Every finding on record at Southeast Iowa Regional Medical - Klein Center

Based on clinical record, policy review, and staff interviews, the facility failed to obtain a consent and provide information about the risks and benefits of psychotropic medications (medications that affected the mind, altering a person's emotions, thoughts, perceptions, or behavior) for 5 of 6 residents reviewed for medications (Residents #5, #6, #13, #17, #109). The facility reported a census of 141 residents.Findings included: 1. The Minimum Data Set (MDS) assessment tool dated 4/29/26, list of diagnoses for Resident #5 included anxiety, depression, and delirium due to a known condition. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 6 out of 15, indicating severely impaired cognition. The MDS documented Resident #5 prescribed medications in the following high risk drug classes: antipsychotic, antianxiety, and antidepressants. A 7/15/23 Care Plan entry stated the resident would not exhibit side effects resulting from psychotropic medication use. A 6/11/25 Family Practice Office/Clinic Note documented the resident took the following medication: lorazepam (an anti-anxiety medication) 0.5 mg (milligrams) twice daily. A 5/27/26 Behavioral Health Office/Clinic Note documented the resident continued to take lorazepam 0.5 mg. The resident's clinical record lacked documentation the facility informed the resident or the resident representative of the risks and benefits of the medication, the treatment alternatives, or other options so the resident could make an informed choice. 2. Resident #6's MDS assessment tool dated 4/29/26, list of diagnoses included non-Alzheimer's dementia, depression, and high blood pressure. The BIMS score of 3 out of 15, indicated a severe cognitive impairment. The MDS documented Resident #6 prescribed medications in the following high risk drug classes: antipsychotic and antidepressants. A 6/18/21 Care Plan entry stated the resident would not exhibit side effects resulting from psychotropic medication use. Resident #6's Active Orders as of 6/18/26 included, in part: a. Aripiprazole (an antipsychotic medication) 4 mg. Start date 3/08/24. b. Bupropion (an antidepressant) 150 mg. First dose: 12/18/24. c. Duloxetine (an antidepressant) 120 mg, First dose 7/01/21. The resident's clinical record lacked documentation the facility informed the resident or the resident representative of the risks and benefits of the medication, the treatment alternatives, or other options so the resident could make an informed choice. On 6/18/26 at 1:11 p.m., via email, the Director of Nursing (DON) stated the facility did not have psychotropic medication consents for Resident #6 because the resident began the medications prior to when the consents began. 3. Resident #13's MDS assessment dated [DATE], list of diagnoses included vascular dementia, unspecified severity, with anxiety. The BIMS score of 5 out of 15 indicated a severe cognitive impairment. The MDS documented Resident #13 prescribed medications in the following high risk drug classes: antipsychotic, antianxiety, and antidepressants. The Care Plan revealed a focus area dated 5/22/26 for psychotropic medication use. Resident #13's Active orders as of 6/18/26 included: a. Amitriptyline (antidepressant) 10 mg. First dose 5/9/25. b. Quetiapine (antipsychotic) 12.5 mg. Ordered 6/4/26. The resident's clinical record lacked documentation the facility informed the resident or the resident representative of the risks and benefits of the medication, the treatment alternatives, or other options so the resident could make an informed choice. During an interview on 6/18/26 at 1:27 PM, Staff H, Registered Nurse (RN)/ Unit Manager queried on the psychotropic consents for Resident #13 and Staff H stated the facility didn't get a consent for amitriptyline because it was a medications Resident #13 has taken at home. Staff H explained Seroquel (quetiapine) got missed because it had been prescribed in the middle of the change in electronic health record systems. Staff H stated the expectation is for medication changes was the nurses spoke to the family about them. 4. The MDS assessment dated [DATE], revealed Resident #109 did not have a BIMS completed. The list of diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, anxiety disorder. The MDS documented Resident #109 prescribed medications in the following high risk drug classes: antipsychotic and antidepressants. The Care Plan dated 5/4/26 revealed a focus area for psychotropic use. Resident #13's Active orders as of 6/18/26 included: a. Trazodone 50 mg. First dose: 5/19/26. b. Duloxetine 90 mg. First dose: 5/29/26. c. Risperidone 0.5 mg. First dose: 5/27/26. d. Quetiapine 25 mg – First dose: 5/19/26. Per an email on 6/18/26 at 12:54 PM, the DON stated there was no psychotropic consent for Resident #109 as she was on psychotropic medications prior to arrival to the facility. During an interview on 6/18/26 at 1:10 PM, Staff H, RN Unit Manager queried on Resident #109 psychotropic consents and Staff H stated Resident #109 was on the psychotropic medications when Resident #109 came to the facility so the facility would of not gotten consents for the medications. During an interview on 6/18/2026 at 2:18 PM, the DON stated when the facility started or increased a medication, the facility received consents. The DON stated they did not do consents if a resident came into the facility with them because it didn't make sense if the resident was already taking them. 5. Review of the MDS assessment, dated 5/26/26 revealed a BIMS score of 13 out of 15, which indicated Resident #17 had intact cognition. The list of diagnoses included cerebrovascular accident (stroke), seizure disorder, and anxiety disorder. The MDS indicated Resident #17 prescribed medications in the following high risk drug classes: anticoagulant and antibiotic Review of a 6/05/26 Care Plan entry stated the resident would not exhibit side effects resulting from psychotropic medication use. Review of Resident #17 Active Order list revealed: a. Quetiapine 12.5 mg. First dose: 6/5/26. Review of an Internal Medicine Progress Note, dated 5/17/26 documented, in part. symptoms of delirium, with agitation at night, and was started on low dose of Quetiapine. Review of the resident's clinical record lacked documentation the facility informed the resident or the resident representative of the risks and benefits of the medication, the treatment alternatives, or other options so the resident could make an informed choice. During an interview on 6/17/26 at 3:20 PM, Staff R, RN Unit Manager, stated that Resident #17's order for quetiapine started during hospitalization for fall on 5/17/26 and order for this medication continued upon return to the facility. Staff R denied obtaining an informed consent for Resident #17's new psychotropic medication. The facility policy Informed Consent, revised 2/2026, stated residents had the right to make informed decisions regarding care. The policy stated this applied to all treatments requiring informed consent. The policy stated the facility would provide information such as the potential risks and benefits of the treatment and stated consents for recurring treatments were valid for up to 12 months.

Based on clinical record review, review facility Call Logs resident and staff interview, the facility failed to ensure sufficient staff available to answer resident calls lights in a timely manner for 6 of 7 residents (Residents #160, #7, #142, #23, #122, and #8) in the sample. The facility reported a census of 141 residents.Findings included: 1. Review of the electronic health record (EHR) Face Sheet revealed Resident #160 admitted to the facility on [DATE], with a primary diagnosis of aftercare for healing traumatic fracture of the left hip. Review of Nursing Assessment and Intervention dated 6/9/26, revealed, in part, an Intervention for Resident #160 for Activity Bed Rest with exceptions; up in chair; ambulate with assistance. Review of a Nursing Note dated 6/15/26, revealed, in part, Transferring and ambulating short distances with assist of one staff, gb (gait belt) and walker. During an interview on 6/15/26 at 10:34 AM, Resident #160 reported concerns with staff answering her call light. Resident #160 explained earlier on this date she had turned her call light on at 6:34 AM, and no one answered the call light until 7:24 AM. She stated she had needed to use the toilet, and her bladder hurt by the time staff responded. During an interview on 6/17/2026 at 3:15 PM, the Administrator explained that staff had a work phone that they received notifications on for the resident call lights. She explained the Call Log included a heading, To Take, which identified when a staff person accepted that they would be the one to respond to a call light. Staff typed their response to take the call on their phone. Review of the Call Log for Resident #160 revealed: a. On 6/15/26, call light on at 6:37 AM for toileting assistance. Staff B, Certified Nursing Assistant (CNA), responded her intent To Take 55 minutes after the resident had turned her call light on. b. On 6/15/26 at 2:20 PM, call light on for toileting assistance. Staff A, CNA, responded her intent To Take 25 minutes after the resident turned the call light on. During an interview on 6/17/2026 at 3:36 PM, Resident #160 stated she knew the length of time she had to wait for her call light to be answered on 6/15/26 because she had used the clock in her room. The resident reported she had to wait about 30 minutes to use the toilet the afternoon of 6/15/26. On 06/17/2026 at 4:29 PM, during an interview, Staff A, CNA, explained that she could see on her phone when a resident turned their call light on. Staff A reported that staff could usually respond to call lights within 15 minutes, unless they were tied up with another resident. Staff A reported she had worked with Resident #160 on Monday evening, 6/15/26. Staff explained that first shift should have taken the resident's call light at 2:20 PM. Staff A reported that she did not come in for her evening shift report until 2:20 PM to 2:30 PM. The length of report time depended, but it was no longer than 10 to 15 minutes. During an interview on 6/17/2026 at 4:37 PM, Staff B, CNA, reported that she received shift report at about 6:30 AM, and report usually lasted about 15 to 20 minutes. If a call light was turned on between 6:30 AM to 6:40 AM, Staff B explained that usually night shift responded to those call lights. Staff A reported one of the day shift CNAs would respond if all of the night shift CNAs were helping residents. Staff B reported when a resident turned their call light on, it showed up on the work phone of all staff working the neighborhoods on this floor. Staff B reported she pressed take on her phone to indicate that she was taking the call light, and she normally pressed take when she was on her way to the resident's room. Staff B confirmed she worked with Resident #160 on Monday day, 6/15/26. Staff B explained that she had given another resident a shower first before responding to Resident #160's call light. Staff B reported Staff E, Physical Therapy Assistant (PTA) was going by Resident #160's room, and went into Resident #160's room just before Staff B got there. Staff B reported Resident #160 did say something about her call light had been on and needing to go to the bathroom. On 6/18/2026 at 11:12 AM, during an interview, Staff E, PTA, confirmed she had worked on Monday, 6/15/26, during the day. Staff E explained she had been walking down the hall around 7:20 AM to 7:30 AM to go to another resident's room when she heard Resident #160 say something. Resident #160 reported she had been waiting a long time for staff and needed to go to the bathroom. Staff E, PTA, reported she had gone into the resident's room less than a minute before Staff B, CNA. 2. Review of the Minimum Data Set (MDS) assessment for Resident #142 dated 5/16/26, revealed a diagnosis of multiple sclerosis and the Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated intact cognition. The MDS indicated the resident had impairments on both sides upper and lower body, and dependent on staff for all activities of daily living (ADLs). During an interview on 6/15/2026 at 11:10 AM, Resident #142 reported she did not feel the facility had enough staff. Resident #142 explained she had to wait until they had two staff available to help her transfer with the Hoyer (type of mechanical lift). She reported there were times she had to wait more than 15 minutes for staff to answer her call light, and she recently had to wait one, one-half hours for staff to help transfer her from her bed to her wheelchair. Review of the Call Log for Resident #142 revealed: a. On 6/14/26, call light on at 4:52 PM for assistance with transferring. A CNA responded their intent To Take 44 minutes after the resident had turned her call light on. b. On 6/16/26, call light on at 4:54 PM. A CNA responded their intent To Take 33 minutes after the resident had turned her call light on. c. On 6/16/26, call light on at 9:00 AM for transfer assistance. Staff C, CNA, responded her intent To Take 20 minutes after the resident had turned her call light on. During an interview on 6/18/2026 at 9:35 AM, Staff C, CNA, reported she worked on the same neighborhood (unit) that Resident #142 resided. Staff C reported when a resident turned their call light on, she would click a button on her phone to take the call prior to entering the resident's room. She would then go to the resident's room, turn off the call light and mark complete on her phone. Staff C, CNA, reported if the call log report identified it took her 20 minutes to take the call light for Resident #160 on 6/16/26, then that was probably accurate. Staff C explained they had a lot of heavy care residents, and they struggled at times to meet the needs of the residents. The last 2 to 3 weeks had been very difficult, and Staff C reported she expressed concerns to the Director of Nursing (DON). In addition to heavier care residents, Staff C felt like she was training new staff every day. Staff C reported she had remembered a specific incident last week when she and another CNA had been assisting a resident for about 45 minutes, and Resident #142 had been waiting during that time for assistance. Staff C explained that it doesn't usually happen, but there had been times that Resident #142 had to wait for one and one-half hours to transfer. 3. Review of the MDS Assessment for Resident #7 dated 5/9/26, revealed a BIMS score of 15 out of 15 which indicated an intact cognition. The MDS listed a diagnosis of stroke, with impairments on one side both upper and lower body, and required partial to moderate assistance with toileting and transfers. During an interview on 6/15/2026 at 10:59 AM, Resident #7 stated there were times she used the call light and had to wait more than 15 minutes. She thought it was worse over the last couple weeks. Review of the Call Log for Resident #7 revealed: a. On 6/10/26 at 1:06 PM, call light turned on for toileting assistance. A CNA responded their intent To Take 33 minutes after the resident had turned on the call light. b. On 6/10/26 at 7:20 AM, call light turned on for toileting assistance. A CNA responded their intent To Take 1 hour and 13 minutes after the resident had turned on the call light. c. On 6/13/26 at 4:20 PM, call light turned on for toileting assistance. A CNA responded their intent To Take 24 minutes after the resident turned on the call light. d. On 6/15/26 at 8:37 AM, call light turned on for toileting assistance. Staff D, CNA responded her intent To Take 27 minutes after the resident turned on the call light. During an interview on 6/18/2026 at 10:32 AM, Staff D, CNA, reported she would press take on her phone prior to answering call lights for residents. She explained that if she was helping another resident, she would not accept a call light for another resident. Staff D reported that if the call log identified it took her 27 minutes to take a call for Resident #7, then that would be accurate. Staff D reported that there were times it took a long time to get Resident #142 transferred because they needed two aides to transfer the resident. During an interview on 6/18/26 at 2:23 PM, the Director of Nursing (DON) reported being aware of staffing concerns. The DON reported Resident #160 had complained of being left on the toilet for long periods of time, but review of the call log revealed the longest staff had left the resident on the toilet was 20 minutes. The DON explained that she understood 20 minutes could feel like a long time, but they had a lot of other residents to take care of. The DON reported she had a staff person come to her and express concern over the heavy loads on the neighborhoods that Residents #160, #142 and #7 resided on. The DON reported she was looking at increasing staffing for all units by adding a float CNA for each area and explained they had an increase in acuity. The DON reported staffing concerns on the memory unit as well. Review of the facility's job description, titled CNA/Universal Worker, dated 2/20/26, revealed, in part, .Utilizes a resident centered approach based on resident centered principles to provide personal care and assistance with activities of daily living. The CNA/ Universal Worker provides each resident with routine daily nursing care and other desired services in accordance with the resident's assessment, choices, and care plan under the supervision of a licensed nurse to ensure the highest degree of quality of care is maintained at all times. 4. The MDS assessment dated [DATE], revealed Resident #8 had a BIMS score of 14 out of 15, which indicated intact cognition. Review of the Call Log for Resident #8 revealed: a. On 6/02/26 at 6:50 AM, call light turned on. A staff responded their intent To Take 52 minutes and 5 seconds after the resident turned on the call light. b. On 6/06/26 at 9:57 AM, call light turned on. A staff responded their intent To Take 52 minutes and 16 seconds after the resident turned on the call light. c. On 6/08/26 at 9:58 PM, call light turned on. A staff responded their intent To Take 52 minutes and 32 seconds after the resident turned on call light. d. On 6/09/26 at 2:37 PM, call light turned on. A staff responded their intent To Take 30 minutes and 12 seconds after the resident turned on the call light. e. On 6/11/26 at 10:00 AM, call light turned on. A staff responded their intent To Take 2 hours, 56 minutes, and 41 seconds after the resident turned on the call light. f. On 6/14/26 at 9:49 PM, call light turned on. A staff responded their intent To Take 25 minutes and 6 seconds after the resident turned on the call light. During an interview on 6/15/26 at 10:00 AM, Resident #8 stated it often could take a half hour or more for staff to answer call light when she pushes it for help. Resident #8 reported that long call light waits times happen at any time of the day depending on staffing available for the shift. 5. The MDS assessment dated [DATE], revealed Resident #23 had a BIMS score of 15 out of 15, which indicated intact cognition. During an interview on 6/15/26 at 9:29 AM, Resident #23 queried on staffing and Resident #23 stated they felt the facility short staffed on the weekends. Resident #23 stated she had sat over 15 minutes for someone to help when she was in the bathroom. Resident #23 stated she called the nurse's station after 15 minutes when staff did not come. Review of the Call Log for Resident #23 revealed: a. On 6/6/26 at 9:54 PM, call light turned on. A staff responded their intent To Take 35 minutes and 46 seconds after the resident turned on the call light. b. On 6/12/26 at 11:37 AM, call light turned on. A staff responded their intent To Take 44 minutes 28 seconds after the resident turned on the call light. 6. The MDS assessment dated [DATE], revealed Resident #122 had a BIMS score of 13 out of 15, which indicated intact cognition. During an interview on 6/15/26 at 2:38 PM, Resident #122 queried on call lights and Resident #122 stated sometimes she waited over a half an hour. Resident #122 stated she looked at the clock before she went to the bathroom and then looked at the clock after staff brought her out of the hospital. Review of the Call Log for Resident #122 revealed: a. On 6/3/26 at 5:21 PM, bed call light turned on. A staff responded their intent To Take 23 minutes after the resident turned on the call light. b. On 6/5/26 at 6:39 PM, bath call light turned on. A staff responded their intent To Take 1 hour, six minutes, and 45 seconds after the returned turned on the call light. c. On 6/6/26 at 5:15 PM, bath call light turned on. A staff responded their intent To Take 23 minutes after the resident turned on the call light. d. On 6/11/26 at 12:12 PM, bed call light turned on. A staff responded their intent To Take 52 minutes and 53 seconds after the resident turned on the call light. e. On 6/13/26 at 8:52 PM, bed call light turned on. A staff responded their intent To Take 39 minutes and 41 seconds after the resident turned on the call light. f. On 6/14/26 at 12:19 PM, bath call light turned on. A staff responded their intent To Take 22 minutes 15 seconds after the resident turned on the call light. g. On 6/14/26 at 10:10 PM, bed call light turned on. A staff responded their intent To Take 22 minutes and 59 seconds after the resident turned on the call light. During an interview on 6/18/26 at 10:34 AM, Staff L, CNA queried on the call lights and Staff L stated call lights could take over 15 minutes to take if the CNAs were with other residents in the room. Staff L stated their hall was pretty busy and if they had 2 assist residents, call lights could take longer. Staff L stated second shift had one the hall from 2:30 PM to 4:30 PM and then an aide came in for 5 hours, but a lot of residents wanted assisted into bed after 9:30 PM and if the resident was a 2 assist, Staff L would have to ask for assistance from the other hall and some residents staff could spend an hour in their room and that could make call light response longer. During an interview on 6/18/26 at 11:50 AM, Staff W, CNA queried on call lights and Staff W stated some of the halls don't have a second CNA come in until 5:00 PM and the hall could have a lot of call lights going off at once. Staff W stated a lot of residents come back from activities around 3:00 PM and all need to use the restroom and one aide for 16 people can be a lot especially if multiple call lights were going off.

Based on observation, staff interview, and facility policy review the facility failed to follow infection control procedures to prevent potential cross contamination during a blood draw procedure performed on 1 of 6 residents (Resident #17) reviewed for infection control, when the specimen drawn was placed on a clean dining room table. The facility also failed to prevent potential cross contamination during the laundry process in 1 of 10 units observed, when clean personal linens were placed on potentially contaminated public seating surfaces. The facility reported a census of 141 residents. Findings include:1. During an observation on 6/16/26 at 8:41 AM, Resident #17 sat at a dining room table with 2 other residents, the 3 residents continued to have a plate of breakfast set on the table in front of them. Staff S, Registered Nurse (RN), approached Resident #17 at the dining room table and collected blood specimen from Resident #17's left forearm. Staff S completed the blood draw from Resident #17, then set the vial containing the blood specimen on top of the dining room table without a barrier in place to prevent contamination of the clean surface. During an interview on 6/16/26 at 12:25 PM, Staff S confirmed performing a blood draw on Resident #17 on 6/16/26 at 8:41 AM for a Keppra (levetiracetam) level (measures the concentration of the anti-epileptic medication within the blood) as ordered by the provider. Staff S reported that Resident #17 doesn't mind having medications given or anything else done in the dining room. During an interview on 6/18/26 at 12:05 PM, Staff U, Infection Preventionist Nurse, revealed the expectation of nursing staff to place a barrier between clean surface and blood draw supplies to prevent the potential of cross contamination. During an interview on 6/18/26 at 2:51 PM, the Director of Nursing (DON), revealed the expectation of nursing staff to complete resident blood draw procedures in private area or in the resident's room and not in the common area or at the dining room table due to concern for resident infection control and preserving resident dignity. The DON revealed the expectation of nursing staff to place a barrier between clean surface and blood draw supplies to prevent the potential of cross contamination. Review of the facility policy titled, Specimen Collection Procedure, not dated, revealed the following Principle statement: To ensure accurate and reliable laboratory results, specimen collection adheres to specific principles, including using the correct collection method, proper identification of patient, aseptic technique, proper labeling, timely transport of specimens, and appropriate storage to maintain specimen integrity. 2. During an observation on 6/15/26 at 1:31 PM, a Certified Nursing Assistant (CNA) staff placed a laundry basket with a cloth fabric covering on top of a couch in a common area, located in the hallway outside of the laundry room and near the common area. The CNA folded the clean resident clothing and with no clean barrier on the couch, stacked the clean linen directly on the seat and armrest before returning the clothing to the basket and proceeding to deliver the laundry to resident rooms. During an observation on 6/17/26 at 12:21 PM, staff placed resident clothing in a laundry basket on top of the couch. Staff also hung shirts on hangers directly on the seat of the couch without a clean barrier. During an interview on 6/17/26 at 10:00 AM, Staff P, CNA, stated that staff on each unit wash and dry the resident's laundry and fold or hang clean clothing near the common area at the couch or kitchenette counter to provide resident supervision. During an interview on 6/17/26 at 3:20 PM, Staff R, RN Unit Manager, stated clean resident clothing should either be folded in the laundry room or taken to the resident room to be folded, hung, and put away. During an interview on 6/18/26 at 12:05 PM, Staff U, Infection Preventionist Nurse, revealed the expectation that staff either fold clean resident clothing in the laundry room or on top of a clean surface and not on a public couch without a barrier, to prevent contamination of clean linen.During an interview on 6/18/26 at 2:51 PM, the Director of Nursing (DON) revealed the expectation of staff to fold clean resident clothing on top of a clean surface to prevent contamination of clean linens. Review of the facility policy titled, Laundry and Linens dated 7/2025, revealed a Purpose section which declared To identify the process for laundry and linen handling. The Section titled, Personal Clothing instructed, in part: 1. Each household has on-site laundry facilities to minimize risk of lost or damaged resident clothing. 2. Resident clothing is washed with the facility provided and approved laundry agents. Resident laundry will be done in individual loads that are designated by baskets assigned to that room number. The basket will be placed on top or in front of the washer/dryer to designate that resident's laundry. For soiled clothing, the hopper may be used and the appropriate pretreatment laundering agents to remove visible debris. Staff should use good hand hygiene after handling soiled or dirty laundry. Staff should wear gloves and consider aprons or gowns when handling soiled or dirty laundry. Staff should use minimal agitation when handling soiled/dirty laundry to decrease contamination of the air. 3. Once laundry is thoroughly washed and dried it will be returned to the resident's room.

Based on record review, staff interviews, and the facility policy, the facility failed to have a resident's Iowa Physician Orders for Scope of Treatment (IPOST) and provider's orders on the electronic health record match for 1 of 2 residents reviewed for advanced directives (Resident #13). The facility reported a census of 141 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #13 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition severely impaired. The MDS indicated medical diagnosis for vascular dementia, unspecified severity, with anxiety. The Review of the signed IPOST dated [DATE] indicated Cardiopulmonary Resuscitation (CPR). The Review of the electronic health record (EHR) for Physician Orders indicated Do Not Resuscitate dated [DATE]. During an interview on [DATE] at 8:20 AM, Staff F, Registered Nurse (RN) queried where advanced directives or IPOST were located and Staff F pulled down a binder in the nurse's station and could not locate a paper form for Resident #13. Staff F stated she would speak to the Unit Manager when the Unit Manager came in. During an interview on [DATE] at 1:45 PM, Staff G, RN asked where she looked for advanced directives and Staff G stated to click on the resident's picture in the EMR and demographics would come up and then Staff G could see the advanced directives. Staff G stated she tried to think if Resident #13 had an IPOST, but Staff G knew Resident #13 was a DNR. Staff G stated the previous EMR would indicate if Resident #13 had an IPOST and Staff G would have to look in the binder because the facility tried to make sure everyone had an IPOST. During an interview on [DATE] at 3:35 PM, Staff H, Unit Manager stated she didn't realize Resident #13 had an IPOST before coming to the facility and the family didn't provide the IPOST. Staff H stated the IPOST was scanned into Resident #13 record a year and half ago. Staff H queried on the process for IPOST and Staff H stated the facility usually asked the family if they wanted one and completing an IPOST was not something the facility automatically completed. Staff H stated Resident #13 admission documentation was where Staff H found Resident #13 was a DNR. During an interview on [DATE] at 4:07 PM, Staff I, RN queried where the resident's advanced directives were located and Staff I stated he was not really sure. Staff I stated some where located in the charting room. Staff I informed Resident #13 did not have advanced directives in the binder and Staff I stated he would speak to the family to see what they wanted. Staff I informed the IPOST in the EMR was CPR and the order indicated DNR and Staff I stated he would speak to the Unit Manager to make sure the orders matched. During an interview on [DATE] at 1:24 PM, Staff H stated looking for resident's IPOST was not something she would go looking for and Social Services would scan them in, if a resident had one. Staff H stated she just went through the papers given to her when a resident admitted . During an interview on [DATE] at 2:15 PM, the Director of Nursing (DON) queried on Resident #13 IPOST indicated CPR and Resident #13 orders indicated DNR and the DON stated a resident didn't have to have an IPOST and in this situation how the facility came to the order of a DNR and who had the conversation with the family about the advance directives. The Facility Advanced Directives Policy dated 10/2024 revealed: a. At the time of admission, the resident will be given written information regarding resident rights and Advance Directives. If there is an Advance Directive already in place, the resident will be requested to furnish the facility with a copy. 1. If the resident does not have an Advance Directive but wishes to make one Social Services will assist with the notarization process. 2. If the resident is unable to supply a copy of their Advance Directive, Social Services will follow-up with the family until a copy is obtained for the record.

Based on observation, staff interview, and clinical record review, the facility failed to provide Resident #17 with privacy during a blood draw when procedure was performed at dining room table during a meal with other residents present for 1 of 3 residents (Resident #17) reviewed for dignity. The facility reported a census of 141 residents.Findings include:Review of the Minimum Data Set (MDS) Assessment, dated 5/26/26, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. The list of diagnoses included cerebrovascular accident ( stroke), seizure disorder, and anxiety disorder. Review of Resident #17's Active Order list, dated 6/18/26, revealed a laboratory order for routine levetiracetam (brand name Keppra) level (measures the concentration of the anti-epileptic medication within the blood to ensure at a therapeutic level), started on 6/05/26, with instructions for the nurse to collect blood specimen. During an observation on 6/16/26 at 8:41 AM, Resident #17 sat at a dining room table with 2 other residents, the 3 residents continued to have a plate of breakfast set on the table in front of them. Staff S, Registered Nurse (RN), approached Resident #17 at the dining room table and collected blood specimen from Resident #17's left forearm. Staff S completed the blood draw from Resident #17, then set the vial containing the blood specimen on top of the dining room table without a barrier in place to prevent contamination of the clean surface. During an interview on 6/16/26 at 12:25 PM, Staff S, RN stated she did perform a blood draw on Resident #17 on 6/16/26 at 8:41 AM for a Keppra level. Staff S reported that Resident #17 doesn't mind having medications given or anything else done in the dining room. During an interview on 6/17/26 at 9:42 AM, Staff T, RN, stated blood draws would be done in a resident's room for maintaining resident dignity. During an interview on 6/17/26 at 3:20 PM, Staff R, RN Unit Manager, stated that blood draw should not be completed at the dining room table during meals because no one would want to see that while they're eating. During an interview on 6/18/26 at 2:51 PM, the Director of Nursing (DON), revealed the expectation of nursing staff to complete resident blood draw procedures in private area or in the resident's room and not in the common area or at the dining room table due to concern for resident infection control and preserving resident dignity.

Based on clinical record review, policy review, and staff interview, the facility failed to complete reviews for gradual dose reduction for residents prescribed psychotropic medications, failed to attempt non-pharmacological interventions prior to the administration of as needed anti-anxiety medication, and failed to ensure as needed psychotropic medication orders did not exceed 14 days without a physician review for 3 of 6 residents (Resident#5, Resident #13 and Resident #109) reviewed for unnecessary medications. The facility reported a census of 141 residents. Findings included: Based on clinical record review, policy review, and staff interview, the facility failed to complete reviews for gradual dose reduction for residents prescribed psychotropic medications, failed to attempt non-pharmacological interventions prior to the administration of as needed anti-anxiety medication, and failed to ensure as needed anti-anxiety medication orders did not exceed 14 days for 3 of 6 residents (Resident#5, Resident #13 and Resident #109) reviewed for unnecessary medications. The facility reported a census of 141 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool dated 4/29/26, list of diagnoses for Resident #5 included anxiety, depression, and delirium due to a known condition. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 6 out of 15, indicating severely impaired cognition. The MDS documented Resident #5 prescribed medications in the following high risk drug classes: antipsychotic, antianxiety, and antidepressants. A 7/15/23 Care Plan entry stated the resident would not exhibit side effects resulting from psychotropic medication use. A 6/11/25 Family Practice Office/Clinic Note documented the resident took the following medications: lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) twice daily and sertraline (an antidepressant) 50 mg daily. A 5/27/26 Behavioral Health Office/Clinic Note documented the resident continued to take lorazepam 0.5 mg twice daily and sertraline 50 mg daily. The facility lacked documentation of a gradual dose reduction (GDR, the tapering of the dose to determine if symptoms, conditions or risks can be managed by a lower dose or the medication possibility discontinued) carried out during the time period of 6/11/25 to 5/27/26 and lacked documentation of a clinical rationale as to why the GDR was contraindicated. On 6/17/26 at 10:40 a.m., Staff M, Registered Nurse (RN) Manager, stated the facility did not have GDR information because they increased the resident's medications. When queried regarding a GDR for the other psychotropic medications which did not have an increase, she stated the last one she located was from 2024. On 6/17/26 at 3:30 p.m. via email, the Administrator stated the facility did not have a policy related to GDRs. 2. The MDS assessment dated [DATE], revealed Resident #109 did not have a BIMS completed. The list of diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, anxiety disorder. The MDS documented Resident #109 prescribed medications in the following high risk drug classes: antipsychotic and antidepressants. Review of Resident #109's Care Plan dated 5/4/26, revealed a Focus area for psychotropic use. Interventions included observing and monitor changes in mood, behavior, or mental status and document any problems; and provide medications as ordered and monitor their effectiveness. Resident #13's Active orders as of 6/18/26 included: quetiapine (brand name Seroquel) 25 mg – 1 tablet TID (three times a day) PRN (as needed) dated 5/19/26. No end dated indicated. The June 2026 Medication Administration Record (MAR) Seroquel PRN given on the following dates with no interventions documented under psychotropic medication behavior: 6/9 at 3:59 PM, 6/10 at 10:07 AM, 6/11 at 9:47 AM and 5:49 PM, 6/12 at 8:44 AM and 3:25 PM, 6/13 at 11:39 AM, 6/14 at 6:16 AM and 1:32 PM, 6/15 at 12:25 AM, 6/16 at 9:44 AM, and 6/17 at 12:00 PM During an interview on 6/18/26 at 1:04 PM, Staff G, Registered Nurse (RN) stated the facility did mood assessments twice daily and before a PRN administered, the nurse would document interventions. During an interview on 6/18/26 at 1:10 PM, Staff H, RN Unit Manager queried on the interventions prior to PRN medication use and Staff H stated the interventions needed documented either in the progress notes or under the flowsheets, and whether or not the staff were doing it was another story. During an interview on 6/18/26 at 1:30 PM, Staff F, RN queried about giving a PRN and Staff F stated she would document the interventions tried before administering the PRN medication under progress notes. Staff F stated staff should be using at least 3 interventions before giving a PRN and then documenting the interventions. During an interview on 6/18/26 at 2:11 PM, the Director of Nursing (DON) queried on GDRs and the DON stated the facility should have the pharmacy do reviews and the pharmacist should recommend GDRs to the provider and the provider needed to follow up on the request and document why they recommended the GDR or not. During an interview on 6/18/26 at 2:20 PM, the DON stated she didn't have any reason for the quetiapine to not be a 14-day order. The DON confirmed staff should document the interventions tried before giving a PRN medications. 3. Resident #13's MDS assessment dated [DATE], diagnoses list included vascular dementia, unspecified severity, with anxiety. The BIMS score of 5 out of 15 indicated a severe cognitive impairment. The MDS documented Resident #13 prescribed medications in the following high risk drug classes: antipsychotic, antianxiety, and antidepressants. The Care Plan revealed a Focus area dated 5/22/26 for psychotropic medication use. Review of Resident #13 Active Orders revealed order for amitriptyline 10 mg at bedtime dated 5/22/25. The facility lacked documentation for any GDR for the amitriptyline. During an interview on 6/18/26 at 2:18 PM, the DON stated Resident #13 should have had a GDR completed.

Based on clinical record review, facility policy review, resident and staff interviews, the facility to ensure only licensed nursing staff applied a prescribed topical medication for 1 of 1 resident (Resident #23) reviewed for professional standards. The facility reported a census of 141 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 with intact cognition based on a Brief Interview for Mental Status (BIMS) score of 15 out of 15. m, which indicated cognition intact. Review of the electronic health record (EHR) revealed an order for clotrimazole (lotrimin) 1% cream topical, 2 times daily- administration instructions: topically to groin and breast folds for redness ordered on 6/6/26 and discontinued on 6/17/26During an interview on 6/17/26 at 11:57 AM, Resident #23 stated the Certified Nurse Assistants (CNA) put a prescribed cream on her and then takes the cream back to the nurses to put back in the medication cart. During an interview on 6/18/26 at 9:55 AM, Staff J, CNA queried if they had ever applied prescribed cream to Resident #23 and Staff J stated yes. Staff J explained the nurse gave them a cup of cream and the Staff J had applied it under Resident #13 folds. Staff J stated they applied the cream in the mornings and also on the night shift. During an interview on 6/18/26 at 10:02 AM, Staff K, Registered Nurse queried if the CNA apply prescribed cream to the residents and Staff K stated are supposed to apply prescribed cream, but sometimes to get things done, CAN's occasionally helped with it. Staff K queried if Staff K ever asked a CNA to apply a prescribed cream and they confirmed they had. During an interview on 6/18/26 at 10:34 AM, Staff L, CNA queried if they ever applied a prescribed cream to Resident #23 and Staff L stated yes, an antifungal cream that the nurse provided. During an interview on 6/18/26 at 11:06 AM Staff V, Unit Manager queried if CNA can apply prescribed creams to the residents and Staff V stated no, the nurse should be applying prescribed creams. During an interview on 6/18/26 at 2:11, the Director of Nursing (DON) confirmed the CNAs should not be applying prescribed ointments on the resident. The DON stated the CNAs should notify the nurse when the resident was ready for the cream. Review of the facility CNA/Universal Worker Job Description revised on 02/20/26, revealed the essential function for personal care: Bathing and dressing residents as care planned and as needed ensuring that the residents are properly and comfortably clothed. Combs hair, shaves resident, trims nails, and assists with personal and dental hygiene.Review of the facility LPN (Licensed Practical Nurse) Job Description dated 01/06/25, revealed the following essential functions: Administer prescribed medications adhering to the six rights of medication administration, IV fluids, enteral feedings, monitoring their effectiveness, and addressing needs.Review of the facility RN Job Description dated 3/30/26, revealed the following essential functions: Administer prescribed medications adhering to the six rights of medication administration, IV fluids, enteral feedings, monitoring their effectiveness, and addressing needs.

Based on observation, clinical record review and staff interview, the facility failed to maintain an environment free from accident and hazards by ensuring staff safely pushed wheelchairs with footrests in place during the transport of 2 of 5 residents (Resident #10 and Resident #138) reviewed for safety. The facility reported a census of 141 residents. Findings include:1. Review of Resident #138's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating a moderate cognitive impairment. The list of diagnoses included Parkinson's disease, anxiety disorder, depression, and chronic pain syndrome. The MDS indicated Resident #138 had one side lower extremity impairment, utilized a walker and wheelchair for mobility and independently propelled the wheelchair. The MDS identified the resident had 2 or more falls without injury since the previous assessment.Review of Resident #138's Plan of Care initiated on 3/13/26, revealed a Plan for Falls with the Outcome of I will not sustain any bony injury from a fall. The Intervention directed Follow fall prevention interventions written on Care Plan and update PRN (as needed) after a fall.During an observation on 6/16/26 at 8:53 AM, Staff N, Certified Nursing Assistant (CNA) pushed Resident #138's in her wheelchair, with no foot pedals attached from the resident's room to the dining room, and then from the dining room into the common living area. Resident #138 walked her feet long the floor while being pushed. 2. Review of Resident #10's MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. The list of diagnoses included osteoarthritis, general anxiety disorder, depression, and abnormalities of gait and mobility. The MDS indicated Resident #10 had impairment on both sides of upper and lower extremities, utilized a walker and wheelchair for mobility independently propelled the wheelchair. The MDS identified the resident had had no falls since the previous assessment.Review of Resident #10's Plan of Care, the Care Plan initiated on 2/13/24, revealed a Plan for Falls with the Outcome come of I will not sustain any bony injury from a fall. Intervention instructed staff to follow fall prevention interventions written on Care Plan and update PRN after a fall and to refer to mobility in fall intervention Care Plan.During an observation on 6/17/26 at 1:00 PM, Staff O, CNA, pushed Resident #10's wheelchair, without foot pedals applied, from the dining room area to Resident #10's room, while Resident #10 held her legs up above the ground. During an interview on 6/17/26 at 10:00 AM, Staff P, CNA, stated that staff are expected to apply foot pedals to wheelchairs and ensure a resident's feet are placed on the foot pedals prior to transporting residents in a wheelchair to prevent injuries.During an interview on 6/18/26 at 11:55 AM, Staff Q, CNA, stated that staff are expected to apply foot pedals to wheelchairs prior to pushing the chair because the resident could fall out.During an interview on 6/17/26 at 3:20 PM, Staff R, Registered Nurse (RN) Unit Manager, stated the expectation was for staff to ensure foot pedals are applied to wheelchairs and the resident's feet placed on foot pedals prior to transportation in a wheelchair.During an interview on 6/18/26 at 2:51 PM, the Director of Nursing (DON), revealed the expectation of staff to apply foot pedals to resident wheelchairs prior to transportation, and stated this should be done anytime a wheelchair is being pushed.

Based on clinical record review, review of facility menu, and staff interviews, the facility failed to assess and intervene after a resident coughed, and then vomited during evening meal. On 12/5/25 at 5:25 PM, Resident #1 coughed and then reportedly vomited during a meal, which consisted of barbeque pork on a bun, pasta salad, buttered corn, and white cake. Another resident sitting at the table with Resident #1 reported to nursing staff Resident #1 vomited. The nursing staff checked Resident #1 and noted labored respirations, and described her as choking. Staff assisted Resident #1 outside of the dining room area while continuing to instruct her to spit out sputum. Nursing staff then assist Resident #1 to her room to use the bathroom, prepared her for bed, applied CPAP (Continuous Positive Airway Pressure, a medical device used to treat sleep apnea by continuous pressurized air through a mask to keep airways open during sleep) connected to an oxygen concentrator. Nursing staff elevated the head of Resident #1's bed and left her to sleep. At 10:30 PM, a Certified Nursing Assistant (CNA) found Resident #1 in distress. Resident #1 assessed as having audible crackles, elevated blood pressure and an oxygen saturation of 34% (normal is 95% to 100%, below 90% considered to be a level that requires medical attention). Resident #1 passed away before emergency services arrived. The facility reported census was 141.The State Agency informed the facility an Immediate Jeopardy (IJ) identified on December 11, 2025 at 5:52 PM. The IJ began on December 5, 2025 at approximately 5:25 PM. The State Agency confirmed removal of the immediacy effective December 12, 2025 by the facility implementation of the following actions: Immediate Response:a. Following the event, the responsible employee was immediately suspending pending investigation.b. Employees and residents were interviewed between December 5, 2025 and December 9, 2025.c. Appropriate administrative action was taken with the responsible based on the outcome of the investigation.Corrective Measures Implemented:a. Choking/Aspiration Response Education: Nursing leadership will conduct an immediate review of the expected choking/aspiration response, including assessment, documentation, and physician notification, with all licensed nurses on December 12, 2025.1. Staff not present during this session will receive re-education prior to their next scheduled shift.2. Training will include a detailed handout outlining response steps and the location of emergency equipment (e.g., suction machine, oxygen concentrators).3. All nurses will sign an education log to verify completion.b. Resource Reinforcement: [NAME] Center utilizes [NAME] Solutions for evidence-based nursing procedures, including choking management. A reminder flyer was posted in all staff break rooms on December 12, 2025, reinforcing the expectation that staff reference these resources regularly to ensure compliance with best practices.c. Policy Review: A comprehensive review of all current applicable policies related to choking and aspiration response was completed on December 12, 2025, to confirm alignment with regulatory standards and organizational protocols.Preventive and Continuous Improvement Actions:a. Enhanced Orientation: Effective immediately, all new nursing staff will receive targeted training on managing high-risk clinical events (e.g., falls, choking episodes), including notification protocols and assessment procedures.b. Process Integration: Orientation checklists were updated on December 12, 2025 to include these requirements, ensuring consistent onboarding and competency validation.c. Ongoing Monitoring: Compliance with these training and procedural standards will be monitored through quarterly audits and annual skills validation, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee.d. Continuous Review: Policies and procedures related to emergency response will be reviewed biennially to ensure alignment with best practices and regulatory requirements. Date of Compliance: December 12, 2025.The scope and severity lowered from a J to G at the time of the survey. Findings include: 1. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Mental Status (BIMS) score of 3 of 15, which indicated a severe cognitive impairment. The MDS indicated Resident #1 speech unclear, and usually understood by others. The MDS revealed Resident #1 required set up assistance to eat, and partial/moderate assistance to move from a sit to stand position, transfer from a chair/bed to chair, and supervision or touch assist to walk 10 feet. The MDS list of diagnoses included Down syndrome, gastroesophageal reflux disease, and sleep apnea. Review of a Nutrition Note, dated 5/27/25 revealed Resident #1 remains independent in dining after set-up, with no concerns noted in chewing or swallowing. Diet: General. Assessment, in part: Nutritional risk with dementia and intellectual disability with decreased physical function.2. Review of the MDS, dated [DATE], revealed Resident #2 had a BIMS score of 15 out of 15, which indicated intact cognition. The MDS indicated Resident #2 speech clear, makes self-understood others, and understands others. 3. Review of a Facility Reported Incident, submitted on 12/06/25 revealed resident [Resident #1] was eating supper and began to cough. Resident tablemate [Resident #2] reported that she thought resident was choking. Nurse assessed and asked for assistance to help take [name redacted, Resident #1] back to her room. Ambulated back to room with Ax2. Stopped to take a break. Then further assisted to bathroom. CNA stayed with resident to provide cares and resident continued to cough with copious amounts of sputum coming up. Resident was talking in between coughing. Unable to take drinks of water and swallow. Nurse instructed to lay resident down in bed with HOB (head of bed) elevated. Nurse put CPAP on. CNA rounded on resident later and noted labored breathing, throw up in her CPAP mask, pale, and lips were blue. Called for nurse to come to bedside. CNA noted pink mucus coming from nose after nurse removed CPAP. Second nurse called to bedside for assessment, VS taken and noted O2 sats 34%. Rechecked on toe and it read 81%. House supervisor notified. At bedside and instructed to send pt (patient) out now as fingers were blue and not responsive. Provider notified and request to send out. 911 called, POA called. Resident passed prior to leaving the facility.Review of the menu served on the evening of 12/5/25 revealed barbeque pork on a bun, pasta salad, buttered corn, white cake with frosting and fruit cocktail were the core items served that evening.During an interview on 2/10/25 at 8:10 AM, Resident #2 stated on the evening of 12/5/25 she was in the dining room eating supper, and shared a table with Resident #1 Resident #2 stated Resident #1 began coughing and turned red in the face. She stated Resident #1 spit up some, but continued to struggle. Resident #2 stated she alerted the nurse and Resident #1 was eventually removed from the dining room. During an interview on 12/10/25 at 4:10 PM, Staff A, Licensed Practical Nurse, stated on the evening of 12/5/25 around 5:25 PM she and two other aides (Staff B, CNA and Staff C, CNA) were sitting at the bar as residents finished their meals. Staff A stated Resident #2, approached the staff and stated Resident #1 was vomiting. Staff A stated she went to check on Resident #1 and noted her respirations as labored and described her as choking. Staff A stated it seemed like water had gone down the wrong pipe and she heard audible wheezing. Staff A, LPN stated she got Staff C, CNA to help her get Resident #1 standing and with her gait belt and wheel walker, ambulated with her to recliner just outside of the dining room area as she continued to instruct Resident #1 to spit out the sputum. Resident #1 was able to evacuate what seemed like a lot of clear sputum. Staff A stated a few moments later, she and Staff B, CNA assisted Resident #1 back to her room and onto the toilet. Staff A continued to instruct Resident #1 to spit out was in her mouth. Staff A stated Resident #1 was talking and seemed fine at this point. When asked whether Staff A completed any assessments like listening for lung sounds, vital signs or checking oxygen levels, Staff A teared up and stated no. Staff A, LPN stated Staff B, CNA remained with Resident #1 and changed her brief and clothing as she prepared her for bed. Staff A stated she placed Resident #1's CPAP mask over her mouth and nose and turned on the CPAP machine. Staff A stated Resident #1 also gets oxygen supplement via her CPAP and noted the concentrator was set at 2 liters per minute. Staff A indicated Resident #1's head of bed was elevated to 40 degrees and music turned on. She later checked on Resident #1 and claimed she was sleeping with no respiratory distress. Staff A reported tt around 10:25 PM Staff B, CNA went to check on Resident #1 and found her with labored breathing and hyperventilating. Staff B alerted Staff A. The CPAP mask was removed and noted pink tinged mucous in the mask and coming from her nose. Staff A stated she left the room to get Staff D, Registered Nurse (RN). Staff D went into the room and assessed Resident #1, noting elevated blood pressure, an oxygen saturation rate at 34% and her fingers were blue. Staff D indicated Resident #1 needed to be sent out. Staff A, LPN stated she alerted their on call nurse practitioner with potential aspiration. Staff A worked on getting orders and notifying family, while Staff D, RN and the house supervisor Staff E, RN and House Supervisor attended to Resident #1. Before arrangements could be made to send Resident #1 out, Staff E, indicated Resident #1 had passed.During an interview on 12/10/25 at 9:10 AM Staff B, CNA, stated on the evening of 12/5/25 at around 5:45 PM to 6:00 PM she, Staff A, LPN and Staff C, CNA were sitting at the bar area following supper as residents finished their meal and conversed with peers. As one resident passed by, he stated Resident #2, was concerned Resident #1, was choking as she kept coughing and wanted the nurse to check on her. Staff B recalled Staff A, LPN stated okay, but never left to check on the resident. Staff B stated about 10 minutes later, Resident #2 propelled herself to the bar area and stated she thought Resident #1 was choking. Staff A, LPN left to check on Resident #1 and then hollered for someone to help her. Staff C, CNA volunteered helping Staff A stand Resident #1 and Staff A escorted Resident #1 with her wheeled walker and gait belt towards her bedroom, but stopped at the recliner in the hall and allowed Resident #1 to sit. Staff B stated moments later, Staff A, LPN asked her to help Resident #1 on to her room. Staff B stated as she Resident #1 to stand, Resident #1 stood and slumped over her wheel walker indicating she was able to stand and ambulated with assistance to her room. Staff B stated they got Resident #1 to her bathroom toilet and were encouraging her to spit up what was in her air passage. Staff B stated this whole time Resident #1 was struggling to get whatever was in her throat up. Staff B stated we would take 8-10 rest breaks. Staff B stated she had prepared getting Resident #1's belongings out for bed, but she remained on the toilet choking and coughing and at one point seemed like she was going to vomit. Staff A, LPN left the room and returned 2-5 minutes later with her evening medications. Staff A placed the pills in Resident #1's mouth and gave her some water, but Resident #1 continued to cough and gag, eventually spitting out the medications. Staff A, LPN again left, this time returning with a nausea medication. Resident #1 began chewing that medication, eventually spitting it out. Staff A then asked her (Staff B, CNA) to get Resident #1 into bed. Staff B stated she questioned in her head whether it as a good idea putting her in bed when she was still coughing, but dismissed it as Staff A, LPN was the charge nurse. Staff B stated they got Resident #1 up and assisted her to her bed. Staff B stated she lifted and placed Resident #1 into bed and elevated her head of bed at 40 degrees. Resident #1 still sounded crackly. Staff A, LPN then placed her CPAP mask on noting maybe this will help. Staff B stated she felt uneasy as no vital signs, oxygen saturation levels or lung sound assessments were conducted by Staff A to this point. Staff B, CNA reported at 9:30 PM, Staff C, CNA left for the evening and Staff B stated she started working on her charting by 9:45 PM Staff B stated at around 10:00 PM to 10:15 PM Staff A, LPN was giving shift change report to Staff E, RN and at 10:20 PM Staff B suggested to Staff A that she probably should call Resident #1's family, while Staff B went to check on Resident #1. Upon entering Resident #1's room she could hear and see labored breathing, pale face and blue lips. Staff B stated she left the room to inform Staff A, LPN and returned to the room. Staff A entered the room and removed the CPAP mask. The mask had a small amount of sputum, emesis in it. Staff A again left the room. Resident #1 remained alert but compromised. Staff D, RN entered the room and brought the vitals machine and stethoscope with her. Staff B reported Resident #1 had been incontinent of bowel which was unusual for her. Staff B stated she cleaned Resident #1 up and assisted Staff D, RN with sitting her upright so Staff D could listen to her lungs and take vital signs. Staff D asked if Staff A, LPN had checked Resident #1's lungs, vital signs or oxygen levels. Staff B stated no. Staff B stated she observed vitas taken by Staff D, noting an elevated blood pressure and oxygen level at 30%. A different oximeter was brought into the room and wouldn't register an oxygen level. Staff B, CNA stated she was upset and gave her shift change report. Staff B stated as she checked residents at shift change, Resident #1 appeared jaundice. Staff F, RN was in the room and said oh my God. Staff B, CNA stated as she finished rounds, she heard someone say Resident #1 had passed. Staff B stated the only time she checked on or had contact with Resident #1 was when she put her into bed at 6:00 PM and when she checked on her at 10:30 PM at the end of her shift.During an interview on 12/11/25 at 3:22 PM Staff C, CNA stated on the afternoon of 12/5/25 at 5:25 PM, she, Staff A, LPN and Staff B, CNA were sitting in the dining room area when Resident #2 informed them that Resident #1 might be choking as she keeps coughing. Staff A checked on her and stated she was talking and fine. A few minutes later Staff A, LPN requested help with getting Resident #1 to her room. Staff C assisted and they got Resident #1 to a recliner just outside of her room. Resident #1 was spitting out mucous. Staff C, CNA stated she continued assisting other residents and that was the last time she had any involvement or contact with Resident #1.During an interview on 12/11/25 at 2:25 PM Staff D, RN stated on 12/5/25 she was working the 2:00 PM to 11:30 PM shift on [name of unit redacted]. At around 10:25 PM she was summoned to [name of unit redacted] by Staff A, LPN who stated she had an emergency involving Resident #1. Staff D immediately responded to Resident #1's room as Staff A proceeded to the nurse's station to make notifications. Staff D, RN stated upon entering the room she could hear crackling from Resident #1's lungs. Staff B, CNA was present. Staff D started doing a lung assessment and taking vital signs. Blood pressure was 140/101, respirations 20 and oxygen saturation at 34%. Staff D stated she elevated Resident #1's head and placed her CPAP mask back on as she also was getting supplemental oxygen through the mask. Staff D, RN stated Resident #1 was alert, but in distress. Staff D stated she checked the O2 saturation on her toes and it was 84%. Staff D stated it all happened quickly, but she stepped out a moment and upon returning, Resident #1 was ashen and without respirations. She called in Staff E, RN and House Supervisor and together they listened for lung sounds, noted none and pronounced her as passing. During an interview on 12/10/25 at 4:30 PM, Staff E, RN and House Supervisor, stated on the evening of 12/5/25 after 9:30 PM she was doing rounds and upon entering the [name of unit redacted] unit, Staff A, LPN reported Resident #1 had choked at supper. Staff E questioned whether the Heimlich was used and Staff A stated no and that Resident #1 was encouraged to spit out the mucous and was okay after that. Staff E, RN asked if Staff A, LPN had completed any assessments per protocol and she stated no. Staff E stated she did not check on the resident as she thought the resident was stable. Sometime after 10:00 PM Staff D, RN called her and stated she needed to come to the [name of unit redacted] unit as Resident #1 was not doing well. Upon arriving Staff A, LPN was at the computer which had Resident #1's vital signs. The oxygen was too low. Staff E, RN entered Resident #1's room where Staff B, CNA and Staff D, RN were cleaning resident up in preparation for her being transported to the hospital. Resident #1's right hand was blue along the edges and lung sounds with rattles. Before the arrangements could be made to send her out, Resident #1 passed.

Based on clinical record review, resident family interview, staff interviews, and the facility policy, the facility failed to ensure the fall intervention of a bed alarm worked properly for 1 of 3 residents reviewed for falls (Resident #1). The facility reported a census of 146 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS indicated resident required substantial/maximal assistance with walking 10 feet, lying to sitting on the side of the bed, and sitting to standing. The MDS revealed resident used an indwelling catheter and always continent of bowel. The MDS indicated medical diagnoses for other neurological conditions; encounter for surgical aftercare following surgery on the nervous system; and hemiplegia. The MDS indicated resident fell once since admission with no injury. The MDS indicated resident took opioids and used bed and chair alarms. The Care Plan revealed a Focus area dated 10/22/25 for Cognitive Loss. The intervention (no date indicated) revealed bed/chair notification to assist staff with awareness of resident needs. The Care Plan revealed a Focus area dated 10/22/25 for Falls. The interventions (no date identified) revealed evaluate assistive devices for strength and safety; evaluate routine and patterns to assist at times needed; and intervene for unsafe behaviors effecting fall risk. 'review of the Fall Interventions Plan dated 10/23/25 revealed the following selected interventions:a. 10/12/25: frequent regular rounding b. 10/20/25: routine toileting with roundingc. 10/20/25: bed alarm evaluated. Batteries replaced, set to audible. Signs posted to call for assist. d. 10/23/25: room change- move closer to nursing med carts/dining room. e. No date identified: seizure precautionsf. No date identified: chair/bed alarms for notification of resident need. Review of the Progress Note dated 10/17/25 at 12:09 PM, revealed patient continues on skilled services PT/OT (Physical Therapy/Occupational Therapy) for meningioma. She transfers 1 assist with walker. WTD (Walk to Dine). Reports 1/10 pain to surgical site to head. Patient received scheduled Tylenol this morning. Patient know to get up on. She needs constant reminders. Bed and chair alarm in use. Call light within reach. Patient straight cathed using sterile technique with 550 ml of urine out. Patient tolerated procedure well. Review of the Post Fall Evaluation dated 10/20/25 at 3:20 AM revealed the following: a. Oriented to self; not oriented to situation or time b. Able to bear weight and no change from their usual ROM or weight bearingc. No apparent injury; no treatment neededd. Neurological Evaluation: pupils are equal and reactive to lighte. Mechanism of Fall: 1. Location of fall: resident bathroom [ROOM NUMBER]. Description of Fall activity: unknown, found on floor 3. Bed alarm in place- yes; alarm sounded- no 4. Resident statement related to fall- resident asked why she got up unassisted and she stated, I don't know. I just want to get back to bed. 5. Fall unwitnessed. 6. First responder statement related to unwitnessed fall: Certified Nurse Aide (CNA) reported hearing someone yell while he was in the hallway. Patient was found sitting on bathroom floor leaning against the wall. Patient was on the right side of the toilet with leg extended out. Front Wheeled [NAME] (FWW) was in front of the toilet. She did not call for assistance before ambulant in room. Patient. denied hitting head. 7. Patient. educated on the importance of safety and calling for assistance. The Fall Scene Investigation Report (no date indicated) revealed Staff B, Registered Nurse (RN)a. Re-creation of last 3 hours before fall: Patient was last seen lying in bed approximately 3:00 AM, CNA (Certified Nurse Aide) was making rounds and heard someone yell. He found patient sitting on BR (bathroom) floor by toilet with legs extended out. Patient had disconnected/pulled cath apart. Patient stated she didn't know why she was in BR, but before returning to bed she stated she needed to have a BM (bowel movement). No apparent injury. Later (complained) back pain approximately 5:00 AM. b. Fall Huddle: What appears to be the initial root cause of the fall? Patient cognitive state c. Describe new intervention put in place to prevent future falls: replace bed alarm Review if the final report of Computed Radiography (CR) hip 2 or 3 View right (RT) with or without pelvis, dated 10/20/25 at 2:37 PM revealed: a. Reason for exam: painb. Clinical history: fall with hip and low back painc. Findings: Bone and joints: Osteopenia. No acute fracture or malalignment. Mild degenerative changes of the bilateral hips and lower lumbar spine. d. Soft tissue: postsurgical changes are seen projecting over the lumbar spine. Sacral stimulator is seen on the right atherosclerosis. e. Impression: no acute findings. Review of the final report of the CR Lumbar Spine AP (anterior/posterior) LAT (Lateral), dated 10/20/25 at 2:49 PM revealed the following:a. Reason for exam: painb. Report: c. Indications: fall today, low back paind. Technique: AP, lateral and spot lateral views of the lumbar spinee. Comparison : prior exam dated 1/17/2019f. Findings: Diffuse decreased bony mineralization. There is a new compression fracture of L1 which was not present on 2019. However still remains age indeterminate given the timeframe since prior exam. However given the history and back pain this could be acute. There is less than 25% height loss seen. No other compression deformities. There is a levoconvex degenerative curvature the thoracolumbar spine. There is endplate degenerative change throughout the lumbar spine with associated disc space narrowing at L5-S1. There is a facet arthroplasty throughout the lumbar spine. Cholecystectomy clips. Additional surgical clips in the lower lumbar prevertebral space. There is nerve stimulator device in the sacrum. g. Impression: Age-indeterminate compression fracture of L1 with less than 25% height loss. Decreased bony mineralization and degenerative changes as above. During an interview on 10/29/25 at 9:52 AM, Resident #1's husband stated Resident #1 had an bed alarms on her bed and he saw them every day before he left. The husband stated Resident #1 had a fall on 10/20/25 in the middle of the night and was a huge setback for Resident #1. During an interview on 10/30/25 at 10:14 AM, Staff A, CNA queried on the fall with Resident #1 and he stated he didn't hear the bed alarm go off and it didn't alarm on his phone. Staff A stated he heard a sound and ran up to the nurse's station first and then back down the hallway to Resident #1 room and found Resident #1 on the floor in her bathroom. Staff A stated he found Resident #1 found lying on her side and he called the nurse. The nurse assessed Resident #1, and he recalled Resident #1 denied pain. Staff A stated he was glad he heard the shout, otherwise he wouldn't have known Resident #1 fell. Staff A stated he relied on the bed alarms to alert him when someone was getting up. Staff A stated Resident #1 was in bed when he started his shift. Staff A stated he checked on Resident #1 an hour before the fall. Staff A stated the nurse assessed the bed alarm to see if it was working.During an interview on 10/30/25 at 10:59 AM, the Physician Assistant (PA) queried on the results of the x-ray and the PA stated in all of his years of practice if the Radiologist deemed an indeterminate date of a fracture, the fracture was old. The PA stated the pain Resident #1 had experienced could have been from aggravating the old fracture. The PA stated if the Radiologist thought it was acute, they would have documented acute fracture. The PA stated he could only go by what the Radiologist documented. During the interview on 10/30/25 at 12:12 PM, the Director of Nursing (DON) queried on the purpose of the bed/chair alarms and she stated the purpose was for the residents who could not communicate or know to use the call light. The DON stated the bed/chair alarms went through the staff phones to notify them when a resident was getting up or where set to audible. The DON confirmed Resident #1 bed alarm did not alarm when Resident #1 got up and fell. The DON asked what the expectation of the bed/chair alarms and she stated they would be tasking the nurse to check the bed alarms to make sure they were working properly every shift just like a wander guard (device used to alarm staff if a resident is wandering to a potentially unsafe location.) During an interview on 10/30/25 at 1:30 PM, the Staff C, RN (Registered Nurse) Unit Manager queried on the incident with Resident #1 and she confirmed the bed alarm did not sound and they trouble shot the alarm and changed the batteries, even though the batteries were not completely dead and the bed alarm worked again. Staff C stated Resident #1a bed alarm started out going through the staff phone, but after the fall, they switched it to audible. During an interview on 10/30/25 at 1:40 PM, Staff B, RN queried on Resident #1 fall in the bathroom and she stated she found Resident #1 in the bathroom on the floor. Staff B stated Resident #1 didn't remember why she was in the bathroom. Staff B stated Resident #1's bed alarm did not sound on her phone and when Staff B checked the bed alarm, Staff B noticed if you wiggled the cord, the bed alarm came back on. Staff B stated she told the day shift to switch out the bed alarm because Staff B didn't have access to the new bed alarms. Review of the facility Fall Procedure dated 3/2024 revealed the following:a. Note any environmental factors that may have contributed to fall. b. Review the care plan for current fall prevention interventions and add new interventions or edit current interventions. New or edited interventions need to be tried to prevent recurrence of falls. Review of the undated [Brand name redacted] Sensor Pad Monitors instructions revealed: a. Place the user on the pad surface to activate system and test to ensure function. (If placed properly, the monitor will sound an alarm to notify staff if the user removes weight from the pad.

Based on observation,staff interview, and clinical record review, the facility failed to ensure adequate supervision to ensure a resident remained free from elopement for one of three residents reviewed for supervision/elopement (Resident #1). The resident exited the facility without the knowledge of facility staff on 5/25/25 when the resident left the area where they resided, walked through an unoccupied area of the facility, and exited to outside of the facility. The resident walked around the facility, was seen outside by staff through a window, and was brought back into the facility by staff. The facility reported a census of 115 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 4/23/25 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, wandering occurred 1-3 days. Review of Resident #1's Care Plan revealed the following dated 11/8/24: LTC elopement risk IPOC. Review of the Investigation Report for Resident #1 dated 5/25/25 at 08:15 revealed the following event description: At the beginning of the shift, approximately 0715 the cna (certified nursing assistant) entered the Resident's room. He was seen to be resting in his bed. At approximately 8:15 am the [Area Name Redacted] Nurse alerted the [Area Name Redacted] staff that she had just seen the Resident outside walking on the sidewalk. On [Area Name Redacted] one cna ran to the south door, the nurse ran to the east door. The nurse saw him walking right outside the door. The nurse opened the door and stated, [Resident #1], would you like to come back in now? Nurse held resident's hand to help him back in the building. Hands warm to touch, vital signs within normal limits, no complaints of pain. The Investigative Notes section of the Investigation Report documented, in part, the following: .It is believed that [Resident #1] followed a new dietary worker out the door while staff was preparing to serve breakfast. The Incident Report further revealed the event could likely have been prevented, and further revealed staff education occurred to check surroundings when entering and exiting the building. Review of the Incident Summary submitted 5/25/25 at 1:44 PM revealed, Resident [Resident #1] followed contracted dietary director employee, [Name Redacted], out of memory care, entered a non-occupied wing of [Facility Name Redacted] and exited the building. Resident was seen from interior of building by [Staff A] RN (Registered Nurse) and immediately redirected back into building by [Staff B] RN and into memory care without incident. No injuries. Staff A found entrance doors to unoccupied area alarming, fire exit door stairwell alarming, and exterior door alarming and all were reset. On 6/25/25 at 10:23 AM, Resident #1 observed at the breakfast bar in the area of facility where the resident resided. Resident #1 had a wander alert device bracelet present to the left wrist. On 6/25/25 at 10:32 AM, Staff E, Certified Nursing Assistant (CNA) explained some days the resident did wander, sometimes the resident would walk by the door and push on it, explained the resident was confused, said wanted to go home, and would ask about his truck. Staff E explained she could usually reassure the resident and he would calm down. On 6/25/25 at 11:00 AM, Staff A, RN explained, in part, the following: They looked out the window, and saw the resident outside the little courtyard gate. Staff A explained she alerted people on other unit on the neighborhood, staff went out the end of their hallway door, and Staff A went out the front door and around the building to make sure to catch the resident both ways. Staff A further explained staff opened the end door and brought the resident in. Staff A explained she walked down the hall to see how the resident could have gotten out and alarms were going off in the units that were not occupied, which was how it was determined got out that way. Staff A explained the resident's wander alert device was working. Staff A further explained the alarm was going off to the main doors of unoccupied area, and could hear it. When just past the elevators (in hall), Staff A explained she heard the first doors alarming which was why she continued to go that way. Per Staff A, there had been exit doors alarming. Staff A explained the resident came in without any argument or anything, had shoes, clothes, and hat on, sat down, had a cup of coffee, something to eat, and did not appear to be in distress. Per Staff A, [other nurse] had checked him over to make sure it didn't look like had fallen, and [Resident #1] looked fine. Staff A acknowledged she was the first person to see the resident, knocked on the door (to other unit in the neighborhood-neighborhood comprised of 2 units), explained staff could hear her through the glass, and Staff A said [Resident #1] is right there. Staff A explained she saw the resident on the other side of fence (noted to be beyond the courtyard). On 6/25/25 at 11:30 AM, Staff C, Certified Nursing Assistant (CNA) acknowledged she had worked the day the resident had gotten out of the building. On interview, Staff C was unsure when the resident got off the unit. Staff C explained she was down in another room, and when she walked back up, the nurse from the other side, [Staff A], was like Hey, is [Resident #1] over there? Staff C explained she responded he was down in his room, and Staff A said no, [Resident #1's] outside. Staff C explained Staff B, RN and herself went down different hallways. Staff C queried if when Staff A said resident outside, if she (Staff C) saw him (Resident #1)? Staff C confirmed, and explained resident was walking in front of the courtyard. When queried if the resident was inside or outside of the gates, Staff C responded outside the gates. Staff C explained Staff B grabbed the resident's hand and brought him back in. On 6/25/25 at 11:55 AM, the General Manager for Food Service and Nutrition (contracted employee) explained he had worked the day the resident got out, and explained he had gone into that neighborhood, did rounds, and when left punched the code, opened the door, and did remember someone kind of in that area. The General Manager for Food Service and Nutrition explained he left, didn't look back, and then got a text from a teammate asking if there was someone by the door when he left because there was an elopement. Per the General Manager for Food Service and Nutrition, he came back in and had talked to the nurse. When queried if he could identify the resident in the area if he saw them, the General Manager for Food Service and Nutrition explained it just wasn't what he was looking for, and further explained he just assumed someone had followed him, and because it had happened around that time. On 6/25/25 at 12:08 PM, Staff D, CNA, confirmed she had worked the day the resident exited the building. Per Staff D, she came in to facility and had shift change. Staff D explained she went and grabbed [Resident #1's] laundry, checked on other residents, and brought [Resident #1's] clothes to the laundry room so had clean clothes. Per Staff D, she came back out and waited a little but until turned 7 (AM) when start getting everyone up. Per Staff D, when she looked for the resident's laundry and checked on rooms the resident was there in bed, was awake, and was working on getting dressed. Per Staff D, she came back out, started the resident's laundry, and brought someone out. Staff D explained whoever staff was (on other neighborhood unit) said she found [Resident #1]. When queried if she ever saw [Resident #1] outside, Staff D denied. Staff D was unaware of how long the resident might have been out, was queried if she heard alarms going off during the time, and responded not that she remembered. On 6/25/25 at 1:00 PM, the facility Administrator explained she was alerted of the situation via [facility messaging system] from the Director of Nursing (DON). When queried as to her perspective on why the event had occurred, the Administrator responded when the contracted dietary staff left the resident followed him out the door, and she was not sure if the contracted dietary staff didn't know Resident #1 was a resident, or didn't realize the resident was behind him. The facility's Administrator explained the resident had multiple elopements from other settings prior to being at the facility and did a lot of wandering, which was why the resident lived in memory care. On 6/25/25 at 1:38 PM, Staff B, RN explained the following about the event: Staff B was alerted from a nurse over on the other side that the resident had gotten out. Staff B explained she went one direction, Staff C went another direction, and Staff D stayed to watch the other residents. Staff B explained she was the one who opened the exit door because could see resident walk by. Staff B explained she said, Hey [Resident #1], grabbed the resident's hand, and said, Why don't we come back in? Staff B explained when grabbed the resident's hand was still warm, and resident not out that long because cold out there. Staff B explained when staff were all talking, Staff D said went in there and got resident's laundry at 7/7:15 right after had done report. Staff B further explained she remembered someone had come to the area of the facility where Staff B worked (memory care), and Staff B had not recognized their voice. Per Staff B, she usually knew who came in and out, and she heard a voice in the kitchen. Staff B explained this was uncommon, and she had gone and talked to the dietary staff member about it to see if he knew anything about it. Staff B explained the dietary staff member said that was [a contracted dietary person]. Staff B reported the contracted dietary staff member told her the resident had followed him out. When queried if the resident wandered prior to this incident, Staff B explained the resident did so, and resident would take all the things out of his room and stack them up in front of the door. Per Staff B, facility had gotten resident in a much better place and much better mood. Review of the Facility Policy titled Elopement-Long Term Care dated 1/25 provided the following definition of elopement: Occurrence where a resident leaves a secured area or the building alone unwitnessed by staff or without an authorized individual and meets the criteria for an EWPD (electronic wandering protection device).

Based on observation, policy review and staff interview, the facility failed to follow the menu, and provide pureed portions per dietician recommendations. The facility reported a census of 116 residents. Findings include: Review of the menu, signed on 3/7/25, by the facility Registered Dietician directed staff prepare and serve the following menu items for the noon meal on 4/29/25: a. Taco casserole prepared for residents on a puree diet. The RD directed a serving two (2) #8 scoops or 7.5 ounces of casserole; and 4 ounces of Spanish, rice apple sauce, and churro stick. b. Fresh grapes served to residents on a regular diet. During an observation of the pureed food preparation for four residents on 4/29/25 at 10:00 AM revealed the following put into a Robo-coup machine by Staff B, Kitchen Chef: a. 6 cups of lettuce, 1-1/2 cups per resident b. 6 cups of meat and beans mixture, 1-1/2 cups per resident c. 4 ounces of salsa, 1 ounce per resident d. 4 ounces of cheese, 1 ounce per resident During the observation, Staff B, Kitchen Chef pureed the food in the machine, added splash of tomato juice, measured the pureed contents which totaled 2-1/4 cups. Staff B looked at the conversion chart and relayed each of the four residents should receive a #8 gray scoop, which equaled 4 ounces. Staff B, then poured a box of rice (in form of an instant powder) into a bowl and added hot water. Staff B did not measure the powered rice or the hot water. After queried on the portion size, Staff B then viewed the instructions on the box that read 3/4 cup per serving and mixed 4 servings per instructions. During a continuous observation of meal service on 4/29/25 at 12:17 PM to 12:48 PM, Staff C, Dietary staff prepared resident plates, which resulted in: a. Staff C used a teal scoop (6 ounces) for the rice, and used the green scoop (2-2/3 ounces) for the pureed taco mixture. b. Staff C did not serve fresh grapes for residents on a general diet. After the meal service observation ended at 12:28 PM, Staff C stated the scoop color guide on the wall indicated the scoop sizes to use. Staff C acknowledged she had used a teal scoop (6 ounces) for the rice and used a green scoop (2-2/3 ounces) for the taco meat mixture. Staff C stated she believed the green scoop was the same size as the teal scoop. During an interview on 5/1/25 at 8:45 AM, the Kitchen Manager stated grapes should have been served, and did not know why that did not occur. The Kitchen Manager stated a poster hung in the Galley kitchen that directed scoop sizes was not correct. He stated he is not sure who put up the poster and it should not have been followed, and he would remove it. Staff A stated dietary staff meet for a huddle before meal service when the menu is reviewed and expectation of scoop size is also discussed. He stated the huddle did not occur on 4/29/25, During an interview 05/01/25 at 9:40 AM, the Dietician stated she approved menus and provided some education. The Dietician stated a taco casserole was on the menu, not a taco salad as was prepared for the 4/29/25 noon meal. The Dietician stated the menu was not followed and the scoop sizes used was a concern.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure residents were free from verbal abuse for 3 of 4 residents reviewed for abuse (Resident ##63, Resident #87, and Resident #126). The facility reported a census of 114 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 3/5/25, listed diagnoses for Resident #87 which included non-Alzheimer's dementia, anxiety disorder, and chronic kidney disease. The MDS listed her cognition as severely impaired. Review of the Care Plan, dated 9/9/24, revealed the resident had cognitive loss and directed staff to allow the resident time to process information and to adjust the tone of voice for her to hear. The facility policy [Facility name redacted] Abuse and Elder Rights Policy and Procedure, revised 7/2021, stated the facility would ensure residents were free from verbal abuse. The facility defined verbal abuse to include oral language that included disparaging and derogatory terms to elders. 2. The MDS assessment tool, dated 3/27/25, listed diagnoses for Resident #126 which included non-traumatic brain dysfunction, irritability and anger, and hypertension (high blood pressure). The MDS listed his Brief Interview for Mental Status (BIMS) score as 3 out of 15, indicating severely impaired cognition. Review of the Care Plan, dated 3/21/25, revealed the resident had behavioral symptoms and directed staff to provide care with a smile, gentle touch, and reassurance. 3. The MDS assessment tool, dated 3/26/25, listed diagnoses for Resident #63 which included non-Alzheimer's dementia, injury of the right shoulder and upper arm, and hypertension. The MDS listed her cognition as severely impaired. Review of the Care Plan, dated 7/15/24, listed psychosocial well-being as a care area and directed staff to provide reassurance and emotional support. An undated staff statement, written by Staff D Certified Nursing Assistant (CNA) stated Resident #126 was concerned about another resident falling. The statement documented Staff F was confronting the resident (#126) and told him not to worry about (the other resident) and to sit your f**** a*** down. Staff D stated Staff F called Resident #126 a b**** and not to worry because she knew how to do her f*** job. She then told the resident to sit the f*** down. During an interview on 4/29/25 at 2:53 p.m. via phone, Staff D, CNA stated Staff F called Resident #87 a b****. She stated she called her this many times. Staff D stated she did not report this until later when there was a situation with Resident #126. Staff D stated Staff F was very vulgar to the residents. She stated she told Resident #126 to shut the f*** up and sit down. She stated Staff F had a filthy mouth She stated she did not report the situation with Staff D until later because she had to work with Staff F regularly. During an interview on 4/29/25 at 4:03 p.m., Staff E, Housekeeper stated Staff F came unhinged and stormed over to the living room. She stated she told a resident to mind his own f***** business and yelled loudly. Staff E stated she was not sure which resident staff F said this too but it was either Resident #125 or Resident #126. She stated this occurred on a Monday and she reported it to the Director of Nursing(DON) immediately after this happened. During an interview on 5/1/25 at 8:33 a.m., the Director of Nursing stated staff should treat residents with respect and dignity and give them the best care they could provide.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure staff reported 3 of 4 incidents of potential verbal abuse to administrative staff in a timely manner (Resident #63, Resident #87 and Resident #126). The facility reported a census of 114 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 3/5/25, listed diagnoses for Resident #87 which included non-Alzheimer's dementia, anxiety disorder, and chronic kidney disease. The MDS listed her cognition as severely impaired. Review of the Care Plan, dated 9/9/24, revealed the resident had cognitive loss and directed staff to allow the resident time to process information and to adjust the tone of voice for her to hear. 2. The MDS assessment tool, dated 3/27/25, listed diagnoses for Resident #126 which included non-traumatic brain dysfunction, irritability and anger, and hypertension (high blood pressure). The MDS listed his Brief Interview for Mental Status (BIMS) score as 3 out of 15, indicating severely impaired cognition. Review of the Care Plan, dated 3/21/25, revealed the resident had behavioral symptoms and directed staff to provide care with a smile, gentle touch, and reassurance. 3. The MDS assessment tool, dated 3/26/25, listed diagnoses for Resident #63 which included non-Alzheimer's dementia, injury of the right shoulder and upper arm, and hypertension. The MDS listed her cognition as severely impaired. Review of the Care Plan, dated 7/15/24, listed psychosocial well-being as a care area and directed staff to provide reassurance and emotional support. An undated staff statement, written by Staff D Certified Nursing Assistant (CNA) stated Resident #126 was concerned about another resident falling. Staff F, CNA was confronting the resident (#126) and told him not to worry about the other resident and to sit your f**** a*** down. Staff D stated Staff F called Resident #126 a b**** and not to worry because she knew how to do her f*** job. She then told the resident to sit the f*** down. During an interview on 4/29/25 at 2:53 p.m. via phone, Staff D, CNA stated Staff F, CNA called Resident #87 a b****. She stated she called her this many times. Staff D stated she did not report this until later when there was a situation with Resident #126. Staff D stated Staff F was very vulgar to the residents. She stated she told Resident #126 to shut the f*** up and sit down. She stated Staff F had a filthy mouth. Staff D stated about a week prior to the situation with Resident #126, Staff F gave a shower to Resident #63 and the resident stated the water was too hot and Staff F told her she would be quick about it and to shut the f*** up it was not too hot for her. Staff D stated the resident was crying after the shower and sat in her chair and asked why that girl was mean to her. Staff D stated she thought Staff F did not want the resident to go down for lunch because of what happened in the shower. She stated she did not report the incidents with Residents #87 and #63 until later because she had to work with Staff F regularly. During an interview on 4/30/25 at 10:00 a.m., Staff G, Certified Nursing Assistant (CNA) stated Staff F, CNA was kind of aggressive. She stated she called Resident #87 a b***** more than once and this started a couple of months ago. She stated she did not report this but stated she should have. On 5/1/25 at 8:33 a.m., the DON stated staff should treat residents with respect and dignity and give them the best care they could provide. She stated if staff witnessed resident mistreatment, they should remove the staff member. She stated staff should notify management and they would investigate the situation. She stated the facility had 24-48 hours to report the allegation to the State Agency. She stated she believed the situation with Resident #126 occurred on 4/1/25. She stated Staff F worked on 4/3/25. The DON stated she was not aware of any behaviors prior to this. She stated if staff was aware of a staff member calling a resident a name, they should have reported this to her. Review of the facility policy titled [Facility name redacted] Abuse and Elder Rights Policy and Procedure revised 7/2021, revealed a Purpose statement which declared To outline the procedure to proactively seek to keep elders free from abuse and conduct an investigation in the event of suspected abuse. The Procedure section directed staff to, in part: d. Identification: Staff is given information on how and whom to report concerns, such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse, without the fear of reprisal. Any situations identified for potential problems are referred to the Administrator for preventative action.

Based on clinical record review, policy review, and staff interview, the facility failed to separate residents from an alleged perpetrator of abuse in a timely manner. The facility reported a census of 114 residents. Findings include: Review of a Facility Reported Incident, dated 4/4/25 revealed on 4/3/25 the facility Director of Nursing submitted an allegation of potential abuse. Per the report A complaint was made to the DON [name redacted] on 4/1/25 by [name redacted, Staff E, Housekeeping] that CNA [name redacted, Staff F, Certified Nursing Assistant (CNA)] was speaking loudly and disrespectfully to resident [name redacted, Resident #126] while out in the memory care common area. On 4/3/25, [name redacted, RN manager (Registered Nurse) was notified of this complaint to further investigate with other CNAs and nurses that may have been present that day. Upon investigation, a second CNA working with [name redacted, Staff F, CNA] was interviewed, [name redacted, Staff D, CNA]. [Name redacted, Staff D, CNA] stated that [name redacted, Staff F} was very loudly telling resident [name redacted, Resident #126] that she knew how to do her f***** job. [Name redacted, Staff D] asked [name redacted, Staff F] to stop talking to the resident like that. In further interview DON [name redacted] and RN manager [name redacted] learned that [name redacted Staff D, CNA] had witnessed [name redacted, Staff F, CNA] showering a different resident [name redacted, Resident #63] and the resident voiced that the water was too hot (unknown date of occurrence). [Name redacted, Staff F, CNA} stated that it wasn't and continued to give the resident a shower . Review of the Facility Reported Incident further revealed, in part: Corrective Action Description: Immediately notified Administrator [name redacted] and [name redacted]. Action plan is place for meeting with [name redacted, Staff F, CNA] on 4/4/25 at 10:00 AM . On 5/1/25 at 8:33 a.m., the DON stated staff should treat residents with respect and dignity and give them the best care they could provide. She stated if staff witnessed resident mistreatment, they should remove the staff member. She stated staff should notify management and they would investigate the situation. She stated the facility had 24-48 hours to report the allegation to the State Agency. She stated she believed the situation with Resident #126 occurred on 4/1/25. She stated Staff F worked on 4/3/25. The DON stated she was not aware of any behaviors prior to this. She stated if staff was aware of a staff member calling a resident a name, they should have reported this to her. Review of the facility policy titled [Facility name redacted] Abuse and Elder Rights Policy and Procedure revised 7/2021, revealed a Purpose statement which declared To outline the procedure to proactively seek to keep elders free from abuse and conduct an investigation in the event of suspected abuse. The Procedure section directed staff to, in part: e. Protection: The facility will take the necessary precautions and remove caregivers or others from elders until the investigation is complete. Staff are to intervene if they witness abuse and move the elder to a safe place or remove the alleged abuser.

Based on observation, resident interview and staff interview the facility failed to ensure adequate food temperature for prevention of bacterial pathogen growth. The facility reported a census of 116 residents. Findings included: 1. The Minimum Data Set, dated dated dated [DATE] identified Resident #52 with Brief Interview for Mental Status score of 15 out of 15 indicated intact cognition. During an interview on 04/28/25 at 03:16 PM Staff #52 relayed food is often cold, at least every other day , fries are always cold. Staff #52 relayed the food has to travel a distance before served. 2. The Minimum Data Set, dated dated dated [DATE] identified Resident #113 with Brief Interview for Mental Status score of 15 out of 15 indicated intact cognition. During an interview on 04/28/25 at 04:18 PM, Resident #113 relayed food has not always been hot, portions can be small, not enough left for seconds and had spaghetti and meatballs recently that was not even warm. During a continuous observation of meal service on 4/29/25 starting at 12:04 PM to 12:40 PM revealed Dietary Worker, Staff C obtained temperature of food with food thermometer measured in Fahrenheit (F) before and after food served, observation of food temps outside of United States Department of Agriculture guidelines included: a. Initial temperature of ground meat/bean mixture 133 degrees, end of service 84 degrees. b. Initial hamburger patties temped at 131 degrees, all three were served During an interview on 5/1/25 at 10:03 AM with Kitchen Manager, Staff A relayed dietary staff should alert the kitchen manager for options if temperatures are above 40 degrees for cold and below 135 degrees for food on the steam table. During an interview on 05/01/25 at 10:05 AM, with Dietician, Staff H acknowledged food temperature concerns and relayed felt education was needed. During an interview on 05/01/25 at 12:13 PM, with the contracted company, General Manager, Staff G Relayed retention of staff had been difficult, continuation of staff education was necessary. 35434 3. The MDS assessment tool, dated 4/9/25, listed diagnoses for Resident #3 which included hypertension(high blood pressure), obesity, and diabetes. The MDS listed his BIMS score as 15 out of 15, indicating intact cognition. During an interview on 4/29/25 at 10:07 AM., Resident #3 stated the food was cold and gave the example of cold scrambled eggs. The resident stated he was discouraged with the food at the facility.

Based on observation, clinical record review, facility incident and investigation reports, and staff interviews, the facility failed to ensure a resident with a severe cognitive impairment did not exit the facility without staff knowledge. On 7/26/24, Resident #1 left a group while walking from an activity area to the memory care unit unbeknownst to the staff supervising. Resident #1 walked through the front lobby and exited out an unlocked, unalarmed door to an unsecured courtyard area. The resident walked on the sidewalk to the area between the B and C wings of the building, a location approximately 100 yards from a large pond. A staff member saw the resident from a window, and went outside to assist her back to the building. Resident #1 estimated to be outside, unsupervised for approximately ten minutes for 1 of 1 resident reviewed for elopement (Resident #1). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of residents who resided at the facility. The State Agency informed the facility of IJ that began as of July 26, 2024 on November 7, 2024 at 2:38 PM. The Facility Staff removed the Immediate Jeopardy on November 13, 2024 through the following actions: a. Exit door where Resident #1 exited is now locked at all times and requires keypad access for egress. Completed on November 8, 2024 by [business name redacted]. b. Memory Care residents have been escorted and supervised by designated employee(s) for all programming outside of the memory care since July 29, 2024 implemented by Administrator. c. All residents of [NAME] Center have been evaluated for elopement risk. Completed November 8, 2024 by unit RN managers under the supervision of the Director of Nursing. d. Residents identified to be at risk for elopement living in a non-secured unit have had an electronic wandering protection device placed and care plans have been updated. Completed November 8, 2024 by unit RN managers under the supervision of the Director of Nursing. e. Residents identified to be at risk for elopement living in a secured unit will have an electronic wandering protection device placed no later than Thursday November 14, 2024 by unit RN manager under the supervision of the Director of Nursing. Care plans were updated on November 8, 2024 by unit manager under the supervision of the Director of Nursing to reflect other interventions initiated. f. Elopement Prevention policy has been developed and approved on November 8, 2024 by the Administrator. g. All staff scheduled today (11/8/24) have been educated on new Elopement Prevention policy, and all other staff will be educated at start of their next scheduled shift. First shift staff education has been completed by unit RN Managers under the supervision of the Director of Nursing; second and third shift staff will be completed at start of shift today (November 8, 2024) by Unit RN managers and RN evening supervisor under the supervision of the Director of Nursing; and all other staff not scheduled today will be completed at start of their next scheduled shift by [NAME] Center staffing specialist, unit RN managers, or evening RN supervisors under the supervision of the Director of Nursing and the Administrator. All staff are required to complete the education prior to starting their next shift effective immediately (11/8/24). The majority of staff education will be completed by 11/11/24. Any remaining staff or PRN staff who have not worked by 11/11/24, will be trained prior to working their first scheduled shift. h. Additional electronic wandering protection devices were ordered through RF Technologies on November 8, 2024, and RF technologies has confirmed delivery for Thursday November 14, 2024. i. Plans in place: 1. Daily checks of resident electronic wandering protection devices to ensure that they are in place and operational are already being completed by nursing staff as of 11/8/2024. Additional residents who receive wandering protection devices will be added to the daily checks as the devices are placed. 2. Weekly door checks - to be completed weekly starting week of November 11, 2024. 3. Elopement drills - to be completed weekly beginning week of 11/11/2024. The Quality Assurance and P Performance Improvement committee will evaluate results and may adjust cadence as appropriate. The scope lowered from a J' to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported census was 106. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #1 scored 7 out of 17 on the had a Brief Interview for Mental Status, indicating a severe cognitive impairment. The MDS identified Resident #1 independent with mobility with the use of a walker, requiring supervision with ambulating more than 50 feet with two turns. The MDS listed diagnoses included non-Alzheimer's dementia, diabetes mellitus, and renal insufficiency. An Elopement Risk tool, dated 6/13/24, identified Resident #1 with a total score of 52. The screening tool indicated an Elopement Risk score of 59 or below indicates a low risk for elopement. The Care Plan included a Plan for LTC (Long Term Care) Falls IPOC (Interdisciplinary Plan of Care) initiated on 2/20/24, and LTC ADL (Activities of Daily Living)- Mobility IPOC. A review of the facility self-report to the State Agency on 7/26/24, Incident Summary revealed [name redacted] is a resident of the [NAME] Memory Care and was attending a group activity in the general common area. At the end of the activity, resident walked out main courtyard doors around south side of the building to the memory care gate. Corrective Action Description: Resident was seen by activity professional, escorted back in the gate to memory care with no further incident. The facility Patient Event: Safety Concern/Safety Event form, date of event 7/26/24 15:00 (3:00 p.m.) revealed, in part: a. Describe Event/Concern: This afternoon during activities in the [NAME] gathering hall, resident exited out of back entrance and started walking around building on the sidewalk. Staff spotted her out of east window and as was able to redirect elder back inside. To prevent this event from occurring again, a wander guard has been placed on her right wrist. b. Could this event have been prevented? Likely could have been prevented c. Describe how the event could have been prevented: Ensuring memory care residents memory care residents at risk for wandering and/or elopement are continuously supervised by trained memory care staff while activities outside of the secured memory care unit. The State Climatologist reported the following weather conditions in [NAME], Iowa on July 26, 2024 at approximately 3:00 p.m.: temperature of 81 degrees F (Fahrenheit), relative humidity 69%, heat index of 85 degrees F, winds out of the ESE (east south east) at 9 mph (miles per hour), with fair conditions and no rainfall reported. During an interview on 11/5/24 at 11:10 a.m. the Administrator stated she was leading an activity group on 7/26/24. Several residents attended, including Resident #1 and at the end of the activity, she was responsible for escorting the memory care residents back to their households. The Administrator stated she did not realize Resident #1 had left their group and veered back into the front lobby area. About ten minutes later Resident #1 was observed through a window, heading East, between the B and C buildings. Resident #1 was immediately escorted back in and found without injury. The Administrator stated there were only two exits Resident #1 could have possibly used to get outside. The front main entrance has two sliding glass doors with a motion detector and a receptionist at the front desk during day hours or a courtyard door at the opposite side of the front lobby which is an unlocked door leading to a courtyard and access to facility grounds. Both exits are unlocked, but have wander guard alarm monitors. The Administrator believed Resident #1 likely used the courtyard door, as it was less visible to the receptionist. During an interview on 11/5/24 at 10:15 a.m., the Activity Director (AD), stated on 7/26/24 there was a group activity in which 15 residents attended, including 5-6 from the memory care halls. The activity was conducted in the main gathering room at the front of the building. It was a Friday, so there was only the AD and the Administrator, who was also the presenter. At the end of the activity around 3:00 p.m., the 5-6 memory care residents exited the room at the southeast door with the Administrator and the others exited the southwest doors and walked towards their halls accompanied by the AD. The AD stated about ten minutes later, as she was walking to her office, she saw Resident #1 walking outside on the sidewalk, between B and C buildings. The AD stated she immediately went outside and escorted Resident #1 back into the building. The AD stated she was not certain what door Resident #1 exited from. During an interview on 11/5/24 at 11:40 a.m., Staff F, Receptionist, stated she was working the day Resident #1 eloped and was at the desk when the 3:00 p.m. activity ended. Staff F stated Resident #1 did not exit through the main entrance doors. During an interview on 11/5/24 at 11:45 a.m., Staff G, Unit Manager, stated she is the Unit Manager on the unit where Resident #1 had resided. Staff G stated Resident #1 was not an elopement risk and never exit seeked while on the unit. Resident #1 usually sat at the dining room table or in her recliner in the living room area. She did not wander or attempt to push doors open. Staff G stated because of her low risk, she was allowed to attend activities off the unit. Residents with high risk for elopement do not attend activities off the unit. Staff G stated instead they have a Recreational Therapist that works with residents and activities on the unit. During an observation on 11/5/24 at 2:00 PM, the facility noted to have an unlocked sliding door facing south at the front entrance. The door is equipped with a motion detector. A receptionist desk, occupied by the receptionist, immediately inside the door and then the lobby area. On the opposite side of the lobby, to the north, is a door to the courtyard. The door found to be unlocked, with a push bar mechanism in place to open. Both the front door and the courtyard doors noted to have a wander guard monitor in place. The courtyard door is not clearly visible from the receptionist desk. Upon walking into the courtyard, there are various concrete sidewalk paths and then a single path that leads around the building. The courtyard area is not secured or the area defined by a fence. North of the courtyard is a grassy area that is well groomed, and leads to a large pond approximately 100 yards away. Access to the pond is open, with no fence or obstruction to entry. Sidewalks lead both east and west around the building. Resident #1 had been discovered on the east side of the building walking on the sidewalk between the B and C wings of the building. During an interview on 11/11/24 at 11:12 a.m., Staff H, Registered Nurse, stated she was responsible for Care Plans and updates. Staff H stated Resident #1 was admitted on [DATE] and determined at risk for falls. Staff H stated Resident #1 had no history of elopement, wandering or exit seeking behavior.

Based on observations, facility policy review, food temperatures, staff and resident interviews the facility failed to provide food at a safe temperature in 2 of the 7 households (Heritage House, and Cobblestone House) reviewed, and palatable food at a preferred temperature for 1 of 2 residents (Resident #90) in the sample. The facility reported a census of 101 residents. Findings Include: On 6/10/2024 at 11:35 AM, Food Service/Dietary Manager stated all food items are temped when they come out of the ovens and all individual household kitchens check and log all of the meal items at the point of service. On 6/11/2024 at 12:20 PM, upon arrival on the unit the Food Service/Dietary Manager learned Staff A, dietary staff had started to plate the noon meal. When asked, Staff A stated he had not checked the food temperatures prior to serving the noon meal. Food service was temporarily halted by the Food Service Manager and all food temperatures were checked by the staff for the steam table and the cold service food. The chicken salad was temped three times resulting in a hold temperature of 46 degrees. The mechanical soft chicken temped at 127 degrees. Staff A stated he had not had time to add more water to the steam table. Staff A also stated the chicken salad was brought upstairs to me as a special order item. On 6/11/2024 at 1:10 PM The Food Service Manager stated he would implement additional training for staff. He also stated this was a learning experience for his workers and they would be following procedure. On 6/12/2024 at approximately 3:20 PM, Staff A stated hot food should be held at 135 degrees or higher on the steam table. Cold food should not be above 41 degrees. Staff A reported he should have taken the time to check and log the noon meal temperatures. On 6/12/23 at approximately 4:05 PM, the Administrator stated it is her expectation that all agency policies and procedures would be followed and residents would not be served any food that was not within normal temperature limits. 47336 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS revealed the resident ate independently. During an interview on 6/10/24 at 9:52 AM, Resident #90 stated the food tasted bad yesterday and the vegetable were overcooked. Resident #90 stated she ate in the dining room and a lot of times the food tasted cold and not hot. She stated a lot of times the potatoes were not fully cooked and if they had something like roast beef they couldn't chew it. Resident #90 stated she was not the only resident who felt this way about the food. During an observation on 6/11/24 at 12:45 PM, Resident #90 took a bite of her broccoli and made a face and turned her plate around so the chicken placed in front of her. Resident #90 finished the bite of broccoli but didn't take another bite. During an interview on 6/11/24 at 3:05 PM, Resident #90 stated the broccoli tasted overcooked and just mush. She stated she took one tiny bit and the broccoli tasted water soaked. She stated the chicken was okay, but a little dry. Resident #90 stated when they served chicken noodle soup, the soup was more liquid and not a good tasting broth and the soup only had a few noodles and a bite of chicken in it. She stated since the new company took over the food, the quality of the food had stayed the same and even though they said they tried to make it better. She stated they rarely offered fresh fruit like apples or oranges, and if served bananas they were placed on top of a bowl of pudding. Resident #90 stated she wanted fresh food in her diet. The facility policy titled SEIRMC-WB [NAME] Center Dietary Guidelines dated 7/2022, directed the following: 11. Hot-cooked foods will be held at temperatures above 140 degrees. Food temperatures will be monitored and recorded on logs. 12. Random testing of food temperatures will be done regularly, and logs maintained of all temperature. 16. Steam tables will keep food above 140 degrees and will be maintained in a safe, sanitary condition.

Based on observation, interview, record review, and the facility policy, the facility failed to ensure nursing staff watched and supervised residents take their medications after issuing in a medication cup for 2 of 7 residents (Resident #7, and Resident #61) reviewed. The failure resulted in a medication being left unattended in common areas within the facility, and a resident not taking her medicaiton for more then 20 minutes after adminstered. The facility reported a census of 101 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 4/17/24, revealed Resident #7 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The MDS revealed diagnoses for non-traumatic brain dysfunction, unspecified dementia without behavioral disturbance, and depression. The MDS revealed resident took antianxiety, antidepressant, and opioid medications. The EMR (Electronic Medical Record) Medication Administration Record (MAR) revealed the following medications that were white pills administered on 6/12/24 at 8:21 AM: a. hydrocodone/acetaminophen 5 mg(milligrams)/325 mg- 1 tablet BID (twice daily) b. loratadine 10 mg- 1 tablet daily c. acetaminophen 500 mg- 1 tablet TID (three times a day) d. amiodarone 100 mg - 1 tablet daily e. buspirone 10 mg -1 tablet BID f. calcium-vitamin D (Calcium 600+D)- 1 tablet TID e. citalopram 40 mg -1 tablet daily g. potassium chloride 10 mEq (milliequivalents)-1 tablet daily During an observation 6/12/24 at 8:56 AM, Staff A, Dietary Aide told Staff C, CNA that he found a pill left on the table. Staff C then informed Staff B, RN (Registered Nurse) that Staff A found the pill left on the table and handed Staff B the medication cup with a white pill in it. Staff B then went down the hall towards Resident #7 room and when Staff B returned to the common area, she no longer had the medication cup in her hand. During an interview on 6/12/24 at 10:30 AM, Staff A stated he found a medication cup with a white pill on the table and he gave it to the nurse. Staff A asked if he had found pills on the table before this incident and he stated it happened once or twice before when he cleared off the table and he just told the nurse about it. During an interview on 6/12/24 at 11:05 AM, Staff B, RN stated normally Resident #7 took her pills when she handed them to her. Staff B asked how she knew the pill was Resident #7 and she stated Resident #7 was the only resident who sat at the table where the pill had been found. Staff B stated normally she would of thrown the pill away, but she felt frazzled. Staff B stated Resident #7 not always cognitive [cognitively aware] but she did always count her pills. Staff B asked what the resident's response was when she took her the pill and she stated Resident #7 said oh, and took it. Staff B confirmed the pill in the medication cup was white. During an interview on 6/12/24 at 12:58 PM, Staff B stated she couldn't identify the white pill because the pharmacy sent bags with the barcode and the pill description on them and she already threw them away. During an interview on 6/12/24 at 1:36 PM, Resident #7 stated she took her medications at the breakfast table this morning and one was left in the cup and they brought it to her this morning. She stated the nurse usually brought her medications to her room and left them on her table. She stated sometimes the nurse watched her take her pills and other times they didn't. She stated the nurses knew she took her pills. During an interview on 6/12/24 at 1:55 PM, Staff C, CNA stated Staff A was clearing off the dining room tables and found a medication cup with a pill left in it. Staff C stated Staff A told her about the pill and she took it and gave it to the nurse. Staff C asked if pills left in the medication cups on the table happened often and she stated every now and then and she didn't think the nurses should leave the medications on the table. Staff C queried if that practice happened often and she stated it depended on the nurse and if the resident cognitive [cognitively aware]. Staff C stated this incident happened with Resident #7 before and she didn't know if the resident didn't tip her cup all the up. 48888 2. The MDS, dated [DATE], revealed Resident #61 had a BIMS score of 10 out of 15, indicative of a moderate cognitive impairment. Diagnoses included bilateral macular degeneration, depression, and anxiety disorder. Medications included an antiplatelet and antidepressant medication. The Care Plan, revised 05/16/24, lacked a focus area and interventions for Resident #61 to self-administer medications. The June 2024 MAR lacked documentation of Resident #61 self administration of medications. On 06/11/24 at 08:06 AM, Staff D, Licensed Practical Nurse (LPN), placed a medication cup that contained various pills and a bottle of eye drops in front of Resident #61. Medications left in front of Resident #61 as Staff D passed medications and drinks to other residents. At 08:27 AM, the medication cup, set in front of Resident #61, continued to contain various pills without direct staff supervision. On 06/13/24 at 08:00 AM, Staff E, Registered Nurse (RN) revealed many residents preferred to take their medications at dining room table after they eat. Staff E stated that neither facility policy or training instructed staff to leave medications with residents at dining room table but was resident preference. Staff E stated residents can refuse to take medications when given, but stated she appreciated the risk of leaving medications at the table. During an interview on 6/13/24 at 9:09 AM, the Interim DON (Director of Nursing) stated she would of expected the nurses to stay with the resident to make sure the medications were taken. She stated the nurse expected to stand by the resident while they take their pills. The Facility Medication Administration Policy dated 9/22 revealed the following information: a. General Considerations 1. Verify that the rights of medication administration have been followed. 2. Accurately record time administered on EHR (Electronic Health Record) medication administration record (MAR). When scheduled time must be changed, the medication is rescheduled, and the reason documented. 3. Self-administration of drugs is permitted only with a physician's order. An assessment will be completed within the EHR. b. Medications may be stored: 1. Elders may keep medications at bedside that have a physician's order and they had been evaluated to be safe in self-administration located in the assessment in the EHR.

THE FOLLOWING DEFICIENCIES RELATE TO THE IOWA ADMINISTRATIVE CODE (IAC) CHAPTER 58. 58.12(135C) Admission, transfer, and discharge. 58.12(1) General admission policies. l. For all residents residing in a health care facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249A on July 1, 2003, and all others subsequently admitted , the facility shall collect and report information regarding the resident's eligibility or potential eligibility for benefits through the Federal Department of Veterans Affairs as requested by the Iowa commission on Veterans Affairs. The facility shall collect and report the information on forms and by the procedures prescribed by the Iowa commissions on veterans affairs. Where appropriate, the facility may also report such information to the Iowa department of human services. In the event that a resident is unable to assist the facility in obtaining the information, the facility shall seek the requested information from the resident's family members or responsible party. For all new admissions, the facility shall collect and report the required information regarding the resident's eligibility or potential eligibility to the Iowa commission on veterans' affairs within 30 days of the resident's admission. For residents residing in the facility as of July 1, 2003, and prior to May 5, 2004, the facility shall collect and report the required information regarding the resident's eligibility or potential eligibility to the Iowa commission on veterans' affairs within 90 days after May 5, 2004. If a resident is eligible for benefits through the federal Department of Affairs or other third-party payor, the facility shall seek reimbursement from such benefits to the maximum extent available before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A. The provisions of this paragraph shall not apply to the admission of an individual as a resident to a state mental health institute for acute psychiatric care or to the admission of an individual to the Iowa Veterans Home. (II,III) Based on clinical record review and staff interviews, the facility failed to screen residents to determine a Veteran's eligibility for 47 of 47 Medicaid recipients at the facility. The facility reported a census of 87 residents. Findings Include: The facility lacked a list of current residents screened for Veterans Administration (VA) benefit eligibility. On 3/15/23 at 3:00PM, the Director of Nursing (DON) reported that the facility does not screen for VA eligibility. They did not screen for VA eligibility in the past and there were no concerns noted during previous annual recertification surveys. The facility is connected to the hospital which she believed may be the reason screens are not required. On 3/16/2023 at 8:45AM, the DON, the Administrator and the Social Services Director discussed VA benefit screenings. Forty seven Medicaid recipients resided at the facility on 3/16/23. Zero of 47 residents had been screened for VA eligibility. The Administrator believed that the facility did not have to screen residents for VA benefit eligibility.

Based on observation, record review, and resident, staff and family member interviews, the facility failed to provide adequate care supervision to prevent injury for 1 of 5 resident records reviewed (Resident #1). The facility reported a census of 143 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 8/8/18 revealed Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident scored 10 out of 15 points possible on the Brief Interview of Mental Status (BIMS) cognitive assessment that indicated the resident displayed moderate cognitive impairment. The MDS also documented the resident did not display symptoms of [MEDICAL CONDITION] and required assistance of at least 1 staff for transfers to and from bed and chair, ambulation (walking), and toilet use. The resident's care card (care plan) last updated 8/9/18 and applicable at the time directed staff the resident required assist of 1 staff for ambulation and transfers in room and hallway. An undated Falls Intervention Plan directed staff the resident required the use of 2 side rails in use when in bed, transferred and ambulated with assist of 1 staff with gaitbelt and wheeled walker. An Incident Report, completed by Staff D, registered nurse (RN), dated 11/3/18, revealed a restorative aide (RA) assisted the resident to ambulate from the dining room to his room after breakfast and was last observed in recliner chair in his room by staff. At approximately 11:10 a.m., staff heard help from his room and an aide (certified nursing assistant - CNA) responded and found resident on the floor on his left side with head against the left leg of the bed at the footboard. A progress note completed by Staff D, dated 11/3/18 at 1:23 p.m., stated at approximately 11:10 a.m., staff heard help from the direction of the resident's room. A CNA found the resident on his left side, on the floor, head leaned against the leg of the bed. The note revealed the resident could barely move the right leg, demonstrated abnormal range of motion, and complained of pain to the hip area. Staff notified the, physician at 11:23 a.m. and received an order to send the resident to the emergency room for an evaluation. Right hip X-ray reports dated 11/3/18 revealed a spiral type [MEDICAL CONDITION] proximal diaphysis of the femur (upper leg bone). Staff interviews revealed: 1/16/19 at 8:59 a.m., Staff A, CNA, stated she worked the day shift on 11/3/18, the resident required 1 staff assistance for transfer and ambulation with walker, used his call light and would tell staff when he had to use the toilet at the time of the fall. She observed the resident seated in the recliner chair in his room as she left for break that morning, and he was on the floor when she came back from break. She reported she helped staff in his room after the fall and observed his call light tied around the siderail on his bed, and not clipped to his chair within his reach. She stated as a CNA, one would normally ensure the resident has their call light, they are comfortable and don't need anything else before you left their room. 1/16/19 at 5:07 p.m., Staff B, CNA, stated she worked the day shift on 11/3/18, between 11 and 11:30 a.m., the other CNA was on break, she heard a resident's yell, she went to investigate and found the resident on the floor by the recliner chair, the nurse came and assessed the resident. Staff B reported she had helped the resident in the past when he used his call light, and when they looked at how he fell that day they said he didn't have his call light and couldn't ambulate without staff assistance. 1/16/19 at 1:40 p.m., Staff C, RA and CNA, stated on 11/3/18, she ambulated with the resident from the dining room to his room, assisting him with a gaitbelt applied to his waist while he used a walker. She then took the resident to the bathroom, assisted him to sit in his recliner chair where his exercises were completed. When she left the resident, he wanted his Bible and his feet elevated, she provided those things and left his room at approximately 8:50 a.m. She stated she had not worked with the resident before that day and didn't remember if she gave him his call light. In a telephone interview on 3/26/19 at 11:34 a.m., the Administrator reported the facility does not have a formal call light policy, but it is a standard of care for the call light to be within reach. She stated she expected staff to follow that standard of care.

Based on record review, facility investigation, and staff interviews, the facility failed to ensure each resident's environment remained free of accidental hazards and failed to implement intervention (s) to prevent injury to one (1) of four (4) residents (Resident #1). The facility reported a census of 151 residents. Findings include: 1. According the Minimum Data Set (MDS) assessment with a reference date of 09/20/17, Resident #1 had [DIAGNOSES REDACTED]., depression. The MDS documented the resident with long and short term memory problem and impaired of cognitive skills for daily decision making. The MDS identified Resident #1 as requiring extensive assistance of two staff member for bed mobility, transfer, dressing, and toilet use, and ambulation did not occur. The MDS identified Resident #1 had a problem with skin tears. Review of the facility's Injury Investigation Form report dated 09/27/17 at 6:00 p.m. indicated a skin tear found on the resident's left lower calf when staff completed a transfer from scooter. The form indicated staff thought the resident bumped into a foot rest which affected her fragile skin. resident sustained [REDACTED]. Review of Progress Notes Nurses Notes dated 9/27/17 revealed nurse summoned to Resident #1 room by certified nurse aide (CNA)'s. Upon entering the room, resident had been lying supine in bed with a wash cloth over her left lower calf with blood noted on wash cloth. The CNA's stated they found the skin tear when they took off the resident's lap robe. Skin tear large and immeasurable with several layers of tissue compromised. Per staff they were unaware of any trauma suffered by the resident. Resident's physicians called and order to send resident to the emergency room for further evaluation and treatment. Review of Resident's #1 emergency room physician documentation dated 9/27/17 indicated Resident #1 is non- ambulatory and uses a mechanical lift for transfers. The resident was being moved and they noticed blood on her shoes which led them to see the laceration at 6:30 p.m. There is a 15 cm (centimeter) laceration to the left lateral aspect of the mid lower leg, not intact. Resident #1 had a left leg laceration full thickness exposing the adipose tissue (connective tissue), no muscle laceration, skin is extremely fragile. The degree of bleeding is minimal, resident denies pain, however the resident had dementia. The resident's laceration required repair with 4-0 nylon and 12 staples. Staff reported no falls reported and staff are not aware of what caused the laceration. The resident did have a shower at approximately 4:45 pm this afternoon and no injury was noted at that time. Resident started an antibiotic. The physician ordered non-weight bearing status until the resident is examined by personal medical provider. Resident discharged back to the facility. Interview was conducted with Staff A, Certified Nurse Aid (CNA) on 10/25/17 at 2:40 p.m. Staff A stated she and Staff B, CNA, transferred Resident #1 from the scooter chair to shower chair using a Sara lift. Staff A stated she gave Resident #1 a shower on 9/27/17 around 3:30 pm and did not see any bruising or injury to the resident. Staff A reported no incident occurred during the transfer or the shower. Staff A indicated after the resident's shower she and Staff B transferred resident to the scooter chair without incident and assisted the resident to the dining room table to visit with family members. Staff A stated at supper time she brought another resident to the same table of Resident #1 in a scooter chair and positioned that resident to the left of Resident #1. Staff A stated Staff B sat between Resident #1 and a peer, assisting residents with their eating. Staff A indicated she sat across the table from Resident #1 and after the meal she took Resident #1 from table to room without incident. Staff A stated Staff B in room and they transferred resident from the scooter chair to bed using the Sara lift (model #3000). Staff A reported once the resident laid in bed, Staff B removed the lap blanket and they noted the skin tear to the lower left leg. Staff A reported putting a wash cloth on wound and immediately contacting the nurse. Staff A stated wound not bleeding very much, did see some blood on resident's slipper. Staff A stated she and other staff looked under, around the dining room floor and table, around the Sara lift and scoot chair, and did not find any blood. Staff A stated she applied Aquaphilic ointment to resident's lower legs after shower. Staff A stated she thinks the skin tear may have occurred when she removed the resident form the table and she bumped into a peer's scooter chair. Interview was conducted with Staff B, Certified Nurse Aide (CNA) on 10/25/17 at 3:16 pm and 10/27/17 at 11:30 am. Staff B stated she assisted Staff A with transferring Resident #1 from the recliner to the shower chair and Staff A assisted the resident with the shower. Afterwards Staff A and Staff B transferred the resident from shower chair to scooter chair without incident. Staff B indicated no injury noted to resident's lower legs at that time. Staff B reported Resident #1 had a history of [REDACTED]. Staff A indicated during the evening meal she sat between Resident #1 and another resident to the left of Resident #1 to assist with feeding. Staff B reported no incident occurred with Resident #1 during the meal that she is aware of. Staff B reported after the meal they (Staff A and herself) took Resident #1 to the room and transferred resident from scooter chair to bed and once in bed removed resident's lap blanket and noticed the wound to lower left leg. Staff B stated they covered wound with a wash cloth and notified the nurse immediately. Staff B indicated no incident occurred during the transfer of resident from scooter chair to bed occurred. Staff B indicated she believes the wound may have occurred when Resident #1 was pulled away from the dining room table and hit against other resident's scooter chair. Staff B stated Resident #1 dressed in a night gown that goes to her knees with short sleeves, slippers and a lap blanket. Staff B indicated they usually do resident's cares earlier in the evening due to resident becomes combative with cares in the evening. Staff C stated she noted blood on resident's floor of room where scooter chair was at time of transfer and also noted what may have been a spot of blood on left of arm of foot pedal on scooter. Interview was conducted with Staff C, Registered Nurse (RN) on 10/25/17 at 10:49 am. Staff C stated Resident #1 had very fragile skin that bruises very easy. Staff C stated she thinks Resident #1's injury occurred when sitting at dining room table next to another resident in a scooter chair and Resident #1 coming in contact with other resident's foot pedals. Staff C stated after injury occurred they looked for blood around dining room table, Sara left and scooter chair and found none. Staff C stated after resident received this injury they padded the arms and pedals of scooter and not to sit two residents by each other at dining room table. Interview was conducted on 10/25/17 at 4:08 pm with Staff F, RN. Staff F stated she was summoned to Resident #1 room by CNA's. Staff F reported when entering room resident lying on bed with wash cloth over wound with blood on it. Staff F reported she assessed the wound, called resident's physician and received orders to transfer resident to emergency room for further evaluation and treatment. Interview with physician assistant (PA) on 10/26/17 at 1:33 pm. The PA stated he treated Resident #1 in the emergency roiagnom on [DATE]. The PA stated the resident had very fragile skin and that it would not take much trauma to cause this type of skin tear. A review of the resident's Care Plan dated 9/25/17, directed staff to pad the resident's (bed) side-rails to protect her skin due to the resident hitting arm/s against side rails during cares. Resident #1's care plan identified she used a mechanical lift (Sara 3000) for transfers. On 9/27/17, the care was updated to transfers with a Hoyer lift. Record review revealed the following: Review of communication documentation from the facility to Resident #1 physician dated 9/20/17, revealed while getting resident ready for bed a previous skin tear on left anterior forearm reopened. Wound measuring 1 cm X 1 cm, wound cleansed and steri-strips applied per protocol. Review of communication documentation from the facility to Resident #1 physician dated 8/20/17, revealed resident had a new skin tear on left anterior forearm measuring 3 cm x 0.1 cm. Area cleaned, will continue to monitor. Review of communication documentation from the facility to Resident #1 physician, dated 7/27/17, revealed resident had multiple bruising to both arms, blue and purple in color. Reported by evening staff on 7/26/17, resident holding on to side rail of chair and swinging arms at staff will continue to monitor. Review of communication documentation from the facility to Resident #1 physician, dated 4/5/2017, revealed during transfer of resident, resident acquired a skin tear from staff's ring. Wound measures 1 x 0.7 cm, area cleaned and steri-strips applied, will continue to monitor until healed. On 9/28/17, the care plan had been updated for the foot pedals of the scooter chair to have padding; and for the residents in scooter chairs to not sit directly next to each other in dining room.

The following deficiency relates to Self Report # -I and # -I. Based on record review, observations, and staff and resident interviews, the facility failed to maintain preventive measures to reduce/prevent falls for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 120 residents. 1. According the MDS (Minimum Data Set) assessment tool with a reference date of [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. The MDS indicated Resident #1 required the extensive assistance of one staff member for dressing, toilet use and personal hygiene and limited assist of one staff for transfers and locomotion. The MDS documented the resident had a prior fall history with a injury since the last assessment. The MDS described the resident as not steady with balance during transitions and walking and had functional impairment in range of motion of the upper and lower extremity that placed the resident at risk for injury. The Elder Care Card dated [DATE] for Resident #1 revealed a fall risk score of 20. A score of 10 or above was identified as high risk for falling. The Falls Intervention Plan dated [DATE] included interventions that directed staff to: a) On [DATE], the plan directed staff to provide assistance in early AM and after meals. b) On [DATE], staff are encouraged to use the call light for assistance with retrieving items from the closet. c) On [DATE], staff are directed to transfer the resident with limited assist of one, gait belt, and wheeled walker, dated [DATE]. d) On [DATE], staff are directed to assist the resident to use the bed side commode at night. e) The resident uses a low bed and staff are to monitor elder when passing his/her room. f) On [DATE], staff are to ensure the resident uses a bed/chair alarm. Review of the facility's Fall Assessment Initial and Follow-up Flow Sheet dated [DATE] at 3:20 p.m. revealed the resident was found on the floor in front of the closet by a staff member after another resident had seen Resident #1 fall. The resident had confusion and unable to state what she/he was doing. Resident confused and hallucinating stating there were kids in his/her room and wanted to get them out of the room. Resident complained of back pain. The staff assessed the resident and sent the resident to the emergency room for further evaluation and treatment. Review of the History And Physical with an admission date of [DATE] revealed Resident #1 was admitted to the hospital for subdural hematoma. The resident had been seen earlier that day on rounds and found to be alert and orientated but stating seeing 2 little girls in his/her room. The staff reported this to be a status change for the resident. A UA (urine analysis) and culture had been ordered. However, several hours later the staff called and reported that the resident had fallen and hit his/her head. The resident had been alert and orientated at that time and desired to go to the emergency room . While in the emergency room the resident and after CT done the resident had a emesis and lost consciousness. The resident found to have a large subdural hematoma. The resident's condition had been discussed with the family and they desired no surgical intervention and wanted comfort cares. The resident remained unresponsive. Assessment and plan of the resident included traumatic large right subdural hematoma with mass effect. Prognosis is very grave. Family desires comfort cares If the resident is still with us tomorrow, consider transfer to Hospice House or back to the facility. Review of the facility's Progress Notes Report dated [DATE] at 6:12 a.m. indicated Resident #1 had been hallucinating. Review of Progress Notes Report dated [DATE] at 7:40 a.m. revealed staff reported increased confusion of Resident #1. The resident did not recognize staff or remember where he/she is at. Review of Progress Notes Report dated [DATE] revealed Resident's physician had seen the resident and gave new orders for a UA and culture. New [DIAGNOSES REDACTED]. Staff contacted the resident's family and notified of new orders and condition status. On [DATE] at 3:00 p.m., Staff E, RN (Registered Nurse) was interviewed and stated he/ she worked 2nd shift on [DATE] and did see Resident #1 prior to his/her fall and that the resident had been confused. Staff E stated the staff reported this confusion had been going on since the 3rd shift. Staff E stated the resident was to use a call light for assistance but the resident would not always do so. Staff E reported the resident would get up on his/her own. Staff E further indicated after the change in status for the resident regarding the new onset of confusion, there had not been no other safety interventions implemented. On [DATE] at 2:00 p.m., Staff D, CNA was interviewed and stated he/she worked second shift on [DATE] and had been assigned to care for Resident #1. Staff D stated they were short staffed that day and he/she had been the only CNA on the hall when there usually are two assigned along with a nurse. Staff D stated he/she had not been given any specific instructions for the resident's safety that day nor did he/she receive a report from the day shift of any change in the resident's condition. Staff D stated he/she started rounds about 2:45 p.m. and he/she had seen the resident around 3:00 p.m. Staff D stated the resident had been sitting in his/her recliner, awake, in their room and did not ask for anything. Staff D stated the next time he/she seen the resident around 3:15 p.m. the resident had been on the floor lying flat with back of head and top of shoulders against the closed closet doors. Staff D reported he/she had seen another resident go into Resident's #1 room and immediately Staff D went into the resident's room. Staff D reported it is common knowledge that Resident #1 would get up on his/her own without assist. Staff D stated this had been discussed prior to the day of the fall in a stand-up meeting between the change of shift. Staff D stated he/she had caught the resident up without assistance and would assist the resident with transfer and instruct the resident to use the call light to ask for assistance. On [DATE] at 1:43 p.m., Staff A was interviewed and stated Resident #1 would put call light on and then go self transfer, not waiting for staff assist. Staff A stated the day of the resident's fall, the resident had been using the call light on occassion and also have been transferring self. On [DATE] at 9:30 a.m., Staff B, LPN (Licensed Piratical Nurse) was interviewed and stated it had been normal for the resident to get up on own without staff assist and not use the call light. The resident had been self transferring on the day of the fall. Staff B stated at times the resident would put the call light on and self transfer before staff could respond to the call light. On [DATE] at 9:45 a.m., Staff C, housekeeping was interviewed and stated Resident #1 would get up on own without assistance. Staff C reported he/she picked up the resident's breakfast tray that morning and the resident didn't seem like her normal self. On [DATE] at 4:39 p.m., the resident's physician stated he did see Resident #1 a few hours before the fall and as staff reported the resident had been confused and hallucinating. The physician stated the resident did not have a subdural hematoma at the time he saw her and yes the fall could have caused it. The physician further reported the cause of the resident's death on [DATE] had been the result of the subdural hematoma. The facility failed to implement safety interventions for Resident #1 to prevent falls. The facility had knowledge the resident would not always use the call light and would self transfer. The facility had knowledge the resident had not been steady with ambulation and required assist of one staff for transfers. The facility also had knowledge that prior to the resident's fall he/she had a change in condition that included confusion and hallucinations and the facility still failed to implement additonal supervision for the resident's safety.

Based on observation, record review, staff interviews, and facility policy, the facility failed to provide one resident (Resident # 1) out of 10 resident's reviewed with the required supervision to prevent a fall and fracture of the right hip. The facility reported a census of 104 residents. Findings include: 1. The Quarterly MDS (Minimum Data Set) with an assessment date of 03/10/2012 identified a BIMS (Brief Interview of Mental Status) score of 7 for Resident # 1 which indicated severe long and short term memory deficits. Resident # 1 required supervision and the support of at least one facility staff person for transfers, walking in the resident's room and hall, dressing, and toilet use. This MDS, dated prior to the fall and hip fracture sustained by the resident on 03/14/2012, coded the resident as not steady and only able to stabilize with human assistance when moving from a seated to standing position, walking, moving on or off the toilet, and not steady for any surface to surface transfer. The resident also utilized a walker and at times a wheel chair. The MDS documented previous falls with no injury for the resident. Current [DIAGNOSES REDACTED]. The plan of care with a problem onset date of 03/02/2012 directed facility staff to provide contact guard assistance with personal hygiene and activities of daily living. The plan advised the staff that the resident might need more assistance in the evening when fatigued. The Elder Care Card, dated 02/21/2012 cued facility staff to use 1 to 2 staff persons, wheeled walker, and a gait belt to assist the resident. On 03/07/2012 the updated plan of care advised the facility staff to provide snacks or the bathroom to the resident when found wandering. On 03/02/2012 another revision of the care plan directed facility staff to provide stand by assist with the wheeled walker when up. The resident still required the supervision of the staff and to be on hand to assist the resident when up and about. The "special information" area of the card documented a [DIAGNOSES REDACTED]. The updated Elder Care Card for 03/19/2012 directed facility staff to use 2 staff persons, a wheeled walker, and a gait belt when assisting the resident. The Falls Prevention Care Plan for Resident # 1 updated on 03/14/2012 (the day the resident sustained [REDACTED]. The Morse Fall Scale sheet last dated 03/07/2012 revealed a score of 80 for Resident # 1, which is considered a very high risk for a fall. Assessments made of 02/21/2012, 02/28/2012, 03/06/201, 03/13/2012, and 03/14/2012 also documented a score of 80 for Resident #1 indicating the resident's risk for falls was consistent. A History&Physical dated 02/18/2012 documented a [DIAGNOSES REDACTED].# 1. On 03/05/2012 and 03/07/2012, physical therapy notes documented Resident # 1's increased level of lethargy, confusion, and wandering a lot at night. Physical therapy recommended 24 hour care due to the increased confusion and decreased resident safety. On 03/07/2012 at 5:10 A.M., facility staff found Resident # 1 sitting on the floor in front of a room recliner. The resident could not verbalize how the event happened. No alarms or other devices to alert staff to the resident's movements provided as interventions at that time. On this date, the plan of care still called for the assistance of 1-2 facility staff, a wheeled walker, and a gait belt to assist the resident when up ambulating. The intervention added on 03/07/2012 advised facility staff to attempt to provide the resident fluid, a snack, or the bath room when found up wandering. A review of the resident's medical record nursing notes revealed: on 02/22/23/24/25/26/27/28/29/2012 and 03/01/02/03/04/05/and 06/2012, the resident demonstrated lower extremity weakness. After the fall on 03/07/2012, nursing documented lower extremity weakness again on 03/09 also. The plan of care did not document any additional interventions to prevent potential falls from the increased lower extremity weakness. According to a Fall Assessment Flow Sheet, on 03/14/2012 at 4:45 P.M., Staff D (Licensed Practical Nurse) found Resident # 1 laying on the floor of his/her room. The documentation indicated the resident was up ambulating per self without assistance and did not use the call light. At this time, the plan of care still identified the resident as needing stand by assist from facility staff when up ambulating. The resident sustained [REDACTED]. On 03/15/2012 Resident # 1 underwent surgery for [REDACTED]. During an interview on 03/26/2012 at 2:30 P.M., Staff D (Licensed Practical Nurse) verbalized being in the hallway and heard Resident # 1's roommate say "you are going to fall". (Resident # 1 did not have a roommate at this time). When Staff D entered the resident's room, the wheeled walker laid on it's side and Resident # 1 laid in the middle of the room. Staff D verbalized Resident # 1 required stand by assist to be up ambulatory. Staff B (Registered nurse) summoned to assess the resident. Staff D stated the facility usually staffed 2 nursing assistants and a nurse on the resident's hall however, on 03/14/2012 only 1 nursing assistant and a nurse covered the hall until 5:00 P.M. The Heritage hall housed 16 residents on 03/14/2012. Staff D described Resident # 1 as forgetful and not really capable of using the call light. During an interview on 03/28/2012 at 3:15 P.M., Staff B (Registered Nurse) revealed she assessed Resident # 1 on 03/14/2012 after the fall. Staff B described the resident as on the floor in the middle of the room supine confused and moaning. Staff B verbalized it was not unusual for Resident # 1 to be up by his/herself at least twice a shift and heard the resident wandered at night. During an interview on 03/27/2012 at 10:30 A.M., Staff G (Licensed Practical Nurse) revealed being aware of the resident's falls prior to being placed in the nursing facility and indicated the resident could be up with stand by assist. Staff G verbalized being aware the resident would be up ambulating with a wheeled walker up by his/herself at least twice a shift . An interview on 03/27/2012 at 9:45 A.M., Staff C indicated Resident #1 would get up without assistance at least twice a shift. Staff C described the resident as confused and verbalized being aware of the resident's need for assistance when up ambulating. During an interview on 03/27/2012 at 10:00 A.M., Staff E verbalized finding Resident # 1 in another resident's bathroom at 6:30 A.M. Staff E described the resident as confused and care planned for being up with 1 assist. Staff E reconfirmed the Heritage hall only had 1 nursing assistant and a nurse for part of the evening shift. An interview with Staff A (working at the time of the resident's fall on 03/14/2012) on 03/26/2012 at 2:50 P.M., revealed Staff D found her in assisting another resident and informed her of Resident # 1's fall. Staff A immediately went to Resident # 1's room and observed the resident on the floor supine. Staff A verbalized Resident # 1 should be up with 1 assist per the care plan. The resident did not use the call light. During an interview on 03/27/2012 at 11:00 A.M., Staff I (registered nurse/clinical manager for Heritage hall) indicated the resident not require the use of alarms to alert staff to the resident's movements because Resident # 1 could get around pretty well with a walker and staff would redirect the resident. Staff I indicated being made aware of the resident's wandering into another resident's room. After the 03/07/2012 fall, the resident's care plan refected the need for 1 assist, however no placement of alarms added. Staff I verbalized the facility staff frequently checked the staff moved the resident to the bed which had a view of the bathroom, so no alarms were added. Staff I verbalized that even with a fall risk score of 80 (very high) she felt the resident ambulated in a steady enough fashion that no alarms would be needed. Staff I indicated all staff knew the resident did get up on her own. The Great River Medical Center Fall Prevention policy revised as of 07/2009 directed facility staff to consider all residents as at risk for falls. Residents with sensory deficits, a history of confusion, falls, syncope, and impaired mobility at a high risk for falls. The facility staff's responsibility included identifying, monitoring, and strategic to prevent the residents from falling. Those residents with frequent falls or behaviors increasing the risk of falls should be reviewed for a fall management plan.

This deficiency relates to facility reported incident # -I Based on record review and staff interview the facility failed to provide adequate supervision and assistive devices to prevent accidents for one of four residents reviewed identified at risk for falls. (Resident #1). The facility census was 111. Findings include: 1. According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 2/11/12, Resident #1 had a brief interview for mental status score of 10 indicating short and long term memory deficits with moderately impaired cognitive skills for daily decision making. Resident #1 required limited assistance with physical assist of one staff with transfers, ambulation, dressing, toilet use, bathing and personal hygiene. Resident #1's balance was determined as not steady and only able to stabilize with human assistance. Resident #1's [DIAGNOSES REDACTED]. Multidisciplinary Progress Notes dated 2/4/12 indicated Resident #1 admitted to the facility from a hospital stay. The facility admitted the resident for skilled care related to a subarachnoid hemorrhage (fall 2/1/12 in assisted living). The documentation for Resident #1 revealed physical and occupational therapies would be implemented for strengthening. The Morse Fall Scale completed by the facility indicated Resident #1 at high risk for falls on the initial 2/4/12 (score 65), 2/11/12 (score 65), 2/18/12 (score 55) and 2/19/12 (score 80). The key indicated a resident with a score of 51 or higher was a high risk for falls. The Falls Intervention Plan dated 2/4/12 indicated Resident #1 needed assistance of one to two staff during all transfers, to and from the toilet and during ambulation. Utilize a bed alarm and assure resident wears non-skid socks or shoes when moving. In an interview 3/8/12 at 2:10 p.m. Staff A (Physical Therapist) indicated Resident #1 was progressing well and anticipating discharge to assisted living. In the last session (2/16/12), Resident #1 was requiring light contact to close guard supervision. Staff A indicated Resident #1 was not safe to ambulate or transfer independently. In an interview 3/8/12 at 2:32 p.m. Staff B (Physical Therapist Assistant) indicated Resident #1 was seen by physical therapy five times weekly with goals to return to assisted living facility once determined safe with transfers and ambulation. Staff B indicated Resident #1's progress had been inconsistent towards independence due to safety concerns and cognitive issues. Resident #1 had not progressed to a level of independence with ambulation or transfers. At the time of Resident #1's fall on 2/19/12, he/she was still requiring close guard assistance due to safety. Multidisciplinary Progress Notes dated 2/4/12 at 11:50 a.m. indicated Resident #1 attempted to ambulate per self several times. Multidisciplinary Progress Notes dated 2/8/12 at 1:30 p.m. indicated Resident #1 tried twice to get up unassisted. Multidisciplinary Progress Notes dated 2/9/12 at 5:50 a.m. indicated bed alarm sounded and Resident #1 found in bathroom, voiding. Multidisciplinary Progress Notes dated 2/10/12 at 5:00 a.m. indicated bed alarm sounding and Resident #1 assisted to toilet. Multidisciplinary Progress Notes dated 2/12/12 at 11:45 p.m. indicated bed alarm sounding and Resident #1 found standing at bedside. Resident #1 confused. Multidisciplinary Progress Notes dated 2/13/12 at 11:00 a.m. indicated Resident #1 had tried several times to ambulate unassisted. Multidisciplinary Progress Notes dated 2/15/12 at 10:15 a.m. indicated Resident #1 got up frequently unassisted. Multidisciplinary Progress Notes dated 2/18/12 at 10:00 p.m. indicated Resident #1 attempted to ambulate and use bathroom unassisted. Multidisciplinary Progress Notes dated 2/19/12 at 3:00 a.m. indicated Resident #1 attempted to ambulate unassisted and ambulated to bathroom. Multidisciplinary Progress Notes dated 2/19/12 at 9:50 a.m. indicated staff heard a noise from Resident #1's room and upon entering, found Resident #1 lying on his/her back with eyes opened, but unconscious. The staff were initially unable to arouse Resident #1. The staff assessed Resident #1 and sent the resident to the hospital for further evaluation and treatment. Falls Intervention Plan dated 2/4/12 had no additional assistive devices or increased supervision interventions after 2/4/12 to address Resident #1's frequent behavior of getting up unassisted as documented in the Multidisciplinary Progress Notes. The hospital History and Physical with admitted [DATE] indicated Resident #1 fell and hit his/her head on 2/1/12 at an assisted living home and sustained a mild subarachnoid bleed in the left frontal lobe, right parietal and right frontal lobes. Resident #1 was hospitalized and discharged to the facility on [DATE]. On 2/19/12 Resident #1 fell in the bathroom, with loss of consciousness. A large hematoma developed on his/her right side of the head. Resident #1 was again hospitalized and a CT (computerized tomography) scan completed. The diagnostic imaging report dated 2/19/12 comparison to the previous CT scan dated 2/1/12 indicated a large scalp hematoma overlying the right temporal and parietal (both are areas of the brain) regions. A new subdural hematoma seen extending along the right frontal convexity and extending along the anterior falx. There is intraparenchymal bleed in the right temporoparietal and left frontal lobes. There is also a subarachnoid bleed overlying the left frontal and right temporal parietal lobes. The amount of subarachnoid hemorrhage is significantly increased from the prior examination on 2/1/12. In an interview 3/8/12 at 4:05 p.m. Staff C indicated she worked second shift and if Resident #1 got up unassisted, staff were to go in and assist him/her. In an interview 3/8/12 at 1:15 p.m. Staff D indicated she knew of Resident #1 getting up unassisted and when this happened, staff were to go in and ask what he/she needed and assist him/her. Staff D indicated Resident #1 used the call light inconsistently. In an interview on 3/8/12 at 1:30 p.m. Staff E indicated on 2/19/12 she was working the day shift and noted Resident #1 had been up two to three times that day unassisted. Staff E stated Resident #1 did not have a chair alarm during the day because there was more staff to supervise during the day and evening shifts. In an interview 3/8/12 at 1:40 p.m. Staff F indicated Resident #1 was admitted to the facility with brain trauma related to a previous fall. Resident #1's goal was to get stronger and return to assisted living. Staff F indicated there was discussion of using a chair alarm; but the team felt he/she was steady and improving with therapy. In an interview on 3/8/12 at 3:36 p.m. Staff G (Nurse Manager) indicated Resident #1 was stable with walking with a walker and was to be up with stand by assistance. Staff G indicated a chair alarm was not used due to the facility wanting to provide the least restrictive use of assistive devices and that Resident #1 had adequate supervision during day time hours.

Based on observations, clinical record review, staff interviews, and facility policy, the facility failed failed to provide supervision for 2 residents who sustained falls with injuries (Resident #1 & #9) with falls, to use foot pedals on the wheelchairs for 3 residents while being propelled in wheelchairs by staff (Residents #2, #7,#14), and failed to use gait belts during tranfers with 3 residents needing the assistance of staff for transfers and who had gait and balance problems, Resident #2, #8, and #18. The standard smaple included 22 residents, five residents in the sample had falls in the last 30 days. The facility reported a census of 108. Findings include: 1. Resident #9 had a quarterly MDS with an assessment reference date 5/18/11, which indicated the resident had a BIMS score of 11 indicated resident's cognition moderately impaired. The MDS indicated the resident required limited assistance of one person to transfer and ambulate. The MDS indicated the resident used a walker and wheelchair as mobility devices. The care plan reviewed 5/25/11 indicated resident required extensive to total assistance with ADLS due to history of head injury with ataxia the approaches were: - provide assistance with bathing/hygiene needed - cue resident to raise arms and legs to assist with dressing - transfer and ambulate with assist of 1 - 2, wheeled walker, up in wheelchair daily - meals in the K-2 dining room - attempt to respond to promptly when resident yells out, when in room/bathroom, as resident does not use call light - refuses side rails - restorative nursing for exercises and ambulation The assessment for Morse Fall Scale done on 6/16/11 and 7/15/11 scored 15 indicating low risk for falls. A review of the clinical record revealed the resident sustained [REDACTED]. - 6/16/11 at 12:20 a.m. in the resident's bathroom - 7/10/11 at 3:10 a.m. the resident's bed alarm sounded and resident found on the floor of the bathroom - 7/27/11 at 4:20 p.m. the resident found on floor in resident's room A review of the nursing notes from 6/02/11 - 8/08/11 revealed the resident sustained [REDACTED]. On 7/31/11 at 4:10 p.m. the nursing notes revealed the resident fell on the ground outside of facility on the sidewalk. The documentation on incident report indicated the staff did not witnessed the fall. The resident sustained [REDACTED]. The resident was transferred to emergency room . The wound was sutured in the emergency room . Observation made of the sidewalk on 8/11/11, and pictures taken, reflect the defects of the sidewalk. On 8/11/11 an observation was made of a maintenance person using to cement to fill in the defects in the sidewalk. The report submitted by the clinical nurse manager Staff KK indicated Resident #9 fell on the front side walk on 7/31/11, witnessed only by Resident # 10. The resident went down the front sidewalk which has a decline. When the resident got to the bottom, the wheel caught and tipped the resident forward. The resident fell out of the wheelchair and onto the sidewalk. Staff GG indicted in an interview on 8/11/11 at 9:45 a.m. when she arrived outside to assess the resident, the resident was sitting indian style in front of the wheelchair. The resident was at the end of the sidewalk ramp to the right of the front door. The resident's hand was bleeding. On 8/10/11 at 4:10 p.m. Staff HH stated in an interview residents can go outside. She stated she looked out the window on 7/31/11 and saw the resident on the ground. She went down, but Staff II was already there assessing the resident. The resident was on the sidewalk to the right and at the end of ramp. Staff II stated in an interview on 8/10/11 at 7:10 p.m. there were some places in the sidewalk which had been patched but there were some broken areas in the sidewalk. On 8/11/11 at 9:30 a.m. Staff EE, administrator, stated the last time the sidewalk had been patched was April 2009. The business office person, Staff JJ, stated she works from 8:30 a.m. to 5 P.M. The residents inform her when they are going outside and she looks outside to check on them. On 8/11/11 at 11:40 a.m. Staff L indicated the facility allows the residents to go out unless they are an elopement risk. Observation during during the survey conducted 8/8/11-8/10/11 showed Resident #9 self-propelling wheelchair. The resident did ambulate with restorative nursing on 8/9/11 at 9:20 a.m. the full length of Cascade Falls hallway. 2. The quarterly MDS (Minimum Data Set) with an assessment reference date of 06/01/2011 rated Resident #1 with a BIMS (brief interview for mental status) score of 3 which indicates severely impaired cognitive skills. The MDS indicated the resident required the extensive assistance of 1 facility staff person for the completion of personal hygiene cares, dressing, toilet use and mobility. The MDS indicated the resident had occasional bladder incontinence. The MDS indicated the resident could only balance with physical assistance from another person and required a wheelchair or walker for mobility. The MDS documented the resident's recent [DIAGNOSES REDACTED]. The resident's care plan with a start date of 03/11/11 instructed staff to provide toileting at routine intervals throughout the day and evening shifts, and to check and change the resident at night or take to toilet whenever resident request it. The care plan instructed staff to provide pericare for any incontinent episodes. The fall intervention plan dated 07/26/11 instructed staff to assist the resident with toileting, transfers and during ambulation. The staff were instructed to monitor use of wheelchair, to monitor and use bed and chair alarm making sure it was on the on position, place walker at chair side, monitor the resident when in wheelchair in hallway, and monitor when in the lobby/television area in recliner. The Morse fall scale dated 06/7/11 documented a fall risk score of 80 which indicates a high risk of falls. The Morse fall scale dated 07/23/11 documented a score of 80 which indicated a high risk for falls. On 07/26/11 the Morse score was documented as 90. Review of the resident's fall assessment flow sheets indicated the resident had fallen several times from 03/27/11 to 07/26/11. The fall on 7/26/11 resulted in a fractured hip. On 03/27/11 at 7:40 p.m. another resident notified the staff that Resident #1 slid out of the chair, the resident found on the floor in the television room. Intervention: Chair alarm On 04/21/11 at 4:10 p.m. the resident on the floor in the hallway Intervention: check to make sure chair alarm on at all times. On 04/24/11 at 1:00 p.m. the resident found on the floor in the television room, unwitnessed but documentation stated had climbed out of the recliner and slid to floor. On 06/21/11 at 4:45 p.m. the resident found on the floor between two recliners in the television room. Intervention: increase monitoring when in the television room. On 07/23/11 at 6:45 p.m. the resident found on the dining room floor next to the wheelchair. On 07/26/11 at 6:49 p.m. the resident was standing and fell , found flat on the floor. Interventions: The resident sent to the local hospital, fall had resulted in a fractured hip. On 08/09/11 at 3:25 p.m. Staff KK stated the charge nurse called to tell her the resident fell and was sent out to the hospital for evaluation related to complaints of back or hip pain. On 08/10/11 at 3:00 p.m. Staff LL stated she was in the kitchenette area across from the dining room on 07/26/11. Staff LL stated she doesn't remember if the resident's alarm sounded but something made her look out to the television room and saw Resident #1 standing. She stated she does not remember if the chair was in a reclining position or not. Staff LL stated she could not get to the resident before the resident fell . Staff LL stated after she witnessed the fall she ran down the Appletree hallway to get the staff nurse passing the evening medications. Staff LL stated she was assigned to work the other hall way and had been in the kitchenette making snacks for her hall. Staff LL stated that the staff assigned to Resident #1's hallway were assisting other residents at the time of the fall. Staff LL stated that the resident had a habit of turning off the chair alarm. On 08/10/11 at 3:30 p.m. Staff HH stated during the time of Resident #1's fall she was down the hallway passing evening medications when Staff LL came to get her and informed her of the resident's fall. She stated that prior to her starting the medication pass, she saw Resident #1 sitting in the recliner in the television room facing the television. Staff HH stated the chair was placed in a reclining position with the chair alarm in place. She stated that Staff LL related she heard an alarm sounding, turned around and witnessed Resident #1 standing up, but before she could get over to the television room, the resident fell . Staff HH stated after assessing the resident, the staff placed the resident back into the recliner and she noticed the deformity to the leg. The resident complained of thigh discomfort. Staff HH stated she notified the resident's doctor and family and sent the resident to the emergency room for evaluation. On 08/10/11 at 5:00 p.m. Staff Z stated he and the other C.N.A. assigned to the Appletree hallway were assisting other resident's when Resident #1 fell . Staff Z stated he and his partner placed Resident #1 in the recliner with the pressure alarm under the resident after supper. Staff Z stated the resident would often climb out of the recliner, so they made sure the alarm was on. Staff Z ststed the routine for the resident was to go to the recliner after supper because he/she liked to watch the television in the common room. Staff Z stated he did not hear the alarm sounding but was at the end of the hallway at the time of the fall. On 08/11/11 at 9:30 a.m. Staff TT stated she was assigned to work in Resident #1's hallway on 07/26/11. She stated that the resident's routine was to sit in the recliner in the television room and watch television after supper. She stated that Resident #1 always sat in the recliner across from the television set. Staff TT stated the resident was taken to the bathroom before supper and right after supper. Staff TT stated about 45 minutes after she toileted the resident, she noticed the resident trying to remove the pressure alarm pad from under him/her. Staff TT stated she went to the resident, replaced the alarm and turned the alarm back on. Staff TT stated the resident turned the alarm off and was holding the alarm box in his/her lap. Staff TT stated after she had replaced the alarm and turned it back on, she went out for a break but notified Staff Z and the nurses she would be off the floor. Staff TT stated when she returned from her break the other staff informed that Resident #1 had climbed out of the recliner and fell . On 08/11/11 at 9:30 a.m. Staff GG stated she was in the kitchenette cleaning up after supper. She stated she did not know the resident had fallen until Staff LL told her. Staff GG stated she did not hear the alarm sounding. 3. Resident #14 had a quarterly MDS (Minimum Data Set) with an assessment date of 6/22/10, which indicated the BIMS (Brief Interview of Mental Status) was 11(indicating the resident's cognition was moderately impaired). The MDS indicated the resident did not ambulate in the room or hall. The MDS indicated the resident used a wheelchair for mobility which the residnet could propell. The care plan of 6/29/11 indicated for ADLS (activities of daily living) the approaches were transfer with the assist of 1-2 to the wheelchair daily and propels self in wheelchair. Observation on 8/9/11 at 12:45 p.m. showed Staff U propelling resident from the dining room on second floor, to resident's room at end of Heritage Hall, in a wheelchair with the foot pedals up. Staff U failed to put the foot pedals down and put the residnet's feet on them to ensure the resident's safety during the movement. Observation made on 8/10/11 at 3:10 p.m. showed Staff V and Staff W remove the foot pedals from the resident's wheelchair in the resident's room. Staff V propelled the resident in the wheelchair into the bathroom for incontinence care and toileting. Before the staff pushed the resident out of the bathroom they put the wheelchair pedals on. 4. The initial MDS (Minimum Data Set) with an assessment reference date of 07/16/2011 rated Resident #2 with severely impaired cognitive skills for daily decision making with long and short term memory deficits. The MDS indicated the resident required the extensive assistance of 1 facility staff person for the completion of personal hygiene cares, but 2 or more for dressing, toilet use and mobility. The MDS indicated the resident had occasional bladder incontinence. The MDS indicated the resident could only balance with physical assistance from another person and required a wheelchair or walker for mobility. The MDS documented the resident's recent [DIAGNOSES REDACTED]. The resident's care plan with a start date of 06/24/11 directed staff to instruct resident to use assistive devices for ambulation, and monitor gait and balance. The fall intervention plan instructed staff that resident uses a wheeled walker for ambulation, monitor closely and required a position or pressure change alarm and bed alarm. Observation on 08/09/11 at 10:30 a.m. revealed Resident #2 sitting on the side of his/her low bed attempting to get up by self. The bed alarm had not been sounding. The certified nursing assistants were occupied with assisting another resident down the hallway. The surveyor notified a restorative aide of resident's attempts to get off the bed. The aide entered resident's room and sat with resident until C.N.A staff were free to assist. On 08/09/11 at 10:45 a.m. after providing personal cares, Staff QQ propelled the resident to the dining room without foot pedals on the wheelchair with the resident's feet skimming the floor. On 08/10/11 at 10:35 a.m. observations revealed Resident #2 sitting at the table in the dining room in a wheelchair. Staff RR approached the resident and informed her/him that she would take the resident for restorative program. Staff RR pulled the resident from the table and proceeded to propel the wheelchair without footpedals to the Appletree Lane hallway entrance. Staff RR placed a gaitbelt around the resident's waist, placed a walker in front of the resident and assisted the resident to stand. Staff RR held the gaitbelt with one hand and pulled the wheelchair with her other hand as the resident ambulated approximately half the length of the hallway. Staff RR assisted the resident to sit in the wheelchair to rest for 3 minutes. Staff RR assisted the resident to stand and ambulated to the end of the hallway and back up the hallway to Room 203. The resident indicated she/he needed to use the bathroom. Staff RR assisted the resident back into the wheelchair and obtained a staff C.N.A to assist her take the resident to the bathroom. Staff RR propelled the resident into the bathroom again without footpedals. At 10:50 a.m., on the same date, observations revealed Staff RR propelling the resident from Room 203 to the dining room without footpedals and the resident's feet sliding along the floor. On 08/10/11 at 5:30 p.m. Staff L indicated she would have expected the staff to use footpedals on wheelchairs if they propelled residents. 5. The MDS, dated [DATE], revealed Resident #7 had a severely impaired cognition and required two staff members to assist the resident to transfer and ambulate. The resident had functional limitations in range of motion in bilateral lower extremities. The resident's care plan, revised on 6/7/11 instructed staff to use a wheelchair for transporting the resident long distances. Observation on 8/9/11 at 10:05 a.m. revealed Staff CC with assist of a second CNA performed peri-care for the resident as part of the morning cares in the resident's room. After the resident was dressed and seated in the wheelchair, the resident was wheeled out to the dining room. The resident's wheelchair did not have foot pedals attached. The resident's feet hung to the floor, skimming the floor while being wheeled into the dining room. The resident had non-skid slippers on at the time. 6. The initial MDS (Minimum Data Set) with an assessment reference date of 07/19/2011 rated Resident #2 with severely impaired cognitive skills for daily decision making with long and short term memory deficits. The MDS indicated the resident required the extensive assistance of 1 facility staff person for the completion of personal hygiene cares, but 2 or more for dressing, toilet use and mobility. The MDS indicated the resident had occasional bladder incontinence. The MDS indicated the resident could only balance with physical assistance from another person and required a wheelchair or walker for mobility. The MDS documented the resident's recent [DIAGNOSES REDACTED]. The resident's care plan with a start date of 06/24/11 directed staff to instruct resident to use assistive devices for ambulation, and monitor gait and balance. The fall intervention plan instructed staff that resident uses a wheeled walker for ambulation, monitor closely and required a position or pressure change alarm and bed alarm. The last Morse fall risk assessment score of 80 obtained 07/23/11 indicated the resident to be at high risk for falls. Observations on 08/09/11 at 10:45 a.m. revealed Staff FF and Staff QQ, C.N.As (certified nursing assistants) entered the resident's room to provide toileting and/or perineal care. Staff FF placed a gaitbelt around the resident's waist as Staff QQ placed a shower chair/commode beside the resident's bed. The two staff assisted the resident to stand and pivoted turned to sit on the shower chair/commode. Staff NN, nurse, held the chair to keep it from rolling. Staff QQ propelled the resident into the bathroom, pulling the chair backwards and with resident's legs dangling down and feet touching the floor. The staff removed the gaitbelt and completely undressed the resident. The staff assisted the resident to stand, without using a gait belt, facing the wall and holding the grab bar. After providing personal care, the staff assisted the resident to stand, without using a gait belt, and pivot turned into wheelchair. The staff combed the resident's hair and propelled resident without foot pedals on the wheelchair to dining room for lunch. The Nurse Aide skills checklist for one and two person transfers with a revised date of 07/2009, instructed staff to place a gait belt around the resident's waist, making sure it is tight enough to be secure, grasp the front of the gaitbelt with the hand closest to the resident and placing the other hand toward the back of the resident. Then move the resident to a standing position and proceed with the pivot turn into the chair/toilet. On 08/10/11 at 4:30 p.m. Staff L indicated she would have expected staff to use a gait belt whenever transferring the residents or providing extended personal cares. 7. The MDS assessment, dated 6/29/11, revealed Resident #8 had severely impaired cognition and required limited assistance of one staff member to provide hygienic cares, activities of daily living, transfers, and ambulation. The MDS revealed the resident had a [DIAGNOSES REDACTED]. The MDS assessed the resident as having limitations of one upper extremity and one lower extremity. The resident's balance during transitions (moving from seated to standing position and moving on and off the toilet) and walking was not steady and the resident once on his/her feet was only able to stabilize with human assistance. The resident's care plan, with a goal date of 10/2011, instructed staff to cue, set-up, and assist with hygienic cares and to assist the resident with walking with a wheeled walker. The resident's care plan instructed staff to provide assistance to the resident for bathing/hygiene cares, provide perineal hygiene after incontinence, and provide one staff member to assist the resident with ambulation. The resident's fall scale, dated 7/1/11, assessed the resident as being high risk for falls with a score of 55 (with a score of 51 or higher indicating high risk. Observation on 8/9/11 at 11:20 a.m. showed Resident # 8 awake in bed. The resident slept in and did not arise for breakfast. Staff CC stated the resident would sleep in on most mornings. Staff CC and Staff UU prepared to assist Resident #8 to the bathroom. Staff CC placed a gaitbelt on the resident and ambulated the resident to the bathroom using a wheeled walker. The resident's gait was unsteady. The resident relied on the walker to assist her with ambulation. The staff assisted the resident to sit on the toilet. The staff removed the gait belt and hung over the walker bar. Once the resident was done voiding, the staff assisited the resident to stand up in front of the toilet without a gait belt. The staff assisted the resident in performing pericare. The resident held tightly to the wheeled walker in front of her/him. Staff UU cleansed the resident's peri-area, then the staff dressed the resident. The resident returned to bed with one staff assist using the gait belt and a wheeled walker. The resident recieved a lunch tray in the resident's room. 8. The Minimum Data Set (MDS), with a reference date of 07/06/11, documented Resident #18 had severely impaired cognitive status resulting in poor decision making and the need for cues and supervision from staff. The MDS indicated the resident was dependent on extensive assist of two staff members for activities of daily living, hygienic cares, transfers, ambulation, and toilet use. The MDS documented the resident did not have any limitations to upper or lower extremities. The resident's balance during transitions (moving from seated to standing position and moving on and off the toilet) and walking was not steady and the resident was only able to stabilize with human assistance. The MDS documented the resident [DIAGNOSES REDACTED]. The resident's care plan with a revision date of 7/13/11 instructed staff to provide assistance to the resident for bathing/hygiene cares, provide perineal hygiene after incontinence, and provide assist of one staff member for ambulation, provide assistance to the resident for bathing/hygiene cares, and provide limited to extensive assist of 1-2 staff members for ambulation. Observation on 08/10/11 at 10:30 a.m. revealed Staff AA, CNA (Certified Nurse's Aide) and Staff CC, CNA- Household Coordinator, preparing to assist the resident into the bathroom. The staff assisted the resident to stand and ambulated the resident to the bathroom using a wheeled walker and the assist of the two staff members. The staff members did not use a gait belt to assist in transferring or ambulating the resident. Staff BB, Registered Nurse, came into the room to assist with cares. The resident was assisted to stand after toileting and pericare given to the resident by Staff AA. The resident was holding tightly onto the walker during cares. The resident's gait while ambulating was unsteady and hesitant. The staff assisted the resident to the recliner without aide of a gait belt. During an interview with the Clinical Manager of the Low-stimulation unit on 8/11/11 at 10:30 a.m. she stated it was facility policy for staff to use a gait belt for ambulation of residents needing assist. The unit manager provided three policies, dated 7/2009, which outlined ambulation and transfer (from bed to chair one assistant and bed to chair two assistants) policies for the staff. Each type of transfer instructed staff to use a gait belt.