Every finding on record at St Anthony Senior Services

Based on observations, clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to protect the resident's right to be free from physical abuse by a facility staff member for 1 of 3 residents (Resident #1). The facility reported a census of 73 residents. Findings include:According to the quarterly Minimum Data Set (MDS) assessment with a reference date of 3/17/2026, Resident #1 scored 0 on the Brief Interview of Mental Status (BIMS). A score of 0 suggested severe cognitive impairment. The MDS documented he had impairments to his bilateral upper and lower extremities and utilized a wheelchair. Resident #1 was dependent on staff for toileting hygiene, upper and lower body dressing, mobility, and toileting transfers. The MDS documented he was not on a toileting program, was frequently incontinent of urine and always continent of stool. The MDS documented Resident #1 received an antipsychotic during the review period. The following diagnoses were listed for Resident #1: Alzheimer's disease, heart failure, stroke, and non-Alzheimer's dementia.The Care Plan Focus Area with a revision date of 12/18/2025, documented Resident #1 required complete assistance of staff to complete Activities of Daily Living (ADLs). The care plan documented he required the assistance of 1 staff for dressing/undressing, total assistance due to cognitive impairment. He required the use of a stand-up lift. The care plan documented Resident #1 had poor comprehension and will become resistive/uncooperative. He required two-person assistance for toileting due to use of a stand-up left. He is frequently incontinent of urine and occasionally incontinent of bowel. He wears incontinent products and staff are to provide peri-care with every incontinent episode and as necessary.A second Care Plan Focus Area with a revision date of 1/16/2024, documented Resident #1 admitted to the facility with the diagnosis of Alzheimer's disease. Resident #1 is known to have episodes of sudden changes in mood and behavior, tendencies to display unwanted and unsafe behaviors such as standing and walking without assistance despite unsafe gait and history of falls, as well as being uncooperative or resistive of cares when needed. He also has the potential for increased behaviors to include becoming combative, unsafe wandering, attention seeking behavior, hallucinations and/or delusion. The care plan directed staff to attempt nonpharmacological interventions prior to using as needed (PRN) medications. Staff are to intervene as necessary to protect the rights and safety of other residents, approach/speak to Resident #1 in a calm manner, divert attention if needed, and remove him from the situation and take him to an alternate location as needed. Staff are also advised to minimize the potential for Resident #1's disruptive behaviors by offering tasks which divert his attention.A third Care Plan Focus Area with a revision date of 4/3/2024, documented Resident #1 had impaired cognitive function, impaired thought processes, short- and long-term memory deficits, impaired decisions making skills and impaired ability to communicate such as making his needs known and understand others related to his Alzheimer's diagnosis.The following Progress Notes documented:a) On 3/5/2026 at 7:18 PM Resident #1 leaning to the right in his wheelchair with his arm hanging over the side. He was repositioned numerous times and continued to put his arm over the edge of the chair and hang over itb) On 3/10/2026 at 5:49 AM Resident #1 was having difficulty using the mechanical lift during the night for toileting. He was not fully alert at this time, he would not hang on to the bars, just hanging from the stand belt, head and arms hanging down. With verbal cues and assisting his fingers around the lift handle, he could not hang on. Staff had to hold on to the resident as he was hardly awake during the transferc) On 3/12/2026 at 7:15 PM when the Certified Nursing Assistants (CNAs) were helping the resident with bedtime cares, he became agitated with staff. Staff were trying to take his clothes off and stand him with the mechanical lift to use the toilet, Staff A CNA became increasingly irritated with resident and being short with him. Staff B held Resident #1's hands, trying to calm him down. Staff A then swatted at resident with an open hand causing a scratch to his right upper lip (1 centimeter (cm) x 1/2cm) that bled immediately, and a scratch to his right upper cheek (3cm long). CNA reported it to this nurse, proper documentation completedd) On 3/13/ 2026 at 6:08 AM Resident #1 rested in reclining chair in common area during the night with eyes closed per his usual. Repositioning completed and checks for toileting/toileted every 2 hours. He was cooperative with all cares during the night. Resident #1 tolerated the use of the mechanical lift with two staff assist. No agitation or aggression noted. A thin scratch to right cheek and scant amount of dried bloody drainage to upper right lip present. No other apparent injuries notede) On 3/13/2026 at 6:30 AM Resident #1 resting quietly, smiles when spoken to while sitting in recliner. Noted a faint pink scratch on his cheek near the right side of his nose and scant amount of dried blood right inner lower lipf) On 3/14/2026 at 10:11 AM noted a small bruise to Resident #1's right lower lip and pink areas to his right cheek. Resident pleasant with transfers this morning and caresg) On 3/14/2026 at 11:00 PM scratch to left cheek is healing, pinkish/red area noted. Resident #1's lower right lip has multiple areas of healingh) On 3/15/2026 at 5:47 AM Resident #1's left cheek is healing, bruise on his lower lip is purple in color; no complaints of paini) On 3/15/2026 at 1:12 PM Resident #1's activity/behavior as usual for him today. He continued to have very faint linear scratch on the right side of his face with a small bruise to his inner right lower lipj) On 3/16/2026 at 5:07 AM the scratch on Resident #1's cheek is almost healed, bruise on his lip is healing with a scab formedk) On 3/17/2026 at 8:50 AM a dark bruise to Resident #1's lip remained unchanged; scab is healed with only pink skin discoloration remaining.On 3/31/2026 at 1:10 PM Resident #1 sat in a recliner in the commons area with his wife sitting to the right of him. At 3:15 PM observed two staff members transfer Resident #1 from his recliner to his wheelchair with a mechanical lift. The resident was cooperative during the transfer. The resident was assisted to a table where an activity had taken place. No signs of injuries were noted to his face.The facility's investigative file included the following statements and summary:Staff B Certified Nursing Assistant (CNA) wrote the following statement: around 8:00 PM on 3/12/2026, myself and Staff A CNA were getting Resident #1 ready for bed. We first took him to the bath house to change his clothes. Before we got him on the mechanical lift we were changing his shirt. When doing that he was aggressive; like hitting and elbowing Staff A. Staff A was not doing anything to calm him down, it seemed as though she had a temper with him. We then got him up with the mechanical lift and brought him to the toilet. When we got him on the toilet, we started taking his pants off, and while doing that Resident #1 was being aggressive and hit Staff A. After I saw that, I then asked Resident #1 if he wanted to hold my hand and see if it would calm him down, which it did. As Staff A started putting his socks on, she hit Resident #1 in the face with an open hand, which cut his lip and scratched his cheek. I saw both things appear, and his lip started to bleed. After this happened, we got Resident #1 up from the toilet and finished all of his nightly cares, we then brought Resident #1 to his recliner with the mechanical lift for bed. As soon as Resident #1 was sitting in his recliner, Staff A reclined him in his chair and put his blanket on him. Staff B went to talk to Staff C, the nurse on duty to report it. Staff B signed and dated the hand written statement on 3/12/2026.Staff A wrote the following statement: at approximately 8:15 PM I assisted a non-verbal resident with evening ADLs in preparation for bedtime. The resident was visibly restless and agitated in his wheelchair. This behavior was unusual for him. A new CNA in training accompanied me with the mechanical lift. We transferred the resident to the bathroom and began assisting with dressing for bed. The resident remained agitated during the entire interaction and attempted to grab staff while providing care. We assisted him in removing his shirt and pants, then transferred him to the toilet using the mechanical lift. His adult brief was slightly wet. While dressing him in clean clothing and preparing to remove his pants, the resident remained restless and moving his arms. While I was leaning down near his feet, I heard a smack sound and looked up. At that time, I saw the resident arm contact with side wall and the other CNA standing next to him. We attempted to verbally redirect and reassured him. We transferred the resident back to his wheelchair using the mechanical lift to returned him safely to his recliner. Later I notified the nurse how the resident had been agitated during care. Clarification: at no time did I strike or intentionally hit the resident. Staff A signed the handwritten statement.The following summary was documented: in a follow up interview with Staff B she was asked specifically at what point did Staff A hit Resident #1. She stated that she was holding both of Resident #1's hands while Staff A put on his socks and she reached up and swiped at his face causing the scratch and cut to lip. I asked Staff B if Resident #1 at the time was still aggressive and she stated no she was holding both his hands. In an interview with Staff A about the incident she described his behavior as being agitated and described the events of toileting similar to Staff B. She stated that resident was aggressive while being toileted while she was bent down putting on socks resident was hitting toilet assist bar and didn't remember if he hit her head. She added that resident seemed to calm down after toileting was complete and resident placed in recliner in lobby area. When asked if she struck at Resident #1 she stated I don't know the time I hit him. Stating she has never raised her hand towards any resident. Asked her how resident would have received an abrasion on lip and scratch and she didn't know that he got scratched or the abrasion. In conclusion the facility has determined that there was some degree of staff to resident contact. Whether it was swiping or open-handed slap/hit we believe there was contact made. Therefore, the facility has terminated employment with Staff A. The summary was completed by the Administrator.On 3/31/2026 at 1:26 PM Staff B stated around 8:00 PM on 3/12/2026 her and Staff A had assisted Resident #1 with getting ready for bed. They assisted him to the bathhouse to change him and brush his teeth. Resident #1 became aggressive when they started to change his clothes: he was hitting and punching at Staff A. After they were able to get his shirt on, they used the mechanical lift to assist him to the toilet. He was aggressive during that transfer but then he calmed down. Staff A took Resident #1's pants and socks off, then she put on new socks. Staff B asked Resident #1 if he wanted to hold her hands while Staff A continued to dress him. Resident #1 held Staff B's hands and then she saw Staff A bring up her right hand and with an opened hand, Staff A smacked Resident #1 on the face. Staff B then noticed a cut on Resident #1's lip and scratch on his cheek. Staff B stated she saw this happen and was in the bathroom the whole time Staff A was in there with Resident #1. Staff B stated Resident #1 did not do or say anything after this happened. She added he is mostly non-verbal but did have a surprised look on his face. Staff A did not say anything either. They continued to assist Resident #1 by assisting him to his wheelchair then to a recliner in the living room. He likes to sleep in the recliner out there. They got him in the recliner, his shoes off, placed a blanket on him and he went to sleep. Staff B stated she then went and spoke to Staff C Licensed Practical Nurse (LPN) about what she witnessed. Staff B denied seeing Resident #1 hitting his hands or face on the wall while they were assisting him. She stated she was with the resident and Staff A during the entire interaction. Staff B stated she stood to the left of Resident #1 and Staff A was crouched down in front of Resident #1, when she reached up and struck him in the face. Staff B felt Staff A had a temper with Resident #1; she seemed angry by the way she was acting and talking to him. Staff A raised her voice when speaking to Resident #1 and acting like she was not putting up with his behaviors. When he became agitated while they attempted to change his clothes, she would not stop, just yelled at him a bit. Resident #1 was acting like he did not want to be touched but Staff A would not stop trying to change his clothes. Staff B stated she talked to Resident #1 to calm him down and had him hold her hands as she did not want to irritate him anymore. Staff B stated she was still in training and was too nervous to offer ways to calm him down to Staff A. Staff B was read the statement she provided to the facility and she stated it was accurate.On 3/31/2026 at 2:13 PM Staff C stated Staff B came to her to report at about 8:00 PM on 3/12/2026 that Staff A hit Resident #1. Staff B told her they had assisted Resident #1 with getting ready for bed Staff A hit Resident #1 in the face causing scratches to his face. Staff C asked Staff B to write her statement as she called the nurse manager for guidance. Staff C stated after her and the charge nurse upstairs escorted Staff A out of the facility she assessed Resident #1. She noted a 3cm long scratch under his right eye and a 1-0.5cm cut to his lip. There was fresh blood present on his lip when she completed the assessment. Staff C stated Resident #1 appeared fine during her assessment, he did not know what was going on. She denied any ill effects with Resident #1 since this incident has occurred.On 4/1/2026 at 9:19 AM the Director of Nursing (DON) stated Staff A worked on the overnight shift and she occasionally saw her. She was always polite but no indication that she was aggressive or rude. Staff A worked part time usually working 6 overnight shifts in 2 weeks and would pick up additional hours here and there. The DON added she did work on the Assisted Living side of the building as well. The DON stated when staff are caring for residents that are displaying behaviors, they should ensure the resident is safe then walk away from the situation, cool down and reapproach. They recently had a staff in-service about how to approach residents with dementia and aggressive behaviors.The facility provided a policy titled Abuse Policy and Procedure with a revision date of 1/2026. The policy documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on clinical record review and staff interviews, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed (Resident #12). The facility reported a census of 75 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) of 03 indicating severely impaired cognition. The MDS revealed Resident #12 had diagnoses of Non-Alzheimer's dementia, depression, and psychotic disorder. The Care Plan with a target date of 7/2/26 revealed Resident #12 took an antipsychotic medication for treatment and management of symptoms of delusional disorder, insomnia and depression. The Clinical record revealed a diagnosis of delusional disorders with an effective date of 9/27/23. A Physician Order dated 4/3/25 directed staff to administer Seroquel (antipsychotic medication) 25 MG (milligrams) one tablet at bed time related to dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; delusional disorders. Review of the Clinical Record revealed Resident #12 had been on Seroquel at different dosages since 9/27/23. A Level 1 PASRR completed on 3/29/23 documented Resident #12 had a mental health diagnosis of major depressive disorder. The PASRR evaluation documented Resident #12 received antidepressant for depression. The clinical record revealed no additional PASRR evaluations after 3/29/23.The Clinical record review revealed Resident #12 did not have a Level 2 PASRR evaluation submitted following the new mental health diagnoses of delusional disorder and with the addition of new antipsychotic medication on 9/27/23. On 2/11/26 at 2:30 PM, the Director of Nursing (DON) acknowledged and verified Resident #12's PASRR had not been updated. The DON reported she would expect a new PASRR to be completed when a new psychotropic medication was started and/or a new mental health diagnosis. On 2/11/26 at 3:26 PM, the DON reported the facility did not have a PASRR policy.

Based on observation, clinical record review, and staff interviews, the facility failed to accurately transcribe written physician orders for psychotropic medications with correct medication end dates into the electronic medical record for 2 of 3 residents reviewed (Resident #5 and #62). The facility reported a census of 75 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of dementia, stroke and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The Care Plan with an initiated date of 8/12/25 showed Resident #5 used psychotropic medications to aid with the treatment of the diagnosis of mild cognitive impairment with behaviors including, restlessness, agitation, inappropriate towards female staff. The written Physician Order dated 1/27/25 for Resident #5 showed Lorazepam 2 milligram (mg)/milliter (ml) give 0.25 ml per mouth every 4 hours as needed for 3 months. The electronic Clinical Physician Orders dated 1/16/25 for Resident #5 showed Lorazepam 2 mg/ml give 0.25 ml per mouth every 4 hours as needed with an end date of indefinite. 2. The MDS assessment dated [DATE] for Resident #62 documented diagnoses of dementia, stroke and depression. The MDS showed the BIMS score of 3, which indicated severe cognitive impairment. The Care Plan with an initiated date of 6/6/25 showed Resident #62 used antidepressant and antipsychotic medication to manage symptoms of depression, anxiety, and unwanted behavior secondary to depression and dementia. The written Physician Order dated 12/1/25 for Resident #62 showed Lorazepam 2 mg/ml give 0.5 ml per mouth every 6 hours as needed for 90 days. The electronic Clinical Physician Orders dated 11/19/25 for Resident #62 showed Lorazepam 2 mg/ml give 0.5 ml per mouth every 6 hours as needed with an end date of indefinite. The Medication Regimen Review policy last revised October 2023 indicated Medication Regimen Review is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication related problems, medication errors, or irregularities, and collaborating with members of the interdisciplinary team. The pharmacist will review the resident's drug regimen for unnecessary drugs. An unnecessary drug is a drug that is used for excessive duration. In an interview on 2/11/26 at 2:06 PM, the Director of Nursing (DON) addressed management of Lorazepam orders. The DON reported maintaining a spreadsheet tracking which Lorazepam orders required reordering and the corresponding dates. When asked if electronic orders should match written physician orders, the DON responded, Yes, but how do I change the end date. When asked if staff could potentially continue administering Lorazepam past the written end date if the electronic order reflected an indefinite duration, the DON stated, Yes, I need to figure out how to change that. The DON acknowledged that discrepancies in end dates could result in residents receiving unnecessary psychotropic medications.

Based on observation, staff interview, and review of facility policy, the facility failed to follow proper infection control practices during catheter care to prevent urinary tract infections and skin infection for 1 of 2 residents observed (Resident #5). The facility reported a census of 75 residents.Finding include:Observation on 2/11/26 at 1:50 PM identified Staff A, Certified Nursing Assistant (CNA), performed hand hygiene and donned personal protective equipment (PPE). Staff A assisted the resident to lower pants and sit on the toilet, gathered supplies, placed two washcloths in the sink, and allowed the sink to fill with water. Staff A removed a washcloth from the sink, folded it into fourths, and provided perineal care to the resident's penis. Observation revealed areas of irritated, reddened skin. Staff A then used the same washcloth to cleanse the tubing of the resident's urinary catheter. After completion of care, when asked if any part of the care should have been performed differently, Staff A responded no, and reported the state had not observed her for several years. When asked if she placed washcloths in the sink each time perineal or catheter care occurred, Staff A responded, Yes, now that I say it out loud, it's not right, then indicated the resident brushed his teeth in the sink.In an interview on 2/11/26 at 2:06 PM, the Director of Nursing (DON) addressed infection control practices for perineal and catheter care. The DON stated washcloths used for perineal or catheter care should never be placed in the sink. The DON further stated, If they are going to use washcloths, they should use a basin. The DON indicated the facility only had a policy related to home perineal care instructions. In an interview on 2/11/26 at 2:25 PM, the Infection Preventionist (IP) reported that placing washcloths in the sink prior to perineal or catheter care increased the risk of infection. The IP stated staff received education and know not to place washcloths in the sink. The IP further stated plans to follow up with staff to re-educate on the proper method for performing perineal and catheter care.

Based on clinical record reviews, hospital record review, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #1) for falls. The facility failed to implement effective interventions and follow the care plan to prevent falls. Resident #1 was at risk for falls and had a history of repeated falls with trends. Resident #1 had eight falls from January 2025 to August 2025. On 6/1/25 Resident #1 had a fall in her room after attempting to self transfer from her wheelchair to her recliner, resulting in her hitting her head and sustaining a laceration to her forehead requiring an emergency room (ER) visit and 8 staples. On 8/8/25 she fell again in her room after attempting to self transfer from wheelchair to her recliner, resulting in her hitting her head and left hip pain. Resident #1 was transferred to the hospital for x-rays and revealed she had a left hip fracture which required surgical intervention. Within days after surgery Resident #1's condition declined, she developed pneumonia and passed away. The facility reported a census of 76 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #1 required partial/moderate assistance with bed mobility, transfers, toileting and ambulation. Resident #1's MDS included diagnoses of progressive neurological conditions, hypertension (high blood pressure), and depression. The MDS revealed Resident #1 had one fall with injury and two or more falls without injury since the prior MDS assessment. The Facility Incident Reports (IR) documented from January 2025 to August 2025 revealed Resident #1 fell on the following dates: 1/8/25, 1/26/25 x2, 5/2/25, 5/10/25, 6/1/25, 6/9/25 and 8/8/25.Resident #1's Fall Risk Evaluations documented the following scores indicating at risk for falls:12/19/24= 163/25/25=145/10/25= 187/1/25= 16The Care Plan with a target date of 10/2/25 identified Resident #1 required staff assistance with activity of daily living (ADLs) and was at risk for falls related to history of falls secondary to impaired balance, poor safety awareness, neuromuscular/functional impairment and the use of medications that may increase fall risks related to multiple diagnoses. The Care Plan interventions included the following:a. Staff to encourage Resident #1 to ask for assistance when wanting to transfer and ambulate- date initiated: 12/20/24b. Staff to encourage Resident #1 to participate in activities that promote exercise, physical activity for strengthening and improved mobility- date initiated: 12/20/24 c. Staff to ensure Resident #1 wearing appropriate footwear when ambulating or utilizing her wheelchair- dated initiated: 12/20/24, revised on 4/3/25d. Resident #1 to have a safe environment with even floors free from spills and/or clutter, adequate lighting and personal items within reach- dated initiated: 12/20/24, revised 4/3/25e. Resident #1 moved to a room closer to the nurse's station in February 2025 to be monitored more closely by staff when in her room- dated initiated: 12/20/24, revised 4/3/25f. Fall 1/8/25- Staff education to be aware of when family leaves and to make sure to keep wheelchair nearby, additional call light added (one by bed and one by recliner) and staff to encourage Resident #1 to use non-skid socks- date initiated 1/21/25g. Fall 1/26/25 at 8:45 AM- Staff educated to be aware of when Resident #1 was returning to her room to be available to assist her. Resident #1 educated to use her call light and wait for staff to assist her. A board was placed between her recliner and wall to prevent the chair from moving back- date initiated 2/18/25h. Fall 1/26/25 at 10:15 AM- Educate staff on use of proper equipment when transferring Resident #1- date initiated 2/18/25i. Fall 5/2/25- Educate staff not to leave Resident #1 unattended while on the toilet and make sure she was seated safely in a chair of her choice. Resident #1 preferred to stay in her room in her recliner for lunch- date initiated 5/5/25 j. Fall 5/10/25- Educate staff to attempt to assist Resident #1 to desired place prior to leaving her alone, checking back on her frequently during times of anticipated movement (going to a meal or activity)- dated initiated 5/10/25k. Fall 5/10/25- Apply auto-lock brake system to Resident #1 wheelchair- date initiated 6/5/25l. Fall 6/1/25- Staff to encourage Resident #1 to call for assistance when she returns to her room and wants to get in her recliner. A floor mat alarm obtained and placed that connected to the call light system- date initiated 6/15/25m. Fall 6/9/25- Educate the bath aide to assist Resident #1 back to her recliner after the bath instead of having her head back to her room on her own. Additional staff reminded to watch for Resident #1 wheeling herself in the hall, anticipating Resident #1 trying to transfer herself and assist her as they see her. n. Addendum 7/28/25- The floor mat alarm removed due to the alarm not working properly and Resident #1 pushed the mat out of the way when she was in the room. Resident #1's husband educated/reminded her to use the call light so staff are present when transfers- Revised 8/8/25. o. Fall 8/8/25- Staff to close Resident #1 door to room when out of the room. Staff to encourage Resident #1 to call and wait for assistance. The Progress Note dated 1/8/25 documented at 1:45 PM staff passed Resident #1's room and found her sitting on the floor, pulling on the bed frame, trying to get herself back up. Resident #1 pointed to the bathroom door and when asked if she was going to the bathroom she said yes. The note documented Resident #1 was educated/reminded to wait for assistance. The IR dated 1/8/25 at 1:45 PM identified Resident #1 had a fall next to her bed. The IR documented Resident #1 had eaten lunch in her room in bed. Resident #1 husband and sons had been visiting and had left approximately 30 minutes prior to the fall. The IR documented Resident #1 did not have her call light, walker or wheelchair within reach at the time of the fall and her socks were slick. The intervention documented staff educated to position the wheelchair next to bed or recliner, 2nd call light provided (one on bed and one on recliner) and encourage use of non-skid socks.The Progress Note dated 1/26/25 documented at 8:45 AM, Certified Nursing Assistant (CNA) found Resident #1 on the floor in front of her recliner. The CNA had gone to get the nurse and upon return Resident #1 had already gotten herself up partially onto the recliner. Resident #1 reported the recliner moved back when she was trying to self transfer from the wheelchair to the recliner. Staff educated to watch for Resident #1 to finish her meal and return to the room after meals. Resident #1 reminded to call and wait for assistance. The IR dated 1/26/25 at 8:45 AM identified Resident #1 had a fall in her room near the recliner. The IR documented after breakfast meal Resident #1 self propelled from the dining room back to her room, attempted to self transfer from wheelchair to recliner and fell. The intervention documented to educate staff to watch for resident to wheel self back after meals, remind Resident #1 to wait for assistance and a board placed between the recliner and wall to prevent it from moving. The Progress Note dated 1/26/25 at 10:15 AM documented the nurse was called to Resident #1's room due to a report of a fall. When the nurse entered room, Resident #1 was sitting in her recliner. The CNA reported she was helping Resident #1 up from the recliner and was going to take Resident #1 to the bathroom. The CNA reported Resident #1 lost her balance which caused the CNA to lose her balance which resulted in Resident #1 and the CNA falling on the floor and Resident #1 landing on the CNA. The IR dated 1/26/25 at 10:15 AM identified Resident #1 had a fall in her room in front of the recliner. The IR documented Resident #1 lost her balance with a transfer from the recliner to the wheelchair. The CNA was unable to help Resident #1 recover her balance which resulted in both Resident #1 and the CNA falling to the floor. Resident #1 landed on the CNA. The IR revealed the CNA was not using a gait belt during the transfer and the CNA got Resident #1 up off the floor before the nurse could assess her. The intervention documented was staff educated to use gait belt with all transfers and ambulation.The Progress Note dated 5/2/25 documented at 10:15 AM, Resident #1 had been in her wheelchair, attempted to transfer herself into the recliner, lost balance, landing on her bottom with her back up against the side of the bed. No injuries noted. The IR dated 5/2/25 at 10:15 AM identified Resident #1 had a fall in her room due to self transferring from the wheelchair to the recliner. The IR documented Resident #1 was previously assisted onto the toilet, staff left her alone and she transferred herself off the toilet and into her wheelchair, and then tried to transfer to the recliner. The intervention documented was to educate staff to not leave Resident #1 unattended while on the toilet and make sure she was seated safely in a chair of her choice.The Progress Note dated 5/10/25 at 7:37 AM documented staff found Resident #1 sitting on the floor near the bottom of her bed. The note documented Resident #1 reported she had been in the recliner prior to the fall and was trying to transfer herself to the wheelchair. The note documented the immediate intervention was to continue to remind Resident #1 to call for help and wait for help to arrive prior to attempting to self transfer. The IR date 5/10/25 at 7:40 AM identified Resident #1 had a fall in her room due Resident #1 self transferring from the recliner to the wheelchair and the wheelchair moved away from her. The IR documented the brakes on the wheelchair were not locked on the wheelchair at the time Resident #1 was found on the floor. The intervention documented was to apply an auto-lock brake system to Resident #1's wheelchair and education provided reminding Resident #1 to use her call light and wait for staff to assist her. Review of Resident #1's Care Plan documented the auto-lock brakes were initiated on 6/5/25. Review of the Progress Notes lacked any documentation regarding when the auto-brakes were applied to Resident #1's wheelchair. The Progress Note dated 6/1/25 at 8:20 AM documented staff found Resident #1 on the floor lying on her left side with a significant amount of blood on the floor. The note indicated there was a laceration to Resident #1's left forehead with a large amount of active bleeding. New order received to send Resident #1 to ER and an ice pack was applied. The Progress Note dated 6/1/25 at 9:30 AM documented Resident #1 was ready to return from the ER and 8 staples were required for wound repair. New orders received from the ER for daily dressing changes with Vaseline and wrap and after two days to switch to a telfa (non-adherent dressing). The note indicated the staples were to be removed on 6/9/25.The IR dated 6/1/25 at 8:20 AM identified Resident #1 had a fall in her room due to Resident #1 attempting to transfer herself from her wheelchair to the recliner. The intervention documented was to continue to encourage Resident #1 to call for assistance when returns to room and wants to get into her recliner. The IR documented staff would check into accessing an alarmed floor mat that connects to the call light system. Review of Resident #1's Care Plan documented the floor mat alarm was initiated on 6/15/25.Review of a facility Invoice dated 6/10/25 revealed the floor mat was ordered on 6/10/25 and delivered to the facility on 6/12/25. The care plan and progress notes lacked any additional fall interventions implemented while the facility was waiting to receive the floor mat. The Progress Note dated 6/9/25 at 9:20 AM documented Resident #1 had fallen. Resident #1 had just wheeled herself back to her room and attempted to self transfer from the wheelchair to her recliner, lost balance, falling onto her bottom with her back against the night stand. No injuries noted. The IR dated 6/9/25 at 9:20 AM identified Resident #1 had a fall in her room after wheeling herself back to her room after a bath. The intervention documented to educate the bath aid to assist Resident #1 back to her recliner after the bath instead of her heading back to her room on her own. Additional intervention was to remind other staff to watch for Resident #1 wheeling self in the hall, anticipating Resident #1 trying to transfer self and assist her as they see her. The Progress Note dated 7/28/25 at 2:26 PM documented the floor mat alarm was removed. The note documented staff reported the mat was not working and Resident #1 would push the mat out of the way when she was in the room. Resident #1 husband present and voiced satisfaction with having the mat removed. Husband stated he would continue to remind Resident #1 to use her call light to call for assistance. The Progress Note dated 8/8/25 at 8:15 AM documented the housekeeper reported she had heard something fall, looked into the room and reported Resident #1 was on the floor. Resident #1 was found lying on her left side on the floor with blood noted from head. No external rotation or shortening of limbs. A 2 centimeter (cm) cut/skin tear noted to the left side of head and a small 0.2 cm cut to right hand/wrist. The note documented Resident #1 had wheeled herself back to her room after breakfast and had attempted to transfer herself to the recliner. Resident #1's wheelchair was parked next to the recliner. The Progress Note dated 8/8/25 at 10:18 AM documented during the neurological assessment at 10:00 AM, Resident #1 reported that her left hip was hurting really bad. Resident #1 attempted to pick up her left leg with her hands when asked to move the left leg. New orders were received for an x-ray and Resident #1 was taken to radiology. The Progress Note dated 8/8/25 at 12:46 PM documented Resident #1 was taken from radiology to ER due to a left hip fracture. The IR dated 8/8/25 at 8:15 AM identified Resident #1 had a fall in her room. The IR documented Resident #1 had a history of making attempts to self transfer from her wheelchair to her recliner when she returned to her room after breakfast and it appeared to have been what she had been doing. The nursing staff are aware and try to anticipate her needs, but unfortunately at this time they were assisting other residents. The IR documented around 10:00 AM, Resident #1 started to complain of pain in her left hip and was having difficulty moving her leg. Her provider was updated and an order was received for x-ray. She was found to have a fractured left hip and was sent to ER. The Hospital Discharge summary dated [DATE] documented Resident #1 was admitted for fall with left hip fracture and underwent surgical repair on 8/9/25. Within 2 days following surgery, Resident #1 had worsening mental status and respiratory difficulty. A workup revealed Resident #1 had left lung pneumonia. Resident #1 was placed on a vapotherm (ventilatory support) and antibiotics. After several days Resident #1 began to improve clinically from a respiratory standpoint but never regained alertness. After several days Resident #1's family elected to pursue comfort care and antibiotic/fluids were discontinued. Despite decreased oxygen needs Resident #1's breathing slowly worsened and she passed away on 8/15 peacefully with family at bedside. The State of Iowa Certificate of Death dated 8/15/25 documented the immediate cause of death was pneumonia due to or as a consequence of progressive supranuclear palsy (progressive neurodegenerative disorder/rare brain disease that affects walking, balance, eye movement swallowing) due to or as a consequence of left femur fracture. On 10/14/25 at 11:34 AM, when asked about the fall on 8/8/25, Staff A, Housekeeper reported she was in the storage room when she heard a bang. She said she went two doors away and saw Resident #1 laying on the floor next to her recliner with her wheelchair behind her. She said she yelled for the nurse who was in the area and the nurse (Staff D) came into the room to assess her.On 10/14/25 at 12:20 PM, Staff B, CNA reported she was assigned to Resident #1's hallway and dining room duty the morning of 8/8/25. She said she came down the hallway and another aide had told her that Resident #1 had fallen. She said she did not see Resident #1 leave the dining room. She said she was assisting other residents with eating. She said Resident #1 was really fast and would leave when she was done eating. She said the staff would try to catch her before she left the dining room. She said she knew Resident #1 would get up on her own. She said that morning Resident #1 was quicker than the staff. She said Resident #1 loved to sit in her recliner. She said she thought Resident #1 had rolled herself to her room and tried to get in the recliner herself.On 10/14/25 at 2:40 PM, the MDS Coordinator reported the floor mat alarm was discontinued because the husband did not like it and Resident #1 kept kicking the floor mat out of the way. She said the floor mat was not effective as you had to stand on it to make it work. When asked if an additional intervention was put in place when the floor mat was discontinued, she said would have to check her notes. On 10/14/25 at 9:06 AM, the MDS Coordinator said the staff reported on 7/28/25 that the floor mat alarm was not working. She said Resident #1 was pushing the mat out of the way and thought it was annoying. She said when Resident #1's husband was in the room, he would also push the mat out of the way. She said that particular day the alarm was not functioning as the batteries had not been checked. She said the staff was using the battery pack with the floor mat alarm and not the cord. She said it was decided when speaking with the husband to discontinue the floor mat alarm. She said the husband reported he would talk to Resident #1 about using the call light. The MDS Coordinator reported she did not know the specific date of when the floor mat alarm was put in place. She said the floor mat had to be ordered and it was put in place sometime between 6/1 and 6/15. When asked about the auto-brakes, the MDS Coordinator reported she did not have a specific date of when the auto-brakes were applied to the wheelchair. She said the restorative staff member gave Resident #1 a wheelchair with brakes on it and she did not like it. She said at some point Maintenance was notified and auto-brakes were applied to Resident #1's wheelchair. She said she thought that happened sometime in May. The MDS Coordinator reported Resident #1 would take it upon herself to leave the dining room. She said she would pedal herself at a fairly steady pace. When asked about the fall on 1/26/25, the MDS Coordinator reported it was an expectation for staff to use a gait belt with transfers. She said verbal education would have been completed at that moment. She said it was an expectation for staff to follow the care plan/care guide and she would frequently remind the staff to check the care guides. When asked about the fall on 5/2/25, the MDS Coordinator agreed Resident #1 should not have been left on the toilet alone due to her history of self transfers. She said she did not know who the aide was that left Resident #1 alone on the toilet. When asked about the fall on 6/9, she said she thought the bath aide was new. She said the bath aide should have let the aides know when Resident #1 was done with her bath. When asked if the facility had a lot of turnover in staff, she said kind of, she said the facility had been using quite a bit of agency staff. When asked about staff education that was documented as a fall intervention, she said the verbal education would have been done at the moment with the fall. She said she did not have any written/formal education for the staff members who were involved. On 10/15/25 at 9:40 AM, Staff C, CNA reported she had been assigned to Resident #1's hall the morning of 8/8/25. She said after breakfast sometimes she can catch Resident #1 coming back from the dining room and other times she can't. She said when the hall trays came out she had to pass them. She said Resident #1 would leave the dining room on her own and if the staff could catch her then they would help her. She said if you don't catch her she would transfer herself from the wheelchair to the recliner. She said every once in a while, she would use her call light. She said when Resident #1 had the floor mat alarm, she would use her call light more. She said Resident #1 would put her feet on the floor mat and the call light would turn on. She said the floor mat was hooked up to the call light. She said she was told by a nurse that the husband did not want her to have the mat because it was embarrassing. When asked if Resident #1 used her call light after the floor mat alarm was discontinued, Staff C reported she would use her call light every once in a while, but it was not consistent. Staff C said she learned Resident #1 had fallen from the housekeeper. She said she was passing hall trays when Resident #1 fell. On 10/15/25 at 10:20 AM, Staff D, Registered Nurse (RN) reported the morning of 8/8/25 she had been down the east hall around the corner passing medication, she said she had just got back to the nurses station by Resident #1's room and was parking the medication cart. She said the Housekeeper, Staff A heard a noise, went to look and saw Resident #1 was on the floor. Staff D said she grabbed the blood pressure machine and went into the room and saw Resident #1 lying on her left side. She said Resident #1 had blood on her forehead from a small cut. She said it looked like Resident #1 had tried to transfer herself from the wheelchair to the recliner on her own. She said Resident #1's head was positioned towards the door and her legs towards the recliner. She said the auto-brakes on the wheelchair were in place and working. She said she had to pick up the wheelchair to move it. She said Resident #1 complained of her left shoulder. She said it was a little pink but was able to move it. She said Resident #1 was trying to get up on her own, pulling herself up. Staff D said Resident #1 was moving her arms and legs on her own/per normal. She said she had to tell Resident #1 to lie down so she could assess her and put a pillow under her head. She said another nurse did come in to help. She said she found no abnormalities except for a small cut on the forehead, hand and a sore shoulder. She said she started neurological assessments. She said there was no external rotation/shortening and no obvious signs of any fractures. She said at 10:00 AM, Resident #1 was complaining of her left hip hurting. She said the left shoulder was okay. She said she obtained orders to send Resident #1 for x-rays. She said they got her on a cart and sent her to radiology. She said they got the results right away and Resident #1 went from radiology to ER and did not return to the nursing home. Staff D reported she did not see Resident #1 coming back from the dining room that morning. She said Resident #1's normal routine was to leave the dining room and wander back towards her room. She said restorative therapy would catch her and do therapy services. When asked what would happen if the restorative therapy was not there, she said the staff tried to keep an eye out and catch her. She said the staff don't always catch her but they try to do their best. She said that morning nobody saw her. On 10/15/25 at 11:37 AM, the Administrator reported per the Nursing Home Fall policy gait belts are used as a fall prevention intervention. On 10/15/25 at 12:30 PM, the Administrator reported he expected staff to follow the care plan. He said looking back at it now, the intervention for staff to be aware of when Resident #1 left the dining room, was poor and probably set the facility up for failure. He reported the facility had done a lot of different intervention for Resident #1. He said some of the interventions worked and others did not. He said Resident #1 was impulsive and she was fast. The Administrator reported the floor mat was ordered on 6/10/25. He said the facility did not realize the floor mat on hand did not go with the alarm boxes they had until they needed the floor mat. He reported the correct floor mat was delivered on 6/12/25 and implemented that day. He reported he was still trying to determine when the autobrakes were put in place by maintenance to Resident #1's wheelchair. He said Resident #1 was given a wheelchair with the brakes in place and she did not like it. On 10/15/25 at 12:58 AM, the Administrator reported if there was not another care plan intervention documented from 6/1 to 6/12 then it was safe to say an additional intervention was not implemented while waiting for the floor mat to arrive. A facility policy titled Nursing Home Fall dated 03/2024 documented the purpose of the policy was to identify residents at risk for falls, the nursing role in caring for residents at risk for falls and how to care for a resident who has fallen. The policy further documented appropriate fall prevention interventions would be implemented based on the resident needs. Fall prevention interventions may include the following:a. Gait beltb. Education resident/familyc. Physical and/or Occupational Therapy Consultd. Medication reviewe. Observation and/or toileting every 2 hoursf. Assistive devicesg. Not be left in bed room unattendedA facility policy titled SNF RAI- Care Planning dated 12/2023 documented once the plan of care was completed, the information would be communicated to staff. Any day to day changes would be added to the care plan as directed by the MDS Coordinator.

Based on observation, staff interviews and policy review, the facility failed to ensure open items were dated, covered and labeled. The facility further failed to ensure staff used proper hand hygiene practices during lunch service while serving food. The facility reported a census of 76 residents. Findings include: 1. Observation 1/21/25 at 10:00 AM in the main kitchen with Staff I, Food and Service Director, present revealed the following: a. Two open undated bags of pasta b. Open undated bag of graham cracker crumbs During an interview 1/21/25 at 10:20 AM, Staff I stated an expectation the food is dated, labeled and sealed after it is opened. Staff I stated an intention to label and date these food items and return them to the pantry. Review of the facility Food Storage Guidelines policy, with a revision date of 12/24, documented food not served in the service of a meal will be handled safely to prevent contamination or spoilage. Unused foods are identified, labeled and dated. 2. During an observation 1/21/25, beginning at 11:30 AM, Staff J, kitchen staff, served residents lunch, plated the food without sanitizing hands in between. Observed Staff J touch the tip of a straw while taking it out of a wrapper and place it in a resident's cup, stirring the chocolate milk with the tip of the straw. Staff J opened cartons of milk for two residents, touching the inner carton where a resident drinks from. Staff J then served two residents, getting the flood plated from the steam table without sanitizing hands in between; touched the tray, dishware, serving utensils and plates, bowls. Staff J then went into the kitchen, touching handle to kitchen door, came back out of the kitchen and did not sanitize hands, began plating food for a resident. Staff J touched a hamburger bun with bare hands while cutting it in half with a knife. Staff J then served the resident, did not sanitize hands. During an observation 1/22/25, beginning at 11:15 AM, Staff K, kitchen staff, did not sanitize her hands in between serving residents. Staff K would plate the food and drinks and silverware, touching surfaces, then deliver the food to residents, touching the table, and at times assisting residents with taking the lid off of ice cream or using the resident's spoon to stir or their knife and fork to cut food. Staff K opened resident's milk cartons, touching the interior of the carton. Staff K served several residents without sanitizing her hands in between residents, touching several surfaces and plating food for residents. During an interview 1/22/25 at 1:01 PM, the Director of Nursing (DON) stated an expectation staff sanitize their hands in between serving residents, there is a hand sanitizer dispenser next to the tray cart, they are expected to put the tray used to serve a resident on the tray cart, and then sanitize their hands before getting a clean tray and serving another resident. During an interview 1/22/25 at 1:20 PM, Staff I stated an expectation staff sanitize their hands in between serving residents. Review of the facility Infection Prevention and Control/Employee Health and Hygiene/Hand Washing in Food and Nutrition policy, with a revision date of 12/24, documented food employees shall keep their hands and exposed portions of their arms clean to prevent foodborne illnesses and the spread of communicable diseases.

Based on resident record review, staff interviews, observation and facility policy review the facility failed to verify the resident's advanced directive choice documented accurately for 1 (Resident #58) of 24 residents reviewed. The facility reported a census of 76 residents. Findings include: The Resident Dashboard for Resident #58, dated [DATE], documented the resident was admitted to the facility on [DATE] and a current Code Status, Advanced Directive of Do Not Attempt Resuscitation (DNR). Resident #58's Iowa Physician Orders for Scope of Treatment (IPOST), signed by the physician [DATE], documented Cardio Pulmonary Resuscitation (CPR). Resident #58's Iowa Physician Orders for Scope of Treatment (IPOST), signed by the physician [DATE], documented DNR. Resident #58's Order Summary Report dated [DATE], documented a physician's order for DNR with order date [DATE]. Interview on [DATE] at 1:25 PM, Staff G, Registered Nurse stated all full code residents are listed on a sheet at the nurse's station, charts are purple, have star on the nametag at resident's room doorway, and have a red band on their walker or wheelchair and in an emergency situation that is the order she would look for the code status usually, depending on where the resident is. Observation on [DATE] at 3:30 PM, Resident #58 did not have a star on the name tag at room doorway, chart was green, and no red band observed on bed or wheelchair. Resident #58 was not on the Full Code list in the nurse's station. Facility policy, Advanced Directives last revised ,d+[DATE], documented changes to the resident choices for advanced directives will be documented, included in the resident plan of care, Iowa specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable and all items will be communicated to staff providing resident care. Interview on [DATE] at 1:49 PM, the Director of Nursing confirmed the physician's order and IPOST did not match and her expectation to for the records to be accurate and match.

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 diagnoses and treatment for urinary tract infection two times since admission and history of within 30 days of admission for 1 resident (Resident #16) of 18 residents reviewed for care plans. The facility reported a census of 76 residents. Findings include: The Minimum Data Set (MDS) for Resident #16, dated 10/31/24, included diagnosis Non-Alzheimer's Dementia and Urinary Tract Infection (UTI) (in the last 30 days). The MDS documented the resident was frequently incontinent of urine. Resident #16's Medication Administration Record (MAR) for 11/24 - 11/30/24 documented a physician's order started 11/27/24 for Macrobid (urinary anti-infective medication) two times a day for a UTI. Resident #16's Order Summary Report dated 1/22/25, documented a physician's order dated 1/14/25 for Cefurixine (antibiotic medication) two times a day for UTI for 10 days. Resident #16's Care Plan lacked inclusion of the UTI's, treatment, and interventions to prevent/monitor. Facility policy Comprehensive Care Plan Development last revised 10/2023, revealed the Care Plan will include measurable objectives and time frames to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. Interview on 1/23/25 at 9:02 AM, Staff H, MDS Coordinator confirmed the UTI's were not included the resident's care plan and expectation for the UTI's to be included in the care plan.

Based on observation, interview and clinical record review, the facility failed to ensure an accurate accounting of Scheduled 2 (II) (high potential for abuse) controlled medications for 1 of 3 residents reviewed. On 1/3/25, staff reported that Resident #44 was missing a dose of Ativan. The facility reported a census of 76 residents. Findings include: According to the Minimum Data Set, dated dated dated [DATE], Resident #44 was rarely understood so he was unable to complete Brief Interview for Mental Status assessment. Resident #44 required substantial assistance with toileting, showering and dressing, and supervision only with chair to bed transfers and walking. The resident had disorganized thinking, hallucinations, delusions, and daily physical symptoms directed toward others such as hitting, grabbing and pushing. The Care Plan for Resident #44 showed that the resident had episodes of behaviors such as combativeness, name calling and occasional refusal of medication/care resist cares. Staff were directed to administer medication as ordered and to monitor/document for side effects and effectiveness. A Nursing Note dated 1/3/25 at 11:40 AM, showed that on the morning of 1/3/25, Staff B Licensed Practical Nurse (LPN), discovered that the number of Ativan for Resident #44 did not match the number of Ativan that had been used. The Orders tab in the electronic chart showed that Resident #44 had an order dated 5/24/24 at 4:13 PM, for lorazepam (Ativan) topical gel, 0.5 milligrams/0.25 milliliter. Apply to wrist topically every 4 hours as needed for anxiety and behaviors, And, apply to wrist topically three times a day for anxiety and behaviors; mid-morning, midafternoon and at bedtime. A Pharmacy Delivery Note, signed by Staff F, Registered Nurse (RN), showed that on 12/31/25, 45 syringes of topical Ativan had been delivered to the facility. The Resident Controlled Substance Record for Resident #44 showed that with the addition of the 45 syringes, on 12/31/24 at 6:30 PM, there were 50 total syringes. The medication was used 7 times from the time of delivery until the night of 1/2/25. Upon count on 1/3/25 at 7:30 AM, there were 42 syringes remaining. On 1/21/25 at 10:45 AM, Staff D, LPN, said that on the morning of 1/2/25, she counted the narcotics with the overnight nurse and everything had been verified. She said that looked at the Ativan syringes for Resident #44, and counted the bundles and compared to the narc sheets with no concerns. She said that when she counted again at 2:00 PM with Staff C there were no discrepancies and they had counted each syringe in the bundles. They were not in a hurry and did not get disrupted during the count. On 1/22/25 at 10:01 AM, Staff C, LPN said that when she came into work at the 2:00 PM on 1/2/25, the outgoing nurse, Staff D was in a rush and told her she didn't need to count all of the syringes. She said that she made the mistake of believing that there were 10 in each bundle and didn't verify. Staff C said that Staff D had given two doses on the day shift, but had only documented that one had been given. She said that she didn't really know what the expectation was for counting of scheduled medications. In an observation on 1/22/25 at 7:35 AM, it was discovered that Staff D had signed the Nurses; Count of Narcotics and Drugs spreadsheet for the ongoing shift at 6:00 AM and also for the outgoing nurse at 2:00 PM. On 1/22/25 at 10:17 AM, Staff B said that when she worked on the morning of 1/3/25 and counted the narcotics with the overnight nurse, (Staff A), Staff A, LPN told her that there had been one Ativan missing from one of the bundles when she counted with the outgoing nurse at 10:00 PM the night before. Staff B acknowledged that the syringes were delivered in bundles of ten, with a rubber band holding the bundle together. She said that she would always count to make sure there were 10 in each of the bundles. On 1/3/25, one of the bundles had just 9 syringes. On 1/22/25 at 10:55 AM, Staff A, LPN said that she worked the overnight shift on 1/2/25 and before she started her shift at 10:00 PM, she counted the Schedule II medications with Staff C. At that time, the number of Ativan syringes for Resident #44, did not correspond with the documentation. She looked around in the drawers and in the medication room for the missing syringe. When she did not find it, she went on with her shift, hoping that it would show up somewhere throughout the night. Staff A acknowledged that in the past, there were times that the nurses would get in a hurry with the counting between shifts, and they wouldn't always look at the bundles to confirm that there were 10 in each bundle. On 1/22/25 at 2:27 PM, Staff E, LPN said that she worked full time at the facility and was aware of the expectation to count all of the Schedule II medications at shift change. She acknowledged that there were times when the nurses would get in a hurry and not count all of the individual syringes in the bundles. On 1/22/25 at 2:13 PM, when asked why she had signed on the line for the 2:00 PM outgoing shift earlier that morning, Staff D she that she was taught to sign both lines right away. She acknowledged that the purpose of the signature would be to verify that she had counted the Schedule II drugs with another nurse. On 1/23/25 at 10:15 AM, The Director of Nursing (DON) said that the nurses were expected to sign the shift change sheet at the time that they count with the other nurse. She said that the agency staff were taught about processes and expectation at the time of orientation. According to the Orientation Checklist For Nurses, Staff C had initialed the Trainee and Trainer columns. The checklist lacked reference to an orientation on the counting and verification of Schedule II medications. According to the Facility Policy titled: Narcotic Medication Management, last reviewed on 2/2024, Narcotic counts would be conducted at shift change by the oncoming nurse and outgoing nurse. Any discrepancies would be reported immediately to the supervisor.

Based on observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to protect residents from possible accidents and injuries. An electric space heater was used to provide supplemental heat to 3 rooms without out monitoring or supervision. Two rooms were in the Memory Care Unit with residents who had Brief Interview for Mental Status (BIMS) scores of 3 and 5 out of 15, indicating severe cognitive impairment. One resident was ambulatory and at risk for unsafe wandering per their Care Plan. Space heaters were provided on the weekend of 1/13/24 and removed 1/22/24 for 4 of 74 residents reviewed (Resident #1, #20, #30, and #173). The facility staff also failed to attach a lift sling to a mechanical lift correctly when transferring a resident, resulting in a fall with injury to 1 of 3 residents reviewed (Resident #29). These failures resulted in an Immediate Jeopardy (IJ) of the safety and welfare for the residents. The State Agency informed the facility the Immediate Jeopardy (IJ) began as of January 13, 2024 on January 23, 2024 at 1:54 P.M. The Facility Staff removed the Immediate Jeopardy on January 24, 2024 through the following actions: a. The Administrator immediately removed the space heaters and power strips and conducted a facility wide investigation and removed all additional space heaters. b. The facility updated their system wide Fire Safety Plan with the following verbiage: FIRE PREVENTION: a. Fire prevention is the primary goal of the St. [NAME] Fire Safety Plan. Cleanliness and orderliness: Trash or other combustible materials are not allowed to accumulate. Hallways are kept clear and free of clutter. b. Care: Fires are often caused by carelessness. [Facility Name Redacted] is a smoke-free campus. Patients and residents may smoke only with a Physician Order outside the facility with a signed consent form. c. All staff are alert for any variance in this policy or carelessness in disposal of smoking materials. d. Staff must exercise due care when operating electrical equipment. Items not in proper working condition must be disconnected and reported for repair. e. Staff must observe warning labels and follow established storage and usage procedures when using flammable liquids and gases. f. The use of portable space heaters is prohibited in all [ Facility Name Redacted] facilities, including non-patient care areas. g. Also all managers were emailed to remove all heaters campus wide. h. All nursing home staff were notified via the electronic health records computer program facility bulletin board. i. To prevent any recurrence a facility designee in conjunction with the Safety Office will complete a weekly safety audit for one month and then monthly for 2 months to ensure no heaters are present. The scope was lowered from a K to an E at the time of the survey after ensuring the facility removed all space heaters, implemented education and their policy and procedures. The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 with a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. The MDS documented a diagnosis of dementia and spastic hemiplegic cerebral palsy. On 1/23/24 at 12:36 PM Resident #1 stated that she had to put a coat on because it was cold. Resident #1 stated a space heater was provided the weekend of 1/13/24 for her room. 2. The MDS dated [DATE], documented Resident #20 with a BIMS of 3 indicating severe cognitive impairment. The MDS documented a diagnosis of Alzheimer's, dementia, and a history of falling. Review of Resident #20's Care Plan dated 11/30/23 revealed the resident is ambulatory with use of a walker and at risk for injury due to unsafe wandering. 3. The MDS dated [DATE], documented Resident #30 with a BIMS of 12 indicating moderate cognitive impairment. The MDS documented a diagnosis of Alzheimer's, dementia, and difficulties in walking. On 1/23/24 at 12:26 PM, Resident #30 stated it was cold in her room the weekend of 1/13 and 1/14 and she requested a heater. Resident #30 stated the facility brought in a heater and it warmed up the room. Resident #30 stated she did not remember who brought the space heater into her room but they just removed them yesterday. 4. The MDS dated [DATE], documented Resident #173 with a BIMS of 5 indicating severe cognitive impairment. The MDS documented a diagnosis of Alzheimer's, fracture of patella (knee), and dementia. Review of Resident #173's Care Plan with a revision date of 1/10/24 revealed Resident #173 a high risk for falls and falls with major injury. Interventions to encourage Resident #173 to ask for assistance when wanting to transfer or ambulate. An observation on 1/22/24 at 3:13 PM, revealed a space heater and power strip in Resident #173's room. Observation further revealed the space heater was on and warm to the touch, with the space heater plugged into the wall outlet. A radio and cell phone were plugged into the power strip. On 1/22/24 at 4:03 PM, the Administrator stated he would remove the space heater immediately. The Administrator stated the temperature outside was cold the weekend of 1/12/24 and 1/13/24 and thought the space heaters were going to be short term. Stated the space heater should not have been in the residents' room. On 1/23/24 at 8:07 AM, the Administrator stated Charge Nurse, Staff A put the space heater in the residents' rooms over the weekend, after requesting to put the space heaters in the room. The Administrator stated the heater in the ceiling was not working appropriately that weekend. The Administrator stated the space heater does not have an automatic shut off that he was aware of. The Administrator stated the facility did not have permission to use space heaters from the State Fire Marshal. The Administrator reported Resident #173's family brought the power strip into the room. The Administrator explained an approved power strip now in the room. The Administrator stated Resident #173's family did not ask to bring the power strip into the resident's room. The Administrator reported the space heater was for temporary situations until the heat could be returned to the room. The Administrator stated space heaters were put in the resident's rooms on the weekend of 1/13/23. On 1/23/24 at 8:31 AM, Staff A, Registered Nurse RN stated she did not work the weekend of 1/13/24. Staff A stated she came in on 1/15/24 and called the Administrator and he stated that the space heaters were the temporary fix for the blizzard. Staff A stated she never requested and space heaters and thought the family brought the space heaters in. Staff A stated she never checked on the space heaters, never turned the space heaters on or off. On 1/23/24 at 8:36 AM, Staff M, Certified Nursing Assistant (CNA) stated she was aware of the space heaters. Staff M stated the residents' rooms were cold and Maintenance brought them in. Staff M stated Resident #20 and Resident #173 had space heaters in their rooms on the Memory Care Unit. Staff M reported she did not touch the space heater, or turn the space heaters on, off, or check them. Staff M explained she had talked to other staff as well as the nurse and was told Maintenance brought the space heaters down and the space heaters that were provided were acceptable to use in the residents' rooms. On 1/23/24 at 8:42 AM the Director of Nursing (DON) stated she was not aware that a space heater was in Resident #173's room, and only used in last resort incidents. The DON reported she unaware the rooms were cold. The DON explained the Administrator stated Resident #20 also had a space heater in her room. The DON stated the facility's expectation was once heat was restored to an acceptable measure that the space heaters would be removed. The DON said the facility had no protocols in place with nursing because she was unaware the space heaters were in the residents' rooms. On 1/23/24 at 9:21 AM, Staff N, Maintenance Staff stated received a phone call on the weekend of January 13th and 14th. Staff N explained there was a request from a resident and a resident's family member because the rooms were cold. Staff N reported he delivered space heaters to room [ROOM NUMBER] and 211 on the weekend of 1/13/14. Staff N stated to his knowledge the heating issue and space heaters were never followed up on. On 1/23/24 at 9:37 AM, Staff O, Facility Maintenance Director, stated he did not know if the space heaters were approved by the State Fire Marshal. Staff O reported unsure if there was an automatic shut off or tip over protection on the space heaters that were used in the residents' rooms. Staff O explained space heaters would only be used when the heating of a room had failed and only until the heating is fixed to provide appropriate temperature. Staff O said to his knowledge nobody had followed up on the space heaters placed in residents' rooms. Staff O indicated room temperatures of 69 and 70 was not an emergency but with the resident and resident's family members' requesting, space heaters were provided. Staff O stated unsure if these space heaters were approved for resident usage in resident rooms. Staff O reported he bought the space heaters and does not know if there is a policy for appropriate space heaters for resident use. During an observation on 1/23/24 at 9:40 AM, Staff O utilized the facility's radiant heat thermometer and revealed the space heaters' temperatures were recorded at 321 degrees Fahrenheit (F) inside a coil of the space heater, top of space heater registered 159 degrees (F), and 242 degrees (F) on out outside lateral portion of space heater opposite the on and off switch. On 1/23/24 at 9:42 AM, Staff P, Weekend Maintenance Staff, stated Resident #173's family member requested the space heater on the weekend of 1/13/24. Staff P stated the space heaters were taken to Resident 173's room (room [ROOM NUMBER]) and to the shared room for Resident #1 and Resident #30 (room [ROOM NUMBER]). Staff P stated the temperature was 70 degrees room [ROOM NUMBER]. Staff P reported he did not turn the space heater on high. Staff P stated he did not do any of that without a request from nursing staff. Staff P explained unsure who requested the heaters as the nurses do not always identify themselves. Staff P stated the need for the space heater was an emergency situation. Staff P stated because he always worked on the weekend he would note in the book and this would tell the on-coming day shift during the week to have them follow up to see if there was a problem with the heater or if the space heater could be removed. Staff P said he always checked the computer first prior to putting the space heaters in residents' rooms to ensure the heater is circulating as much water as it can. Staff P stated the thermostats in the resident rooms would give the room temperatures, with room [ROOM NUMBER]'s room temperature at 69 and room [ROOM NUMBER]'s room temperature at 70. Staff P explained he would have to look at the space heater to see if there was automatic shut off or tip over protection because he did not know for sure. Staff P commented he assumed if the facility had the space heaters that they were okay to use. Staff P stated he felt better with family members present in the residents' room on the Memory Unit, and as far as he knew no resident was burned or dangerously close to the space heater. On 1/23/24 at 12:38 PM, Staff Q, CNA stated residents were complaining about the facility being very cold, especially down in the Memory Care Unit on the weekend of 1/13/23. Staff Q reported she spoke with the nurse about the use of space heaters and was told by the nurse it was acceptable, but she did not think space heaters were allowed in nursing homes at all but the nurse assured her the space heaters were acceptable. Staff Q stated she did not remember which nurse she spoke to. On 1/23/24 at 12:20 PM, the Administrator stated Resident #20 had a space heater in her room as well. The Administrator explained he was previously unaware of the space heater being placed in room [ROOM NUMBER] but removed it yesterday when this was brought to his attention. The Administrator reported the facility did not have a policy for the use of space heaters, and the space heaters should not have been in the rooms on 1/22/23. Review of an untitled document referred to as Maintenance Journal, revealed that on 1/13/24 and 1/14/24 small heaters were placed in nursing home rooms [ROOM NUMBERS]. 41785 5. According to the MDS dated [DATE], documented Resident #29 with a BIMS score of 13 out of 15, (moderate cognitive deficit). The resident identified with lower extremities impairment on both sides and required substantial assistance with transfers. The Care Plan for Resident #29 showed that she had a diagnosis of peripheral vascular disease and was at risk for numbness/tingling weakness in leg. She had self-care deficit and required assistance with Activities of Daily Living (ADL's) related to impaired balance during transitions. Resident #29 required one-person assistance with the sit to stand lift. On 1/23/24 at 9:27 AM, noted Resident #29 in a recliner chair in her room and said that she had a fall from an EZ Stand (a Sit to Stand mechanical lift) when the staff failed to ensure the loop on the sling was properly fastened in the hook. An Incident Report dated 10/23/23, documented Staff E, CNA, reported the resident fell when the sling came undone on the right side from the EZ Stand. Staff E unable to hook it back on so she lowered the resident to the floor. An intervention to prevent future falls was to ensure proper placement of sling and loops, and the DON observed staff use the EZ Stand to transfer and education was provided regarding double check proper use of sling. On 1/23/24 at 12:28 PM, Staff L, LPN, said that she was the nurse on duty when Resident #29 slid from the EZ Stand. She said that there was just one staff in the room at the time, and the aide was Agency Staff (Staff E). Staff E told the nurse that she thought a loop had ripped off the sling but they examined the sling and didn't find any rips. They determined that the loop hadn't been completely attached in the latch, the resident leaned back and fell to the floor. She said that there were no injuries. According to the Operators Instructions for EZ Way Smart Stand, staff were to attach the harness to the EZ Stand with the lift arm in lowest position, attach the harness to the hooks at the end of the EZ Stand arm using the loops at the end of the harness.

Based on clinical record review, observations, and staff interviews, the facility failed to provide dignity by leaving a catheter bag uncovered and easily visible in the dayroom and in the bedroom to 1 of 1 resident reviewed with catheters (Resident #32). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #32 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. The MDS documented a diagnosis of fluid overload, urinary retention, overactive bladder, and urinary incontinence. Observation on 1/23/24 at 10:19 AM, revealed Resident #32 sitting in a recliner in the dayroom with a catheter bag hanging on the right side of the recliner without a privacy bag in place. Observation on 1/23/24 at 2:41 PM, revealed Resident #32 lying in bed with a catheter bag hanging from the frame of the bed on the right side without a privacy bag in place, visible from the hallway On 1/23/24 at 4:23 PM, Staff H Certified Nursing Assistant (CNA), stated Resident #32 did not have a privacy bag in place while lying in bed in her bedroom when she came onto the 2 PM - 10 PM shift. Staff H stated she put Resident #32's catheter bag in a privacy bag on the wheelchair when assisting the resident in getting up for an afternoon activity of cards. Staff H stated Resident #32's catheter bag should always be covered with a privacy bag On 1/23/24 at 4:25 PM, Staff I, CNA stated the catheter bag should also be covered with a privacy bag. On 1/23/24 at 4:29 PM the Director of Nursing, (DON), stated the privacy bag should have been in place at all times. The DON stated the facility did not have a policy on the requirements of a privacy bag for catheters.

Based on clinical record review, family and staff interviews, and facility policy review, the facility failed to provide family with requested medical records in a timely manner for 1 of 1 resident reviewed (Resident #123). The facility reported a census of 74 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #123 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (severe cognitive deficit.) The resident had daily behavioral symptoms such as hitting, pacing and rummaging. Resident #123 required partial assistance with eating, was dependent with toileting, required substantial assistance to transfer from sit to stand. His diagnosis included renal insufficiency, diabetes mellitus, Alzheimer's Disease, Dementia and anxiety disorder. The Care Plan updated on 10/9/23 showed that Resident #123 admitted to Hospice level of care and staff directed to administer medication and treatments as ordered and monitor for side effect and effectiveness. He had self-care deficits, required assistance with activities of daily living, impaired balance during transitions and required assistance. The resident identified with episodes of behaviors such as being combative, refusal of medications/care, resisted care, was known to hit others. On 1/25/24 at 8:05 AM, a family member for Resident #123 said that they felt that the facility did not respond timely when they requested medical records and it had taken months before they followed through. The family understood that the resident had some challenging behaviors but they were concerned that he was being over-medicated and not being thoroughly assessed. The resident had a significant decline in his functioning and they were looking for answers. On 1/25/24 at 10:54 AM, the Administrator said that initially, the family had verbally requested records and they were asked to submit a written request and they followed through and sent the filed. He said that they were working to write a nursing home policy on records request because they had been going by the hospital medical records policy which allows for a 30 day response time. He just learned that the regulation for Nursing Homes is 24 hours. A record request form signed on 12/18/23, showed that the family requested a summary of Staff and Clinic Notes, Nursing Home Documentation and Medication Administration Records. The form showed that the information was sent certified mail to the family on 12/27/23. Policy titled: Procedures for Release of Information. Policy on Patients/Families Receiving Copies of Medical Records. An Authorization of Release of Medical Information must be filled out by the patient. The record would be reviewed and completed within 7-10 business days of the request for information.

Based on clinical record review, observation, staff interviews and facility policy review, the facility failed to follow Physicians Orders for special dietary needs for 1 of 3 residents reviewed (Resident #62). Resident #62 served a regular texture meal when the order was for pureed texture. The facility reported a census of 74 residents Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #62 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (severe cognitive deficit). The resident identified severely impaired, never/rarely made decisions and was totally dependent on staff for help with meals. The Care Plan dated 2/9/23, showed that Resident #62 at risk for fluid imbalance related to being dependent on staff to provide and prompt her to consume adequate fluids. She had self-care deficits and required assistance with activities of daily living. The resident was unable to effectively communicate her basic needs. In an observation on 1/23/24 at 7:51 AM, Staff F, Certified Nurse Aide (CNA) was sitting next to Resident #62 at the breakfast table and was encouraging the resident to take bites of French Toast. She put the fork up to the resident's mouth and the resident was sleepy and uninterested. A Breakfast Meal summary dated 1/23/24, showed Resident #62 to be served pureed eggs with cheese and pureed French toast. When asked about the pureed order, Staff F took the plate, went to the buffet and plated up some pureed eggs and French toast. A review of the order tab revealed an order dated 1/22/24 at 9:09 AM for regular diet, pureed texture, related to the resident being unable to chew food. On 1/25/24 at 9:00 AM, the Director of Nursing (DON) acknowledged that the CNA feeding Resident #62 simply did not look at the meal ticket before she plated up the food for breakfast. According to the facility policy titled, Long Term Care Meal Service and Feeding Assistance last reviewed on 12/23, the facility would provide each resident with a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs.

Based on clinical record review, observations, resident and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed, requiring the use of oxygen (Resident #17). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #17 had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating no cognitive impairment. The MDS documented a diagnosis of chronic obstructive pulmonary disease. On 1/23/24 at 9:02 AM Resident #17 stated she did not remember oxygen tubing changed by staff at the facility. An Observation on 1/23/24 at 9:02 AM of Resident #17's oxygen tubing revealed a date of 12/15 on the tubing. Review of Resident #17's orders revealed current order for oxygen to be delivered at 1-5 liters as needed to maintain oxygen saturations above 88% and no current order for oxygen tubing change. On 1/23/24 at 2:44 PM, Staff G stated she does not change oxygen tubing unless there was an issue. Staff G stated sometimes changing the oxygen tubing is scheduled on the resident's Medication Administration Record (MAR). Staff G stated oxygen tubing was usually scheduled to be changed on the 10 PM to 6 AM shift. On 1/23/24 at 2:48 PM, the Director of Nursing (DON) stated the oxygen tubing standard was the tubing be changed once a month. The DON explained the facility's expectation was the oxygen tubing would be changed once a month. The DON stated her expectation was the oxygen tubing should have been changed for resident #17 if the tubing was dated 12/15. The DON reported the facility does not have a policy on oxygen tubing change.

Based on clinical record review, resident and staff interviews, the facility failed to ensure that all staff were adequately trained on the use of mechanical lifts for 1 of 3 residents reviewed who required a mechanical lift to be transferred (Resident #29). Resident #29 fell from the EZ Stand Lift (a Sit to Stand mechanical lift) when an Agency Staff person failed to ensure that the loop on the sling was secured with the hook. The facility did not have an orientation process in place to ensure skill competency on the use of mechanical lifts. The facility reported a census of 74 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, (moderate cognitive deficit). The resident identified with lower extremities impairment on both sides and required substantial assistance with transfers. The Care Plan for Resident #29 showed the resident with a diagnosis of peripheral vascular disease and was at risk for numbness/tingling and weakness in leg. She had self-care deficit and required assistance with Activities of Daily Living (ADLs) related to impaired balance during transitions. Resident #29 required one-person assistance with the EZ Stand (Sit to Stand) Lift. On 1/23/24 at 9:27 AM, Resident #29, observed in a recliner chair in her room and said that she had a fall from the Sit to Stand mechanical lift when the staff failed to ensure the loop on the sling was properly fastened in the hook. A Nursing Note dated 10/23/23 at 1:07 PM, showed that while staff was getting the resident out of bed she hooked her to the Sit to Stand lift and during transfer, the sling loop came off the lift and the resident fell back. An Incident Report dated 10/23/23, showed that Staff E, Certified Nurse Aide (CNA), reported that the resident fell when the sling came undone from the Sit to Stand lift, on the right side. She was unable to hook it back on so she lowered the resident to the floor. An intervention to prevent future falls was to ensure proper placement of sling and loops. The Director of Nursing (DON) observed staff use the Sit to Stand lift to transfer and education provided regarding double check proper use of sling. On 1/23/24 at 12:28 PM, Staff L, Licensed Practical Nurse (LPN), said that she was the nurse on duty when Resident #29 slid from the EZ Stand lift. She said that there was just one staff in the room at the time, and the aide was Agency Staff, Staff E. Staff E told the nurse she thought a loop had ripped off the sling but they examined the sling and didn't find any rips. They determined that the loop hadn't been completely attached in the latch, the resident leaned back and fell to the floor. She said that there were no injuries. On 1/24/24 at 12:45 PM, the DON revealed there was not an Orientation Checklist for Agency Staff at the time of the incident with Resident #29. The DON said that they were making some changes to their procedure and using a standard Orientation Checklist.

Based on clinical record review, staff interviews and facility policy review, the facility failed to review the use of as needed (PRN) psychotropic medications for Resident #54's PRN topical Ativan ordered 6/19/23. The facility also failed to ensure psychotropic medications are only used when the medication is necessary and PRN use is limited for Resident #123 who had a diagnosis of dementia with agitation and confusion. Resident #123 had several different as needed (PRN) psychotropic medication orders to help with the anxiety. Staff overlapped the administration of these PRN medications and the resident was found to be lethargic the next day. The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 as rarely/never understood for documentation of Brief Interview for Mental Status (BIMS). The MDS documented a diagnosis of Neurocognitive disorder with Lewy Bodies. Review of Resident #54's Physician Orders revealed Lorazepam topical gel milligram per 0.5 milliliters (mg/mL was to be applied to wrist topically every one hour as needed (PRN) for agitation ordered 6/19/23. Review of documents titled PRN Psychotropic Medication Review Sheets for Resident #54 revealed no review of PRN topical Ativan usage conducted. Review of Resident #54's Medication Administration Record (MAR) revealed topical Lorazepam was administered in the following months: a. September 2023: 8 times, after 14 day review should had been completed. b. October 2023: 4 times. c. November 2023:12 times. d. December 2023: 11 times. e. January 2024: 9 times. Review of policy titled, Medication Regimen Review last revised 10/23 revealed PRN orders for psychotropic drugs were limited to 14 days unless the attending Physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days and had documented the rationale in the resident's medical records and indicated the duration for the PRN order. On 1/25/24 at 10:33 AM, the Director of Nursing (DON) stated the facility had a Spreadsheet that was monitored for PRN medications and they were reviewed by Nurse Practitioners per regulations. The DON stated if there were no PRN psychotropic medication review sheets in the chart her presumption was that the topical Lorazepam was not reviewed. The DON stated the PRN topical Lorazepam should have been reviewed as a PRN at 14 days with a Nurse Practitioner. 41785 2. According to the MDS dated [DATE], Resident #123 had a BIMS score of 0 out of 15, (severe cognitive deficit.) The resident had daily behavioral symptoms such as hitting, pacing and rummaging. Resident #123 required partial assistance with eating, was dependent with toileting, required substantial assistance to transfer from sit to stand. His diagnosis included renal insufficiency, diabetes mellitus, Alzheimer's Disease, Dementia and anxiety disorder. The Care Plan updated on 10/9/23, showed that Resident #123 admitted to Hospice level of care and staff directed to administer medication and treatments as ordered and monitor for side effect and effectiveness. The resident had self-care deficits, required assistance with activities of daily living, impaired balance during transitions and required assistance. Resident #123 identified with episodes of behaviors such as being combative, refusal of medications/care, resisted care, was known to hit others. On 1/25/24 at 8:05 AM, a family member for Resident #123 acknowledged the resident had some challenging behaviors but they were concerned that he was being over-medicated and not being thoroughly assessed. The resident had a significant decline in his functioning especially in the month of October 2023, and they were looking for answers. A review of the paper chart revealed a written order dated 9/28/23, for liquid lorazepam (Ativan, an antianxiety medication) 1 milligram (mg) every (q) 4 hours as needed (PRN) for anxiety or agitation. The order went on to indicated that staff may give lorazepam topical gel 1 mg q 4 hours as needed for anxiety or agitation if the resident was resisting the liquids. A review of the Medication Administration Record (MAR) and Nursing Notes revealed the following medication administration: a. On 10/6/23 at 6:00 PM, 0.5 mg oral Ativan given for agitation. b. On 10/6/23 at 8:49 PM, 0.5 mg. gel Ativan given. c. On 10/6/23 at 10:38 PM, 0.5 mg. oral Ativan given. d. On 10/7/23 at 12:50 AM, 0.5 mg. gel Ativan given. e. On 10/7/23 at 2:37 AM, 0.5 mg oral Ativan given. f. On 10/7/23 at 5:36 AM, 0.5 mg. gel Ativan given. g. On 10/7/23 at 6:46 AM, 0.5 mg. oral Ativan given. h. On 10/7/23 at 10:42 AM, the resident remained in bed asleep. No morning medication or breakfast administered. i. Scheduled Haldol 1 mg given at noon and in the evening. j. On 10/7/2023 1:43 PM, the resident continued sleeping throughout entire shift. Lethargic, with a blood pressure of 86/53. The resident did not have any intake of food or fluids. Neurological assessment completed. On 1/25/24 at 11:38 AM, Staff A Registered Nurse (RN) said that she worked with Resident #123 many times and she found that the Ativan gel had worked well to calm him when he was agitated. She said that the Haldol tended to cause him to be over sedated to where he couldn't even stand up. On 1/25/24 at 11:54 PM, Staff K, Licensed Practical Nurse (LPN) said that she had worked with the resident many times and he did get to a point where he was no longer standing and they were using the mechanical lift for transfers. She said she hadn't ever use the PRN Haldol, she would go to the Ativan first. On 1/25/24 at 1:07 PM, Staff B, LPN said that she did see a difference in the resident when the Haldol was being used for agitation. She said she preferred to use the Ativan. 1/25 at 12:21 PM, Staff J, RN said that she was the Hospice Nurse and when she first met with the resident in October, he was not transferring on his own. He was very drowsy, up in a chair eating very little. The son had voiced concerns about the Haldol use and they started to decrease it from 3 mg a day to 1.5 mg a day and the resident did much better. On 1/25/24 at 1:51 PM, the Director of Nursing (DON) said that the resident would go for a day without rest so it was difficult to tell if/when he would become sleepy and weak and if it was related to medication use. According to a facility policy titled: Medication Regimen Review, documented as last reviewed 10/2023. The medication regimen review was a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.

Based on clinical record review, document review, and staff interviews, the facility failed to keep accurate drug records for all controlled medications (Hydrocodone-APAP 5/325 milligram (mg)) for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 with a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating no cognitive impairment. The MDS documented a diagnosis of multiple sclerosis, muscle spasm, and migraine. Review of Resident #4's Physician Orders revealed an order for Hydrocodone-Acetaminophen tab 5-325 mg give one tablet by mouth two times a day for pain hold if lethargic. Review of a document titled Resident's Controlled Substance Record for Resident #4 starting 12/6/23 ending 12/11/23 revealed 2 Hydrocodone-APAP 5-325 mg tablets remaining. Review of a document titled Nursing Home Medication Variance dated 12/12/23 documented 1 missing Hydrocodone-APAP 5-325 mg tablet missing from the cassette. The document revealed Staff B, Licensed Practical Nurse (LPN) and Staff C, Registered Nurse (RN) found the medication missing the morning of 12/12/23. The document revealed Staff B potentially administered medication to another resident due to Resident #4's denial of receiving or requesting a PRN dose. On 1/24/24 at 12:12 PM Staff D, Licensed Practical Nurse (LPN) stated she worked the 3 pm -11 pm shift and all counts were correct when counted on 12/11/23. Staff D stated she counted the narcotics with Staff B. On 1/24/24 12:41 PM, Staff C, RN stated she worked the morning of 12/12/23 and when narcotic count was completed the noon dose was missing of Hydrocodone-APAP 5-325 mg for Resident #4. Staff C stated the narcotic count was completed with Staff B, LPN. Staff C stated she always counted the narcotic medications when she came onto a shift. Staff C stated she notified the Director of Nursing (DON) right away. Staff C stated she looked through the medication cart drawers. Staff C stated she did not discover any cassette tabs or missing medications. Staff C stated only the nurse for that cart has access to the keys for narcotics on that cart. On 1/24/24 at 3:30 PM, Staff B, LPN stated she worked the overnight shift 12/11/23 from 10 PM till 6 AM. Staff B stated she counted medications with Staff D at 10 PM on 12/11/23 and count was correct. Staff B stated she physically counted the medications and in the morning there was one pill missing Hydrocodone-APAP 5-325 mg for Resident #4. Staff B stated that she took the fall for it but didn't really know what happened to the medication. Staff B stated she always counts all the narcotic at the beginning and end of her shifts. Staff B stated the count was correct at 10 PM and was not at 6 AM. Staff B stated she was the only person that had access to the keys to the medication cart at that time. Staff B stated she had no idea what happened to the missing medication. Staff B stated she did not take the medication. On 1/24/24 at 10:12 AM, the DON stated 6 AM - 2 PM, Staff C was counting at 6 am as the oncoming nurse. The DON stated the noon cassette (yellow cassette) was missing a dose of Hydrocodone-APAP 5-325 mg for Resident #4. The DON stated the narcotic count procedure is that the on-coming nurse counts the medications and off-going nurse ensures that the count is correct in the narcotics book. The DON stated both nurses signed the medication book. Review of the document titled, Nurses' Count Of Narcotics And Drugs revealed the count correctly counted all shifts on 12/11/23 and 12/12/23. On 1/24/24 at 2:35 PM, the DON stated the nurse in the north hall on both the am and pm shift was the only nurse that would have the key. The DON stated the facility's expectation was that medications would have been counted and administered appropriately. A request to DON was made for a facility policy on counting narcotics, with no policy provided.

Based on observation, clinical record review, staff interview, and facility policy review, the facility failed to provide appropriate infection prevention practices by not utilizing proper hand washing during administration of medications to 1 of 7 residents reviewed (Resident #59). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #59 rarely/never understood for documentation of Brief Interview for Mental Status (BIMS) . The MDS documented a diagnosis of fracture of an unspecified part of neck of unspecified femur closed fracture with routine healing. An observation on 1/24/24 at 8:07 AM, revealed Staff A, Registered Nurse (RN) removed medication cassettes from the medication carts for Resident #59. Staff removed medications from medication cassettes into a medication cup. Staff A dropped an Acetaminophen tablet onto the medication cart. Staff A picked the medication up with bare hands and put the medication into the medication cup. Staff A emptied all medications from medication cassettes into the medication cup. Staff A then removed medications from the medication cup with bare hands into a medication crushing sleeve. Staff A crushed the medications in the sleeve. Staff A administered medications from the medication cup with ice cream and followed the medications with sips of water. Hand hygiene completed at end and Staff A returned to the medication cart. On 1/24/24 at 2:35 PM, the Director of Nursing (DON) stated hand hygiene should be completed when hands are contaminated and prior to and after medication administration. The DON stated the medication should have been destroyed once it came in contact with contaminated surfaces. Review of a facility policy titled, Medication Administration last revised 10/2023, revealed a goal of safe administration of resident medications and policy to ensure medication administration is done properly for all residents. Policy does not have procedures for contaminated medications.

Based on observations, clinical record review, staff interviews, and facility policy the facility failed to provide adequate supervision to ensure residents remained safe from another resident for 3 of 5 residents reviewed (Residents #3, #4 and #5). In addition, the facility failed to provide 1 of 5 residents reviewed with enough supervision to prevent him for attempting to hurt other residents (Resident #6). Resident #6 had physical altercations on 11/18/23 with Resident #4, 11/21/23 with Resident #5, and 11/24/23 with Resident #3. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified him with short- and long-term memory impairments and severely impaired for decision making abilities. Resident #6 displayed altered mental status changes, inattention, and disorganized thinking. Resident #6 experienced physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing), other behavioral symptoms not directed towards others (pacing, rummaging, verbal/vocal symptoms like screaming, disruptive sounds), and daily wandering that affected others. The MDS indicated worse symptoms since the previous assessment. Resident #6 required maximum assistance with going from sitting to standing and is dependent for oral hygiene, and personal hygiene. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, Non-Alzheimer's dementia, anxiety, and depression. The Care Plan Focus dated 11/22/23, reflected that Resident #6 had behavior episodes of being combative, negative verbalizations, name calling, refusal of medications, refusal of care, resistive to cares, hit other residents, hallucinations, and/or delusions. The Interventions include: *(11/18/23) agitated, wandering unit, hitting medication cart, and walked up behind another resident and hit him on the head *(11/21/23) Conference with family to discuss interventions that will protect other residents. The Director of Nursing (DON) and Administrator agreed to give the scheduled anxiolytic a chance to provide therapeutic effectiveness, call the family immediately when behaviors started and at time of incidence to help deflect residents' behaviors. *(11/21/23) Implemented schedule anxiolytic due to 11/18/23 incident *(11/21/23) Intervention to chart shiftily and as needed regarding behaviors *(11/22/23) Resident #6 in dining room walking around, stopped, and hit another resident in the stomach, unprovoked and without an observation of agitation. *(11/24/23) The facility notified the family of the requirement for them to be with resident starting at 7:00 a.m. and until bed time to help intervene in potential altercations *(11/24/23) Resident #6 wandered the hall, walked up to another resident, and hit her in the head. No observation of provocation noted. Resident #6 told the other staff to git and swore at the staff. *Administer medications as ordered. Monitor/document for side effects and effectiveness. *Attempt nonpharmacological interventions before using as needed medications. *Intervene as necessary to protect the rights and safety of the other residents. Approach/ speak in a clam manner, divert attention if needed. Remove from the situation and take to alternate location as needed. *Minimize the potential for Resident #6's disruptive behaviors by offering tasks which that divert his attention. *Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. *Observe and chart behaviors as necessary, then report to physician. *Observe for early warning signs of oncoming behaviors - Approach in a calm manner, call by name, remove from unwanted stimuli *Refer to psychological/psychiatric consults as indicated On 11/30/23 at 3:00 p.m., observed Resident #6 walk independent throughout the unit with family and/or staff next to the resident. Resident #6 could not recall the incidents with the other residents. The General Note dated 11/18/23 at 8:04 p.m. labeled Late Entry described Resident #6 as agitated, wandering, and banging cart into doors. The note indicated that he hit another resident on the back of their head that shift. His hits looked soft in nature. The assessment determined no injury to the other resident. The staff redirected the resident who refused his medication The Variance Report dated 11/18/23 on the 2:00 p.m. - 10:00 p.m. shift, detailed the objective description as Resident #6 walked up behind Resident #4, who sat in a Broda chair (specialized wheelchair) and began hitting Resident #4 on back of his head approximately 4-5 times for an unknown reason. Both residents had dementia and the staff described the hits as more of pat or without force. The hits did not appear to phase Resident #4. The staff removed Resident #6 from the area. The nurse's assessment of Resident #4 revealed no injuries. The General Note dated 11/21/23 at 12:30 p.m. indicated a Hospice Certified Nursing Assistant (CNA) sat with Resident #6 during meal time, he began to walk around. He stopped and pushed another resident in the stomach. The other resident maintained their balance and side stepped. The Hospice CNA stood between Resident #6 and the other resident, as they called for assistance. Resident #6 started to follow the Hospice CNA with a spoon. A second CNA interceded between the Hospice CNA and Resident #6, removing the spoon from him. Resident #6 left the dining room and began wandering the unit. The Variance Report dated 11/21/23 at 12:30 p.m., detailed the objective description as Resident #6 walked, stopped, and pushed Resident #5 in the stomach. The assessment of Resident #5 revealed no injury. Resident #5 side stepped after contact and maintained their balance. A CNA stood between Resident #5 and Resident #6 while other staff called for help. Resident #6 started to follow the staff with his arm raised with a spoon, a second CNA intervened and removed the spoon from Resident #6. After the incident, Resident #6 he left the dining room. The Variance Report dated 11/24/23 at 7:30 a.m. listed the immediate action as the facility redirected Resident #6 away from other residents, offered him fluids, food, bathroom, and one-to-one 1-1. The Behavior Note dated 11/24/23 at 8:35 a.m. reflected Resident #6 paced the halls at 7:30 a.m., he walked over to another resident sitting in the lobby, and hit her in the back of the head with an open hand. The staff redirected him away from the resident. Resident #6 walked down the hall without further incidents, then returned at 7:35 a.m., and headed towards a male resident. As Resident #6 raised his hand to swing, the nurse intervened, and attempted to redirect him away from the other residents. At that time Resident #6 raised his fist, threatened the nurse multiple times squeezing their arm, and swinging at them with the other arm. Resident #6 then pushed the nurse down the hall calling profanities at her. When out of range of other residents, he started walking away yelling back at the nurse. A visitor entered the unit and Resident #6 raised his hand at her. Resident #6's son arrived and took Resident #6 down the hall with him. The nurse called Resident #6's family and DON after the first incident. At that time, the family asked the nurse to take his blood sugar, due to him drinking a lot of water. His blood sugar measured 150 (range is 80 to 130 before a meal, and less than 180 two hours after a meal) at the time. The General Note dated 11/24/23 at 12:43 p.m., indicated Resident #6 walked the halls with his wife. Resident #6's wife went to the nurses' station to request more medication, stating the gel did not work. The nurse explained he didn't have other orders they could give him at that time. Resident #6's wife reported he pushed her away when she tried to get him to cooperate or when she followed him. She explained that he had increased agitation and aggression. She reported that he resisted everything she tried. When his son called her phone to check on Resident #6, she put the phone to his ear so he can visit with his son. He remained uncooperative so his wife returned to his room. At this time, the nurse heard her telling Resident #3 to leave the room. When the nurse got to the room, they found Resident #3 in front of Resident #6's wife with Resident #6 behind her so she could separate them. Resident #6's wife said they had a little confrontation, the nurse got Resident #3 to walk down the hall. As Resident #3 walked with the nurse he appeared emotional and said Resident #6 put his hand on her stomach. A CNA came to the room to help care for Resident #3. The General Note dated 11/24/23 at 1:18 p.m., reflected the nurse spoke to Resident #6's wife in his room. She blocked the door to prevent Resident #6 from getting out of his room. He paced around and said to get out. Resident #6's wife reported him as unsettled and kept flipping her hands around, then he moved towards her to discuss the incident with Resident #3. She stated Resident #3 came into the room and had both fists clenched holding them up at Resident #6 saying she hated him. At that time, the wife explained she got in between them. Resident #6's wife reiterated that they should have held him down and squirted the medication in his mouth. When the nurse asked if she wanted them to call the doctor to see if they could get more medication for him and she stated she wanted to speak to her son first. 2. Resident #4's MDS assessment dated [DATE], identified he had short- and long-term memory impairments with severely impaired decision-making abilities. The MDS documented the resident displaying altered mental status changes and inattention along with disorganized thinking. The MDS documented Resident #4 with physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing,) and other behavioral symptoms not directed towards others (pacing, rummaging, verbal/vocal symptoms like screaming, disruptive sounds) directed towards others. Resident #4 required substantial maximum assistance to dependent assist with all aspects of activities of daily living. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, non-Alzheimer's dementia, and traumatic brain injury. The Care Plan Focus dated 10/28/23 reflected that Resident #4 had the potential for behaviors due to episodes of unwanted, inappropriate physical, and non-physical behaviors as evidenced by resisting care both verbally and non-verbally, physically pushing items or people/staff away during multiple types of care provided. He is also known to be resistive to taking prescribed medications that may be beneficial for treating conditions that may be the cause the behavior such as anticipated pain or discomfort, thus placing him at risk for not having his needs met effectively. Interventions include: *Intervene as necessary to protect the rights and safety of the other residents. *Approach/ speak in a clam manner, Divert attention if needed. Remove from the situation and take to alternate location as needed. *Minimize the potential for disruptive behaviors by offering tasks which divert attention. Such as offering snacks, toileting/clothing changes, position changes, large or small group activities, one on one or individual activities, periods of rest, ambulation/change in activities, as he is willing and able. *Observe for early warning signs of oncoming behaviors- Approach in a call manner, call by name, remove from unwanted stimuli report significant of frequent or prolonged changes in behavior to PCP as needed for follow up care and medication review/adjustments as warranted/ordered. *TRANSFERS: 1 person assist with EZ stand. At times may need 2 persons to ensure safety if becoming agitated or resistive related to dementia. On 11/29/23 at 4:30 p.m., observed Resident #4 in a Broda chair wearing glasses, dressed in slacks, and a shirt. Resident #4 could not recall the incident with Resident #6. The Progress notes dated 11/18/23 at 8:01 p.m., documented Late Entry indicated that another resident (Resident #6) hit Resident #4 on the back of his head. Resident #4 did not appear to be upset and no injury noted. 3. Resident #5's MDS assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS documented the resident displayed altered mental status changes, inattention, and disorganized thinking. The MDS indicated Resident #5 had verbal behaviors (threatening, screaming, cursing) directed towards others. Resident #5 walked independently throughout the unit, with no assistive devices. The MDS included diagnoses of cancer, osteoporosis, Alzheimer's disease, non-Alzheimer dementia, and anxiety. The Care Plan Focus initiated date 11/9/23, I have the potential for episodes of alteration in mood as evidenced by repetitive vocalizations/obsessions on one subject, restlessness, easily fatigued, being irritable, excessive worrying or difficulty controlling feelings of worry and having trouble falling asleep and/or staying asleep related to diagnosis of anxiety. Interventions include: *Administer medications as ordered. Monitor for side effects and effectiveness. *Monitor/ document/ report mood to determine if issues seem to be related to external causes, i.e.: Medications, treatments, concern over diagnosis *Monitor/document/report as needed any signs/symptoms of anxiety including hopelessness, excessive worrying, insomnia, repetitive anxious. *Pharmacy review of medication as indicated. On 11/30/23 at 9:30 a.m., observed Resident #5 ambulating throughout the facility independently without an assistive device. Resident #5 did not recall any incidents with Resident #6. The Progress Notes dated 11/21/23 at 1:13 p.m., reflected Resident #5 walked out of the dining room leaving her table, when another resident pushed her in the stomach. Resident #5 side-stepped and kept her balance, the staff interceded without further incident. No injuries observed from incident. The nurse called the Resident #5's husband to update regarding the incident, he voiced understanding. 4. Resident #3's MDS assessment dated [DATE], identified a BIMS score of 3, indicating severely impaired cognition. The MDS documented the no physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing). The MDS described Resident #3 as independent with ambulation throughout the unit. The MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus, arthritis, Alzheimer's disease, non-Alzheimer's dementia, anxiety, depression, and psychotic disorder (Mental disorders characterized by disconnection from reality which results in strange behavior often accompanied by disturbances of thought (excessive suspiciousness, guilt, etc.) and perception (hearing voices, seeing things, feeling things, etc.).). The Care Plan Focus dated 9/27/23, indicated that Resident #3 had unwanted and inappropriate episodes of behaviors as evidenced by frequent crying episodes with no apparent reason or cause related to vascular dementia (A condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain). In addition, she has a history of agitation, making negative verbalizations, name calling, as well as refusal of medications, resisting care, attention-seeking behavior, as well as often seeking romantic interactions with other residents. Interventions include: *Administer medications as ordered. Monitor/document for side effects and effectiveness. *Approach in a calm non-aggressive manner. If gets agitated staff will ensure she is safe and leave her to calm down and attempt to reoffer the cares later. *Attempt nonpharmacological interventions before using PRN medications. *Intervene as necessary to protect the rights and safety of the other residents. *Approach/ speak in a clam manner, Divert attention if needed. Remove from the situation and take to alternate location as needed. *enjoys listening to classic country music. Observations showed her become or remain calm when provided music as a diversion. She has a tablet (electronic device) that she uses to listen to music. The facility encouraged the staff to use this avoid agitation and or promote relaxation as she allows. *is independent with ambulation. *Minimize the potential for disruptive behaviors by offering tasks which divert attention as she allows. *Observe and chart behaviors as necessary and report to physician. *Observe for early warning signs of oncoming behaviors- Approach in a call manner, call by name, remove from unwanted stimuli On 11/30/23 at 2:00 p.m., observed Resident #3 ambulating independently throughout the unit with no assistive devices. Resident #3 did not recall the incident with Resident #6 On 12/12/23 at 9:30 a.m., Staff A, CNA, and Staff B, Licensed Practical Nurse (LPN), confirmed that Resident #6 needed an increase in supervision due to the unprovoked incidents, without an increase in supervision after the first incident. On 11/12/23 at 1:15 p.m., the Director of Nursing (DON) verified Resident #6 needed more supervision due to the resident-to-resident altercations with other residents. The DON confirmed it is the facility's responsibility to keep residents supervised and safe. The undated Your Rights and Protections as a Nursing Home Resident form indicated the following: *As a nursing home resident, you have certain rights and protection under Federal and state law that helps ensure you get the care and services you need. You have the right to receive information, make your own decisions, and have your personal information kept private. *Be Treated with respect: You have the right to receive dignity and respect, as well as make your own schedule and participate in the activities you choose. *Be free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse. Nursing homes can't keep you apart from everyone else against your will. The nursing home must investigate and report all suspected violations within 5 working days of the incident to the proper authorities.

Based on observations, clinical record reviews, staff, and resident interviews the facility failed to ensure that residents were free from accidents and hazards for 2 of 4 residents reviewed (Resident #60 and #58). Resident #60 had a risk for falls and the staff failed to follow the established interventions to prevent injury. She later sustained a major injury after a fall from her bed. During an observation of Resident #58, they could not reach the call light due to it being across the room and not within reach. The facility reported a census of 69 residents. Findings include: Resident #60 ' s Minimum Data Set (MDS) assessment dated [DATE] indicated an admitted [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 3 out of 10, indicating severe cognitive impairment. Resident #60 required extensive assistance of one person for bed mobility, transfers, toilet use, and walking. The Care Plan updated on 10/27/21 Resident #60 had impaired decision making ability related to lack of short term memory with a known history of poor recall of previously given instructions after repeated reminders or placement of visual cues. The Care Plan directed the staff the following interventions Initiated 10/8/18 Keep her call light available and answer promptly. Initiated 10/27/21 Resident #60 did not always remember to use her call light. The Care Plan Problem dated 10/27/21 indicated that Resident #60 had a risk for falls due to problems with balance, history of falls prior to her admission, impaired memory, poor safety awareness, use of antianxiety and antidepressant medications. Resident #60 had weakness in her lower legs, especially in her right leg due to a history of a proximal tibia fracture. The interventions directed the following Staff to make sure that she wore appropriate, well-fitting footwear to decrease risk of slipping. Have her sit in a recliner in the lobby to prevent her from trying to get up on her own. An intervention dated 9/15/21 instructed to not leave Resident #60 in the wheelchair in her room unattended because she would attempt to transfer without assistance. According to an incident report dated 8/6/21 at 6:30 PM the staff returned Resident #60 to her room after supper. Resident #60 attempted to self-transfer and fell in the process without staff present. Resident #60 said that she tried to get into her bed from her wheelchair. The nurse observed the foot pedals remained attached to her wheelchair with the wheels unlocked. The Nursing Note dated 8/6/21 at 6:30 PM indicated that the staff found Resident #60 on the floor between the bed and the wheelchair. The Nursing Note dated 8/9/21 at 10:42 AM documented that the staff implemented an intervention to bring Resident #60 into the lobby while in her wheelchair. The nurse directed the staff to not to leave her unattended in her wheelchair. The Incident Report dated 9/14/21 at 7:05 AM recorded that a Certified Nursing Assistant (CNA) answered the call light and found Resident #60 lying face and chest forward onto bed. Resident ' s #60 had her left knee on the wheelchair footrest. She reported that she tried to get into bed. The Nursing Note dated 9/15/21 at 11:56 AM included an intervention to not leave Resident #60 unattended in her room while in her wheelchair and to do frequent rounds on her. The Incident Report dated 1/19/22 at 1:30 PM indicated that Resident #60 had an unwitnessed fall. She went to the toilet around 12:30 PM and then put her to bed. She did not have her call light within reach and did not have on shoes or gripper socks with her antiembolic stocking (blood clot prevention sock). The intervention instructed to assure that she wore the proper footwear and to clip the call light to the resident. A Hospital X-Ray report dated 1/19/22 at 2:42 PM, documented that Resident #60 sustained a displaced intertrochanteric fracture of the left femur (broken hip). A Major Injury Determination form dated 1/19/22 at 2:30 PM indicated the Medical Doctor determined that Resident #60 sustained a major injury related to her fall. On 10/12/22 at 02:10 PM Resident #60 slept in her bed with her call light hanging down between the wall and the bed. She wore gripper socks with heel protective boots over the top of the socks. On 10/12/22 at 2:22 PM Staff A, Registered Nurse (RN), said that on 1/19/22 she worked when Resident #60 fell . She explained that Resident #60 did not typically use her call light. At times, she would remove her call light if clipped to her clothing. Staff A said that she would try to get up from the wheelchair on her own and staff would keep a walker by her bed. Staff A added that they also put a sign on her bedside table to remind Resident #60 to ask for help, but she didn't believe that Resident #60 had an understanding of the message or paid attention to the sign. On 10/12/22 at 2:58 PM Staff B, CNA, said that she assisted Staff A on 1/19/22 after Resident #60 fell . She said that Resident #60 would often try to get out of her chair or recliner. Due to that they would usually have her out in the dayroom to monitor her closely. Staff B did not think that Resident #60 knew about the call light and she did not use it. On 10/13/22 at 11:15 AM the Director of Nursing (DON) said that she expected the staff to communicate with each other at shift change regarding the residents ' interventions. She said that the staff used a communication book to write out any status changes or intervention changes. The DON explained that she did random audits to make sure that the residents had their call lights within reach. 44420 2. Resident #58 ' s MDS assessment dated [DATE] identified a BIMS score of 10, indicating moderate cognitive impairment. The MDS indicated that Resident #58 required total assistance or extensive assistance of two persons for bed mobility, transfers and toilet use. The MDS included diagnoses of Parkinson's disease and non-Alzheimer's dementia. On 10/12/22 at 11:38 AM observed Resident #58 unable to reach the call light located on the other side of the bed from where they sat in the recliner. A night stand also separated the bed and recliner that further extended the distance between Resident #58 and the call light. Resident #58's Care Plan directed the staff to: Keep the call light within reach and promptly respond to all requests. In an interview on 10/13/22 at 9:32 AM, the Administrator reported that the facility lacked a call light policy. The Administrator stated that he expected the staff to place the call light within reach of the residents. In an interview on 10/13/22 at 11:08 AM, the DON stated that she expected the staff to place the call light within reach of the resident before exiting the room.