Every finding on record at Spurgeon Manor

Based on clinical record review, staff interviews and policy review the facility failed to develop a care plan to address suicidal ideations and interventions for suicidal precautions for 1 of 3 residents (Residents #1) reviewed for comprehensive care plans. The facility reported a census of 50 residents.Findings include: Resident #1'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 #1 required partial/moderate assistance with bed mobility and transfers. The MDS included diagnoses of vascular dementia with anxiety disorder and depression. A Hospital Psychiatry Consult Note dated 1/6/26 documented Resident #1 presented from the assisted living care facility for suicidal gestures. Resident #1's daughter was present and reported there had been discussion with the assisted living care facility to transition Resident #1 to a higher level of care given the number of falls she has had despite optimizing her environment. Resident #1 was informed of this which precipitated her using a pen to cut her wrist and using the lens of her glasses to attempt to cut her wrist. The note documented there had been history of one other suicidal gesture using a plastic cup to express her frustration per family report while transitioning care. The note documented clinical impression was non-suicidal self-harm and recommended discharging back to the care facility. A Progress Note titled admission Note dated 1/7/26 at 2:50 PM, documented Resident #1 admitted from the emergency room for suicidal ideation. Review of the Interim Plan of Care dated 1/7/26 and the Comphrensive Care plan initiated on 1/8/26 did not address suicidal ideation or gestures. The plan of care lacked direction or interventions on suicide precautions, what to do if Resident #1 expressed suicidal ideation or attempted self harm.A Progress Note dated 1/24/26 at 5:40 PM documented Resident #1 was in the recliner rubbing a drink coaster across her wrist. Staff A, Licensed Practical Nurse (LPN) asked what she was doing and she stated she was trying to kill herself. Staff A took the coaster away and provided one on one. A Progress Note dated 1/24/26 at 5:48 PM documented Resident #1 was sitting in her recliner, she took off her glasses, twisted them and broke them. Resident #1 made statements about wanting to die. Resident #1 assisted to bed to lie down. Resident #1's daughter notified and one on one provided. A Progress Note dated 1/24/26 at 6:54 PM documented Resident #1 had been in bed with Staff A providing one on one. Resident #1 took off her rings and tried to put them in her mouth to swallow them. Staff A took the rings. Resident #1 then took off her earrings and tried to put them in her mouth and Staff A intercepted the earrings. Resident #1 then reached for the telephone cord on the floor and Staff A took the cord away. Resident #1 kept saying that she wanted to kill herself and just die. The note documented one on one was not working with the nurse sitting with Resident #1.A Progress Note dated 1/24/26 at 7:18 PM revealed Staff A notified the Provider, daughter and called for an ambulance. A Progress Note dated 1/24/26 at 7:32 PM revealed Resident #1 left the facility via ambulance.The Clinical Census revealed Resident #1 was admitted to the hospital on [DATE] and returned to the facility on 2/10/26. Review of the Comprehensive Care Plan revealed the care plan was not updated when Resident #1 return from the hospital on 2/10/26. The care plan was updated on 2/18/26 to include interventions related to self harm. On 4/21/26 at 11:40 AM, the Director of Nursing (DON) acknowledged she had updated Resident #1's care plan to include interventions related to self harm on 2/18/26. The DON said she would have expected self harm and interventions to be addressed prior to 2/18/26 on the baseline care plan and comprehensive care plan. On 4/21/26 at 2:25 PM, the MDS Coordinator acknowledged the comprehensive care plan was not updated when Resident #1 returned from the hospital. She said she had 19 assessments due that week and no help to update the care plans.The facility policy titled Comprehensive Care Plans revised 2025 documented it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. f

Based on observations, staff interviews and recommendations from the Food Code United States Public Health and Safety 2017, the facility failed to properly thaw/defrost meat and serve food under appropriate sanitary conditions to prevent, reduce or eliminate potential hazards. The facility reported a census of 49 residents.Findings Include:1. On 09/22/2025 at 10:03 AM during the initial kitchen tour, observed roast thawing in water in the sink without continuous running water. At 12:55 PM the roast remained submerged in the water in the sink. When questioning the Certified Dietary Manager (CDM) about the roast that was in the water in the sink, he said that he had forgotten about the roast in the sink. When asked what his expectations were from his staff when thawing meat he said that typically they would let the water just run over the meat. He stated that the roast was being thawed for lunch the next day. On 09/23/2025 at 2:00 PM, the CDM stated he needed to update the current policy to include continuous running water while thawing meat. The 2017 Food Code, published by the Food and Drug Administration stated thawing food should be completely submerged under running water, as stated in section 3-501.13 Thawing. 2. Observation on 9/24/2025 at 8:30 AM, Staff C, Dietary Aide, with a bare hand observed holding a piece of toast while buttering the toast, still holding the toast with her bare hand, she cut the toast, placed the toast on a plate and served the plate to a resident. 3. Observation on 9/24/2025 starting at 12:20PM, Staff did not wash hands, applied gloves, and touched the dietary paper slips, cabinet handles, scoops, and proceeded with the same gloves on to remove 3 hot dog buns from the package. Staff C proceeded and removed her gloves, touched her glasses, served 3 plates, touched scoops, ladles and the refrigerator door. Staff C then removed her gloves and continued to serve and touch objects, then applied new gloves, opened a bun with her gloved hands, touched a dressing bottle with the gloved hand and then touched the bun again. Interview on 9/25/2025 at 11:15 AM, the CDM stated expectation to not use bare hands to touch any food, to wash hands before applying and after removing gloves, and gloves for 1 time use only. Facility Dietary Employee Personal .Hygiene policy , revised 9/25/25, revealed employees should never use bare hand contact with any foods and gloves are to be worn and changed appropriately to reduce the spread of infection.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 1 of 3 residents reviewed (Resident #6). The facility failed to ensure use of enhanced barrier precautions (EBP) when required. The facility reported a census of 49 residents. Findings include:The Minimum Data Set (MDS) for Resident #6, dated 7/10/25, included diagnoses of Alzheimer's and obstructive uropathy (blockage in the urinary tract). The MDS identified the resident was dependent on staff for toilet hygiene. The MDS indicated the resident had a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder). The MDS indicated the resident had a BIMS score of 7, indicating moderate cognitive impairment. Resident #6's Care Plan with revision date 4/3/25 documented the resident was on enhance barrier precautions related to a catheter and directed staff to follow precautions wearing gown and gloves while providing close contact cares.Observation on 9/23/25 at 1:30 PM, Staff B, Certified Nurse Aide, wore a gown and gloves and emptied Resident #6's catheter bag. Staff A, without a gown and gloves, proceeded to assist the resident to lay down in bed, moved the resident's tray table next to the bed, placed a wedge under the resident's legs, and covered the resident with the blanket on the bed. Facility's Enhanced Barrier Precautions, implemented 10/19/23, revealed enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents with wounds or indwelling medical devices and high-contact resident care activities include transferring, changing linens, and providing hygiene. Interview on 9/25/25 at 1:00 PM, the Director of Nursing stated expectation of staff to wear gown and gloves when completing contact care with any resident on EBP.

Based on resident record review, staff interview, and facility policy review the facility failed to develop and implement a comprehensive person-centered care plan to include a resident's repeated hospitalization s for pneumonia for 1 resident (Resident #36) and high-risk medications for 2 residents (Resident #7 and #35) of 15 residents reviewed for care plans. The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #36, dated 8/29/24, included diagnoses of pneumonia, Coronary Obstructive Pulmonary Disease, and respiratory failure. A Brief Interview for Mental Status (BIMS) score of 15, indicated no cognitive impairment for decision-making. Resident #36's hospital admission records documented resident admitted to the hospital on 4/15/24 for pneumonia of left lower lobe due to infectious organism and sepsis (infection in blood). Resident #36's hospital records documented resident admitted to the hospital on 6/11/24 for an abscess of left lung with pneumonia. Review of Resident #36's Care Plan initiated 11/27/23, lacks inclusion of repeated hospitalization s for pneumonia and monitoring of respiratory failure. 2. The Quarterly MDS for Resident #35, dated 9/19/24, included diagnoses of diabetes, anxiety disorder, and neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function). A BIMS score of 4, indicated severe cognitive impairment for decision-making. Resident #35's Order Summary Report documented the resident received Lantus(insulin)injections 1 time daily for diabetes with start date of 8/15/24, and Sertraline (antidepressant medication) for anxiety and negative behavior with start date of 8/8/24. Review of Resident #35's Care Plan, initiated 3/12/24 with revisions on 9/3/24, lacked documentation of focus for diabetes with use of insulin and monitoring for high and low blood sugars, and for the use of an antidepressant with monitoring for side effects and usage. 46875 3. Resident #7's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS identified Resident #7 required substantial/maximal assistance with bed mobility, and was dependent on staff for transfers and toileting. Resident #7's MDS included diagnoses of hypertension (high blood pressure), renal disease (kidney), and anxiety disorder. A Physician order dated 8/5/24 directed staff to administer Lasix (diuretic) 20 mg (milligrams) one tablet two times a day for bilateral lower extremity edema and coarse crackles in the lungs. A Physician order dated 4/17/24 directed staff to administer Apixaban (anticoagulant) 5 mg one tablet two times a day for anticoagulation, which contained an alert black box warning. A Physician order dated 3/19/24 directed staff to administer Sertraline HCL (antidepressant) 25 mg one time a day for anxiety. Review of Resident #7's Care Plan with a revision date of 10/1/24 lacked information about the usage of the diuretic, anticoagulant and/or antidepressant medications, potential side effects and what to monitor for while taking the high risk medications. On 11/6/24 at 3:15 PM, the MDS Coordinator acknowledged and verified the high risk medication for Resident #7 were not addressed on the care plan. She stated she must have missed adding those medications to the care plan. On 11/6/24 at 3:32 PM, the ADON (Assistant Director of Nursing) reported she would expect the care plans to address the usage of high risk medications and respiratory care/services. A facility policy titled Care Plan Revision Upon Status Change 10/12/2023 documented the purpose of the procedure was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The policy further documented the comprehensive care plan to be reviewed, and revised as necessary, when a resident experiences a status change. The policy directed the following procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident ' s care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observations, record review, staff interviews and facility policy the facility failed to properly prevent an unstageable pressure ulcer to bilateral heels consistent with professional standards of practice for 1 of 1 residents reviewed (Resident #28). The facility reported a census of 49 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Annual Minimum Data Set (MDS) assessment tool dated 9/19/24, for Resident #28 documented diagnoses that included Non-Alzheimer's dementia, arthritis, anxiety and depression. The MDS showed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS identified the resident as at risk for pressure ulcers. The MDS also identified the facility had placed a pressure reducing device in the resident's chair and pressure reducing device for the bed. The MDS identified Resident #28 is dependent on transfers, bed mobility, toileting and dressing. Resident #28's care plan revised on 5/10/24 contained the following information; a. Resident #28 is at risk for impaired skin integrity related to limited mobility and catheter tubing. The care plan directed staff to: apply lotion to bilateral upper extremities two times daily as I allow assist with bathing at least two times per week. encourage to call for assistance to help with bed positioning geri-sleeves or long sleeves at all times as I will allow a pressure reducing mattress on my bed. have an gel cushion in my recliner The resident's Care Plan lacked preventative interventions to help prevent the unstageable pressure areas specific to the right and left heels. The Resident's Care Plan Identified risk for impaired skin integrity related to limited mobility with initiated date of 10/09/2023. The facility provided Braden Scale dated 9/18/24 showed Resident #28 scored a 15 which indicates at risk for pressure ulcers. Review of Resident #28's progress notes revealed the following; 1. On 10/27/24 at 11:55 AM, Resident #28 complained of right heel pain, noting two small areas on the right heel, the area is red to brown in color. New interventions started to apply bunny boots while sitting and lying down and to float heels at all times. Skin prep applied per geriatric protocol. 2. On 10/28/24 at 3:07 PM, Resident #28 continues to have sore areas on both heels. Received fax back with an ok to apply skin prep twice a day and float heels. 3. On 11/4/24 at 12:30 PM revealed Resident #28 was seen by a Nurse Practitioner stating the pressure ulcer of right heel and left heel are unstageable, continue skin prep twice a day to both heels, float heels at all time when sitting/lying down and utilize bunny boots when in bed/chair. The facility provided Skin & Wound Evaluation revealed the following area measurements; 10/28/24 Left heel - 1 centimeters (cm) x 1 cm (length x width) 10/30/24 Left heel - 0.8 cm x 1.0 cm 11/7/24 Left heel - 0.9 cm x 1.0 cm 10/27/24 Right heel - 1.2 cm x 0.8 cm 10/30/24 Right heel - 1.4 cm x 0.8 cm 11/7/24 Right heel - 1.3 cm x 0.5 cm The evaluations documented unknown as to how long the in house acquired pressure wounds had been present to the right and left heels. Review of [NAME] Manor fax sheet dated 10/28/24 revealed new orders from physician as to follow geri protocol, apply skin prep twice daily on both heels, float heels all times when sitting/lying down and apply bunny boots to bilateral heels. Review of wound physician Doctor [NAME]'s progress notes dated 11/6/24 revealed right heel measures 1 cm x 1 cm, skin is intact with purple/maroon discoloration. Left heel measures 2 cm x 2 cm, skin intact with purple/maroon discoloration. New order to do betadine twice daily for 30 days with gauze island with border apply twice daily for 30 days. Interview on 11/6/24 at 3:30 PM with Doctor (Dr) [NAME] stated Resident #28 was a new patient and the facility asked to consult today. Dr. [NAME] reported that Resident #28 has two deep tissue injury (DTI's) to her right and left heel. Dr. [NAME] reported the areas are not open, one is softer than the other one. Dr. [NAME] reported she gave new orders to do betadine with border gauze and hopefully in a week the betadine will dry up and I will be able to peel off the scab area. Dr. [NAME] reported we figured out that Resident #28 was putting pressure down on the foot stool and in the wheelchair. Dr. [NAME] stated if she did have to say she thought they were unavoidable. Facility provided a policy named Skin and Wound Protocol with an effective date of 10/10/24 revealed the purpose is to identify residents at risk for potential breakdown or ulcerations, to prevent breakdown of tissue ulcerations and to provide treatment that promotes prevention and healing of skin issues. Staff will institute a plan for any resident who has potential for skin breakdown or whose condition is deteriorating. This may include: a. Turn and reposition every 2 hours as appropriate b. Pressure reduction surfaces for beds, wheelchairs when appropriate c. Floating areas of concern such as heels when appropriate d. Separation of body prominences with a pillow or other pressure reduction device when side lying or as appropriate e. Use of elbow or heel protectors when appropriate f. Promotion of clean, dry, and well moisturized skin g. Following Registered Dietician recommendations (such as the NIP Program) to promote optimum nutrition when possible h. Reduction of shearing force by using appropriate body mechanics when moving, turning, or repositioning a resident. The nurse aides will report any clothing, shoes, braces, and splints that may not be fitting properly to the supervisor or floor nurse. Do not massage any areas of concern as this may cause further tissue damage and breakdown. Encourage residents to change position frequently and ambulate as capable. Keep the bed as free from wrinkles as possible. Nurse aides will complete body audits with bathing and care and report changes in skin condition to the nurse. The nurse will determine if the skin condition is new or needs further intervention. Interview on 11/06/24 at 1:07 PM with ADON stated they talk about skins in a multidisciplinary rounding meeting four times a week and they put interventions in place by that information. ADON revealed interventions that were in place before these areas to Resident #28's heels. ADON stated that Resident #28 had been wearing shoes and put her heels into the recliner. ADON revealed we are now floating and applying bunny boots to her heels. Interview on 11/7/24 at 11:41 PM with the ADON revealed they look at resident's mobility and try to keep them active. We got therapy involved with Resident #28 because she used to ambulate. We have used lotions, and we will utilize a pillow to float their heels if the resident will allow it.

Based on observation, family interview, staff interview, and policy review the facility failed to properly post past survey results and ombudsman information in a readily accessible area for residents, family members of residents, and legal representatives. The facility reported a census of 48 residents. Findings include: During an interview 8/5/23 at 10:07 AM Resident #1's family member revealed that the facility does not have the survey results or ombudsman notification information in the facility. The family member further revealed that the only place where an ombudsman information sheet was located was by the locked unit and it was outdated. During an observation 8/5/24 from 11:25 AM until 11:40 AM only one copy of ombudsman information was noted on an easel by the southeast entrance of the facility. This ombudsman information was covered by another document and was not readable. During this observation no past survey results were located. During an observation 8/5/24 at 1:05 PM with the Administrator revealed past survey results were in a binder in a hallway across from the kitchen. This binder was noted to have a faded label that was barely legible. During an interview 8/5/24 at 1:05 PM with the Administrator revealed her expectation would be for survey results, and ombudsman information to be easily accessible for residents, family of residents, and legal representatives to obtain without asking. Review of a facility policy revealed that there was no policy to review for having past survey results and ombudsman information in an accessible area in the facility.

Based on clinical record review, staff interview, and facility policy review the facility failed to update Care Plans in a timely manner to reflect the resident's condition for 2 of 5 residents reviewed (Residents #19 and #39). Findings include: 1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS included diagnoses of stroke, cancer, coronary artery disease (narrowing of the arteries in the heart), diabetes mellitus, and hyperlipidemia (an elevated form of cholesterol). Resident #19's Clinical Physician's Orders included an order dated 7/8/23 for Plavix (medication used to prevent clots that can increase the risk for bleeding) oral tablet 75 milligrams (mg). Give one tablet once a day for anticoagulant (blood thinner). Resident #19's Care Plan with a completion date of 7/19/23 lacked information regarding use of medications that can increase the risk of bleeding. Review of Resident #19's EHR page titled Care Plans revealed no further updates. 2. Resident #39's MDS assessment dated [DATE] listed an entry date of 8/4/23 from an acute hospital stay. Resident #39's Clinical Physician's Orders listed an order dated 8/16/23 for a 16 French (size) indwelling catheter. The Admission Note dated 8/4/23 at 12:32 PM indicated that Resident #39 had a urinary catheter. The Nurses Note dated 8/24/23 at 7:35 PM include a note that the nurse removed Resident #39's urinary catheter as ordered by the physician before she got out of bed for the day. After she voided around 1:40 PM the physician gave an order to discontinue the placement of the urinary catheter. Resident #39's Care Plan Focus revised 8/14/23 reflected that she had an indwelling Foley catheter related to a diagnosis of urinary retention. The Care Plan lacked addition updates after 8/14/23. On 10/10/23 at 2:51 PM the Administrator explained that she expected the Care Plans to be revised in a timely manner. On 10/10/23 at 3:06 PM the facility's Care Plan Coordinator reported that she missed Plavix on the Care Plan and she is expected to revise the Care Plans in a timely manner. On 10/11/23 at 2:59 PM the Director of Nursing (DON) reported that the facility did not have a policy on Care Plans or Care Plan revisions. In addition, the DON said that they are currently writing new policies and procedures. They do not have a Care Plan policy at that time, but she expected revisions for the Care Plans happen in a timelier manner.

Based on observation, policy review, manufacturer's instruction, and staff interview the facility failed to properly clean and disinfect a shared glucometer (medical device to measure the amount of glucose in the blood) to maintain standard precautions for infection control. The facility reported a census of 42 residents. Findings include: On 10/11/23 at 11:28 AM observed Staff A, Registered Nurse (RN), used a facility glucometer and completed an accucheck (blood placed on strip into device to check blood sugar) on a resident. Staff A then took the supplies back to the medication cart, wiped off the glucometer with a Sani-Cloth, laid the glucometer on the tray. Within one minute the glucometer dried. Staff A said she thought the contact time (time required for a device to remain wet after cleaned to properly disinfect) for the glucometer to remain wet was 2 minutes and agreed the glucometer did not remain wet for the 2-minute contact time. Staff A reported that she usually just wipes off the glucometer with the Sani-Cloth and allows the glucometer to dry. Staff A explained that it is a facility glucometer and they use it for other residents on the unit. Review of Sani-Cloth manufacturer's instructions revealed to disinfect nonfood contact surfaces thoroughly wet surface and allow treated surface to remain wet for 2 minutes. Review of undated facility policy Standard Precautions, directed to ensure that reusable equipment is not used for the care of another patient until it has been cleaned and sanitized properly. On 10/11/23 at 4:04 PM, the Director of Nursing reported that she expected staff to clean the glucometer with a Sani-Cloth after each resident's use, then have the glucometer remain wet for 2 minutes for the required 2-minute contact time to disinfect.

Based on record review, facility investigative file review, staff interviews and facility policy review the facility failed to implement their policy and procedures after an allegation of abuse for 1 of 3 residents (Resident #2) reviewed. On 12/3/22 (Saturday) a Certified Nurse Aide (CNA) reported concerns of abuse to her charge nurse about another CNA. After the charge nurse learned of the allegation, she sent a nonspecific text message to the on-call leadership staff. In addition, the charge nurse failed to assess Resident #2 for injuries following the allegation of abuse. Due to the nonspecific nature of the text message, the on-call leadership did not respond, evaluate, or report the incident to the Iowa Department of Inspections and Appeals (IDIA) within two hours. The facility failed to report the allegation of abuse to IDIA or assess Resident #2 for injuries until 12/5/23 (Monday). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had severely impaired cognitive skills for daily decision making. The MDS indicated that Resident #2 required extensive assistance of two persons for transfers, walking in her room, walking in the corridor, and with toilet use. She utilized a walker and wheelchair for mobility. The MDS included diagnoses of dementia, hyperlipidemia, anxiety, delirium, and hearing loss. The facility's investigative file included the following summary: -Incident on 12/3/22 at 5:45 AM with Resident #2 -12/3/22 at 5:45 AM Staff A, Certified Nursing Assistant (CNA), went to help Staff B, Licensed Practical Nurse (LPN), perform incontinence care on Resident #2. Staff A stated that she and Staff B cleaned up Resident #2 and transferred her back to her wheelchair. Resident #2 became combative with the transfer. As Staff A cleaned the toilet, she stated that she witnessed Staff B hit (later described as small slap) Resident #2's left shoulder blade and told her do not hit me. Staff A stated she did not think it was meant to hurt Resident #2, but rather more of a reaction to her hitting him. Staff A finished cleaning up and told Staff C, LPN, who was the charge nurse on the other unit. -12/3/22 at 6:26 AM Staff C stated Staff A brought the incident with Staff B and Resident #2 to her attention. Staff C told Staff A to write a statement regarding what happened. Staff C sent a text message to the Leadership by cell phone on 12/3/23 at 6:26 AM stating Staff A reported a situation to her, wrote a statement, and put it under the Director of Nursing's (DON) door. The Assistant Director of Nursing (ADON) was on call at the time. Via text Staff C stated that Staff A was pretty upset and provided the ADON with her number. In a follow-up interview on 12/5/22 at 8:05 AM Staff C told the Director of Nursing (DON) she knew of the abuse policy and the protocol to report immediately. The DON instructed Staff C to call the leadership phone rather than text, if no answer, then call the personal phone of the DON or Administrator until she could contact someone. -12/5/22 at 8:35 AM the ADON completed a head-to-toe skin assessment with no injuries noted to Resident #2's left shoulder blade area. -The Administrator immediately re-educated all other staff to call immediately with suspected abuse until contact with leadership is made. The review of the Self-Report Notification report provided by the facility, the facility reported to the State Agency of an incident on 12/5/22 at 11:13 AM that involved Resident #2. On 2/14/23 at 2:17 PM Staff C explained that Staff A came up to her during report, indicating she wanted to speak with her. After Staff C finished report she met Staff A in the hallway and who indicated they had a situation. Staff A told Staff C that Staff B and her assisted Resident #2 to the toilet when she struck out at Staff B and he smacked her back. Staff A added that he struck her hard enough that her body moved. Staff C advised Staff A to write a statement. Staff C explained that she would call the on-call nurse to let them know about that situation and to have them call Staff A. She sent a text to the on-call phone because of the time of day. She stated the text was brief that said hey there's been a situation with Staff A and that they needed to get ahold of her. She did not leave specifics on a text because it was a text message. Later that day the ADON sent her a text asking if she needed to call Staff A. Staff C messaged her back and indicated it would be a good idea. On that Monday, the DON called her and Staff C explained the situation. The DON informed her that she should have not sent a text, and that she should have called someone about the situation. Staff C stated her thought process was since she reported it to the on-call nurse via test they would take it from there. She knew they had 2 hours to report the incident to the State Agency and she sent a message to her supervisor (on-call at the time) about it. Staff C was asked if she completed an assessment on Resident #2, she indicated Staff A had told her the resident was ok. Staff C's thought process was since she sent the text to the on-call phone they would take it from there. On 2/14/23 at 2:53 PM the ADON stated she was on-call the week Staff C sent a text but could not remember what was sent, something with Staff A being upset. She stated their reporting policy encouraged the staff who are reporting abuse to get a hold of their manager on duty within two hours. It should be reported right away because the facility has to report to the State Agency within two hours of the incident taking place. All the ADON knew was Staff A was upset. When asked if Staff C should have completed an assessment after Staff A had reported the allegation to her, she stated more follow-up should have been done on her part. The ADON indicated she completed the head to toe assessment and found no injuries. She asked Resident #2 what had happened but due to her dementia she could not say. On 2/15/23 at 9:17 AM Staff D, CNA, stated she would report an allegation of abuse to her nurse and/or Administrator. When asked what she would do on the weekend if an allegation of abuse needed to be reported she stated she would call the nurse and/or Administrator until she spoke with them to get guidance on what to do next. She stated report, report, report. On 2/15/23 at 9:18 AM Staff E, Registered Nurse (RN), stated she would report to management if an allegation was reported to her. When asked what she would do if the allegation took place on a weekend she stated she would keep calling management until they answered the phone. She added that she knows that they have two hours to report to the State Agency so she would make sure she spoke to someone about the reported allegation. On 2/15/23 at 10:00 AM the DON stated she was not on call that week, she came to work on Monday and was alerted in some shape or form that something had happened that she needed to follow-up on. She called Staff C and she indicated Staff A was upset that Staff B allegedly struck Resident #2 on the back. Staff C sent a text to the on-call phone about Staff A being upset and to follow up with Staff A. The DON indicated Staff C should have called the on-call number instead of texting; hindsight she knew she should have called. If they are unable to get a hold of the on-call person, they should keep calling until they reach someone. They need to make contact with someone. The DON was asked if Staff C should have completed an assessment after the allegation was reported to her, she indicated should have completed one. On 2/15/23 at 10:08 AM Staff A stated before shift change, her and Staff B assisted Resident #2 to the bathroom and completed care for her. Staff A stated Resident #2 tried to swing at Staff B to hit him and Staff B smacked the resident on her left shoulder blade and said don't hit me. Staff A stated he smacked her hard enough that her upper body moved forward, the resident just looked at Staff B, but she did not say anything. Staff A stated she reported this to Staff C after she gave a report to the on-coming CNAs. Staff C advised her to write up a statement and put it under the DON's office door. Staff A indicated Staff C sent a text to the on-call nurse. The facility's Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 indicated all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator or designated representative. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals no later than two hours after the allegation is made. The policy also stated should an incident or suspected incident of resident abuse be reported or observed the Administrator or designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident. Staff are to: review documentation in the resident record (including review of assessment if resident has an injury) and assess the resident for injury if the allegation involves physical or sexual abuse.

Based on record review, facility investigative file review, staff interviews and facility policy review the facility failed to report an allegation of abuse within two hours to the Iowa Department of Inspections and Appeals (IDIA) for 1 of 3 residents (Resident #2) reviewed. On 12/3/23 (Saturday) a Certified Nurse Aide (CNA) reported to her charge nurse a concern with another CNA hitting a resident. The charge nurse sent a nonspecific text to the on-call leadership after learning of the allegation. The on-call leadership failed to follow up with the facility staff following the text message. On 12/5/23 (Monday) after completing an investigation the facility notified IDIA of the allegation of abuse. The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had severely impaired cognitive skills for daily decision making. The MDS indicated that Resident #2 required extensive assistance of two persons for transfers, walking in her room, walking in the corridor, and with toilet use. She utilized a walker and wheelchair for mobility. The MDS included diagnoses of dementia, hyperlipidemia, anxiety, delirium, and hearing loss. The Care Plan Focus dated 9/28/22 indicated that Resident #2 had impaired cognitive function related to an age-related cognitive decline. She has dementia, inappropriate behaviors, and resides in the memory care unit. Her behaviors included hitting, pinching, spitting, bending staff fingers backwards, licking, biting, scratching, use of different foul, and swear words. The interventions directed the following a. Staff should talk to her in a calm voice when her behaviors are disruptive. b. Reduce any distractions, provide her with necessary cues but stop and return if she is agitated. c. Staff were also encouraged to use redirection techniques when her actions or comments become inappropriate: one-on-one, an activity, food, drink, walk, or change of environment as she allows. The Care Plan Focus dated 10/25/22 listed that Resident #2 needed assistance with her activities of daily living (ADLs) due to her limited mobility and diagnosis of dementia. The interventions instructed that a. Resident #2 has a tendency to refuse help with her ADLs and care. Staff were encouraged to approach her calmly from the front. Provide simple verbal cues and prompting with all of her care as able. If she refuses, staff are to ensure her safety and re-approach at a later time. The facility's investigative file included the following summary: -Incident on 12/3/22 at 5:45 AM with Resident #2 -12/3/22 at 5:45 AM Staff A, Certified Nursing Assistant (CNA), went to help Staff B, Licensed Practical Nurse (LPN), perform incontinence care on Resident #2. Staff A stated that she and Staff B cleaned up Resident #2 and transferred her back to her wheelchair. Resident #2 became combative with the transfer. As Staff A cleaned the toilet, she stated that she witnessed Staff B hit (later described as small slap) Resident #2's left shoulder blade and told her do not hit me. Staff A stated she did not think it was meant to hurt Resident #2, but rather more of a reaction to her hitting him. Staff A finished cleaning up and told Staff C, LPN, who was the charge nurse on the other unit. -12/3/22 at 6:26 AM Staff C stated Staff A brought the incident with Staff B and Resident #2 to her attention. Staff C told Staff A to write a statement regarding what happened. Staff C sent a text message to the Leadership by cell phone on 12/3/23 at 6:26 AM stating Staff A reported a situation to her, wrote a statement, and put it under the Director of Nursing's (DON) door. The Assistant Director of Nursing (ADON) was on call at the time. Via text Staff C stated that Staff A was pretty upset and provided the ADON with her number. -12/5/22 at 8:35 AM the ADON completed a head-to-toe skin assessment with no injuries noted to Resident #2's left shoulder blade area. -The Administrator immediately re-educated all other staff to call immediately with suspected abuse until contact with leadership is made. The review of the Self-Report Notification report provided by the facility, the facility reported to the State Agency of an incident on 12/5/22 at 11:13 AM that involved Resident #2. On 2/14/23 at 2:17 PM Staff C explained that Staff A told her that when she and Staff B assisted Resident #2 to the toilet. Resident #2 she struck out at Staff B and he smacked her back. Staff A added that he struck her hard enough that her body moved. Staff C advised Staff A to write a statement. Staff C explained that she would call the on-call nurse to let them know about that situation and to have them call Staff A. She sent a text to the on-call phone because of the time of day. She stated the text was brief that said hey there's been a situation with Staff A and that they needed to get ahold of her. She did not leave specifics on a text because it was a text message. Later that day the ADON sent her a text asking if she needed to call Staff A. Staff C messaged her back and indicated it would be a good idea. On that Monday, the DON called her and Staff C explained the situation. The DON informed her that she should have not sent a text, and that she should have called someone about the situation. Staff C stated her thought process was since she reported it to the on-call nurse via test they would take it from there. She knew they had 2 hours to report the incident to the State Agency and she sent a message to her supervisor (on-call at the time) about it. On 2/14/23 at 2:53 PM the ADON stated she was on-call the week Staff C sent a text but could not remember what it said, something about Staff A being upset. She stated their reporting policy encouraged the staff who are reporting abuse to get a hold of their manager on duty within two hours. The ADON explained that it should be reported right away because the facility has to report to the State Agency within two hours of the incident taking place. The ADON said that all she knew was that Staff A was upset. On 2/15/23 at 9:17 AM Staff D, CNA, stated she would report an allegation of abuse to her nurse and/or Administrator. When asked what she would do on the weekend if an allegation of abuse needed to be reported she stated she would call the nurse and/or Administrator until she spoke with them to get guidance on what to do next. She stated report, report, report. On 2/15/23 at 9:18 AM Staff E, Registered Nurse (RN), stated she would report to management if an allegation was reported to her. When asked what she would do if the allegation took place on a weekend she stated she would keep calling management until they answered the phone. She added that she knows that they have two hours to report to the State Agency so she would make sure she spoke to someone about the reported allegation. On 2/15/23 at 10:00 AM the DON stated she was not on call that week. When she came to work on Monday, she learned that something had happened that she needed to follow-up on. She called Staff C who indicated that Staff A was upset that Staff B allegedly struck Resident #2 on the back. The DON explained that Staff C sent a text to the on-call phone about Staff A being upset and to follow up with Staff A. The DON indicated Staff C should have called the on-call number instead of texting; in hindsight she knew she should have called. If they are unable to get a hold of the on-call person, they should keep calling until they reach someone. The DON expressed that they need to make contact with someone. On 2/15/23 at 10:08 AM Staff A stated before shift change, she and Staff B assisted Resident #2 to the bathroom and completed care for her. Staff A stated Resident #2 tried to swing at Staff B to hit him and Staff B smacked her on her left shoulder blade and said don't hit me. Staff A stated he smacked her hard enough that her upper body moved forward, Resident #2 just looked at Staff B, but she did not say anything. Staff A stated she reported this to Staff C after she gave report to the on-coming CNAs. Staff C advised her to write a statement and put it under the DON's office door. Staff A indicated Staff C sent a text to the on-call nurse. The facility's Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 indicated all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator or designated representative. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals no later than two hours after the allegation is made.

Based on record review, facility investigative file review, staff interviews and facility policy review the facility failed to assess 1 of 3 residents (Resident #2) following an allegation of abuse. On 12/3/22 (Saturday) a Certified Nurse Aide (CNA) reported concerns of abuse to her charge nurse about another CNA. Following the allegation, the clinical record lacked documentation of an assessment on Resident #2 to determine if any injuries occurred. The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had severely impaired cognitive skills for daily decision making. The MDS indicated that Resident #2 required extensive assistance of two persons for transfers, walking in her room, walking in the corridor, and with toilet use. She utilized a walker and wheelchair for mobility. The MDS included diagnoses of dementia, hyperlipidemia, anxiety, delirium, and hearing loss. The Care Plan Focus dated 9/28/22 indicated that Resident #2 had impaired cognitive function related to an age-related cognitive decline. She has dementia, inappropriate behaviors, and resides in the memory care unit. Her behaviors included hitting, pinching, spitting, bending staff fingers backwards, licking, biting, scratching, use of different foul, and swear words. The interventions directed the following a. Staff should talk to her in a calm voice when her behaviors are disruptive. b. Reduce any distractions, provide her with necessary cues but stop and return if she is agitated. c. Staff were also encouraged to use redirection techniques when her actions or comments become inappropriate: one-on-one, an activity, food, drink, walk, or change of environment as she allows. The Care Plan Focus dated 10/25/22 listed that Resident #2 needed assistance with her activities of daily living (ADLs) due to her limited mobility and diagnosis of dementia. The interventions instructed that a. Resident #2 has a tendency to refuse help with her ADLs and care. Staff were encouraged to approach her calmly from the front. Provide simple verbal cues and prompting with all of her care as able. If she refuses, staff are to ensure her safety and re-approach at a later time. The facility's investigative file included the following summary: -Incident on 12/3/22 at 5:45 AM with Resident #2 -12/3/22 at 5:45 AM Staff A, Certified Nursing Assistant (CNA), went to help Staff B, Licensed Practical Nurse (LPN), perform incontinence care on Resident #2. Staff A stated that she and Staff B cleaned up Resident #2 and transferred her back to her wheelchair. Resident #2 became combative with the transfer. As Staff A cleaned the toilet, she stated that she witnessed Staff B hit (later described as small slap) Resident #2's left shoulder blade and told her do not hit me. Staff A stated she did not think it was meant to hurt Resident #2, but rather more of a reaction to her hitting him. Staff A finished cleaning up and told Staff C, LPN, who was the charge nurse on the other unit. -12/3/22 at 6:26 AM Staff C stated Staff A brought the incident with Staff B and Resident #2 to her attention. Staff C told Staff A to write a statement regarding what happened. Staff C sent a text message to the Leadership by cell phone on 12/3/23 at 6:26 AM stating Staff A reported a situation to her, wrote a statement, and put it under the Director of Nursing's (DON) door. The Assistant Director of Nursing (ADON) was on call at the time. Via text Staff C stated that Staff A was pretty upset and provided the ADON with her number. In a follow-up interview on 12/5/22 at 8:05 AM Staff C told the Director of Nursing (DON) she knew of the abuse policy and the protocol to report immediately. The DON instructed Staff C to call the leadership phone rather than text, if no answer, then call the personal phone of the DON or Administrator until she could contact someone. -12/5/22 at 8:35 AM the ADON completed a head-to-toe skin assessment with no injuries noted to Resident #2's left shoulder blade area. On 2/14/23 at 2:17 PM Staff C explained that Staff A told her that when she and Staff B assisted Resident #2 to the toilet. Resident #2 she struck out at Staff B and he smacked her back. Staff A added that he struck her hard enough that her body moved. When asked if she completed an assessment on Resident #2, Staff C indicated that Staff A had told her that Resident #2 was ok. Staff C's thought process was since she sent the text to the on-call phone they would take it from there. Resident #2 ' s progress notes lacked documentation of a skin assessment following the allegation of abuse on 12/3/22 until 12/5/22. On 2/14/23 at 2:53 PM the ADON stated she was on-call the week Staff C sent a text but could not remember what it said, something about Staff A being upset. When asked if Staff C should have completed an assessment after Staff A had reported the allegation to her, she stated more follow-up should have been done on her part. The ADON indicated she completed the head to toe assessment and found no injuries. She asked Resident #2 what had happened but with her dementia she was unable to say. On 2/15/23 at 10:00 AM when asked if Staff C should have assessed Resident #2, the DON reported that Staff C should have completed an assessment after learning of the allegation. On 2/15/23 at 10:08 AM Staff A stated before shift change, she and Staff B assisted Resident #2 to the bathroom and completed care for her. Staff A stated Resident #2 tried to swing at Staff B to hit him and Staff B smacked her on her left shoulder blade and said don't hit me. Staff A stated he smacked her hard enough that her upper body moved forward, Resident #2 just looked at Staff B, but she did not say anything. Staff A stated she reported this to Staff C after she gave report to the on-coming CNAs. Staff C advised her to write a statement and put it under the DON's office door. Staff A indicated Staff C sent a text to the on-call nurse. The facility's Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 directed staff to review documentation in the resident ' s record (including review of assessment if resident has an injury) and assess the resident for injury if the allegation involves physical or sexual abuse.

Based on record review, physician and staff interviews, the facility failed to adequately assess and provide timely interventions and notify the physician of a resident's change in condition for 1 of 12 residents reviewed (Resident #47). Following the condition change, the resident who was a full code, experienced [CONDITION(S)] and the facility failed to perform CPR (cardio pulmonary resuscitation) as required. This situation resulted in immediate jeopardy (IJ) which was removed on [DATE] when the facility provided staff education and reviewed their policy. The facility reported a census of 46 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment). Resident #47 required the assistance of 2 staff for bed mobility, transfers, toileting and assistance of 1 staff for personal hygiene. The resident ambulated with the assistance of two staff and a walker at the time of the assessment. He experienced occasional urinary incontinence. He had constant pain during the lookback period. The resident was at risk for falls and developing a pressure ulcer. The resident actively participated in the MDS assessment, and his overall expectation was: release to the community upon discharge. A Hospice Certification and Plan of Care, dated [DATE] documented advanced directives: full code. An Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #47 on [DATE] contained the following resident directives: a) Cardiopulmonary Resuscitation (CPR) checked yes b) Medical interventions checked full treatment, including intubation, advanced airway interventions, mechanical ventilation and cardioversion as indicated, transfer to hospital if indicated, includes critical care c) Artificially administered nutrition checked yes for long-term artificial nutrition by tube d) Medical decision making checked by patient Rationale for these orders checked patient knows preference A Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of care update report dated [DATE] starting with page 7 documented: Resident able to sign own consents When discussing IPOST/DNR he elected full code status with full treatment option Resident stated he had been a 'first responder' and had seen the benefit of CPR Resident not ready to elect comfort measures and allow a natural death Advance directives- full code Hospice IDG notes included: [DATE] at 2:48 a.m.: Call from Staff A RN (registered nurse) with facility identifying resident with a change in condition and respirations in the 40's per minute and resident unresponsive. On call nurse notified and visit sent [DATE] at 4:20 a.m.: Call from Staff M, Hospice RN that resident passed away. Death visit sent. Record review of facility document titled Nursing communication, dated [DATE] documented Resident #47 as a resident who wanted CPR (full code). Resident #47's Baseline plan of care, undated, documented Resident #47 as a full code. A facility document titled, Geriatric protocols dated [DATE] and signed by the Medical Director documented standing orders will in no way relieve the nurse from notifying the doctor in any emergency or significant change of the resident condition, under the professional standards of practice. Progress notes dated [DATE]-[DATE] revealed the following: [DATE] at 2:50 p.m. recorded vitals: blood pressure (BP) ,d+[DATE], pulse ox (P.OX) 91% on room air (RA), respirations 15, temperature 98.4 [DATE] at 12:22 a.m. recorded vitals: lack of BP recorded, P.OX 99% RA, respirations 55, temperature 98.4. Staff A RN (Registered Nurse) documented: Resident #47 sleeping soundly, 55 respirations, open mouth breathing, P.OX ,d+[DATE]% on room air, heart rate 122. Resident refused repositioning at midnight. Will continue to monitor. At 2:03 a.m. recorded vitals: B/P ,d+[DATE], P.OX 58% RA (very low), respirations 44, temperature 98.2 At 2:57 a.m. Staff A documented she watched the resident's vital signs. At midnight 55 respirations, 99% room air, 122 heart rate. At 2 a.m. 98.2, ,d+[DATE], 70 heart rate, 44 respirations, 57% oxygen on room air. RN started oxygen at 5 liters per nasal cannula. Resident open mouth breathing. Staff A RN called Hospice and spoke to the Hospice RN and informed her orders listed the resident as full code and that the resident's condition was starting to change. Staff A informed the Hospice RN of current vital signs and oxygen started. The Hospice RN stated she would call the on-call Hospice RN who will come and make a visit. Staff A RN will continue to monitor. At 4:01 a.m. Staff A documented she contacted Hospice at 2:45 a.m. and the Hospice nurse arrived at 3:30 a.m. When Staff A and Staff M (hospice RN) entered resident room, they observed the resident no longer breathing and without a pulse. Staff M hospice nurse confirmed this. The resident was pronounced dead at 3:40 a.m. Staff A called the on-call physician at 3:48 a.m. and the on-call physician called back at 4:05 a.m. and gave a Do Not Resuscitate(DNR) order as well as order to release the body. The facility notified the resident's family notified. Record review of facility document titled Physician Telephone orders dated [DATE] documented the DNR order, Staff A RN signed order with time of 4:05 a.m. (after the resident expired) Record review of facility document titled Death Record dated [DATE] documented Resident #47 expired [DATE] at 3:40 a.m. Review of facility document titled Resident #47 Investigation completed by the Administrator dated [DATE] identified the following: Resident admission day [DATE] Diagnosis-malignant neoplasm of oropharynx Time administrator notified of occurrence (7 a.m.) Administrator contacted Staff A at 7:50 a.m. regarding her nursing entries: she was in resident room at midnight and 2 a.m. to obtain vital signs, placed call to hospice to make aware of change in resident condition and that resident is a full code, hospice nurse arrived at 3:30 a.m., both nurses entered resident room who was not breathing and without a pulse, resident was pronounced at 3:40 a.m. Administrator asked Staff A if she performed CPR and Staff A began to cry and stated she did not administer CPR saying she just couldn't do it. Staff A stated she was afraid she would break him as he is so fragile! Reported incident by phone to the Department of Inspections and Appeal (DIA) at 8:30 a.m. On [DATE] at 9:50 a.m. the Administrator (ADM) stated the following: Resident #47 admitted to hospice but still had an IPOST identifying he still wanted to have treatment. Staff A RN worked 10 p.m.-6 a.m. ,d+[DATE]-[DATE] Staff A RN stated she and the hospice nurse went to Resident #47's room and he was not breathing and they did not do CPR. Staff A told ADM she did not perform CPR because the resident was so fragile she feared breaking him as he was skin and bones. The resident pronounced dead at 3:40 a.m. on [DATE]. On [DATE] at 2:00 p.m. Staff A RN stated the following: Staff A was an RN since 2010 and Staff A's Basic Life Support (BLS) certified and updated ,d+[DATE] Staff A stated if a resident had a change in condition, she would assess the resident, take vitals, give medication or oxygen support and call the doctor for orders She would continue to monitor the resident's responsiveness and call the family or send the resident out If she found a resident unresponsive or not doing well, she would check to see if she could get the resident to respond by calling their name or do a sternal rub, check breathing and pulse, call a code if not breathing or without a pulse, get the resident on the floor to perform CPR, get a crash cart and another nurse for help to call the ambulance and unlock the door so first responders could enter the facility. Staff A revealed the code status of residents kept on report sheets and IPOST in front of the chart. Staff A noticed Resident #47's respiratory rate at midnight when administering his medication via gastrostomy tube (GT). She wanted to keep an eye on him but had other medications to administer and needed to manage her shift. Staff A identified Resident #47's pulse oxygen level (P.OX) at 2 a.m. as 78% (low), she told Staff O, Certified Nurse Assistant (CNA) that the resident needed oxygen but she got interrupted while she retrieved the equipment. Ten minutes later, she applied oxygen at 5 liters/nasal cannula and got the resident's P.OX up to 80% so she tried to increase the oxygen but he was mouth breathing and it (his P.OX) would not go any higher. Staff A called hospice and informed them of the resident's decline and wanted orders, and to send the Hospice nurse to the facility. When the hospice nurse arrived they found the resident expired with a fixed stare, not moving, and without respirations. The Hospice nurse identified time of death as 3:40 a.m. Staff A said she did not call family when the resident had a change of condition or the primary care physician on-call. Staff A stated she did not expect the resident to pass that quickly even with last documented vitals. Staff A said she used to work as a hospice nurse and if a patient was a full code, they would transfer them to the hospital. She felt she was stuck between a rock and a hard place and did what was instinctual for her. She saw the resident as a hospice patient first and a full code second. Staff A revealed the facility kept the code status of residents on report sheets and IPOST in front of the chart Staff A stated CPR would not bring the resident back. He had fixed eyes and no P.OX. Staff A stated she knew when someone was dead and the resident was gone. The resident did not have rigor mortis present but there were no signs of life. Staff A stated CPR would desecrate Resident #47 body Staff A said she last saw the resident around 2:15 a.m. Staff A said she wished she would have called and had the resident transferred out. On [DATE] at 2:56 p.m. Staff M Hospice RN stated the following: Staff M had been an RN since 2018 and BLS certified ,d+[DATE] Staff M stated she arrived to the facility and was met by Staff A at 3:27 a.m. Staff A told her Resident #47 respirations were 40. When they arrived to the room they observed the resident as not responsive. Staff M performed an assessment and the resident did not have a pulse or respirations Staff A left the room to call the on-call Physician Assistant (PA). Staff M attempted to notify family, then her administrator. Staff M called the on-call PA and requested a DNR order post-mortem at 4:30 a.m. as her administrator instructed Staff M identified advanced directives are listed in chart and the Hospice triage nurse who had called her to go to the facility notified her Resident #47 was a full code Staff M said if a resident is a full code, staff should start CPR and carry out facility Code protocol. Staff M said in her experience the facility transferred residents to the hospital when their condition declined because of their full code status. She said there was not a conversation about transferring Resident #47 to hospital or calling an ambulance on [DATE]. On [DATE] at 12:00 p.m. the Physician stated the following: Physician stated the on-call PA was not notified in a timely manner. Physician stated Resident #47 indicated he wanted full code status and everything possible done. Physician identified resident as a full code, expired, and following that Staff A called the on-call PA requesting a DNR (do not resuscitate order), which the PA refused to order and then Staff M called back and requested a DNR order in a threatening manner. Physician stated when a resident is a full code and their health condition declines, as a physician its is treated differently than a DNR. The physician would order an electrocardiogram (EKG), place oxygen on the resident and draw labs. The resident would not be kept in the facility if his/her condition declined-the resident would transfer to a higher level of care. Physician revealed full code status trumps a hospice care order. Medical staff would follow the code status and the code status is on the chart. Physician stated if resident is a full code and without pulse or respirations, the expectation is staff should initiate CPR. The only time staff would not perform CPR on a full code resident is if the resident is blue in color or rigor mortis set in. On [DATE] at 1:10 p.m. Staff P, Licensed Practical Nurse (LPN) stated the following: Staff P had been an LPN [AGE] years and worked at facility 7 years Staff P states she knew Resident #47 status as a full code Staff P stated if a resident experiences a decline in condition or needed assistance she would reach out to co-workers, call the on-call physician, and call for an ambulance. On [DATE] at 1:35 p.m. Staff Q, RN (Hospice Director) stated the following: Staff Q stated when a resident is in hospice and a full code, Staff should uphold the full code status and staff expectation is to do CPR. Staff Q stated when Staff M notified her on [DATE] at 4:30 a.m. Staff M informed Staff Q that protocol not followed correctly in the facility and the facility should have enacted a full code. Staff M contacted the resident's family and received a DNR order. Staff Q stated if a hospice resident who is a full code experiences a change in condition, the facility should notify the facility physician or hospice physician if the change is life threatening, and call 911 if a full code. On [DATE] at 2:15 p.m. the PA who was on-call [DATE] stated the following: PA stated an advanced directive is what a resident wishes at the time of death and if a full code, no matter hospice or not, all measures are taken to keep the person alive. PA stated her expectation is for staff to initiate CPR immediately if a resident is a full code and not breathing. PA stated Staff A called her for DNR order on [DATE] at 4:03 a.m. after Resident #47 expired. Staff A explained the resident was a full code and that she called hospice when he started to decline. The PA told Staff A she would not give a DNR order. PA stated Staff M called her at 5:17 a.m. and requested DNR orders as it is required for release of the body. The PA stated she did not feel comfortable and the PCP needed to give a verbal order. PA stated Staff A admitted she did not perform CPR. Staff A identified the resident as a full code and did not know why she did not initiate CPR. PA stated if she had been called with the change in Resident #47's vital signs, she would of verified his code status and encouraged them to transfer the resident to the hospital to the emergency room and then notify the resident's family. On [DATE] at 12:56 p.m. the resident's primary physician stated he signed the IPOST with the resident on [DATE] after being his provider for [AGE] years. The resident was very clear about his wishes. The physician stated in his opinion, staff should have initiated CPR, as the resident made his wishes to have CPR clear. The physician further stated in his opinion, there was no chance that CPR would have been effective. He described the resident as malnourished, weak, emaciated, and lost weight. The physician stated the facility should not have requested a post mortem DNR. The physician stated if the facility would have notified the provider at midnight when vital signs changed there could have been a chance that the resident's condition could have been stabilized. Facility Policy Review of facility documented titled CPR policy dated [DATE] documented CPR refers to a range of procedures used to attempt to restore heartbeat and breathing following cardiopulmonary arrest. Basic CPR means to open and maintain the airway, providing ventilation through rescue breathing and providing artificial circulation through the use of cardiac compressions. Upon determination that a resident is in cardiopulmonary or respiratory arrest, CPR will be immediately initiated by nursing staff and 911 called unless the resident or surrogate indicated that resuscitation is not desired and the attending physician issues a written do not resuscitate (DNR) order that is maintained in the facility's clinical record, or there is presence of obvious clinical signs of irreversible death such as rigor mortis or dependent lividity. Review of a facility document titled Residents' Bill of Rights dated ,d+[DATE] documented: The resident's wishes and preferences must be considered in the exercise of rights o The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive. Record review of a facility document titled Resident Handbook dated ,d+[DATE] documented: The facility recognized the fundamental rights of residents to execute advanced directives to control the decisions relating to their own medical care and specifically, the right to make an informed acceptance or rejection of proposed treatment, including life sustaining measure. These decisions clearly rest with the resident or, if incompetent, legal representative/family. Immediate Jeopardy Removal: The facility removed the IJ on [DATE] when they educated staff and revised their policy and no remaining deficiencies were found. The State Agency notified the facility of the IJ on [DATE]. Based on observation, record review, resident and staff interviews, the facility failed to provide timely assistance for residents taking diuretics, with issues of incontinence per care plan indicates (#21), and answer the residents call light in less than 15 minutes for 2 of 4 residents (#21 and #22) reviewed. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for Mental Status (BIMS) score of 13 (no cognitive impairment). Resident #21 required the assistance of 2 staff with bed mobility, transfers, dressing and personal hygiene. He did not ambulate due to multiple fractures at the time of this assessment. A Fall Risk Assessment Form dated [DATE] indicated a score of 75, indicating high risk for falls. A Braden scale for predicting pressure ulcers dated [DATE] scored resident at 16 indicating at risk for developing pressure ulcers. Observation showed on [DATE] at 12:59 p.m. Resident # 21 sat in a chair. At that time, he revealed he gets horrible service from some of the nurses. He stated he will use the call light and wait ,d+[DATE] minutes for staff to respond. Record review of facility document titled, Past calls, dated [DATE]-[DATE] for all shifts revealed Resident #21 waited longer than 15 minutes for his call light to be answered 106 times during this timeframe with the longest wait time 1 hour 8 minutes on [DATE] at 6:35 p.m. Record review of facility document titled Care Plan, dated [DATE] revealed: Problem: Resident risk for falls related to history of falling, limited mobility with weakness, and pain. Interventions: Resident receives a daily diuretic which may cause resident to hurry to the bathroom and increase risk for falls. Problem: Resident requires assistance with toileting and receives a daily diuretic. Interventions: Resident receives a diuretic and may need to toilet in a hurry or more frequently; offer and assist to toilet upon rising, around meal times, at HS, and as needed. Staff to assist with peri and incontinence cares. Problem: Resident receives a diuretic related to [CONDITION(S)]. Interventions: Administer diuretic medication as ordered by physician. Problem: The resident requires tube feeding related to dysphagia and inability to consume adequate nutrition orally. Interventions: Monitor/document/report PRN any signs/symptoms of: constipation or fecal impaction, diarrhea. Record review of facility document titled, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #21 received the following medications which may increase his urgency to require the bathroom include: 1- [MEDICATION(S)] 40 mg give 1 tablet by mouth one time a day for diuretic 2- Polyethylene [MEDICATION(S)] 3350 Powder give 17 grams by mouth one time a day for constipation 3- Tamsulosin HCL capsule 0.4 mg give 1 capsule by mouth at bedtime related to [CONDITION(S)] 4- [MEDICATION(S)] Suspension 400 mg/5 ml give 30 ml by mouth two times a day for constipation On [DATE] at 12:03 p.m. Resident #21 pushed his call light and stated he would laugh if staff arrive quickly because he has had to wait an hour when on the toilet for someone to help him in the past. On [DATE] at 9:48 a.m. Resident #21 revealed he once waited an hour and twenty minutes for staff to answer his light and he pooped the bed because staff took too long. Resident #21 revealed it made him feel horrible and embarrassed to make a mess and have to have someone wipe his bottom. He stated that there is not a certain time of day when call lights take longer to be answered. On [DATE] at 12:15 p.m. the Director of Nursing (DON) revealed staff should answer resident call lights within 15 minutes and residents should never have to wait over an hour for their light to be answered. The DON said she provided staff a copy of the weekly call light reports every Friday and posted next to the employee timecard. 2. The Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #24 with a BIMS score of 15, ( cognition intact). The MDS documented the resident required extensive assistance of one staff for bed mobility, transfers, and toileting. The care plan dated [DATE] revealed Resident #24 required assistance of one staff for toileting and pericare/incontinence cares. The care plan directives for staff included to remind the resident to use her call pendant for assistance whenever needed. Review of the Past Calls Report dated [DATE] -[DATE] for Resident #24 revealed the following call light response times: [DATE] at 1:49 p.m. = 15 minutes, 48 seconds [DATE] at 7:06 a.m. = 23 minutes, 4 seconds [DATE] at 1:34 p.m. = 19 minutes, 2 seconds [DATE] at 9:01 p.m. = 16 minutes, 28 seconds [DATE] at 9:09 p.m. = 16 minutes, 59 seconds [DATE] at 5:53 a.m. = 26 minutes, 36 seconds [DATE] at 3:05 p.m. = 25 minutes, 3 seconds [DATE] at 10:24 a.m. = 23 minutes, 29 seconds [DATE] at 12:41 p.m. = 16 minutes, 48 seconds On [DATE] at 1:27 p.m., Resident # 24 reported call light response depended upon the time of day. The resident reported it took staff longer than 15 minutes to respond and provide assistance when she pushed her call pendant. The longer response times tended to occur in the morning and during mealtimes.

Based on record review, resident and staff interview, facility policy review, and manufacturer recommendations, the facility failed to perform proper follow up and investigation to determine the cause of a burn injury after a resident had an e-stim treatment for 1 of 1 residents reviewed who had an e-stim treatment (Resident #24) and failed to remove equipment from operation when found the equipment defective or broken, which resulted in a resident sustaining skin tears to her legs for 1 of 12 sampled residents reviewed (Resident #37). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 with diagnoses that included: pyrogenic arthritis (a serious and painful infection of a joint), [CONDITION(S)], Type 2 diabetes, [CONDITION(S)], and [CONDITION(S)]. The MDS identified the resident with a Brief Interview for Mental Status (BIMS) score of 15, (intact cognition). MDS documentation revealed the resident had moisture associated skin damage and a surgical wound, but did not identify 2nd or 3rd degree [CONDITION(S)]. The care plan revised 12/4/20 identified the resident with a risk for impaired skin integrity related to her activity level and diagnoses of psoriatic arthritis, diabetes, obesity, and chronic right hip wound. Staff directives included to observe the skin daily with cares, perform skin assessments and skin treatments as ordered, and report any concerns to the physician as needed. A fax communication to the physician revealed the following: a. On 1/12/21, the resident had two circles with a white center and redness surrounding the area on her left knee. The areas measured 1.7 centimeters (cm) x 1.1 cm and 0.8 cm x 0.6 cm circles. PT (physical therapy) reported the [CONDITION(S)] from the e-stim machine to the nurse. The areas had no redness or marks when the [MEDICATION(S)] pads removed on 1/8/21. The physician response included to observe for any skin breakdown. b. On 2/22/21, a skin observation tool faxed to the physician revealed 2.0 cm x 1.0 cm wound on the inner side of the resident's left knee from TENS (transcutaneous electrical nerve stimulation) (low voltage electrical current to provide pain relief). The outside of center wound area had redness and irritation and appeared infected. The resident reported pain when the area palpated. The physician ordered [MEDICATION(S)] (antibiotic) ointment and a Band-Aid BID (twice a day). c. On 2/26/21, the resident continued to have a burn to the left knee from an ultrasound used during PT. The area appeared too moist and no longer healing despite [MEDICATION(S)] treatment BID. The physician ordered to discontinue the [MEDICATION(S)] and ordered silver [MEDICATION(S)] to areas affected BID. The medication administration record (MAR) dated 2/1 - 2/28/21 revealed an order for: [MEDICATION(S)] ointment to the left knee BID started 2/22/21, and discontinued on 2/26/21. An order for silver [MEDICATION(S)] cream 1 % applied to the left knee burn BID started 2/27/21. The MAR dated 3/1- 3/31/21 revealed silver [MEDICATION(S)] cream 1% applied to left knee burn 3/1 - 3/22/21. Nursing progress notes dated 1/1 to 3/22/21 revealed the following: a. On 1/19/21 at 1:29 a.m., resident had a recent knee injury 1-3-21 and complained of frequent generalized pain. b. On 2/22/21 12:56 p.m., fax received with a new order to apply [MEDICATION(S)] and Band-Aid BID to the left inner knee wound area. c. On 2/23/21 at 12:46 a.m., a new order to apply [MEDICATION(S)] BID to the inner sore/burn on the left knee. Resident requested pain medication and stated the sore on her left knee did not bother. her. d. On 2/23/21 at 11:26 p.m., resident continued on [MEDICATION(S)] BID to inner sore/burn on the left knee. The area without signs or symptoms of infection. e. On 2/26/21 at 9:34 p.m., order clarified to discontinue [MEDICATION(S)] to left knee burn and apply silver sulfa 1% cream to the left knee burn BID. Family and pharmacy updated. f. On 3/1/21 at 1:05 a.m., resident monitored for treatment of [MEDICATION(S)] BID to left inner knee burn. No signs or symptoms of infection to area. g. On 3/1/21 at 9:27 p.m., resident remains on hotchart monitoring for scabbed area on left inner shin. Applied [MEDICATION(S)] cream during HS (bedtime) cares. The skin assessment observation tool revealed the following to the left lateral inner knee: a. On 1/9/21: two white spots below the knee had two connected circles 1.5 cm x 0.8 cm, and 0.5 cm x 0.5 cm b. On 2/6/21: a dark red, crusted wound 0.5 cm x 1.0 cm and 0.5 cm x 0.5 cm. The surrounding tissue pink and granulating. No treatment applied per orders. c. On 2/20/21: 2.0 cm x 1.0 cm wound from TENS therapy on inner side of left knee. Wound had a red center and scabbed over. The outside of the wound center appeared red and irritated. The resident reported pain when the area palpated. A 0.5 cm x 0.5 cm scabbed over area on the inner side of left knee (above the other wound). The skin around the scabbed area appeared pink and healing well. d. On 2/27/21: the wound had a 1.5 cm x 1.4 cm circular area and 0.1 cm in depth. The wound contained some blackened brown tissue and slight redness noted around the periwound. The PT daily treatment note revealed electrical stimulation performed 1/7/21 for 23 minutes and thermal ultrasound performed for 8 minutes to the resident's lateral left knee at 1.0 to 1.3 to improve circulation for swelling management and pinpoint pain, and to promote healing. Quadripolar [MEDICATION(S)] placement at 80/150 for 10 minutes. Intensity increased to resident tolerance, and resident monitored throughout for intensity and comfort, necessitating adjustments in intensity to improve comfort and cease muscle twitch. The resident also had electrical stimulation 1/8/21 for 22 minutes and thermal ultrasound performed for 8 minutes to the lateral left knee. The PT daily treatment note dated 1/12/21 at 4:31 p.m. revealed thermal ultrasound to lateral left knee for 9 minutes. The resident tolerated treatment well with no sensation felt during the treatment time. Upon visualization of the knee, two areas at medial superior and inferior left knee had wound spots from the Estim treatment. The resident reported she had not noticed the area. Nursing notified but nursing had not noticed the areas either. The nurse documented on the areas. Observations on 3/16/21 at 10:19 a.m., with Staff I, Registered Nurse (RN), revealed a dime sized raised scabbed area to the left lateral inner knee. At the time, Staff I reported she believed the injury occurred when the resident had an ultrasound treatment to the area, and the resident had decreased sensation to the area. Staff I stated the ultrasound possibly got too warm and the resident didn't know it. On 3/18/21 at 1:22 p.m., the Administrator and social worker designee reported no incident reports found for Resident #24. On 3/18/21 at 2:35 p.m., Staff H, Physical Therapy, reported they used an All in One machine to do E-stim, ultrasounds, and TENS treatments. The All in One machine was calibrated once a year at the hospital. Staff H reported she performed an Estim procedure on Resident #24 for circulation and healing to her left knee after the resident twisted her knee and had increased pain and swelling to the area. Staff H stated she placed the electrodes around the resident's knee joint, then started slowly to increase the intensity. Staff H stated the resident had an E-stim treatment in the past and knew to let her know if she had any sensation to the area. Staff H stated the resident should feel a gentle [NAME] sensation, and the resident told her if the current felt too strong or if she needed the setting changed. She relied on the resident to tell her as it's a subjective evaluation. Staff H stated she performed the treatment less than 15-20 minutes. Staff H reported Estim treatments are contraindicated if the resident is a quadriplegic or resident has a lack of sensation to the area treated. Staff H reported if the electrodes not 100 % on the skin or not sticky enough, it could cause surface irritation and redness to the area where the electrodes were placed. Staff H stated the resident only had Estim once, the next time Estim performed, she let the nurse know about the reddened skin area. Staff H reported no incident report filled out, she just let the nurse know. On 3/22/21 at 11:55 a.m., Resident # 24 reported she got a small burn to her left knee when she had a procedure done in therapy a couple of months ago. The resident recalled the procedure lasted only a few minutes, and she felt the area getting warm but did not feel a burn at that time. The resident reported she had diabetes and numbness and tingling in her feet. On 3/22/21 at 3:30 p.m., Staff H, showed the surveyor the Chattanooga All in One machine used for E-stim and ultrasounds at the facility. Staff H reported they used the multistim electrodes. Staff H stated she applied the electrodes to the affected site whenever a treatment was performed. The electrodes were obtained from the facility's vendor. The electrodes came in a package of four electrodes, and the electrodes already had the gel on the [MEDICATION(S)] pads. She marked the package each time the electrodes used. The electrodes are good for ten uses. Staff H reported the machine gave a warning if they had bad contact with the [MEDICATION(S)] and the Estim machine, or if something was overheated. Staff H stated she received training on the machine when she attended therapy training but had no other training on the All in One equipment or device. Staff H confirmed Resident #24 had e-stim treatments on 1/7/21 and 1/8/21. She then switched to an ultrasound on 1/12/21 when she noticed the resident had discoloration to her left leg/knee area. Staff H stated she let the resident's nurse know when she noticed the wound area. On 3/23/21 at 3:45 p.m., the Director of Nursing (DON) reported she was told at a multidisciplinary (MDR) team meeting that during Resident #24's therapy session and use of a TENS machine, it resulted in a burn to the residents leg. The DON reported she was unsure of the date when the injury occurred or the date of the MDR team meeting but planned to check her notes and let the surveyor know. The DON reported they place the resident on hotchart in order to track the resident and do a skin assessment each week. When she found out about the burn, she spoke with Staff H, PT and Staff H relayed to her what occurred during the resident's therapy session. The DON acknowledged she was unsure what had caused the burn. The manufacturer's equipment manual for the Chattanooga Intelect Legend XT 2 Channel Electrotherapy System revealed an application of therapeutic deep heat for the treatment of selected chronic medical conditions such as for pain relief, muscle spasms, and joint contractures, soft tissue injuries. The electrotherapy system is contraindicated in residents for symptomatic local pain relief unless etiology is established or unless a pain syndrome has been diagnosed , and should not be used on ischemic tissues in individuals with vascular disease where the blood supply would be unable to follow the increase in metabolic demand and tissue necrosis might result. Stimulation should not be applied over swollen, infected, and inflamed areas or skin eruptions, such as phlebitis, thrombophlebitis, or varicose veins. Some patients may experience skin irritation or hypersensitivity due to the electrical stimulation or electrical conductive medium. The irritation can usually be reduced by using an alternative conductive medium or an alternative [MEDICATION(S)] placement. [MEDICATION(S)] placement and stimulation settings should be based on the guidance of the prescribing practitioner. The equipment manual revealed powered muscle stimulators should be used only with the leads and electrodes recommended for use by the manufacturer, to keep the electrodes separated during treatment because electrodes in contact with each other could result in improper stimulation or skin [CONDITION(S)]. The output current density is related to [MEDICATION(S)] size. Improper application may result in patient injury. If any question arises as to the proper [MEDICATION(S)] size, consult a licensed practitioner prior to therapy session. The manufacturer recommended DURA-STICK (Trademark) Electrodes used, a self adhesive, single patient, one time use disposable product designed specifically for use with Chattanooga Group Electrotherapy systems. It is recommended that Chattanooga Group DURA-STICK (Trademark) Electrodes be used whenever possible to ensure the highest level of contact with the treatment area and most uniform delivery of the prescribed electrotherapy treatment. DURA-STICK (Trademark) Electrodes are manufactured to ensure the optimum conductivity during therapy when properly applied. Potential adverse effects with therapy are skin irritation and [CONDITION(S)] beneath the electrodes have been reported with the use of powered muscle stimulators. The procedural steps included the following: a. Examine the skin for any wounds and clean the skin. b. Apply the electrodes to the treatment area. Ensure the electrodes are applied securely to the skin. c. Check the [MEDICATION(S)] contact regularly during the treatment. d. Examine the skin again after the treatment. e. Choose electrodes that fit the anatomy. f. Follow [MEDICATION(S)] manufacturer instructions. (https://www.healthproductsforyou.com/p-chattanooga-intelect-legend-xt-2-channel-electrotherapy-system.html?utm_source=google&utm_medium=surfaces&utm_campaign=shopping%20feed&utm_content=free%20google%20shopping%20clicks&gclid=Cj0KCQjwo-aCBhC-ARIsAAkNQiuaGzR1ncpEjZVT9DNHau5UFjsKmGtFRdHpFMEAxi485csSaOT0gk8aAupPEALw_wcB) According to: https://www.verywellhealth.com/electrical-stimulation- 22 If electrical stimulation is applied with an intensity that is too great, tissue [CONDITION(S)] may occur. 2. The MDS assessment dated [DATE] documented Resident #37 with diagnoses of: non-Alzheimer's dementia, [CONDITION(S)] Disease, and adult failure to thrive. The MDS identified the resident had severely impaired cognition. The MDS revealed the resident required extensive assistance of two staff for transfers and utilized a wheelchair. The MDS documented the resident had no wounds, ulcers, or other skin problems. The care plan revised 8/18/20 identified the resident had a risk for impaired skin integrity related to immobility, incontinence, and very fragile skin. The care plan intervention instructed staff to use caution during transfers and repositioning and cares to prevent arms, legs, and hands from rubbing against any sharp or hard surface, observe skin daily with cares and report as necessary, and place a pillow on the wheelchair footrest before transfers for skin protection. The care plan revealed the resident transferred with the assistance of two staff, and used a Broda wheelchair for all mobility and staff to propel the resident on and off the unit. The medication review report dated 3/4/21 signed by the physician, revealed an order to monitor the resident's left lower leg lateral side skin tear areas daily for any signs or symptoms of infection, and complete a skin assessment until the area healed started on 2/28/21. A fax communication to the physician dated 2/26/21 revealed the resident sustained a skin tear while two CNA's transferred the resident from her wheelchair for her shower. A gait belt was wrapped around the base of the resting foot panel and the buckle of the gait belt stuck out on the side and consequently the resident's leg rubbed against the buckle. The physician ordered Vaseline and a non-adherent dressing with gauze roll applied to the area BID until the area healed. An incident report dated 2/26/21 at 7:15 p.m., documented the resident received three skin tears to her left outer lower leg during a transfer. The skin tear measurements recorded as 3.5 cm (L) x 2.0 cm (W) x 0.1 cm (D), 2.5 cm (L) x 1.5 cm (W), and 3.5 cm (L) x 2.5 cm (W). All were surface wounds and had light sanguineous drainage. A fax was sent to the physician and an order obtained to apply Vaseline, a nonstick dressing, and kling BID. Family was notified. At 10:41 p.m., Staff E, Registered Nurse (RN) recorded a witness statement as to what had happened. Staff D, CNA, reported the resident sustained the open areas to her left outer lower leg upon transfer from the chair to the bed. Staff D indicated a gait belt wrapped around the lower foot platform and the resident's leg came in contact with the buckle located on the side of the platform. Staff unaware of why a gait belt had been placed around the foot platform. In a follow up report of the incident on 3/2/21 at 12:08 p.m., the DON documented no occurrence specific follow up factors available, no staff interviews available, and no recommendations. The DON concluded staff education provided and maintenance to repair the Broda chair. The MAR dated 2/1- 2/28/21 revealed a treatment for petroleum jelly, non-adherent dressing and rolled gauze to the right lower leg skin abrasion until the area healed, started on 2/13/21 and discontinued 3/7/21. The MAR dated 3/1 - 3/31/21 revealed an order to monitor the left lower leg lateral side skin tear areas for signs and symptoms of infection, and complete a skin assessment daily until the area healed started on 3/6/21. A treatment to the left lower leg included to cleanse the wound with wound cleanser, pat dry, apply a collagen pad to the wound bed, cover with [MEDICATION(S)] pad, and gauze until the area healed began on 3/6/21, and treatment changed on 3/18/21. The MAR included treatment to the right lower leg to apply a thin layer of petroleum jelly, and cover the wound with a non-adherent dressing and rolled gauze until the skin abrasion area healed was discontinued on 3/7/21. The progress notes revealed the following: a. On 1/29/21 at 3:27 a.m., resident is a two person pivot transfer or EZ stand and used the Broda wheelchair. b. On 2/12/21 at 2:04 p.m., during morning time this nurse called into the resident's room. Noted the resident had a small superficial open area to her right shin area. Dried blood noted on the resident's pajamas. Skin area cleansed with saline and Vaseline and [MEDICATION(S)] dressing applied. A fax sent to the physician's office and family notified. c. On 2/17/21 at 1:16 p.m., the physician noted the skin issue to the resident's right lower leg and in agreement with treatment per protocol. d. On 2/26/21 at 8:01 p.m.,Vaseline and non-adhesive dressing and gauze roll applied to three open areas on the left outer lower leg. A fax sent to the physician's office to see if treatment may be performed BID until the area healed. Family made aware. e. On 2/28/21 at 10:25 a.m., the left lower leg lateral side had three open areas: 3.5 cm x 2.5 cm half skin flap missing, 2.5 cm x 2.5 cm and tried to pull back skin flap, 3.5 cm x 2.5 cm skin flap intact, steri- strips applied. During dressing change fresh blood oozed from the wound. The wound cleansed with wound wash, patted dry, and Vaseline and non-stick [MEDICATION(S)] dressing and rolled gauze applied to the open areas. f. On 3/5/21 at 7:07 a.m., right lower shin skin abrasion healed. g. On 3/5/21 at 3:37 p.m., resident seen by a wound care nurse and recommended collagen pad to the wound bed. Physician in agreement with the treatment. Order carried out for left leg treatment and family notified. h. On 3/15/21 at 3:01 p.m., left lower leg cleansed with wound cleanser, and collagen pad applied to the wound bed. Area covered with [MEDICATION(S)] pad and gauze. Collagen pad held due to areas are scabbed and dry. i. On 3/17/21 at 9:17 p.m., new dressing orders received for left lower extremity to apply a think layer of petroleum jelly and cover the area with a nonstick dressing and rolled gauze daily until the area healed. The skin observation tool documented the following skin assessments: To the right lower leg (front) 2/9/21 at 5:24 p.m., no skin issues identified. 2/12/21: at 2:05 p.m., a 1.5 cm x 1.0 cm open area. Vaseline applied. 2/17/21: a fading bruise and skin tear had no drainage or swelling, and area healing 2/26/21: 0.4 cm x 0.3 cm superficial open area without drainage and healing. Bruise fading and no redness or swelling. 2/28/21: 0.3 cm x 0.3 cm superficial open area. Vaseline applied. 3/4/21: wound healed. Area left open to air. To the left lower leg: 2/9/21 at 5:24 p.m., no skin issues identified. 2/26/21 - 3 open areas: 3.5 cm x 2 cm, 2.5 cm x 1.5 cm, 3.5 cm x 2.5 cm. Vaseline and nonstick dress and gauze roll applied. 2/28/21 On the left lateral side had three open areas: 3.5 cm x 2.5 cm half skin flap missing, 2.5 cm x 2.5 cm tried to pull back skin flap, 3.5 cm x 2.5 cm skin flap intact, steri- strips applied. The wound had fresh blood oozing. Vaseline and nonstick dressings and gauze roll applied. 3/4/21 3 open areas: 3.5 cm x 2.5 cm half skin flap missing, 2.5 cm x 2.5 cm tried to pull back skin flap, 2.5 cm x 2.5 cm skin flap intact, steri- strips intact. dry drainage noted on old dressing, Vaseline and nonstick dressing and gauze applied 3/9//21 the wound had moderate dried red drainage and scabbing. Area left open to air after whirlpool. 3/15/21 wound almost healed. Dry scabs intact. Collagen pad held due to no open areas. 3/16/21 skin tears are healing well. The proximal area had a pinpoint open area with small amount of clear red drainage. The middle skin tear had closed and the distal skin tear had an intact scab. A Maintenance Request form dated 2/17 at 10:45 a.m. Staff N, Activities, wrote the resident's wheelchair footrest would not go down. On 2/18 at 5:00 p.m., Staff R wrote the wheelchair foot rest broken and would not go down, and it was not safe and very difficult to transfer the resident. Staff G, Maintenance, documented the wheelchair equipment checked on 2/1/21 at 8:30 a.m. A Company Sales Order dated 3/1/21 revealed a cable and handle ordered (for the Broda chair). Observations revealed the following: a. On 3/15/21 at 9:07 a.m., Resident # 37 sat in a Broda chair in the dining room. The resident had geri-sleeves on her arms. b. On 3/16/21 at 11:20 a.m., two CNA's used a gait belt and transferred the resident from a recliner to a Broda chair. Staff placed a pillow between the residents legs and knees. c. On 3/16/21 at 11:25 a.m., Staff C, LPN, performed a treatment and dressing change to the resident's left lower leg. The lower and middle wounds had a scabbed area, and the upper wound had an approximate 1.0 cm open area. Staff C performed the wound treatment and applied a small piece of collagen to the open wound, then applied petroleum jelly on all of the wound areas to prevent the dressing from sticking. Staff C then applied a non-adherent dressing and gauze to the left lower leg. On 3/16/21 at 11:36 a.m., Staff C, Licensed Practical Nurse (LPN), reported Resident #37 had gotten a wound to her left lower leg when the leg pedal on her Broda chair wouldn't stay up. Staff C reported maintenance had fixed the chair, and the wound area healing. On 3/18/21 at 1:51 p.m., Staff D, Certified Nursing Assistant (CNA), reported Resident #37 required assistance of two staff and use of a gait belt for transfers. Staff D reported the resident incurred a skin injury to her left lower leg on 2/26/21 when Staff R, CNA and her transferred the resident from the shower chair to the Broda chair. Staff D reported there was a gait belt wrapped around the lower part of the chair by the foot/leg rest. Staff D said someone had told someone to put the gait belt on the chair. Staff D stated she was unsure how long the gait belt had been on the chair, she normally worked on another unit. Staff D reported she had talked to the DON and was told someone had ordered a CNA to put the gait belt around the chair but didn't know who instructed the order, or who had attached the gait belt to the chair. Staff D explained the pedal part on the Broda chair sprung up and lifted up but the hydraulics were broken and there was no way to keep the foot pedal from coming up, so they used a gait belt as a rope to hold it down. Staff D reported whenever equipment or something broken they notified maintenance. Staff D stated she called maintenance or filled the maintenance request form found in a file at every nurse's station and placed it in the file. On 3/18/21 at 2:54 p.m., Staff E, Registered Nurse (RN), reported whenever equipment needed checked or repaired, she filled out a form for maintenance. Maintenance checked the notebook to see whatever needed repaired or checked. Staff E stated Resident # 37 required assistance of two staff and she thought a hoyer for transfers but needed to look at the care plan to know how the resident transferred. Staff E confirmed she was the charge nurse on 2/26/21 when Staff D reported to her that resident #37 had sustained a cut on her left lower extremity. Staff E checked the resident while she was lying in bed. The CNA had reported to her that the injury had occurred when they transferred the resident. Staff E reported a gait belt had been used to stabilize the footrest on the bottom portion of Broda chair. It was her understanding someone had ordered a part for it. Staff E stated the buckle of the strap was supposed to be toward the back of her chair, but the buckle had somehow moved to the side of the chair. She acknowledged she saw the chair after the incident had occurred and this is what she saw. She thinks that the buckle caused the wound or opening on the resident's leg during the transfer. Staff D stated she was uncertain what was wrong with the Broda chair or how long the chair had been broken, she just knew a part had been ordered for it. The gait belt was used to stabilize the pedal near the bottom of the chair. Staff D reported she was uncertain why the chair had not been taken out of service or who made the decision to keep the chair in operation. On 3/22/21 at 9:40 a.m., the DON reported she had spoken to Staff D when Resident #37 got a skin tear to her lower leg. Staff D reported she had another staff person come from another unit and assisted when transferred the resident. The DON reported the resident's Broda chair had something broken and had maintenance repair it. On 3/22/21 at 10:29 a.m., Staff F, Environmental Specialist, reported whenever something needed repaired or checked by maintenance, staff wrote in a maintenance log book located on each unit. When the equipment or item repaired, maintenance staff wrote the date and time completed on the same form in the book. On 3/22/21 at 10:50 a.m., Staff G, Maintenance, reported he completed the repair on resident #37's Broda chair on 3/1/21, not 2/1/21. Staff G acknowledged he made an error when he dated the requesting maintenance form. Staff G reported he removed a cable from another resident's chair that needed a [NAME], and placed the cable on Resident #37's chair while he waited for the part to get shipped. He knows the date was 3/1/21 because that was the date he ordered the cable. Staff G provided a copy of the order requisition to the surveyor. Staff G reported he became aware of broken chair on 3/1/21, when someone wrote footrest broken on the maintenance request form. Staff G reported he checked the footrest but couldn't find anything wrong with it. The footrest was down. The next day, someone wrote the foot rest broken. He again checked the foot rest and it looked fine, so he asked someone what was wrong with it. At that time, staff showed him the chair, and it was the leg rest, not the foot rest that was broken. Someone had put a strap around the leg rest to keep if from going up. Staff G recognized that the cable was broken and ordered a new one. Staff G reported nobody took the chair out of service when they had first requested maintenance. On 3/23/21 at 3:45 p.m., the DON reported the staff wrote in the maintenance book located on each nursing area whenever equipment or something not working or needed checked. The DON reported all staff expected to write in the maintenance book but uncertain how often maintenance checked the book. The DON reported she had no idea who put the gait belt on Resident #37's Broda chair foot/leg rest, she had asked staff but nobody came forward. The DON stated they had other equipment available that could be used in order for broken equipment to get fixed. She reported she was uncertain why staff continued to use the chair because they had another Broda chair that was not in use. The DON reported she expected staff took broken equipment out of service and not use the broken equipment in order to prevent injury to the residents. On 3/24/21 at 8:28 a.m., Staff N, Activities Coordinator, reported whenever she noticed equipment broken or something not working properly, depending upon what it is, she picked it up and wrote a request in the maintenance log to have the item looked at. Staff N reported if something is in harms way, she picked it up, and called maintenance staff right away for them to check the item. Staff N reported she worked on 2/17/21 and reported Resident #37's Broda chair footrest not staying up. Staff N thought maybe the hydraulics went out on the footrest part of the Broda chair because when she tried to elevate the resident's feet, the leg rest wouldn't stay up, so she put a pillow under it to try to keep the leg rest up. Staff N reported she was uncertain how long the chair had been like that, but on 2/17/21 was the first time she had found the problem. Staff N reported she paged maintenance on the walkie to let them know about the chair and wrote in the maintenance log book. Staff N stated there was no strap or belt or anything else attached over the lower portion of the Broda chair on the day she found it malfunctioning. On 3/24/21 at 10:45 a.m., Staff G reported a CNA, not sure which CNA, came up to him and on 3/1/21 to show him Resident #37's Broda chair and what they referred to about the footrest not working. He had looked at the chair prior to that but didn't find anything wrong with it. Staff had written down what they thought was wrong and indicated it was the footrest, but it wasn't, it was the leg rest. Staff G reported he had not noticed any kind of strap or device on the chair to hold the broken leg/footrest in place. Staff G reported the facility had another chair just like the one the resident used and they could've used another chair when they found the resident's chair broken. Staff G stated he planned to work on letting staff know to call and report something broken if needed fixed right away, and not just write it in the maintenance book if something needed looked at right away.

Based on personnel file reviews, facility policy review and staff interview, the facility failed to assure all employees had an Iowa criminal background check and abuse registry checks completed prior to working in the facility for one of five current employees sampled (Staff A). The facility identified a census of 46 residents. Findings include: 1. A new hire staff list provided to surveyors by the facility during the survey week revealed Staff A's hire date 9/7/20. The personnel file for Staff A, Registered Nurse, documented a hire date of 9/7/20. Staff A's criminal background and abuse registry checks completed 9/17/20. An employment history attendance record (time sheet) revealed Staff A worked at the facility on the following dates: 9/7/20, 9/8/20, 9/9/20, 9/10/20, 9/13/20, 9/14/20, 9/15/20, 9/16/20. The facility's Abuse Prevention, Identification, Investigation, and Reporting Policy updated 2/2020, revealed the facility screened all potential employees for abuse, and conducted an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire. On 3/16/21 at 3:45 p.m., the Administrator reported Staff A hired 9/7/20. The administrator reported she was unsure why Staff A's background check not completed until 9/17/20. When completed on 9/17/21, the checks revealed no criminal or abuse background.

Based on clinical record review and staff interview, the facility failed to refer one of one sampled residents (Resident #37) with a negative Level I result for the Pre-Admission Screening and Resident Review (PASRR) who had a possible serious mental disorder, intellectual disability, or other related condition to the appropriate state-designated authority for Level II PASRR evaluation and determination. The facility reported a census of 46 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 indicated the resident not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident took an antipsychotic and and an antidepressant medication seven of seven days during the look-back period. The quarterly MDS dated [DATE] revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident took an antidepressant medication seven days during the look-back period. The care plan initiated 3/19/20 revealed the resident at risk for side effects due to taking [CONDITION(S)] medications. The staff directives included to administer medications as ordered, and monitor for side effect and effectiveness of the medications, monitor mood state, and report any changes in mood or behaviors to the physician. Review of the electronic health record diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a Level 1 PASRR with a notice date 7/7/14. The PASRR indicated the resident had no suspected or confirmed mental health disability. The PASRR revealed the resident met criteria for nursing facility placement. The PASRR instructed the facility that re-evaluation required if the resident had a known or suspected major mental illness or intellectual disability or had significant change in her treatment. The clinical record lacked documentation that facility staff referred Resident #37 for a PASRR re-evaluation and determination, and review, when had a change in mental health diagnoses. On 3/17/21 at 2:00 p.m., the social worker designee confirmed Resident #37's last PASRR completed on 7/7/14.

Based on observation, clinical record review, resident and staff interviews, the facility failed to follow the plan of care for twice a week bathing assistance, as well as provide assistance at the resident's (Resident #21) choice of time for bathing for 1 of 5 residents reviewed. The facility reported a census of 46 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) revealed a score of 13 (no cogntive impairment). Resident #21 required the assistance of 2 staff with bed mobility, transfers, dressing and personal hygiene. The resident did not ambulate due to multiple fractures at the time of the assessment. A Fall Risk Assessment Form dated 1/13/21 revealed a score of 75, indicating high risk for falls. A Braden scale for predicting pressure ulcers dated 1/13/21 scored resident at 16 indicating at risk for developing pressure ulcers. Observation revealed on 3/8/21 at 12:59 p.m., the resident appeared thin, hair combed, clothes with food stains, disheveled overall appearance. Observation revealed on 3/10/21 at 7:57 a.m., the resident with hair combed, glasses on, pants pulled down (appear to be clothes worn during last conversation) while he sat in chair while using a urinal. At that time the resident revealed he did not recieve routine showers. Review of facility shower logs titled, ADL-bathing from 2/15/21-3/16/21, revealed Resident #21 received 5 showers and refused 3 showers. The time of the showers documented as from 8:01 pm-9:59 pm. for all showers. On 3/15/21 at 12:03 p.m., the resident revealed staff offered a shower last Friday night at 11 pm. The resident stated he was asleep when they asked if he wanted a shower so the resident said no. The resident asked if he could have the shower in the morning, and staff informed him he would have to wait until his next shower day on Tuesday. The resident revealed he did not receive a shower in two weeks. On 3/18/21 9:48 a.m. the resident identified no choices given to when he preferred to take a shower and staff informed him that they only had evening showers avilable. The resident verified he did not want showers at 10 pm at night and he informed staff of this preference. Thge resident stated he asked all last week for a shower and did not get it until this past Tuesday. The resident revealed he refused one bath and that was only because it was offered at 11 pm at night. On 3/16/21 at 11:12 p.m. the resident clarified he only refused one bath since admission, which was last Friday (3-12-21) due to it being at 11 pm at night and he was asleep. The resident revealed his clothes contained stains and staff had not assisted him with putting in clean clothes for 2 weeks. On 03/18/21 at 12:15 p.m. the Director of Nursing (DON) revealed upon resident admission the nursing staff ask if there is a preference for shower times. She stated when someone has an evening shower the certified nursing assistants (CNA's) will ask if they want to shower before or after dinner. The DON revealed she would not expect any residents to be showered as late as 10 or 11 p.m. unless the resident specifically requested. On 3/18/21 at 3:00 p.m. the Administrator (ADM) identified it as acceptable for a resident to request a shower the next day from their scheduled day and stated the CNA's would carry that request out. The ADM verified residents would not have to wait for a shower on their next scheduled shower day.

Based on observation, clinical record review and staff interviews, the facility failed to administer [CONDITION(S)] medications to promote or maintain a resident's highest practicable mental, physician and psychosocial well-being for 2 of 5 residents. The facility administered antipsychotic medication in the presence of adverse consequences to Resident #29. The resident also had an unwarranted increase in an antipsychotic drug. Staff indicated Resident #29 slept during the day and was awake at night. Staff failed to document Resident #29's drug side effects in the record. The facility failed to attempt non-pharmacological interventions prior to administration of a PRN (as needed) anti-anxiety medication for Resident #20. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 with a diagnosis of [CONDITION(S)] without behavioral disturbance; non-traumatic brain dysfunction; non-Alzheimer's dementia; anxiety; depression; [CONDITION(S)]. The resident had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Resident #29 is usually able to understand others and make herself understood by others. Resident on anti-psychotic 7 of 7 days during lookback period. She did not display any behaviors indicating [CONDITION(S)] such as hallucinations or delusions, nor did she exhibit any behaviors which impacted herself or others. Resident #29 required the assistance of 2 staff with bed mobility, transfers, toileting, and assistance of 1 staff for eating. She was able to ambulate with assistance of 1. Resident #29 is frequently incontinent of urine and occasionally incontinent of bowels. She has had an 11.6% weight loss in the past 6 months. She is at risk of developing pressure ulcers. Observation of Resident #29 on 3/8/21 at 12:11 p.m. in dining area, hunched over in wheelchair, eyes closed, and appeared asleep. Review of nursing progress notes revealed staff failed to document the drug side effect in the notes. Observation of Resident #29 on 3/15/21 at 9:55 a.m. sitting in recliner in common area with a blanket on her lap, head leaned forward, eyes closed, appeared to be asleep. Observation on Resident #29 on 3/15/21 at 11:20 a.m. sitting in wheelchair, head down, appeared to be asleep. Review of nursing progress notes for 3/15/21 revealed staff failed to document the drug side effect in the notes. Observation on 3/17/21 at 10:44 a.m. of Resident #29 sitting in common area with head leaning to left sitting in recliner, appeared to be asleep. Staff B, Certified Nurse Assistant (CNA) revealed the staff was told in morning report Resident #29 had a restless night and she that she had slept most of morning. Review of nursing progress notes revealed staff failed to document the drug side effect in the notes. Observation of Resident # 29 at 3/18/21 09:55 a.m. sitting at dining table with head down and eyes closed. Staff J (CNA) shared she was told the resident had a good restful night. Observation of Resident #29 on 3/18/21 at 12:30 p.m. sitting at dining table with lunch meal in front of her, resident head was down and she appeared asleep. Staff J, CNA shared with the Staff C, Licensed Practical Nurse (LPN) that Resident #29 would not wake up so she could feed her and continued to sleep. Resident did not eat lunch. Review of nursing progress notes for 3/18/21 revealed staff failed to document the drug side effect in the notes. Observation of Resident #29 3/22/21 at 9:50 a.m. sitting in a wheelchair in the dining room with her head down appeared to be asleep. Review of nursing progress notes revealed staff failed to document the drug side effect in the notes. Nursing progress notes revealed the following: 1/6/21 at 1:13 p.m. Slept half the shift 1/7/21 11:37 p.m. Slept all afternoon. Pocketing food and not swallowing. Let house supplement drip from mouth. 1/8/21 3:03 p.m. Slept half the shift. Pocketing food. fell asleep on the dining room table. At 9:45 p.m. of the same date, let fluids run from mouth 1/11/21 3:38 a.m. Resident declining 1/13/21 2:29 p.m. Physician decreased [MEDICATION(S)] (antipsychotic) to 2.5 milligrams (mg.) at bedtime for 7 days and then evaluate. The general care clinic note dated 1/13/21 revealed the physician observed the resident sleeping and ordered the drug decrease due to deterioration in heath status. 1/14/21 3:17 p.m. No behaviors 1/15/21 1:51 p.m. Resident lethargic on 6 a.m. -2 p.m. shift, to be expected as resident awake quite a bit throughout the night. Cooperative with shower 1/16/21 3:38 p.m. Very quiet slept half the shift 1/17/21 11:20 p.m. Combative with toileting 1/18/21 3:05 a.m. Resting quietly 1/19/21 2:46 a.m. Trying to stand 1/20/21 3:56 a.m. No behaviors 1/20/21 4:14 p.m. [MEDICATION(S)] increased. Additional information submitted to the State Agency on 3/30/21 revealed the increase in response to a fax the facility sent the physician reporting resident more restless over the past week. The fax identified the resident as awake all night at least twice that week so physician increased the antipsychotic drug. On 1/23/21 at 1:10 p.m. Resident #29 lethargic and quiet this shift, awake for meals (eating very little) but no verbal response. 1/25/21 1:25 p.m. Slept on and off this shift 1/27/21 7:47 p.m. Resident has days she is quite sleepy and other days and nights when very restless. On 2/4/21 at 9:48 p.m. documented resident asleep most of shift. On 2/13/21 at 12:48 a.m. documented resident compliant with cares without negative behavior. On 3/2/21 at 4:37 a.m. Resident restless at beginning of shift. She was assisted to bed, she moved about in bed, was talking to self and not sleeping. Awake part of shift before falling asleep. 3/3/21 4:17 p.m. Slept through supper On 3/10/21 at 12:48 p.m. Resident #29 no negative behaviors. On 3/13/21 at 3:47 a.m. Resident #29 restless at beginning of shift, was in recliner trying to get up per self. She was toileted twice then went to bed. On 3/17/21 at 5:53 a.m. documented not behaviors, rested well this night with eyes closed. Record review of facility document titled Medication Administration Record (MAR) dated 2/1/21-2/28/21 and 3/1/21-3/31/21 revealed: [MEDICATION(S)] tablet 2.5 mg give 1 tablet by mouth two times a day related to Major Depressive Disorder (MDD) until 2/4/21 (started 1/20/21) Record review of facility document titled Care Plan, with a revision date of 12/1/2020: Problem: Resident risk for side effects is due to [CONDITION(S)] medication. Interventions: Administer medications as ordered. Monitor for any ASE (adverse side effects) and report concerns to doctor; Evaluate effectiveness and side effects of medications for possible decrease/elimination of [CONDITION(S)] drugs; GDR (gradual dose reduction) as appropriate; Monitor mood state and report any changes in mood, behavior, or affect to doctor. Problem: Resident has impaired cognitive function related to diagnosis of [CONDITION(S)]. I have exhibited aggressive behaviors staff in the past. Interventions: Administer medications as ordered. Monitor/document/report PRN any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty understanding others, level of consciousness, mental status; Monitor and chart behaviors if they occur; Offer a calm, quiet environment if resident agitated or upset. Record review of facility document titled Nutrition/Dietary Note: Significant Change/Nutritional Care Area Assessment, dated 1/30/21 at 12:57 p.m. documented: Nutritional status triggered on MDS by significant weight loss, Mechanical soft texture required due to poor dentition and some pocketing BMI of 25, poor oral intake with significant weight loss Eating only small amounts (average intake during the look back period was 30%) and weight is down .7% x 30 days, down 9% in 90 days and down 11.6% in 180 days. Placed on the Nutritional Intervention Program and house supplement has been increased to 4 oz. QID. Identified with a nutritional problem related to inadequate intake of food/fluid with significant weight loss and dementia and depression diagnosis On 3/15/21 at 11:39 a.m. with Staff K, Certified Nurse Assistant (CNA) and Staff J (CNA), revealed Resident #29 experienced a decline in ambulation abilities in the past 6 months. On 3/16/21 at 11:00 a.m. with Staff C, Licensed Practical Nurse (LPN) identified the resident awake for lunch. She stated she noticed the resident is drowsy but the resident also talked in the third person when awake at night. On 3/16/21 at 2:16 p.m. Staff C, LPN on 3/16/21 at 2:16 p.m. revealed the resident tended to be drowsy during the day and awake all night. 2. The MDS assessment dated [DATE] revealed Resident #20 with diagnoses of anxiety disorder and depression. The MDS documented the resident had a BIMS score of 15 (cognition intact.) The MDS documented the resident without behaviors, and received antianxiety and antidepressant medications during 7 of 7 days during the look-back period. The care plan initiated 7/22/20 revealed the resident had major depressive disorder and took [CONDITION(S)] medications. Staff directives included to administer medications as ordered, monitor for side effects, evaluate effectiveness of the medications for possible decrease or elimination of the [CONDITION(S)] drugs, monitor the resident's mood state, and report any changes in mood or behavior to the doctor. The medication review report (physician's orders) dated 1/20/21, revealed an order for [MEDICATION(S)] (lorazepam) 0.5 mg as needed (PRN) for anxiety or sleeplessness. The medication administration record (MAR) dated 3/1-3/31/21 revealed [MEDICATION(S)] 0.5 mg PRN given on the following dates/times: 3/9/21 at 1:05 a.m. 3/11/21 at 1:03 a.m. 3/1521 at 12:26 a.m. 3/15/21 at 11:06 p.m. The progress dated 3/1 - 3/15/21 lacked documentation of non-pharmacological interventions attempted prior to administration of [MEDICATION(S)]. On 3/22/21 at 9:40 a.m., the DON (Director of Nursing) reported staff documented non-pharmacological interventions in the progress notes whenever a PRN medication administered. The DON reported when they switched to a new electronic health record, they had no easy way to mark the non-pharmacological interventions that staff attempted or did.

Based on observations, staff interview, and policy review, the facility staff failed to followed infection control practices in order to prevent or reduce the risk of spreading infection and disease. The facility reported a census of 44 residents. Findings include: 1. During observation 7/29/20 at 11:55 a.m., Staff A, Registered Nurse (RN), obtained supplies from a medication cart, donned a pair of gloves, and performed a blood sugar on a resident. After Staff A completed the blood sugar, she disposed of a used cotton ball and lancet, obtained a disinfectant wipe and cleansed the glucometer and a small tray, then removed her gloves. 2. During observation 7/29/20 at 12:05 p.m., Staff M, housekeeper pushed a cart down the(NAME)hallway by the resident rooms. Staff M wore a mask over her mouth, and had goggles on top of her head. 3. During observation 7/29/20 at 12:20 p.m., Staff N, dietary cook served food from the Eby unit kitchenette. Staff N wore a mask and hairnet, but had no goggles or faceshield on. 4. During observation 7/30/20 at 9:53 a.m., Staff B, Certified Nursing Assistant (CNA) and Staff O, CNA stood by Resident #8 in his room. A Quarantine sign hung on the resident's door. Staff B wore no gown , and Staff O wore no goggles or faceshield. Staff B removed a gown off the hook by the resident's door and donned the gown quickly. Staff B and Staff O, assisted the resident to stand and transferred the resident to a chair. At 9:58 a.m., Staff B removed the gown and gloves, and pushed the weight chair into the hallway by the resident's door. Staff B walked across the hallway and washed her hands in the sink adjacent to the kitchenette. Staff O continued to wear the gown and walked into the hallway by the resident's room, placed a bag of trash on the floor, then went back into the resident's room and removed her gown and gloves. At 10:05 a.m., Staff B pushed the shower/weight chair to the central bath room and sanitized her hands. Staff failed to disinfect the shower/weight chair. 5. During observation 7/30/20 at 1:10 p.m., Staff F, physician, entered resident room [ROOM NUMBER]. A Quarantine sign hung on the door. Staff F had no gown or gloves on when he entered the resident's room. In an interview 7/30/20 at 1:15 p.m., Staff B , CNA, reported whenever a resident on isolation or quarantine, the staff needed to wear a gown before they entered the resident's room. Staff B reported whenever a resident came from the hospital, the facility placed the resident in isolation/quarantine for 14 days. Staff should wear a gown, mask, gloves, and eye protection before entering the resident's room. Staff B confirmed she did not wear a gown on when she entered Resident #8's room [ROOM NUMBER]/30/20 a.m., and stated she should have worn a gown. In an interview 7/30/20 at 2:00 p.m., Staff C, RN, reported a sign placed on the door of the resident's room whenever a resident in isolation. Staff C reported whenever a resident admitted from the hospital, they placed the resident on droplet precautions for 14 days. Staff required to wear gloves, gown, mask and goggles before entering the resident's room, and the gown and gloves removed before staff left the room. In an interview 8/6/20 at 3:45 p.m., the infection preventionist reported quarantine and droplet precautions meant the same thing. The infection preventionist stated the facility placed a resident on droplet precautions for 14 days whenever admitted to the facility from the hospital because the resident was presumed positive for COVID-19. The infection preventionist reported she expected staff to wear a gown, gloves, mask and goggles or faceshield before they entered a resident's room whenever a resident on droplet precautions or quarantine status. The infection preventionist reported all staff required to wear a mask and goggles or faceshield when in resident care areas. A facility policy titled Standard Precautions revealed standard precautions used to prevent the transmission of infectious agents. The policy revealed gloves changed between tasks and procedures, and patient care equipment cleansed and sanitized between uses. A facility policy for initiation of isolation precautions revealed standard precautions used for all residents whenever cares provided regardless of the resident's [DIAGNOSES REDACTED]. Droplet precautions used for a resident known or suspected of infection with a microorganism transmitted by droplets generated during coughing, sneezing, or talking.

Based on clinical record review, staff interviews, and facility record review, the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals (DIA) within 24 hours for one of one residents reviewed who reported missing valuables (Resident #2). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had rejected cares 1-3 days but had no [MEDICAL CONDITION] or other behaviors during the look-back period. The Care Plan revised 5/4/20 revealed the resident had impaired cognitive function related to a [DIAGNOSES REDACTED]. The care plan indicated the resident had some personal effects in her memory box outside of her room. Staff directives included monitor and document behaviors whenever they occurred, and assist the resident to navigate to her room and activities as desired. A Missing Item Tracking report dated 11/5/19, completed by Staff D, Licensed Practical Nurse (LPN) revealed staff reported Resident #2 missing three band stackable wedding rings. The on-line abuse or incident reporting revealed the facility notified DIA on 11/7/19. A CNA (certified nurse aide)notified the CCDI (chronic confusion & dementing illness) unit charge nurse of Resident #2 missing rings. The resident normally wore the resident but the resident's rings were not on the resident's fingers that day. The charge nurse notified family of missing items on 11/6/19, and staff proceeded to look for the missing rings. The report documented the charge nurse was unaware of the policy for missing items because of status as a newer employee. Leadership was notified of the missing rings on 11/7/19, and an internal investigation initiated. On 11/7/19, the facility notified the resident's family the rings were not found after staff searched for them, and asked family if they wanted the missing rings reported. Family thought the facility should report the missing rings. The administrator reported the missing items to the local police department and DIA 11/7/19. In an interview 7/29/20 at 4:00 p.m., Staff J, Registered Nurse, reported she filled out a missing belongs form if she or someone reported items missing, then made the Administrator or environmental services staff aware of items missing. Staff J reported staff completes an inventory of belongings whenever a resident admitted to the facility and updated the list whenever items brought or taken from the facility. In an interview 7/30/20 at 12:45 p.m., Staff G, Licensed Practical Nurse (LPN), reported she completed a missing item report whenever someone reported belongings missing and gave the report to all of the department heads. Staff G reported staff searched for the missing item(s). Staff G reported she recalled Resident #2 wore rings that looked like costume jewelry. In an interview 7/30/20 at 1:40 p.m., Staff K, Certified Nursing Assistant (CNA), reported she recalled Resident #2 wearing rings on 11/4/19, but not on 11/5/19. Staff K stated if a resident missed belongings, she reported to the nurse and then looked for the item missing. Staff K reported residents in the dementia unit often times wandered and placed items in other locations or threw items in the garbage. In an interview 7/30/20 at 3:10 p.m., Staff D, LPN, reported Staff E, Certified Medication Assistant (CMA), informed her of Resident #2's missing rings, and stated the resident usually wore rings. At that time (11/5/2019), she saw a bruise on the resident's right arm where the resident normally wore her bracelet. Staff D stated she should have contacted the Director of Nursing that evening when Staff E reported the incident, but at that time, she didn't know the facility's policy or procedure very well and what she needed to do, or that she needed to report the incident right away. Staff D stated it's not uncommon for residents in the dementia unit to misplace things or place items in other locations, and she thought staff would find the rings. Staff D reported she completed the adult and child abuse course, and the facility covered the abuse policy during her orientation. Staff D stated she now knew she should have reported the missing belongings right away. In an interview 8/3/20 at 8:30 a.m., Staff E, CMA (certified medication aide), stated she reported missing belongings to to the charge nurse right away, filled out a missing item report form, looked for the item, and then followed up the next time she worked to see if anyone found the item. Staff E reported Resident #2 had Alzheimer's could not remember day to day. Staff E reported Resident #2 wore rings and a bracelet. Staff E recalled the resident wore the rings and bracelet because she made comments whenever she provided cares for the resident. Staff E reported the resident had a bruise on her right arm and she noticed the bracelet and rings gone. Staff E reported the rings missing to Staff D, LPN, on 11/5/19. Staff E stated she looked for the rings but never found them, and she was not sure if family had taken the rings home. In an interview 8/10/20 at 9:40 a.m., Staff L, LPN, reported she did not work on 11/5/19, the day staff noticed Resident #2's rings missing, but she worked the following days. Staff E reported to her about Resident #2's missing rings. Staff E stated she reported the missing rings to Staff D the day before. Staff L stated she then spoke with Staff D. Staff D knew of the missing rings but did not report the missing items or filled out a report. Staff L gave Staff D instructions on what she needed to do. Review of employee file revealed Staff D hire date of 9/26/19, and orientation checklist completed 9/27/19. The orientation checklist included instructions on the policy and procedure for resident abuse prevention, reporting, and investigation. An employee coaching dated 11/8/19 revealed a coaching notice in Staff D's file that identified she did not report missing items during her shift. Staff D received education and acknowledged abuse policy education during orientation, and reviewed the abuse policy again. A facility policy titled Abuse Prevention, Identification, Investigation, and Reporting dated 7/2019, revealed all allegations of resident abuse and misappropriation of resident property required a report to the charge nurse immediately, and to DIA no later than two hours after the allegation made.

Based on clinical record reviews and interviews, the facility failed to assure all residents are treated with dignity and respect for 1 of 4 current residents sampled. Resident #1. The facility identified a census of 50 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documented [DIAGNOSES REDACTED].#1. The same MDS documented a Brief Interview of Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. The resident required extensive assistance for transfers and ambulation and, had limitations in functional range of motion of one leg. The resident utilized a walker or wheelchair for mobility. A care plan problem dated 12/27/19 identified the resident at high risk for falls and directed 1 staff to assist the resident with walking to activities, dining room and so forth, at the resident's pace, with the use of a front-wheeled walker. On 7/2/19 at 4:45 PM Staff D, dietary aide (DA) stated she worked in the 10th Street dining room for the evening meal on 6/12/19 and also provided orientation to new employee Staff C, DA. Staff B and E, DA's, were also present in this dining room. She observed Staff A, certified nursing assistant (CNA), holding on to a gait belt around Resident #1's waist while assisting her to walk to a table. Staff D stated that when the resident got about 2-3 feet away from the chair, she observed Staff A abruptly and roughly jerk the resident into the chair. Staff A identified this as the meanest thing she ever observed someone do to a resident. She stated the resident had a startled look on her face. Staff D stated Staff A did not say anything to the resident and walked out of the dining room with a non-emotional look on her face. Staff D then left the dining room to report the incident to management. On 7/3/19 at 3:55 PM, Staff C stated she observed Staff A hold the gait belt and the resident's upper arm and assist the resident to walk into the dining room. She stated Staff A rolled her eyes because the resident walked slowly. When the resident got about 12 inches away from the chair, Staff A told the resident to sit down and the next thing she observed was Staff C slam the resident into the chair by pulling on her arm and the gait belt. She observed Staff A roll her eyes again after it happened and staff just left the dining room. Staff C stated she felt shocked and stated that is not how anyone should be treated and it appeared to her that Staff A had a bad day and took it out on the resident. On 7/9/19 at 12:55 PM, Staff B stated she stood on the right side of the dining room table where Resident #1 sat and observed Staff A hold the gait belt around the resident's waist and assist the resident walk to the table. Staff B stated the resident faced the dining room chair, but not anywhere near it when Staff A roughly and abruptly pulled the resident into the chair. Staff B stated Staff A appeared frustrated and kept telling the resident to back up. Staff B identified herself as stunned and dumbfounded at what she observed. Staff A moved the resident alittle closer to the dining room table leaving the gait belt around the resident's waist and then left the dining room. Staff B felt Staff A deliberatively and forcefully placed the resident in the dining room chair. Staff B never witnessed a CNA treat a resident in such a careless manner. Staff B stated that Staff A's body language communicated frustration any time she observed her and Syaff A acted like she did not want to work at the facility. On 7/3/19 at 4:15 PM the director of nursing (DON) stated she came to the facility and interviewed Staff A after the incident. Staff A told her she held the gait belt and forcefully placed the resident in the dining room chair, but it was an accident. The DON suspended Staff A at that time. When the surveyor attempted to interview Resident #1 on 7/3/19 at 4:45 PM, the resident had difficulty finding words to communicate her thoughts. When asked how may children she had she replied she she didn't know for sure and would have to think about it. When asked if anyone had treated her roughly or unkindly she again stated she did not know and would have to think about it. On 7/9/19 at 9:55 AM Staff A stated she felt a little frustrated before coming to work on 6/12/19 due to a personal issue. She stated Resident #1 could be very demanding and had difficulty communication her wants and needs and on this day she identified thee resident as difficult to care for because she repeatedly activated the call light but could not express what she wanted. Before the evening meal, she placed a gait belt around the resident's waist and assisted her to stand up from her room chair. The resident used a front-wheeled walker but on this day she had difficulty using it and veered off towards walls so she had to hold on to the resident's gait belt with her right hand and hold on to the walker with her left hand and guide her to ambulate into the dining room. Staff A stated it had been slow-going to the dining room as she needed to keep the walker on track. When she arrived at the table, the resident faced the dining room chair with her walker off to the right side. Staff A stated she jerked the resident to get her to turn around so her buttocks would be in alignment with the chair. She said she left the gait belt on the resident that day and is not sure why. During the interview, Staff A stated he felt a little frustrated with the resident because the resident continually activated the call light but could not say what she needed. Staff A felt that frustration may have led to jerking the resident back in the chair. She stated after the incident she felt angry and frustrated with herself for jerking the resident.

Based on observation, record review and staff interview, the facility failed to ensure the resident environment remained as free from accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents reviewed for supervision concerns. Resident #10 required staff assistance for ambulation. Prior to falling and sustaining injury on 11/17/17, staff observed the resident fail to use the call light and self-transferred. The facility failed to implement interventions to increase supervision based on their knowledge that the resident failed to use the call light and made self-transfer attempts. Resident #12 fell and fractured her femur while staff failed to use a gait belt. The facility identified the facility census as fifty-four (54) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 9/15/17 assessed Resident # 10 with a brief interview for mental status (BIMS) score of 7. A score of 7 reflected the resident had a severe cognitive impairment. The resident had no behaviors identified including rejection of care. The resident required extensive staff assistance with bed mobility, transfers, ambulation, dressing and toileting. The resident had functional range of motion limitations in both lower extremities. The resident used a walker and wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had one fall without major injury since the prior assessment. A CAA (care area assessment) worksheet for falls identified the resident had no recent falls. The resident was at risk for falls related to generalized weakness, obesity and fluid retention causing heaviness and clumsiness of limbs. The resident also had some behaviors and resistance to care at times. The resident drug his feet during ambulation with FWW (front wheeled walker). The resident needed a lot of encouragement to walk and mobilize. The resident required extensive staff assistance of one to ambulate and a wheelchair for long distances. A Care Plan dated 6/27/16 identified the resident with problem of a risk for falls. The Care Plan directed staff to wear nonslip soled shoes for transfers and ambulation, assistance of 1 for transfers and ambulation using gait belt and FWW (front wheel walker), remind the resident to use the pendant for assistance and not to try to get up on his own, monitor closely for episodes of weakness or lethargy and report to doctor and bring resident to the common area when he is yelling out in his room. Addendums dated 11/15/17 identified the physician reviewed and adjusted the resident's medications and 11/17/17 to keep walker in reach at all times when in room. A Pocket Care Plan for the certified nurse aides (CNAs) (undated) included the directive to bring the resident to the common area when the resident yelled out in his room. The Pocket Care Plan did not contain directive to increase supervision of the resident or interventions for self-transfers. Neither Care Plan identified a night time toilet plan. A fall occurrence report dated 11/17/17 at 5:15 a.m. revealed an unwitnessed fall in the resident room. The resident received the following skin injuries from the fall: Skin tear: right forehead above right eyebrow measuring 0.5 centimeters (cm.) with a dark purple bruise surrounding the skin tear and a 4 cm. by 3 cm. abrasion surrounding the skin tear. Skin tear: of the 5th finger of the right hand with purple bruise and 0.5 cm. skin tear at the base of the right 5th finger. Skin tear: of the 4th finger of the right hand with purple bruise and 0.5 cm. skin tear at the base of the right 4th finger and also bruising to the upper knuckle. Skin tear: of the 3rd finger of the right hand measuring 1 cm. Bruise: of the right forearm reddish/purple bruise to the right upper forearm measuring 8 cm. in diameter. The fall occurrence report identified the intervention following the incident was walker in reach at all times when in room. Departmental notes dated 11/17/17 at 7:44 a.m. and documented by Staff E LPN (licensed practical nurse) revealed identified at approximately 4 a.m. the resident rested quietly in his chair. At 5:15 a.m. a nurse aide called Staff E to the resident's room. Staff observed the resident lying face down on the floor in front of his chair. The resident stated he tried to stand up by self and fell . Staff rolled the resident to his side and then to his back and placed the Hoyer lift sling under the resident and then used the Hoyer lift to lift the resident into the wheelchair. Staff E checked the resident and found multiple bruises and skin tears. The resident sat with the nurse in his wheelchair for the rest of the shift. Departmental notes dated 11/20/17 at 3:40 a.m. revealed staff heard hollering and went to the resident's room. The resident had his legs kicked out of bed and the resident attempted to sit up on the side of the bed per self. Staff assisted the resident back to bed. The resident stated he was peeing his pants and wanted to go to the bathroom. Staff instructed the resident not to try and get up per self. Observation showed, on 11/20/17 at 12:50 p.m. the resident in a wheelchair assisted by staff. The resident stated he fell and hit the floor. The resident stated he hit his head and hand during the fall. Observation revealed a bandage to the right hand/wrist area and a large bruise on the right forehead and eye. Steri strips covered a gash on the forehead. At that time, 2 staff transferred the resident with a gait belt to a recliner in the common area. Prior self transfer attempts: Departmental notes dated 11/12/17 at 6:24 a.m. and documented by Staff F LPN revealed staff observed the resident ambulating with his walker last night at 11 p.m. and staff attended to the resident stat (immediately) and redirected the resident to his room. Departmental notes dated 11/15/17 at 10:54 p.m. and documented by Staff G RN (registered nurse) revealed the resident yelled on and off throughout the shift and got up from the recliner per self. Staff assisted the resident back to the recliner. On 11/20/17 at 4:40 p.m. Staff G RN stated the resident did try and get up a couple times last week prior to the fall. Staff G also stated the resident did not reliably use the call light. Staff G stated she also found the resident in bed with his feet on the floor so she put the resident back to bed. When asked, the resident didn't know what he needed. On 11/21/17 at 8:35 a.m. Staff F LPN (licensed practical nurse) stated she knew of one self transfer prior to the fall incident. The resident walked up the corridor to the dining room with a walker. Staff walked the resident back to his room. Staff F stated she charted the incident. She stated staff checked the resident every 2 hours and if the resident wants to use the toilet, they take him at that time. On 11/21/17 at 10:56 a.m. Staff E LPN stated the resident did get up on his own prior to the fall incident. On the night the resident fell , Staff E last saw the resident at 4 a.m. The night before Staff E caught the resident sitting on the side of the bed. Staff E stated she made frequent checks on residents by making minimum hourly checks. Staff E stated she always did this even before the resident got up on his own. The resident informed Staff E that he stood up and fell . She stated she didn't know when staff last toileted the resident but they generally take the resident a couple times through night at no particular time. On 11/21/17 at Staff H, CNA stated the resident tried to get up all week without using the call light. The resident also yelled at night that past week. Staff H stated he worked when the resident fell on [DATE]. He stated he found the resident at 4:54 a.m. when staff was going to do last rounds. The resident started yelling and he found the resident on the floor in front of the recliner. He observed the recliner all the way up when he found the resident. The resident didn't know why he tried to get up. The resident also did not use the call light. He stated staff checks the resident every 2 hours. Information provided to the surveyor from the Administrator on 11/28/17 at 9:31 a.m., revealed a discussion in MDR (multidisciplinary rounds) on 11/20/17. The resident was in the recliner prior to the fall and attempted to take self to the restroom without pushing the call pendant. Staff felt the resident would benefit from having a walker available if he attempted to self-transfer without using a call light. Review of the Pocket Care Plan for Resident #10 from 11/21/17 to 11/27/17 did not reveal any changes. Observation identified on 11/29/17 at 9:20 a.m. and 10:15 a.m. the resident asleep in a recliner in the common area. 2. A MDS with a reference date of 8/18/17, assessed Resident #12 with a brief interview for mental status (BIMS) score of 8 (moderate cognitive impairment). The resident had no behaviors including rejection of care. The resident required extensive staff assistance with transfers, ambulation, dressing, toileting and personal hygiene. A balance test during transitions and walking revealed the resident scored 2 in all areas of testing. A score of 2 identified the resident as not steady and only able to stabilize with staff assistance. A physical therapist (PT) discharge plan dated 3/13/17 identified the resident required assistance of one (staff person) for all functional mobility for safety. A Care Plan dated 2/15/17 Identified the resident needed help with all areas of care. The Care Plan directed staff to ambulate the resident with assistance of one staff with walker and a gait belt in place. A Pocket Care Plan dated 11/26/17 identified the resident's transfer and mobility status as 1 assist. The Pocket Care Plan did not identify the use of a gait belt. A gait belt policy and procedures (undated) revealed gait belts should be used for all weight bearing and non-weight bearing residents who require: Assistance with ambulation Assistance when getting in and out of bed Assistance with transfer to chair or toilet Assistance in repositioning resident already sitting in chair. Gait belts are to be used for ambulating residents who need assistance and for support during transfers. On 11/28/17 at 10:17 a.m. the Director of Nursing (DON) stated staff needed to use a gait belt when assisting residents unless it is care planned otherwise. On 11/29/17 at 12:37 p.m. the DON identified the gait belt policy as in place for at least 3 years. Departmental notes dated 11/27/17 at 6:50 a.m. and documented by Staff F LPN identified a nurse aide summoned her to the resident's bathroom at approximately 5:20 a.m. When Staff F arrived at the room, she observed the resident lying in the supine position on the floor with her back against the bathroom wall and a CNA with her. The CNA lowered the resident to the floor. Assessment revealed inner and outer rotation. The resident tolerated range of motion and said ouch once. The resident stated she was Ok and requested staff assist her up. Staff F and 2 CNAs transferred the resident with a gait belt from the floor to a standing position. The resident did not bear weight well. The resident sat in the wheelchair without difficulty. The facility notified the physician who directed staff to send the resident to the emergency room (ER) for an evaluation. The CNA informed Staff F that she assisted the resident to the toilet and the resident ambulated prior with the walker without difficulty. The resident fell forward during toileting when the resident attempted to pull up her night gown. She then lost her balance and the CNA lowered her to the floor for safety. Staff Working the Night of the Incident: On 11/28/17 at 11:02 a.m. Staff F stated Staff L CNA lowered the resident to the floor because the resident lost her balance lifting her gown for toileting. When initially assessed, the resident did not have complaints. Upon further assessment, shortening and rotation was observed and the extremity appeared broken. The resident took some Tylenol (analgesic) and went to ER. Staff F stated she was not aware Staff L did not use a gait belt at the time of the fall until this morning. Staff F stated she didn't know why Staff L did not use the gait belt. She stated the resident does not refuse the gait belt. On 11/27/17 at 4:43 p.m. Staff L, CNA stated she worked 2 a.m. to 6 a.m. on the night of the incident. Other than peeking in the resident room, she stated she didn't see the resident that night until she got the resident up at 5:20 a.m. to use the toilet. The resident wore nonskid socks. Staff L helped the resident get up and walked with her to the toilet with her hands near the resident's hips. Staff L did not use a gait belt. She stated she never used one with the resident. She was not sure the resident was care planned for it. She stated she had access to Pocket Care Plans but she did not carry one that night. She stated when a Care plan says 1 assist that means staff should use a gait belt. She stated the resident positioned herself in front of the toilet and started to pull up the night gown. She started leaning forward and Staff L tried to steady the resident but she kept going forward into the walker. The resident landed on the walker. The resident's torso and arm hung on the walker and the resident's lower extremities were on the floor so Staff L helped the resident the rest of the way down. The walker didn't move. Staff L called for Staff F. The resident's leg was in a funny position. Staff F took the resident's vital signs and gingerly examined the leg. The resident could move the leg but it was angled weird and it looked broken. The resident said ouch. Another staff arrived and put a gait belt on the resident and they got the resident into the wheelchair. The EMTs (emergency medical technicians) came shortly after that. When asked if it would have made a difference if a gait belt was around the resident when the resident leaned forward, Staff L stated she would have been able to slow the resident's fall down a little more with a gait belt. Staff L CNA signed a form that verified she received orientation information on the gait belt policy. The form was undated. On 11/30/17 at 5:29 a.m. Staff N CNA stated she worked the night of the incident but was not in the room at the time of the incident. She stated she assisted Staff L to get the resident up from the ground. The resident's right leg/knee was bent and the resident repeatedly stated she thought it was broken. When the resident sat in the wheelchair she did not have pain. When she got on gurney for transport to the hospital, she did have some pain. On 11/28/17 at 10:30 a.m. Staff N stated she uses a gait belt when she transfers the resident as the resident allows. The need for the gait belt varies as some days the resident is sleepier than other days and the resident leans more. The CNAs carry the pocket care plans. Staff uses a gait belt on all 1 to 2 assist residents unless they don't want it or resist. When that happens, Staff N gets another staff. She knows about using gait belts through her CNA training, orientation and the care plan. On 11/29/17 at 2:31 p.m. Staff O CNA stated she sat with the resident after the fall when the resident was in the wheelchair. The resident's leg was angled and the resident said she thought it was broken. Staff O stated she used a gait belt when she transferred or walked the resident. She stated the resident didn't refuse when she worked with her but she stated she had not worked with the resident much. A hospital history and physical dated 11/27/17 at 6:15 p.m. identified the resident with a closed right mid-shaft femur fracture. Notes identified the resident underwent [REDACTED]. Other staff: On 11/29/17 at 12:01 p.m. the ADON stated she spoke with Resident #12's surgeon. The surgeon informed her there was no way to know if the fracture was from the fall or if the fracture occurred first causing the resident to fall. The surgeon did not return the surveyor's phone call. On 11/28/17 at 3:25 p.m. Staff A CNA stated they usually use a gait belt when ambulating (walking) the resident. Staff A stated if the Pocket Care Plan says to use a gait belt then they use one. If it just says one assist, then they don't always use one. On 11/28/17 at 3:20 p.m. Staff M CNA (hired 4/24/17) stated when she first started working at the facility, the resident didn't use a gait belt. Lately the resident has used one. Staff M stated she knows when to use a gait belt from the Care Plan. She asked about using a gait belt for a resident that was so light she could put her arm around her to transfer. The surveyor asked if the resident's Care Plan indicated the resident required one person assistance and Staff M said yes. Staff M was informed it was her understanding that residents that required one assistance needed a gait belt. Past non-use of gait belt: A fax to the physician dated 10/3/17 at 10 a.m. revealed the resident stood holding onto the walker and then decided to sit down with no chair behind the resident. The resident landed on her bottom on the carpet and then rolled onto her back without apparent injury. A fall occurrence report dated 10/3/17 at 7:50 a.m. revealed the resident fell while ambulating with staff. The staff received education. On 11/28/17 at 1:30 p.m. the DON stated Staff P CNA did not use a gait belt and received education regarding the incident.

Based on record review and staff interviews, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 11 residents reviewed (Residents #1, #7, #8 and #9). The facility reported a census of 51 current residents. Findings include: 1. Resident #7 had a Minimum Data Set (MDS) assessment dated [DATE] that documented a score 4 of 15 on BIMS (brief interview for mental status) test which indicated the resident severe cognitive and memory impairment. The resident required extensive assistance of one staff for mobility, dressing, toileting and hygiene. A balance during transitions and walking test identified the resident as not steady and only to stabilize with staff assistance when walking, turning around, moving from seated to standing position, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had a fall with no injury since the prior assessment. Review of the Fall Risk assessment dated [DATE] identified the resident scored a 17 on the assessment scale. A score of 10 or above represented the resident at a high risk for falling. The Care Plan, dated 12/23/15 and updated 3/23/16, identified the resident at risk for falls and reflected Resident #1 transferred and ambulated using a front wheeled walker independently in his/her room and common area. Additionally, interventions included and directed staff keep the resident's walker in reach at all times, and if the resident forgets his/her walker, bring the walker to him/her. A Care Plan intervention dated 6/1/16 directed one staff provide assistance with ambulation using a gait belt and front wheeled walker as needed, and wheelchair as needed for distance or complaints of increased knee pain. A fall incident report dated 6/27/16 at 5:30 p.m. reflected the staff discovered Resident #7 sitting on the floor in front of his/her recliner. The nurse assessed the resident and noted the resident complained of left hip discomfort. A portable X-Ray revealed the resident sustained [REDACTED]. During interview on 6/30/16 at 12:02 p.m. Staff F, certified nursing assistant (CNA), stated on 6/27/16 she checked Resident #7 at 3:30 p.m. Resident #7 was sitting in a chair in his/her room. The resident's walker was not in his/her room because staff provided wheelchair transfer to his/her room. Staff F was aware Resident #7 ambulated with a walker, but at times required wheelchair transfer when complained of knee pain. Staff F went to break at 4:15 p.m. She became aware of the resident's fall upon return from break. Staff F was aware Resident #7's walker was to be placed beside him/her. She did not look for the walker prior to going to her break, instead asked Resident #7 to stay in his/her room and offered him/her water. On 6/30/16 at 12:19 p.m. Staff G, CNA, stated on 6/27/16 she observed Resident #7 sitting in his/her room. The walker and wheelchair were positioned beside him/her. Resident #7 was transferred per wheelchair to the bathroom. She was aware the wheeled walker was to placed near the resident. Staff G found Resident #7 sitting on the floor in front of his/her recliner and notified the nurse. Resident #7 complained of leg pain. The resident complained of a lot of pain when the nurse palpated his/her leg. Staff G stated sometimes Resident #7 forgot the walker and staff had to provider reminders. On 6/30/16 at 12:33 p.m. Staff H, CNA, stated that on 6/27/16 at approximately 4:15 p.m. he observed Resident #7 sitting in a chair in his/her room watching television. The resident's legs were elevated on the foot rest. Staff H did not observe the walker beside Resident #7. Staff H was in centerfield (the center of the unit) and observed residents in the center area of unit. At approximately 5:15 p.m. Resident #7 was found on the floor. He/She complained of pain on his/her side and said ow. Staff H and Staff F assisted the resident to standing position so the nurse could complete her assessment. Staff H stated we held him/her up while the nurse completed her assessment and you could tell he/she had pain. Resident #7 was positioned in his/her chair and Staff H returned to centerfield. Staff H was aware Resident #7's walker was to be near at all times. He did not get the walker because Resident #7 appeared content and he had to go to centerfield. Staff H stated if the walker was anywhere in the resident's room he would have seen it because the resident's recliner was in the corner of the room. On 6/30/16 at 2:19 p.m. Staff J, registered nurse (RN), had not observed the resident prior to the fall. Upon entry she observed Resident #7 sitting on the floor in front of the recliner. Staff J did not observe the resident's walker in his/her room. Resident #7's walker was found in centerfield. Staff J thought Resident #7 had a fall history and was aware the walker was to be in reach. Resident #7 ambulated alright unless he/she had knee pain, and then he/she ambulated very slowly. Upon entrance to the facility on [DATE], the Director of Nursing (DON) stated her fall investigation for Resident #7 revealed his/her walker was not in reach as directed on the Care Plan. 2. Resident #1 had an MDS assessment dated [DATE] that documented a score of 13/15 on a BIMS (Brief Interview of Mental Status) test which reflected the resident was cognitively intact. The resident was dependent upon staff for all activities of daily living such as transfer, mobility, dressing, toileting and hygiene. The resident was non-ambulatory. A balance during transitions and walking test identified the resident unable complete the following: walking, turning around, moving from seated to standing position, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE] identified the resident scored a 16 on the assessment scale. A score of 10 or above represented the resident at a high risk for falling. The Care Plan, revised on 4/13/16, identified the resident at risk for falls. The interventions included and directed the staff transfer the resident with a mechanical lift and two staff, keep touch pad call light in reach while in room, use a non-slip pad on the seat of the Broda chair due to a tendency to slide and protect the resident from injury during witnessed seizure activity. The Care Plan indicated Resident #1 was dependent upon staff for activities of daily living and required assistance of 2 staff for bed mobility and Hoyer transfer (mechanical lift). a. A fall incident report dated 5/24/16 at 6:30 a.m. reflected staff discovered Resident #1 face down on the floor between his/her bed and adaptive wheelchair. The resident sustained [REDACTED]. During interview on 6/30/16 at 1:36 p.m. Staff I, CNA stated on 5/24/16, approximately 15 minutes into the day shift, she heard yelling. Upon entry to Resident #1's room, she observed Resident #1 face down on the floor. The back of the Broda chair (adaptive chair) was positioned straight up, a position used during meals. (A Broda chair is an adaptive chair that reclines for positioning.) Resident #1 reported he/she just fell out of the chair. Staff I recalled overnight staff transferred Resident #1 into the reclining chair on shower days. Staff I stated we do not leave him/her unattended in the upright position for a reason. She was not aware if overnight staff offered Resident #1 fluids after transfer as it was not included in morning report, only that he/she was up. On 6/30/16 at 2:41 p.m. Staff D, CNA, arrived for her shift on 5/24/16 and heard a resident call help, help. She entered Resident #1's room and observed him/her on the floor, face down, next to the bed. Staff I and the nurse entered to assist. Resident #1 reported the back of his/her chair was positioned straight up and he/she had a muscle spasm, then slid forward out of the chair. Staff D stated Resident #1 is unable to change position without assistance from staff. He/She can only minimally move his/her arms. Staff D stated the back of the reclining chair (adaptive chair) was positioned straight up, which was not normal except at mealtime. She stated the chair was to be reclined at all times except at meals. On 7/1/16 at 6:00 a.m. Staff L, CNA, stated on 5/24/16 she and Staff K assisted Resident #1 out of bed per mechanical lift. Typically his/her chair is reclined back because he/she may fall out if sitting straight up in the chair. Staff L thought the chair was reclined, however may have been mistaken. Staff L was aware Resident #1 was dependent upon staff assistance for transfer and mobility and would not be able to independently correct a change in position. On 7/1/16 at 5:45 a.m. Staff K, CNA stated she did not provide transfer assistance to Resident #1 on 5/24/16, and unable to recall who provided assistance. On 6/30/16 at 1:57 p.m. Staff E, CNA, stated two staff assist with mechanical lift transfers, one of which ensures Resident #1's legs do not cross during transfer. Staff E stated at times, Resident #1's feet go over the foot tray and require staff reposition so he/she doesn't slide down. On 7/1/16 at 5:00 a.m. Staff C, RN, stated on 5/24/16 she observed Resident #1 in bed at 4:00 a.m. rounds. Night staff provided transfer assistance prior to his/her shower and transferred him/her per mechanical lift into his adaptive chair. Resident #1 is not able to self correct if he/she falls. The resident was unable to roll/move in bed and was dependent upon staff for all activities of daily living. She stated Resident #1 was found on the floor just after she left the facility. On 6/30/16 at 9:28 a.m. Resident #1's spouse stated Resident #1 had been at the facility for 8 years without incident, and now he/she has had 2 falls in a 2 month period. This caused concern because Resident #1 is unable to independently move. Resident #1's spouse visited Resident #1 on Saturday afternoon prior to the 5/24/16 fall and noted Resident #1's feet were off the foot tray. She requested staff reposition his/her feet because without proper placement of his/her feet there are no dynamics holding him/her in the chair. Upon notification of the 5/24/16 fall, he/she immediately recalled the resident's feet off the foot tray. Resident #1's spouse indicated there was an additional time recently when he/she observed improper placement of Resident #1's feet. He/She was unable to recall a date or time of day. He/She planned to address this issue at the next care conference and added staff respond in a prompt manner upon request. b. A fall incident report dated 6/14/16 at 6:15 a.m. revealed staff lowered Resident #1 to the floor during transfer per Hoyer (mechanical lift) because the mechanical lift tilted over during transfer. During interview on 6/30/16 at 6:13 a.m. Staff B, CNA, stated she assisted Staff E transfer Resident #1 per mechanical lift. Resident #1 was dependent upon staff for activities of daily living, which included transfer. Staff B stated she was a newer CNA, so she was at the top of the mechanical lift. Staff B positioned the sling and attached the top black tabs to the mechanical lift. She thought all tabs were attached. Resident #1 used an extra large sling which was a different sling than used by other residents. This sling had 6 tabs and did not cross between his/her legs. Staff B had difficulty moving the mechanical lift, so Staff E moved the lift control and Staff B held Resident #1's legs. Staff B stated the legs of the Hoyer lift were not opened wide enough to go around his/her chair like it was supposed to, and Resident #1 began to fall onto her as (Resident #1) was suspended approximately 12 inches above the chair. The Hoyer lift tipped. Staff B stated as she attempted to push the mechanical lift into an upright position, the tabs on the lower portion of the sling slid off the hook. When the tabs slid off the hook, Resident #1 slid down onto the floor. The mechanical lift then tipped onto her chest/nose. She had difficulty pushing the lift into an upright position as she was positioned against the wall. She stated the mechanical lift caused pain to her chest and nose after it fell on to her. Staff B demonstrated the transfer/fall in the presence of the surveyor as followed: Staff B demonstrated proper sling placement and appropriate placement of the tabs onto the hooks of the mechanical lift. She placed the mechanical lift near a chair and slid one of the mechanical lift legs under the middle portion of the chair and the other leg placed directly in front of the chair. Staff B stated Resident #1 was placed in the chair from the side. Staff B stated it happened so fast and she was unsure how the resident slid and the mechanical lift tipped. On 7/1/16 at 5:20 a.m. Staff E, CNA, stated she and Staff B transferred Resident #1 per mechanical lift. Resident #1 was secured in the sling. Staff B had difficulty moving the mechanical lift, so they traded places and Staff E ran/moved and mechanical lift and Staff B had the resident's legs. As Staff E was about to lower the resident into the chair, the mechanical lift moved and tipped. She was unsure if Staff B pulled Resident #1's legs. The mechanical lift tipped and hit Staff B in the chest. Staff E tried to hold the mechanical lift in an upright position as Staff B attempted to push the lift up. Staff B was pinned against the door, so additional staff were unable to enter the resident's room. Staff E demonstrated proper sling placement and appropriate placement of tabs onto the hooks of the mechanical lift. She stated she was on the resident's right side and Staff B was on the resident's left side. She placed the mechanical lift on the left side of the chair, positioned one leg under the chair and demonstrated how the mechanical lift tipped to the right and how the upper portion of the lift hit Staff B. Staff E stated she removed the right hook when additional staff entered the room. She was not aware when the other hooks were removed. Staff E then stated Resident #1 was in the sling and the lower portion was off the mechanical lift because his/her feet were over the right side, and his/her head was near the base/lift controls. On 6/30/16 at 6:00 a.m. Staff C stated at approximately 6:15 a.m. staff reported Resident #1 was lowered to the floor. Upon entry to Resident #1's room, she observed the mechanical lift upright. Staff B and Staff E, both CNAs, were in the room. Resident #1 appeared frightened. The sling was near Resident #1's neck, and attached to the mechanical lift. Staff C stated it appeared Staff B and Staff E attempted to transfer Resident #1 in the mechanical lift in a sideways position which caused the lift to become unstable. On 6/29/16 at 4: 40 p.m. the DON confirmed the incident with the mechanical lift and stated she was not sure how Resident #1 fell out of the lift. 3. Resident #8 had a MDS assessment dated [DATE] with documented [DIAGNOSES REDACTED]. The resident had a BIMS score of 6, indicated severe cognitive impairment. The resident needed supervision with walking inside and outside the facility. The resident's record indicated the resident resided in a locked memory care unit. Resident #8's care plan with a problem onset date of 11/25/15 established an intervention directing staff to provide supervision with ambulation when not in h/her room. 4. Resident #9 had a MDS assessment dated [DATE] which documented a [DIAGNOSES REDACTED]. The resident needed supervision with walking inside and outside the facility. The resident's record indicated the resident resided in a locked memory care unit. Resident #9's care plan with a problem onset date of 11/25/15 indicated the resident independent with ambulation but had trouble finding h/her room, had wandering behavior and would look for h/her spouse when h/she was off the unit for a few minutes. Resident #8's departmental notes dated 7/23/16 at 1:47 revealed at 10:55 a.m. the resident and spouse had been seen walking on the sidewalk on the south side of the facility heading east. The resident and h/her spouse had been at a music activity in another part of the facility from 10:00 a.m. - 10:45 a.m. Staff (E, a certified nursing assistant (CNA) sitting in her car) in the parking lot noticed the residents were alone and escorted both into the facility. The resident told staff they had walked down by the old apartment and out the door and started walking east to where they now lived. An occurrence report dated 7/23/16 at 10:55 a.m. indicated the resident had told staff the music was over and nobody came to get us. We went outside and I knew we lived over that a way (pointing to h/her left.) We saw someone and they walked in with us. During an interview dated 7/26/16 at 10:50 a.m., the Activity Director reported she had posted and gave copies of the weekend activity (Saturday 7/23/16 10:00 a.m. Music Group) to all nurses and that she would not be present for the activity and staff needed to escort and stay with the residents during the activity. A surveillance photo taken 7/23/16 at 11:08 a.m. (the DON reported the time listed is actually 10 minutes fast) showed Residents #8 and #9 leaving the south entrance of the facility. During an interview dated 7/26/16 at 10:35 a.m., the State of Iowa Climatologist reported on 7/23/16 at 10:55 a.m. the ambient temperature 88 degrees Fahrenheit (F), with a heat index of 104 degree F with a south wind of 8 miles per hour and clear skies. The facility Nursing Assignment Sheet work schedule dated 7/23/16 documented staffing for the memory unit consisted of one nurse and three CNAs. During an interview on 7/26/16 at 12:10 p.m. Staff M, CNA reported she had escorted both Resident #8 & #9 from the memory care unit around 10:00 a.m., to an activity located in another part of the facility outside of the memory care unit. She then left and returned to the unit. Staff M did not realize that neither resident wore a wanderguard (a device that alarms and locks an exit door when the wearer comes in close proximity of the door). Staff M had not been directed to stay with the residents during the activity and she returned to the unit and at 10:30 a.m. left for her break. During an interview on 7/26/16 at 11:17 a.m. Staff N, CNA reported she worked on the memory care unit the day of the incident (7/23/16). She reported she saw Staff M take both Residents #8 & #9 down to the music activity at 10:00 a.m. but then went on break at 10:15 a.m. - 10:45 a.m. and she didn't know the residents hadn't returned to the unit until Staff Q brought both residents back to the unit from the southeast entrance to the facility. During an interview on 7/26/16 at 11:40 a.m. Staff O, CNA reported she worked on the memory care unit the day of the incident. She reported she went on break at 10:05 a.m.-10:35 a.m. and she wasn't aware of Resident #8 & #9 had gone to the music activity. At 10:45 a.m. she heard of the radio that both residents needed escorted back to the unit. She reported she couldn't leave the unit until Staff M or Staff N returned to the unit. Staff N returned shortly after and Staff O then went down to the activity area, didn't see the residents. Another staff person (staff unknown) told her the residents were taken back to the unit. She assisted another resident who didn't live on the unit back to h/her room and then answered a resident call light before returning to the unit when she then saw the residents being escorted into the southeast entrance of the facility. During an interview on 7/26/16 at 9:30 a.m. Staff P, a licensed practical nurse (LPN) reported she had not received morning report and did not look at the activity calendar that the Activity Director would not be at the music activity scheduled from 10:00 a.m.-10:45 a.m. Staff P stated she knew Staff M had escorted both Resident #8 & #9 to the music activity at 10:00 a.m. An announcement at 10:45 a.m. over the facility radio noted the music activity had ended but did not direct staff to escort the residents back to the unit. Staff P stated she was getting report from a medication aide at the time of the announcement. During an interview on 7/27/16 at 8:57 a.m. Staff Q, CNA reported she took her break at 10:45 a.m. and ate lunch in her car, which had been parked by the southeast entrance of the facility. At 11:00 a.m. she saw both Residents #8 & #9 walking toward the entrance to the facility. She asked the residents where they were going and Resident #1 stated h/she and spouse were going to their apartment. Staff Q escorted both residents into the facility and to the memory care unit. She reported the residents didn't appear to be in any distress. During an interview on 7/26/16 at 10:00 a.m., the Director of Nursing (DON) confirmed the events that are documented above. She reported the Activity Director told the memory care staff the day before (7/22/16) that she would not be attending the activity. Staff bringing residents to the activity needed to stay with the residents during the activity and escort the residents back to the memory care unit. The DON stated her expectation is for staff to be with residents when residents are off the memory care unit.