Every finding on record at Southfield Wellness Community

Based on clinical record review, staff interviews, camera/video footage review and policy review, the facility failed to provide adequate supervision and operational alarm safeguards to prevent the elopement for 1 of 1 resident reviewed (Resident #7). On 7/17/26 at 3:45 PM, Resident #7 exited the building unattended. At 3:46 PM, Staff F, Dietary Staff member entered the lobby and shut off both the door alarm and wander guard alarm (across 2 separate keypads) without investigating the cause or checking the exit. Another resident (Resident #12) asked Staff G, Certified Medication Aide (CMA) if she was going to get Resident #7 who went outside. At 3:50 PM, Staff G, CMA asked staff via walkie-talkie if anyone saw Resident #7. Staff G, CMA retrieved Resident #7 from the parking lot of the facility at 3:52 PM.The facility sits at the end of a residential road, 0.1 miles (approx. 500 feet) north of Highway 20-a high-speed road with a 65-mph speed limit-separated only by grass and trees. An unmonitored resident wandering onto a 65-mph highway creates an immediate risk of severe vehicular trauma or death. Additionally, the Climatologist measured the temperature at 90 degrees with a heat index of 103 degrees. Resident #7 wore a long-sleeve t-shirt, sweatpants, and shoes, creating a rapid risk of severe heat exhaustion, hyperthermia, heat stroke, or death. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/23/26 at 11:08 AM that began as of 7/17/26. The Facility Staff removed the IJ on 7/17/26 through the following actions:-Resident #7 was assessed immediately on 7/17/26 with no negative findings. -Resident head count completed and everyone accounted for. -House wide facility staff education initiated on 7/17/26 regarding door alarm and wander guard alarm response. -Staff who are currently on leave or new agency staff will receive training prior to the next scheduled shift. -Newly hired staff will be trained regarding door alarm protocols and Wanderguard alarm response during orientation. -Door alarm audit and Wanderguard audits were completed on 7/17/26 and continued daily with no negative findings. - Staff F, Dietary Aide, received verbal warning on 7/17/26. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education regarding the door and Wanderguard alarms. The facility reported a census of 56 residents. Findings include:Resident #7's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severely cognitively impaired. Resident #7's MDS documented Resident #7 required partial or moderate assistance with transfers and ambulation (walking). Diagnoses included cerebrovascular accident (stroke), coronary artery disease (clogged heart arteries), diabetes mellitus (high blood sugar), and legal blindness (severe vision loss). Resident #7's MDS documented Resident #7 didn't use a wander or elopement alarm. Resident #7's Care Plan with a target date of 10/4/26 documented Resident #7 at risk for elopement or wandering related to confusion and impaired cognition. The Care Plan documented the following interventions with implementation dates:Alert bracelet or Wanderguard - 7/17/26Staff to check alert bracelet and placement every shift and function every day - 7/17/26Staff to engage Resident #7 in purposeful activities - 5/8/26Provide care in a calm and reassuring manner - 5/8/26Provide care in simple instructions - 5/8/26Provide reorientation to surroundings and environment - 5/8/26 A Progress Note dated 6/19/26 at 10:17 PM documented Resident #7 wandering into another resident's room and sitting in a closet in a room across the hall. A Progress Note dated 6/28/26 at 7:02 AM documented Resident #7 staying up all night wandering with a walker. The note documented staff observing from a distance due to agitation, and documented Resident #7 experiencing confusion, reporting military service and staff holding Resident #7 back from saving people. A Progress Note dated 6/28/26 at 7:54 AM documented Resident #7 requiring one-on-one (1:1) supervision most of the morning due to exit seeking. A Progress Note dated 7/1/26 at 7:05 PM documented Resident #7 wandering throughout the facility, needing constant prompts to use the walker. Resident #7 displayed dangerous transfer habits, including sitting on a walker with one knee, placing hands on the wall, attempting to scoot down the wall to sit on the floor, and walking backwards. A Progress Note dated 7/4/26 at 9:42 AM documented Resident #7 wandering since the nurse arrived in the morning, requiring staff intervention when Resident #7 left the walker to continue walking. The note documented Resident #7 required one-on-one (1:1) supervision most of the morning. A review of the Clinical Record showed a lack of an Elopement Risk Evaluation prior to 7/17/26. A review of June and July 2026 Medication Administration Records (MAR) showed a lack of documentation regarding Resident #7's Wanderguard placement and function until 7/18/26. An Incident Report (IR) dated 7/17/26 at 3:45 PM completed by the Director of Nursing (DON), documented at 3:45 PM the Wanderguard and front door alarm sounded. The report documented a staff member shut off the alarm and returned to previous duties. Resident #12 alerted a staff member after observing a resident walk out the door, causing alarms to sound, and the staff member immediately exited the building to locate Resident #7 and redirect Resident #7 inside. A review of facility Camera and Video Footage dated 7/17/26 documented the following:Resident #7 exited the building at 3:45 PM wearing a long-sleeve shirt, sweatpants, and shoes.Staff F, Dietary Aide (DA), manually shut off the door and Wanderguard alarm at 3:46 PM.Staff G, Certified Medication Aide (CMA), approached by Resident #12, headed outside at 3:51 PM.Staff G brought Resident #7 back into the building at 3:52 PM. The Climatologist Report dated 7/22/26 at 1:54 PM documented on 7/17/26 at 3:45 PM in Webster City the outdoor temperature measured 90 degrees Fahrenheit with a heat index of 103 degrees Fahrenheit. Google Maps reviewed 7/23/26 identified the facility sat at the end of a residential road, 0.1 miles (approx. 500 feet) north of Highway 20-a high-speed road with a 65-mph speed limit-separated only by grass and trees. The Employee Warning Notice form dated 7/17/26 documented Staff F responded to an alarm located at the front doorway on 7/17/26. Camera review confirmed staff didn't follow guidelines appropriately when responding to an alarm. The notice documented Wanderguard alarms represent critical safety alerts designed to protect residents at risk for wandering or elopement. Facility policy required all staff to immediately respond and investigate any Wanderguard alarm, regardless of current duties, to ensure resident safety and security. The notice documented failure to respond places residents at risk for adverse outcomes and injury. Staff F wrote on the bottom of the notice not receiving information regarding Wanderguards and checking the perimeter. The DON, the Administrator, and Staff F signed the form on 7/17/26. On 7/22/26 at 6:42 AM the DON stated identifying on 7/17/26 Resident #7's Wanderguard didn't appear on the Care Plan or MAR, and corrected the omissions. The DON acknowledged staff didn't complete an elopement assessment prior to the incident, completing the assessment on 7/17/26. The DON stated expecting the Wanderguard to appear on the Care Plan and MAR, and expecting staff to complete an elopement assessment upon admission and as needed if identifying a resident as an elopement risk. The DON stated uncertainty regarding when staff implemented Resident #7's Wanderguard. On 7/22/26 at 12:57 PM Staff E, Registered Nurse (RN), stated the front door alarm sounded on 7/17/26 while Staff E performed a treatment on [NAME] Hall. Staff E stated a medication aide reported over the walkie-talkie Resident #7 exited into the parking lot. Staff E stated asking over the walkie-talkie if someone could assist Resident #7 because Staff E remained mid-treatment, and the medication aide reported assisting Resident #7 back inside. Staff E reported the DON informed Staff E a dietary staff member shut off the door alarm without confirming if a resident exited. Staff E stated not observing Resident #7 return to the building because Resident #7 returned before Staff E completed the treatment. Staff E reported Resident #7 wore a Wanderguard at the time of the elopement and stated hearing staff say the door alarm sounded, assuming both alarms sounded. Staff E stated Resident #7 attempted to leave the building once or twice previously, but staff intervened. Staff E stated believing Resident #7 stayed outside around 5 minutes. On 7/22/26 at 1:16 PM Staff F, Certified Medication Aide (CMA), stated walking up front around 3:45 PM to prepare the medication pass. Staff F reported she heard the Wanderguard sound before someone shut it off. Staff F stated Resident #12 asked if Staff F planned to get Resident #7 because they walked outside, and Resident #7's roommate confirmed Resident #7 walked outside. Staff F stated Resident #12 reported someone turned off the alarm and walked away. Staff F stated they walked to the front door, asked over the walkie-talkie if anyone held eyes on Resident #7, and then observed Resident #7 standing in the handicapped parking stall looking around with a walker. Staff F stated Resident #7 reported feeling better outside due to warm weather. Staff F stated bringing Resident #7 back into the building without problems, noting the DON and the Administrator knew about the incident and planned to review the camera to identify who turned off the alarm. On 7/22/26 at 1:59 PM Staff F confirmed they turned off both the Wanderguard alarm and door alarm without checking outside to see if a resident exited the building. Staff F explained they started working at the facility 4 months prior without receiving training regarding alarm responses, adding staff didn't provide door codes. They had to figure out the door codes during the first month after a medication aide provided the code. Staff F stated they heard the front door alarm sound while in the kitchen. They exited through the side kitchen door, hearing the Wanderguard sound, and shut off both alarms at the front door. Staff F stated they looked through the window without seeing anyone, and acknowledged they didn't physically walk outside to check if anyone exited. On 7/23/26 at 8:20 AM the DON stated they planned to add the door alarm checking procedure to all platforms and orientation packets for new staff. The DON stated they expected the charge nurses or Human Resources to review orientation packets with new staff, noting they didn't add the form to orientation packets yet, but started communicating the instructions verbally on 7/17/26. On 7/23/26 at 4:12 PM Staff B, Certified Nursing Assistant (CNA), stated they worked from 6:00 AM to 2:00 PM on 7/20/26. Staff B asked about door alarms and codes upon arriving at a new facility because the facility didn't provide the information automatically. Staff B reported they turned off the Wanderguard alarm by the kitchen door on 7/20/26 because the alarm sounded without anyone coming to shut it off. Staff B stated they didn't know who set off the alarm and looked around without knowing whom to look for due to unfamiliarity with residents. Staff B explained they didn't see anyone, acknowledged shutting off the alarm didn't represent the smartest action, and confirmed they didn't check the hallway or outside for a resident. On 7/23/26 at 4:46 PM The Administrator stated an elopement binder remained at the front of the building by the nurse's desk, noting four residents wore Wanderguards. The Administrator reported they updated the binder on 7/17/26 and adding they planned to post a communication note in the electronic medical record [EMR] to ensure staff knew about the binder location. The undated Missing Patient Actions Table protocol instructed staff to react and respond to alarms or possible missing resident concerns immediately, directing the Administrator or Licensed Nurse in charge to assume the role of search coordinator. The facility education policy dated 7/17/26 directed all available staff to respond immediately if a door alarm or Wanderguard sounded. The policy instructed staff to shut off the alarm if staff easily determined the cause and resident, but directed staff to silence the alarm and search immediately the inside and outside areas if the cause remained unknown. The policy directed staff to notify all staff via walkie-talkie to complete a head count and initiate the missing person drill if staff still couldn't determine the cause.

Based on record review and interview, the facility failed to ensure staff monitored weight loss, followed Dietitian recommendations, and notified the Physician of significant weight loss for 1 of 6 residents reviewed (Resident #1) for weight loss. The facility reported a census of 56 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. Resident #1's MDS documented Resident #1 required setup or cleanup assistance with eating. Resident #1's MDS included diagnoses including cerebrovascular accident (stroke) with left-side hemiplegia (one-sided paralysis), traumatic brain injury (brain damage from trauma), chronic obstructive pulmonary disease (COPD) (long-term lung damage), and coronary artery disease (clogged heart arteries). Resident #1's MDS documented weight loss, they ate a mechanically altered diet (modified food texture), and received hospice services (end-of-life care). Resident #1's Care Plan with a target date of 7/14/26 identified potential nutritional risk related to missing teeth, a mechanically altered diet, fair food intake, and malnutrition (poor nutrition). The Care Plan directed staff to provide diet as ordered, monitor weights, and offer snacks or meal substitutions as appropriate. A Weight/Nutrition Note dated 6/13/26 documented Resident #1 experienced a 13-pound weight loss over 36 days, dropping from 153.4 pounds to 140 pounds. The Registered Dietitian (RD) requested a reweight, recommended trying 8 ounces of Breeze (nutritional supplement) daily, and instructed staff to document refusals. The Weight Summary documented Resident #1 weighed 153.4 pounds on 5/5/26 and 140.4 pounds on 6/10/26, reflecting an 8.46 percent weight loss in 1 month. A review of Resident #1's Clinical Record showed staff didn't obtain a reweight or start the Breeze supplement per RD recommendations. Additionally, Resident #1's Clinical Record showed staff didn't notify Resident #1's Physician regarding the weight loss. On 7/23/26 at 1:23 PM the RD reported Resident #1 held a history of refusing supplements, noting staff needed to document any refusals. The RD recalled speaking with the Director of Nursing (DON) about trying the supplement with Resident #1, instructing staff to document refusals if Resident #1 declined. On 7/23/26 at 1:33 PM the RD reported finding no documentation in Resident #1's Clinical Record showing staff sent weight loss and dietary recommendations to the Physician or hospice. The RD stated reassessing Resident #1 on 6/19/26, noting progress notes indicated Resident #1 actively died and refused food and drink. The RD stated she didn't re-recommend the supplement on 6/19/26 and confirmed finding no record showing staff obtained a reweight or tried the supplement. On 7/23/26 at 2:22 PM the DON verified staff didn't follow up on the reweight or start the Breeze nutritional supplement per dietary recommendations. Additionally, the DON reported she couldn't locate Physician notification regarding the weight loss, stating an expectation for staff to follow up on dietary recommendations and notify the Physician of weight loss. The Weight Management Guidelines policy dated June 2023 directed the RD to review weight changes and make recommendations as necessary. The policy noted staff may implement weight management strategies, including nutritional supplements as ordered, at any time during a resident's stay.

Based on observations, resident interviews, facility records review, staff interviews and policy review, the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility (Residents #8, #10 and #11). The facility reported a census of 56 residents. Findings include: 1. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A review of the Census showed Resident #8 resided in room B42-2. A review of Resident #8's call light reports for room B42-2 from 7/16/26 to 7/23/26 showed the call light remained active for 15 minutes or more on the following dates and times:7/18/26 at 9:00 PM - 22 minutes7/19/26 at 5:53 PM - 18 minutes7/22/26 at 1:12 PM - 19 minutes7/22/26 at 8:54 PM - 21 minutes On 7/21/26 at 10:53 AM Resident #8 stated staffing didn't feel good. Resident #8 stated call lights can remain active for an hour or more. Resident #8 stated they monitored the call lights using 2 clocks in their room. Resident #8 stated staff explain they are busy with other residents. Resident #8 stated when staff enter the room they should focus on them, but staff receive calls to help other residents. Resident #8 stated they lived at the facility for 9 years and understood how things worked. 2. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A review of the Census showed Resident #10 resided in private room D24. On 7/22/26 at 7:46 AM an observation showed Resident #10 lying in bed with the call light activated. Resident #10 yelled out asking for help. On 7/22/26 at 8:00 AM an observation showed Resident #10 remaining in bed with the call light activated. Resident #10 yelled out asking for help. On 7/22/26 at 8:21 AM staff answered Resident #10's call light. Resident #10 informed staff of needing to urinate. A review of Resident #10's call light reports for room D24 from 7/16/26 to 7/23/26 showed the call light remained active for 15 minutes or more on the following dates and times:7/19/26 at 3:00 AM - 45 minutes7/19/26 at 6:08 AM - 44 minutes7/21/26 at 8:31 PM - 19 minutes7/22/26 at 7:46 AM - 36 minutes On 7/22/26 at 8:34 AM Resident #10 stated they felt tired and just got up to use the bathroom. Resident #10 stated the call light can remain active for half an hour at times, requiring them to wait for assistance. 3. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. A review of the Census showed Resident #11 resided in room E29-1. On 7/22/26 at 7:57 AM an observation showed Resident #11's call light activated, and staff answered the call light at 8:15 AM. A review of Resident #11's call light reports for room E29-1 from 7/16/26 to 7/23/26 showed the call light remained active for 15 minutes or more on the following dates and times:7/16/26 at 8:42 AM - 28 minutes7/16/26 at 10:54 AM - 20 minutes7/17/26 at 1:26 AM - 25 minutes7/17/26 at 9:00 PM - 28 minutes7/18/26 at 12:19 AM - 18 minutes7/18/26 at 6:25 AM - 31 minutes7/18/26 at 8:06 PM - 20 minutes7/19/26 at 6:45 AM - 52 minutes7/22/26 at 7:57 AM - 18 minutes On 7/22/26 at 8:45 AM Resident #11 stated staff don't always answer the call light within 15 minutes. Resident #11 stated staff eventually answer call lights, but response times take much longer than 15 minutes. Resident #11 stated the facility doesn't have enough staff to meet resident needs. Resident #11 stated they feared getting in trouble for talking, noting the staff scold them and treat them like a child. On 7/21/26 at 7:37 AM Staff D, Certified Medication Aide (CMA), stated the facility needed a better call light system. Staff D stated 2 monitors exist, one at the front nurse's station and one at the back nurse's station. Staff D stated medication aides and nurses must watch monitors and inform staff about active call lights using walkie-talkies. Staff D stated when call lights exceed 15 minutes, Staff D attempts to answer lights, but medication passes sometimes interfere. On 7/21/26 at 9:20 AM Staff A, Certified Nursing Assistant (CNA), stated the facility needs a better call light system. Staff A stated staff must check for call lights at the nurse's station because hallways lack lights and staff don't carry pagers. Staff A stated call lights remain active for half an hour or more at times. Staff A stated seeing monitor displays showing call lights in other hallways active for 45 minutes. Staff A stated attempting to assist other hallways when caught up with duties. Staff A stated reporting concerns to Staff B, Director of Nursing (DON), approximately two weeks prior, and Staff B stated the facility planned to install iPads or kiosks in each hallway to monitor call lights. On 7/22/26 at 7:00 AM Staff C, CMA, questioned why management instructed staff to answer call lights due to state presence, asking if responses shouldn't happen even without state presence. Staff C stated management doesn't leave offices to assist with call lights, creating frustration. Staff C stated the facility experiences long call light response times, not due to lack of staff effort, but because the facility stays very busy. Staff C stated staff lack awareness of active call lights unless walking to the nurse's station to check monitors, delaying response times. Staff C stated some residents, including Resident #10, must yell for help because staff don't know call lights or pendants remain active. Staff C stated the facility lacks sufficient walkie-talkies for all staff. Staff C stated the facility planned to install hallway call light devices, but installation hasn't occurred. Staff C verified the facility utilizes many agency staff and questioned whether walkie-talkies leave with agency staff. Staff C stated feeling bad for residents paying to live at the facility, noting residents don't receive baths or must eat in bed due to inadequate staffing. Staff C expressed hope of not getting in trouble for sharing information, noting issues can't be fixed without speaking up. On 7/22/26 at 12:57 PM Staff E, Registered Nurse (RN), stated call lights sometimes exceed 15 minutes, noting residents using call lights more frequently tend to experience longer wait times. Staff E stated staff don't carry pagers and walking to the nurse's desk to check monitors wastes time, contributing to long call light response times. Staff E stated not hearing resident complaints regarding long call lights, but wouldn't feel surprised if complaints exist. On 7/23/26 at 8:00 AM Staff B stated expecting call lights answered as soon as possible, within 15 minutes. Staff B stated the facility works on installing iPads in hallways and obtaining pagers for staff. Staff F, Administrator, stated hallway brackets for iPads were installed while awaiting required cords, expecting iPad and pager implementation within the next week. The Call Light Policy undated directed staff to ensure prompt responses to resident requests for assistance and maintain call systems in proper working order. The policy directed staff to answer call lights in a timely manner, ensuring triggered call lights alert staff visually, audibly, or both.

Based on diet orders, staff interviews, clinical record review, and facility policy review the facility failed to serve the appropriate therapeutic diet to meet resident's needs according to their diet order for 1 of 6 residents reviewed (Resident #5). The facility reported a census of 56 residents. Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 1, indicating severely cognitively impaired. Resident #5's MDS documented Resident #5 required partial or moderate assistance with eating. Resident #5's MDS documented diagnoses including Alzheimer's disease (progressive memory loss disorder), non-Alzheimer's disease (brain disorder causing memory loss), and malnutrition (poor nutrition). Resident #5's MDS documented receipt of a mechanically altered diet (modified food texture). Resident #5's Care Plan with a target date of 7/26/26 documented an actual risk for altered nutritional status related to fair to poor meal intakes and diagnoses of dementia (memory loss). The Care Plan directed staff to provide diet as ordered and assess for signs and symptoms of aspiration (food or liquid entering the lungs) or difficulty swallowing. A diet order dated 4/13/26 directed staff to provide a regular diet with a pureed (smoothly blended) texture and nectar (mildly thick) fluid consistency. A Progress Note dated 7/2/26 documented Staff A, Advanced Registered Nurse Practitioner (ARNP), examined Resident #5 during rounds. Staff A provided new physician orders and feeding instructions directing staff to give honey (moderately thick) thickened liquids, sit on the right side of Resident #5, give a drink after each bite, and continue the pureed diet. A review of Resident #5's clinical record showed staff didn't update the new physician orders and feeding instructions dated 7/2/26 in the Physician's order tab or on the Kardex (care summary sheet). Resident #5's July 2026 Medication Administration Record (MAR) directed staff to administer a 4-ounce mighty shake (nutritional supplement) three times daily for weight loss. The MAR listed the mighty shake as a nectar (mildly thick) thickened liquid. The MAR documented Resident #5 received the nectar thickened mighty shake from 7/2/26 through 7/20/26. On 7/21/26 at 7:07 AM an observation showed a cup of thickened water with a lid and straw sitting on the tray table in Resident #5's room. The lid documented the date 7/21/26. On 7/21/26 at 8:13 AM an observation showed Resident #5 receiving one-on-one feeding assistance from Staff B, Certified Nursing Assistant (CNA), in the dining room. Staff B sat on Resident #5's left side instead of the right side per physician orders. On 7/21/26 at 8:40 AM the Director of Nursing (DON) verified the thickened water in Resident #5's room contained a nectar consistency. On 7/21/26 at 8:46 AM an observation showed Staff C, Certified Medication Aide (CMA), assisting Resident #5 with a mighty shake. Staff C sat on Resident #5's left side. On 7/21/26 at 10:45 AM the Director of Nursing (DON) acknowledged staff didn't transcribe the physician orders dated 7/2/26 to Resident #5's electronic medical record. The Physician Order/Transcription of Orders policy dated July 2023 instructed staff to correctly and safely receive and transcribe physician orders so staff follow and administer correct orders. The policy directed staff to enter orders into a resident's medical record exactly as stated or written by the Provider, and directed staff to follow and carry out active orders as written or transcribed.

Based on observation, record review, and interview, the facility failed to ensure staff accurately documented meal intakes in the Electronic Medical Record (EMR) for 1 of 11 residents reviewed (Resident #6). The facility reported a census of 56 residents.Findings include: A record review of the Clinical Census showed Resident #6 entered the facility on 7/14/26. Resident #6's Minimum Data Set (MDS) assessment remained incomplete. On 7/20/26 at 1:45 PM an observation showed Resident #6 lying in bed on Resident #6's back with eyes closed. A tray table stood next to Resident #6's bed with a lunch tray sitting on top of the table. The food on the lunch tray remained untouched, saran wrap covered the dessert, and silverware remained inside the napkin. A record review of Resident #6's Clinical Record showed Staff A, Certified Nursing Assistant (CNA), documented Resident #6 consumed 75 to 100 percent of the breakfast and noon meal on 7/20/26. On 7/21/26 at 9:20 AM Staff A reported receiving an assignment to the A Hallway on 7/20/26. Staff A stated Staff B, CNA, received an assignment to Resident #6 in the B Hall. Staff A reported Staff B worked a first day at the facility on 7/20/26 and lacked login information to document in the EMR. Staff A reported the Director of Nursing (DON) held awareness and instructed staff to visit the Social Services Director to obtain login information. Staff A reported this occurred between 12:00 PM and 1:00 PM on 7/20/26. Staff A reported not remembering charting Resident #6's breakfast or lunch amounts. Staff A stated when not assigned to a resident, Staff A typically asks the assigned caregiver and charts reported amounts. Staff A stated charting what Staff B reported, noting Staff A didn't see Resident #6's breakfast or lunch tray. On 7/21/26 at 7:50 PM Staff B stated working a first day at the facility on 7/20/26. Staff B stated not giving Resident #6 a lunch tray. When asked about completing charting on 7/20/26, Staff B stated no. Staff B stated receiving login information after lunch. Staff B stated attempting to log in on a computer first, which didn't work, and attempting on a tablet, which didn't work either. When asked about reporting Resident #6's meal intakes to Staff A, Staff B stated no. On 7/23/26 at 8:30 AM the DON reported new staff receive a packet containing login information for the EMR. The DON stated charge nurses can call Information Technology (IT) for login information if needed, noting someone remains available at all times to help obtain login information. The DON stated lacking awareness regarding Staff B's inability to access the EMR to complete charting. The DON stated an expectation for each staff member to complete individual charting rather than having another staff member do it. On 7/27/26 at 8:53 AM the Administrator reported the facility didn't maintain a policy regarding CNA documentation in the EMR.

Based on clinical record review, staff interviews, and wound center interview, the facility failed to notify the Physician when a wound VAC, or negative pressure wound therapy (NPWT) (device that uses gentle suction to promote healing in chronic or acute wound) was placed on hold and a previous treatment restarted for 1 of 2 residents reviewed (Resident #2) for pressure ulcers. The facility reported a census of 55 residents.Findings include: Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #2 was dependent on staff with bed mobility, transfers, and toileting. Resident #2's MDS included diagnoses of pressure ulcer of sacral region, stage 4 (dull thickness tissue loss with exposed bone, tendon or muscle). The MDS identified Resident #2 was at risk for developing pressure ulcers and had one stage 4 pressure ulcer. The MDS documented Resident #2 had a pressure reducing device to chair and bed, pressure ulcer/injury care, application of nonsurgical dressing including applications of ointments/medication other than to feet. The Care Plan with a target date of 4/26/26 revealed Resident #2 had an alteration in skin integrity related to morbid obesity, history of transient ischemic attack (TIA) manifested by a sacral wound. The care plan directed staff to administer treatment per physician orders.The Wound Center Discharge Instruction dated 2/2/26 directed staff to start a wound vac to the sacrum wound continuously at 125 mm/hg (millimeters of mercury) pressure and to use black foam when replacing dressing. The instruction sheet documented to continue current treatment until wound vac could be placed. The current treatment order was to moisten strength Dakins on kerlix, squeeze out excess, pack into wound daily and cover with abdominal (ABD) pad one time per day. The February 2026 Treatment Administration record (TAR) documented the wound vac was started on 2/6/26. The February 2026 TAR revealed the wound vac was put on hold beginning 2/13/26 and the treatment for Dakin's moist kerlix packing was restarted daily. Review of the clinical record lacked documentation the Physician and/or the wound center was notified that the wound vac was put on hold and the previous treatment restarted. On 2/17/26 at 9:08 AM, Resident #2 reported he had a large pressure wound to his buttocks. He said it had been the size of his fist and went down to his bone. He said he was supposed to have a wound vac, but it had not been on since last Wednesday as the filter to the machine was on back order. He said the wound was being packed daily. He reported he was not sure if the Wound Center was aware or not that the wound vac was not in place.On 2/18/26 at 10:45 AM, the Director of Nursing (DON) reported the facility was out of wound vac canisters since the end of last week and that the supplies had been ordered. On 2/18/26 at 3:45 PM, the DON reported the Wound Center was not notified that the wound vac was put on hold. She said the facility used an active secondary order for the pressure ulcer treatment. She said the Wound Center probably should have been notified. The DON reported she had checked on supplies, and they were supposed to be arriving tomorrow (2/19/26). On 2/19/26 at 8:17 AM, the Wound Center Registered Nurse (RN) reported the wound center was not aware that Resident #2's wound vac had been put on hold. The Wound Center RN verified the wound center had not received a call regarding the facility being out of canisters. She reported the wound center would have preferred to be notified when the wound vac was put on hold and the previous treatment restarted. The Wound Center RN reported when the wound vac was ordered, the Dakin's treatment would have been discontinued on their end but if the facility still had the order active on their medication administration record, then the treatment would be appropriate. A facility policy titled Notification for Change of Condition revised 6/2023 documented the facility would provide care to residents and provide notifications of resident change in status.

Based on clinical record review, staff interviews and policy review, the facility failed to report an allegation of potential abuse to the Department of Inspections, Appeals and Licensing (DIAL) for 1 of 14 residents reviewed (Resident #45). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #44 revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS listed diagnoses including Alzheimer's dementia and cerebral vascular accident (stroke). The Care Plan with a target date of 4/262/6 revealed the resident had an activity of daily living (ADL) deficit and required assistance from staff with all ADLs. Review of Progress Notes dated 2/3/26 at 1:44 PM revealed staff observed a bruise to the resident's right eyebrow area that had not been observed on a skin assessment that had been completed that morning. Resident was unable to state how or when the incident occurred. The certified nursing assistant (CNA) had reported the bruise had not been there that morning when cares were completed. Review of facility policy titled, Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation, revised 9/25 revealed the Administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Definitions include injury of unknown source- injury should be classified as an injury of unknown source when the source of the injury was not observed by any other person, or the source of the injury could not be explained by the patient, and the injury is suspicious because of the extent of the injury or the location of the injury. During an interview 2/18/26 at 10:45 AM the Administrator revealed they did not report the resident's right eye bruise to DIAL as a family member was adamant that it was unnecessary to report it to the state because they didn't want the state involved. The Administrator added after a discussion with corporate personnel, they completed a facility form titled, Concern Form, instead of notifying DIAL. Review of the Concern Form lacked documentation in the Resolution of Concern section of the form.

Based on clinical record review and staff interviews, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis and start of new psychotropic medications (Resident #4). The facility reported a census of 55 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) of 09 indicating moderately impaired cognition. The MDS revealed Resident #4 had diagnoses of non-Alzheimer's dementia, depression, bipolar disorder, and post-traumatic stress disorder. The Care Plan with a target date of 5/13/26 revealed Resident #4 took an antipsychotic medication for bipolar disorder.The Clinical record revealed Resident #4 had the following diagnosis with effective dates:Major Depressive Disorder - 12/22/25Bipolar Disorder - 1/21/26Post Traumatic Stress Disorder - 9/14/22Adjustment Disorder with mixed anxiety and depressed mood - 9/14/22A Physician Order dated 5/15/25 directed staff to administer aripiprazole (antipsychotic medication) 5 MG (milligrams) one and half tablets daily related to dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the Clinical Record revealed Resident #4 took aripiprazole since 1/27/25.A Level 1 PASRR completed 1/22/25 documented Resident #4 had a mental health diagnosis of anxiety and depression/depressive disorder. The PASRR evaluation documented Resident #12 received antidepressant medications for depression and antianxiety medication for anxiety. The clinical record revealed no additional PASRR evaluations after 1/22/25.The Clinical record review revealed Resident #12 did not have a Level 2 PASRR evaluation submitted following the new mental health diagnoses of bipolar disorder and with the addition of new antipsychotic medication on 1/27/25. On 2/18/26 at 2:45 PM, the Social Worker reported she submitted a new PASRR on 2/17/26 for review. She said the PASRR came back for a level 2 review onsite. She reported nursing was supposed to tell her when there was a new mental health diagnosis or psychotropic medication so she can update the PASRR. She said there are new management staff, and the information was not communicated to her, so it was missed. On 2/18/25 at 3:46 PM, the Administrator reported the facility did not have a specific policy related to PASSR and that the facility follows the PASRR company's guidelines.

Based on clinical record review and staff interviews, the facility failed to resubmit a Preadmission and Resident Review (PASRR) evaluation as required for 1 of 2 residents reviewed for PASSR (Resident #35). The facility reported a census of 55 residents. Findings include: Resident #35's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS included a diagnosis of schizophrenia (psychotic disorder). The clinical record review revealed the resident's Notice PASRR Level II Outcome dated 12/30/25 listed a short-term time limited Level II approval with an end date of 1/29/26. The clinical record lacked evidence that a Level II evaluation had been resubmitted following the short-term end date of 1/29/26.During an interview on 2/18/26 at 2:48 PM Staff E, Social Services, reported she missed the date of 1/29/26 to resubmit the PASSR. Staff E reported she resubmitted the PASSR on 2/18/26 and it came back queued for review. On 2/18/25 at 3:46 PM the Administrator reported the facility didn't have a specific policy related to PASSR and that the facility followed the PASRR company's guidelines.

Based on clinical record review and staff interviews, the facility failed to develop a care plan to address risk factors and interventions for 1 out of 14 residents (Resident #3) reviewed for comprehensive care plans. The facility reported a census of 55 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #3 dated 12/10/25 identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of heart failure (heart not pumping efficiently) and hypertension (high blood pressure). The MDS documented Resident #3 received an anticoagulant medication during the last 7 days. A Physician order dated 5/19/25 directed staff to administer apixaban (Eliquis) (anticoagulant) 2.5 mg (milligrams) by mouth twice a day for atrial fibrillation.Review of Resident #3's Care Plan with a target date of 3/12/26 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high-risk medication was not addressed on the Comprehensive Care Plan. On 2/17/26 at 4:10 PM, the Director of Nursing (DON) verified the Care Plan didn't address the anticoagulant medication and it should. On 2/18/26 at 8:45 AM, the Administrator reported the facility didn't have a specific Care Plan policy related to anticoagulants. They expected for the medication be added to the Care Plan within the next care plan review.

Based on observation, clinical record review and staff interviews, the facility failed to follow physician orders related to a wound intervention for 1 of 5 residents reviewed for skin conditions (Resident #45). The facility reports a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #45 revealed diagnoses of Alzheimer's disease, stroke and diabetes mellitus (DM). The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment and received maximal assistance with lower body dressing. Review of the physician orders for the resident revealed an order effective 2/11/26 to cleanse the left foot 2nd and 3rd toes with normal saline, paint with iodine (broad spectrum antibiotic), allow it to dry and to make sure the sock is inside out to prevent rubbing two times a day for wound treatment. The Appointment Note dated 2/12/26 at 4:34 PM indicated Resident #45 returned to the facility after her appointment. Resident #45 returned with papers that directed turn socks inside out to avoid irritation to toes. The Care Plan with a target date of 4/26/26 lacked direction related to the treatment to the resident's left foot 2nd and 3rd toes. On 2/18/26 at 10:09 AM observed Staff A, Registered Nurse (RN), complete Resident #45's treatment to the left foot toes. Staff A removed the resident's tennis shoes prior to the treatment, noted the socks not inside out as ordered. Staff B, Assistant Director of Nursing (ADON), present during the observation and acknowledged Resident #45 didn't have their socks inside out as ordered. Staff B directed Staff A to ensure Resident #45 had their socks inside out when reapplied.

Based on clinical record reviews, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 2 residents reviewed (Resident #54) for falls. The facility reported a census of 55 residents. Findings include: Resident #54's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #54 required partial to moderate assistance for all transfers. The MDS included diagnoses of seizure disorder, dislocation of right hip prosthesis, muscle wasting and atrophy of the right thigh (loss of muscle), ataxic gait (unbalanced walking), weakness and other abnormalities of gait and mobility. The Care Plan with a target date of 3/18/26 revealed Resident #54 required assistance with activities of daily living and used a gait belt with transfers. In addition, the care plan documented Resident #54 had a risk for falls with a goal to utilize transfers with a gait belt. The Incident Report (IR) titled Fall, staff assist dated 11/27/25 at 7:15 AM documented a staff member assisted Resident #54 down to the floor. Resident #54 reported he was walking and his legs gave out. The incident reported documented staff assisted Resident #54 to the bathroom from his bed using a walker but no gait belt. The Progress Note titled Incident Report dated 11/27/25 revealed a staff member reported they assisted Resident #54 to the floor while transferring him from his bed to the bathroom as his legs gave out. When the nurse asked the staff member if they had a gait belt on him, they stated they did not because he normally walked okay for them. The note documented they educated the staff member on gait belt usage. On 2/18/26 at 3:35 PM, Staff D, Licensed Practical Nurse (LPN), reported she was the nurse on duty when Resident #54 fell on [DATE]. She said the certified nursing assistant (CNA) didn't use a gait belt at the time of fall. She said she verbally educated the CNA they needed to use a gait belt with all transfers. She said she did not put the education in writing. On 2/18/26 at 3:45 PM, the DON reported she expected the staff to use a gait belt with transfers and ambulation. The facility policy titled Gait Belt revised October 2023 documented the purpose of the policy as to safely and effectively transfer or ambulate a resident.

Based on observations, record review, staff interviews,and resident interview the facility failed to administer oxygen according to physician orders for 1 of 1 resident reviewed (Resident #24) for respiratory services. The facility reported a census of 55 residents. Findings Include: The Minimum Data Set (MDS) assessment for Resident #24 dated 1/16/26 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS included diagnoses of asthma and chronic lung disease. The MDS documented Resident #24 was on oxygen therapy while a resident at the facility. The Care Plan with a target date 4/19/26 revealed Resident #24 had a risk for ineffective breathing patterns related to chronic respiratory failure, emphysema and asthma. The care plan directed to administer oxygen per order. A Physician order dated 7/3/25 directed staff to administer oxygen at 2 liters per nasal cannula (n/c) continuously every shift related to bronchiectasis and asthma. On 2/16/2026 at 11:40 AM, observed Resident #24's oxygen at 0.5 liters per n/c.On 2/17/26 at 1:40 PM, observed Resident #24's oxygen at 0.5 liters per n/c.On 2/17/26 at 1:50 PM, Staff C, Licensed Practical Nurse (LPN) verified Resident #24's oxygen concentrator was set at 0.5 liters. Staff C said she wondered if the concentrator got bumped and nobody noticed. During the observation, Resident #24 reported her oxygen was to be set at 2 liters. On 2/17/25 at 1:55 PM, the Director of Nursing (DON) verified Resident #24's oxygen order was 2 liters continuously. She reported she would expect the physician order to be followed. On 2/17/25 at 2:35 PM, the DON reported the facility did not have a policy on oxygen therapy.

Based on record review and staff interviews, the facility failed to ensure adequate monitoring of a resident's lab orders to ensure the resident had the correct thickness of their blood to prevent blood clots for 1 of 1 resident reviewed (Resident #2) for blood thinners. Due to the facility's inadequate monitoring of Resident #2's blood work, the physician didn't order a new dose of blood thinner, resulting in them missing a dose of their blood thinner. The facility reported a census of 55 residents.Findings include:Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #2 was dependent on staff with bed mobility, transfers, and toileting. Resident #2's MDS included diagnoses of atrial fibrillation and personal history of other venous thrombosis and embolism (blockage of blood vessels). The MDS identified Resident #2 was taking anticoagulant medication during the last 7 days. The Care Plan with a target date of 4/26/26 revealed Resident #2 took Warfarin and Lovenox (anticoagulant medications) related to venous thrombosis and embolism. The Care Plan directed staff to administer the medications per order. The Progress Note on 1/21/26 documented new orders to increase Warfarin to 5 mg daily and recheck INR on 1/26/26.The Physician Progress Note on 1/22/26 documented Resident #2 restarted on Warfarin and once he was therapeutic the Lovenox would be discontinued. The Physician Progress Note on 1/26/26 revealed an INR result of 1.6 (international normalized ratio) (blood test that measures how long it takes for the blood to clot) and the results were faxed to Provider. The clinical record lacked a response from the Provider on 1/26/26 and 1/27/26. The Progress Note on 1/28/26 revealed Resident #2's Warfarin medication order had dropped off the medication administration record (MAR) and the last dose given was on 1/25/25. The Provider gave orders to put Resident #2 back on the Warfarin 5 mg daily and recheck INR on 2/2/26. Review of the January 2026 MAR directed staff to administer Warfarin 5 mg 1 tablet one time a day with a start date of 1/21/26 and an end date of 1/26/26. The MAR revealed there was not a dose of Warfarin given on 1/27/26.The Hospital Laboratory Form dated 2/9/26 documented an INR result of 1.5. The form was signed by the Provider on 2/10/26 with no directions related to Warfarin medication or when to check the next INR. On 2/18/26 at 9:29 AM, review of Resident #2's Physician orders revealed there was no active order for Warfarin medication. Review of the February 2026 MAR directed staff to administer Warfarin 6 mg 1 tablet on Monday, Tuesday, Wednesday, Thursday and Friday with a start date of 2/9 and end date of 2/16/26. The MAR had an additional order for Warfarin to give 5 mg on Saturday and Sunday with a start date of 2/14/26 and an end date of 2/16/26. The MAR revealed Resident #2 did not receive a dose of Warfarin on 2/17/26.The Progress Note titled Communication with the Physician dated 2/18/26 at 10:16 AM documented a call was placed to the Provider to discuss the recent lab draw on 2/9/26 and Warfarin orders. New orders were received to check INR on 2/18/26 and restart Warfarin at last dosage. The note documented the Warfarin order was to remain indefinite until new/different orders were received from the Provider. On 2/18/26 at 10:45 AM, the Director of Nursing (DON) reported the Physician signed the INR lab result from 2/9/26 but did not provide any new orders and did not address when the next INR was due. The DON reported there was a stop date on the Warfarin order on the MAR for 2/16/26. She said she did not put the physician order in the computer and did not know why there was a stop date. She reported Resident #2 did miss one dose of coumadin on 2/17/26. She said they were going to recheck an INR today and restart the coumadin depending on the INR results. She said the facility would complete a risk management form. The Progress Note titled Incident Report - Medication Event dated 2/18/26 at 1:13 PM documented Warfarin medication order for 6 mg daily Monday through Friday was entered with a stop date of 2/16/26 and the order fell off the MAR as it was completed based on the date. On 2/18/26 at 12:30 PM, the DON reported the stop dates for the Warfarin medication were coming from the Pharmacy as they would only send enough medication until the next INR or maximum of two weeks until the INRs were therapeutic and the doses were not changing often. On 2/18/26 at 2:40 PM, the DON reported there were no clarification orders received regarding the INR results on 2/9/26. She said the nurse continued the coumadin orders and put an end date according to how long the pharmacy would send the medication. She reported going forward the Warfarin has been ordered indefinite unless new/different orders were received from the Provider. On 2/18/26 at 8:50 AM, the Administrator reported the facility follows the stand of care for following physician orders.

Based on interviews and clinical record review, the facility failed to start an antibiotic for more than 2 days after a resident received the physician's order for a resident with a urinary tract infection for 1 of 5 residents reviewed (Resident #33) for infection. The facility reported a census of 55.Findings include:The Minimum Data Set (MDS) assessment for Resident #33 dated 1/22/26 identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. The MDS identified Resident #33 as dependent on staff for toileting hygiene. The MDS included diagnoses of neurogenic bladder (dysfunction of the bladder caused by nerve damage) and obstructive uropathy (blockage of urine flow). The MDS documented Resident #33 had an indwelling catheter (tube inserted into the bladder to drain urine).The Care Plan with target date of 3/29/26 revealed Resident #33 received antibiotic therapy related to urinary tract infection (UTI). The Care Plan directed staff to administer medications as ordered. The Progress Note dated 1/2/26 at 1:38 PM documented Resident #33's urine as cloudy, dark yellow with thick white mucous like sediment. The noted documented Resident #33 had suprapubic pain with palpation and a functional decline in activities of daily living (ADLs). The facility notified the provider and received a new order to get a urinalysis (UA).The Progress Note dated 1/2/26 at 4:48 PM documented abnormal UA results.The Progress Note dated 1/2/26 at 4:57 PM indicated the facility received a new order from the provider to start Cefadroxil (antibiotic) 500 mg (milligrams) one capsule two times a day for 7 days for a UTI.The Physician order dated 1/2/26 directed staff to administer Cefadroxil 500 mg one capsule two times a day for 7 days for a UTI. The Microbiology Report Preliminary report dated 1/3/26 documented the UA grew out 10,000 - 100,00 cFu/ml (colony-forming units per milliliter) gram negative rods and >100,00 cFu/ml gram negative rods #2 (indicating abnormal results).The Microbiology Report Final Report dated 1/4/26 documented the UA grew out 10,000 - 100,00 cFu/ml klebsiella pneumoniae (gram negative bacteria) and greater than 100,000 cFu/ml proteus mirabilis (gram negative bacteria). The Progress Note dated 1/4/26 documented the facility notified the on-call Provider due to not receiving the antibiotic from the pharmacy. The Provider requested the facility to contact the pharmacy. The note documented the pharmacy was closed and did not have an emergency number. The Progress Note dated 1/5/26 at 12:04 PM documented the facility contact the Pharmacy. The Pharmacy reported they just received the order for the antibiotic and would send out in the evening. The January 2026 Medication Administration Record (MAR) reflected the facility didn't start the antibiotic until the evening of 1/5/26. On 2/18/26 at 6:25 AM, the Director of Nursing (DON) reported the facility had a Pharmacy emergency number for after hours. On 2/18/26 at 7:45 AM, the DON reported the facility had the antibiotic in the emergency kit and the nurse didn't think about taking the antibiotic out of the kit. She said the nurse tried to call the on-call pharmacy number and did not get a response back. She said it was not the first time they didn't receive a call back. On 2/18/26 at 8:30 AM, the DON reported she expected the staff to take the medication from the emergency kit and follow the physician orders. On 2/18/26 at 8:50 AM, the Administrator reported the facility follows the stand of care for following physician orders. On 2/18/26 at 10:44 AM, the Administrator reported the facility did not have a policy or protocol regarding the emergency kit. She reported the facility expected the staff to pull the medication from the emergency kit if available, if the facility didn't receive it from the pharmacy.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interview, the facility failed to correct their own deficiencies for 5 of 9 areas of concern. The facility reported a census of 55 residents.Findings include:The facility QAPI report, reviewed December 10, 2025, defined the mission as to provide resident-centered healthcare services, excellence in clinical care, and to promote caregiver engagement and empowerment to better serve the resident, family, and the community. The guiding principles included: a. QAPI outcomes are directly related to the quality of care and the quality of life of our residents. b. Our QAPI program focuses on our organization's systems and processes and we strive to continually identify and make changes to our systems/processes in order to improve outcomes.c. Our organization sets goals for performance and measures progress toward those goals. The QAPI program strives to promote safety and high quality throughout clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life forresidents and family. The QAPI program will accomplish this by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. The facility had the following concerns identified at the current recertification survey that had been cited at previous surveys within the past year:a. Reporting of alleged violations of abuseb. Develop/Implement comprehensive care planc. Services provided meet professional standardsd. Free of accident hazards/supervision/devicese. QAPI program/plan, disclosure/good faith attempt During an interview 2/19/26 at 10:55 AM, the Administrator acknowledged the repeated concerns, stated these are not fully resolved, however the facility is continually working on them. The Administrator advised there is more work to do in QAPI to address these repeat concerns and the facility is building their team.

Based on clinical record review, facility record review, staff interviews, and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 57 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS included diagnoses of heart failure, hypertension (high blood pressure), and traumatic brain injury. On 1/27/26 at 12:13 PM Staff A, Certified Nursing Assistant (CNA), explained the incident happened on 1/14/25 between 2:45 PM and 3:00 PM. Staff A reported as she helped Staff C, Radiology Technician, position Resident #1 for an x-ray, she observed Staff C put her gloved hand over Resident #1's mouth due to him coughing. Staff A stated Staff C asked him to stop coughing. Staff A stated when Staff C completed the x-rays, Staff A stated she went to the nurse and explained to her what she saw. On 1/27/26 at 1:21 PM Staff B, Registered Nurse (RN), confirmed Staff A reported Staff C told Resident #1 to quit coughing. Staff A stated Staff C put her hand on his mouth, told him or asked him to quit coughing. Staff C stated it wasn't very clear if they asked or told Resident #1. Staff C stated she believed Staff A stated Staff C put her hand on Resident #1's mouth. Staff C stated they felt like Staff A made it sound more shocking, like they couldn't believe she did that. Staff C stated they didn't think of it as an allegation of abuse. Staff C stated they didn't report the allegation to the Administrator or Director of Nursing (DON). The Health Status Note dated 1/22/26 at 3:36 PM labeled Late Entry for 1/15/26 at 8:00 AM revealed the day shift front nurse reported to Staff D, Assistant Director of Nursing (ADON), when they walked in the front door. The day shift nurse explained the night before when Staff C came to the building, she put her hand over Resident #1's mouth and asked him not to cough. Staff A reported the information to the evening nurse. When Staff D spoke with Resident #1 and asked if anything happened since the previous day, Resident #1 replied no, they didn't think so. Staff D reported his response to the DON and Administrator. The facility submitted a self-report on 1/15/26 at 6:19 PM related to the incident. The Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation policy reviewed September 2025 directed to report all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation to the Iowa Department of Inspections, Appeals and Licensing and any other required state agency if applicable (ie: law enforcement). Reports of abuse or if there is resulting bodily injury, the facility should report immediately and not later than two (2) hours. Allegations of neglect, exploitation, misappropriate of resident property, or mistreatment to be reported not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. On 1/28/26 at 2:20 PM, the Administrator, reported they expected the staff to notify administration right away of any allegations as soon as they knew of them.

Based on the facility investigation, dignity policy/procedure review, resident and staff interviews, the facility failed to provide personal care to a resident incontinent of stool in a timely manner that promoted their dignity and quality of life for 1 out of 4 residents reviewed. (Resident #1). The facility identified a census of 56 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #1 could understand and other understood them with no behavior or mood issues. Resident #1 required dependent assistance with toileting hygiene and frequently incontinent of bowel. The MDS included diagnoses of hypertension (high blood pressure), neurogenic bladder (condition where nerve damage disrupts the brain-bladder communication, causing problems with storing and releasing urine), non-Alzheimer's dementia, and depression.The Care Plan with a target date of 1/17/26, indicated Resident #1 required assistance of 2 staff for pivot transfers and use of front wheeled walker for toileting.Resident #1's Documentation Survey Report dated 11/30/25, documented large amounts of diarrhea at these times: 4:28 PM, 5:15 PM, 5:50 PM, 6:40 PM and 7:20 PM.The Final Investigation Summary for Incident Report dated 11/30/25, documented, on 11/30/25 Staff A, Licensed Practical Nurse (LPN) with the Director of Nursing (DON) on the phone went to Resident #1's room to interview them about an incident Staff C, Certified Nursing Assistant (CNA), reported. Staff A asked Resident #1 if anyone said anything mean that evening. Resident #1 stated they couldn't recall. Staff A asked if an aide came and told him he would have to wait to be changed. Resident replied yes, they said I'd have to wait in my poopy diaper. Resident #1 couldn't recall who made the comment. Staff C reported she assisted Resident #1 with cares before leaving to go on break at approximately 6:00 PM. Staff C reported when she came back from break at approximately 6:30 PM, Staff D, CNA, told them, they let Resident #1 know he would have to wait until Staff C got back from break to get assistance which would be in a few minutes. Resident #1 told Staff D, he had a bowel movement when they answered the call light at approximately 6:25 PM. Staff C reported when she went to Resident #1's room and did incontinence cares on him, Resident #1 told her the other aide said he had to wait until she got off break. The DON followed up with Staff D, via phone call as they left the building after their shift ended. Staff D confirmed to the DON she let Staff C know when they returned from break Resident #1 called and needed help with incontinence cares. At the time of reporting to Staff C, Staff D helped another resident and told Staff C if she couldn't find another staff on shift to help her, Staff D would help her with Resident #1 when Staff D finished with the resident she currently was with. Staff D reported to the DON she responded to Resident #1's original call light and when she entered the room, Resident #1 told Staff D he had a bowel movement. Staff D reported she told Resident #1 she would go and find another staff to help her as Resident #1 required assistance from 2 staff for incontinent cares. Staff D had every intention to go back and help Resident #1. Staff D reported to the DON while trying to find another CNA to help her with Resident #1's incontinent cares, Staff D found another resident needing immediate assistance and had to assist them due to safety concerns. Staff D adamantly denied telling Resident #1 to wait in a poopy diaper.On 12/16/25 at 1:00 PM, Staff D stated on 11/30/25, Resident #1 put on his call light sometime after supper. When Staff D went to answer the call light, Resident #1 stated he soiled his brief again, due to diarrhea and he needed changed. Staff D told Resident #1 she needed to find another staff member to assist cleaning Resident #1 up and left the room. Staff D, said Resident #1 put on the call light again and Staff D went back into the room and explained she couldn't find another staff member to assist her clean Resident #1 and asked if it was ok to wait 15 minutes or so until Staff C, got done with break and then they would come and change him. Staff D, proceeded to go down another hallway and noticed another resident needing immediate assistance and forgot to tell Staff C Resident #1 needed changed. Staff D said when she remembered Resident #1 needed changed, Staff C and another staff member already completed the task. Staff D adamantly denied telling Resident #1 to sit in a poopy diaper. Staff D acknowledged it is Resident #1's right to have their brief changed as soon as possible, and Resident #1 has the right to have respect and dignity from all staff. On 12/16/25 at 1:45 PM, Resident #1 stated after supper on the evening of the incident, not sure of the date, he put on his call light due to soiling his brief due to having diarrhea. Staff D, sometime after supper answered the call light, and said they needed to go and find another staff member to assist them with changing Resident #1's soiled brief. Staff D left the room. Resident #1 then put on the call light again, Staff D came back into the room and explained Staff D couldn't find another staff member to assist them and if Resident #1 could wait 15 minutes or so for Staff C to finish her break and then he would get changed. Resident #1 said he was upset he had to wait to get changed and felt staff did not treat him with dignity and respect by letting him sit in the soiled brief for a long period of time.On 12/16/25 at 2:45 PM, Staff C stated Resident #1 was having lots of diarrhea on the evening shift of 11/30/25. Staff C, explained she went for supper break around 6:15 PM and returned around 6:45 PM. Resident #1 had the call light on so Staff C proceeded to go in and answer the call light, Resident #1 told Staff C Staff D forgotten about them and Resident #1 had diarrhea again and a soiled brief. Staff C proceeded to get another staff member and did incontinent cares on Resident #1. Staff C, stated after Resident #1 was cleaned up and staff were walking out of the room, Staff D came and explained she forgotten to tell Staff C Resident #1 needed to be changed. On 12/17/25 at 12:15 PM, the facility administrator acknowledged it is the expectation of the staff to treat the residents with dignity and respect.The Residents Rights-Dignity and Respect policy dated 4/24, the purpose is to lay the foundation for treating all residents with dignity and respect and maintaining and enhancing his or her self-esteem and self-worth. Each resident has the right to considerate and respectful care and to be treated with honesty, dignity, respect and with reasonable accommodation of individual needs.

Based on electronic health records (EHR), document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed (Residents #1, #3, #4, and #6). The facility reported a census of 56 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 6 indicating cognitive impairment. Review of Electronic Health Record (EHR) documented Resident #1 resided in room D17.Interview on 9/30/25 at 1:30 PM Resident #1 stated the facility was short of staff on the evening shift. Resident #9 stated she had to wait longer than 15 minutes to have her call light answered. Review of document titled, Past Call Report for room number D17 documented on 9/28/25 call light was turned on at 10:37 AM and to room elapsed time of 18 minutes.2. The MDS dated [DATE] for Resident #3 documented a BIMS score of 15 for which indicated no cognitive impairment.Review of the EHR documented Resident #3 resided in room D23.Interview on 9/30/25 at 1:00 PM, Resident #3 stated that she had to wait longer than 15 minutes to have her call light answered.Review of the document titled, Past Call Report for room number D23 documented on 9/28/25 call light was turned on at 10:02 PM and to room elapsed time of 20 minutes.3. The MDS dated [DATE] for Resident #4 documented a BIMS score of 14 for which indicated no cognitive impairment.Review of the EHR documented Resident #4 resided in room C14Review of the document titled, Past Call Report for room number C14, documented on 9/26/25, call light was turned on at 8:31 AM and to room elapsed time of 22 minutes, on 9/27/25, call light was turned on at 6:21 AM and to room elapsed time of 22 minutes and on 9/29/25, call light was turned on at 6:29 PM with to room elapsed time of 24 minutes.4. The MDS dated [DATE] for Resident #6 documented a BIMS score of 15 for which indicated no cognitive impairment.Review of the EHR documented Resident #6 resided in room B42Interview on 9/30/25 at 8:30 AM, Resident #6 stated that it takes longer than 15 minutes to have her call light answered.Review of the document titled, Past Call Report for room number B42 documented on 9/27/25, call light was turned on 5:14 AM and to room elapsed time of 16 minutes. On 9/29/25, call light was turned on at 12:50 PM and to room elapsed time of 21 minutes. Interview on 9/30/25 at 2:15 PM, Staff D, Licensed Practical Nurse (LPN), acknowledged that the call lights take longer than 15 minutes to answer on the evening shift due to short of staff.Interview on 10/1/25 at 2:00 PM, the facility Administrator and Director of Nursing acknowledged that the call lights are over the 15 minutes and that the expecation are for staff to answer within the 15 minutes per the guidelines.Interview on 10/1/25 at 4:45 PM, Staff E, Certified Nursing Assistant (CNA), verified that it takes longer than 15 minutes to answer call lights due to short staff on the evening shift.The Call Light Policy dated September 2023, instructed to ensure a prompt response to the residents call for assistance. The facility also ensures that the call system is in proper working order. Facility shall answer call lights in a timely manner.

Based on observations, resident, and staff interviews the facility failed to provide the residents with a comfortable homelike environment by failing to keep a resident bed in functioning order and the toilet properly maintained. The facility reported a census of 56 residents. Findings include:Observation on 9/29/25 at 11:20 a.m., revealed, the footboard in Resident #1's room, split in half with silver brackets placed on the inside holding the foot board together.Observation on 9/30/25 at 1:30 p.m., revealed the footboard in Resident #1's room, split in half with silver brackets placed on the inside holding the footboard together.Interview on 9/30/25 at 1:30 p.m., Resident #1 explained the footboard has been broken since they admitted to the facility in July and they are afraid to sleep in the bed causing the footboard to break and falling out of bed. Resident #1 also commented that their bathroom toilet was not working for a couple of days and that they had to use a commode and is embarrassed with the commode still in their room.A work order, given to the surveyor on 10/1/25 at 2:00 p.m., by the Administrator, documented a created dated 8/13/25 at 5:00 p.m., toilet is now broken, work order for new toilet in progress.A receipt dated 8/14/25 at 12:15 p.m., documented toilet purchased due to needing replaced.Interview on 10/1/25 at 9:45 a.m., Staff A, Maintenance, and Staff B, Maintenance, confirmed that Resident #1 toilet was broken for a couple of days a month ago, not sure of the exact date, and that a work order was filled out. Staff B replaced the foot board on the evening of 9/30/25, when they became aware by the surveyor that it was broken, and was not aware on how long the foot board had been broken. Staff A stated that staff pull on the foot board and they break easily. Staff A and Staff B were not aware of any audits or scheduled room checks to be completed for residents' beds, toilets or furnishing.

Based on observations, interviews, and record review, the facility failed to routinely assess and provide interventions for retracting the foreskin of the penis and returning to its original position for 1 out of 3 residents reviewed (Resident #2). Resident #2 required intervention at the Urology Clinic to reduce paraphimosis (foreskin pulled back but unable to return to its original position over the head, or glans, of the penis) on 3 different occasions. This facility reported a census of 52 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE], listed an admission from an acute hospital stay on 9/24/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #2 required substantial assistance with rolling left and right, toileting hygiene, and dressing. The MDS listed Resident #2 had a catheter. The MDS included diagnoses of congestive heart failure (CHF), renal (kidney) insufficiency, chronic obstructive pulmonary disease (COPD), and paraphimosis. A list provided by the facility on 11/25/24 of residents with BIMS scoring 8 or greater reflected Resident #2's score of 13, indicating intact cognition. Resident #2's Hospital Records dated 9/24/24 listed the following physician orders: a. Admit to skilled level of care. b. Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat upon arrival. c. Urology placed a urinary catheter, recommend leaving the catheter in place until the patient is more mobile and penoscrotal (penis/scrotum) edema (swelling) has improved. The Structured Progress Note dated 9/24/24 at 1:29 PM reflected the note as the Admission Nursing Assessment. The note indicated Resident #2 had abnormalities, edema, with his genitalia. The note lacked documentation of a catheter. The Health Status Note dated 10/4/24 at 4:50 PM indicated the nurse assessed Resident #2's penis due to a report of it looking swollen. Upon assessment the nurse documented Resident #2 penis as swollen at the base of the tip on top. It looked like a crescent starting from one side and going to the other side of the tip. The note reflected the nurse attempted the doctor's suggestion to try and pull his foreskin back with lubricant, but had no success. The swelling is noted as part of the skin under the foreskin. Underneath his penis looked discolored, he denied pain to area. The doctor directed to send Resident #2 to the emergency room if he started to complain of pain and it started turning purple. The Health Status Note dated 10/6/24 at 6:16 AM written by Staff L, Registered Nurse (RN), indicated the certified nurse aides (CNAs) reported Resident #2 got up to the bathroom multiple times throughout the night. The nurse catheterized him to see if he had residual (urine left in bladder after urinating). The nurse emptied 1,025 milliliters (ml) of urine, and left the urinary catheter left in place. The day nurse would notify family and the provider. The Skilled Note dated 10/10/24 at 10:45 PM identified Resident #2's had 2 plus (+) edema. Urinary catheter remains in place. The Health Status Note dated 10/11/24 at 12:38 PM reflected the facility's Advanced Registered Nurse Practitioner (ARNP) saw Resident #2 on 10/10/24 at the facility. The ARNP wrote orders to use a secure lock for his urinary catheter to prevent pulling. In addition, related to his paraphimosis put an icepack to his groin area for 20 minutes, then try manual manipulation with KY gel. The ARNP planned to see him the next week. The Communication with the Physician Note on 10/13/24 at 9:27 PM indicated the facility faxed an update to Resident #2's primary care provider (PCP) that the current treatment didn't help his paraphimosis. The New Order Follow-Up Note dated 10/14/24 at 9:19 AM reflected Resident #2's urinary catheter drained yellow urine. His penile edema remained. The staff continued to apply ice for 20 minutes and attempted manipulation without success. Resident #2 continued to have flat affect, but compliant with care and assessment stating he'd do what the girls told him. Resident is quiet, responded when spoken to but didn't offer conversation per his usual. The Physician Visit Note dated 10/16/24 at 4:05 PM, indicated Resident #2 returned to the facility without incident from seeing the Urology Clinic Provider ARNP. They ordered medication and directed to follow-up at his appointment on 11/20/24 at 3:00 PM. The nurse updated the Medication Administration Record (MAR), faxed the pharmacy, updated the calendar, and notified his daughter. The Urology Progress Notes dated 10/16/24, identified Resident #2 had urethral (urinary tract opening at end of penis) erosion (breakdown of tissue surrounding the urethra) and paraphimosis. The Urology staff reduced the paraphimosis in the clinic. The Urology team would provide education to the nursing staff at his care facility. The Impression/Plan listed they reduced the paraphimosis at the bedside. They provided education to the nursing home (NH) staff to ensure they retract the foreskin back over the head of the penis after catheter care. The New Order Follow-up Note dated 10/17/24 at 12:43 PM, reflected Resident #2 appeared more tired than usual and would see the facility ARNP the next day on rounds. The Urology Clinic Provider and facility ARNP discontinued the treatment of ice and manipulation. The Communication - with Outside Vendor dated 10/18/24 at 2:06 PM reflected the facility received a fax from the Urology Clinic Provider. The fax identified the Urology clinic would do the next couple catheter changes. Resident #2 would follow up in the office on 10/20/24 at 3:00 PM. The provider gave a new order to apply bacitracin to tip of penis/urethra twice a day (BID) and ensure the foreskin is not behind the head of penis. The note instructed to pull the foreskin back and clean it daily then pull it back over the penile head to prevent edema paraphimosis. A Clinical Physician's Order dated 10/18/24, directed to apply bacitracin (antibiotic ointment) to the tip of the penis twice a day. The order directed the nurses to ensure the foreskin is not behind the head of the penis. The note instructed to pull the foreskin back and clean it daily then pull it over the penile head, twice a day for paraphimosis. In a Urology Clinic Conversation between a Urology Clinic Nurse and the Urology Clinic Provider dated 10/18/24, the provider instructed the Clinic Nurse to make sure the NH staff know they need alternate the catheter so it didn't cause tension. The NH needs an order to apply bacitracin to the end of the penis/urethra twice daily on the sore area. In addition, make sure they know when they do catheter care they must make sure the foreskin is not left behind the head of the penis. Resident #2 had significant swelling/paraphimosis when they saw him from this. They should pull the foreskin back daily and clean with catheter care but the foreskin needed returned over the penile head. The Health Status Note dated 10/28/24 at 12:23 AM reflected Resident #2's penis remained enlarged. The attempts to apply cooling packs and ointment to get the foreskin over the head of penis without success. Resident #2 became very tearful at times. The Health Status Note dated 10/28/24 at 10:03 PM indicated Resident #2's penis remained full of fluid. Resident #2 denied discomfort or pain. The Health Status Note dated 10/30/24 at 11:01 PM, reflected the nurse applied triple antibiotic to tip of Resident 2's penis. The head of his penis remained enlarged. The staff provided peri care and attempted to pull his foreskin over his penis without success. The Physician Visit Note dated 10/31/24 at 2:43 PM identified the facility ARNP saw Resident #2 and ordered labs. The Communication - with Physician dated 10/31/24 at 2:54 PM, indicated the facility called the Urology Clinic to report edema to Resident #2's foreskin of his penis. The Urology Clinic Provider would see Resident #2 the next day on 11/1/24 at 9:00 AM. The Health Status Note dated 10/31/24 at 11:36 PM reflected the staff provided catheter care. His penis remained swollen and they couldn't to pull foreskin over the penis head. The Appointment Note dated 11/1/24 at 8:15 AM identified Resident #2 left the facility via van to an appointment with his Urology Clinic Provider. The Appointment Note dated 11/1/24 at 9:55 AM, indicated Resident #2 returned to the facility. The Communication Sheet lacked notes, transportation reported the clinic would call. A Urology Clinic Progress Note dated 11/1/24, reflected the reason for Resident #2's visit as his foreskin retracted and the NH unable to get it back in place. It caused pain and paraphimosis. The clinic saw Resident #2 that day for penile pain and swelling. The NH called the previous day and reported his foreskin was retracted and they couldn't get it back over the head of his penis. The Urology Clinic Provider managed to manipulate the foreskin back. The clinic called the NH and gave instructions to Staff G, Licensed Practical Nurse (LPN). The instructions were to avoid fully retracting the foreskin all the way behind the glans, only pull back enough to clean, apply ointment, and place back. Staff G verbalized understanding and thanks. The Health Status Note dated 11/6/24 at 11:13 PM identified Resident #2's penis didn't have redness. The staff applied ointment as ordered. The catheter patent (in place and working) at the time with urine in the drainage bag. The Health Status Note dated 11/11/24 at 11:03 PM indicated Resident #2's penis remained swollen. The staff completed his treatments as ordered. The New Order Follow-Up Note dated 11/12/24 at 7:02 AM reflected Resident #2's penile edema remained. Resident #2 denied complaints of pain/discomfort. The Skin Condition Note dated 11/14/24 at 4:00 PM identified the facility completed the weekly skin assessment. The note lacked information regarding Resident #2's penis or scrotum. The Health Status Note dated 11/15/24 at 7:42 PM indicated Resident #2 didn't have a sore on his penis. The Health Status Note dated 11/18/24 at 10:17 PM reflected Resident #2 continued to have large amounts of edema in his lower body, as well as penile edema. The New Order Note dated 11/20/24 at 4:37 PM identified Resident #2 returned from his urology appointment. The instructions directed to continue with routine monthly catheter changes. In addition, nursing must pull the foreskin back over the head of penis after peri-cares. The Health Status Note dated 11/20/24 8:00 PM indicated Resident #2's penis remained swollen. The attempt to bring his foreskin over the penis failed. The Urology Progress Notes dated 11/20/24 identified Resident #2 as well since his last visit, but again noted to have paraphimosis. The clinic has instructed the staff at his nursing facility on 2 separate occasions to make sure they pull the foreskin back over the penile head with peri-care, however, it appeared that didn't happen. The clinic would reach out again to the facility with proper instructions. Resident #2's October 2024 and November 2024 Treatment Administration Records (TARS) reflected the nurses started signing on 10/18/24 at his hour of sleep (HS) that they applied bacitracin to the tip of the penis twice a day. The documentation reflected the nurses signed they ensured the foreskin wasn't behind the head of the penis, it should be pulled back, and cleaned daily then pulled forward over the penile head. On 11/25/24 at 10:32 AM, the Urology Clinic Nurse stated they saw Resident #2 three times at their Urology Clinic. She stated all 3 times Resident #2 had paraphimosis that the clinic's provider had to reduce. The Urology Clinic Nurse stated she talked with the NH's Director of Nursing (DON) on 10/16/24 and discussed the clinic's concerns. The Urology Clinic Nurse stated at the 11/20/24 visit, it took approximately 10 minutes to reduce the paraphimosis. She described the reduction of the paraphimosis (pulling the foreskin back into place over the penile head) as painful and almost like torture for him. On 11/25/24 at 10:44 AM, the Urology Clinic Provider stated the first visit they had with Resident #2 happened on 10/16/24, he had a catheter in place. Resident #2 had erosion of the penis, edema, and paraphimosis. The Urology Clinic Provider stated the erosion looked like it started from the catheter tension to the urethra. On 11/1/24, Resident #2 had paraphimosis again and the Provider was able to reduce it. The Provider called and told them to only pull the foreskin back enough to clean the head and apply ointment then put foreskin back over the glans penis. On 11/20/24 the Urology Clinic Nurse described Resident #2's penis as significantly swollen again with the foreskin stuck behind the glans. Resident #2 didn't have his catheter connected properly to the leg and caused tension. It was very painful for him. The Urology Clinic Provider stated they didn't have any way to know how long he had his foreskin pulled back. The Urology Clinic Provider stated Resident #2 already had CHF so he would already have more swelling to that area. Resident #2 told the clinic staff that he had pain since the last time he came to the clinic. The Urology Clinic Provider reported they had a lot more difficulty with getting his foreskin back in place on that visit then his prior visits and he had extreme pain. The Urology Clinic Provider described Resident #2 as not one to complain. The Urology Clinic Provider stated she called the facility and gave education every time and sent orders. She didn't know if the facility needed more education or what. The Urology Clinic Provider reported it as concerning that he had paraphimosis on all of 3 of his visits. On 11/25/24 at 1:30 PM, Resident #2 and his wife sat in their room together. They gave permission to enter the room and close the door. Resident #2 stated he didn't have any pain. He nodded in agreement when asked about the 3 times the Urology Center had to move the foreskin back over the head of his penis. He said the girls do a good job at the facility and the only time he had pain happened when they cleaned him up down there. He stated they did those cares in the morning and in the evening. He stated he believed his foreskin was, at this time, over the head of his penis and his wife agreed. Resident #2 gave permission to observe peri-care in the morning. On 11/25/24 at 7:32 PM, Staff E, LPN, stated she knew Resident #2 returned with a doctor's order instructing the aides only to pull the foreskin back so far. Staff E stated they used ice packs and ointment to try to get the foreskin back over the glans penis. Staff E stated Resident #2 didn't say anything about being in pain. She described his foreskin as just a tiny bit past the head of the penis. She stated the penis didn't change colors at all. Staff E reported to her knowledge the Urology Clinic didn't ever get the foreskin back over the head of the penis. She stated the past week was the first time the Urology clinic ever got the foreskin back over the head of the penis. Staff E said she never saw Resident #2's foreskin pulled back into place until the prior week. Staff E said to her knowledge the other 2 times Resident #2 went to Urology, they couldn't get the foreskin back into place. When they said they did, Staff E said she never saw it. When asked when would it be considered urgent to send Resident #2 out, Staff E replied if his penis turned blue or something like that. Staff E said they tried to make the swelling go down with an ice pack and putting the lubrication on it. She said the TAR included that treatment. Staff E stated they checked his penis and foreskin every night. Staff E said she taught a new CNA how to do it appropriately. Staff E said the CNA told her they never learned how to pull the foreskin back in place in school. So, Staff E showed the CNA how to do it. Staff E couldn't remember the name of the CNA. Staff E couldn't believe they didn't teach the CNA that in school. On 11/25/24 at 7:41 PM, Staff F, LPN, reported she knew when Resident #2 first came to the facility he had a fluid filled (edema) area on the shaft of his penis. Staff F described it as hard to get the foreskin to retract and go back over the head of Resident #2's penis. Staff F stated Resident #2 always had sensitivity down there. She said it didn't look like the swelling came from trauma. Staff F stated she always could get the foreskin retracted back from the head of his penis and then back over the head of the penis. Staff F said Resident #2 never complained (of pain) to her. Staff F stated she only worked at the facility as needed (PRN), like 2 or 3 times a month. She only worked with Resident #2 a couple of times. Staff F never saw any of the moments where the foreskin couldn't be pulled back into place over the head of the penis. Staff F never saw any difficulties with the CNAs being able to replace the foreskin back over the head of the penis. Staff reported they went with the CNAs because they had to apply the bacitracin on to the tip of Resident #2's penis. Staff F stated it took a few more steps to get the foreskin retracted and then pulled back over into place related to the swelling. Staff F stated Resident #2 could voice his concerns and he would voice if he had pain. On 11/26/24 at 7:15 AM, observed Staff H, Certified Medication Aide (CMA)/CNA, and Staff I, CNA, provide morning care for Resident #2. Observed edema in his lower legs and feet. During the peri-care/catheter care witnessed Resident #2's foreskin retracted half way down the head of his penis, they cleaned the penile head, and returned the foreskin back in place. The observation showed no redness, discharge, or swelling. The DON applied the bacitracin to the penis after retracting the foreskin and then she pulled the foreskin back over the glans. On 11/26/24 at 8:00 AM, Staff H and Staff I stated they both received training on how to do peri care on an uncircumcised resident. They both said they had to corrected their peers at times for not pulling the foreskin back over the head of the penis and/or not retracting the foreskin to clean the head of the penis. Staff I explained if they don't retract the foreskin to clean, then discharge can build up under the foreskin, which could result in it becoming cheesy and yellow. They didn't see anything recently where they needed to intervene with the staff. Staff H stated Resident #2 came into the facility with the foreskin retracted and the head of his penis swollen. She stated she thought he went to have it taken care of about 1 week after he got to the facility. On 11/26/24 at 8:25 AM, Staff J, CNA, stated she received training on how to clean an uncircumcised penis. She stated when Resident #2 first came into the facility, Staff J couldn't tell if Resident #2 was circumcised or not because of the swelling in his penis. In addition, she couldn't tell if he even had a foreskin. Staff J stated Resident #2 retained a lot of water. She stated she gave him a bath the previous Sunday (11/24/24) and his penis looked swollen but he had the foreskin pulled over the head of his penis. On 11/26/24 at 8:40 AM, Staff K, CMA/CNA, reported she learned how to provide peri care to uncircumcised males. She explained the process as you need to pull the foreskin back, cleanse the penis, and then replace the foreskin back over the penis. She described Resident #2's penis as swollen. Staff K saw him with his foreskin pulled back behind the head of the penis, when they couldn't pull it back over the penis. She estimated it was probably the previous week, but she didn't know a certain day. She stated when she realized this she went and told the nurse. She stated she didn't observe any of her peers leaving the foreskin down. She stated they used to be able to take the foreskin down, clean the head of the penis, and then pull the foreskin back up, but then his penis started swelling. She didn't know when or who pulled the foreskin down and didn't get it back up over the head of his penis. On 11/26/24 at 11:46 AM, the DON reported he didn't document the conversation she had with the Urology Clinic on 11/20/24 and 11/21/24 as it just happened. She stated she would document the conversation. When asked about the admission order to remove the catheter after his penile and scrotal swelling decrease, but his clinical record lacked documentation of penile and scrotal swelling until 10/4/24 with exception of a mention in an admission note, she responded it would be in the daily skilled documentation. When asked about Resident #2 having paraphimosis on 10/16/24, she replied she would look into it more. When asked how the nurses signed that they applied the bacitracin BID to the tip of his penis and ensured they pulled the foreskin back over the head of his penis, but, Resident #2 went out again on 11/1/24 and 11/20/24 with paraphimosis, the DON responded she needed to look into it more. She stated that since changing corporations, they updated the systems and they are looking into getting information that the survey team requested. She reported she understood the concern with the lack of documentation of assessments and interventions. On 12/3/24 at 3:55 PM, Staff L, RN, stated Resident #2 had a lot of edema to his penis in general as well as the foreskin and the shaft. Staff L stated Resident #2 had an issue with his foreskin for a long time. The staff pulled it back to perform peri-care and then they couldn't get it back over because of the swelling. She stated this already happened when she started working with him. Staff L said her first encounter with Resident #2 happened when she catheterize him on 10/4/24. Staff L noticed his foreskin retracted and they couldn't pull it back over the head of the penis. Staff L stated if his penis was like that prior to Staff L putting the catheter in, she didn't know of it. Staff L didn't recall when they put the bacitracin order in place. After the beginning of November, when Staff L went back to day shift, he already had the order to apply bacitracin to his penis in place. Staff L stated she applied the bacitracin to Resident #2 multiple times. He had foreskin retracted where it couldn't be pulled back over, except right before he moved to the back on 11/26/24, somebody did get it back over the penis head. The majority of the time his penis had too edema and it hurt him, the facility staff couldn't get the foreskin back over. Staff L noticed one time he had his foreskin back over the head of his penis. Luckily on that day she could pull the foreskin back, do his treatment, and replace the foreskin back over the penis. Staff L stated she didn't recall if the bacitracin order directed to pull the foreskin back over the head of the penis. Staff L said she didn't remember his penis being discolored at all. Staff L stated she didn't know if anyone reported it to the Provider. Staff L stated he already had the issue when she went to the day shift. Staff L said if somebody reported the issue it wouldn't been her. Staff L reported it as questionable too, how long it had been like that. She said she believed that at one of his Urology appointments, they couldn't pull the foreskin back over. When told the documentation showed they did reduce the paraphimosis at all 3 of his appointments, she responded after he came back from one of his appointments, she didn't know if it was that same day or the next morning when she did the treatment, she looked at it and they didn't get the foreskin back over. When read the 11/20/24 progress note to Staff L, she replied she may have said that wrong. Staff L stated she saw issues with not being able to pull his foreskin over the glans prior to 11/20/24. Staff L stated she worked on 11/22/24 and described his penis as edematous, during care, treatment, and retracting of the foreskin back over the head of his penis. Staff L stated she didn't believe she knew the bacitracin order directed to pull the foreskin back over the glans penis. Staff L explained ideally, they would perform the necessary cares and treatment. In Resident #2's case, he had a very painful and edematous penis. Staff L stated she didn't remember Urology telling them know how to decrease the edema. Staff L stated in Resident #2's case, they thought they would do more damage to him to try and force the foreskin back over the head of the penis then to leave it. He didn't really complain much but they could tell that it was tender, and when they tried to pull the foreskin back over the penile head, it caused him pain. Staff L reported she would probably described it as tender because of the edema with the foreskin pulled back. He didn't complain of it bothering him on a day to day basis when they had issues. Staff L wondered if the facility could do something. Staff L said that after his last Urology appointment, the DON told them Urology called. She explained they were really mad and wanted to know if staff didn't clean him well, or what the problem was because they had to pull his foreskin back again over the head of his penis. The DON wanted 2 nurses to do Resident #2's peri-care to ensure the foreskin got put back into place. Staff L described it as very frustrating. On 12/4/24 at 2:13 PM, Staff M, LPN, stated she didn't remember for sure the first time she got report of Resident #2's retracted foreskin. The facility ARNP told Staff M to ice and elevate the penis, then try to retract. Staff M stated the Facility ARNP said if Staff M could get the swelling down then to use ointment to try and pull the foreskin back over. Staff M stated they couldn't get the swelling down. Staff M stated the ice and elevation didn't work. Staff M stated she told the Facility ARNP, who made a Urology appointment. Staff M stated Resident #2 never really complained of pain. She said that Urology told them to use bacitracin and that didn't really work to get the foreskin back over. Staff M said she knew Resident #2 had a history of paraphimosis and swelling. Staff M wondered if the catheter was a contributing factor to the swelling and paraphimosis. Staff M stated she made sure the staff did proper catheter care. Staff M didn't see any concerns with the CNAs providing care. Staff M didn't recall talking to the Urology Clinic Provider or anyone about anything other than to schedule the appointment. Staff M stated they couldn't return the foreskin back over the head of the penis at the facility. When the documentation was read to Staff M that the Urology Clinic Provider wrote they talked to Staff M, she responded she didn't remember talking to anyone on the phone. She explained she didn't say it didn't happen, she just didn't remember it. Staff M stated she remembered an order basically saying the same thing read to her. Staff M stated they looked into his visits, they didn't remember the date, but they wrote a note to not fully retract the foreskin. Staff M stated she applied bacitracin to his urethra several different times. Staff M acknowledged she knew the order directed to pull the foreskin back over the head of the penis after applying the bacitracin. Staff M stated she honestly didn't know if she called a physician/provider to let them know the nurses couldn't get the foreskin back over the penile head. Staff M stated she knew she talked to the Facility ARNP about it at different times. Basically, we had the bacitracin order and he went to urology. Staff M stated they could try ice too. When asked if she should have called a provider she said yes. She stated at the time, because it wasn't new, she just . She added again it wasn't new. On 12/4/24 at 3:36 PM, the Facility ARNP stated she knew she saw Resident #2 in October. They had difficulty getting his foreskin back over the penile head. The Facility ARNP believed she ordered a consult to Urology at that time. The Facility ARNP stated she didn't know that the paraphimosis was persistent and stated she didn't receive any calls from the facility regarding his ongoing paraphimosis. She stated she is available all the time and the facility's nurses didn't call her reporting persistent paraphimosis. She acknowledged the bacitracin order was to ensure they could move the foreskin back into place twice a day and acknowledged no one notified her that they couldn't get it back. The Facility ARNP stated Resident #2 had a urinary catheter that drained correctly. On 12/4/24 at 4:35 PM, the Administrator and the DON, stated periodically the nurses couldn't pull Resident #2's foreskin back into place, but not always. When informed about the concern of nurses documenting twice a day they pulled the foreskin back over the head of the penis after retracting it to apply ointment, and the facility ARNP stated no one contacted her regarding not being able to pull the foreskin back over the head of the penis, nor did she know he had this as a persistent problem, the DON and the Administrator acknowledged the concern. The DON and Administrator couldn't provide any further information regarding documentation of the penile/scrotal swelling . The DON didn't provide the documentation from the conversation she had with the Urology Clinic. The facility couldn't provide any additional documentation from the skilled daily nursing notes. The facility stated they follow the standard of practice for assessment, intervention, following doctor's orders, and peri care on un circumcised males.

Based on observations, interviews and record review, the facility failed to follow standards for bladder care and services for 2 out of 3 residents reviewed (Residents #1 and #2). Resident #2 had a voiding trial (trial to see if resident could go without a catheter to drain the urine from his bladder) without measuring output or documenting his output for 1 shift. Resident #2 couldn't urinate on a separate shift and had over 1 liter of urine drained from his bladder. Resident #2 had urethral erosion (tissue breakdown around the urinary meatus, opening at the end of the penis) from a Urinary catheter (tube placed in the urethra to drain urine out of the bladder). The facility failed to ensure Resident #2 wore a secure device to hold the catheter in place and to prevent pulling on the catheter. The facility failed to provide timely incontinence care to Resident #1. The facility reported a census of 52 residents. Findings include: 1. Resident #2's Minimum Data Set assessment dated [DATE], listed an admission from an acute hospital stay on 9/24/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #2 required substantial assistance with rolling left and right, toileting hygiene, and dressing. The MDS listed Resident #2 had a catheter. The MDS included diagnoses of congestive heart failure (CHF), renal (kidney) insufficiency, chronic obstructive pulmonary disease (COPD), and paraphimosis. Resident #2's Hospital Records dated 9/24/24 listed the following physician orders: a. Admit to skilled level of care. b. Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat upon arrival. c. Urology placed a urinary catheter, recommend leaving the catheter in place until the patient is more mobile and penoscrotal (penis/scrotum) edema (swelling) has improved. d. Recommend voiding trial at nursing facility in 3 to 4 days. The orders repeated to please do a voiding trial at nursing facility in 3 to 4 days to remove the urinary catheter. The Care Plan Focus initiated 10/8/24 indicated Resident #2 required the use of an indwelling catheter related to obstructive uropathy (blocked urinary passage). The Interventions directed staff to use a catheter securement device. The Structured Progress Note dated 9/24/24 at 1:29 PM reflected the note as the Admission Nursing Assessment. The note indicated Resident #2 had abnormalities, edema, with his genitalia. The note lacked documentation of a catheter. The Structured progress notes on 9/26/24 at 4:16 PM, 9/27/24 at 7:46 PM, 9/28/24 at 8:06 PM, 9/29/24 at 10:16 PM, and 9/30/24 at 8:58 PM indicated Resident #2 had an indwelling catheter. The Skilled Note on 10/1/24 at 9:57 PM reflected Resident #2's urinary catheter remained. The New Order Note dated 10/2/24 at 4:18 PM indicated the facility received new orders to remove Resident #2's urinary catheter from the physician. The orders directed if once removed Resident #2 can't void within 8 hours, replace the urinary catheter and notify the provider then refer to urology. The Skilled Note dated 10/2/24 at 10:24 PM reflected they took out the catheter as ordered and gave Resident #2 a urinal. The Skill Note dated 10/2/24 at 11:44 PM, indicated the staff provided 100% assistance with urinary catheter management. The Health Status Note dated 10/6/24 at 6:16 AM written by Staff L, Registered Nurse (RN), reflected the certified nurse aides (CNAs) reported to the nurse Resident #2 went to the bathroom multiple times throughout the night. The nurse catheterized Resident #2 to see if he had residual (urine remaining after voiding), he had 1,025 milliliters (ml) of urine out. The nurse left the urinary catheter in place. The day nurse would notify the family and provider. The General Progress Note dated 10/6/24 at 9:27 PM identified Resident #2's urinary catheter as intact and patent (in place and working). The urinary output appeared clear and yellow with adequate output noted. Resident #2 denied pain/discomfort with the re insertion of his catheter. The Health Status Note 10/7/24 at 10:27 PM, identified Resident #2 had a large amount of urine in his bag (3/4 full at 8:00 PM) that night. The nurse asked the staff to empty the catheter bag. The Skilled Note dated 10/7/24 at 11:14 PM indicated Resident #2's urinary catheter remained in place. The New Order Follow-up Note dated 10/8/24 at 9:43 AM identified Resident #2 had a catheter in place, patent, and draining clear yellow urine. The Skilled Note dated 10/8/24 at 7:51 PM indicated Resident #2's urinary catheter remained in place. The New Order Follow-up Note dated 10/9/24 at 12:10 PM reflected Resident #2 had a patent catheter draining clear yellow urine. Resident #2 reported he didn't feel the urge to go constantly, like he did before. He explained he actually could get some sleep. No tearfulness observed on assessment. The Skilled Note dated 10/9/24 at 6:57 PM indicated Resident #2's urinary catheter remained in place. The Health Status Note dated 10/9/24 at 9:08 PM identified Resident #2 had a patent catheter draining clear yellow urine. He denied urinary discomfort. The New Order Follow-up Note dated 10/10/24 at 7:10 AM, reflected Resident #2 reported he had relief when they placed the catheter as he didn't have the constant urge to urinate. The Skilled Note dated 10/10/24 at 10:45 PM, identified Resident #2's scrotum had 2+ edema and his urinary catheter remained in place. The Health Status Note dated 10/11/24 at 12:38 PM reflected the facility's Advanced Registered Nurse Practitioner (ARNP) saw Resident #2 on 10/10/24 at the facility. The ARNP wrote orders to use a secure lock for his urinary catheter to prevent pulling. In addition, related to his paraphimosis put an icepack to his groin area for 20 minutes, then try manual manipulation with KY gel. The ARNP planned to see him the next week. The Skilled Note dated 10/11/24 at 11:31 PM indicated Resident #2's urinary catheter remained in place. The Skilled Note dated 10/12/24 at 7:32 PM indicated Resident #2's urinary catheter remained in place. The Skilled Note dated 10/13/24 at 11:53 PM, indicated Resident #2's urinary catheter remained in place. The Communication - with Outside Vendor dated 10/18/24 at 2:06 PM reflected the facility received a fax from the Urology Clinic Provider. The fax identified the Urology clinic would do the next couple catheter changes. Resident #2 would follow up in the office on 10/20/24 at 3:00 PM. The provider gave a new order to apply bacitracin to tip of penis/urethra twice a day (BID) and ensure the foreskin is not behind the head of penis. The note instructed to pull the foreskin back and clean it daily then pull it back over the penile head to prevent edema paraphimosis. Resident #2's October 2024 Documentation Survey Report related to bladder elimination report lacked documentation on the night shift of 10/4/24. The report didn't document the amount of urine output for each shift. It documented Resident #2 had a catheter in on 10/2/24 and 10/6/24 on the first shift. The documentation between the two shifts reflected Resident #2 as continent or incontinent, with the exception of the 10/4/24 night shift due to no documentation. The Clinical Physician's Order printed 12/3/24 included an order by the Facility Advanced Registered Nurse Practitioner (ARNP) dated 10/11/24 entered in the electronic health record by the Director of Nursing (DON), to place a urinary catheter secure lock to prevent pulling of the catheter two times a day (BID) for catheter safety. Resident #2's October 2024 and November 2024 Treatment Administration Records (TARs) reflected the nurses started signing on 10/11/24 at bedtime (HS) twice a day that he had a secure lock in place. In addition, the TARs reflected the nurses started signing on 10/18/24 at HS that they applied bacitracin to the tip of his penis twice a day. The documentation reflected the nurses signed they ensured the foreskin wasn't behind the head of the penis, it should be pulled back, and cleaned daily then pulled forward over the penile head. The Clinical Physician Orders dated 10/18/24, directed to apply bacitracin (antibiotic ointment) to the tip of the penis twice a day. The order directed the nurses to ensure the foreskin is not behind the head of the penis. The note instructed to pull the foreskin back and clean it daily then pull it over the penile head, twice a day for paraphimosis. The Urology Progress Notes dated 10/16/24, identified Resident #2 had a recent hospitalization and had urinary retention. They placed a urinary catheter and started tamsulosin. The facility reported conducting 2 separate voiding trials without success. After further discussion with him and his daughter, they attempted a voiding trial, however, he couldn't urinate. They discussed starting a catheter and adjusting his medications. They planned to do a follow-up voiding trial in one month. If unsuccessful at that time, they would start a permanent catheter that the nursing home (NH) could change monthly. He is not a surgical candidate and not interested in surgery. He didn't have hematuria or urinary tract infection issues. He did have urethral (urinary tract opening at end of penis) erosion (breakdown of tissue surrounding the urethra) and paraphimosis (foreskin pulled back but unable to return to its original position over the head, or glans, of the penis). The Urology staff reduced the paraphimosis in the clinic. The Urology team would provide education to the nursing staff at his care facility. The Impression/Plan listed they reduced the paraphimosis at the bedside. They provided education to the nursing home (NH) staff to ensure they retract the foreskin back over the head of the penis after catheter care. The Urology Clinic would do the next couple of catheter changes. In a Urology Clinic Conversation between a Urology Clinic Nurse and the Urology Clinic Provider dated 10/18/24, indicated the facility needed urinary catheter instructions sent to them. In addition, the provider instructed the Clinic Nurse to make sure the NH staff knew they needed to alternate the catheter so it didn't cause tension. The NH needs an order to apply bacitracin to the end of the penis/urethra twice daily on the sore area. In addition, make sure they know when they do catheter care they must make sure the foreskin is not left behind the head of the penis. Resident #2 had significant swelling/paraphimosis when they saw him from this. They should pull the foreskin back daily and clean with catheter care but the foreskin needed returned over the penile head. A Clinical Physician's Order dated 10/18/24, directed to apply bacitracin (antibiotic ointment) to the tip of the penis twice a day. The order directed the nurses to ensure the foreskin is not behind the head of the penis. The note instructed to pull the foreskin back and clean it daily then pull it over the penile head, twice a day for paraphimosis. The Urology Progress Note dated 11/20/24, reflected the staff provided urethral erosion education to the NH staff, apply bacitracin BID, and adjust the urinary catheter to avoid tension on the catheter. On 11/26/24 at 7:15 AM, observed Staff H, Certified Medication Aide (CMA)/CNA, and Staff I, CNA, in Resident #2's room to provide his morning care. When they rolled Resident #2 to his left side, he had his catheter bag attached to the right side of the bed with the tubing taunt (pulled tight). The Director of Nursing (DON) entered the room to apply bacitracin to the glans penis, and noted the tight tubing. She grabbed the tubing and pulled on the bag side to provide slack to the catheter insertion site of Resident #2's urethra, then they placed the catheter bag on the bed. The DON applied the bacitracin to the penis after retracting the foreskin and then she pulled the foreskin back over the glans (head of the penis) after applying the bacitracin. The DON stated something about a secure lock for him when they took the slack out of the tubing. She left and retrieved a secure lock then applied it to his right leg, removed the catheter from the catheter strap on the left leg and placed the tubing in the secure lock. She then moved the leg strap over to the right leg as well, right below the secure lock and put the tubing through the catheter strap as well. When asked who can apply the secure lock the DON replied it wasn't licensed. Both the CNA and the CMA stated they never put a secure lock on a resident before. Unable to visualize Resident #2's full urethra as they didn't fully pull down the foreskin over the glans penis. On 11/26/24 at 8:00 AM, Staff H and Staff I both stated they didn't like working with the catheter lock device the DON placed on Resident #2. On 11/26/24 at 8:25 AM, Staff J, CNA, stated when Resident #2 first came into the facility, they couldn't tell if Resident #2 was circumcised or not due to the swelling in his penis and she couldn't tell if he had foreskin. The CNA stated Resident #2 retained a lot of water. She stated she gave him a bath the previous Sunday (11/24/24) and his penis looked swollen but he had his foreskin pulled over the head of the penis. When asked about the secure locks, she said she hated those things. She said the facility normally didn't put the secure locks on but residents who come from the hospital wore them. Staff J stated that, in fact, Resident #2 had one on the day she gave him a bath, but she took it off and put a catheter strap on him instead because they are more comfortable for the resident and they didn't have the risk of spinning the tubing. She said the secure lock on Resident #2 caused the tubing to be too tight on his leg. When asked how they knew what each resident needed and what they are Care Planned for, she said it's in the tablets, such as if they had a catheter or how they transfer. She added at the beginning of each shift the nurse would let them know if about any changes to the residents' plan of care. On 11/26/24 at 11:46 AM, the DON reported she didn't document the conversation she had with the Urology Clinic on 11/20/24 and 11/21/24 as it just happened. She stated she would document the conversation. When asked about removal of the catheter on 10/2/24 and then Resident #2's clinical record didn't have anything documented about outputs or tolerance until 10/6/24 when the nurse did a residual and he voided over 1 liter of urine, she replied she would look into it. She stated since changing corporations, they updated the systems and they are looking into getting information that the survey team requested. She reported she understood the concern with the lack of documentation of assessments and interventions. On 12/3/24 at 3:55 PM, Staff L, RN, reported she had her first encounter with Resident #2 when she catheterized him. Staff L reported she worked as the overnight nurse in the back area of the facility until November 1st. It happened very early in the morning when the CNAs came to her and told her Resident #2 wasn't urinating. Staff L said Resident #2 kept saying to the CNAs that he had to go to the bathroom and he kept trickling urine. That's when Staff L looked into it more and discovered Resident #2 was on a voiding trial. Staff L went ahead and catheterized Resident #2. She got over 1,000 milliliters (ml) out. Staff L left the catheter in and the dayshift nurse Staff M, LPN, was to call the physician. It was around 6:00 AM when they asked if Resident #2's clinical record had documentation for the voiding trial. Staff L stated she didn't know what they were doing as far as monitoring because she was the night shift nurse for the back. Staff L stated that usually, for a trial, the nurses ask the staff or resident, if they could tell them, if they are voiding. Staff L stated she read the order that night, and that's how she knew. Staff L stated she knew that they told her in report they removed his catheter. Staff L saw the order that directed if he didn't void in 8 hours or something like that to place a catheter. That's when Staff L inserted a catheter for Resident #2 and he had residual urine. On 12/4/24 at 2:13 PM, Staff M stated she knew Resident #2 had a sticky strap (catheter tubing holder) when he first came in and they switched it to a catheter strap. On 12/4/24 at 4:35 PM, the Administrator and the DON, stated they didn't have further information on Resident #2's voiding trial as they sent what they had which was mostly the CNAs documentation on output. The DON stated that a secure lock meant a leg strap. When asked if she had a policy on that, she stated no, it's a standard of practice. When asked if leg straps are Care Planned on residents with catheters, she stated no. When asked if an order is needed for a leg strap she said no. When asked why she wrote an order then for a Secure Lock, this DON stated she didn't remember writing an order for a Secure Lock. She checked another resident's (who also had a catheter) doctor's orders to see if he had a secure lock order, and he didn't. Information was then requested from the Administrator and the DON, to be sent that would show a secure lock was the same as a catheter leg strap. When shared the concern regarding a delay in the start of a voiding trial, a shift going without documentation of whether or not he voided, and Resident #2 ending up retaining over 1 liter of urine, they acknowledged the concern. When shared the concern regarding the observation of the pulling of Resident #2's catheter during care and no secure lock in place at the time, the DON and Administrator acknowledged the concern. The DON acknowledged walking in during the care, noticing the tension on the catheter tubing and relieving the tension on the tubing. The DON acknowledged she then left the room and grabbed a Stat Lock (secure lock), then placed it on his leg and also applied the catheter leg strap on his leg attaching the catheter tubing to both of the devices. This DON acknowledged Resident #2 had urethral erosion. As of 12/5/24 at 4:30 PM, the facility provided no regarding a secure lock. On 12/5/24 at 3:12 PM, the Facility's ARNP responded the secure lock she ordered was for a stat lock device, as they are the same thing. The facility stated they follow the standard of practice for following doctor's orders. 2. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Resident #1 required supervision/touching assistance with toileting transfers and partial/moderate assistance with toileting hygiene. The MDS listed Resident #1 as frequently incontinent of bowel and bladder. The MDS included diagnoses of hypertension (high blood pressure), renal disease (kidney), cerebrovascular accident (CVA), non Alzheimer's dementia, Parkinson's disease, and neurocognitive disorder with Lewy bodies (a type of dementia). The Care Plan Focus with a target date of 12/24/24 reflected Resident #1 required assistance with activities of daily living (ADL's) related to neurocognitive disorder with Lewy bodies, possible stroke, confusion and weakness. The Care Plan Interventions directed the staff the following: a. Provide extensive assistance from 1 staff member for toileting needs. b. See if Resident #1 was incontinent, aid with incontinence cares, and changing incontinence products. The Care Plan lacked direction on how often to check Resident #1 for incontinence. On 11/25/24 at 8:22 AM, Resident #1's daughter reported she came to the facility on [DATE] in the afternoon. She stated the staff told her that her dad was sleeping and they couldn't get him up. She stated she returned to the facility later that evening and found her dad in a urine-soaked bed. She stated the aide (Staff B) cried because of it. On 11/25/24 at 4:35 PM, Staff B, CMA, described Resident #1 as combative and resistant to care at times. Staff B stated the Assistant Director of Nursing (ADON) called her into Resident #1's room to help with incontinent cares. She stated Resident #1's daughter was present. Staff B reported Resident #1 stayed in bed all day. Staff B reported Resident #1 looked like nobody touched him all day. She described Resident #1's clothes and bedding as soaked with urine. She stated Resident #1 had urine from the back of his knees to his hair line. Staff B reported she broke down and started crying. She stated she cleansed Resident #1's back side and changed his bedding. She stated she had to wipe down the bed with a sanitizing wipe. She reported confusion on why the other aides didn't tell her no one changed Resident #1 or did his care. She stated she didn't understand why the other aides didn't take care of Resident #1 themselves or tell her so she could. She stated reported there was a big difference between being in bed all day and not receiving care. On 11/26/24 at 8:12 AM, the ADON reported she expected the staff to complete incontinence care and check on the residents every 2 hours and as needed (PRN). The ADON reported they had a time when they didn't perform incontinence cares for Resident #1 and the facility took disciplinary actions. She explained the 2 10 shift was involved and the first shift may have been a contributing factor. The ADON reported she came in to work at 6 PM and around 6:30 PM, she observed Resident #1 laying in a wet bed full of urine. She described Resident #1 as very sleepy (lethargic) and he didn't get up that day. She couldn't recall if Resident #1 ate or not that day. She stated it was common for Resident #1 to have days where he was sleepier than others. She identified herself as the one to issue the disciplinary actions with the staff members who were involved. On 11/26/24 at 8:16 AM, Staff C, CNA, reported Resident #1's daughter came to the facility and told the staff to leave Resident #1 be as he slept. Staff C described Resident #1 as very noncompliant with his care. She stated she worked 6 AM to 6 PM that day. Staff C reported she went in Resident #1's room approximately every 2 hours to check on him. Staff C stated she asked Resident #1 if she could change him and he told her no, he wanted to be left alone. She stated it was uncommon for him to be in bed and not get up. She stated he didn't eat either. She stated Resident #1's daughter instructed her to let him sleep. Staff C reported she received a write up for not completing incontinence care. She stated she wrote a statement on the write up that the daughter wanted him to be left alone. A facility form titled Employee Counseling form dated 9/21/24 for Staff B, Staff C, and Staff D listed the problem as providing and assisting Resident #1 with incontinence cares approximately every 2 hours or as needed. The form described Resident #1 as laying in urine-soaked bedding from head to toe at 6 PM. The counseling forms documented the following employee statements: a. Staff B documented she received report at 2 PM that Resident #1's daughter stated he was comfortable sleeping, leave him because he had an eventful night before. b. Staff C documented Resident #1's daughter told them not to mess with Resident #1. c. Staff D documented multiple people, multiple times tried to get Resident #1 changed, but he refused. Resident #1's daughter came and she told them to leave him and let him sleep. Staff D documented the daughter commented she couldn't get him to wake up or do anything. A facility form titled Employee Counseling form dated 9/21/24 for Staff A, CMA, listed the problem as a failure to report to the charge nurse due to lack of care for Resident #1. The form indicted they found Resident #1 lying in a urine-soaked bedding from head to toe at 6 PM. Staff A documented on the counseling form that Resident #1's daughter said to leave him around noon when they tried to re approach him to check and change him, so they left him be. On 11/26/24 at 11:42 AM, the Administrator reported the facility didn't have a policy related to urinary incontinence and the facility followed the standard of care. On 11/26/24 at 11:45 AM, the DON reported she expected the staff to check for incontinence after each meal, at HS, and on rounds during the night, approximately every 2 hrs. The DON reported Resident #1's daughter dictated his care and would help develop interventions. She stated if a resident refused to get out of bed or have cares completed, she expected the staff to check on the resident, reproach, and offer care again. An Appropriate Use of an Indwelling Catheter Policy, revised on 12/10/05, directed to not use an indwelling catheter unless there is valid medical justification. It will be discontinued as soon as clinically warranted and services will be provided to restore or improve normal bladder function after the removal of the catheter. A resident will receive appropriate care and services to prevent urinary tract infections while utilizing an indwelling catheter. The assessment for indwelling catheter use should include consideration of the risks and benefits (supra pubic or urethral); the potential for removal of the catheter; and consideration of complications resulting from the use of an indwelling catheter, such as, but not limited to: a. Symptoms of blockage of the catheter with associated bypassing of urine. b. Expulsion of the catheter. c. Pain d. Discomfort and bleeding. A Care Plan will be implemented to detail the treatment regime with the following information: a. Measurable objectives with time frames to be able to assess whether the objectives have been met. b. Interventions specific enough to outline treatment required including approaches to minimize risk of infection. Interventions may include, but not be limited to the following: i. Type of drainage device. ii. Tubing and bag care. iii. Catheter care. iv. Time frames for changing the catheter, tubing and bag. v. Type of anchoring device to prevent excessive tension on the catheter during transfers and care delivery. vi. Assessing and managing catheter related pain. An indwelling catheter for which continuing use is not medically justified will be discontinued as soon as clinically warranted.

Based on observation, interview and record review the facility failed to implement treatment orders for pressure sores for 2 of 3 residents reviewed (Residents #307 and #39). In addition, the facility failed to identify a new skin injury for 1 of 3 residents (Resident #307). Resident #307 admitted to the facility on [DATE] with 2 skin injuries but the facility failed to get him treatment orders until 10/30/23. On 11/1/23 staff found Resident #307 with 2 additional areas of concern. Resident #39 had a chronic ulcer on his sacrum and saw a wound specialist on 10/25/23. The recommended treatment changes did not get implemented until 10/30/23. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. 1. The Baseline Care Plan (BCP) dated 10/26/23, identified that Resident #307 required assistance from 2 persons with bed mobility, transfers and toilet use. He had a coccyx wound that measured 1.2 centimeters (cm) length x 1 cm width x 0.1 cm depth. In addition, he had a sore on his penis that measured 1 cm x 1 cm x 0.1 cm. The BCP described Resident #307 as very weak and admitted to the facility with hospice services. The Medical Diagnosis Sheet reviewed on 11/1/23 at 10:02 AM listed diagnoses of pneumonia and congestive heart failure. The Care Plan with a Target Date of 1/24/24 included the following Focuses: a. Resident #307 had a terminal prognosis related to heart failure. The Intervention directed the following: 1. Work with nursing staff to provide maximum comfort and wishes with him and/or his family. In addition, assure all staff knew of his requests. b. Resident #307 need assistance with his activities of daily living (ADL) related to sarcopenia (accelerated loss of muscle mass and function), his terminal status, and progressing overall weakness. The Interventions directed the following: 1. Resident #307 required total assistance with incontinence care. Please check and change him approximately every two hours. 2. and staff were to provide maximum comfort and to check and change him every 2 hours. 3. He required extensive assistance from 2 staff to turn and reposition. 4. Check his skin for redness and open areas. On 10/30/23 at 2:49 PM observed Resident #307 grimaced in pain as laid in bed on his back with a couple of his family members visiting. He said that the staff didn't come in very often to reposition him and he had difficulty moving around on his own. He said that he had a sore on his bottom that caused him some pain. Resident #307's October 2023 Medication and Treatment Administration Record (MAR/TAR) lacked orders to treat his wounds. On 10/31/23 at 12:57 PM the Hospice nurse said that they planned to have a wound specialist evaluate Resident #307. She did not know that he did not have any wound treatment orders. She expected the facility to call hospice for any orders that they needed. The on-going observation of Resident #307 on 10/31/23 revealed the following: a. 12:35 PM on his back in bed. b. 1:32 PM same position sleeping. c. 2:47 PM same position sleeping. d. 3:33 PM same position on his back. e. 4:12 PM same position on his back. On 11/1/23 at 7:50 AM, observed Staff L, Certified Medication Aide (CMA), and Staff O, Certified Nurse Aide (CNA), as they provided morning cares and cleaning for Resident #307. Staff L noted that he had two open areas on his coccyx where he initially only had one. Resident #307 had a red irritated spot on his right upper thigh where he had a sticker there to secure the urinary catheter. Staff O said that he had the sticker on his thigh since admission. The Skin Condition note dated 11/1/23 at 3:44 PM reflected a new abrasion to Resident #307's right inner thigh that measured 5 cm x 5 cm caused by the urinary catheter securement sticker. The document noted a reddened coccyx area but did not include measurements. On 11/2/23 at 10:52 AM the Director of Nursing (DON) said that Hospice should have provided orders for the treatments upon admission. She agreed that the spot on the thigh caused by the catheter sticker should have been found sooner. 2. Resident #39's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderately impaired cognition. Resident #39 required limited assistance from one person for bed mobility, transfers, dressing. The MDS included diagnoses of sepsis, muscle weakness, open wound of unspecified buttock, limitation due to disability, a stage 2 pressure ulcer of sacral region (base of the spine), and diabetes mellitus. On 10/31/23 at 8:14 AM, observed Resident #39 lying in bed with the wheelchair at the foot of the bed. He said that he had a sore on his bottom that was supposed to get changed daily but that did not happen every day. The Baseline Care Plan dated 9/15/23 at 1:36 PM, indicated that Resident #39 had an ulcer labeled as a stage III on his sacrum that measured 5 centimeters (cm) length x 5.5 cm width x 0.2 depth. The additional information detailed that he had a septic decubitus ulcer (bed sore) to his sacrum that he had for his last 3 hospitalization s. He had an above knee right amputation and could get himself into a wheelchair with good upper body strength. The Skin Condition Note dated 10/5/23 at 3:51 PM indicated Resident #39 had an area to his sacrum that measured 7 cm x 3 cm x 0.2 cm with a scant amount of serosanguineous drainage noted to bandage. The wound appeared beefy red. The wound looked as the size increased some, with some granulation, and some pain noted to area. He denied any complaints or needs at that time. Resident #39's October 2023 Medication and Treatment Administration Record (MAR/TAR) included an order dated 10/24/23 to apply Bactroban (an antibiotic ointment to treat skin infections) and cover with an Allevyn sacrum dressing daily. The Wound Care * Skin Integrity * Evaluation dated 10/25/23 reflected a change in treatment orders. The Treatment Intervention directed to clean the wound with normal saline. Then apply a collagen pad to the wound bed to promote autolytic debridement (slow, painless, removal of dead tissue through a moist environment that causes the body's natural enzymes to liquify). Cover with silicone bordered super absorbent dressing. Change dressing daily and as needed. On 10/31/23 at 2:56 PM the Wound Nurse Specialist said that she first saw Resident #307 on 10/26/23 and made some recommendations for treatment changes at that time. According to the electronic charting, the order did not get entered until 10/30/23 at 10:24 AM. On 11/1/23 at 9:15 AM, the Pharmacy Technician said that they received the new treatment order at the pharmacy on 10/30/23 at 10:50 AM. They delivered the supplies at 9:00 PM on 10/30/23. The Pressure Ulcer Risk Assessment and Documentation policy updated January 2011 instructed that to prevent pressure sores, interventions include to assist with repositioning immobile residents at a minimum of approximately every 2 hours. Observe for proper placement of tubing to reduce pressure risk and obtain treatment orders from the physician.

Based on observation, interview, and record review the facility failed to keep residents safe from accidents and hazards for 4 of 4 residents reviewed (Resident #7, #28, #1, and #11). Staff failed to use a gait belt or ensure proper footwear use when transferring Resident #7. Resident #7 fell on her way to the bathroom and sustained a major injury. After Resident #28 fell , the staff failed to complete neurological assessments. During an observation of a transfer of Resident #1, staff failed to use a gait belt. After Resident #11 sustained a foot injury while off campus, the facility failed to complete an incident report. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status score (BIMS) of 12, indicating moderately impaired cognition. She required extensive assistance from 1 person for bed mobility, transfers, walking, dressing and toilet use. She used a walker and wheelchair for mobility. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. She required extensive assistance from 2 persons for bed mobility, transfers, dressing, and toilet use. The Care Plan with a target date of 11/28/23 included the following Focuses a. Resident #7 had a risk for falls related to deconditioning and bilateral lower extremity weakness. The Interventions directed the following: - Please ensure that Resident #7 wore appropriate footwear when she walked, transferred, or moved in her wheelchair. b. Resident #7 required assistance with her activities of daily living (ADLs) related to weakness, fatigue, and a fracture. - 2/17/23: She needed limited assistance from 1 staff with toilet needs, revised 9/17/23. - 9/17/23: She needed extensive assistance from 2 staff with toilet needs. The Incident Report provided by an anonymous source dated 8/31/23 at 4:35 PM lacked an incident description, an immediate action, and indicated that Resident #7 did not go to the hospital. Resident #7 had a pain level of 10 out of 10 on the pain scale, indicating severe pain with a mental status of oriented to person, place, time, and situation. The report indicate that Resident #7 did not have injuries observed following the incident. The Predisposing Factors reflected the following: a. Environmental: Other (Describe) b. Physiological: Gait imbalance c. Situational: Ambulating with assistance and using a wheeled walker. d. Other info listed oxygen tubing. The facility's report labeled Investigation, Summary and Findings, dated 9/1/23 showed that Resident #7 had a BIMS score of 12, indicating she is alert and oriented. On August 31 at approximately 4:35 PM, Staff I, Certified Nurse Aide (CNA), walked with Resident #7 to the bathroom. Resident #7 fell , landing on her right knee. She complained of severe pain to her right knee. Staff Q, Registered Nurse (RN), called for an emergency transfer to the hospital. While at the hospital, they found that Resident #7 had a distal femoral periprosthetic fracture (broken bone that occurs around an implants following a bone replacement) to her right leg. Staff Q reported that she just finished completing a treatment for Resident #7 and putting the supplies away. At that time, Resident #7 stood up and started walking to the bathroom. When she saw this, Staff Q called for Staff I to help Resident #7 to the bathroom due to her being nearby at the time. Staff I reported that she did not have time to apply a gait belt to Resident #7 because she already started walking hurriedly towards the bathroom. Staff I said that as Resident #7 reached for the bathroom light, her legs gave out and she fell on her knee. Staff Q reported that she could not complete range of motion (ROM) due to the amount of pain Resident #7 had. The reported reflected that Resident #7 could use the toilet and transfer independently in her room with her walker but, required limited assistance from one staff member to assist with her toilet needs. The Care Plan included the intervention for Resident #7 to wear appropriate footwear. At the time of her fall, Resident #7 did wear appropriate footwear. The handwritten statement received by the facility on 9/7/23 from Staff I indicated that she used the gait belt when transferring or assisting a resident with ambulating. For the incident with Resident #7, she did not have the opportunity to put a gait belt on her, due to her already standing and walking to the bathroom. Instead, she continued to help Resident #7 balance by holding her arm while she walked without difficulty. Staff I added that she felt the gait belt would not have prevented the fall from happening. On 10/30/23 at 12:30 PM, observed staff prepare to transfer Resident #7 from her bed to the bathroom with the use of a sit to stand lift. Resident #7 said that she remembered some things about the fall and thought that she may have tripped on the transition going to the bathroom. Resident #7's family member stated that a few days before that fall, Resident #7 got lowered to the ground. They alerted the staff that her legs did not appear as strong as before and that she needed extensive assistance. On 10/30/23 at 4:18 PM, Staff I said that on the afternoon when Resident #7 fell , she did not put on her call light for help. Staff I walked down the hall and noted the nurse just left Resident #7's room, the nurse stepped out and told Staff I that Resident #7 needed to use the restroom. When Staff I entered the room, she saw Resident #7 standing with her walker, heading towards the bathroom. She said she didn't have time to put on the gait belt. I saw her already standing up. I couldn't catch her. She reported that Resident #7 already started to fall when she entered the room. She maintained that Resident #7 wore shoes and stockings. Staff I said that she ran to catch Resident #7 but did not have time to put a gait belt on. Staff I reported it as unusual for Resident #7 to get up on her own, she usually waited. Resident #7 never refused to wear a gait belt. Staff I said that when the paramedics arrived, they used the full-body mechanical lift to get her off the floor. She said that Resident #7 wore her oxygen while ambulating and it dragged behind her during the fall, Staff I did not think that she tripped on the tubing. The Emergency Services Report dated 8/31/23 at 4:53 PM indicated that the Emergency Medical Services (EMS) arrived to find Resident #7 leaning on a pillow on her right side. The staff reported that Resident #7 walked with only socks to the bathroom when she slipped and landed on her right knee. Resident #7 appeared stuck between the door and the toilet in a very small restroom. They applied a gait belt to Resident #7 and a blanket beneath her arms to assist her to stand on her good leg. Resident #7 rated her pain at a 10 with movement but denied pain with movement. On 10/31/23 at 10:45 AM Staff Q said that around supper time she began providing wound treatment for Resident #7. Resident #7 stood by her bed as she did the wound treatment on her coccyx. Resident #7 told her then that she needed to use the restroom. Staff Q said that she still had a lot of the treatment left to complete. Resident #7 sat down on the bed as Staff Q stepped out in the hallway and asked Staff I to take her to the bathroom. Staff Q saw Resident #7 start to stand with her walker, then left the room when Staff I started to walk her toward the bathroom. Staff I did not put on a gait belt. Staff Q got a little way down the hallway when she heard a thump. She did not know for sure what Resident #7 had on her feet, she thought it was either non-skids stockings, shoes, or slippers. When the paramedics came in they put on a gait belt, assisted her to stand on her good leg and pivoted her to the cot. On 11/2/23 at 10:52 AM when asked if the oxygen tubing could have caused the fall, the Administrator reported that Resident #7 reported 4 different things that may have caused the fall, indicating that she had confusion. He said that he did not think they could have done anything differently to prevent the fall. On 11/6/23 at 9:38 AM the Paramedic that picked up Resident #7 on 8/31/23 said that she remembered Resident #7 wore socks, not gripper socks, and no shoes. She remembered this because when getting Resident #7 off the floor, she put her foot up against her foot to help support her and noticed the socks. They put a gait belt on her and wrapped her with a blanket to use as a gait belt as well. She said that they had her put weight on her left leg and pivoted her to the cot. She reported the bathroom as a very tight and small making it difficult to maneuver her off the floor. The Transfer/Gait Belts/Ambulation and Use of Safety Straps/Belts policy reviewed November 2008 directed the staff to use gait belts on residents who required assistance with transfers and /or ambulation when not using a mechanical lifting devices. 48003 2. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment described her as independent with set up assistance with locomotion on and off the unit. The MDS indicated the she used a wheelchair. The Care Plan with a Target Date of 12/5/23 indicated that Resident #11 used a motorized wheelchair. The Interventions directed the following: a. Resident #11 understood that she must maintain the appropriate skill in the manipulation of an electric wheelchair to have the freedom of its use for independent locomotion. b. Resident #11 could go outside in the community with her electric wheelchair. The Incident Report Note dated 8/25/23 at 11:30 AM reflected that staff noted a burn to Resident #11's left mid back. Resident #11 reported that it happened over the weekend when she had too hot of a hot pack put on her back. The area measured 2.8 centimeters (cm) by 4 cm with part of the area open and not fluid filled. Resident #11 did complain of some discomfort to the burned area. The note listed preventative measures as educating the staff on heat packs and safety. Resident #11's clinical records lacked an order for a heat pad at the time of the incident. During an interview on 11/2/23 at 11:50 AM, Staff D, Licensed Practical Nurse (LPN) reported that Resident #11 no longer had a hot pack order. She verbalized they removed the order after the incident on 8/25/23. During an interview on 11/2/23 at 12:00 PM, Staff L, Certified Medication Aide (CMA), reported that the staff would heat the rice hot pack in the microwave in the therapy room. She explained that Resident #11 told the staff how long she wanted it heated. During an interview on 11/2/23 at 12:34 PM, Resident #11 reported that the nurse on the evening shift of 8/24/23 recommended a heat pad due to her being constipated. The staff heated the pad up and applied it to her back when she laid in the bed. Resident #11 reported that she felt burning on her back but could not remove the heat pad herself so she put on her call light. Due to it being supper time, the staff assisted residents to and from the dining room, so it took a long time for them to answer her call light. She reported that after the incident the staff never used a heat pad again for her. During an interview on 11/2/23 at 12:40 PM, the Director of Nursing (DON) reported she expected the staff to offer other options for pain relief and to not use a heat pad if they do not have an order for one. She reported that she remembered them talking about the incident at the safety meeting but they did not do a root cause analysis. She did not know which staff applied the heat pad because the facility did not investigate the incident further. She reported the facility put an intervention to no longer use a heat pad for residents. During an interview on 11/2/23 at 1:15 PM, Staff M, Certified Nurse Aide (CAN) reported that staff received education to heat the heat packs only in the microwave in the therapy room and wrap it in a towel, but they are no longer able to use heat pads. During an interview on 11/2/23 at 1:25 PM, Staff N, CMA, reported the staff received education to heat the heat pads only in the microwave in the therapy room and wrap it in a towel, but they are no longer able to use heat pads. An email communication provided from the facility on 11/2/23 at 4:00 PM documented on 9/18/23 to change to no hot pads in the facility and to get orders to discontinue the current orders for any residents who have an order for hot packs. 3. Resident #28's MDS assessment dated [DATE] identified a BIMS score of 3, indicating severely impaired cognition. Resident #11 required moderate assistance with transfers and supervision with ambulation. The MDS included diagnoses of dementia, type 2 diabetes, hypertension (high blood pressure), and malignant melanoma (a type of skin cancer). The Care Plan with a target date of 11/29/23 listed that Resident #28 had a risk for falls related to gait and balance problems. The included interventions indicated the following: a. Be sure that his call light is within reach and encourage him to use it for assistance as needed. b. Grip strips to be put in front of recliner. c. Ensure that he wore appropriate footwear when ambulating, transferring or mobilizing in his wheelchair. d. Leave Resident #28's door open at night. The Incident Report Note dated 10/12/23 at 9:15 PM reflected that staff found Resident #28 lying on the floor on his left side. He appeared alert, denied pain, and immediately requested to get up. He denied hitting his head when assessed. The completed assessment revealed vital signs within normal limits. The Incident Report Note dated 10/15/23 at 12:00 AM indicated that someone called the nurse to Resident #28's room. The nurse visualized Resident #28 lying on the floor in the bathroom doorway in front of his sink, positioned on his left side/buttock with walker in reach. Resident #28 reported that he lost his balance coming out of the bathroom. He had his shoes on and his floor appeared clean, dry, and without clutter. The Incident Report Note dated 10/21/23 at 5:27 AM labeled Late Entry reflected the staff found Resident #28 on the floor with his back against the wall. The CNA reported that she heard a thud that came from room C37 while at the desk. Resident #28 could not say what he did before his fall. He laid on the floor in front of his recliner, lying on his right arm, stomach, with his head, and feet toward his TV. He reported that he hit his head. The nurse completed the assessment with neurological checks (neuros) revealing a blood pressure of 170/79. His right outer leg had a skin tear and his head had some scrapes. The Incident Report Note dated 10/29/23 at 12:15 PM reflected that the CNA called the nurse to Resident #28's room. Upon arrival, the nurse observed Resident #28 on the floor, near his window, lying on his left side with his left arm behind his back. He could not say what he tried to do when he fell . The note described Resident #28 as having a decline in his cognition, had increased restlessness, confusion, agitation, and aggression in the previous few days. Resident #28 used as needed Ativan (antianxiety medication). The assessment revealed abrasions to his left forehead, the left side of his head, and a skin tear to his left cheek. During an interview on 10/30/23 at 1:00 PM, the DON reported that the facility does not do root cause analyses. The facility reviews the incident reports and discusses interventions to put into place at Quality Assurance (QA) and safety meetings. During an interview on 10/31/23 at 1:20 PM, the Administrator reported that any information collected for QA and safety is privileged information protected by law and he could not give that information out. 47261 4. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition. The MDS indicated that Resident #1 required extensive assistance of one person for bed mobility, transfers, ambulation, dressing, and personal hygiene, and extensive assistance of two persons for toilet use. The MDS included diagnoses of non-traumatic brain dysfunction, diabetes, Alzheimer's disease, moderate intellectual disabilities, and Down syndrome. Resident #1's Care Plan revealed that resident is to transfer with one assist using a gait belt and four wheeled walker. On 10/30/23 at 2:00 PM, observed Resident #1 sitting in a chair at the nurses' station. Staff G, CNA, and Staff J, CNA, approached him, then assisted him to stand by putting their arms under his armpits and pulled up on the belt loops of his pants. No observation of the CNAs using a gait belt with Resident #1 for his transfer. On 11/1/23 at 1:30 PM, Staff J stated that she knew she should have used a gait belt to assist Resident #1 to stand. On 11/2/23 at 2:25 PM, the DON said that she expected the CNA's to use a gait belt to transfer the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure safety interventions were followed during a transfer of 1 out of 3 residents reviewed (Resident #2). Resident #2 was transferred by 1 staff instead of 2 using an EZ Stand (lift for transfers) which resulted in the resident sliding down from the stand. Follow up after this incident was not sufficient from the covering nurse to ensure resident was assessed, to prevent future falls, and to report the incident to the oncoming shift so they would have knowledge about this incident. Resident was diagnosed the following day with a fractured leg. This resident was transferred with 1 staff and the EZ stand again at least three times after this incident and prior to being sent out to the hospital the following day with the fracture. The facility reported a census of 52. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that Resident #2's diagnoses included congestive heart failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). This resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated her cognition was intact. This resident required extensive assist of 2 for transfers. A Care Plan with a focus area revised on 4/11/16, documented that Resident #2 needed assistance with her ADL's (activities of daily living) related to limited ROM (range of motion). An intervention created on 4/11/22 directed staff that Resident #2 needed extensive assistance of 2 staff and EZ stand for all transfers. It documented that on 2/14/23 the transfer was revised to direct staff that Resident #2 needed extensive assistance of 2 staff and a Hoyer lift for all transfers. An Incident Report dated 2/12/23 at 6:42 a.m., and documented as a late entry for 2/11/23 at 4:10 a.m., documented the following: -Describe Situation: Staff A, Certified Nurse Aide, (CNA) summoned Staff B, Registered Nurse (RN) to Resident #2's room where Staff A was transferring Resident #2 via the EZ-Stand from the bed to the wheelchair. As Staff A was performing the transfer Staff A noted that the resident was starting to slide out of the sling and lower towards the floor. Staff B arrived and Resident #2 was still standing up right with the EZ stand but knees were bending and the resident was chicken winging her bilateral arms slowly out of the EZ stand. Staff B was able to slide behind this resident before her bilateral buttocks came to a rest on the floor, slowly as Staff A lowered Resident #2 to that position for safety. Staff B remained behind resident with Staff B's leg pressed up firmly against this resident's back serving as a backrest to a chair for the resident as Staff A retrieved the hoyer lift (a lift that does not require standing) to be used to assist Resident #2 from sitting position on the floor into her wheelchair. -The Assessment of Resident Including ROM and pain: documented that Resident #2 complained of discomfort to bilateral lower extremities as she was resting on the floor in a sitting position due to Resident #2 sitting with her left lower extremity bent to the left as she was positioned on the floor during the landing and there was a very limited amount of space to do transfer and it was too cramped of an area to unbend her knee as she was lowered to the floor. -Describe Any Injury Noted: none visible, Resident #2 only complained of pain to bent knee but after Resident #2 was assisted to wheelchair via Hoyer and assist of 3 staff and was able to straighten leg out better, pain significantly subsided. -List Any Treatment Provided: none -List Relevant Interventions That Were in Place At The Time of Incident: (left blank) -Preliminary Recommendations, If any, for consideration as further preventative measures: Assist with 2 staff with Hoyer ONLY! For resident and staff safety. Physician was notified This Incident Report was signed by Staff B. A 24 hour follow up to incident report dated 2/12/23 at 4:38 a.m., documented the following: -Describe the Incident Being Followed Up on:: staff assist fall lowered to floor via EZ stand. -Document New Interventions Placed following the incident: Resident #2 to be assist X 2 with hoyer at all times for transfers. -Document Any Further Notifications Regarding Incident: (no entry) -Document any New Injuries discovered after the initial assessment that are a Result of Incident:: None visible or reported by resident. A Communication with Physician, progress note, dated 2/12/23 at 1:18 p.m., documented that this nurse (Staff E, Licensed Practical Nurse (LPN)) was notified that Resident #2 fell out of the EZ stand yesterday a.m. Staff E was called STAT (immediately) to this resident's room this a.m. at 5:30 to help get resident back in her wheelchair. Assist X 4 was needed with the EZ stand to get resident scooted back in her wheelchair. This nurse informed staff to only transfer this resident with a hoyer. This resident informed of this and explained why. Resident #2 then complained of left knee pain and rated it at an 8 out of 10 (with 10 being the worst pain) and described it as an aching pain with movement. Resident #2 denied pain with movement. This resident denied pain at rest. Scheduled and PRN (as needed) acetaminophen given with little relief. A bruise and crease mark noted to lower left knee measuring 5 cm X 4.5 cm. The bruise was brown in color. The provider was notified and a new order to get a STAT X-ray of the left knee was obtained. Message was left for the daughter and skin sheet was updated. This Resident was aware of the orders. A Transfer to Hospital Summary, progress note, dated 2/12/23 at 5:03 p.m., documented the following: Reason for transfer: Recent fall, suspected femur (thigh bone) fracture post X-ray. A Diagnostic Test progress note documented as a late entry on 2/12/23 at 9:30 p.m., documented that X-ray results were received. Left knee findings included a comminuted oblique fracture of the distal left femoral metaphysis. (a fracture of the thigh bone close to the knee) The distal fracture component is displaced and angulated posteriorly and medially (the fracture is angled off the bone). Moderate to severe tricompartmental degenerative diagnosis (knee arthritis). Diffuse osteopenia (decrease in bone density). A hospital Final Report dictated or performed on 2/15/23, documented that Resident #2's injury was an acute, comminuted displaced distal left femoral metadiaphyseal (growth plate at the end of a long bone fracture) fracture. It documented that procedure done was an ORIF (Open Reduction Internal Fixation) of left femur on 2/13/23. A Therapy Screen done on 2/14/23 documented that Resident #2 was now non-weight bearing on Left lower extremity and unable to use EZ stand. It documented that Resident #2 would now require a hoyer lift to complete safe transfers. On 4/12/23 at 11:14 a.m., Resident #2 was up in her wheelchair with a Hoyer sling underneath her. She stated she did not remember if there were 1 or 2 staff that normally transferred her with a stand lift (EZ Stand). She stated the night that she fell , there were 2 staff there. Resident #2 stated she really didn't know why she fell . Resident #2 stated that they use the swing lift (Hoyer) on her now. She stated she had to go to the hospital after her fall. On 4/12/23 at 12:56 p.m., Resident stated she wanted to go back to bed to get cleaned up. Staff C, CNA called the Director of Nursing (DON) to come to room. The DON entered room and stood by the window to watch. Resident #2 stated I'm scared of this thing (referring to the Hoyer lift). The DON responded to Resident #2 to just hug yourself. Resident #2 stated don't let me fall and I've fallen too many times now. Staff C and the Certified Occupational Therapy Aide (COTA) lifted resident up with the Hoyer lift from her wheelchair and turned the resident toward the bed. Resident stated I don't like this. They had to turn the resident around in the Hoyer (so that her feet would be at the end of the bed and her head at the top of the bed), then lowered her onto her bariatric bed. On 4/13/23 at 11:22 a.m., Staff A stated she was working night shift and this resident was to get up early before the day shift arrived. Staff A stated this resident was care planned to wake up early as that is what this resident wanted. Staff A stated that Resident #2 usually gets up by using the EZ Stand. They then would transfer her to a commode in the room as the EZ Stand they used to transfer this resident was a large one and would not fit into the bathroom. Staff A stated she had gotten Resident #2 up to the commode the morning of her fall and then she was transferring Resident #2 from the commode to the chair. Staff A stated that when she was turning the EZ Stand with Resident #2 in it from the commode to the chair, Resident #2 started saying put me down, put me down. Staff A stated Resident #2 was not above the chair when she was saying this. Staff A stated she called the nurse for help on the walkie. The nurse came before completely putting this resident down. Staff A stated that Resident #2 was close to the chair but not close enough for her to sit. Staff A stated that Staff B came right away as Staff A was not very far away. Staff A stated that Staff B was trying to hold her. Staff A stated she said she could let the lift down and that Staff B was not able to hold her. Staff A then let the lift down slowly. Staff A stated Resident #2 was sitting on the floor on top of Staff B's leg. Staff A stated she then grabbed the hoyer lift and then lifted Resident #2 to the bed. Staff A stated that Resident #2 didn't complain of pain. Staff A stated they then transferred Resident #2 from the bed to the wheelchair using the hoyer lift. She stated Resident #2 did not like the hoyer lift. Staff A did not remember Resident #2 complaining of pain. Staff A stated that she and Staff B asked Resident #2 if she had pain and Resident #2 said no, she didn't have any pain. When asked why she lifted this resident by herself using the EZ Stand, Staff A stated the care plan said 1-2 for EZ Stand. When the care plan was read to Staff A, Staff A stated she thought the care plan stated 1 person. Staff A stated she was trained to transfer by herself using an EZ Stand in school and at the facility. Staff A stated she did not remember who trained her at the facility. Staff A stated the Care Plan that was read to her directed to use 2 people with the EZ stand transfer for Resident #2. Staff A stated she looks at the care plan in the computer and that staff have tablets and Kardex in the computer that they can find anything they need to know about a resident. Staff A stated she did not know that Resident #2 was a 2 person lift, and stated she had been transferring Resident #2 by herself without a second person. On 4/13/23 at 11:50 a.m., the Administrator and the Nurse Consultant were asked about care plan directing staff to use extensive assist of 2 with EZ stand for transfers. The Administrator stated he did not know if he followed up with sister regarding need for a 2nd person for the transfer. The Administrator stated he would look at his notes to see if the conversation happened. The Nurse Consultant looked up the Care Plan and concurred that at the time of the fall the Care Plan directed staff to use an extensive assist of 2 with the EZ Stand for Resident #2's transfers. When the Administrator and Nurse Consultant were told that there was a concern with this, they both nodded in understanding. When told a concern would be submitted to the office, they nodded in understanding. On 4/13/23 at 2:30 p.m., the Administrator stated that he does not know all of the resident's Care Plans and depends on the DON to provide that information. On 4/13/23 at 3:29 p.m., the DON stated she did not know that Staff A had transferred Resident #2 by herself. The DON stated that when she came in on Monday (2/13/23), she was told that Resident #2 had slipped out of the EZ stand and staff had just sat her down. The DON stated she had talked to Staff A about it and the Administrator also talked to Staff A about it. The DON stated that Staff A did not tell the DON that Staff A had transferred Resident #2 by herself. She stated then Staff A talked with the Administrator. The DON stated her expectations were for the CNAs to follow what the Care Plan says and to know how to access the POC (Point Of Care(care plan interventions on Kardex/where CNAs document when they complete interventions)). The DON stated she had not talked with Staff A after her initial conversation with Staff A following the incident. On 4/13/23 at 6:30 p.m., Staff B, RN, stated she was walking down the hall Resident #2 lives on at the time of the incident, so she was right outside of the room. Staff B noticed that Resident #2 was probably about 1/2 way to the floor sliding out of the EZ Stand. Staff B went to the side of Resident #2 and helped ease her the rest of the way down to the floor. Staff B stated that Resident #2's back was against Staff B's leg and Resident #2 was kind of propped up against Staff B. Staff B stated that Staff A then went and got the Hoyer lift. Staff B believed the Hoyer lift was out in the hall. Staff B stated another CNA came into the room to help with the transfer off of the floor but was not sure which CNA helped. The other CNA helped maneuver Resident #2 and transferred this resident with the Hoyer to her to the wheelchair. Staff B stated she did not remember if they lifted Resident #2 to the bed first or to her wheelchair. Staff B stated they may have put her in the bed, but she honestly could not remember. Staff B stated she then did an assessment. Staff B stated this resident's vital signs were within normal limits. Staff B stated Resident #2 was not complaining of pain then or the rest of the day, until she complained of pain on the following day. When asked about why her documentation read that Resident #2 had pain while Resident #2 was sitting on the floor, Staff B stated that maybe Resident #2 did say that, but once they got her up, Resident #2 was better. Staff B added, that now that she was thinking about it they were kind of in tight quarters and Resident #2's legs were kind of bent. When asked if Staff B had checked Resident #2's ROM, She stated she did. Staff B stated she moved Resident #2's legs as much as Staff B could move them. Staff B stated that Resident #2 was a larger woman and that Resident #2 did not do a lot of bending. When asked how this resident transferred, Staff B stated she believed Resident #2 was supposed to be assist of 2. Staff B stated she talked with Staff A about the transfer after they got Resident #2 all situated. Staff B stated she asked Staff A wasn't Resident #2 an assist of 2 and Staff A answered she didn't know that. Staff B stated she thought everyone knew that. Staff B stated she thought Resident #2 was care planned (to use an EZ Stand lift with assist of 2 staff). Staff B stated she hadn't witnessed any staff prior to this that were transferring with using just one person. Staff B stated that staff have access to see what assistance level each resident needed, so Staff B stated she would think they would all know. Staff B stated that for safety Resident #2 should have always been a 2 person transfer with the EZ Stand. Staff B stated if she were to transfer Resident #2, Staff B would have always used 2 staff. Staff B stated she thought with Resident #2's size that definitely Resident #2 was more of safety risk for sure. Staff B stated that Resident #2 really didn't stand all that well to begin with. Staff B said she had not helped with transfers for Resident #2 before but had walked in before to do something with Resident #2's roommate and have seen the girls (staff CNAs) taking Resident #1 to the bathroom. Staff B stated the girls have always said that taking her from the bed to the bathroom was difficult to push Resident #2 in the EZ Stand and with her weight and all, they always used 2. Staff B stated she had never seen anyone transferring Resident #2 alone. Staff B stated Resident #2 was not one to complain at all about pain. Staff B stated she felt that Resident #2's weight and all and going down in the EZ Stand probably caused her leg to break. When asked why Staff B thought this, she stated that Resident #2 has had a broken leg in the past. Staff B said that Resident #2's weight going down on that leg was probably what caused the fracture. Staff B stated she was surprised that they did operate on Resident #2's leg because Staff B did not think Resident #2 would have been a surgical candidate. Resident #2 guessed that Resident #2 had low bone density. On 4/17/23 at 1:08 p.m., Staff D, CNA, stated she did not know about Resident #2's fall when she transferred Resident #2. Staff D stated that when she transferred Resident #2, Resident #2 complained of her knee and her leg hurting. Staff D did not know what day this resident was complaining of pain with transfer, if it was the day she went to the hospital or the day before. Staff D stated she told the nurse and the nurse came to look at it. Staff D didn't know which nurse she told. Resident #2's knee was red and was starting to bruise. Staff D stated she transferred Resident #2 once by herself that's when Resident #2 complained and once with someone else on the day the resident complained of pain. Staff D stated she did not know what the care plan directed. Staff D stated she tried to get help whenever she could because Resident #2 was kind of heavy and the transfer could hurt Staff D. Staff D stated she did know how to look up things in the care plan. Staff D reiterated she didn't know that this resident was a 2 person transfer. Staff D stated that when she was trained in January, she was told that Resident #2 was a one person transfer. Staff D did not remember who trained her as she was kind of just thrown in to it. Staff D thought she had maybe a couple of days of training. Staff D stated they have to use the laptop or the computer to get to the care plan. Staff D stated they use the facilities phones to get to the Kardex, and that was what they carry because it has all of their charting on it as well as the call light system. When Staff D was asked to pull up this resident's Kardex on her phone and Staff D did. Staff D pulled up Resident #2's Kardex and stated that it documented I need extensive assist of 2 with a hoyer for all transfers. On 4/17/23 at 1:49 p.m., the DON stated her expectation for follow up after a fall would be to assess immediately after the fall and then again 24 hours after a fall, unless the resident had hit their head, then neuros (neurological assessment) need to be done. When repeated back to DON, that the expectation for nurse assessment and follow up would be that unless the resident hit their head, the nurses did not need to assess a resident again after a fall until 24 hours after the fall, she stated that was true, unless they hit their head, or there was pain, or other extenuating circumstance that would require closer evaluation. On 4/17/23 at 1:57 p.m., Staff E, Licensed Practical Nurse (LPN), stated she did not know that Resident #2 had slipped in the EZ Stand. The nurse (Staff B) had not told Staff E that Resident #2 had fallen the day before. Staff E stated staff were struggling with Resident #2 using the EZ Stand about 5:30 a.m., on 2/12/23. Staff E stated that she had arrived to the facility at 5:00 a.m. that morning. Staff E stated that Staff H, CNA was transferring Resident #2 by herself. Staff E told Staff H that she needed to use 2 staff for Resident #2's transfers. Staff E stated she did not know why people don't know that Resident #2 was an assist of 2 with all transfers. Staff E stated that staff can look up Resident #2's transfer needs in her care plan as well. Staff E stated that Staff H responded that she didn't know that Resident #2 required assist of 2 for transfers. Staff E stated she was very upset that Staff B had not told her that this incident had happened the day before. Staff E stated that Staff B told her she did not think it was a fall. Staff E told her that it was an incident. That any time a resident goes from a higher elevation to a lower elevation and it is not purposeful, it was considered a fall. Staff E stated that Staff B had to do a late entry for the fall after they had this discussion on 2/12/23, after Staff E found out that this resident had a fall in the EZ stand. Staff E stated that Resident #2 was not expressing a lot of signs of pain, which is crazy. Staff E stated because Resident #2 was bruising and if you just moved her a little, you can tell she had signs of pain. Staff E stated Resident #2 was having facial grimacing, but verbally she would say she was fine. Staff E stated that Resident #2 was not really a complainer. Staff E stated that Resident #2 liked to be told everything staff are doing, because she finds things scary. Staff E stated she changed Resident #2 to a hoyer lift and Resident #2 wanted Staff E there in the room for a couple of transfers. Staff E stated that the slip in the EZ stand the day prior was an incident even if you go from one level to another, you have to report it. And chart on it of course. Staff E stated the morning of 2/12/23 they got Resident #2 into her bed. Staff E stated she could tell Resident #2 was in pain. Staff E stated Resident #2 had a bruise on her left knee. Staff E stated they ordered a STAT X-ray too. Staff E stated the X-ray tech said leave her in bed as he saw there was a fracture. Staff E stated they did not know if Resident #2 would be a surgical candidate, but Staff E stated she called the doctor and the doctor wanted Resident #2 sent out. Staff E stated what should have happened was when there's an observed fall the nurse does a 24 hour and then a week follow up assessment. Staff E stated that the fall should be documented in Risk Management and the nurse (Staff B) should have verbally told Staff E (the oncoming shift nurse). Staff E stated that with each fall the nurses are to notify whoever is on call. Staff E doubted that Staff B notified the on call. Staff E stated that Staff B put in an incident report the other day. Staff E stated that Resident #2 was probably transferred 3 or 4 times after her 'fall' that morning and that Staff E wasn't told that Resident #2 was in pain prior to that. 4/18/23 at 11:16 a.m., Staff H, contact attempted, voicemail left and text sent requesting a call back. A Southfield Wellness Community Documentation Survey Report (CNA documentation of work done) for 2/2023 printed on 4/13/23, revealed that the 8 of the 18 transfers for Resident #2 were documented from 2/1/23 to 2/12/23, were documented as 1 person transfers. Staff A's initials were not on this document. Staff D signed that she transferred Resident #2 on 2/11/23 twice by herself at 10:23 a.m. and at 4:38 p.m. Staff D signed that she transferred Resident #2 once on 2/12/23 at 11:58 a.m. with a second person. Staff F, Staff K, and Staff L had all signed that they had transferred the resident by themselves during the time period above (2/1/23 to 2/12/23). Staff L's initials were not on this document the morning of 2/12/23 when Staff L stated she transferred this resident by herself with the EZ stand. 4/18/23 at 11:32 a.m., Staff F, CNA, stated they were told to transfer Resident #2 using a 2 person assist with the EZ stand. Staff F stated she wouldn't feel comfortable transferring her without a second person. Staff F stated she would not have transferred Resident #2 by herself especially because Resident #2 is larger and Staff F would not feel comfortable at all transferring her alone. When asked about signing that she did a limited assist transfer by herself, she stated that she started in November and really doesn't know all of the residents, so she probably got this resident mixed up with another resident. Staff F added that if she charted it was a limited assist of 1 then she was probably charting about doing part of Resident #2's care and charted in the wrong place. On 4/18/23 at 2:00 p.m., Staff K, CNA, stated that Resident #2 had always been a 2 assist EZ Stand transfer. Staff K stated that at first it was a regular EZ Stand and then it was changed to the larger EZ Stand. When asked about her documenting that she transferred Resident #2 by herself, Staff K stated that she had transferred Resident #2 once or twice because no one would come to help her. Staff K stated she would walkie (radio) others for help and go looking for help, but because no one was coming and it was taking so long, Staff K just went ahead and transferred Resident #2. On 4/19/23 at 9:52 a.m., Staff L, CNA, stated that she transferred Resident #2 by herself. Staff L stated she did not know Resident #2 was a 2 person EZ stand transfer. Staff E stated that direction might be in the Kardex or Resident #2's care plan but Staff L was not trained on how to look the information up. Staff E stated nobody had told her that Resident #2 was a 2 person EZ stand. Staff L stated that every place she had worked prior to this facility EZ stand transfers had been done by 1 person. Staff L stated she was never told anything until the incident that Staff L had with the resident. Staff L stated that she talked with other staff and they told Staff L that when COVID 19 hit the facility changed their policy to 1 person EZ stand transfers. Staff L stated that it would have been nice to know that Resident #2 had fallen the day before. Staff E stated she wasn't informed of the fall until after the fact. When asked if she knew why the information wasn't shared, Staff L stated that from her understanding there was a bunch of miscommunication about it, they said she didn't fall, but Resident #2 told Staff L that she had fallen and Resident #2's roommate said the same thing. Staff L stated she had an incident the day after the fall, on the morning of 2/12/23 around 5:00 a.m Staff L stated she transferred Resident #2 by herself and Resident #2 did not fall, but Staff L could not get this resident far enough back in to the wheelchair, so Staff L called for help. Staff L stated when she called for help the EZ stand was still attached to Resident #2. Staff L stated Resident #2 complained of pain during the transfer. Staff L asked Resident #2 what was wrong, and Resident #2 stated it was her leg. Staff L stated later on Resident #2 said that the fall had hurt her the day before. When asked if she was talked to the day she transferred Resident #2 to her wheelchair, Staff L stated the charge nurse didn't tell Staff L that this resident was a 2 person assist with EZ stand. Staff L stated the DON called Staff L after this. Staff L stated she asked the DON if this resident was a 2 person EZ stand transfer and the DON said this resident was a 2 person assist with EZ stand. Staff L stated she then asked the DON what to do if they didn't have enough help and the DON answered that Staff L would need to do the transfer by herself. Staff L stated that when she transferred Resident #2 the morning that she could not get this resident far enough back in her wheelchair seat, the night shift nurse (Staff B) was still there and Staff B and Staff E were going back and forth about why the fall the night before wasn't reported. Staff L stated that it was a big deal. Staff L stated that Staff B said that Resident #2 had not fallen. Staff L stated that this resident said she had fallen and Staff E said that the resident had fallen and they had to use a hoyer to get this resident off of the ground. Staff L stated that this resident told her that her leg did hurt and that her leg was stuck under the bed the day before, Staff L stated that Resident #2 was well aware of what was going on. Staff L stated the staff have had no training regarding EZ stand transfers after these incidents occurred On 4/12/23 at 11:46 a.m., Staff G, CNA stated she has worked at the facility since January. She stated she looks at point of care for residents ADL and transfer needs. She stated it will say how a resident is to be transferred. She stated that an EZ stand can be run by 1 or 2 staff. She stated a hoyer lift always takes 2 staff and sometimes 3. When asked about Resident #2 and if she had transferred her with an EZ stand prior to her fall, Staff G stated she had but she would always use 2 staff as the EZ stand was a wide one and she would not be comfortable with transferring Resident #2 by herself. Staff G stated the lift could get wobbly and possibly tip. Staff G stated that she also would use 3 people when using the Hoyer lift on Resident #2 now, depending on the day. This CNA stated she had not been trained at this facility on how to transfer with the EZ Stand by herself. She stated she had education on this at another facility prior to coming to this facility. On 4/12/23 at 11:50 a.m., Staff H, CNA stated that it was on the computer where we find what a resident's plan of care was. Staff H stated that the nurse would also let the CNA's know if there were any changes. Staff H stated that the EZ stands normally require 2 staff because a lot of the residents do the chicken wing thing with their arms, so they have 2 people even if it would say 1 or 2 people in the care plan. Staff H stated she had not worked with Resident #2 as usually Staff H worked in the front of the building. On 4/12/23 at 12:00 p.m., Staff I, CNA, stated there should always be 2 staff with EZ stands. There may be someone that says 1 or 2 but Staff I preferred 2. Staff I stated that sometimes they may need 3 to transfer using a Hoyer lift. Staff I stated she thought there was 1 resident who was care planned as a 1 assist EZ Stand, she stated even then she always used 2. Staff I stated that she received no official training on a 1 person EZ Stand Transfer and added that Hoyer lifts are always at least 2 assist. A Fall Risk Assessment & Intervention Policy revised on 2/2000, documented that residents will be assessed upon admission, re-admission, and change in condition for potential risk factors associated with falls. Initial interventions specific to the resident will be implemented at the time of the assessment. Procedure: 1. The assigned nurse will complete the Admission / Readmission Fall Risk Assessment and Interventions tool on new admissions, readmissions, and residents experiencing a significant change in condition. a. If the facility prefers, they may use the Falls Risk Assessment from Dextrosity instead of the Admission / Readmission Fall Risk Assessment and Interventions tool. 2. Determine the risk factors placing the resident at risk for falls by highlighting or circling those factors (left side of Admission / Readmission Fall Risk Assessment and Interventions tool). 3. Determine what interventions could be used, specific to the resident, and highlight or circle the appropriate interventions - and /or write additional interventions (right side of Admission / Readmission Fall Risk Assessment and Interventions tool). 4. The nurse completing the falls assessment will be responsible to communicate interventions to appropriate staff. 5. Risk factors and interventions identified on the falls assessment tool should be carried over - and used - to facilitate development of the resident's plan of care. (The tool may be added as a part of the care plan). 6. Elicit ideas to reduce the likelihood of falls from the resident (if capable), family members, therapies, physician, and interdisciplinary staff. 7. Orthostatic blood pressure should be taken, if possible, following a fall to determine whether the fall could be related to dizziness associated with a sudden drop in blood pressure with position changes. a. Refer to the Orthostatic Hypotension policy for guidelines related to protocol for taking orthostatic blood pressures. 8. Should the resident experience a fall, an Incident Report and Quality Assurance Investigation form will be completed. a. Each fall will be assessed to try to determine the cause (may need to reenact the fall by taking a team and actually going to the site where the fall occurred). b. The care plan must be

Based on interviews and record reviews, the facility failed to provide appropriate supervision for a cognitively impaired resident for one of four residents reviewed (Resident #1). On 4/22/20, the resident went on the facility provided van to an appointment in an unfamiliar clinic and town. Despite being informed by the clinic staff that the resident would need to wait awhile to see the Physician, the facility van driver left a business card with the hospital clinic staff and left the area. The facility van driver left the resident unsupervised to park the facility van and have lunch. While having lunch, the driver received a call from the clinic staff reporting the resident got upset and left the waiting area, taking an elevator to unknown regions of the hospital. Upon arriving at the floor, the resident's location was unknown, necessitating a search involving hospital security and other personnel. The length of time the resident was missing is unknown. However, the driver estimated the time to be 15 to 20 minutes. The van driver left the resident at an unfamiliar hospital clinic on the third floor unsupervised, which placed him at severe risk of injury or harm. There were hazards present, including stairwells and exits leading to areas trafficked with vehicles coming and going from the hospital. Either option would result in serious impairment or death. Due to the resident left alone in an unfamiliar area, the resident became upset, refused to be seen, and left the appointment. The resident then missed his appointment for evaluation and removal of 21 staples following a recent major abdominal surgery. Due to the lack of adequate supervision, the facility's actions caused the resident's health and safety to be in Immediate Jeopardy. The facility reported a census of 70 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) completed with an Assessment Reference Date (ARD) 5/15/20 showed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The resident required limited staff assistance of one staff for locomotion on and off the unit in the seven day lookback period. The resident required extensive assistance of two staff with transfers in the seven day lookback period. The resident had [DIAGNOSES REDACTED]. A MDS with observation end date of 4/7/20 also identified the resident with a BIMS of 9. A Clinic/Office Note - Physician dated 6/24/20 indicated the resident had mild cognitive impairment so stated. The Mini Mental State Examination (MMSE) completed at the visit indicated a score of 6/30, indicating severe cognitive impairment. Resident interviews: On 6/22/20 a 1:05 PM the resident reported that his appointment in Des Moines was mediocre. The resident answered yes to seeing the doctor at the appointment. The resident responded yes to having the staples removed at the appointment by the doctor. During a follow-up interview on 6/23/20 at 9:36 AM, the resident did not know the day of the week or the name of the President. When asked if the resident knew the day of the week, the resident responded with their name. Resident's Durable Power of Attorney (DPOA)/representative interview: On 6/18/20 at 11:49 AM, the resident's DPOA/representative reported the facility did not ask her about going with the resident to the appointment or about using an escort. The resident previously went to the Veterans Affairs (VA) Hospital prior to nursing home placement, but the clinic 4/22/20 visit on was the first time to go to this clinic. The resident's representative stated the facility should not leave the resident unattended in the waiting room as the resident has a history of a [MEDICAL CONDITION] (TBI). Care plan review: A care plan problem dated 4/4/18 indicated the resident had a hearing deficit with difficulty communicating because of TBI. The TBI affected the resident's ability and willingness to participate in activities. The intervention revealed the resident would like staff to assist when the resident decides to attend the organized events. A care plan intervention dated 4/22/20 revealed when the resident goes out for a Physician appointment, that a staff should stay with the resident. The resident tends to become frustrated and refuse the appointment due to the resident's TBI. The intervention was updated on 6/23/20 to reflect the sister requested family or an escort to stay with the resident at outside medical appointments on 4/22/20. A care plan problem dated 12/9/16 indicated the resident requires assistance with activities of daily living (ADL's) related to right-sided weakness. An intervention dated 2/4/19 indicated the resident could assist one staff with a gait belt to stand at the sink for toileting tasks and perineal hygiene assistance during the day shift only. An intervention dated 4/4/18 indicated the resident required the moderate assist of 2 staff for transfers with a pivot disc/turner pro. Elopement and Fall Risk Assessments: The Elopement Risk Assessment V0714.1 dated 3/31/20 at 1:55 PM showed the resident disorientated in two spheres and unable to move independently in the wheelchair. The resident did not have a history of wandering. The resident had a [DIAGNOSES REDACTED]. The resident scored a ten which identified the resident at risk to wander. The Fall Risk Assessment V1013.1 dated 3/31/20 at 1:55 PM showed the resident with a score of 9, indicating moderate risk for falls. The Elopement Risk Assessment V0714.1 dated 5/15/20 at 10:44 AM showed the resident forgetful with a short attention span and could move independently in the wheelchair. The resident had no history of wandering. The resident did have a [DIAGNOSES REDACTED]. The resident scored a ten identifying the resident at risk to wander. The Fall Risk Assessment V1013.1 dated 5/15/20 at 10:42 AM showed that the resident with a score of 9, indicating moderate risk for falls. The daily skilled nursing assessment dated [DATE] at 6:46 PM completed by the DON stated that the resident had short term memory impairment. The assessment continued to show the resident orientation was only to only person and place with impaired decision-making ability. The daily skilled nursing assessment dated [DATE] at 7:28 PM completed by the DON stated the resident had short term memory impairment. The assessment continued to show the resident's orientation was to only person and place with impaired decision-making ability. Progress Notes: A progress note dated 4/22/20 at 5:36 PM revealed Staff I, Transportation, alerted the Director of Nursing (DON) that the resident wheeled away from the doctor's office due to the resident stating it took too long to be seen. The resident was found within the same building in a patient room. No injuries observed, family and doctor notified of this behavior. The progress note labeled 24 Hr Follow Up To Incident Report dated 4/23/20 with a creation date of 5/21/20 stated Late Entry revealed the driver alerted the DON that the resident wheeled himself away from the doctors' office due to resident saying it took too long to be seen. The resident was found within the same building in a patient room with no injuries observed. The family and doctor received notification of this behavior. An assessment of the resident was not applicable. New interventions following the incident identified as: driver not to leave the resident during appointments. No further notifications regarding the incident completed. No new injuries discovered due to the incident. The progress note labeled 1 Week Follow Up To Incident dated 4/29/20 at 4:35 AM with a creation date of 5/21/20 stated Late Entry revealed the driver alerted the DON that the resident wheeled himself away from the doctors' office due to the resident saying it took too long to be seen. The resident was found within the same building in a patient's room with no injuries observed. The family and doctor received notification of this behavior. An assessment of the resident was not applicable. New interventions following the incident identified as: was for the driver not to leave the resident during appointments. No further notifications regarding the incident completed. No new injuries discovered due to the incident. The progress note dated 4/22/20 at 4:36 PM labeled Communication - with Physician showed the clinic called to tell the staff that since the resident refused to come to the appointment that the nurse could have an order to remove the staples. The progress note dated 4/22/20 at 5:40 PM labeled Communication - with Family or Related Party indicated completion of the entry was late. The facility notified the resident's Power of Attorney (POA) regarding the resident leaving the doctor's appointment and not seeing the Surgeon. After the conversation, the POA voiced understanding that the resident became impulsive and left his appointment without being seen. The POA reported being thankful for the follow-up phone call. The progress note dated 4/22/20 at 6:19 PM labeled Communication - with Staff with a creation date of 6/22/20 at 9:23 AM by the DON identified going forward the facility did not plan to send the resident to any appointments alone. If the POA could not accompany the resident to doctor's appointments, the facility would make arrangements for the resident to have a staff member with him at all times while out to doctor's appointments. A progress note dated 4/22/20 at 5:42 PM identified the intervention following the incident as informing the van driver not to leave the resident unattended during appointments. Staff interviews: On 6/17/20 at 2:24 PM, Staff F, MDS/Care Plan Registered Nurse, reported the resident went to Des Moines to have staples removed following surgery. The van driver left the resident to park the van and planned to return. When the driver returned, the resident was gone. The resident left his appointment because he didn't want to be there. The resident then wheeled himself into an empty room. Once found, the resident was too late for the appointment, so they returned to the facility. The Administrator said that the incident did not need to be reported as the van driver left the resident with a nurse. When the driver returned to the clinic, the resident left the nurse. On 6/17/20 at 3:45 PM, Staff I said he provided the transportation for the resident to the appointment in Des Moines. When they arrived at the clinic, the staff stated there were a couple of people in front of the resident. Staff I reported telling the clinic staff that he needed to move the facility vehicle, and the clinic staff said it was no problem. Staff I said he parked the resident in between two chairs in the lobby before going down to move the facility van. Staff I stated he received a call from the clinic staff who reported the resident got upset because the resident was third instead of first. The clinic staff said that the resident began to push the wheelchair away from them and then got into the elevator. Staff I stated he went back up to the floor to speak to the clinic staff and Physician. The clinic staff reported the resident went towards the elevators. Staff I said after notifying security, he got back onto the elevator. Staff I stated he went to each floor and check with other staff. Staff I reported going into a conference room after seeing the resident in the doorway. The resident was calm, sorry, and knew he screwed up. The resident did not want Staff I to be mad with him. Once found, the resident repeatedly apologized for leaving the waiting area. Staff I took the resident back to the clinic, and the resident apologized to the clinic staff. The clinic staff said it was too late for the resident's appointment, so he could not be seen. During a follow-up interview on 6/17/20 at 4:02 PM, Staff I, said he stopped at the reception desk before going downstairs to move the van. The lady said there were a couple of appointments ahead of him that they would have him into the appointment and back out before he returned. After learning the resident left the clinic and got onto the elevator, Staff I said he rode up and down the elevators to look for the resident as the resident just went down on the elevator opposite of him. After the elevator, Staff I reported going up and down the stairs checking each floor to make sure the resident wasn't there. Staff I stated the situation happened very fast but no longer than 15 to 20 minutes. Staff I (Van Driver) Undated Statement: An undated statement provided by the facility from Staff I indicated that on 4/22/20 Staff I drove the resident to an appointment in Des Moines. Once they arrived at the office, they went up to the third floor and met with the receptionist, who said they were in the right place. The receptionist told Staff I there were several people in front of the resident so that it would be a small wait. Staff I pushed the resident to the waiting area and told the resident that the doctor would see the resident shortly. Staff I told the receptionist that the van was parked out front and it needed to be moved. The receptionist said that it was fine. Staff I gave the receptionist a business card with Staff I's cellular (cell) phone number on it. Staff I left and went to get food from across the street of the hospital before parking the van in the parking lot. While Staff I ate, the receptionist called to report the resident refused care and became frustrated. Staff I moved the van back to the previous location in front of the hospital before returning to the clinic. Once Staff I got to the third floor, Staff I could not locate the resident. The receptionist reported the resident was mad and left the area towards the elevator, going down the opposite elevator Staff I came up on. Staff I went back to the entrance and spoke to the nurse taking temperatures who reported the resident did not come by her. Staff I then returned to the third floor in the opposite previously used elevator. Staff I went back to the receptionist, who stated the resident did not return to their floor. Staff I asked the receptionist to contact security to assist with finding the resident. Staff I returned to the elevator and went to the second floor before checking all the hallways and checking rooms that the resident could access. Then Staff I went to the first floor, where there were many corridors that the resident may have went down. This portion of the search was time-consuming but had a negative outcome on his location. Staff I moved to the stairwell and went back to the ground floor. While there, the same nurse reported not seeing the resident. Staff I gave the nurse his cell phone number in case the resident did come to that area. There, Staff I, went up the stairwell, checking each floor for the resident's movement. Upon returning to the third floor Staff I found the resident peeking from a door outside of the waiting room. The resident saw Staff I and reported that the resident messed up. The resident apologized for being a bother, and the resident wanted to tell the staff the resident was sorry. Staff I returned with the resident to the clinic area to allow the resident to apologize to the staff. Once the resident apologized, they left the hospital and returned to the facility. On 6/18/20 at 9:09 AM, the Administrator reported the standards were one driver and one resident per transport. The driver was not supposed to stay with the resident; they are to leave the resident with the medical professional. The facility only has two vans and two drivers. On 6/22/20 at 2:50 PM, the DON said the resident always went alone to appointments unless the resident's DPOA went with the resident. The team manager talked to the DPOA and notified the DON if the DPOA could not transport the resident. The transportation supervisor was notified and told no one is to leave Resident #1 alone, so this situation did not happen again. There was no education written. The DON did not know if any documentation was done about this as the DON was working in the Assisted Living at the time. On 6/23/20 at 10:34 AM, Staff L, Certified Nurses' Aide (CNA), said the resident was very cognitive. The resident could set up their television (TV), but anything could set the resident off. Then there are some days the resident is unable to say what is wrong. Some days, the resident would know the day but cannot tell who the President. The resident has a calendar. The resident does not know the staff by name but can recognize their voice and looks. On 6/23/20 at 11:29 AM, Staff K, CNA, reported the resident knows when the resident is in pain and able to report it to the staff. The resident can tell the staff if there is a problem with the [MEDICAL CONDITION] bag. The resident has a nightly routine, and if something is forgotten, the resident inform the staff. Staff K was not sure if the resident would know what to do if the resident were outside of the facility. In the evening, Staff K has to remind the resident two to three times that it is time for supper. If the resident was able to see a calendar, and it was updated, the resident would be able to say the date. The resident can identify the staff but not by their name. The resident has gone onto the patio but just stayed there. On 6/23/20 at 1:16 PM, Staff M, RN, stated the resident was pretty cognitive, but the resident apologized repeatedly. The resident apologizes whenever the [MEDICAL CONDITION] bag is changed as the resident feels its the resident's fault. Staff M said that staying in a familiar environment helped to keep the resident stable. Staff M reported surprise that more residents did not go to appointments with an escort. At a previous job, everyone went with an escort unless they were completely independent. Staff M said that when the resident apologizes, Staff M is unsure if the resident knows the reason for the apology. Staff M reported just seeing a paper from the DON that staff received education on 4/22/20 and something about the transportation staff. Staff M said the DON said this was for education on 4/22/20. Staff M reported that it was the first time to be educated about that situation. On 6/23/20 at 2:03 PM Staff N, Licensed Practical Nurse (LPN), reported that she did not know anything about education regarding the transportation policy. Staff N said the first time hearing about the information was from the surveyor. Staff N reported not working with the resident at all. On 6/23/20 at 2:23 PM, Staff O reported not regularly working with the resident. Staff O said that she remembered hearing about the situation with the resident at the clinic but did not personally remember getting educated about it before 6/23/20. On 6/23/20 at 4:08 PM, Staff A, RN, said that when hired, she received a brief explanation as to what the transportation's job duty was, but was not much on specifics. Staff A said she was familiar with completing BIMS on residents as the facility specifically educated on this for admissions or as needed. Staff A stated not being aware of any specific assessment related to transportation. Staff A said there was no education given because the nurses don't go to appointments, that is the transportation's job. Hospital clinic staff interview: During an interview on 6/23/20 at 2:51 PM, Hospital Clinic Staff #1, Receptionist, reported remembering the resident sitting in a wheelchair. However, the driver was not able to stay. The clinic had a long day that day, so they were slow. The resident kept asking about going back to see the doctor. When the resident couldn't go back to see the provider, the resident became frustrated and then suddenly used his legs to move the wheelchair and left the clinic area. The clinic manager attempted to stop the resident. The staff tried to get into touch with the driver but had problems reaching the driver. After reaching the driver, the driver came back to the floor. In the meantime, the resident disappeared out of the office. The staff started to look for the resident and called security, then the driver. The driver eventually brought the resident back, and the resident kept apologizing, but the resident did not want to stay. Hospital Clinic Staff #1 thought it was 5-10 minutes, ten minutes max that the resident's location was unknown. Hospital Clinic Staff #1 did not remember the driver asking if the resident could stay but did believe there was a receptionist there. Hospital Clinic Staff #1 stated if they knew the resident was mobile enough to wheel out of the clinic, the staff wouldn't have let the resident staff unaccompanied, but the staff did not know. Hospital Clinic Staff #1 said sometimes staff, family, or others come and sit with residents. This situation was the first time this issue ever happened since she worked at the facility since September or October of last year. On 6/23/20 at 4:20 PM, Hospital Clinic Staff #2, Certified Medical Assistant (CMA), reported the resident had an appointment scheduled with the emergent general surgeon. The clinic always sees patients once a week for one to one-half hour increments. The resident was to see the Surgeon at 2:00 PM. The driver brought the resident early to the appointment and dropped the resident off in the waiting room. The driver said he would be downstairs. The resident was placed into the waiting room. The clinic staff was unaware that the resident needed watching. Hospital Clinic Staff #2 reported that the staff wasn't instructed that the resident was nonverbal. The receptionist reported that the resident was yelling and angry. The resident kept saying the resident was done. Hospital Clinic Staff #2 stated that the resident would be seen next due to the resident being upset. Hospital Clinic Staff #2 went out to calm the resident and he continued to be angry. Hospital Clinic Staff #2 said their manager came out, as she was nearby, to stop the resident. They could not calm the resident down and left the clinic area. The resident got onto the elevator then went wandering around the hospital for about twenty minutes. The clinic staff called security and attempted to call the driver. The clinic staff was concerned as the resident needed to reschedule the appointment and the resident required an escort. The clinic staff asks for a companion for nursing home residents. However, they get some that are cognitive, and they don't usually screen for the need for an escort. Physician interview: On 6/24/20 at 7:57 AM, the resident's Primary Medical Doctor, Physician, reported not being aware of the situation but had taken a leave for the past six months. The Advanced Registered Nurse Practitioner (ARNP) assisted with covering the Physician's patients. The Physician reported that based on the resident's medical diagnoses, the resident has a cognitive impairment without documentation of dementia, [MEDICAL CONDITION], and mood disorder. The resident had all of these medical issues and would be safer if with someone with him. It would have been better if the driver could have moved the van after the appointment, but he was not there and was unsure of the situation. The Physician said he did not expect the drivers to know the resident's cognition. Residents with this [DIAGNOSES REDACTED]. This resident should not have been left alone. Residents with these conditions, if not in their natural settings as with residents with dementia, can become upset waiting. This situation is similar to leaving a child in the waiting area while the adult sat in a car. The loop lacked completion between the driver, the clinic, and the facility. ARNP Interview: On 6/24/20 at 8:41 AM, the ARNP stated the resident's cognition varies. The ARNP reported overseeing the residents in the nursing back in January 2020. Since taking over, the ARNP saw the resident twice at the end of April in person and once in June through telehealth. The ARNP reported having a vague memory of seeing fax regarding the resident's incident in April. The ARNP did not recall notification that the resident never saw the Surgeon when the incident occurred. Since the resident never saw the Surgeon, the ARNP was concerned due to the intensity of the resident's surgery. The resident had staples from the sternum through the abdomen. Due to the current concern with the resident's incision, the ARNP was hoping the issues were with the sutures and not the surgery. The ARNP reported seeing the resident on April 13th without problems with the resident's surgical site. The ARNP said she monitored the resident's laboratory values (labs) and noted an increased sedimentation rate. The ARNP instructed the facility to notify the Surgeon. The ARNP said she only met the resident once in person and then once on telehealth. The ARNP reported being very concerned when the resident had staples that the resident would mess with the staples. The ARNP said thankfully, the resident did not mess with the staples and luckily did not get pneumonia. Psychiatry Note: A Psychiatry Note dated 6/25/19 indicated the resident was awake, alert, and orientated times three. The resident was wheelchair bound with left sided paralysis. The resident had minimal spontaneous speech. The resident had marginal insight and impaired judgement. His fund of knowledge was below average. The resident lived in a nursing home and was reliant upon others for twenty-four hours, seven days week care with chronic medical ailments. In the area protective factors the note revealed the resident received clinical care for mental and physical disorders and had access to a variety of clinical interventions and support for help seeking. The resident had restricted access to highly lethal means of suicide. Education: The Administrator provided an undated form identifying completion of education on 4/22/20 to nursing and transportation staff regarding the resident's transportation. The form said the family elected to have an escort to medical appointments. The DON and Administrator discussed with the Maintenance/Transportation Supervisor that nursing staff would communicate instructions regarding an escort for each resident at the time of transport. The staff received the facility's policy on transportation for review. The form continued to indicate that on 4/22/20 the facility provided education to the nursing staff re-iterating the facility's transportation policy by the Administration staff. The nursing staff received re-education on the policy and residents should have a family member, a facility escort, or a volunteer present as required based on the resident's assessment, for the duration of the medical appointment. The resident and or family may also choose to have an escort at any time. The staff received the facility's policy on transportation for review. Policy review: The Resident Transportation and Escort Policy - Medical revised 8/12 indicated the facility informed residents and/or families on admission that the facility did not routinely provide an escort to accompany the resident to medical appointments. If a resident required an escort to the medical appointment, the expectation is that the resident or the family arrange for someone to accompany the resident. If the resident and or family are unable to locate an escort, the facility will help find a volunteer that can provide the service. If the facility could not locate a volunteer, the facility would arrange for a paid escort. Abatement: The facility abated the immediate jeopardy on 4/22/20 after education of staff on the directive that no resident is to go to appointments without an escort other than [MEDICAL TREATMENT] residents. This abatement resulted in past noncompliance for the facility. The State Agency notified the facility of immediate jeopardy on June 22, 2020.

Based on record review and staff and resident interviews, the facility failed to maintain dignity for 1 of 4 residents (Resident #16). The facility reported a census of 67 residents. Findings included: 1. Resident #16's 9/5/16 Minimum Data Set (MDS) documented the resident had no cognitive impairments as demonstrated by the resident's score of 15 (out of 15) on the Brief Interview for Mental Status (BIMS) cognitive test. The resident required extensive assistance of 2 staff for bed mobility, transfers and toileting, the resident did not ambulate. The resident's Care Plan with a Target date of 12/6/16, identified the resident needed assistance with Activities of Daily Living related to a musculoskeletal impairment and directed 2 staff to assist the resident using the EZ Lift for all transfers. The Care Plan also identified the resident had potential for urinary tract infections and noted the resident received [MEDICATION NAME] injections to help with bladder spasms and bladder control. The Care Plan directed staff to remind the resident to go to the bathroom and not hold their urine too long. During interview on 9/28/16 at 1:22 p.m. Resident #16 stated he/she had concerns about adequate staffing. The resident stated it had not been unusual to wait 35 minutes for staff to respond to the call light and he/she had waited as long as 1 hour and 30 minutes. During interview on 9/28/16 at 8:41 a.m. the resident stated he/she had been incontinent due to waiting too long for staff. The resident stated he/she had discussed it with his/her physician. The resident stated he/she had [MEDICATION NAME] treatment to improve urinary control. The resident said the doctor told him/her it wouldn't help hold urine longer than 10 minutes and said if he/she had to try to hold it 20 or 30 minutes it wouldn't do any good. The resident stated he/she had experienced urinary tract infections and the doctor said having to hold urine so long might be a factor. The resident stated when he/she experienced incontinence this made her/him feel kind of crappy and made her/him feel bad about themselves.

Based on record review and staff and resident interviews, the facility failed to display respect for residents when speaking with or caring for 1 of 7 sampled residents reviewed for dignity (Resident #1). The facility reported a census of 68 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/19/16 which reflected the resident's BIMS (Brief Interview for Mental Status) was 10 of 15 which indicated moderate cognitive impairment. The resident had [DIAGNOSES REDACTED]. The MDS indicated Resident #1 was independent with activities of daily living such as transfer, toilet use, and ambulation and was continent of bowel and bladder. On 4/21/16 at approximately 11:47 a.m. the Administrator and Director of Nursing (DON) provided an investigation summary completed on 4/20/16 for a resident reported abuse allegation which occurred on 4/19/16. The Administrator and DON indicated Staff C, certified nursing assistant (CNA) notified Staff A, registered nurse (RN) and nurse manager that Resident #1 reported a potential allegation of abuse. Resident #1 informed her that Staff I, certified nursing assistant/certified medication assistant (CNA/CMA) grabbed his/her crotch while he/she was in bed. Resident #1 was upset because he/she did not wear briefs and was not incontinent. The investigation indicated on 4/19/16 at approximately 10:00 a.m. Resident #1 provided the same statement to the Administrator, DON, and Staff A. The resident typically had short term memory impairment, however was able to recall Staff I grabbed his/her crotch while he/she was in bed which made him/her uncomfortable. During an interview on 4/21/16 at 1:50 p.m. Resident #1 reported a staff member entered his/her room. Resident #1 told the staff member he/she was fine and was not wet however the staff member grabbed him/her inappropriately. Resident #1 demonstrated placement and grabbed the upper, inner portion of his/her left thigh/pubic area. Resident #1 was unable to recall the staff member's name however provided specific information to indicate an accurate description of Staff I. Resident #1 then reported that was not the first time Staff I grabbed him/her. The resident indicated he/she felt dirty and ashamed. Resident #1 stated he/she is forgetful however can tell staff when he/she was wet and can go to the bathroom independently. On 4/21/16 at 1:33 p.m. Resident #3, Resident #1's roommate, stated he/she witnessed Staff I enter the room and grab Resident #1's privates. Resident #3 demonstrated the incident with placement of his/her hand on his/her upper, inner left thigh/pubic area. Resident #3 indicated that was not the first time Staff I grabbed Resident #1 in that manner and that's uncalled for. Resident #3 was aware Resident #1 had a stroke and problems with recollection, however remembered this incident vividly. Resident #3 stated Resident #1 cries when he/she talks about it and is embarrassed. At the time of the interview, Resident #3 correctly stated the day, month, year and current President. On 4/21/16 at 2:40 p.m. Staff C, CNA, stated Resident #1 notified her that (Staff I) entered his/her room and touched his/her privates and asked if he/she was wet. The resident was upset and didn't know why because he/she toilets independently. Staff C reported to Staff A and Staff D, licensed practical nurse (LPN). Staff C stated Resident #1 was able to recall and report the same information each time which is unusual with his/her short term memory loss. On 4/21/16 at 2:56 p.m. Staff D, LPN, stated Staff C reported Resident #1 reported the concern with staff inappropriate touch. Staff D recalled typically after meals Resident #1 will lie down and rest however was still up. Resident #1 stated he/she was too freaked out to sleep, and reported (Staff I) grabbed him/her to see if he/she was wet. Staff D indicated Resident #1 was upset because he/she told (Staff I) he/she can go to the bathroom independently. On 4/21/16 at 10:15 a.m. the Administrator and DON indicated Resident #1 was upset and didn't understand why Staff touched him/her in that manner. The Administrator indicated the incident was reported and Staff I received education on the expected technique to check a resident's brief. He felt because of Resident #1's reaction, he reported to the appropriate State Agency.

Based on record review and staff interviews, the facility failed to provide adequate supervision and implement or update care plan interventions identified to prevent accidents for one of three residents (Resident #1). The facility used sensor alarms to alert staff when Resident #1 attempted to self-transfer. Resident #1 fell and fractured his/her hip. Staff interviews identified the resident's alarm did not sound to alert staff of the resident's safety needs. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 2/21/14, documented [DIAGNOSES REDACTED]. The MDS documented the resident required the assistance of one staff for bed mobility and transfers. The test for balance identified the resident not steady, only able to stabilize with staff assistance when moving from seated to standing position, when walking, when turning around, when moving on and off the toilet and when completing surface transfers. (Surface transfers are described as transfers between bed and chair or wheelchair.)The MDS documented the resident scored a 7 on the Brief Interview for Mental Status (BIMS) which indicated he/she had moderately cognate impairments. The care plan for fall prevention dated 12/12/13, included a problem for at risk for falls related to unsteady gait. The resident a closed fracture of the humerus and coronary atherosclerosis (native coronary artery). The problem included the following interventions: a. Be sure that my call light is within reach and encourage me to use it for assistance as needed. b. Ensure Resident #1 is wearing gripper socks or shoes when he/she is ambulating, transferring, or mobilizing in his/her wheelchair. c. Resident #1 is receiving physical and occupational therapy. Please follow their recommendations as received. d. Resident #1 has a personal alarm in place to alert staff when he/she self transfers occur. e. Review information on his/her past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate Resident #1, his/her family, caregivers, and interdisciplinary team as to potential causes. An admission fall risk assessment (not dated), documented the resident with a score of 19 for which indicated moderate risk for falls. The assessment revealed the resident had fallen within the last 90 days, unsteady gait, fracture, cannot walk unassisted, steps are short and resident may shuffle. The assessment revealed [DIAGNOSES REDACTED]. The assessment did not identified the resident had visual disturbances. An entry in the Interdisciplinary progress notes dated 1/14/14 at 9:00 a.m., documented resident noted standing at sink independently with alarm string pinned to their shirt. The staff shortened the string and educated resident to use call light with understanding. An entry in the Interdisciplinary progress notes dated 1/15/14 at 10:00 a.m., documented spoke with physical and occupational therapies and resident not ready to be independent in room due to balance issues. To remain assisted with all transfers and ambulation and activities of daily living. Continues with alarms. An entry in the Interdisciplinary progress notes dated 1/19/14 at 5:00 a.m., documented resident has been removing pull alarm away and alarm and self transferring this shift. Provided education to resident concerning safety and call light usage, resident stated understanding. An entry in the Interdisciplinary progress notes dated 1/22/14 at 5:30 a.m., documented resident had self transferred this shift. Educated on safety and reinforced what resident and this nurse have discussed previously, resident states understanding, but stated "sometimes he/she just can't wait." An entry in the Interdisciplinary progress notes dated 1/22/14 at 7:30 p.m., documented called to resident room per certified nursing assistant (CNA). Resident self transferred to bathroom. An entry in the Interdisciplinary progress notes dated 1/23/14 at 5:50 a.m., documented resident self transferred several times this shift. Reinforced safety education resident stated understanding but continued to do so. An entry in the Interdisciplinary progress notes dated 1/24/14 at 5:50 a.m., documented resident has been self transferring this shift, continuing to reinforce educating safety with the resident. The resident stated he/she did not care and had to use the bathroom. Assisted resident back to bed, personal alarm in place, call light within reach. An entry in the Interdisciplinary progress notes dated 1/24/14 at 9:00 a.m., documented no behaviors noted this a.m., with exception of self transfers reported, educated resident on call light use and importance of waiting for assistance. Alarm sounding with each transfer. An entry in the Interdisciplinary progress notes dated 1/27/14 at 9:00 a.m., documented CNA reports resident self transferring times 2 this a.m., alarm sounding. Reminded resident to pull light and wait for assistance and assisted resident with ambulation back to recliner. Alarm on and in place. An entry in the interdisciplinary progress notes dated 1/28/14 at 9:00 a.m., documented that the CNA reports resident self transferring times 2 this a.m., with alarm sounding, call light not on, re-educated resident on call light use and not waiting for assistance. Resident voiced "ok". An entry in the interdisciplinary progress notes dated 2/1/14 at 5:50 a.m., documented resident self transferred this shift. Staff educated resident on the importance of waiting for assistance, resident said, "well, I can ' t wait." Resident took off the alarm and ambulated to restroom. An entry in the interdisciplinary progress notes dated 2/5/14 at 1:15 a.m., documented resident had fallen while being assisted from restroom to sink. Resident was found initially in restroom when CNA heard personal alarm sounding while helping another resident, CNA responded quickly to find resident had self transferred to restroom. Re-educated and reinforced importance of waiting for assistance, resident reluctant to information given. An incident report form dated 2/5/14 at 1:15 a.m., documented the resident was found initially in the restroom when certified nursing assistant heard personal alarm sounding while helping another resident, and the resident had self transferred to the restroom. Resident was re-educated and reinforced importance of waiting for assistance, resident reluctant to information given. Physical and Occupation therapies screen requested. A request for therapy screen dated 2/5/14 at 4:30 p.m., documented please screen for walker for stability, had one at home with wheels. Therapist ' s responded, the 4 wheeled walker was not appropriate for Resident #1 secondary to vision (impairments). A request for therapy screen dated 2/5/14 at 10:00 p.m., documented recent fall, change in status, poor balance, uses objects for support and behavior, and resident has self transferred to restroom several times recently, resident has poor vision, impatient with waiting for call light to be answered, tends to walk on heels, poor balance, gait and unsteady. The therapist ' s responded, train staff on walking with resident, cues for how far away destination is at, and no therapy recommended. An entry in the interdisciplinary notes dated 2/11/14 at 2:30 a.m., documented resident walking out into the hallway. Resident had detached personal alarm and self transferred to doorway, quickly responded to resident and asked resident what they needed. Resident stated "I need to use the restroom." Gait unsteady. Applied gait belt and transferred to restroom. Educated resident on safety. Resident was reluctant to information per usual. Assisted back to bed. An entry in the interdisciplinary notes dated 2/13/14 at 3:30 a.m., documented resident frequently on call light and setting off personal alarm. Complains of having to urinate frequently, often 15 minutes of just going. Resident complained of "I can ' t wait!" "I can ' t help it!" Resident yelling at CNA. Explained to resident for safety they must wait for help and that staff comes to help as soon as they can. An entry in the interdisciplinary notes dated 2/13/14 at 4:15 a.m., documented nurse again spoke with resident related to being patient, using call light an voiced understanding to resident about understanding their frustration related to frequent urination related to urinary tract infection. An entry in the interdisciplinary notes dated 2/25/14 at 10:00 p.m., documented resident continued to yell for pain medicine and attempting to self transfer multiple times. Slid out of recliner a couple of times and was constantly on the phone. An entry in the interdisciplinary notes dated 3/2/14 at 7:05 a.m., documented resident found lying on left side, knees up, pillow place behind their head, lacerations noted to right ear. Resident complains of right hip pain, states "I broke my hip." Resident reports self transferring to bathroom from recliner, foot of recliner down. An incident report dated 3/2/14 at 7:05 a.m., documented the resident found lying on their left side, knees up, pillow had been placed under their head, laceration noted to right ear. Resident complained of right hip pain. The resident reported self-transferring to bathroom from recliner, foot of recliner down. Physician notified of fall and orders to transfer to the emergency room . An entry in the interdisciplinary notes dated 3/2/14 at 7:05 a.m., documented the resident left facility at 7:25 a.m., to local emergency room . A radiology report dated 3/2/14 at 7:56 a.m., documented the resident had sustained a comminuted intertrochanteric fracture of the right hip with various deformity. There was severe osteoporosis and extensive vascular calcification. A fall risk assessment dated [DATE], documented Resident #1 readmitted to the facility. The assessment revealed the resident had fallen within the last 90 days, and had the following [DIAGNOSES REDACTED]. The assessment revealed the resident overestimates or forgets limits. The assessment did not identify the resident had visual disturbances, or CHF or did the assessment include a fall score. The assessment form titled alarm, monitors, voice activated screening assessment (not dated), documented Resident #1 had 2 falls in the past, and sustained a hip fracture. The form noted the personal alarm intervention (#4) had been ineffective in stopping falls since the resident does not follow directions and had increased anxiety. The environmental considerations which may contribute to the fall as blindness. The rationale for the device was to alert staff of resident attempting to self transfer. The potential consequence of using the devise was to help remind resident to ask for assistance and alert when attempts to self transfer. An incident report form dated 3/15/14 at 8:17 p.m., documented resident found on floor mat, observed resident sitting upright on fall mat with back against bed. Bed alarm sounding when CNA found resident, monitor on and functioning. Bed locked and in low position. During an interview on 3/17/14 at 1:38 p.m., Staff A (licensed practical nurse) stated that when they went into the room to assist the resident after the fall, the clip alarm was attached to the resident but the switch on the alarm box was in the off position for which was attached to the back of the recliner. The alarm did not sound when the resident went to get up. During an interview on 3/17/14 at 2:09 p.m., Staff B (certified nursing assistant) stated that they were across the hall assisting another resident when she heard the resident call light sounding. Staff B stated that they went into the resident room and found the resident on the floor on their left side, between the recliner and the heat register. Staff B stated that the clip alarm was attached to the resident and the string of the clip alarm was hanging down their back and that the alarm box was behind the recliner, the alarm did not sound. Staff B stated that they checked the alarm box behind the recliner and that the switch for the alarm was in the off position.. Staff B stated that there were times that the resident would remove the clip alarm for their shirt. During an interview on 3/17/14 at 3:25 p.m., Staff C (certified nursing assistant) stated that the resident will self transfer all the time. During an interview on 3/17/14 at 3:40 p.m., Staff D (certified nursing assistant) stated that the resident will self transfer all the time and that staff had to keep an eye on the resident because of that. Observation on 3/17/14 at 10:10 a.m., revealed resident lying in bed, covers over them, bed in low position, oxygen on per nasal cannula, eyes appeared closed. An alarms, voice activated devised, monitoring devices policy and procedure with no dated documented the policy is to use any type of alarming device, including audio devices( such as personal alarms, monitors and voice activated chair commands) used to alert staff or a change in position, will be assessed for appropriateness and continued effectiveness. The Procedure consisted of: 1. An assigned nurse will complete the alarm or activated device screening tool. 2. If the interdisciplinary care plan team or safety committee determines the alarming/monitoring device or voice activated device is appropriate for the resident, then an alarm acknowledgment form will be completed, review and signed by the resident and/or responsible party. 3. The Director of Nurses, or designated person, will be responsible to review the effectiveness of each alarming or voice activated device at the time the devise is initiated and on a monthly basis, until the device is discontinued. The result of these reviews will be documented in the interdisciplinary notes. During an interview on 3/17/14 at 2:42 p.m., the facility Director of Nursing would expect that staff check the alarms to make sure the alarm was in the on position before leaving the room. The DON reported the resident had been at risk for falling and it is the responsibility of the staff to make sure the (alarms) work.

Based on record review, staff interviews and review of the Manual for the Bariatric Low Bed, the facility failed to plan for and direct the nursing services to ensure each resident received adequate supervision and assistive devices to prevent accidents and protect residents from hazards to themselves and elements in the environment for 3 of 10 residents reviewed, (Residents #1, #6 and #10). Resident #1 had moderately impaired cognitive skills with dementia. The resident had experienced multiple falls and had altered perception and anxiety. The facility staffs had witnessed the resident self transfer and not consistently use the call light for assistance. After the resident returned to the facility on [DATE], after a hospitalization , the care plan was revised. The facility did not utilize alarms as prior to alert staff the resident was self transferring or try additional interventions to supervise the resident. The resident had self transferred again and fractured the right hip. Resident #10 was found lying on the floor. The resident had cognitive deficits. The resident had blood coming from nose and eye and had multiple skins tears present on both arms. The CT scan showed fractures around the left eye orbit and maxillary sinus region. The physician had ordered the resident have a personal alarm on at all times. At the time of the fall, the alarm had not sounded when the resident attempted to rise to alert staff the resident required assistance. Resident #6 was found on the floor between the wall and the bed. Based on staff interviews, the bed wheels had not been locked and the resident fell between the bed and the wall which resulted in a head contusion. The facility reported a census of 65 residents. Findings include: 1. Based on the Minimum Data Set assessment, with a reference date of 8/17/11, revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated moderately impaired cognitive skills for daily decision making. The assessment identified the resident had [DIAGNOSES REDACTED]. The resident had an admission date of [DATE] to the facility from the assisted living facility. The CAA (Care Area Assessment) dated 6/6/2011 indicated the resident to be at risk for falls due to periods of altered perception and anxiety. The resident tried at times to self transfer. The resident received Ativan (antianxiety medication) each morning and Seroquel (antipsychotic medication) at bedtime Review of information provided by the facility indicated Resident #1 had 23 falls from 6/2/11 to 7/14/11. Record review of the Resident Care Plan with a printed date of 6/27/11 revealed the following interventions: a. Transfer with assist of two staff and a two wheeled walker. (6/28/11) b. When in room must be in bed or recliner, the recliner must have legs up when unattended in room.(6/28/11) c. Physical therapy services 5 times a week for 4 weeks for gait, balance training and transfers.(6/29/11) d. Fall mat when in bed. No bedside table next to bed.(7/4/11) e. May use merry walker as needed with 1:1 supervision to help decrease anxiety and promote independence.(7/5/11) f. Stop sign to door when out of room.(7/5/11) g. Do not leave Resident #1 unattended in his/her room unless in bed.(7/5/11) h. Body pillow in bed for positioning.(7/5/11) i. Winged mattress to bed.(7/10/11) j. Seat alarm when in chair.(7/12/11) k. Sensor alarm attached to foot of bed or wall, turn on when in bed.(7/12/11) Resident #1 had been admitted to a geriatric psychiatric hospital floor on 7/15/11 and returned to the long term care facility on 8/10/11. Upon her return the above care plan had been discontinued and a new one printed 8/10/11. The following interventions were included: a. Transfer with assist of one.(8/10/11) b. Large bed with alternating air mattress with bolsters. (8/10/11) c. Body pillow to south side of the bed when in bed.(8/10/11) d. Physical therapy services 5 times a week for 4 weeks for therapeutic exercises/activities, neuromuscular re-education, gait training.(8/10/11) e. Toilet on 5:00 a.m. rounds.(8/11/11) f. Fall mat to bedside when in bed.(8/11/11) g. Toilet before going to meals and when he/she returns to room. (8/12/11) h. Bell within reach at all times.(8/14/11) i. Hipsters on at all times.(8/14/11) On 8/11/11 at 5:58 a.m. the nurse ' s notes documented Staff N passed Resident #1's room and saw the resident on knees, body pillow on the floor with the resident kneeling on it facing and leaning on the bed. On 8/12/11 at 1:10 p.m. the nurses notes documented, to Resident #1's room when summoned by Staff F as resident seated on the floor in front of recliner. On 8/14/11 at 5:45 a.m. the nurse ' s notes documented, called to Resident #1's room, Certified Nursing Assistant (CNA) found the resident on his/her left knee on the floor between the bed and bathroom. Call light on, fall mat and body pillow in place. At 4:25 p.m. CNA reported resident self transferred one time this shift. The resident stated he/she had pulled call light but it took too long for the girls to get here and I had to go. Educated the resident on the importance of waiting for assistance. The resident stated I made it and I am fine. An entry in the nurse notes on 8/17/11 at 2:00 p.m. indicated Resident #1 had 3 to 4 falls since admission (8/10/2011) with preventions in place. The resident would self transfer and forgets to use the call light. At 8:00 p.m. it was noted the resident self transferred 2 times this shift and dressed self in pajamas. CNA came upon the resident while standing at the sink. On 8/18/11 at 6:00 a.m. the nurses notes had an entry that Resident #1 had been caught self transferring multiple times this shift. Staff educated the resident on safety of pulling call light or ringing bell and wait for assistance. The resident voiced understanding each time. The nurse ' s notes on 8/20/11 documented at midnight the resident self transferred from the bed to the recliner. At 1:00 a.m. the staff caught the resident self transferring from the recliner to the couch Staff applied gait belt and assisted to the couch. The resident refused the bathroom and hipsters. Resident #1 stated I don't need help with anything, I can do this myself. Re-educated resident on the importance of call light use, again the resident stated, I don't need help. At 4:15 a.m. an entry noted Resident #1 self transferred multiple times throughout shift, educated each time on importance of call light and bell use. The resident stated, I can do it myself no need to ask for help. The resident refused to wear hipsters. At 7:25 a.m. summoned to the resident ' s room by CNA, Resident #1 found sitting on the floor in front of recliner. The resident complained of right hip and thigh pain, unable to do range of motion. The doctor was notified and order received to transfer to the hospital for further evaluation. At 10:30 a.m. the facility received call from emergency room nurse, the resident had been transferred for right hip fracture repair. On 8/24/11 at 10:00 a.m., Staff F (Social worker) was interviewed and stated on 8/12/11, she was walking up to the front with the Administrator when she saw Resident #1's call light turned on. Staff F went in to see what the resident needed and found the resident on the floor. Staff F stated the Administrator used the walkie talkie to call for the nurse. Staff F stated Resident #1 would use the call light off and on (not consistent) and the resident would self transfer. Staff F stated the resident ' s cognitive status varied throughout the day. On 8/24/11 at 9:20 a.m. Staff K (Licensed Practical Nurse) was interviewed and stated she had worked 10:00 p.m.to 6:00 a.m. on 8/20/11. Resident #1 did not use the call light one time that night. Staff K stated she had caught the resident 4 times during mid transfer and helped the resident complete the transfer. The resident refused help and would state he/she can do it myself. Staff K stated she would educate the resident on using the call light and the bell and the resident voiced understanding. Staff K stated she would check on the resident ' s hall frequently because of the resident ' s history of self transfers. Staff K stated she had provided a taped report for the day nurse and reported the resident had self transferred multiple times and needed to keep a close eye on the resident. On 8/24/11 at 9:50 a.m. Staff N (Registered Nurse) was interviewed and stated she was coming into work and walked by Resident #1's room when she saw the resident kneeling on the body pillow on the floor next to the bed. Staff N stated she did not think the call light was turned on (activated) and just saw the resident as she walked by. Staff N stated Resident #1 was not to self transfer but did. Sometimes Resident #1 used the call light and sometimes did not. The resident forgets easily; when he/she came back from Hope Harbor was easily redirected and would repeat what you said but would forget. Staff N stated on 8/20/11 she had been paged on the walkie talkie by a CNA. The CNA had walked by the resident ' s room and found him/her on the floor. Staff N stated she did not think the call light had been on. Staff N stated the resident ' s closet was open and the resident had dressed self. Staff N stated the night nurse had communicated on report that Resident #1 had self transferred multiple times. Staff N did not get a chance to listen to report till after the resident had fallen. 2. Resident #10's Care Plan with the print date 8/11/11 noted the resident had a [DIAGNOSES REDACTED]. The resident required assist of one to two staff for all transfers. The intervention for staff to do frequent checks on the resident had been added to the care plan on 8/17/11. The physician order [REDACTED]. The Nurse ' s Notes dated 8/21/11 at 9:10 p.m. indicated the nurse was summoned to the resident ' s room by a Certified Nursing Assistant. The nurse found the resident lying on the floor in a supine position. Blood was noted from the resident ' s nose and left eye and multiple skin tears to both arms. The nurse called 911 and the resident ' s family. The resident went to the emergency room via ambulance and returned at 11:15 p.m. The assessment done at that time revealed the left outer knee had a 1.5 centimeter abrasion, a 2 centimeter abrasion on the left knee, a 3 centimeter bruise light blue/purple to left outer calf, a 17 centimeter bruise to left outer calf, a 4 centimeter diameter bruise light blue/purple to right inner calf, a 3 centimeter diameter bruise to the right calf, a 2 centimeter diameter light blue/purple bruise to the right calf, a 1 centimeter red area on the left wrist, a 4 centimeter diameter dark blue/purple bruise to the left eye, and a swollen 3 centimeter laceration to the left outer eye. On 8/22/11 at 2:35 p.m. reported to the doctor Resident #10 had not had any intake all day other than a few sips of water and sleepy. At 9:10 p.m. the doctor called the facility and ordered to send the resident to the hospital on [DATE] at 8:00 a.m. for a CT scan of the brain. A late entry for 8/21/11 documented on 8/23/11 noted Resident #10's bed was in low position and alarm was not sounding. The CT report of Resident #10's head done on 8/23/11 showed a minimally displaced fracture involving the floor of the left orbit and a nondisplaced fracture of the lateral wall of the left orbit. There is a slightly displaced fracture involving the lateral aspect of the left maxillary sinus. Resident #10 had been admitted to the hospital on [DATE] due to the fall and fracture of the left orbit and maxillary sinus. During an interview on 8/25/11 at 9:00 a.m. the Director of Nursing stated the personal alarm did not sound on 8/21/11 at the time of the fall because the Certified Nursing Assistant had not put the alarm on Resident #10. 3. Record review of the Minimum Data Set (MDS), dated [DATE] for Resident # 6 revealed multiple [DIAGNOSES REDACTED]. The MDS documented the resident had short and long term memory loss and cognitive skills for decision making were severely impaired. The resident required extensive assistance for bed mobility and transfers. The MDS documented the resident had 1 fall with no injury and 2 falls with no major injury in the assessment period for the MDS. Record review of the Resident Care Plan with a team conference date of 6/18/11 revealed the resident at risk for falling related to dementia, schizophrenia, and cognitive declines. Staff interventions included: a. To give the resident verbal reminders not to ambulate/ transfer without assistance. b. Provide the resident with a clutter free environment. c. Keep the bed in the lowest position when he/she is in the bed and use a mattress beside the bed in lieu of a fall mat. d. Provide a body pillow on both sides when in bed. e. Provide a sensor alarm on the bed frame for safety when in bed. f. If awake early in the morning, take the resident to the dining room to monitor. g. Provide an extra large bed as the resident moved around in the bed and restless at times. h. Use an EZ lift to transfer the resident. i. Provide an alternating mattress (discontinued in 6/1/11). Record review of the Admission/ Readmission Fall Risk Assessment and Interventions, dated 6/30/11, revealed the resident had potential fall risk factors which included: a. assistance required for transfers. b. bed height appropriate. c. cognitive impairment. d. history of falls. e. resident incontinent of urine. f. resident having involuntary movements including tremors. g. medication changes. h. patterned carpet. i. resident had poor safety awareness. Interventions included: a. provide a bed/ chair alarm and body pillow. b. staff to provide frequent monitoring of the resident. c. staff to provide a hi/ low bed and hipsters. d. staff provide a mattress next to the bed ,a motion sensor and bed alarm and keep the resident's room free of clutter. e. staff to offer snacks/ beverages to the resident. f. the facility to screen the resident for physical therapy, speech therapy and occupational therapy as needed. Record review of the Incident Report Form, for resident or visitor revealed: a. On 4/28/11 at 5:00 AM revealed the resident was found lying on the floor on the right side of the body between the bed and wall. The Certified Nursing Aid reported the alarm sounded. The resident was found on the mattress right next to the wall. The resident had a pink area noted on the left eye measuring 10 by 7 centimeters (cm) and a 2 cm diameter area on the left side of the back of the resident's head. b. On 5/21/11 at 2:30 AM the resident was found lying on the floor between the bed and wall with the seat alarm sounding. Staff found a 2 cm by 0.2 cm high bump on the left side of the back of the head. Staff transferred the resident to the emergency room for further evaluation. Record review of the Preliminary Radiology Report, dated 5/21/11 revealed a Cat Scan for an indication of a fall and hematoma on the left side of the head, done with findings including a left occipital extacranial soft tissue thickening consistent with a contusion/ and or laceration. Staff interview with Staff U (Licensed Practical Nurse/ Unit Manager) on 8/24/11 revealed the intervention for fall prevention on 4/28/11 included to provide bed pillows on both sides of the resident when in bed. Staff U stated the resident's bed had not been in a locked position at the time of the fall. The intervention for the fall on 5/21/11 included to lock the bed wheels while the resident in the bed. Again the bed had not been in a locked position prior to the fall on 5/21/11. She said the resident moved a lot because of the Parkinson's disease and the resident moved the bed away from the wall. The air mattress provided on the bed allowed the resident to move even more so they finally changed the mattress after the resident fell several times because of the mattress. Staff interview on 8/24/11 at 2:45 PM with Staff G, (Maintenance Supervisor) revealed when he set up the Bariatric beds (the bed Resident # 6 had in place) he made sure all four of the pivots were in a locked position. Staff G stated staff would have to unlock the bed in order to move the bed. Staff G stated the resident constantly moved his/her extremities but could not physically move the bed because the weight of the bed. Staff G stated for the resident to be lodged between the bed and wall, the bed would have to be unlocked. Review of the User Manual for the Bariatric Low Bed, Model 3748 revealed warnings and instructions included to take special care to lock the casters securely when reclining or inclining the bed and also when transferring the patient to or from the bed. The Caster lock function cautioned to lock the brakes when transferring a patient or when a patient is entering or exiting the bed. Failure to do so could result in injury. An interview on 8/25/11 at 5:45 AM with Staff N 1 (Certified Nursing Assistant (CNA)) revealed she worked on the night of 5/21/11. Staff N1 stated she worked the other end of the facility. Staff N1 stated she heard the report of the fall the next night at work. Staff N1 stated she heard the resident fell out of bed and landed between the bed and wall. Staff N1 continued to state the resident's interventions prior to the fall included a seat alarm, sensor alarm on the floor, a fall mat, and a pillow placed at the foot of the bed. The new interventions placed after the fall included to place a second body pillow in place against the wall, provide frequent checks on the resident and to lock the bed brakes. Staff N1 stated she heard the resident's brakes on the bed were not locked at the time of the fall. An interview with Staff K( LPN) on 8/25/11 at 6:00 AM revealed she heard the resident's alarms sound. She said a CNA found the resident between the wall and bed. Staff K stated she sent the resident to the hospital because the resident had a bump on the head. Staff K stated the resident's brakes on the bed were not locked at the time of the fall and normally the wheels would be locked.