritional deficiency, personal history of [CONDITION(S)], personal history of traumatic brain injury and age related [CONDITION(S)]. The Minimum Data Set (MDS) dated [DATE], documented Resident # 1 scored 10 out of 15 points on the Brief Interview for Mental Status (BIMS) indicating moderately impaired for decision making skills. The assessment also described Resident #1 as requiring extensive staff assistance with all activities of daily living (ADL's) including bed mobility, transferring, ambulation, dressing, toilet use, personal hygiene and bathing. The individual Care Plan dated/revised 5/10/21 identified Resident #1 at risk for falls due to impaired mobility from MS and post-polio syndrome. The plan directed staff to transfer Resident #1 via the Hoyer lift and the assist of two staff. Resident #1's used a wheel chair for her primary mobility and able to propel herself short distances. Documentation in the facility Nurse's Notes dated 5/22/21 indicated at 11:40 a.m. a Certified Nursing Assistant (CNA) transferred Resident #1 via the Hoyer lift and the strap slipped, dropping Resident #1 first on the shoulder and then the left orbital brow impacted the floor. The entry included the following assessment: Blood noted, the Resident voiced a painful response but confused, Vital signs: blood pressure 147/123 per automatic arm monitor, heart rate (HR) 101, temperature (T) 97.7, oxygen (O2) 90%, respirations (RR) 24. The resident complains of shoulder pain, moves upper extremities/lower extremities per baseline, pupils fixed, dilated, and vision blurry. A hematoma noted on the left brow and the resident, alert and oriented times 0 (zero). Noted her speech slightly slurred, unable to tell nurse name, date of birth, location, and season, year. Per baseline, resident knows name, date of birth, most of the time location and can identify season, month, often day of week and year, 911 called and paramedics arrived at 11:50 a.m. to perform assessment. Documentation in the Hospital History and Physical dated 5/22/21, indicated Resident #1 fell when being transferred via Hoyer lift. The entry also indicated that at the facility Resident #1's baseline is confused, but was more so after her fall. The resident indicated not having significant pain, but clutching at her left temple and left forehead and when asked if she had a headache, she said yes. The Hospital Record (also dated 5/22/21) indicated the Computerized Tomography (CT) of the head without contrast, showed an acute appearing 1 centimeter (cm) x 4.5 cm x 8 cm left-sided subdural hematoma. Resident #1 also had a temporal laceration which required sutures. Hospital Progress Notes dated 5/23/21 indicated a repeat CT scan showed a left subdural hematoma, unchanged from yesterday's (5/22/21) scan. A Hospital Radiology Report dated 5/23/21 documented results of a CT of Resident #1's head which read: A 4 millimeter (mm) focus of increased attenuation along the cortical surface of the right frontal lobe is unchanged compared to yesterday's exam but not present on the exam of 2/25/21 and could represent a tiny focus of parenchymal hemorrhage (a bleed that occurs in the brain and can lead to disruption of oxygen in brain cells and subsequent functional tissue death). Documentation in the facility Nurse's Notes dated 5/25/21 revealed Resident # 1 returned to the facility at 2:08 p.m Resident #1 rolling her head back and forth, rubbing her eyes and head and complaining of a very bad pain; left head and all over. She was moaning and crying off and on. According to a typed report dated 5/22/21, the Director of Nursing (DON) reported Staff A, Certified Nursing Assistant (CNA) was getting residents up for lunch on 5/22/21. Staff A indicated she looked for a nurse to help her with Resident #1 because she required a Hoyer lift transfer. Staff A could not find the nurse, so she decided to do the transfer herself. Staff A hooked the resident up with the sling, and when she had the resident approximately 3-4 feet in the air, the top loop of the harness came off the Hoyer hook, and the resident fell to the floor landing on her left shoulder and left side of her head. Staff A noticed a hematoma and blood from the left side of Resident #1's head, and went to find a nurse. The DON reported he asked Staff A if Resident #1 was in a hurry to get up and Staff A said she was not. The DON also confirmed with Staff A that she knew that Hoyer lift transfers always required assist of two staff. When asked why Staff A then made the decision to go ahead and do the transfer herself, she responded that Resident #1 is always an easy transfer with the second person just being there and not having to do anything and it has always gone smoothly.

Based on observation, record review, family and staff interviews, the facility failed to implement and monitor an effective screening process for staff to prevent a Coronavirus Disease (COVID-19) outbreak affecting 36 of 70 residents causing 5 residents to be hospitalized and failed to provide staff education. The facility reported a census of 70 residents. Findings include: 1. A review of the facility Screening Forms revealed no consistency with completion of the Screening Form; as evidenced by the following: a. The week of 7/21/20 through 7/28/20: 6 staff came in to work with symptoms and instructed to continue to work on positive COVID Unit with no testing completed to determine if they were COVID positive and not sent home. b. No official screener consistently in place to monitor those coming through the front entrance when employees enter. c. On 7/27/20, the Surveyor entered at 9:28 a.m. greeted by Administrator, Director of Nursing (DON), and Dietary Director. At 10:18 a.m., after prompting by the Surveyor, the DON then screened the surveyor d. On 7/28/20, the surveyor entered the facility and completed the screening form, took her own temperature, however, no verification received from any of the staff on the information provided. 2. Documentation lacked staff education on COVID-19 after April 2020. A review of nine human resources records revealed no documentation of education after April 2020. 3. The facility failed to restrict visitors from entering the facility per CMS guidance. a. One resident's spouse who lived in the independent living apartments was entering. The spouse entered the facility six or seven times in the span of a month. The facility instructed the spouse to call first prior to entering the facility and try to monitor at mealtimes which was usually when the spouse would come to visit b. The family of two other residents were allowed to visit the residents who had not been identified to be in the active phase of dying or receiving hospice services. During an observation on 8/5/20 1:08 p.m., the Administrator showed the signs posted on the entrance from the independent living apartments to the facility. The door had a push bar and required the person to push a button to deactivate the alarm. On the other side of the door were signs posted on red paper with bold font with instructions that no visitors allowed in the facility (no date posted on the sign). A button to push would deactivate the alarm in order to enter the facility. She also reported a visitor who lived at the independent living apartments knew how to deactivate the alarm and staff would not know he entered the facility until they actually saw him. During an observation on 8/6/20 at 5:27 a.m., the Surveyor entered through a door, which had signs posted employees only, push button to enter. The Surveyor entered the facility, silenced the alarm, since no staff near the entrance, took own temperature and answered screening questions on the Screening Tool which asked if symptoms of cough, sore throat or new shortness of breath. At 5:42 a.m., Staff U, Registered Nurse (RN), informed the surveyor of the need to have her temperature taken and answer screening questions. During an observation on 8/6/20 at 6:14 a.m., Staff V, agency Certified Nurse Aide (CNA) screened by Staff U, RN who asked if she had any symptoms. Staff V reported she had a cough that she has had for a couple days, not constant, but had allergies [REDACTED]. Staff U instructed her to wait while she talked to the DON. The DON asked Staff V if she had the cough constantly or any contact that was positive. Staff V reported she had been working the COVID unit and that she had a history of [REDACTED]. At 6:21 a.m., Staff U asked Staff V what the DON said. Staff V reported he never responded. Staff U then instructed Staff V that she would be alright to work. Staff V proceeded to don mask, face shield and isolation gown before going out to the hallway where resident rooms were located. During an observation on 8/6/20 at 12:15 p.m., Staff V, CNA wore a mask, face shield, isolation gown, stood outside a room in the 200 hallway (one of the units designated for residents who tested positive for COVID-19). She reported she had not had any problems with coughing since she punched in this morning. No coughing noted during this observation. During an observation on 8/6/20 from 1:50 p.m. through 2:19 p.m., Staff P, Licensed Practical Nurse (LPN) utilized the original screening form utilized when the survey began on 7/27/20 on 12 employees. The form did not address other symptoms such as diarrhea, headache, or if they had been exposed to anyone that tested positive for COVID-19. In an interview on 7/27/20 at 2:23 p.m., Staff A, CNA, reported the following: a. The screening process is not consistent, staff are expected to take their own temperature and answer the questions, however, there are people not doing this and nothing is done about it. Approximately 75% of the staff will forget to complete the screening process. b. There are several people that work here that have tested positive and are allowed to work. There is one CNA tested positive, she had a fever, cough, and sore throat, and never been quarantined, and they told her she could work with the residents who have already tested positive. c. On Friday (7/24/20), Staff A had been vomiting, had a fever of 100.9 then they took it again 98.9 then 100.1. She also had a cough and sore throat, very dizzy and not sent home. The symptoms started when she first arrived to work, she worked the entire shift and was not tested until 7/27/20. She also reported all employees who have symptoms are supposed to get tested here. During an interview on 7/27/20 at 5:07 p.m., Staff B, RN, reported the following: a. Employees are expected to take their own temperature and answer the screening questions. Usually a nurse is supposed to be there. b. When asked if the screening completed consistently, she reported she is not always good about signing out and checking her temperature before she leaves for the day. In an interview on 7/28/20 at 7:38 a.m., Staff C, RN, reported the following: a. Employees are supposed to check their own temperature and answer the questionnaire when they enter and when they leave for the day. b. The facility protocol is that if an employee has tested positive for COVID and asymptomatic, they can continue to work on the 2 COVID units. She also reported if an employee had any symptoms, they would need to stay home for 14 days. During an interview on 7/28/20 at 7:54 a.m., Staff D, CNA, reported when employees start their shift, they are to take their own temperature and answer four questions. If anyone answers yes to any of the questions, they will be asked to go home but before going home, the DON would need to do the COVID-19 test out in the parking lot. No one sits at the table (where the screening is completed by employees), but at shift change there is always a nurse around. In an interview on 7/28/20 at 11:30 a.m., Staff E, Dietary Aide, reported on 7/21/20 and 7/22/20 she had marked the screening tool as yes for cough and sore throat, and not sent home, she worked for the next few days afterward. She had never had been told to stay home and did not know what symptoms she should have to stay home. During an interview on 7/28/20 3:41 p.m., Staff G, CNA, reported the following: a. Employees are to check their own temperature and answer questions upon arriving and before leaving. If anyone answers yes to any of the questions they can still work unless they had a temperature above 100.4. b. The screening is not completed consistently and she admitted she is one that forgets to, as there is no one to enforce the staff to complete it. c. On 7/24/20 she answered yes on the screen for cough and not instructed to go home. d. There are two residents in the 200 hall (one of the units designated for COVID positive residents) that are still negative for COVID, not sure why they are not in the other hallway where the other negative residents are. During an interview on 7/29/20 10:23 a.m., Staff H, RN, reported the following: a. Employees are to take their own temperature before their shift and before leaving. There is no staff sitting at the entrance by the dining room. There is usually a nurse by the employee entrance. b. If anyone answers yes to any questions should call the DON and if anyone had a temperature above 100, should go home. During an interview on 7/29/20 at 2:52 p.m., the Director of Nursing (DON) reported he did not have a written policy on when to contact the public/state health departments of outbreaks and did not have any surveillance on the residents who tested positive for COVID-19. In an interview on 8/3/20 9:28 a.m., the DON reported the following: a. If a staff member marks any of the screening questions with a yes, they are to report it to him and he would check them. b. He would send staff home if they had a temperature above 100.4, he would recheck in an hour and if still above 100.4, he would test them and send them home until he got the test results. If they have a negative test, then they can work. c. There are three residents residing in the 200 hall (designated for COVID positive residents) that have been negative for COVID. There have been no other rooms for them to move to. A review of the list of residents revealed 8 empty beds in the 100 hallway and 4 empty beds in the 300 hallway. During an interview on 8/4/20 at 10:00 a.m., when asked what he felt caused the outbreak to occur, the DON reported the following: a. The facility had a visitor come through a hallway connecting the independent living apartments (where he resided) to the facility through a door which can not be locked. He would just walk through the door as he knew how to silence the alarm to the door b. The visitor probably entered the facility 6 or 7 times over the course of a month, during that time he had not tested positive for COVID-19 c. On 7/10/20 the visitor's daughter reported he had tested positive for COVID-19 d. When the DON became aware of the visitor coming to the facility, he asked him to call the facility first so they could meet him at the door. The DON reported there had not been much he could do except monitor meal times, which is usually when he would visit. In an interview on 8/6/20 at 1:02 p.m., Staff V, CNA reported when she came to work this morning, the DON never returned to tell her if she should go home and had not tested her for COVID-19. She also reported her first day to work was 7/31/20 and no one took her temperature or screened her. She followed the other employees, took her own temperature, and answered the questions on the screen. During an interview on 8/10/20 at 7:56 a.m., the DON reported beginning 8/10/20; he will start a line list of monitoring residents and staff that tested positive for COVID-19. When asked for a copy of the facility policy on COVID-19 outbreaks, the DON provided the following: a. A checklist provided by the Iowa Department of Public Health dated 3/27/29 titled: Checklist for Long-Term Care Facilities experiencing COVID-19 outbreaks had documentation of the following: a. Screen all employees for fever and cough/breathing problems at the start and end of each shift. Ill staff should be sent home immediately b. No visitors should be allowed in the facility (unless end of life situation per CMS guidance). b. An untitled form dated 3/27/20 with documentation of the following: all residents should be screened for COVID-19 by taking their temperature and oxygen saturation at least twice per day on first and second shifts, and more often if necessary. If findings show an increase in temp or decrease in oxygen saturations from their norms, then they should be placed in palliative care unit for isolation. c. A form titled: COVID-19 Isolation Plan dated 4/6/20 with documentation of the following: If a resident were to test positive for COVID-19 or be presumed positive based on symptomology, that resident would be placed in the palliative care unit for isolation. Selective staff would be designated to work on the unit and not other units while a resident is isolated. In the event that more than four beds are needed to isolate, then the residents in the skilled unit would be incorporated into the nursing home, and the unit would be set up for isolation. In the event that they would need to use more than those 13 beds, then the east hall would be set up for isolation. A review of the facility policy tiled: Infection Control Program dated 2009 had documentation of the following: The facility will perform surveillance and investigation of infections, prevent, and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. The infection control nurse/designee in case of an outbreak of a communicable disease will: monitor and document infections, including tracking and analyzing outbreaks of infections as well as implementing and documenting actions to resolve related problems. A review of the facility policy titled: Checklist for Long Term Care Facilities experiencing COVID-19 outbreaks (Iowa Department of Public Health stamped) dated 3/27/20 had documentation of the following: screen all employees for fever and cough/breathing problems at start and end of each shift. Ill staff should be sent home immediately. A review of the COVID-19 Isolation Plan dated 4/6/20 had the following documentation: a. If a resident were to test positive for COVID-19 or be presumed positive based on symptomology, that resident would be placed in the palliative care unit for isolation. Selective staff would be designated to work on the unit, and not other units while a resident is isolated. b. In the event that more than 4 beds are needed to isolate, then the residents in the skilled unit would be incorporated into the nursing home and the unit would be set up for isolation. In the event that we would need to use more than those 13 beds then east hall would be set up for isolation. A review of the facility policy titled: Long Term Care Respiratory surveillance line list had documentation of the following: The respiratory surveillance line list provides a template for data collection and active monitoring of both residents and staff during a suspected respiratory illness cluster or outbreak at a nursing home. The information in the columns of the worksheet capture data on the case demographics, location in the facility, clinical signs/symptoms, diagnostic testing results and outcomes. The incident detailed above resulted in determination of Immediate Jeopardy for the facility and notified of such on 8/4/20 at 4:15 p.m. The Facility staff abated the Immediate Jeopardy situation on 8/7/20 through the following actions: a. Changed the screening area for staff to the employee entrance on the north side of the building. b. Assigning a designated employee (the Nurse coming off shift) to be available to complete all screenings to include temperature and screening questions and anyone presenting with either a temperature or failing the screening questions will be sent home. c. All staff reeducated to not report to work if displaying any symptoms of COVID-19, and reeducated that visitors are not allowed in the building unless prior approval by the Administrator and/or DON. d. The residents in the independent living area connected to the facility contacted and additional signage posted at entrance doors to notify of visiting restrictions imposed in the Nursing Home. e. The questions on the Screening Tool were changed to be more inclusive of COVID-19 signs and symptoms. Based on the results of the corrective measures taken by the facility lowered the scope and severity of the deficiency from an L level to an F level.

Based on record review and staff interviews, the facility failed to assess and provide timely interventions when Resident #3 fell and displayed a change in physical condition. The sample consisted of 5 residents and the facility reported a census of 87 residents. Findings include: 1. Resident #3 had an MDS (Minimum Data Set) assessment with a reference date of 8/2/2012 which identified [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS (Brief Interview for Mental Status) score of 12 out of 15, which reflected the resident had moderately impaired skills for daily decision making. The MDS indicated the resident required extensive assist of one person for bed mobility, transfers, ambulation, toilet use, and dressing. The MDS documented the resident had a history of [REDACTED]. The Care Plan dated 8/08/12 identified the resident had a problem with decreased mobility from arthritis and a left [MEDICAL CONDITION]. The care plan directed one staff member to assist the resident with transfers, ambulation using a wheeled walker, and a gait belt. The care plan documented the resident had been continent and required assist of one staff member for routine toileting. The MDS with a reference date of 10/15/12 reflected the resident had been totally dependent on two staff members for transfers. The MDS documented the resident had functional limitation of both lower extremities. The Discharge Instructions from Mercy Hospital dated 10/07/12 indicated the resident sustained [REDACTED]. The Discharge Instructions indicated the resident needed to follow up with the orthopedic physician in two weeks, keep the foot elevated and use ice for swelling. On 11/05/12 at 8:00 a.m. Staff A, (Certified Nursing Assistant-CNA) was interviewed. Staff A described the incident on 10/06/12 at 10:50 p.m. Staff A indicated she assisted the resident to the toilet and then went to assist another resident. Staff A then saw Resident #3' bathroom light flashing at about 11:00 p.m. Staff A stated she entered the resident ' s room and saw the resident attempting to transfer from the toilet to the wheelchair. The resident ' s wheelchair slide out from under the resident and the resident fell on to the floor, on to the buttocks area. Staff A yelled for assistance and Staff E arrived. Upon direction from Staff A, Staff E left and attempted to locate the staff nurse. Staff A stated the nurse did not arrive and the resident requested to get up. Staff A and Staff E transferred the resident to the wheelchair and then to bed. Staff A stated she saw the resident at 1:00 a.m. and the resident was asleep. Staff A stated another facility resident fell at 1:30 a.m. and required nurse and staff assistance. Staff A stated she informed the nurse, Staff B of Resident #3 ' s fall at that time. At 3:00 a.m., the resident awoke and needed to use the bathroom. The resident ' s foot was swollen the size of a baseball. Staff A informed the nurse (Staff B) that the resident had pain and needed to use the toilet. Staff B instructed Staff A to offer the resident the bed pan. At 5:15 a.m., Staff A stated she informed Staff B of the resident ' s pain and swelling. Staff B told Staff A she didn ' t know what to do and would ask the Staff F when she arrived at the facility (scheduled for 6:00 a.m.). On 11/1/2012 at 12:32 p.m. Staff E (Certified Nursing Assistant) was interviewed she saw a call light on for 10-15 minutes so she went to the west hall. Staff E entered Resident #3 ' s room and found the resident on the floor and Staff A next to the resident. Staff E stated she could not locate the charge nurse. Staff E and Staff A transferred the resident to the wheelchair and into bed. At 3:00 a.m. Staff A informed Staff B that the resident had pain. On 11/1/2012 at 1:34 p.m., Staff B (Registered Nurse) was interviewed and didn ' t observe the incident when on duty on 10/6/2012. At 3:00 a.m. Staff A informed her that Resident #3 had fallen at 11:00 p.m. Staff A had informed Staff B the resident was sleeping and not hurt. At 4:55 a.m., Staff A requested Staff B look at the resident because the resident voiced complaints of leg pain. Staff B stated she checked the resident ' s leg and it was swollen at 5:00 a.m. (6 hours after the fall). Staff B stated the resident did not want to be transferred to the hospital but did agree to ice and elevation of the foot. Staff B stated the staff are always to get a nurse after a fall and confirmed this to be the facility policy. On 11/1/2012 at 11:37 a.m., Staff F (Licensed Practical Nurse) arrived at the facility on 10/6/2012 at 5:30 a.m. Staff B informed her of Resident #3 ' s fall. Staff F went to check Resident #3. Resident#3 had a swollen ankle and Staff F obtained ice. Resident #3 was sent to the hospital and returned to the facility with a splint and non- weight bearing. On 11/1/2012 at 3:00 p.m., the Director of Nursing was interviewed and stated Staff A did not report fall to nurse right away. The Progress Note, written by Staff F, dated 10/7/2012 at 5:43 a.m. identified the resident lying in bed and had complaints of right ankle pain. The nurse noted the right ankle as swollen. The Progress Note dated 10/7/2012 at 6:00 a.m. and written by Staff F indicated the physician was contacted and ordered to send to the hospital. The resident left for the hospital via ambulance at 7:00 a.m.

Based on observation, clinical record review, staff and resident interviews, the facility failed to provide adequate supervision by ensuring the resident had alarm devices in good repair that helped meet the current needs of the resident for one of seven residents (Resident #1) with an adverse change in physical condition. The facility reported a census of 63 residents. Staff did not ensure the resident ' s personal alarm worked properly (missing batteries). The resident had been assessed as at high risk for falls. The alarm would alert staff when the resident began to self transfer. The resident fell and fractured a hip and the alarm did not sound to alert staff the resident needed assistance. The Administrator voiced the facility did not have a policy for checking alarms. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE], documented Resident #1 had severely impaired cognitive skills for daily decision making, and [DIAGNOSES REDACTED]. The MDS revealed the resident transferred between surfaces and ambulated with extensive assistance of two staff, and had no falls since admission. The Care Plan indicated Resident #1 ambulated with a walker and the assistance of two staff and a gait belt and on 8/29/2011 staff transferred the resident to the commode with a stand up lift. The Care Plan revealed the resident had chair and bed alarms, low bed, non skid strips at bedside and in front of the recliner and directed staff to unplug the recliner when seated and to place the control out of reach. The Fall Risk assessment dated [DATE] and 8/1/2011, documented the resident had a high risk for falls. Nurse notes dated 8/14/2011 for the 2:00 p.m.-10:00 p.m., shift documented staff observed Resident #1 on the floor lying on back in the hallway, near the dining room, and a staff member in the dining room heard a thump. Staff assessed the resident, notified thy physician and family, and transferred the resident to the emergency room . The Hospital History and Physical report dated 8/14/2011 documented Resident #1 had a fall from a wheel chair, had pain in the leg and a left hip fracture. The resident resided at the nursing home for approximately one year and had dementia, previous subarachnoid hemorrhage, hypertension, and transient ischemic attacks. The resident was admitted to the hospital and had surgical repair of the hip. Observation on 8/29/2011 at 12:00 p.m., revealed Resident #1 seated in a wheel chair with head phones on and a personal alarm attached. At 12:10 p.m., two staff along with therapy staff, ambulated the resident in the hallway a short distance. The chair alarm sounded when staff assisted the resident to rise. At 1:40 p.m., the resident rested in a low bed, positioned with pillows, and a bed alarm in place. The wheel chair sat at the foot of the bed. On 8/29/2011 at 2:00 p.m., Staff A, CNA (Certified Nursing Assistant) was interviewed and stated had worked from 8:00 a.m. until 8:00 p.m. on 8/14/2011. After lunch Staff A and Staff B, CNA assisted the resident to the toilet and the recliner. Staff A transferred the chair/pad alarm from the wheel chair to the recliner and when doing so, the alarm box dangled over the side of the chair and hit the floor. Staff A went around the recliner to unplug the alarm and in doing so either stepped on the chair remote or hit the alarm box with his/her foot. Staff A picked up the alarm box, observed batteries and closed the lid. After 2:00 p.m., Staff A and Staff C walked down the hall and observed the resident sitting up in the chair, leaning forward, holding the alarm box. Staff A and Staff C assisted the resident to transfer from the recliner to the wheel chair. Staff A reported holding the side buttons on the alarm box to deactivate it during the transfer. Staff A pushed the resident to the nurse's station area and reported to the nurse that the resident needed a new foot pedal on the wheel chair. Staff A took a fifteen minute break and when he/she returned observed the resident with nursing staff who reported the resident's alarm failed to sound and the resident fell . Staff reported the alarm box had batteries missing and the lid had been taped shut. Staff A denied taping the lid shut and indicated the lid fit loosely and easily fell off, exposing the batteries. Staff A reported being questioned by the facility attorney who felt the tape had been on the box for awhile. Staff C went into the resident's room and found one battery on the floor and another on the vanity near the recliner. Staff A indicated the resident could have tampered with the battery box and removed the lid and batteries. On 8/30/2011 at 9:05 a.m., Staff C was interviewed and reported on 8/14/2011 at approximately 2:30 p.m. Staff A asked for assistance with transferring Resident #1 from the recliner to the wheel chair, as the resident attempted to climb out of the chair. Resident #1 held the cord to the alarm in his/her hand. Staff A held the alarm box during the transfer. Staff C assumed Staff A pushed the reset button since it failed to beep. Staff C failed to check the alarm to ensure it functioned. Staff C observed a battery on the vanity table, but stated didn't think anything of it. Staff A took the resident out of the room via wheel chair with one foot pedal, the other broke. After the resident fell , Staff D, Rehab Aide checked the alarm and reported it lacked four batteries. Staff C checked the resident's room and found another battery on the floor. The resident does attempt to stand and gets antsy at times. On 8/29/2011 at 2:35 p.m., Staff F, CNA reported working Sunday, 8/14/2011 from 6 a.m. to 2 p.m. When Staff A and Staff F transferred Resident #1 to the recliner at approximately 1 p.m., the alarm sounded. Staff A put the alarm box on the floor out of reach. Staff F heard a noise and Staff A reported tripping over the box. Staff F never observed the resident tamper with the alarm box, but has seen the resident attempt to get up unattended. Staff checks alarms with transfers; it beeps and lets staff know it works. The box did not have tape on it when Staff F observed the box. Around 2:00 p.m., Staff F saw Staff A pushing the resident towards the nurse's station. On 8/29/2011 at 2:30 p.m., Staff D reported checking the alarms weekly and checked Resident #1's alarms on Saturday and the alarms functioned correctly. On Sunday, 8/14/11 Staff D observed Resident #1 on the floor, checked the alarm and saw two batteries missing. Staff D observed the lid had a loose screw and a piece of tape over it. Staff D replaced the alarm with a new one. Staff D indicated the box failed to have any tape on it the day before and had no knowledge of staff taping the box. Aides should check the alarm with each transfer to make sure it functions correctly. During interview on 8/30/2011 at 10:00, the Administrator reported the facility had no written policy regarding checking alarms. The Restorative Aide checks every alarm weekly and documents they function correctly. Aides document every shift that resident alarms function and part of their resident safety orientation is to check resident alarms and make sure they function. During interview on 8/30/2011 at 8:50 a.m., Staff E, LPN (Licensed Practical Nurse) reported Resident #1 fell at the change of shift. Staff E went to clock out and returned to the nurse's station and a resident said the resident fell by the dining room. No staff witnessed the fall as staff were in the dining room charting. Staff E failed to hear the alarm sound, and assumed the resident held onto the hand rail and stood, and the wheel chair scooted backwards. The resident complained of left hip pain. Staff D checked the alarm and found two batteries missing and the bottom screw not screwed in. The resident attempted to stand occasionally. The aides check alarms when they transfer residents and are supposed to listen for a beep and make sure it functions. The aides have a log that they sign documenting they check alarms. During interview on 8/29/2011 at 12:00 noon, Staff G, LPN reported working on 8/14/2011 and Resident #1 fell near the dining room, Staff G had briefly used the restroom, and observed the resident on the floor upon returning. Staff G did not hear any alarm sound. Staff G assessed the resident and called family and emergency medical services to transport the resident to the emergency room . Staff G has observed the resident ambulate with assistance. Staff G never observed the resident attempt to stand unsupervised or set off the alarm. During interview on 8/30/2011 at 1:40 p.m., the DON (Director of Nursing) revealed on 8/14/2011 staff called and reported Resident #1 had a fall and transferred to the emergency room . Staff informed the DON the alarm failed to sound and it had two batteries missing, and a piece of tape had been placed over the alarm box lid. Staff D reported checking the alarm on 08/13 and the alarm functioned with no tape present. During the investigation Staff A reported dropping or stepping on the alarm, but failed to recall if the alarm had batteries or made an activation sound when Staff A and Staff C transferred the resident prior to the fall. The facility placed Staff A on leave pending the outcome of the investigation. The AliMed TR-2 Tamper Resistant Alarm Instructions for Use, Application, and Care instruction sheet included: Test alarm daily to ensure patient safety, status light will blink once when turned on and it will blink when activated or reset. Alert light flashes continuously while alarm sounds, lo battery light indicates that batteries must be replaced if blinking. The alarm had molded reset buttons (one on each side). Note 1: The alarm cannot be turned off when in use. Note 2: Test alarm with sensor device before using with patient to ensure both alarm and sensor are operating properly. The alarm includes four batteries.