Every finding on record at Southern Hills Specialty Care

Based on review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. This resulted in the facility receiving a Sanitary food serving deficiency for the third consecutive recertification survey. The facility reported a census of 86 residents. Findings Include:The CASPER report, dated 08/13/2025, documented the facility had been cited by the Iowa Department of Inspections, Appeals, and Licensing for failures to serve food in a sanitary manner, resulting in an F0812 deficiency, twice in 2024. At the conclusion of the recertification survey on 08/21/2025, the facility was found to again be in non-compliance for Sanitary Food serving practices.The QAPI policy, last revised in 2020, identified a monitoring process which included multiple sources of data. It did not identify a process to address repeat deficiencies.In an interview on 08/21/2025 at 09:56 AM with the Director of Nursing (DON) in her role as the Quality Assurance Officer, stated they will be implementing a Performance Improvement Plan (PIP), related to the repeat deficiency. She stated facility leadership had identified issues in the dining room prior to the 08/18/2025 survey, but they had not yet implemented a plan on action before the start of the survey. She acknowledged the previous attempts at correcting the sanitary serving issues had failed.

Based on direct observation, staff interview, and facility document review, the facility failed to serve food in a manner that prevents cross contamination and promotes food hygiene. The facility reported a census of 86. Findings include: A direct observation of the lunch meal on 08/19/2025 at 12:39 PM revealed Staff M, Certified Nurse Aide (CNA), take a crescent shaped rocker style knife from the dining cart and cut the food of several residents. During the observation, after cutting the first resident's food, she cut the food of Resident #2 after the resident had begun to touch and cut her own food. The resident was observed licking her finger and touching her food before Staff M, CNA, used the rocker knife to cut her food. After cutting this resident's food, Staff M proceeded to cut the food of 7 more residents. At no point during the observation did Staff M change utensils or sanitize the rocker knife. The rocker knife was carried through the dining hall without a cover and was observed visibly soiled with food. After she was done cutting food for residents, she placed the rocker knife in a dirty dish bin and assisted residents with eating. In an interview on 08/21/2025 at 09:36 AM with Staff M, CNA, she stated she does not normally cut residents food in the manner she did on that day and acknowledged it was a mistake. She stated she knew it was a cross contamination issue but stated she was attempting to catch up on the delayed dining service. She stated she had already been talked to by facility administration and would not do this again. In an interview on 08/21/2025 at 09:43 AM with Staff B, CNA, she stated she would never use the same utensil to cut up multiple resident's foods. She stated they are trained to use the resident's silverware if they are requested to cut food, and to practice hand hygiene before and after. She stated it is a cross contamination issue at it's finest.In an interview on 08/21/2025 at 09:14 AM with Staff L, Licensed Practical Nurse, she stated they are trained to use a resident's own silverware to cut a resident's food up when requested. They are not to share utensils between residents and she would never use a rocker knife to cut a residents food for them unless it was their own assigned utensil. She stated if she accidentally cut food for a resident using cross contaminated silverware she would get the resident new food. In an interview on 08/21/2025 at 09:56 AM with the Director of Nursing (DON), she acknowledged she was made aware of the incident in the dining hall earlier in the week and confirmed it was an unacceptable practice. She stated her expectation is for staff members to use a resident's own utensils and to not share utensils between residents. She stated there would be a Performance Improvement Plan (PIP), related to the incident in the dining room, as it has been a repeat issue in the dining hall during the last three surveys. During the interview it was brought up that there had been an email chain between the Administrator, Dietician, and other supervisory staff on 08/15/2025 in which they had acknowledged dining service needed more oversight to reduce issues.Review of a facility provided document titled Assistance with Meals, with a last revised date of July 2017, stated the following: All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene and safe food handling.

Based on clinical record review, facility record review, video evidence, staff interview, and facility policy review, the facility failed to provide a private space free from being recorded without their consent and free from being degraded by staff members for 1 of 3 residents reviewed (Resident #73). The Facility reported a census of 86. Findings Include: The discharge Minimum Data Set (MDS) assessment for Resident #73, dated 08/12/2025, did not document her Brief Interview for Mental Status (BIMS) score. It documented the following relevant diagnosis: unspecified dementia, unspecified severity. The Progress Notes, dated from 08/08/2025 through 08/21/2025, failed to document the incident. In an interview on 08/18/2025 at 10:53 AM with the Facility Administrator, she stated she had been alerted by Staff H, Certified Nurse Aide (CNA), of an incident involving Staff G and Resident #73 on 08/11/2025. The incident related to a recording of Resident #73, sent to Staff H via a social media platform, that showed the resident wandering. It included a message stating Look how crazy this one is. Referring to Resident #73, the message appeared to have been sent by Staff G. The Administrator reported she immediately suspended the staff member pending investigation, as well as suspended Staff H while the investigation was ongoing. At this time, the Administrator provided the video on question, sent through social media to Staff H, showing Resident #73 wandering the halls, speaking to another resident, and otherwise acting normally. The social media video contains the name of Staff G as the sender, and Staff H as the recipient.In an interview on 08/18/2025 at 02:12 PM with Staff H, CNA, she confirmed that on 08/11/2025 she had been sent a video from 08/08/2025 by Staff G. The video was confirmed to be the video showed to the investigator by the Administrator, and Staff H confirmed there was a message attached to the video calling Resident #73 crazy. Staff H stated she was not friends outside of work with Staff G, and she was unsure why Staff G sent her the video and message. She stated she is very new to being a CNA, but she knew immediately that this was a violation of the Health Information Portability and Accountability Act (HIPAA). She stated she reported it to Staff I, Assistant Director of Nursing(ADON). In an interview on 08/18/2025 at 03:25 PM with Staff I, ADON, she confirmed she took report from Staff H about a resident having been filmed without her consent and against corporate policy. Staff I reported it to the Facility Administrator and the Director of Nursing (DON), at which point both Staff H and Staff G were suspended pending investigation. She was unaware why the video was taken, but noted staff are not permitted to record/photograph residents who cannot give consent. She confirmed that Resident #73 was unable to give consent due to her diagnosis of dementia. In an interview on 08/18/2025 at 03:34 PM with the DON, she stated she received the report regarding the video from Staff I as well as a now-terminated staff who was unavailable to speak with. As soon as she was made aware, both Staff G and Staff H were suspended pending further investigation, and investigation confirmed the presence of the video taken on 08/08/2025. In an interview on 08/21/2025 at 04:36 PM with Staff G, CNA, she acknowledged she had sent the message and recorded and sent video of Resident #73. She stated she did not know why she did it, and confirmed she had sent the video to Staff H. She apologized, and acknowledge what she did was wrong, but could not provide a rationale as to why she recorded the resident. She acknowledged her statement about the resident was degrading. In an interview on 08/21/2025 at 11:14 AM she stated her expectations are for staff members to never record residents. She confirmed it is corporate policy that if they will be present in pictures of videos they have to have a signed media release and it has to be requested and signed for each appearance. She stated it is never appropriate to record a resident for personal use or for staff member entertainment, nor to share those videos on social media. Review of Staff G's employment file documented she had been previously given a written warning for sleeping on the job on 04/28/2025. It also contained documentation that Staff G had successfully completed the Iowa Department of Human Services Dependent Adult Abuse Mandatory Reporter Training on 03/14/2024. Review of a facility provided document titled Videotaping, Photographing, and Other Imaging of Residents, with a last revised date of April 2017, stated the following: 1. Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect, or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family.2. Transmitting unauthorized images of any resident through email, internet, or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such.

Based on observation, staff interview, and policy review, the facility failed to ensure foot pedals were applied to residents' wheelchairs during transport for 2 of 2 residents (#11, #22) reviewed. The facility reported a census of 86 residents. Findings include: 1) On 8/18/25 at 9:32 AM, observed Staff C, Certified Nurse Aide (CNA) transporting Resident #22 in his wheelchair without his foot pedals from the dining area to the bump-out (area used for residents to watch television).The Minimum Data Set (MDS) assessment for Resident #22 dated 8/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of end-stage renal disease, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and reduced mobility. It indicated Resident #22 was independent with toileting, required setup assistance for eating, moderate assistance for oral and personal hygiene, dressing, and footwear, and maximal assistance with bathing. It also indicated he was independent with mobility except supervision with shower transfers. It further indicated he used a manual wheelchair.The Care Plan dated 12/09/24 indicated the resident used a manual wheelchair for long distances.On 8/20/25 at 10:38 AM, Staff C stated residents who are transported in wheelchairs by staff should have pedals on their chair. She stated Resident #22 should have had pedals on his wheelchair since she pushed him but didn't think about it because the resident is typically independent with mobility.2) On 8/19/25 at 9:00 AM, observed Staff F, CNA transporting Resident #11 out of her room in her wheelchair without foot pedals.The Minimum Data Set (MDS) assessment for Resident #11 dated 8/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of end-stage renal disease, non-Alzheimer's dementia, diabetes mellitus (DM), and abnormalities with gait and mobility. It indicated Resident #11 required setup assistance for eating, maximal assistance with bathing, was dependent with toileting, and required moderate assistance with all other ADL's and mobility. It further indicated she used a manual wheelchair.The Care Plan revised 8/18/25 indicated the resident used a wheelchair at times but only wanted one pedal on it.On 8/20/25 at 11:54 AM, Staff F, CNA stated staff have to make sure residents' legs are on the pedals and their arms are inside the chair when transporting residents in a wheelchair. She also stated there were no residents who could be transported without pedals. She further stated Resident #11's wheelchair had only one (1) pedal per the resident's request.On 8/20/25 at 3:22 PM, the Director of Nursing (DON) stated staff should have gotten the residents' foot pedals and offered it to the residents. If the residents refused, then it should be documented.A policy titled Safety and Supervision of Residents revised 7/2017 indicated employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.

Based on observations, staff interview, and policy review the facility failed to disinfect a mechanical lift after use between 3 of 3 residents (#3, #16, #45), failed to don appropriate Personal Protective Equipment (PPE) during the transfer for 1 of 1 resident on Enhanced Barrier Precautions (EBP), failed to maintain 1 of 1 resident's indwelling catheter bag below the resident's bladder during transfer, and failed to perform hand hygiene for 1 of 1 resident when moving from dirty to clean equipment. The facility reported a census of 86 residents. Findings include: 1) The Minimum Data Set (MDS) assessment for Resident #3 dated 6/12/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of atrial fibrillation (irregular heartbeat), neurogenic bladder (improperly functioning bladder caused by nerve damage), multiple sclerosis, and seizure disorder. It indicated the resident was dependent with all aspects of Activities of Daily Living (ADLs) and mobility.The Electronic Health Record (EHR) included an order for EBP due to suprapubic Foley (urinary catheter that is surgically inserted directly through the bladder wall).The Care Plan revised 4/25/25 directed staff to position catheter bag and tubing below the level of the bladder and away from the entrance door.2) On 8/18/25 at 11:33 AM, Staff A, Certified Nurse Aide (CNA) used a mechanical lift to transfer Resident #45 from her bed to her wheelchair. Staff A exited Resident #45's room with the mechanical lift and pushed it directly into Resident #16's room. Staff A and Staff B, CNA used the mechanical lift to transfer Resident #16 from her bed into her wheelchair. Staff B transported Resident #16 to the dining area. Staff A pushed the mechanical lift into Resident #3's room to transfer him to his wheelchair. Staff A and Staff B, CNA donned gloves upon entering the resident's room. Staff A repositioned Resident #3's urinary catheter bag on his shins and connected the resident's transfer sling to the mechanical lift. She raised Resident #3 off of the bed and the partially full catheter drainage bag was observed hanging above the resident's bladder on a V shape area (shape made by crossing the sling components that support the legs) of the sling. After the resident was positioned over his wheelchair, Staff A grabbed the resident's tube-feeding (TF) equipment (pump and tube-feeding bag), unfastened them from the bedside pole, and handed them to Staff B. Neither staff donned a protective gown before manipulating the resident's urinary catheter bag and Staff A did not perform hand hygiene or change gloves between handling the urinary bag and the resident's tube feeding equipment.At 11:42 AM, Staff A pushed the mechanical lift out of Resident #3's room and placed it against the wall outside another resident's room. Staff A did not sanitize the mechanical lift before or after each resident use.On 8/20/25 at 10:09 AM, Staff C, CNA and Staff D, CNA stated PPE gowns are always required when handling Resident #3's urinary catheter and anytime a catheter is manipulated. Staff C stated sometimes staff only wears gloves when transferring Resident #3 but added the gown and gloves are used to protect both the resident and staff. Staff D also stated the catheter bag could be a source of infection to both staff and a resident if staff weren't wearing PPE. She also confirmed Resident #3 was on EBP and both acknowledged staff should wear a protective gown and gloves while transferring Resident #3. On 8/20/25 at 10:05 AM, Staff E, Assistant Director of Nursing (ADON) and Infection Preventionist (IP) stated shared equipment (i.e. mechanical lifts) should be disinfected after every use and before each use in case previous disinfection is unknown. On 8/20/25 at 10:36 AM, Staff C stated mechanical lifts should be wiped down after each use before being used for another resident.On 8/20/25 at 3:22 PM, the Director of Nursing (DON) stated staff should have sanitized the equipment between each use. She also stated the catheter bag should have been kept below the resident's bladder during transport, and staff should have removed gloves, sanitized hands, and replaced their gloves before handling the TF equipment.A policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised 10/2018 indicated reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).A policy titled Catheter Care, Urinary revised 9/2014 directed staff that the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. It also directed staff to use standard precautions when handling or manipulating the drainage system.An undated facility sign titled Enhanced Barrier Precautions indicated:PROVIDERS AND STAFF MUST ALSO:Wear gloves and a gown for the following High-Contact Resident Care Activities:DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use:central line, urinary catheter, feeding tube,tracheostomyWound Care: any skin opening requiring a dressing

Based on review of the facility policy and staff interviews, the facility failed to immediately shower residents, bag clothing and linens for laundering, and sanitize resident furniture after the discovery of a bed bug in a resident room. The facility reported a census of 86 residents. Findings include: During an interview on 4/9/25 at 5:27 p.m., Staff E, Certified Medication Aide (CMA) stated on the evening of 2/19/25 while passing medications in room [ROOM NUMBER] she saw something move on the arm of a recliner. Staff E stated she went over to the chair and picked up a bug. She stated she took the bug to the nurse's station and taped it onto a white piece of paper. Staff E stated the Maintenance staff was informed and instructions were given to leave the bug at the nurse's station and maintenance would look at it tomorrow [2/20/25]. She stated she did not bag clothing or shower the residents as she did not know it was a bed bug. During an interview on 4/9/25 at 6:16 p.m., Staff G, CMA stated she worked on 2/21/25, and on that date room [ROOM NUMBER] was placed in isolation due to a bed bug having been found on 2/19/25. Staff G stated she recalled the Laundry staff also bagged the linens and resident clothing from room [ROOM NUMBER]. During an interview on 4/10/25 at 1:00 p.m., the Administrator stated a bed bug had been discovered in room [ROOM NUMBER] on 2/19/25. The Administrator acknowledged staff failed to follow the Bed Bug process after the bug was found on 2/19/25. The Administrator stated when a bed bug is discovered during day hours, Maintenance is notified and they contact the pest control provider, while Housekeeping is responsible for bagging clothing, linens, curtains and sanitizing the mattress. The Administrator stated Certified Nursing Assistants would assist with showering the residents. She explained after hours, Nursing staff is responsible for following the policy. The Administrator stated Maintenance was notified on 2/19/25, but the Bed Bug process was not initiated until 2/21/25. Review of the undated facility policy, titled Bed Bug process directed staff, in part to: 2. Current Resident a. The resident is to be immediately taken to the shower. Bag the clothes and take them immediately to the laundry. If the clothes cannot be immediately placed in the washer, set the bag outside until they can go straight into the machine. b. Bag and remove all the clothes and linens (includes curtains and privacy curtains) from the room and launder them right away. If they cannot be laundered, store outside until they can go directly into the machine. c. Mattresses should be inspected. If there are any holes, the mattress should be bagged within the room and discarded. A new mattress can be replaced, once the room has been treated. d. Resident owned chairs in the facility should be bagged and removed from the facility. e. Facility chairs in the room. If the chair is owned by the facility, the chair is to be bagged and removed from the facility.

Based on direct observation, staff interview, and facility document review, the facility failed to serve meals in a manner that protects residents from cross-contamination. The facility reported a census of 85. Findings include: A direct observation of the lunch meal on 09/09/24 at 12:26 PM revealed Staff A, Restorative Aide (RA), used her ungloved fingers and hand to move ice from a Styrofoam cup into a resident's drink when the resident requested ice in his drink. A direct observation of the lunch meal on 09/09/24 at 01:08 PM in which Staff B, Certified Nurse's Aide (CNA), assisted three separate residents with eating without using hand hygiene in between each resident. During the same meal observation she served three meals with her fingers touching resident's food. A direct observation of the lunch meal on 09/10/24 at 12:38 PM revealed Staff C, CNA, providing feeding assistance for two residents without using hand hygiene between either resident. In an interview on 09/12/24 at 10:38 AM with Staff D, she stated policy dictates nursing staff should never touch a resident's food. They are to avoid putting their fingers on the top of the plate. If they do touch resident food, they are to take the food back to the kitchen and request a fresh plate. She acknowledged when providing feeding assistance hand hygiene must be performed between each resident. In an interview on 09/12/24 at 10:45 AM with Staff E, Registered Nurse (RN), she stated staff are to perform hand hygiene before serving food and to never touch the food or top of the plate. If staff are providing feeding assistance they should wash or otherwise sanitize their hands in between each resident assisted. In an interview on 09/12/24 at 10:34 AM with the Director of Nursing (DON), she stated nursing staff are expected to follow facility policies and procedures when providing feeding assistance or serving food. She acknowledged this included the sanitation of hands before serving food, avoiding contact with resident food, and sanitizing hands when switching to assist a new resident. She stated it is never acceptable to touch food or drink directly. Staff should acquire fresh food should a mistake be made. Review of a facility provided document titled Handwashing/Hand Hygiene, last revised in August 2019, documented hands are to be washed after coming into contact with a resident, before and after eating or handling food, and before and after assisting a resident with meals.

Based on observations, interviews, and record review the facility failed to identify and assess an injury on 1 of 3 residents reviewed (Resident #6) at the time the bruise occurred. The facility found a large bruise that partially wrapped around Resident #6's upper left arm. The bruise was yellow in color which meant it was in it's final stages of healing. The facility reported a census of 80 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that Resident #6's diagnoses included non-Alzheimer's dementia, delusional disorders, and difficulty in walking. A Brief Interview for Mental Status (BIMS) revealed a score of 3 out of 15, which indicated severe cognitive impairment. Resident #6 required supervision of 1 staff for locomotion on the unit. This resident required limited assist of 1 for dressing and total dependence of 1 for bathing. The Progress Notes for Resident #6 documented the following: On 11/6/23 at 6:54 p.m. Nurse notified by staff resident on floor in front of her recliner on her bottom with her legs out in front of her. Assessed with no injuries noted, full range of motion and denied pain. The resident stated the chair bucked me out. Resident assisted by the Registered Nurse (RN) and staff via gait belt back on to feet. Provider made aware. On 11/19/23 at 2:34 p.m., Nurse assisting CNA in the shower room changing Resident #6's clothes. While changing this resident's shirt, the nurse noted a bruise to resident's left bicep. Bruise yellow and older looking. The resident had no complaints of pain. The on-call nurse manager and the provider made aware. A Wound Evaluation dated 11/19/23, documented that Resident #6 had a bruise on her upper inner left arm that measured 13.39 cm (centimeters) in length by 5.92 cm in width. It documented the bruise facility acquired and the age of the bruise unknown. An internal investigation regarding the bruise found on 11/19/23, documented the findings as the most probable cause of the bruise a fall that occurred on 11/6/23. It documented the Root Cause Analysis as the positioning of the hand on Resident #6's bicep to steady resident while providing 2 person assist from floor following the fall. On 12/11/23 at 11:02 a.m., Staff A, Certified Nurse Aide (CNA), Staff A stated that she had heard about the bruise on Resident #6's arm. Staff A stated that Resident #6 was mainly independent with occasional dressing assistance. She stated that Resident #6 usually toileted herself. She stated that Resident #6 needs assistance in the shower which consists of staff taking the rag and cleaning her body. Staff A stated she was not aware of Resident #6's fall. Staff A stated that she may have charted that she gave Resident #6 a shower but it might have been her partner that gave it as they work as a team to get the charting done. Resident #6 usually wears long sleeves and Staff A stated she did not recall being made aware that this resident had a bruise (after a shower). Staff A stated that if she saw a bruise, she would have reported it right away to a charge nurse. Staff A stated if there was a medication aide on the unit, she would have reported it to the Assistant Director of Nursing (ADON) or to the Director of Nursing (DON)s. Staff A stated that due to this resident's dementia, if Resident #6 stated the nurses already knew about a bruise, Staff A would report it anyway. Staff A stated, she would report it even if a resident didn't have dementia, just to cover bases. Staff A stated that Resident #6 was a very well rounded resident. Staff A stated that she had never seen residents or staff that have put hands on this resident (roughly). Staff A stated that Resident #6 was pretty amazing and easily taken care of. Staff A stated that Resident #6 was able to state what she wanted, with a little confusion here and there. Staff A said that Resident #6 was not difficult. Staff A stated that all the staff and residents Staff A had seen got along with Resident #6 well. Staff A stated that this resident did not have any tendency to become agitated. A statement written by Staff B, CNA, and provided by the facility as part of their internal investigation was dated 11/19/23. The statement documented that Staff B gave Resident #6 a shower on 11/15/23 and she noticed an older looking bruise on Resident #6's left bicep. Staff B wrote that when she asked Resident #6 if Resident #6 had told the nurse about the bruising, Resident #6 said she had, so Staff B didn't report it further. On 12/11/23 at 12:02 a.m., Staff B stated she did not remember what day she saw the bruise. She stated that there was yellow around the bruise and that Resident #6 had said she had reported it. Staff B stated that she should have followed up and told the nurse anyway. Staff B stated that it was a good sized bruise and it looked old so she had assumed that Resident #6 was right and the nurses did know about it. Staff C stated that Resident #6 was very sweet. Staff B stated she had never seen anyone, resident or staff, be rough with this resident in any way. Staff B said that this resident was easy to work with was independent on most days but sometimes she will accept help. Staff B stated that morning she asked Resident #6 if she wanted help with putting her shirt on and she said 'yes, because she gets a little dizzy putting it on.' Staff B stated on other days she will say she can do it herself. All residents like her as well. Staff B stated she didn't know how Resident #6 got that bruise. Staff B said she did not think anyone intentionally would harm this resident. On 12/11/23 at 2:45 p.m., Staff C, Licensed Practical Nurse (LPN), stated she had brought clothes into the shower room and the CNA in the shower room was taking Resident #6's top off. They noticed the bruise on her arm. Staff C stated she took a picture and she asked Resident #6 what happened. She said that somebody grabbed her but couldn't remember when. Staff C stated she then told the Nurse Manager. Staff C stated they had talked about this resident having a fall a week or so before. Staff C stated that the team was going to talk more about it and try to figure out where the bruise came from. Staff C stated she was surprised it had not been documented prior. Staff C stated she also knows sometimes Resident #6 refuses to shower and refuses to change clothes a lot too. Staff C stated that part of her could see how that could happen. On 12/11/23 at 12:30 p.m., the Regional Director of Clinical Services and the DON, when told there was a concern with not identifying a large bruise in a timely manner, they stated they have had past non-compliance with the issue. The Regional Director of Clinical Services acknowledged this was a concern. They stated last week they initiated a new skin check form to be filled out by a nurse weekly. Their expectation is the nurse fills out the form on night shift. Prior to last week they were having the day shift nurses fill it out, but it was not always getting done related to workload issues. They provided policies but stated these policies come into play after a skin issue has been identified, and realized the bruise was not identified until over a week later. The expectation now is the nurses do skin checks on all residents weekly. The expectation is CNAs report all skin concerns to RN's at the time they see something. The DON stated he provided education to the nurses and to the CNAs. When asked about a CNA seeing the bruise in the shower but not reporting it because the resident said that she had reported it to the nurse and because the bruise looked old, they both said that is why they provided education on their expectation to report on skin conditions even if a resident would say it had already been reported. An Accident and Incident-Investigating and Reporting policy revised 2017, directed staff that the Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall b included on the Report of Incident/Accident form: the nature of the injury/illness (e.g. bruise).

Based on observation, record review and staff interviews, the facility failed to prevent a resident that exhibited signs of cognitive impairment from eloping from the facility. Elopement means a resident that leaves the facility without staff knowledge or permission. On 10/29/22, staff failed to thoroughly investigate when the front door alarm had been activated. Resident #14 eloped and was found a quarter mile from the facility on the side of the road, near the entrance to the interstate. The resident wore a wanderguard alarm that failed to work properly at the front door. These findings constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 84 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] showed that Resident #14 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits). The MDS revealed the resident remained independent with transfers, locomotion, toilet use and dressing. The care plan dated 1/8/19, identified Resident #14 as at risk for wandering and had diagnoses that included: Alzheimer's disease, wandering, anxiety disorder and major depressive disorder. An update on 5/15/22 documented an addition that directed staff to stay with the resident if she exhibited wandering behaviors. A Wandering Evaluation dated 2/20/22 at 4:07 PM showed Resident #14 scored 26 points (high elopement risk). On 9/8/22 at 12:03 PM, she scored 20 points (also high risk). The nursing notes contained the following documentation: 1) On 2/22/22 at 3:17 PM, Resident #14 exit seeking and trying to the leave the facility. The census tab showed that on 2/22/22 after these behaviors, resident moved to the 500 hallway (locked memory unit). 2) On 5/13/22 at 5:56 PM Resident #14 involved in an incident in the memory unit, so staff moved her out of the locked department. The Medication and Treatment Administration record showed she wore wanderguard (WG) alarm that staff checked twice daily. From 5/14- 21, wanderguard was on her left ankle; on 5/22/22, staff attached it under the tray of her walker. 3) On 8/5/22 at 5:07 PM Resident #14 agitated, exited via the front door and started down the driveway. Staff convinced her to come back inside at that time. Another note dated 10/19/22 at 11:15 AM showed the resident attempted to leave through the front door. 4) On 10/29/2022 3:10 PM, Resident #14 approached the nurse at main nurses station and asked the nurse to find her a ride home. The nurse redirected the resident with conversation and snack, resident calmed with redirection and walked hall where she lived. She no longer made statements of wanting to leave. 5) On 10/29/2022 at 4:00 PM, Resident #14 found outside of facility walking in the grass on Clay Street at 3:50 PM. Resident assisted back to facility. Staff conducted a head-to-toe assessment, found no injuries, and then provided 1:1 supervision. On 11/15/22 at 3:13 PM the Director of Nursing (DON) said she was not working the day that Resident #14 left the building unattended. She reported she lived close by and while driving down the road, she saw the resident walking in the grass. The DON stated she the resident had crossed Clay Street and left her walker on the sidewalk where there was a curve. She continued to walk through the grass up the hill toward the interstate (according to a fitness application, the resident was found a quarter of a mile from the facility). The resident recognized the DON right away and she agreed to get into the car with her and she was brought back to the facility. On 11/15/22 at 2:42 PM, Staff D, Certified Nursing Assistant (CNA) verified she had worked the day that Resident #14 got outside undetected. She said that there was an agitated resident in the 400 hallway that afternoon, so they had closed the fire doors to keep her confined. Staff D was on the other side of the doors so it was difficult for her to hear the alarms and announcements regarding what door was open. She said that when she came into work at 2:00 on 10/29/22, Resident #14 had been at the nurse's station talking to the nurses. That was the last time she saw her before she left the facility. Staff D said that the alarms had gone off many times that afternoon because there were many people in and out for a party for another resident. She said that since the elopement, the staff were more diligent in investigating an alarm. Before the elopement, if there was a door alarm going off, we didn't think much of it. On 11/15/22 at 2:33 PM, Staff A, Licensed Practical Nurse (LPN) reported she worked on the afternoon of 10/29/22 - Resident #14 had been at the nurses station, acted agitated and said wanted to go home. The resident asked Staff A to call a cab for her. Staff A redirected the resident with a snack and the resident headed back down the hallway toward her room. She later learned that the resident had been outside when the Director of Nursing (DON) contacted the facility and told them she found the resident outside. Staff A said that she had heard alarms earlier in the afternoon. She had shut off the alarm at the front door once, then checked the perimeter but didn't see any residents outside at the time. The alarms went off a couple more times, but other staff members responded and had turned it off. Staff A said that she did not do a head count to account for all residents. Staff A added there were many family members at the facility that day for a party in the 300 hallway; they do not always push the red button before entering, therefore the alarm had sounded many times. On 11/17/22 at 11:29 AM, Staff C, Certified Nursing Assistant (CNA) said that there was a resident at the facility that was having a party on 10/29/22 and there were many family members in and out of the front door. She said that she had turned the alarm off several times and she didn't see any residents around. She said that staff were always expected to investigate when an alarm had sounded, but it was not enforced and many did not follow through with this expectation. On 11/17/22 at 9:50 AM, LPN Staff B reported that she had been instructed by the facility to go to the door when that alarm sounded was sounding and to look for any residents that may have exited. If there were no residents observed at the door, she would check the perimeter of the building. On 11/17/22 at 6:40 AM the DON explained that the keypad on the wall wired to the door alarm would not work if a resident with a WG was nearby. If the code had been punched into the key pad the door could be opened without the alarm going off, but, if a resident with a WG alarm walked through the doorway, the alarm would then be activated. She said that this was the point that failed when they tested the WG later in the afternoon of 10/29/22 after Resident #14 had been brought back to the facility. They then went to other doors throughout the building with the same WG and it worked at those doors. She said that they called the service provider for the alarms and he inspected the wiring. He determined that they would need to do some rewiring. In the meantime, the facility put an extra alarm on the front doors. On 11/16/22 at 6:43 AM the DON checked the WG at the front door and it was working. On 11/16/22 at 3:39 PM the administrator said that the facility did not have a policy related to door alarm response. She said that it was expected that staff would go to the door that is alarming and if they did not see who set it off, they would not turn the alarm off until they determine how it was set off. Staff were then expected to do a headcount of all residents. According to the facility policy: Emergency Procedure - Missing Resident, dated August 2018, a resident at risk for wandering and/or elopement would be monitored and staff would take necessary precautions to ensure their safety. The immediate jeopardy was removed on 10/29/22 and the IJ was identified as past noncompliance when the facility took the following actions: 1) All residents were assessed via a wandering evaluation. If not current, the evaluations were completed. 2) Posted signs on the handicap exit button for visitors to wait for staff to assists. 3) Posted sign on front entrance door for visitors to call the facility before entering and exiting so a staff member could assist with entry and exit until wander guard alarm could be serviced. 4) Elopement binder with listing of high-risk residents placed at nurses stations 5) Maintenance supervisor checked for functioning of all exit door alarms and wander guard alert. 6) Call to RF Technologies to schedule a service call to address inconsistent functioning of front door wander alerts. 7) Residents with wander guards in place had tested and were check for placement, functioning and expiration date. 8) Resident #14 was moved to the locked memory unit on 10/29/22. 9) Secondary alarms were added to the front door 10) Missing resident drills conducted randomly. 11) Education to staff regarding the door alarm response with resident at risks 12) Staff educated on outside check around outside of the building when door alarmed. 13) Attention signs at exit doors reminding visitors to not allow residents to exit. 14) Door alarm and missing resident protocol added to the agency orientation checklist.

Based on observation, clinical record review, and resident, and staff interviews, the facility failed to maintain the resident's dignity for 2 of 18 residents reviewed (Residents #39 and #20). The facility reported a census of 84 residents. Findings Include: 1. According to the Minimum Date Set (MDS) assessment tool dated 9/19/22, Resident #39 scored 15 on the Brief Interview for Mental Status, which indicated the resident demonstrated no cognitive impairment. The MDS showed Resident #39 required extensive assist from staff for transfers and repositiong. The MDS documented the resident had diagnoses that included weakness, muscle atrophy, and other abnormalities of gait and mobility. The care plan last revised 11/11/22 revealed Resident #39 required assistance with Activities of Daily Living (ADL's) due to a recent hip fracture. The care plan documented the resident required assist from staff for repositioning in bed and surface-to-surface transfers. In an interview on 11/15/22 at 11:43 AM, Resident #39 reported a few months ago Staff K, Certified Nursing Assistant (CNA), told her I'm not going to hold you, as he assisted Resident #39 to lower herself into a sitting position on the side of the bed. Resident #39 reported Staff K then let her go too soon as she sat down and was not kind about it. Resident #39 also reported on another occasion, Staff K assisted her from the wheelchair to her bed. She described his behavior as acting very upset; although the resident could not recall Staff K's exact statements during the event, she described his statements mean. In an interview on 11/17/22 at 3:35 PM, the Administrator and Director of Nursing reported they expected staff to treat residents with dignity and respect at all times. 44475 2. The MDS dated [DATE] revealed Resident #20 had a BIMS score of 12 (mildly impaired cognition) and had diagnoses of cerebrovascular accident (CVA or stroke) and irritant contact dermatitis due to fecal, urinary or dual incontinence. The MDS documented the resident required total assist of 2 staff for transfers and extensive assist of 2 staff for toilet use. Observation on 11/15/22 revealed the following: - At 03:12 PM revealed Resident #20 sat in her wheelchair in her room and faced a wall clock. During an interview at that time, the resident reported staff told her to go to the bathroom in her incontinence brief if they don't get to her in time, and added that she soiled her incontinence brief at least once daily because staff took over an hour to answer her call light. Resident #20 commented she knew how long it took because she tracked the time on her wall clock. She also reported staff told her at 1:00 PM today they would help her transfer to her recliner this afternoon, but no one had returned to help her yet. Resident #20 hung her head at times during the conversation and reported that it made her feel like she was not important enough to get the care she needed. - At 3:20 PM, Resident #20 pressed her call light. - At 3:32 PM, Staff J, Certified Medication Aide (CMA) answered the call light and told the resident she would get another staff member for assistance. - At 3:42 PM, the resident reported that she had soiled her incontinence brief right after the CMA came into her room at 03:32 PM. - At 4:16 PM, Staff J, CMA, returned to the resident's room with a mechanical lift. The Dignity facility policy dated 2001 directed staff to promote dignity and assist residents; for example: promptly responding to a resident's request for toilet assistance. The policy revealed demeaning practices and standards of care that compromise dignity are prohibited. In an interview on 11/21/22 at 1:52 PM, the Director of Nursing (DON) reported she visited with Resident #20 everyday, but she had never reported these concerns to her. When asked, she added she expected a resident to receive the assistance needed to prevent incontinence and maintain dignity.

Based on staff interviews and record and policy review, the facility failed to maintain accurate records related to Cardiopulmonary Resuscitation (CPR) status for 1 of 16 residents reviewed (Resident #31). The resident admitted to hospice services on [DATE] and then signed an order declaration requesting that staff not initiate CPR in the case of cardiac arrest (Do Not Resuscitate). However, an order declaration dated [DATE] showed the resident did want staff to initiate CPR in the event of cardiac arrest. The facility reported a census of 84 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive deficits). The care plan updated on [DATE] instructed staff to honor the resident's wishes according to his advanced directives. The care plan showed the resident had diagnoses that included heart failure, Parkinson's disease, and anxiety disorder. A CPR and DNR Order Declaration form electronically signed on [DATE] showed Resident #31 requested that staff initiate CPR in the case of cardiac arrest. Another CPR and DNR Order Declaration form dated [DATE] indicated Resident #31 did not want staff to initiate CPR if the resident experienced cardiac arrest. The electronic record included an order revised on [DATE] that identified Resident #31 wanted CPR initiated. In addition, a Code Status binder in the nurse's station included a hard copy of the resident's CPR wishes. On [DATE] at 9:29 AM, Staff F, Certified Nursing Assistant (CNA) said in the case of a resident's cardiac arrest, she would look in the binder at the nurse's station for their code status. On [DATE] at 9:01 AM, Staff G, Registered Nurse (RN) stated she would probably look in the computer or at the binder at the nurse's station for code status. On [DATE] at 9:24 AM, RN Staff H stated she checked residents' code status in the Medication Administration Record (MAR). According to the Emergency Procedure - Cardiopulmonary Resuscitation facility policy updated on February, 2018 if a resident's DNR status was unclear, staff would start CPR until it is determined whether or not the resident had a DNR order. On [DATE] at 8:54 AM, the Administrator reported the social worker was responsible for reviewing and updating the resident's code status and nurses were expected to locate the status in the physician orders.

Based on observations, interviews, and record reviews, the facility failed to implement adequate nursing interventions in an attempt to monitor or prevent inappropriate resident-to-resident behavior for 1 of 7 residents reviewed (Resident #53). The facility reported a census of 84 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #53 documented diagnoses of cerebral vascular accident (CVA or stroke), dementia, Parkinson's disease, bipolar disorder, and schizophrenia. The Physician Query Form for Dementia Severity with/without Behavioral Disturbances dated 10/17/22 documented based on agitation, other behavioral disturbances, and psychotic and mood disturbances, the physician determined Resident #53 had severe dementia. The Progress Notes documented two separate episodes of inappropriate behavior that occurred between Resident #53 and Resident #24: a. On 9/14/22 at 2:21 PM, Resident #53 approached Resident #24, told her he was going to kiss her, and then bent over and kissed Resident #24 on the lips. b. On 10/30/22 at 6:22 PM, staff observed Resident #53 kissing Resident #24 on the lips with his hand on her upper, inner left thigh. Staff documented they were unsure of who instigated the actions first. Staff removed Resident #24 from the dining room and escorted to the main nurse's station. Staff then took Resident #53 aside and educated about acceptable behavior in the dining hall. Resident #53's care plan revised on 11/2/22 documented incidents of inappropriate behavior that occurred between Resident #53 and Resident #24 on 9/14/22 and 10/30/22. The care plan also documented that after the first occurrence on 9/14/22, the facility failed to initiate effective measures to prevent inappropriate resident-to-resident interactions between Residents #53 and #24. The care plan lacked staff directives related to monitoring expectations for Resident #53, and showed the facility failed to implement effective measures and therapeutic interventions to manage or mitigate behaviors which corresponded with Resident #53's severe dementia. The Resident-to-Resident Altercations policy revised in December 2016 directed that all altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services, and the Administrator. The Policy Interpretation and Implementation included: a. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Supervisor, Director of Nursing Services, and to the Administrator: b. If two residents are involved in an altercation, staff will: Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents. c. Make any necessary changes in the care plan approaches to any or all of the involved individuals. d. Document in the resident's clinical record all interventions and their effectiveness; e. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team. In an interview on 11/17/22 at 3:35 PM, the Director of Nursing (DON), explained the facility separated Resident #53 and Resident #24 by moving their rooms to different halls and separate dining areas. The DON added that measures and interventions were completed for the other resident, but the facility needed to work to prevent further occurrences by improving supervision plans, interventions, and care plan communication. In an interview on 11/22/22 at 3:26 PM, the Administrator reported that she expected staff to implement effective resident measures and interventions to prevent inappropriate resident-to-resident behavior.

Based on clinical record review and staff interview, the facility failed to submit a significant change review for Pre-Admission Screening and Resident Review (PASARR) to the Ascend organization as required for 1 of 2 residents reviewed (Resident #24). The facility reported a census of 85 residents. Findings include: Resident #24's Minimum Data Set (MDS) assessment tool dated 09/08/22 revealed she scored 5 on the Brief Interview for Mental Status (BIMS) test, which indicated the resident demonstrated severely impaired cognition. The PASARR dated 04/26/19 revealed the following: a. Resident #24 had diagnoses of schizophrenia, major depressive disorder, and delusional disorder. b. The resident took medications named fluoxetine and risperidone. c. Nursing home staff must report any significant change associated with Resident #24 to the Ascend (organization) through submission of a Status Change Level 1. The Progress Note signed by a nurse practitioner and dated 07/22/22 revealed Resident #24 had a diagnosis of violent behavior. The Progress Note dated 06/27/22 directed staff to administer buspirone 5 milligrams (mg) twice daily starting 12/21/21. An order for fluoxetine had an end date of 10/15/22. The Order for depakote 125 mg twice daily for schizophrenia had a start date of 11/14/22. The facsimile (fax) dated 08/02/22 documented the resident displayed increased behaviors and contained an signed by a nurse practitioner revealed that the facility reported that and had received an injection of Haldol. In a fax dated 08/12/22 and signed as acknowledged by a nurse practitioner, staff documented the facility reported that the resident demonstrated behaviors with a tendency to escalate. The Admission Criteria policy dated 2001 directed if the Level I screen indicates the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. In an interview on 11/21/22 at 2:13 PM, Staff I, Social Services Director said she was not aware that the resident had major changes in behavior or had medication changes since the completion of the 2019 PASARR from 2019. Staff A, also present, reported there have been no PASARR submissions since 04/26/19.

Based on clinical record, facility policy, and staff interview, the facility failed to revise a care plan related to oxygen use to include a change in physician orders for 1 of 18 residents reviewed (Resident #3). The facility reported a census of 85 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 09/29/22 revealed Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS) test, which indicated the resident demonstrated intact cognitive abilities. The MDS documented the resident had diagnoses of multiple sclerosis (MS) and dementia without behavioral disturbance. A physician order directed staff to administer the resident oxygen (O2) as needed (prn) to maintain an oxygen saturation level of 86% starting 10/06/21. The care plan documented Resident #3 wears oxygen delivered via nasal cannula (NC). The care plan lacked staff directives for Certified Nursing Assistants (CNA) related to signs and symptoms the resident would exhibit if they needed their prn oxygen and also failed to include any safety measures required information related to the use and storage of the same. The Care Plans, Comprehensive Person-Centered policy dated 2001 revealed that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. In an interview on 11/21/22 at 2:01 PM, the Director of Nursing (DON) reported Resident #3 previously used continuous oxygen and when discontinued by the physician, staff removed the oxygen focus area/care plan. The DON verified staff did not update the care plan when the physician then prescribed as needed oxygen.

Based on staff interview and record review, the facility failed to ensure the physician visited every 30 days for the first 90 days after admission for 1 of 3 residents (Resident #81) reviewed. The facility reported a census of 85 residents. Findings include: Resident #81's Minimum Data Set (MDS) dated [DATE] revealed Resident #81 demonstrated severely impaired daily decision-making skills and both long and short term memory problems. The MDS indicated Resident #81 showed signs and symptoms of delirium which included disorganized thinking that fluctuated. The MDS identified Resident #81 required full assist of two staff for bed mobility, transfers, and toilet use. The MDS listed diagnoses of cerebral palsy, seizure disorder of epilepsy, malnutrition, other bacteria infections, mood disorder, and developmental disorder of speech and language. The census tab of the electronic clinical record revealed Resident #81 admitted to the facility on [DATE] with hospice services. A Hospital Clinical Support note dated 8/25/22, a physician completed an initial comprehensive physical assessment for Resident #81. The clinical record lacked documentation to show a physician saw Resident #81 within 30 days or in the month of September 2022 after the initial physician assessment completed on 8/25/22. The Physician Visits facility policy revised April 2013 directed the attending physician will make resident visits in accordance with applicable state and federal regulations. The policy advised the attending physician must visit their patients at least once every 30 days for the first 90 days following the resident's admission, and then at least every 60 days thereafter. During an interview on 11/22/22 at 10:35 a.m. the Administrator verified Resident #81 did not have a physician visit during the month of September.

Based on observation, facility policy, resident and staff interview, the facility failed to answer call lights in a timely manner 1 of 18 residents reviewed (Resident #20). The facility reported a census of 85 residents. Findings include: The MDS dated [DATE] revealed Resident #20 had a BIMS score of 12 (mildly impaired cognition) and had diagnoses of cerebrovascular accident (CVA or stroke) and irritant contact dermatitis due to fecal, urinary or dual incontinence. The MDS documented the resident required total assist of 2 staff for transfers and extensive assist of 2 staff for toilet use. Observation on 11/15/22 revealed the following: - At 03:12 PM revealed Resident #20 sat in her wheelchair in her room and faced a wall clock. During an interview at that time, the resident reported staff told her to go to the bathroom in her incontinence brief if they don't get to her in time, and added that she soiled her incontinence brief at least once daily because staff took over an hour to answer her call light. Resident #20 commented she knew how long it took because she tracked the time on her wall clock. She also reported staff told her at 1:00 PM today they would help her transfer to her recliner this afternoon, but no one had returned to help her yet. - At 3:20 PM, Resident #20 pressed her call light. - At 3:32 PM, Staff J, Certified Medication Aide (CMA) answered the call light and told the resident she would get another staff member for assistance. - At 3:42 PM, the resident reported that she had soiled her incontinence brief right after the CMA came into her room at 03:32 PM. - At 4:16 PM, Staff J, CMA, returned to the resident's room with a mechanical lift. The facility's Answering the Call Light policy dated 2001 revealed the purpose of the procedure is to ensure timely responses to the resident's requests and needs. In an interview on 11/21/22 at 1:52 PM, the Director of Nursing (DON) reported she visited with Resident #20 everyday, but she had never reported these concerns to her. When asked, she added she expected a resident to receive the assistance needed to prevent incontinence and maintain dignity.

Based on observations, staff interviews, and facility policy reviews, the facility failed to store and prepare food under sanitary conditions. Observations revealed open spices and food debris on a shelf, frozen chicken stored without a date label, a dented can in food storage and missing information on cleaning and temperature logs. The facility identified a census of 85 residents. Findings include: An initial kitchen tour conducted on 11/14/2022 at 12:57 PM revealed the following observations: Kitchen: a. A dented can of Sysco pears on the can rack. b. Open onion powder, poultry seasoning, white pepper, and clove containers and food debris on the bottom shelf of the metal prep cart. c. The freezer contained an open bag of chicken breasts that failed to contain a label or a date. October and November 2022 Food Temperature logs lacked full or partial documentation for the following dates: a. 10/5, 9, 11-13, 15, and 17-21 b. 11/6, 8-10 and 12 October and November 2022 cleaning logs lacked full or partial documentation for the following dates: a. 10/1-12, 14-17, 19, 21-24, and 26-30. b. 11/8, 10, 12, and 13. The Food Temperature facility policy dated February 2016 directed staff to take and record temperatures before and after meals. The Storage policy dated February 2016 instructed staff to store dry staples in a ventilated room protected from condensation, leakage and rodents or vermin. The policy also instructed staff to date all food when they place it into the storage area. The Leftover policy dated February 2016 instructed that leftovers shall be covered, labeled and dated. The Dietary Services Cleaning Schedule policy dated February 2016 instructed that cleaning schedule records shall be completed and filed and kept from survey to survey. The Purchasing and Receiving policy dated February 2016 instructed any item with a dent along seams shall be refused. In an interview on 11/14/22 at 12:37 PM, the Dietary Manager (DM) verified that the unlabeled bag in the freezer appeared to be chicken breasts. In an interview on 11/17/22 at 09:10 AM, the DM agreed that staff should close spice container lids and label food, and should not store dented cans. The DM also agreed staff should clean, take food temperatures before and after meals, and document both.

Based on observation, clinical record review and staff interview, the facility failed to identify COVID-19 symptoms, initiate transmission based precautions and perform COVID-19 antigen testing for 1 out of 15 residents reviewed (Resident #35). The facility reported a census of 85 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #35 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The care plan revised on 11/21/22 identified Resident #35 to be at risk for infection related to signs and symptoms of COVID-19. The care plan instructed staff to follow the facility protocol for COVID-19 Screening/Precautions and to follow isolation precautions. In an interview on 11/14/22 at 12:51 PM, Resident #35 reported she developed a cough last week and had a negative COVID-19 test. During the interview the resident presented with a frequent loose cough. Resident #35 reported she did not receive another COVID-19 test on November 11-14th. Observation showed the facility failed to place the resident in Transmission Based Precautions (TBP). The Progress Note dated 11/13/22 at 10:27 PM recorded the first documented occurrence of a cough. The nurse administered the resident a cough drop lozenge. The Progress Note dated 11/14/22 at 1:42 PM recorded the nurse administered Resident #35a cough drop lozenge to . The Progress Note dated 11/14/22 at 4:07 PM documented Resident #35 complained of a cough and requested cough drops earlier. The resident reported a nonproductive cough at times. The Progress Note dated 11/15/22 at 8:25 AM documented Resident #35 had a cough. The resident denied shortness of breath. Lung sounds diminished in the lower left lobe. A COVID-19 antigen test showed a negative result. Resident #35 placed on TBP. The COVID-19 Testing progress notes dated 11/16/22 showed Resident #35 received a COVID-19 antigen test on 11/10/22. The next COVID-19 antigen test did not occur until 11/15/22. Center for Clinical Standards and Quality/Survey & Certification Group last revised on 9/23/22 instructed for further information on contact tracing and broad-based testing, including frequency of repeat testing, see Centers for Disease Control and Prevention guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. The Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated on September 23, 2022 documented personal protective equipment for HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Duration of Empiric Transmission-Based Precautions for Symptomatic Patients being Evaluated for SARS-CoV-2 infection. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. In an interview on 11/15/22 at 9:16 AM, the Director of Nursing (DON), reported Resident #35 should have been placed in droplet TBP at first sign or symptom of a cough and a COVID-19 antigen test should be conducted immediately then repeated 48 hours after the first negative COVID-19 test. In an interview on 11/21/22 at 3:26 PM, the Administrator reported that she expected staff to initiate TBP precautions and COVID-19 testing when residents present with signs or symptoms of COVID-19.

Based on observation, clinical record review, staff and resident interviews, and facility document review, the facility failed to serve coffee free of a soapy/chemical taste during supper on 8/28/22 for 32 residents in the facility. This failure resulted in adverse consequences for one of six residents reviewed (#1). The facility identified a census of 88 current residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 had diagnoses that included high blood pressure, Non-Alzheimer's dementia, malnutrition, depression and muscle wasting. The assessment recorded he experienced severe cognitive impairment, as evidenced by a brief interview for mental status (BIMS) score of 6. Resident #1 required supervision while he ate and staff assistance with locomotion via his wheelchair or with a walker. Resident #1's Care Plan, initiated on 2/24/21, identified a focus area of the risk for altered nutrition related to dementia, [CONDITION(S)] and a history of dysphasia (difficulty swallowing). The Care Plan instructed to serve Resident #1 a regular diet with thin liquids and that he preferred to eat in the dining room. Resident #1's Order Summary Report dated 8/28/22 directed to serve him a regular, no added salt diet with thin liquids. A Nursing Note dated 8/28/22 at 5:30 PM, authored by the Director of Nursing (DON) documented staff noted Resident #1 ingested urnex urn and brewer cleaner diluted in coffee. Staff noted the urn cleaner in the coffee and immediately removed the coffee. Staff called Poison Control immediately and received instruction that indicated the urn cleanser was likely very diluted in the coffee and ingested in small amounts. Poison Control directed to monitor residents for burning of the esophagus, vomiting and nausea for one hour. If a resident had signs and symptoms, they would start within one hour. Staff monitored the resident with no signs or symptoms of burning and notified his Primary Care Provider. A Nursing Noted dated 8/29/22 at 2:32 AM, authored by Staff A, LPN (Licensed Practical Nurse) documented Resident #1 had a moderate amount of dark red/black coffee ground consistency emesis (vomitus) on his bedding. The resident's voice sounded hoarse and he complained of his throat burning. Staff called 911 and the resident transferred to the emergency room . A later entry by Staff A at 4:07 AM documented the resident admitted for observation. The emergency room (ER) History and Physical dated 8/29/22 at 7:11 AM documented Resident #1 was admitted for ingestion of a caustic substance and resulting hematemesis (vomiting blood). The resident had a past medical history that included [CONDITION(S)] (GERD) and a history of prior gastrointestinal bleeds. He presented to the ER with complaints of two episodes of hematemesis; the nursing home reports that around 5 PM, multiple residents within their facility received Urnex coffee cleaner mixed with water. The resident had no signs of vomiting blood in the ER as he had been cleaned up. Upon arrival, ED staff contacted Poison Control who suggested lab work and further monitoring. The resident had no episodes of nausea or vomiting throughout the night and he would start on a clear liquid diet with breakfast. The resident stated his throat felt a little sore. The resident's physical exam showed his nose appeared normal and did not document the appearance of his mouth or throat. Resident #1 left the ER at 7:45 AM with a new prescription for Pepcid (an antacid) 20 milligrams twice a day. A Nurse's Note dated 8/29/22 at 10:22 AM (late entry) recorded Resident #1 returned from a short observational stay at the hospital. He denied gastrointestinal upset, sore throat or nausea, vomiting or diarrhea at the time. Staff assessment revealed no negative findings. During email communication with Resident #1's ER Hospitalist on 9/12/22 at 6:25 AM, she described the resident's examination as quite benign. The resident complained of a sore throat, but it was not notably red and he had no [CONDITION(S)]. During his stay the resident had no further episodes of vomiting. Hospital staff never saw any emesis and it only occurred at the facility, so it was difficult to say that the resident truly had hematemesis. The Hospitalist concluded that if the resident had hematemesis, she would say it likely occurred due to a combination of his history and the situation. Interview with DON on 9/1/22 at 3:15 PM revealed she worked all day on 8/28/22, went home and received a call from the floor nurse (Staff A) at 7:30 PM. Several residents complained the coffee tasted funny and the Certified Nursing Assistant (CNA), Staff B took all the coffee away. The DON returned to the facility. The DON stated that kitchen staff cleaned out the coffee pots that afternoon, were supposed to drain and rinse the pots but did not do so. The DON got a Material Safety Data Sheet (MSDS) for the facility's coffee cleaner, called Poison Control and learned that possible adverse symptoms would occur in an hour and that none should appear after that. The DON stated staff monitored for residents' throats burning, vomiting, and/or their stomachs burning); the facility had a list of who was affected (about 25 total residents) and the residents were then monitored for 48 hours. The DON stated that Resident #1 couldn't say how much coffee he drank, but he had a history of vomiting at night and really bad GERD. Since Resident #1 vomited in the early morning on 8/29/22, he went to the ER. The DON stated she learned the coffee machine was cleaned but not rinsed from Staff A, but the coffee was gone by the time the DON returned to the facility. The DON stated her focus as getting Poison Control input and assessing the residents. The DON thought that the taste of the coffee could have come from a lack of an effective dishwasher rinse and that's why residents tasted soap. The DON provided a list of residents who consumed coffee during supper on 8/28/22, which included 18 residents in the nursing facility and 14 residents on the Chronic Confusion and Dementing Illness (CCDI) unit. Interviews with residents who consumed coffee during supper on 8/28/22 were conducted on 9/6 and 9/7/22 with 9 of 14 interviewable residents within the nursing facility. Residents stated the coffee tasted either weak, bad, off, funny or like soap or dishwater. All residents denied experiencing adverse effects after they drank the coffee. Review of Nurse's Notes for the 14 residents who resided on the CCDI Unit revealed staff monitored the residents for adverse effects following coffee consumption with supper on 8/28/22. None of the residents experienced adverse effects. Interview 9/1/22 at 3:50 PM with the Dietary Services Manager (DSM) revealed she came into work on 8/29/22 and learned from the Assistant DSM (ADSM) that residents reported complaints with coffee and that it tasted like chemicals the night before. The DSM stated she checked the coffee machine to see if it had been cleaned and didn't think it had been since the glass tubes weren ' t clear and they should have been. The DSM talked with dietary staff on duty during supper on 8/28/22, who denied cleaning the coffee machine. She thought possibly staff mixed coffee and tea together or that maybe the dish machine didn ' t rinse as well. The DSM stated since the incident, she had in-serviced staff to post a laminated sign to inform them not to use the machine while cleaning is going on. The DSM stated the facility normally cleaned the coffee machine normally once a week, but it hadn ' t been cleaned since 8/28/22; she did not know when it was last cleaned. The DSM stated for monitoring, she is at the facility 24-7 and looks all the time, but she had not talked to residents about how the coffee tastes. On 9/7/22 at 9:40 AM, Staff B, CNA stated she worked on 8/28/22 from 2 - 10 PM. Just as supper finished, a resident came up the hall and told her the coffee tasted like dish soap. Staff B stated she could see the bottom of the cup, it had a hint of brown but looked mostly clear. Staff B stated the coffee smelled gross, but she doesn't like coffee and the coffee smelled like a hint of cleaning products. Staff B then went to the kitchen to get the resident a new cup; she went to pour another cup from the nutrition room and it looked the same. Staff B tasted the coffee (it was the decaf pot) and it tasted soapy. Staff B asked Staff C, DA (Dietary Aide) if he made coffee that day and he said no, it was already done. Staff B stated she also overheard either Staff D, Cook or Staff E, Cook say they were cleaning the pots earlier; she didn ' t catch who said it and could not say whether she heard a male or female voice. Staff B stated she went to Staff A and reported what happened. Staff A asked the cleaning pack, since Staff B told Staff A she heard staff talking about cleaning the coffee pot. Staff A asked staff to pull out coffee cups from resident rooms and the dining room. When Staff A and Staff B asked Dietary staff specifically if they had cleaned the coffee pots, they said they had not. Staff then got all residents' coffee out, made a list of everyone who drank coffee and the DON contacted PC. The DON told all staff what to watch for towards side effects. Staff B stated her residents did not display any ill effects and other staff monitored everyone else. During an additional interview on 9/12/22 at 10:40 AM, Staff B stated after thinking more, she was pretty sure it was a female voice who said she had cleaned the coffee pots prior to supper. Interview on 9/6/22 at 1 PM with Staff A revealed that during supper on 8/28/22, Staff B reported that residents complained of the coffee taste. Staff A and Staff B went to the kitchen and tasted the coffee; it tasted like soap. They talked with Dietary staff and Staff C, Dietary Aide told them it was probably the coffee pot cleaner that wasn ' t rinsed out well. Staff C said he saw some brown at the bottom of the pot thinking it was coffee, but did not say he made coffee on top of the brown at the bottom. Staff A called the DON, who came out and called PC. PC told the DON to watch residents closely for an hour and if they had no symptoms after that, there likely wouldn't be any. Resident #1 then got sick later in the night. Staff A stated the resident vomited dark brown, coffee grounds emesis in his bed, had no other complaints, but with that she wanted him sent to ER. Staff A did not know if Resident #1 had a history of GI bleeds, but he does vomit when laying flat in bed. On 9/12/22 at 10:30 AM, Staff A stated that she did not hear any Dietary staff talking about cleaning the coffee pot the evening of 8/28/22. As they went down the hall and asked Dietary staff, they just heard I didn ' t do it repeatedly. Staff A further described the coffee as tasting soapy and slimy with a bitter aftertaste. Review of the Dietary schedule for 8/28/22 revealed Staff D, Cook, Staff E, Cook and Staff C, DA worked during supper service and Staff F and the Assistant DSM worked during the breakfast and lunch service on 8/28/22. Interview on 9/6/22 at 3:30 PM with Staff D revealed she arrived at the facility on 8/28/22 about 1:30 PM; day shift had been short. No one told Staff D they cleaned the coffee machine that afternoon. Staff D stated she never cleaned the coffee pots or machine or talked about cleaning them either. Staff D thought if they tasted soapy, maybe the cup was not rinsed well in the dishwasher; she sometimes saw white residue on clean dishes. Staff D was unsure of any staff besides dietary who actually knew where the Urn cleaner was kept. On 9/12/22 at 2:05 PM, Staff D thought maybe other staff heard someone that sounded like her talking about cleaning the coffee machine; she denied cleaning the coffee machine or pots on 8/28/22. During interview on 9/6/22 at 3:50 Staff E remembered he worked in the CCDI unit on 8/28/22 and worked there from 2:20 and 2:30 PM. Staff E stated he got their air pots, rinsed those out in the kitchen and made sandwiches. About 3:15 PM, he filled the pots with decaf coffee and dropped them off to the CCDI unit at 3:20 or 3:25 PM. Staff E stated the pots and urns looked clean and clear when he filled them. About 7 PM, someone came into the kitchen and said the coffee had a cleaner in it (Staff E could not remember the staff ' s name) and denied telling anyone about cleaning the coffee maker. Staff E stated he told the staff member not to serve the coffee; she dumped it and they got new coffee. Staff E was not sure where Urn cleaner is kept and he hasn't cleaned the coffee machine or pots; 8/28 was his second day working at the facility. Staff E stated the only thing he could think of is that someone cleaned the coffee pot, didn ' t tell anyone and someone else made coffee on top of that. Staff E stated he was sure it was not done on purpose. Now, the facility had signs to post on the pot to not use the pot while staff clean it. During interview on 9/7/22 at 9:20 AM, Staff F, Cook/DA stated he worked 8/28/22 from 6 AM to 2 PM. That weekend, he was by himself and the ADSM DSM came in to cook and Staff F worked as a DA. Staff F stated he did not know or hear of any coffee concerns while he worked, but heard about it a few days later; that something was wrong with the coffee. Staff F stated he did not clean the coffee makers that day and would not have had time to; he was running all over the place. Observation and interview on 9/7/22 at 9:30 AM revealed the coffee machine as just inside the door to the kitchen area, but not in the kitchen preparation area. The facility stored Urn cleaner 50 feet away from the entrance to the kitchen in a utility closet off the kitchen's dry storage area. Observation of 6 random coffee cups revealed no residue of any kind. The coffee machine had 2 glass tubes running from the drip area to the spigot. The DSM stated the glass tubes were the ones she mentioned that did not appear clean on 8/29/22 and the facility had no other coffee brewing machines. Interview 9/7/22 1230 with the ADSM revealed on 8/28/22, she arrived at the facility approximately 6:45 AM and left between 2:30 and 3 PM. The ADSM cooked and Staff F worked as a DA. The ADSM stated she had heard about concerns with the coffee but did not know what happened. She heard a resident and staff reported the coffee tasted funny; someone said it looked funny. The ADSM stated she did not clean the coffee machine and that Staff F would not have had time to. The ADSM thought that maybe the coffee cups had not been rinsed out well enough as she sometimes saw white residue in coffee cups, but not often. The ADSM stated if that if the coffee tasted soapy, she thought it had to come from the cups Interview on 9/8/22 at 4:05 PM with Staff C revealed he worked from 2 - 8 PM on 8/28/22. He normally starts doing drinks and that day, he worked the main dining room and started putting table cloths on the tables. After serving supper, he picked up the tables. A CNA whose name he did not remember came up to him and said the coffee tasted like cleaner. After that, all the staff gathered up the coffee cups. Another staff (unknown name) washed out the pot that coffee had been brewed in, made new coffee and disposed of the old coffee. Staff C stated he did not taste or smell the coffee. Staff C stated that Staff D said that she cleaned the coffee machine that day. Staff C stated he did not touch the coffee machine until it was serving time and another Dietary staff member must have made the coffee; Staff C was mainly focused on getting tables ready for the residents. Staff C stated he didn ' t even know they had urn cleaner and he never cleaned the coffee maker. Staff C denied making a fresh pot on top of an old pot of coffee. During observation and interview on 9/12/22 at 1:40 PM, the DSM cleaned the coffee machines. She removed the coffee urn reservoir, discarded unused coffee and placed Urn cleaner directly in the reservoir. The DSM turned on the machine to send the urn cleaner through the machine and stated the cycle takes 7 minutes. Observation of the urn cleaner after the cleaning cycle revealed the cleaner appeared bluish-green in color with a mild chemical smell. After the cycle completed, the DSM stated she then rinsed the reservoir out 4 - 5 times to make sure no cleaner remained. When asked if everyone rinsed the cleaning solution out 4 - 5 times, the DSM stated she did not stand and watch the staff. The DSM stated she planned to do an in-service next week as the facility had many new DAs. The MSDS for urn cleaner, revised 5/14/21, documented the cleaner could cause skin and eye irritation. The MSDS documented that the product may be harmful if swallowed and may cause stomach distress, nausea or vomiting. The MSDS instructed that if swallowed, to rinse the mouth and do not induce vomiting. The MSDS for Solid Power XL machine warewashing detergent, dated 9/27/19, identified the detergent could cause eye damage and skin corrosion as sold. When used at dilution, the product was not considered a hazardous substance or mixture. The MSDS instructed that if swallowed, to rinse the mouth and do not induce vomiting.

Based on observation, clinical record review and staff and resident interviews, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 residents reviewed (Resident #14). The facility reported a census of 85 residents. Findings include: The Minimum Data Set (MDS) assessment tool defines pressure ulcer stages as follows: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). May be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. According to MDS dated [DATE], Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had the ability to understand others and scored 10 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated mild cognitive impairment. The MDS also documented Resident #14 required assist of 2 staff with bed mobility, surface-to-surface transfers, and dressing and required set up assist with eating. The MDS revealed the resident depended on a wheelchair for locomotion, showed impairment on one side of her upper extremities and both sides of her lower extremities, utilized an indwelling, suprapubic urinary catheter for bladder elimination and experienced bowel incontinence. The MDS indicated the resident's weight had remained stable, she had 1 unstageable pressure injury presenting deep tissue injury during the lookback period and the facility had preventative treatments in place. The MDS documented the resident as at a high risk for falls. The Braden Scale (an evidence-based too that predicts the risk for developing a hospital- or facility-acquired pressure ulcer or injury) dated 2/18/21 deemed the resident as at risk for pressure sores. The Care Plan dated 9/16/20 documented Resident #14 had actual skin impairment (an unstable pressure injury to the left heel). An addendum dated 5/7/21 revealed Resident #14 had a Stage 4 pressure injury to the left heel and directed staff to implement interventions that included: a. Prove a new recliner with more padding to the foot rest until Resident #14's daughter can provide more padding to the resident's previous recliner's footrest. b. Apply Alternating Pressure Mattress (APP) mattress to bed (completed 2/16/21) c. Provide a body pillow for positioning in bed d. Educate Resident #14, their caregivers, and family of causative factors and measures to prevent skin injury e. Encourage the resident to maintain good nutrition and hydration to promote healthier skin f. Apply Equagel cushion to wheelchair (completed 2/16/21) g. Float the resident's heels elevate the heels to position them in such a way as to remove all contact between the heel and the bed or recliner) with a pillow when they rest in the recliner and in the bed (added 11/9/20). h. Follow E-TAR (Electronic Treatment Administration Record) for blister to right thigh (added 6/8/20) and treatment (added 12/1/2020). i. Apply a foot cradle (a frame that is installed at the foot of the bed to keep sheets/blankets off legs/feet to help with air circulation, sensitive skin, and keeping skin dry, especially if for a resident lying in bed for long periods of time.) to the bed. j. Apply heel cushion to wheelchair pedals. k. Provide the blue pillow under the resident's heels when in wheelchair The Braden Scale for Predicting Pressure Sore Risk dated 2/18/21 revealed Resident #14 scored 16 points which indicated a risk of pressure sore development. A Pressure Injury Evaluation dated 2/22/21 documented a Stage II wound to Resident #14's left heel. A Pressure Injury Evaluation dated 5/7/21 documented a Stage IV wound to Resident #14's left heel that measured 3 centimeters (cm) in length; 3 cm in width; 2.5 cm in depth with tunneling present and large amounts of odorous purulent drainage. The Treatment Administration Record (TAR) dated 2/1/21-2/28/21 directed staff to complete a pressure skin evaluation for the resident's her left heel every Monday The TAR dated 3/1/21-3/31/21 directed staff to complete a pressure skin evaluation with regard to the resident's left heel every Monday starting 9/21/20 and ending 3/1/21. Review of the documentation on the TAR revealed no assessments documented regarding the left after 3/1/21. The TAR dated 3/1/21-3/31/21 directed staff to apply [MEDICATION(S)] to bilateral heels to prevent breakdown twice daily starting 11/11/20. Review of the documentation from 3/1/21 to 3/31/21 revealed 9 instances when the TAR failed to contain documentation to show that staff completed the treatment as ordered. Observation on 5/5/21 at 12:57 p.m. revealed Resident #14 sat in a recliner with her eyes closed with her feet resting on pillows rather than arranged in a manner to float heels as directed on the Care Plan. An observation on 5/10/21 at 10:30 a.m. revealed the foot cradle placed in an incorrect manner below Resident #14 legs while her heels touched the bed. The wound on her left did not contain the dressing the physician had ordered and the wound drainage had had saturated the bed sheets. An observation on 5/11/21 at 9:04 a.m. revealed Resident #14 sat in a wheelchair and ate breakfast. Closer observation showed her heels rested on the properly positioned heel cushion, but the blue pillow sat in a chair next to her bed rather than under her heels as directed by the Care Plan. Observation on 5/12/21 at 11:00 a.m. revealed Resident #14 sat in a wheelchair, with the foot cushion in place on foot rests and the blue pillow in a chair next to the bed. During an interview on 5/10/21 at 10:45 a.m. with DON reported she discovered Resident #14 had a Stage IV pressure ulcer on her left heel and notified the physician who ordered lab work, a wound culture, oral antibiotics, wet to dry dressing changes to the left heel twice daily and directed staff to float the resident's heels. The DON added the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/11/21 at 9:04 a.m., Resident #14 denied staff applied the daily lower extremity lotions or ointment to her legs or heels. The resident commented the only person that had applied any type of lotion was her daughter, but she had not seen her since prior to the COVID-19 lockdown. During an interview on 5/12/21 at 10:12 a.m., the DON reported staff routinely completed skin assessments, but could not verify whether or not staff included the heels in their assessments. The DON stated the resident's mattress was based on weight but did not know what a setting of 2 meant. During the interview, she reviewed the interventions on the care plan and stated she did not routinely complete audits to check if staff followed all of the interventions and had not been aware they weren't using the blue pillow. She stated the education to staff regarding the interventions was verbal and she did not have documentation that verified when or to whom it had been provided. During an interview on 5/12/21 at 10:45 a.m., the DON reported the mattress in use for Resident #14 was a PressureGuard Easy Air XL mattress rather than an APP mattress. She stated staff placed the mattress on the most comfortable setting for the resident and confirmed the PressureGuard Easy Air XL was not a mattress that alternated pressure as the Care Plan specifically directed. During an interview on 5/12/21 at 11:45 a.m. with Staff F, Certified Med Aide (CMA) revealed she often showered Resident #14 and she had notified nursing staff approximately a month ago that Resident #14 had a red spot on her left heel. She demonstrated the use of the shower chair used and showed how she could easily view a resident's heels. Staff F said she was not surprised to learn Resident #14 developed another pressure ulcer. I have found her without her heels floated multiple times and opined, with the facility as short staffed as we have been, staff does not slow down and provide cares like they should. A facility policy titled, Assessments-Residents at Risk dated January 2015 documented its purpose as follows: to identify at-risk individuals needing preventative interventions and the specific factors placing them at risk, to provide a supportive care prior to need, and to minimize skin problems. The policy directed staff to: a. Complete the Braden Scale quarterly and with a change in the resident's condition. b. Utilize and complete the MDS Assessment according to guidelines to identify residents at risk c. Establish a plan of care to minimize risks and initiate interventions. d. Keep the resident's family/physician informed of findings and status of skin. e. Reevaluate the resident periodically for effectiveness and alter plan of care according to need. f. Document the use of protective measures according to facility policy The policy directed staff to include the following information and activities in the Care Planning Process: a. Identify the problem and include the diagnosis, pre-existing conditions, nutrition, and past history of ulcers. b. Establish goals with resident input. c. Develop approaches and identify disciplines responsible for completion d. Review the problem daily at the QA meeting e. Provide information to assure staff are aware of preventative measures. An undated guide PressureGuard Easy Air XL documented the design of the mattress was intended to provide a high level of comfort, but did not contain any information to indicate the mattress had the alternating pressure ability as directed on Resident #14's care plan. The Director of Nursing (DON) verified Resident #14's room contained this bed for her to sleep in rather than the alternating pressure mattress.

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent a resident with impaired decision-making skills from leaving the facility without knowledge or authorization of the staff (elopement) for 1 of 5 residents reviewed (Resident #1). On 10/16/18 at approximately 6:00 p.m., Resident #1 left the facility through a door equipped with an alarm. The door alarm sounded, but staff failed to assess the cause of the alarm and determine if all residents remained in the facility. As a result, staff were unaware Resident #1 had wandered outside 200 feet away and uphill to a neighboring assisted living facility, until notified by staff from said facility approximately at 6:30 p.m. This constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility identified a census of 84 residents. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment tool dated 10/19/18, Resident #1 had a [DIAGNOSES REDACTED]. The MDS documented Resident #1 ambulated (walked) independently and required supervision with dressing, eating and personal hygiene and limited assistance with toilet use and bathing. The MDS revealed Resident #1 admitted to the facility on [DATE]. The Elopement Risk Assessment completed upon admission and on 10/8/18 documented Resident #1 had no history of wandering or exit seeking behavior, no statements of wanting to leave, and was determined as at low risk for elopement. According to a statement written by Staff A, RN, on 10/16/18 and sometime after 6:00 p.m., Staff A heard the front door alarm sound. After about a minute, she responded to the door and didn't observe anyone in front of the building or parking lot. Staff A stated she did not believe any resident would have had time to walk around the building and out of her sight, so she came back into the facility to disarm the alarm. At 6:30 p.m. Staff A was notified that a resident had left the building. Observation during the investigation revealed the facility remained in an area outside of town with a fenced field and residential street adjacent to the nursing home. The assisted living facility next door was approximately 200 yards away, with a street running from the nursing home to the assisted living facility uphill, at an approximately a 30 degree incline. The open grass hill between the facility contained an incline of approximately 45 degrees. In an interview on 11/28/18 at 10:00 a.m. the Director of Nursing (DON) stated the evening of 10/16/18 she was in the dining room (back of the building) when she heard the front door alarm sound. The DON stated she walked toward the front, and when she arrived at the front door, Staff A was there and asked how to shut off the door alarm. The DON showed her and asked if everything was fine; Staff A stated yes. About 15-20 minutes later, she was at the nurse's station and a call came in that informed staff Resident #1 found at a neighboring, non-affiliated assisted living facility. The DON reported she notified the Administrator, then drove to the facility to bring the resident home. The DON stated Resident #1 was laughing, smiling and remained unharmed. He wore jeans, a flannel shirt, socks and shoes, but did not have his wheeled walker with him. The DON reported Staff assessed the resident and found no injuries, then notified the family, who stated it was not uncommon for Resident #1 to walk around the community when he lived at home. In an interview on 11/27/18 at 9:45 a.m. the Administrator stated there was no formal facility policy related to responding to door alarms, but noted during new employee orientation she provided education on the proper response to door alarms. The Administrator stated when an alarm sounds, staff are to respond and not shut off the alarm until they have identified the cause for the alarm. Staff should go outside and search and, if no cause can be identified, staff need to initiate missing resident protocols. Missing Resident protocols address procedure once a resident is identified as missing, but failed to direct or address how staff should determine who is missing. In an interview on 11/27/18 at 10:30 a.m. Staff B, licensed practical nurse stated when a door alarm sounded staff should respond immediately to determine the cause. If they observe a visitor leaving, staff should ask if they set off the alarm. If there is no apparent cause she and other staff would search the grounds for the resident and if no resident found, they would initiate a resident count to determine if anyone was missing. Staff B stated Resident #1 was a mellow person and not known to exit seek. In an interview on /27/18 at 10:20 a.m. Staff C, certified nurse aide, stated when a door alarm sounds, staff are to respond and find the reason. If it was a visitor, the alarm can be shut off. If unknown, staff are to search outside while other staff initiate a head count. Staff C stated Resident #1 could move pretty fast with his walker, but typically stayed in his hall and dining room and was not known to display exit seeking or wandering behavior. The facility abated the immediate jeopardy on 10/16/18 (the same day) by implementing the following: 1. The facility educated the staff regarding the expectations when a door alarm sounds. Staff should not silence, turn off, or reset the alarm until they have identified the cause for the alarm. The facility directed staff to go outside and search and, if no cause can be identified, staff need to initiate missing resident protocols (beginning with a head count). 2. The facility ensured no staff clocked in to work with residents until they were re-educated about the above policy.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards (Resident #1,#2). The sample consisted of 3 residents with a high risk of falling. The facility reported a census of 81 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 8/3/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS also noted that Resident #1 required limited assistance of 1 staff person for most ADLs (activities of daily living) skills including transfer and ambulation. The MDS indicated the resident had inattention, disorganized thing and a BIMS (Brief Interview for Mental Status) score of 0. A score of 0 identified the resident as severely impaired cognitively. The MDS indicated the resident received antipsychotic and antianxiety medications as prescribed. The Care Plan dated 3/30/17 noted the resident to be at risk for falls and instructed staff to keep the bed in the lowest position and a landing mat at the bedside. Revisions noted that a one way slide to the bed had been implemented on 4/3/17, a one way slide to the recliner and a concave mattress on r/8/17, 15 minutes checks when in bed at night on the 5/15/17, gripper socks on at all times on 7/19/17 and Dycem (material placed in seat to keep from sliding) to the wheelchair on 8/1/17, The Fall Risk Evaluation dated 5/1/17 identified Resident #1 at high risk for falling. A Nurse's Note dated 7/11/17 at 3:50 p.m. indicated the staff found Resident #1 sitting on the floor in front of her recliner with the leg resident still up in place. According to the note, family had been notified and agreed to call visitors that had been there to instruct them Resident #1 should not be left alone in her room. A Nurse's Note dated 7/19/17 at 2:10 a.m. noted staff observed the resident lying face down on the ground near her roommate's bed with a laceration to her upper lip and complaints of bilateral (both) hip pain, right knee pain and facial pain. An x-ray dated 7/24/18 noted an [MEDICAL CONDITION] (forearm bone) and not identified on a previous x-ray. The subsequent x-ray was ordered because of continuing pain from an injury sustained in the 7/19/17 fall. A Nurse's Note dated 7/31/17 at 10:30 p.m. noted Resident #1 fell trying to get out of her wheelchair and sat on the pedals. A Nurse's Note dated 8/7/17 at 9:25 p.m. indicated Resident #1 was left under the direct supervision of a CNA (certified nursing assistant) at the nurses' station. According to the nurse, she heard a CNA calling for assistance and saying She's on the floor. The nurse noted that she arrived to find the resident lying on her right side and complained of right hip pain. The nurse obtained orders to send the resident to the emergency room . A Nurse's Note dated 8/7/17 at 1:00 a.m. noted the physician admitted the resident to the hospital with a right [MEDICAL CONDITION]. On 2/20/18 at 3:30 p.m., Staff B, CNA, was interviewed and stated she remembered the resident at the nurses' station, sitting in her wheelchair. This is when they went to answer call lights. Staff B stated they found the resident on the floor when they returned. Staff B stated although Staff A, LPN (licensed practical nurse) did not tell her to watch the resident, she knew the resident was a fall risk. Staff B stated she did not hear an alarm sounding when the resident fell , but the resident typically had an alarm on the recliner and the wheelchair. Staff B stated the resident would not sit still, she kept getting up and down. As a result, Staff B stated they took her out to the nurses' station to keep a better eye on her, but she ended up falling any way. Staff B stated the resident would just get up on her own and go; she did not understand that she shouldn't. Staff B stated a co-worker and her were only gone 5 minutes from the nurses' station. Staff B stated she found the resident lying on the floor by the cabinets near the nurses' station. Staff B stated she told Staff C to get the nurse. On 2/20/18 at 3:47 p.m., Staff A was interviewed and stated the resident seemed anxious and restless, which warranted one to one supervision. Staff A stated Resident #1 kept setting off the chair alarm so they transferred her into the wheelchair. Staff A and Staff C were behind the nurses' station charting. Staff A stated she told them to supervise the resident while she went to complete her duties. Staff A stated she could not recall if the alarm got transferred from the recliner to the wheelchair, but should have been transferred. Staff A stated the resident should be behind the nurses' station because they probably could not have gotten to her in time if she self-transferred. Staff A stated she heard the CNAs calling her to the nurses' station from the end of the 400 hall. Staff A stated once she assessed the resident and obtained orders to send her to the emergency room , she asked the CNAs how she could have fallen once she told them to provide one to one supervision. According to Staff A, they told her they left Resident #1 unattended to answer call lights. Staff A stated she thought the incident could have been prevented if they had supervised her as they were told. Staff A stated it would have eventually happened anyway. On 2/21/18 at 11:35 a.m. Staff C, CNA, was interviewed and stated the resident had sat in her wheelchair behind the nurses' station. Staff C stated she thought her and Staff B were charting. Staff C stated staff A told her to provide one to one supervision to Resident #1 although the behaviors the resident exhibited required close supervision. Staff C stated she remembered Resident #1 getting up frequently and wandering. Staff C stated a resident that required assistance of 2 staff persons had activated the call light and they left to attend to that resident. Staff C stated she could not remember where the nurse was when they left, but they were gone only for about 5 minutes. Staff C stated they found the resident alone on the floor crying out in pain returned. Staff C stated the resident remained in the same position until the ambulance arrived. On 2/21/18 at 12:15 p.m. the Director of Nursing (DON) was interviewed and stated the staff are to remain with a resident if they had been instructed to provide one to one supervision. The DON stated if the nurse did not specify how long they should supervise the resident; it should be assumed they should supervise until hearing otherwise. The DON stated they should inquire or bridge any communication gaps before leaving the resident unsupervised. 2. Resident #68 had a MDS assessment with a reference date of 2/22/18. The MDS identified the resident had [DIAGNOSES REDACTED]. According to the MDS, the resident had short and long-term memory problems and inattention and disorganized thinking. The MDS indicated the resident required limited assistance of 1 staff member for transfers, locomotion on and off the unit and used a wheelchair. The Care Plan dated 10/21/16, indicated the resident needed assistance with activities of daily living (ADLs) and the resident's primary mode of locomotion is wheelchair propelled by staff. Observation on 02/19/18 at 11:01 AM, Staff P (CNA) pushed Resident #68 from the TV area to the dining area with no foot pedals on the wheelchair. Staff P pushed the resident in the wheelchair for approximately 22 yards. Observation on 02/21/18 at 08:41 AM Staff P, CNA pushed resident #68 from the dining area to the TV area with no foot pedals on the wheelchair, approximately 22 yards. On 02/22/18 at 08:28 AM Staff Q, Nurse Manager was interviewed and stated she would expect staff to use foot pedals while pushing residents. Pushing a resident in a wheelchair without foot pedals can be considered hazardous. In the event the resident lowered feet onto the floor, the resident can be propelled out of the chair and onto the floor. The resident can also injure feet and ankles.

The following deficiency relates to complaint -I: Based on record review, observation and staff interviews, the facility failed to provide adequate supervision and assistance devices to mitigate a resident's risk for falls for 1 of 4 residents reviewed. (Resident #3) The facility reported census was 84. Findings include: According to the Minimum Data Set (MDS) assessment tool with assessment reference date of 10/29/15 revealed Resident #3 ' s Brief Interview for Mental Status score of 2 indicated a severely impaired cognitive status. According to the MDS, Resident #3 required extensive assistance of two staff members for, bed mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #3 required a wheelchair for mobility. The MDS identified Resident #3 was determined as always incontinent of bowel and contained an indwelling catheter for urinary continence. Resident #3's [DIAGNOSES REDACTED]. The MDS identified a history of one fall and no injury noted. Resident #3's plan of care with initiation date of 12/23/13 indicated Resident #3 at risk for falls due to history with approaches that included wearing gripper socks or shoes when up, staff to transfer Resident #3 into a recliner after supper, bed to be in lowest position and Resident #3 not to be in wheelchair while alone in bedroom. In an interview on 12/2/15 at 4:45 p.m. Staff E, certified nurse aide (CNA), stated at around 10:00 p.m. on 11/19/15, she and Staff F CNA assisted Resident #3 into bed. Staff E stated Resident #3 had to go to the bathroom so she placed a bed pan under him/her and gave him/her a call light. Staff E stated Resident #3 was good about using a call light. Staff E stated she got busy and never returned to Resident #3's room. In an interview on 12/9/15 at 6:01 p.m. Staff F CNA, stated on the evening of 11/19/15, he and Staff E assisted Resident #3 into bed. Staff F indicated he was uncertain what time it was. When he left Resident #3 was comfortable. Staff F stated he was not involved with placing Resident #3 on a bed pan. Staff F was later called to Resident #3's room, where he saw him/her sitting on the floor with the call light switch underneath him/her. Staff F stated the call light had been activated, but was not showing up on the marquee, computer or pager. Staff F attempted to fix the call light, but it didn't work. Staff F filled out a work order that evening. Staff F stated Resident #3 could sit up in bed and was known to get up unassisted, but rarely. Staff F stated Resident #3 seldom uses his/her call light. Staff F stated during the day Resident #3 was taken to the bathroom, but at night he/she uses a bed pan. Staff F stated residents on bed pans should be checked upon every 10-15 minutes. In an interview on 12/2/15 at 5:00 p.m. Staff G CNA, stated sometime around 11:00 p.m. on 11/19/15 she was checking lights on the 300 hall and heard someone crying. According to the interview Staff G entered the room of Resident #3 and found him/her sitting on the floor with his/her back up against the bed. Resident #3 had no bottoms on and when asked what happened he/she stated, My butt. Staff G noticed a bed pan on the bed. Staff G summoned the nurse Staff H registered nurse, (RN) and returned to the room. As Staff H attended to Resident #3, Staff G noticed the call light button was depressed, but not working. According to a statement during the interview Staff G unplugged the call light and plugged it back in, but could not get it to work. Nurse's Notes dated 11/19/15 at 11:30 p.m. and written by Staff H RN, indicated Resident #3 found sitting upright on floor beside bed, crying. When asked what happened, Resident #3 stated he/she was going to the bathroom. Both legs extended equally. Resident #3 complaining of pain 6/10 to buttocks. Bruise, bright red 4.8 centimeter (cm) by 0.4 cm noted to upper thigh/buttocks due to sitting on call light cord. Resident #3 assisted to standing position and back into bed. Range of motion completed independently. Vital signs within normal limits. Incident report dated 11/19/15 at 10:45 p.m. indicated Resident #3 was found sitting on the floor next to his/her bed crying. Resident #3 stated he/she was attempting to go to bathroom. Resident #3 was sitting on the call light cord, which left a bright red bruise on his/her upper right thigh/buttocks area. Resident #3 complaining of pain to bruised area. Nurse's Notes dated 11/20/15 at 4:00 a.m. and written by Staff H RN, indicated Resident #3 complaining of pain in left lower extremity. Head of bed lowered and resident re-assessed for fracture. No abnormal rotation to the left lower leg. According to the nursing assessment both legs appeared to be the same length. Range of motion still active. Hips feel equal without popping or rolling at joint. As needed Tylenol provided and left lower extremity propped up on pillow. Nurse's Notes dated 11/21/15 at 9:50 a.m. indicated Resident #3 not bearing weight as much as usual, but with no facial grimacing. Resident #3 not responding to pain assessment questioning. Nurse's Notes dated 11/24/15 as a late entry for 11/21/15 at 8:00 p.m. indicated CNA ' s reported Resident #3 in pain during transfer from wheelchair to bed, stating, ow, ow. Resident #3 assessed and rated pain at 10/10. Tylenol given. Left leg assessed and found without bruising or swelling. When checked on again in 30 minutes, Resident #3 was sleeping. Nurse's Notes dated 11/22/15 at 3:00 a.m. indicated Resident #3 continues to have pain and unable to roll to left side without crying. Physician notified and Resident #3 sent to the hospital for x-rays. Left facility at 3:20 a.m. Nurse's Notes dated 11/22/15 at 5:00 a.m. indicated hospital emergency department called informing facility Resident #3 has a hip fracture and will be admitted . Radiology report dated 11/22/15 indicated findings of acute subcapital fracture of the left femoral neck with mild displacement and impaction of the fracture. The hospital record revealed on 11/23/15 Resident #3 went to surgery for [REDACTED]. Record review noted two falls in last ninety days prior to 11/19/15 incident: Incident report dated 10/15/15 at 7:00 p.m. indicated Resident #3 attempted to transfer from his/her wheelchair into a swivel chair and slid to the floor. No injuries noted. Incident report dated 10/16/15 at 7:20 p.m. indicated Resident #3 was observed attempting to stand from his/her wheelchair and slid to the floor onto his/her buttocks. The wheelchair brakes were unlocked. No injuries noted. In an interview on 12/10/15 at 10:00 a.m. the Director of Nursing (DON) indicated residents placed on bed pans should be checked upon within 15 minutes. The DON stated it may vary depending on the resident, but notes there is no known facility policy on bed pan usage. In an interview on 12/9/15 at 5:05 p.m. Staff I CNA, indicated Resident #3 was capable of telling you when he/she needs to use the bathroom and can use the call light, although not consistently. Resident #3 was known to get up unassisted from his/her chair, but not the bed. Resident #3 was known to sit up in bed unassisted. In an interview on 12/2/15 at 2:40 p.m. Staff J, Licensed Practical Nurse (LPN) stated Resident #3 may attempt to get up unassisted 3-4 times a week prior to his/her fall with fracture. Resident #3 requires assist of two with transfers. On 11/21/15 staff reported Resident #3 was not moving or helping as much with transfers. Staff J stated she assessed Resident #3 and found no concerns. In an interview on 12/2/15 at 3:00 p.m. Staff K RN, Unit manager, indicated Resident #3 will self-propel in his/her wheelchair, but was unlikely to self-transfer. In (MONTH) (YEAR) there were two similar falls without injury. It was thought his/her attempts to get up unassisted related to a urinary tract infection. The falls were discussed in the morning quality assurance meetings and interventions added which included to not leave Resident #3 in his/her wheelchair in his/her room alone and to transfer Resident #3 into a recliner after supper since both falls occurred in the evening when trying to self-transfer. Resident #3 had done well until 11/19/15 at which time he/she attempted to get out of bed unassisted. Staff K stated there was initially no known injury, but within a couple days Resident #3 was having significant pain and when x-rayed, discovered a fractured left hip. During observations of residents at risk for falls, Resident #3 was observed sitting in his/her wheelchair in the 300 hall TV area following supper on 12/1/15 at 7:20 p.m. Observation revealed the wheelchair brakes as unlocked at that time. Staff K and the Administrator transferred Resident #3 into a recliner at 7:40 p.m. In an interview on 12/1/15 at 7:50 p.m. Staff K, Unit manager, questioned whether Resident #3's care plan had changed related to transferring him/her into a recliner after supper since his/her fall 11/19/15. Staff K stated she believes the expectations remain the same, despite Resident #3 having a recent hip fracture.

Based on clinical record review, staff interview and facility policy review, the facility failed to ensure staff provided adequate supervision and supervise interventions, to prevent falls and/or injury for one of five residents reviewed with a history of falls (Resident #1). The facility census was 75 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the Resident had short and long term memory deficits, moderately impaired cognitive skills, required extensive assistance of staff with bed mobility, transfers, ambulation, locomotion on and off the unit, dressing, toilet use, personal hygiene and had one fall since admission to the facility. A Care Plan, documented the Resident had been at risk for falls due to his/her poor safety awareness and recent decline in mobility/strength. The resident's goal was to not experience any major injuries related to falls. The care plan directives included the following: a. Monitor the resident for changes in his/her condition that may have warranted an increased supervision/assistance and notify the physician. b. Resident shall wear gripper socks or shoes at all times. c. Staff assistance with transfers and ambulation. d. Hipsters at all times. e. 7/27/12 - Pressure alarm at all times in bed and chairs. f. 4/12/12 - Personal alarm on bed. (discontinued on 7/27/12. An Incident/Accident/Unusual Occurrences Form dated 8/9/12 at 4 p.m., documented a Certified Nursing Assistant (CNA) had been toileting the Resident and had been putting on gloves when the Resident stood up to re-adjust himself/herself on the toilet and had fallen between the toilet and wall. The Resident had then began to stand back up before the staff could have stopped the Resident but had been able to intervene and assist when the Resident had been 1/2 way to a standing position. The Resident had no injuries and active range of motion (AROM) had been performed without limitations. The incident report noted the resident normally confused all the time. A hand written statement dated 8/10/12 (with Staff D's name) revealed the Resident was being toileted (on 8/9/12) and was positioning him/her(self) on the toilet as Staff D was putting her gloves in place(on). As Staff D was getting a new brief the resident stood up and moved to his/her left and fell to the ground. (The statement revealed the resident was not completed seated on the toilet when staff started cares which was the same repeated issue as the fall on 6/13/12.)The resident hit his/her hand on the toilet. The resident refused to sit on the ground and automatically got back up to use the toilet. The resident had a gait belt on at the time and Staff D was toileting him/her in the shower room. The briefs are in a cupboard in the shower room. A Nurse's Notes entry dated 8/9/12 at 11 p.m., documented the nurse had observed injuries related to a fall during cares. The injury had been noted to the Resident's left hand which had been swollen with bruising noted throughout the posterior hand which extended onto the Resident's left wrist. The area had been warm to the touch and the Resident complained of pain. The radial and brachial pulses had been present. A skin tear had also been present on the Resident's left elbow which measured 1.0 CM by 2.0 CM. The physician had been called and an order had been received to send the Resident for an X-ray in the morning. A left wrist X-ray report dated 8/10/12, documented the Resident had degenerative changes and osteopenia with a possible nondisplaced lateral distal radial metaphyseal fracture. A left hand X-ray report dated 8/10/12, documented the Resident had degenerative changes and osteopenia with a possible non displaced lateral distal radial metaphyseal fracture, osteoarthritis and a mild apparent irregularity at the base of the forth metacarpal. Both X-rays (dated 8/10/12) noted the resident had pain in his/her left hand and wrist. The facility self-reported the fall incident regarding the resident's left wrist/hand injury. A typed document dated 8/13/12 revealed an intervention for staff to have all the necessary supplies to preform cares within arm's reach prior to positioning the resident on the toilet. An Incident/Accident/Unusual Occurrences Form dated 6/13/12 at 6:10 a.m., documented a CNA had been walking with the Resident from his/her bed to the bathroom. While in the bathroom the CNA turned to retrieve and put on a pair of gloves when the Resident attempted to sit him/her(self) down on the toilet but instead sat to close to the edge of the toilet and slid to the floor. The Resident had been assisted to a standing position and AROM had been performed without limitations and no apparent injuries. The incident report noted the resident normally confused all the time. According to a documented (undated) titled Falls, after the fall on 6/13/12 the new intervention directed staff to ensure the Resident was completed seated on the toilet before starting cares. Other Falls: An Incident/Accident/Unusual Occurrences Form dated 7/26/12 at 5:55 p.m., documented the Resident had left the dining room and went to his/her room to put on his/her shoes. When the CNA had checked on the Resident he/she had told the staff member he/she had fallen. The Resident had a 4 centimeter (CM) by 3 CM contusion on his/her right temple/forehead. An Incident/Accident/Unusual Occurrences Form dated 5/23/12 at 12:45 a.m., documented the Resident's alarm had been sounding and upon investigation the Resident had attempted to toilet himself/herself. The CNA then assisted the Resident to bed and when the Resident sat down he/she slipped on the blankets and fell . The Resident complained of hip pain. An Incident/Accident/Unusual Occupancies Form dated 4/12/12 at 5:30 p.m., documented a CNA had entered the Resident's room and observed him/her had been sitting on the floor next to the bed. AROM had been performed without limitations, the Resident had been assisted to a standing position and ambulated to the dining room without difficulty. During a telephone interview 8/29/12 at 8:40 a.m., Staff D, Certified Nursing Assistant confirmed he/she ambulated the Resident with a gait belt from a lunch table to the shower room in the CCDI unit to toilet the Resident. The staff member said the Resident had refused to allow him/her to stop and get gloves in the bathroom so he/she assisted the Resident onto the toilet as the gait belt remained in place. The staff member then reached to get gloves from the wall to the right of the Resident and said he/she only had his/her eyes off of the Resident for like 2 seconds, as the Resident fell between the toilet and the wall. The staff member said the Resident had been 1/2 way back up to a standing position when he/she began to assist the Resident back onto the toilet. The staff member said he/she knew the Resident had hit his/her left hand/wrist on the toilet when he/she had fallen because the Resident's right hand had never left the grab bar when he/she had fallen and he/she heard a hand hit the toilet. The staff member stated he/she had paged the charge nurse via the Accu/Nurse system and ambulated the Resident back to the dining room table. When Staff C, Licensed Practical Nurse had returned to the unit Staff D, Certified Nursing Assistant told him/her he/she needed a fall report and confirmed he/she had failed to tell Staff C, Licensed Practical Nurse that the Resident had hit his/her left hand/wrist on the toilet during the fall. The staff member confirmed he/she had been aware that Residents were not to have been moved following a fall and that the charge nurse should have been informed of the fall immediately. During an interview 8/28/12 at 3 p.m., Staff C, Licensed Practical Nurse, confirmed he/she had been working as the charge nurse on 8/9/12 from 6 a.m. to 6 p.m. but at 4 p.m. he/she had left the CCDI unit to assist another Resident and had been off of the unit for approximately 15 minutes. When the staff member returned to the CCDI unit Staff D, Certified Nursing Assistant, had told him/her he/she needed a fall report for the Resident. Staff C, Licensed Practical Nurse, retrieved the appropriate reports and the Residents medical record and sat down with the Resident and the staff member. Staff D, Certified Nursing Assistant then explained what had happened. Staff C, Licensed Practical Nurse proceeded to assess the Resident's ortho's. Staff C, Licensed Practical Nurse, confirmed he/she had not performed range of motion exercises to the Resident's left arm/hand/wrist and/or removed the Resident's geri sleeves to visualize the Resident's skin because the Resident showed no signs of pain and had been using his/her left arm/hand/wrist per usual. The staff member also stated that he/she had been more worried about the Resident's hips and knees rather than the wrist/hand and that Staff D, Certified Nursing Assistant had never told him/her the Resident hit his/her left hand/wrist during the fall. Review of the facilities Accu Nurse paging system, revealed no pages had occurred on 8/9/12 between 3 p.m. and 6 p.m. between Staff D, Certified Nursing Assistant and Staff C, Licensed Practical Nurse. Review of the facilities call light monitoring system 8/29/12 at 10:05 a.m., revealed no call light had been utilized in the shower room on 8/9/12 between 3 p.m. and 5 p.m. The facilities Falls Protocol Quick Reference form dated 11/10, documented one assessment and intervention process when a fall occurred had been for the charge nurse to complete a head to toe assessment.

Based on observation, record review and staff interview, the facility failed to plan for and direct nursing care and services to meet one (1) of four (4) resident's supervision needs (Resident #1). The resident's record identified the facility discontinued a safety intervention that was in place to alert staff of Resident #1's supervision needs. Staff interviews revealed the resident continued to get up without assistance and fell sustaining a hip fracture. Staff interviews revealed the facility failed to plan for and direct nursing services after the safety intervention had been removed. The facility reported a census of 74 residents. Findings include: A Progress Note dated 03/01/12 documented Resident #1's [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated 05/17/12 Resident #1 did not complete the Brief Interview for Mental Status (resident rarely/never understood). Resident #1 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. Resident #1 required extensive assistance with activities of daily living (ADL's) including transfer, ambulation, and toilet use. The Nurse's Notes dated 05/08/11 at 6:00 a.m. documented Resident #1 lying on the floor outside of the bathroom in his/her room. Resident #1 complained of left arm discomfort and after staff noticed swelling sent the resident to the emergency room . The resident sustained [REDACTED]. The Nurse's Notes dated 05/09/11 at 5:30 p.m. documented the facility received orders for Resident #1 to a use a merry walker as needed when up to promote safety and independent ambulation. A Care Plan with a goal target date of 08/28/11 identified Resident #1 had a history of [REDACTED]. An Incident/Accident/Unusual Occurrences Form dated 11/17/11 at 7:50 p.m. documented Resident #1 laying on the floor on his/her back in front of the merry walker. The facility implemented a preventative measure of putting a personal alarm on Resident #1. The Care Plan dated 05/09/11 identified Resident #1 at risk for injury due to use of a merry walker. The interventions included Resident #1 wore a personal alarm when up in the merry walker to promote safety dated 11/18/11, and discontinued 02/01/12. The care plan failed to identify Resident #1 with a personal alarm at all times. The Treatment Record documented Resident #1 with a personal alarm (PA) at all times, all of January 2012, February 2012, March 2012, April 2012, and May 1st to the 6th. On May 6th the treatment record documented the PA had been discontinued. The clinical record lacked any documentation of why the facility discontinued the personal alarm. A Physical Restraint Informed Consent Form dated 03/30/12 documented the family was aware the physician ordered a merry walker for Resident #1's specific target behaviors of increased falls, unsteady and swaying gait, and the medical symptoms of confusion and decreased safety awareness. A Fall Risk assessment dated [DATE] scored Resident #1 at 21, with a score of 10 or above representing high risk for falls. A Care Plan with target goal date of 05/02/12 identified Resident #1 with a history of falling. The interventions included: a. Wear gripper socks or shoes at all times. b. Use 2 half rails when in bed. c. Wear hipsters at all times. d. Use a merry walker to promote safety and independence with ambulation. The Care Plan failed to identify Resident had a personal alarm at all times until 05/06/12. The clinical record failed to document an evaluation of the use of the personal alarm at all times. According to a Monthly Restraint assessment dated [DATE] Resident #1 had a lurching, unsteady gait, with decreased safety awareness. The assessment documented Resident #1 demonstrated balance problems when walking, decreased muscular coordination, a lurching, swaying or slapping gait, a gait pattern change when walking through the doorway, and jerking or instability when making turns. The assessment documented the facility had tried diversion, hipsters and personal alarms. Based on the findings Resident #1 needed a merry walker. The Interdisciplinary Progress (IDP) Notes dated 05/02/12 identified the facility was unable to reduce Resident #1's restraint of the merry walker. Resident #1 continued with an unsteady gait and decreased safety awareness. The merry walker provided Resident #1 with safe and independent ambulation. The IDP notes dated 05/16/12 documented Resident #1 required extensive assistance of 2 staff with bed mobility, transfers, toileting, bathing, personal hygiene, and dressing. The notes documented Resident #1 required extensive assistance of 2 staff with ambulation when not in the merry walker. A Side Rail Rationale Screen dated 05/16/12 documented Resident #1 had an alteration in safety awareness related to cognitive decline, a history of falls, and difficulty with balance or poor trunk control. An Incident/Accident/Unusual Occurrences Form dated 05/25/12 at 5:30 a.m. documented and aide reported to the nurse Resident #1 laid on the floor in the doorway. The nurse assessed Resident #1 who informed the staff he/she needed to use the toilet due to an episode of diarrhea. Resident #1 was able to pull his/her knees toward his/her chest and push back out. Resident#1 had no signs or symptoms of pain, and no facial grimacing noted. Resident #1 did not cry out. The form documented Resident #1 went to the emergency room . An orthopedic consult dated 05/25/12 at 4:30 p.m. documented Resident #1 had an unwitnessed fall at the nursing home. The X-rays obtained from the local hospital showed a displaced left femoral neck fracture (just below the hip joint). Resident #1 not likely a surgical candidate, recommended conservative treatment and pain management. A Patient Discharge and Transfer Form (from the hospital back to the facility) dated 05/26/12 documented Resident #1's rehabilitation potential poor and activity bedrest. An Internal Quality Assurance Investigation Form dated 05/25/12 documented the MDS/Care plan extensive assist times 2 followed. The interventions according to the care plan; hipsters at all times was followed. The possible contributing factors were a need to toilet and increased confusion. Staff educated to check Resident #1 more frequently. A Major Injury Form dated 05/25/12 documented Resident #1 had a poor prognosis, and after reviewing the circumstances, injury, and prognosis of the resident, the physician believed Resident #1 sustained a major injury. During an interview on 06/14/12 at 5:22 p.m. Staff E CNA stated she worked the shift Resident #1 fell . She checked and changed Resident #1 around 4:30 a.m. for incontinence of urine. Resident #1 was in bed. Staff E went to do bed checks around 5:30 a.m. when she found Resident #1 on the floor in the hall on the carpet. Staff E confirmed Resident #1's bed was closer to the window (rather than the door). Resident #1 did not have an alarm the night he/she fell . Staff E stated the facility had discontinued it a few weeks earlier. Staff E stated she did not know why the facility discontinued the alarm. Staff E stated Resident #1 would attempt to get out of bed unattended. She would catch Resident #1 putting his/her legs over the side of the bed, but she would catch him/her before he/she could get up. During an interview on 06/14/12 at 5:33 p.m. Staff F LPN stated Resident #1 did not have an alarm on the night he/she fell . Staff F stated the facility discontinued the alarm a week or 2 earlier. Staff F did not know why they discontinued it. She had not personally caught Resident #1 trying to get out of bed unattended. During an interview on 06/19/12 at 10:10 a.m. Staff B MDS Coordinator stated they had the Nurse Consultant there and they were trying to see if they could discontinue some alarms. Staff B stated they talked to some staff about whether Resident #1 made attempts to get up and they did not think he/she did. Staff B stated she did not document this, and they did not put any interventions in place to compensate for discontinuing the alarm. Staff B stated Resident #1 did not demonstrate improved cognitive function or physical ability to ambulate. During an interview on 06/14/12 at 2:35 p.m. Staff C Certified Nursing Assistant (CNA) stated she didn't normally work in the special care unit, but when she did, Resident #1 set the alarm off trying to get up. During an interview on 06/14/12 at 3:38 p.m. Staff D Licensed Practical Nurse (LPN) stated Resident #1 had an alarm, and then she did not. She stated Resident #1 did make attempts to get up unattended. She didn't know why they discontinued the alarm. During an interview on 06/15/12 at 7:52 a.m. Staff G CNA stated Resident #1 would get up from bed unattended, so she was not surprised Resident #1 got up and fell . Staff G stated when they laid Resident #1 down for a nap they would have to watch him/her really close, because he/she would try to get up. During an interview on 06/14/12 at 12:15 p.m. the Director of Nursing stated Resident #1 did have an alarm, then he/she went 6 months without an incident so they discontinued it. The Care Plan (after the fall) with a goal target date of 09/07/12 identified Resident #1 required assistance with activities of daily living. The interventions included: a. Bedrest (discontinued 06/09/12). b. Transfer with the use of Hoyer (mechanical) lift and 2 assist. c. Primary mode of transportation, geri-chair without a tray, which staff propelled for him/her. During an observation on 06/14/12 at 5:00 p.m. staff provided cares to Resident #1. They placed a mechanical lift sling and lifted him/her out of bed and transferred him/her to a geri chair.

Based on record review and staff and family interviews, the facility failed to administer [MEDICATION NAME] (a diuretic medication used to treat [MEDICAL CONDITION], a condition in which the heart is an inadequate pump and a build-up of body fluids occurs) as ordered by the physician for 1 of 5 residents (Resident #6). The staff failed to transcribe the [MEDICATION NAME] 80 mg (milligrams) daily dose on the Medication Administration Record after the physician ordered an increase in the [MEDICATION NAME] 80 mg to twice a day for a seven day period ending on 3/20/11 after staff administered the p.m. dose of [MEDICATION NAME]. The staff failed to identify the transcription error, failed to notify the physician after the 7 day course of twice daily dosing of the diuretic was completed on 3/20/11 and clarify with the physician about the continued administration of [MEDICATION NAME] for the treatment of [REDACTED]. The facility failed to assess the resident after a change of condition which warranted the resident to be sent to the hospital and failed to follow the plan of care. The facility reported a census of 63 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 5/5/11 identified Resident #6 was admitted to the facility on [DATE]. The quarterly MDS identified the resident's BIMS (Basic Interview Mental Status) score for cognition scored at 7 (severely impaired cognition). The MDS reflected the resident required extensive assistance of staff for Activities of Daily Living (ADL's) including transfers, ambulation in the room, dressing, toilet use, personal hygiene and bathing. The MDS further identified the resident with [DIAGNOSES REDACTED]. The MDS identified the resident frequently incontinent of bladder and occasionally incontinent of bowel. The MDS reflected the resident's attending physician (or authorized assistant or practitioner) examined the resident and changed the resident's orders twice in the past 14 days. The care plan with a goal date of 5/24/11 identified the resident had potential for weight changes related to [MEDICAL CONDITIONS], memory loss/confusion and variable meal intake. The care plan directed staff to provide a regular diet, monitor intake at each meal and report changes in intake patterns, monitor weights weekly until stable, then monthly or as directed. The care plan also directed staff monitor for signs and symptoms of fluid retention ([MEDICAL CONDITION], shortness of breath, lung sounds) and report to the physician. The care plan with a revised goal date of 8/19/11 identified the resident at risk for dehydration or other electrolyte imbalances because the resident used a diuretic to treat his/her [MEDICAL CONDITION]. The care plan directed staff to monitor the resident for [MEDICAL CONDITION], and for signs and symptoms of dehydration: dry mucous membranes, sunken eyes, poor skin turgor, etc. and notify the M.D. (the resident's attending physician) when indicated. Review of the admission orders [REDACTED]. The physician ordered staff to administer [MEDICATION NAME] 40 mg daily by mouth, administer continuous Oxygen at 2L (Liters) and check the resident's weight daily. Review of the Physician's Telephone Orders dated 1/21/10 revealed the physician ordered staff to increase the resident's daily dose of [MEDICATION NAME] to 60 mg daily, recheck labs in 7 days and continue daily weights. The Telephone physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the physician's orders [REDACTED].S.) dated March 2011 revealed the physician ordered staff to administer the resident [MEDICATION NAME] 80 mg daily. The P.O.S. also identified the resident with [DIAGNOSES REDACTED]. Review of the P.O.S. dated April 2011 revealed a lack of documentation for an order for [REDACTED]. Review of the Physician's Telephone Orders dated 3/14/11 revealed the physician ordered staff administer the resident [MEDICATION NAME] 80 mg twice daily for 7 days and apply Ted Hose (Support stockings applied to the residents legs to treat [MEDICAL CONDITION]( swelling of the body tissues due to excess fluid). The Ted Hose support the blood vessels in the lower extremities and assist with the return of blood/fluids to the heart. Further review of the physician's orders [REDACTED]. Review of the Physician order [REDACTED]. measured less than 92 % (normal SPO2 usually considered 90 - 100 %). The Physician order [REDACTED]. Review of the Nurse's Notes dated 7/13/10 revealed Staff D documented the Restorative Aide reported to her the resident complained of shortness of breath with activities or exercising, the resident's lung sounds clear, vital signs, the resident's oxygen level (SPO2) in his/her blood at 97 % and the resident had 2+ to 3 + [MEDICAL CONDITION] of his/her lower extremities, Ted Hose on and legs elevated. Review of a Physician Notification Facsimile (FAX) dated 7/13/10 revealed Staff D notified the physician of the resident's complaint of shortness of breath, lung sounds clear, 2+ to 3+ [MEDICAL CONDITION] of bilateral lower extremities, the resident had Ted Hose on and legs elevated. The physician acknowledged receipt of the notification and ordered staff to continue to monitor the resident's [MEDICAL CONDITION]. The Physician Notification FAX dated 2/14/11 revealed staff N reported the resident had 3+ [MEDICAL CONDITION] to his/her lower extremities, the resident refused to wear the Ted Hose, legs elevated and staff continued to administer [MEDICATION NAME] 80 mg daily and questioned if the physician requested any new orders. The physician acknowledged receipt of the FAX and requested no new orders for the resident. Review of the Nurse's Notes dated 3/18/11 at 2:40 a.m., revealed Staff A documented staff administered the resident [MEDICATION NAME] 80 mg twice daily as ordered without adverse side effects noted, had 2+ [MEDICAL CONDITION] (deep tissue swelling), vital signs, SPO2 of 93 %, no cough present and legs were elevated. On 3/18/11 at 10:00 a.m., Staff L documented in the Nurse's Notes the resident continued to receive the [MEDICATION NAME] 80 mg twice daily, had decreased [MEDICAL CONDITION]- 1+ non-[MEDICAL CONDITION], no cough, vital signs and SPO2 measured at 97 % on room air (no oxygen administered during the reading). Review of the Nurse's Notes from 3/19/11 through 5/8/11 revealed the notes lacked staff documentation of assessment of presence/absence and extent of the resident's [MEDICAL CONDITION]. Further review of the Nurse's Notes, revealed the next entry documentation performed by Staff M on 5/9/11 at 7:45 a.m., at which time the resident had complained of shortness of breath and observed holding his/her chest. Staff M documented the resident already had oxygen on being delivered at 2 L/min per nasal cannula (a tube placed in the resident's nares connected to an oxygen supply). The Notes lacked documentation of the time oxygen was initiated and identification of staff who applied the oxygen on the resident. Staff M documented the resident's vital signs as: Temperature- 98.8 degrees Fahrenheit, pulse-44 beats per minute bpm (normal heart rate for an adult is 60 -100 bpm), Blood Pressure 187/110 (the measurement of the blood pressure in the resident's arteries) the normal blood pressure is below 130/80. Staff M notified the on call physician of the resident's condition and received an order to transfer the resident to the local hospital ER (emergency room ). Staff M documented she called "911", requested an ambulance to transport the resident and the resident transported per ambulance to the hospital. Staff M documented she called the local hospital to obtain an update on the resident's condition. The local hospital staff notified Staff M the resident transferred to a Des Moines Hospital by air ambulance. Review of the Nurse's Notes revealed the Notes lacked staff documentation of an assessment of the resident's [MEDICAL CONDITION] swelling that usually develops first in the feet and legs), vital signs, dyspnea (shortness of breath), pain, lung sounds and the resident's pulse oximeter readings for the 5 day period prior to the resident's complaints of chest discomfort and dyspnea at 7:45 a.m. on 5/9/11. Review of the Iowa EMS Report dated 5/9/11 at 8:10 a.m., revealed the responding Paramedics of the local hospital Ambulance documented they arrived at the facility after dispatched via 911 call for the resident's complaints of shortness of breath, chest pain and hypertension. The Paramedic documented upon their arrival the resident set in a chair, in moderate distress and complained of chest pain and shortness of breath. The resident had frothy sputum. The Paramedic documented the resident alert and oriented 15 on the Glasgow Coma Scale (no loss of consciousness and vital signs present). The Paramedic documented the resident had 4+ ( a large amount of swelling - 1+ = minimal [MEDICAL CONDITION]/swelling of the lower legs and 4+ being the maximum swelling on the scale) pitting. The Paramedic documented treatment rendered the resident enroute to the local hospital via ambulance as follows: Oxygen applied, heart monitor applied and interpreted as Sinus Rhythm, an Intravenous Line (IV) started in the resident's left hand, given [MEDICATION NAME] 80 mg through the IV for treatment of [REDACTED]. The Paramedic documented the resident had continued difficulty breathing enroute to the hospital. Upon arrival to the local hospital the resident had an abnormal heart rhyth During an interview on 6/9/11 at 6:15 p.m., Staff C stated she normally generated the resident's new Medication Administration Record (MAR) for the next month via her computer. Staff C stated she used the MAR and the physician's order [REDACTED]. Staff C stated two facility nurses were responsible for checking the accuracy of the new month's MAR by comparing it with the physician's orders [REDACTED]. Staff C reviewed the March 2011 MAR and the physician's orders [REDACTED]. Staff C stated obviously the facility nurses did not question or call the physician to clarify if the previous order for [MEDICATION NAME] 80 mg should be continued. Staff C confirmed the nursing staff failed to administer the resident [MEDICATION NAME] 80 mg since March 20, 2011 (at which time the resident received the last dose of [MEDICATION NAME] 80 mg twice a day dosing. During an interview on 6/20/11 at 10 a.m., Staff N stated she was the facility's MDS (Minimum Data Set Coordinator. Staff N stated she normally performed the MDS assessment for resident's reviewed Hot Charts-resident being specially monitored for changes), notifying physicians/families of changes in resident's condition or orders. Staff N stated she rarely passed medications or noted the physician's orders [REDACTED]. During an interview on 6/20/11 at 9:32 a.m., Staff D stated she rarely administered Resident #1 medications. Staff D stated if staff administered the resident [MEDICATION NAME] 80 mg daily for a long period of time and the physician increased the dose to 80 mg twice daily due to increased [MEDICAL CONDITION] (a build-up of fluid in the resident's body tissues), she expected facility nurses to either ask the physician if he wanted staff to continue to administer the resident [MEDICATION NAME] 80 mg daily or follow up with the physician after the 7 days of [MEDICATION NAME] 80 mg twice daily regimen completed. Staff D stated normally the nurses contacted the physician to notify him of improvement or a decline in the resident's condition had occurred after the 7 day increased dose administered. During an interview on 6/20/11 at 11:42 a.m., Staff A stated she had administered the resident [MEDICATION NAME] during the 7 day increased dosing in March 2011. Staff A stated she was not aware the resident was not administered [MEDICATION NAME] 80 mg daily after the 7 days and would have called the physician for further orders. On 6/20/2011 at 3:30 p.m. a family member stated had visited the resident the day before transferred to the hospital. The resident had " a little " swelling of both ankles and feet the day of the visit. The family member received a telephone call and notified the resident had been transferred to the hospital. The family member stated had felt shocked at the appearance of the resident. The resident had looked as though had gained 200 pounds and had swelling over the entire body. The family member stated this would be noticed over several hours and doubted the facility staff had checked the resident during the previous night shift. During an interview on 6/9/2011 at 6:15 p.m., Staff C stated she expected the facility nurses to document in the nurse ' s notes of any resident symptoms of dyspnea.

# -M A Based on clinical record review, staff interview and observation, the facility failed to ensure the resident environment remained as free of accident hazards as was possible when they failed to provide adequate supervision for confused residents while in the restroom for 2 of 4 residents sampled for review. The facility reported a census of 75 residents. (Resident #3 and Resident #4) Findings: Based on record review, staff interview and observation, the facility failed to provide residents with adequate supervision to ensure against hazards from self and elements in the environment (Resident #2 and #4). The sample consisted of 4 residents. . The facility reported a census of 75 residents. Findings: 1. A Minimum Data Set (MDS) assessment with a reference date of 9/20/2010,identified Resident #3 with long and short-term memory loss, modified cognitive impairment in new situations, socially inappropriate behaviors and required extensive assistance with activities of daily living skills. The assessment also reflected Resident #3 experienced occasional bladder incontinent episodes, had a recent history of falls, received anti-anxiety and anti-depressant medications each day and received Hospice services. An accumulative [DIAGNOSES REDACTED]. On 11/1/10 the administrator notified the Iowa Department of Inspections and Appeals of an incident which occurred on 10/31/10 at 12:30 a.m. The report indicated two Certified Nursing Assistants assisted Resident #3 into the bathroom. The staff left the resident alone/unsupervised and seated on the toilet. The staff left the room to care for another resident. The staff returned to the bathroom and found the resident on the bathroom floor. The resident sustained [REDACTED]. A Result Review Report (History and Physical) dated 9/27/10 noted Resident #3 was transferred to a local hospital for a right hip injury. The resident had sustained a right hip fracture one month ago. Past medical history included osteoporosis. A physician progress notes [REDACTED]. The resident initially entered the facility for Skilled therapy after a hip fracture and subsequent repair. Unfortunately while in skilled therapy, the resident experienced another fall and broke the other hip. The resident required and had surgical repair of that hip also. At the time of the most recent fall, the resident was very frail, weighed 66 pounds upon admission and had become very confused. A Pain Assessment tool, dated 10/4/10 assessed Resident #3 with moderate right hip pain. The plan of care dated 10/21/10 identified a problem of alteration in nutrition and overt muscle wasting. The plan noted the resident was on a rehab to home plan, working with therapy with a goal to return home. The plan noted a risk of injury due to a history of falls. This plan directed the staff to assist the resident with walking and to remind the resident to ask for assistance for all ambulation. The plan of care lacked any direction/instruction to staff not to leave this resident alone in the bathroom. The Care Card for Resident #3 was updated on 11/8/10 and again on 11/16/10 which included gripper socks at all times, personal alarm at all times and a bed alarm. The care card lacked any instruction to stay with this resident while in the bathroom. A Social Progress Note dated 9/14/10 assessed this resident as alert, tires very easily and showed short and long-term memory impairment. A physician's orders [REDACTED]. A Clinical Update/Progress Note dated 9/16/10 diagnosed this resident with failure to thrive. The resident fell at home with a fractured hip, developed pneumonia, sustained a significant weight loss, was very confused, worse since recent hospitalization and was appropriate for Hospice care. A physician's orders [REDACTED]. A Nutritional Progress note dated 10/13/10 assessed this resident with a left hip fracture and weighed 83.9 pounds. The resident received Hospice services. A Nursing Order: Discharge to Licensed Facility dated 10/2/10 assessed this resident with a fractured hip and required a gait belt and assistance of two persons for ambulation. A Physician order [REDACTED]. The fall risk assessments dated 8/31/10, 9/8/10, 9/14/10 and 10/4/10 all assessed Resident #3 at a high risk for falls. A Physician Notification dated 10/28/10 informed the physician the staff heard this resident's alarms sounding and found the resident on the floor in front of the bathroom door with cotton socks on. The resident stated they were going to the bathroom. A Nurse's Note dated 10/31/10 at 12:30 a.m. noted a Certified Nursing Assistant summoned the nurse to the resident ' s room. The resident was observed lying on the floor of the bathroom. The resident reported pain in the right rib cage area. Staff reported the resident wanted to use the restroom so was assisted to the resident ' s bathroom. The resident wanted to be alone so the nursing assistants made sure the resident had a call light. Two or three minutes later, the staff were going back to check on the resident when they heard a loud noise. Staff found this resident on the floor. At 2:00 a.m. the nurse sent the resident to the emergency room by ambulance. At 5:30 a.m. the resident returned to the facility with a new [DIAGNOSES REDACTED]. An Incident/Accident/Unusual Occurrence Form dated 10/31/10 at 12:30 a.m. noted the resident wanted to be left alone in the bathroom so the staff made sure the resident had a call light. Two or three minutes later, the nursing assistants was returning when they heard a noise and found the resident lying on the bathroom floor. An x-ray report dated 10/31/2010 identified fractures of the lateral aspect of at least the ninth and tenth right sided ribs. An Interdisciplinary Progress Note dated 11/2/10 documented a meeting with the resident's family. The family expressed concerns regarding the resident's increased confusion and falls. The nurse explained a possible admission to the dementia unit with a room closer to the nurse's station to increase monitoring and staff ability to hear alarms as well as monitoring of confusion. A Corrective Action Form dated 11/2/10 noted on 10/31/10 at 12:30 a.m. Staff C assisted resident to the toilet. resident had a history of [REDACTED]. Staff left the resident unattended, resulting in a fall and injury. The form indicated staff must use a gait belt when assisting a resident who is a one or two person assist and to follow the policy and procedure. Do not leave resident's with alarms unattended on toilet. Staff c received a three day suspension. A Corrective Action Form dated 11/2/10 noted on the 10:00 p.m. to 6:00 a.m. shift on 10/30/10 Staff B assisted a resident to the toilet. Staff B did not use a gait belt when walking the resident. The resident was left unattended on the toilet. The Corrective Action: Use a gait belt any time staff are ambulating a resident who is a one or two person assist. Residents with alarms cannot be left unattended on the toilet. When interviewed on 11/18/10 at 2:30 a.m., Staff C stated on 10/31/10 they (Staff B and Staff C) assisted Resident #3 to the bathroom. Staff C stated they stayed with the resident a few minutes. Staff C then sent Staff B across the hall to start on another resident that required two people assistance. Staff C handed the resident the call light and instructed the resident to use the call light when finished. Staff C then left the room to assist Staff B with another resident. Staff C stated there is another resident who utilized personal alarms and when they assist that resident in the bathroom, Staff C will step out of the bathroom to give the resident privacy, however staff stay in the resident's bedroom. When interviewed on 11/17/10 at 11:55 p.m. Staff B stated Resident #3 insisted on going to the restroom. Staff B stated she/he put on the resident's shoes and assisted the resident to walk to the restroom. The resident walked a little unsteady. While in the bathroom, Staff C handed the resident the call light and told the resident not to get up without pulling the light Staff B then walked out of the bathroom and Staff C followed him/her across the hall to another resident's room. They were just beginning care for the other resident when then heard a loud thud. Staff B ran across the hall to find Resident #3 on the floor. Staff B reported had failed to use a gait belt when walking Resident #3 to the restroom. Staff B denied being informed during orientation to not leave an alarmed resident alone in the bathroom. At the time of this incident, staff did leave this resident alone in the bathroom. Staff B stated they would not have left this resident alone in the bathroom had they known the facility policy about not leaving an alarmed resident alone in the bathroom. When interviewed on 11/16/10 at 5:23 p.m. the Administrator stated he/she was disappointed when she/he learned Staff C left a resident unattended on the toilet. Staff C told the administrator had thought the resident would remain on the toilet; Staff C thought Resident #3 was alert and oriented. Staff C left Resident #3 alone on the toilet to go across the hall to assist Staff B in repositioning another resident. The Administrator stated, "When someone comes to work at Southern Hills Specialty Care it is standard practice not to leave any resident that has alarms in the bathroom unattended. Standard of practice comes from C.N.A. classes and the orientation process." The administrator stated they asked several employees how they knew they were not to leave a resident unattended in the bathroom. Their responses included: it's common sense and it's our job. We just know. When interviewed on 11/16/10 at 5:50 p.m. the Director of Nursing described Staff C as a very conscientious aide. The Director of Nursing stated staff know not to leave a resident alone in the restroom if the resident had an alarm because the resident was either a fall risk or had fallen and that is why the alarm is in place. The Director of Nursing stated staff were made aware of the facility policy during orientation by other C.N.A.'s (Certified Nursing Assistants). 2. An Accumulative [DIAGNOSES REDACTED]. A Physician Notification form dated 11/11/10 instructed this resident's physician that the staff found Resident #4 sitting on the floor. A physician's orders [REDACTED]. A Physician Notification dated 8/16/10 informed the physician staff observed this resident fall to the floor. A Physician Notification dated 8/2/10 noted the resident claimed to have slid down the bathroom wall. A Physician Notification dated 8/2/10 notified the physician staff found the resident sitting on the floor next to their bed. The resident claimed someone pushed him/her out of bed. A Physician Notification dated 7/1/10 informed the physician staff found the resident on the floor. A Physician's Progress note dated 11/3/10 assessed the resident with progressive dementia. A Physician's Progress note dated 5/19/10 assessed the resident with falls and osteoarthritis. The note included: "(He/she) has had a fall recently. Monitor the falls." A Physician's Progress note dated 9/23/09 noted the resident had a history of [REDACTED]. The resident reported a couple incidents of falls and some worry about their balance. Fall Risk Assessments dated 7/9/10, 9/16/10 and 11/15/10 all assessed this resident at a high risk for falls. A Minimum Data Set (MDS) assessment tool dated 9/16/10 included: short-term memory loss, moderate cognitive impairment, limited assistance required for transfers, walking and dressing. The assessment noted a history of falls in the past 30 days and in the past 31 to 180 days. A resident plan of care, dated 9/30/10 included: short-term memory deficit, confusion, wandering, required assistance with care due to dementia, at risk for injury due to a history of falls. The plan of care instructed the staff to use hipsters when up and use an alarm on this resident's bed. The plan of care also noted the resident at risk of injury due to attempting to get out of the merry walker independently and without regard to the resident ' s safety needs. The plan of care instructed the staff to assist the resident with position change every 30 minutes, provide the resident with diversion activities and to utilize an alarm on the merry walker device. This plan of care lacked any direction to the staff to stay with this resident while in the bathroom. A Social Progress note dated 10/19/10 noted staff talked with this resident's family about moving the resident to the locked unit for safety purposes due to the resident removed themselves from the merry walker several times. The family voiced a desire not to move this resident to the unit. Staff explained it was a smaller area and the resident could be monitored more easily. Observation on 11/17/10 at 10:30 p.m. revealed Resident #4 sitting up in bed. It was noted t that three different staff members walked by the resident's room. One staff member commented, "Oh (he/she) is sitting up." Staff continued to walk past the room. Observation on 11/17/10 at 10:40 p.m. revealed Resident #4 sitting up in bed. Staff A entered the room and asked the resident if she/he needed anything. The resident responded, "No not really." Staff then exited the room. Observation on 11/17/10 at 10:45 p.m. revealed Staff A returned to this resident's room and encouraged the resident to lie down. Staff then covered the resident with a blanket and exited the room. Continued observation revealed as soon as staff left the room, the resident sat back up. Resident #4 then swung his/her feet over the side of the bed. Observation revealed no gripper socks on this resident's feet as planned. The resident stated, "I have to go to the bathroom." The resident then stood up and set off the alarm. The resident then walked into the bathroom and immediately went to the bathroom. Staff A then came running down the hall. Staff A entered the bathroom and said, "You're not supposed to get up by yourself remember." Staff A then exited the bathroom, retrieved the resident's walker from the bedroom, brought the walker into the bathroom and set the walker directly in front of the resident. Staff A then left the resident alone/unsupervised. Staff A then exited the bathroom and closed the bathroom door. Staff A then stated the resident was supposed to have gripper socks on in bed. Staff A then searched four different drawers prior to finding socks. Staff A then searched for the resident's shoes. Staff A then opened the bathroom door and entered the bathroom. When interviewed on 11/17/10 at 11:00 p.m., Staff A stated she/he found the resident alone in the bathroom. Staff A informed the resident she/he needed help to go to the bathroom. Staff A then obtained the resident's walker and noted the resident not wearing gripper socks as planned. The staff then left the resident in the bathroom and closed the bathroom door for privacy as she/he searched the resident's room for socks and shoes. Staff A reported she/he could leave this resident alone in the bathroom to go and look for socks and shoes as long as she/he stay close in the bedroom. A Corrective Action Form dated 11/18/10 noted the charge nurse instructed Staff A to assist Resident #4 to the bathroom on 11/17/10. Instead of taking the resident to the bathroom Staff A covered the resident up. This resident was a fall risk resident and he/she did not follow direction from the charge nurse. Staff A had to return to this resident's room three times when alarms sounded. A Five Minute Meeting for Employees dated 11/1/10 and signed by Staff A indicated: "REMINDER-if a resident has an alarm of any kind they are not to be left unattended on the toilet." B. Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one random observation of a housekeeping cart left unlocked in a resident hallway. The facility reported a census of 75 residents. Findings include: 1. A random observation on 11/18/10 at 10:20 a.m. revealed an unlocked, unsupervised housekeeping cart in the 200 hallway. Continued observation revealed this cart sat unsupervised for seven minutes. This cart contained: a. 20 ounces of 256 Centry Q 256. Disinfectant, cleanser, sanitizer, fungicide, virucide. The bottle contained a warning label. The label read, "Do not breath spray. Keep out of reach of children. Harmful if swallowed. Do not get in eyes. b. Fresh 100, One Step Virucidal, ready to use germicidal. The warning label read, "Keep out of reach of children. Harmful if absorbed through skin." c. RTU All Purpose Cleanser, ADC with Bleach, 32 ounces. The warning label read, "May be harmful if swallowed. May be irritating to eyes and skin." When interviewed on 11/18/10 at 10:27 a.m. Staff E stated they left the cart unlocked when they left the 200 hall to move a resident to the 500 hallway. Staff E stated the policy required them to lock the cart when not supervised. Staff E stated they failed to lock the cart when the left the area due to they "spaced it off."