Every finding on record at St Luke Lutheran Nursing Home

Based on observations, clinical record review, facility policy review and staff interviews the facility failed to ensure residents needing a mechanical lift were provided safe and appropriate transfers to prevent injuries for 1 of 1 residents reviewed (Resident #54). This failure resulted in the resident falling out of the mechanical lift during a transfer and obtaining injuries and therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The facility failed to prevent further falls by following the care plan and implemented interventions for 1 of 1 residents reviewed (Resident #70). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 16, 2025 on August 28, 2025 at 10:32 a.m The Facility Staff removed the Immediate Jeopardy on August 28, 2025 through the following actions:Notification to Nursing Staff on private Facebook page. Reminder to staff that if a sling needs readjustment that they need to place the resident back into bed or the chair while making adjustments before proceeding with transfer. Completed on 8/16/2025Education: All nursing staff educated on Smart Lift Operating Instructions. Furnished instructions for review and acknowledgment of understanding by staff. Completed on 8/18/2025. Assessments: All residents utilizing a mechanical lift were re-sized to ensure properly sized slings are being used for each resident. All residents were correctly sized. Notice of correct sling sizing placed by each resident room via a magnet for staff notification. Sizing of slings completed by Unit Managers on 8/27/2025.EZ Lift Slings1.The EZ Lift Slings stay with the resident, and in the resident's room.2.The EZ Lift Slings will be labeled with the resident's name.3. Residents will be sized for correct sling usage according to the sizing guide.4. Re-sizing will occur when needed by the charge nurse/unit managers according to the sizing guide.5. Magnets with matching colors to the sizing guide will be placed outside the resident rooms to identify what size lift sheet to use. EZ Way Sling Sizing Charts placed at each nurses' station. 8/27/2025.Education: Assigned all staff to watch video via CE Solutions (EZ Way Smart Lift Training Video). Assigned on 8/27/2025.Notification to Nursing Staff on a private Facebook page to educate staff on not locking the brakes when lifting or transferring a resident. Those employees that don't have Facebook access education provided with in-person or one-one education. Completed on 8/28/2025 User/Operating Manuals attached to each lift for staff reference if needed along with a reminder to not lock the brakes during transfers. Completed on 8/28/2025Nursing management will randomly monitor staff competency for safe transfers.All PRN nursing staff will be required to watch Training Video before being allowed to work the next scheduled shift. The scope lowered from a J to G at the time of the survey after ensuring the facilityimplemented education and their policy and procedures. The facility identified a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 documented diagnoses of Alzheimer's Disease, heart failure and anemia. The MDS showed a Brief Interview for Mental Status (BIMS) score was not completed as resident is rarely or never understood. Review of Progress Notes revealed the following: On 8/16/25 at 9:32 a.m., facility requesting patient to be seen in Emergency Department (ED) for evaluation due to fall from mechanical lift that was above that height. On 8/16/25 at 9:38 a.m., Certified Nursing Assistant (CNA) getting the resident out of bed with mechanical lift, they stated there was a kink in the sling that they tried to fix and she fell to the side onto the floor. She did not hit her head, but did hit her left shoulder. On 8/16/25 at 1:11 p.m., new orders received and noted 8/16/25 new diagnosis bilateral sacral body fractures. On 8/16/25 at 1:12 p.m., resident leaves facility via ambulance at 7:45 a.m., to go to the ED. Returns to the facility at 12:10 p.m., via facility van. Review of the medical chart revealed Resident #54's weight on 8/15/25 was 141 pounds. Review of the facility investigation dated 8/18/25 revealed the following information: Resident is dependent on the facility staff for all Activities of Daily Living (ADL's) and require the use of mechanical lift for transfers. On 8/16/25 two CNA's were getting ready to transfer Resident #54. Upon interview with both staff members, they had placed the sling under Resident #54. Attached the appropriate loop device to the hanger bar with the leg portion of the sling crossed and double looped (using the bigger loop as a safety net) in case the first loop failed. After beginning the transfer, they noticed that the hanger bar was not level and that the loop on the right side had moved and folded upon itself. The nurse aide stated that she fell before they could even do anything. The 2nd loop was also unattached. In review of the lift sheet itself it was in good condition with loops not fraying or thinned. The resident was using the appropriate size lift sheet (large) at the time. Resident was sent to the emergency room for evaluation out of precaution. She was not exhibiting any signs of pain or injury at the time of the fall. She did wince with the left arm movement. A CT scan was performed and found to have severe osteopenic disease and closed fracture of sacrum. Review of facility provided report dated 8/16/25 at 7:10 a.m., revealed the following information: Injuries rule out left shoulder sent to hospital for evaluation following fall Under notes witness statement on 8/19/25 at 10:02 a.m., Staff G, CNA and Staff H, CNA revealed the following: We noticed the hoyer was slanted weird at the top, Staff H reached up to fix it and it slipped off the machine. As a result Resident #54 slid out of the hoyer lift and fell to the floor on her left side. We called for the nurse immediately. Review of hospital Discharge Plan dated 8/16/25 at 11:24 a.m., revealed resident had a fall from a mechanical lift at the facility and fell approximately four feet. Following CT imaging revealed bilateral sacral body fractures as suspected. Recommendations based on orthopedic consultation revealed conservative management as the patient is not a surgical candidate. Pain management with existing morphine regimen from nursing home. Review of Major Injury Form dated and signed by the physician 8/18/25 revealed the following information: Resident up in hoyer, kink in sling causing loop to slide off, staff attempted to fix sling. Resident fell out of the side onto the floor. X was marked in front of after reviewing the circumstances, injury, and prognosis of the patient, I believe the injury sustained is a major injury. Interview on 8/26/2025 at 10:15 a.m., with Resident #54's family member revealed the resident had a fall from the mechanical lift. Resident #54's family revealed they had spoken to the CNA that was in the room when the fall happened. Resident #54's family member revealed the CNA was transferring resident with mechanical lift and the other staff was supposed to use a clip for safety before transferring her to her bed and the staff didn't use it and that is what caused the resident to fall from the lift. Resident #54's family revealed the resident went to the ED and the resident had fractures in her lower region but was unsure of exactly where. Interview on 8/26/2025 at 10:56 a.m., with Staff H revealed her and Staff G were assisting resident #54 with the mechanical lift transfer. Staff H explained that they were getting resident up and when they hooked up the hooks to the mechanical lift they hooked up all four hooks onto the lift. Staff H stated the one strap on the front did not get hooked all the way and when noticed that she was going to put the lift back down and it went the opposite way and came unhooked and the resident fell to the floor. Staff H revealed she should have lowered her right back down onto the bed and fixed the hook and re-lifted her up. Staff H revealed the staff do not use a particular size lift sheet size and it was our fault. Staff H explained she had learned her lesson and didn't want this to ever happen again. Interview on 8/26/2025 at 1:08 p.m., with Staff G revealed her and Staff H were assisting Resident #54 with a mechanical lift. Staff G stated she lifted the resident in the mechanical and noticed there was a kink in the sheet. Staff H went to straighten it out and it fell off and the resident fell to the floor. She further revealed the resident was sent to the hospital for an evaluation. Staff G explained she used a large lift sheet underneath her but was unsure of what was under her when they lifted her that day. Staff G explained if a large was not available then she would use a medium lift sheet. She explained the sheets go by dimensions and weight of the person. Observation on 8/27/2025 at 9:57 a.m., of Staff A, CNA and Staff B, CNA assisting resident #54 with transfer from wheelchair to bed. Staff A and Staff B assisted the resident to place the sling underneath her in the wheelchair. Staff locked the wheels on the mechanical lift and hooked up the sling to the mechanical lift. With the mechanical lift wheels still locked, staff lifted resident out of the wheelchair and moved over to the bed and lowered down until comfortable onto the bed. Interview with Staff A and Staff B revealed the staff just picks a sling that fits the resident. Staff A explained the staff just pick a sling that fits the resident and they use a size medium or a size large for Resident #54. Staff B explained the aides usually just try and pick a sling that fits around the resident's shoulder and that's not too big. There isn't a size assigned to the resident that she is aware of. Staff A confirmed there is no book that she is aware of that has a chart to help the staff pick a lift sheet for the resident. Observation on 8/27/2025 at 12:43 p.m., with Staff C, CNA and Staff D, CNA transfer Resident #11 into bed. Staff D told Staff C to lock the wheels on the mechanical lift. Staff C locked the wheels on the mechanical lift and hooked the resident's lift sheet to the mechanical lift. Staff D with mechanical lift wheels still locked raised Resident #11 up and unlocked the wheels and placed him onto this bed. Staff D explained they use a medium lift for this resident as he is not a giant man and it goes around his shoulders nice. Interview on 8/27/2025 at 1:54 p.m., with the Director of Nursing (DON) revealed she understood the situation to have happened as Staff G and Staff H were transferring Resident #54 and the lift sheet came loose and was coming off the mechanical lift and they wanted to push it back down and the sheet came off and the resident fell to the floor. The DON revealed the lift sheets stay with the residents in the facility. The DON confirmed she felt the resident was in the right lift sheet size during the transfer. The DON explained after the fall the facility changed the sling size for Resident #54 to a medium sling as that was a better fit for her. The DON revealed the Business Office Manager (BOM) does the sling sizing for the residents. The DON explained the BOM was a CNA for twenty plus years and she did the sizing but has not had any education regarding how to size the lift sheets. When asking the DON how do the CNA's and other staff members know the appropriate size lift sheet to use for the mechanical list she replied I don't know as there was nothing in writing for them to refer to. Review of the mechanical lift instruction manual with a revision date of 5/5/25 revealed the following information: The wheels of the mechanical lift should never be locked when lifting or lowering a patient. Sling sizing chart within the manual revealed the sling size large weight of the patient range is 190-320 pounds. Review of facility provided policy titled Safe Lifting and Movement of Residents with a revised date of February 2014 revealed the following information: Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Enough slings, in the sizes required by residents in need, will be available at all times. Interview on 8/27/2025 at 1:54 p.m., with the DON revealed she felt the facility did everything they could to prevent the fall and she has been doing education since the fall occurred. 2. Resident #70's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS documented Resident #70 required supervision or touching assistance with toileting (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity). The MDS included diagnoses of dementia, Parkinson's disease and anxiety disorder. Resident #70's fall investigation dated 5/31/25 documented the staff left Resident #70 unattended by staff in the bathroom. When staff returned to Resident #70's room, she was ambulating unattended and fell. The intervention put in place at the time of the fall documented staff to not leave Resident #70 unattended in the bathroom. Resident #70's Care Plan under safety date 5/31/25 directed staff to not leave her unattended and alone in my bathroom. Resident #70's fall investigation dated 7/31/25 documented the resident fell in the bathroom when washing her hands. The Fall Scene Investigation Report completed by Staff G, Certified Nurses Aide documented she left Resident #70 unattended at the bathroom sink to go into the room to get her wheelchair and the resident fell. It further documented the root cause was the resident was left unattended and staff not using a gait belt. On 8/28/2025 at 9:52 AM, the Director of Nursing reported staff are made aware of care plan changes with a care plan alert and it is at the nurses station to follow. Staff should not have left Resident #70 unattended in the bathroom. The facility policy titled Falls-Clinical Protocol dated 8/10/2008 documented staff and physicians will identify pertinent interventions to try to prevent subsequent falls. It lacked documentation of follow up to ensure interventions are being done.

Based on personnel file review, facility policy review and staff interview the facility failed to meet requirements for Dependent Adult Abuse Mandatory Reporter Training for 1 of 5 employees reviewed (Staff H). The facility identified a census of 68 residents.Findings include:Review of Staff H, Certified Nursing Assistant (CNA) personal file revealed Dependent Adult Abuse Mandatory Reporter Training certificate dated [DATE]/22. The file also revealed Staff H repeated the training on [DATE]. Review of timecards showed Staff H worked the following dates without being certified in Adult Abuse Mandatory Reporter Training: [DATE]/[DATE]/25 The Nursing Facility Abuse prevention, Identification, Investigation and Reporting policy dated [DATE] identified training of employees upon initial employment, each employee shall be provided with a copy of the facility's policies and procedures relating to abuse identification and reporting requirements. Within 6 months of hire, each employee shall be required to complete an initial 2 hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse. Each employee will take one hour recertification training within three years of the initial training and every three years thereafter. In an interview on [DATE] at 2:14 PM, Staff E, Licensed Practical Nurse (LPN) reported staff are required to be certified in Dependent Adult Abuse Mandatory Reporter Training. When asked about the facility's process to ensure all staff stay current in training, Staff E stated, I don't know if there's a process or how they handle that. In an interview on [DATE] at 6:03 AM, the Director of Nursing (DON) acknowledged that Staff E worked with residents while certification in Dependent Adult Abuse Mandatory Reporter Training had expired. The DON stated, Staff E should have taken the class sooner. She worked a couple of shifts but is now certified.

Based on observation, resident interviews, and staff interviews the facility failed to respect each resident's dignity throughout all care and services provided to 6 out of 22 residents reviewed (Resident #5, #44, #54, and #80 ). The facility reported a census of 68 residents.Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of dementia, vision impairment and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. The MDS also showed Resident #5 required partial/moderate assistance for hygiene, bathing and toileting.In an interview on 8/27/25 at 11:29 AM Staff I, Certified Nursing Assistant (CNA) reported they witnessed Resident #5 attempting to exit the bed when Staff C, CNA entered the resident's room without knocking, flipped on the light, failed to introduce herself then flung the resident's feet in bed and told her to stay in bed. 2. The MDS assessment dated [DATE] for Resident #44 documented diagnoses of Alzheimer's Disease, anxiety disorder and pain unspecified. The MDS showed the BIMS score assessment unable to be completed. The MDS also showed Resident #44 dependent for toilet hygiene, bathing, and dressing. In an interview on 8/27/25 at 11:29 AM Staff I, CNA reported while transferring Resident #44, she became incontinent of bowel movement which Staff C, CNA commented, in the presence of the resident, Are you fucking kidding me? 3.The MDS assessment dated [DATE] for Resident #54 documented diagnoses of heart failure, dementia and seizure disorder. The MDS showed the BIMS score of 6, which indicated severe cognitive impairment. The MDS also showed Resident #52 dependent for toilet hygiene and lower body dressing. On 2/10/25 at 12:00 PM Staff I, CNA reported Resident #54 voiced she felt another CNA was upset at her because they didn't get her up for supper. While Staff I and Staff C, CNA worked to get the resident up for supper, in the presence of the resident, Staff C talked about why staff didn't like the resident.4. The MDS assessment dated [DATE] for Resident #80 documented diagnoses of heart failure, dementia and malnutrition. The MDS showed the BIMS score of 4, which indicated severe cognitive impairment. The MDS also showed Resident #80 required substantial/maximal assistance for hygiene and dressing. On 2/10/25 at 12:00 PM Staff I, CNA reported while in the presence of Resident #80, Staff C stated that she believed the resident would pass away soon. In an interview on 8/27/25 at 11:29 AM Staff I, CNA witnessed Staff C, CNA rapidly removed Resident #80's shirt which caused the resident to elevate her voice. Staff C informed Staff I the resident suffered from gout. Staff I reported Staff C, knowing the condition of the resident, failed to use a method that could have possibly avoided discomfort. Staff C then stated to the resident, you're fine. Staff I reported, Staff C didn't ask the resident if she was okay. Observation on 8/27/25 at 2:57 PM of Staff C's personnel file showed an untitled document dated February 21, 2025 recorded the following:We have received some complaints concerning the care you are providing to the residents. Careful on how you talk to residents or about them in front of the residents and your co-workers. It is my experience that all residents are treated in a kind and considerate manner, and that they are always treated with dignity and respect in all interactions. You need to explain what you are doing to the resident while providing cares so they know what you are doing and so you don't come across as being rude or rough. The document was signed by the Administrator and Assistant Director of Nursing. An untitled policy last revised November 2016 identified the resident has a right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.In an interview on 9/2/25 at 3:06 PM, the Director of Nursing (DON) reported she expected staff to treat all residents with dignity and respect. The DON reported submitting all information regarding Staff C, had no further documentation regarding Staff C, and couldn't recall if other incidents were reported.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 4 of 4 residents reviewed for abuse (Resident #5, #44, #54, and #80). The facility reported a census of 68 residents. Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of dementia, vision impairment and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. The MDS also showed Resident #5 required partial/moderate assistance for hygiene, bathing and toileting.In an interview on 8/27/25 at 11:29 AM Staff I, reported they witnessed Resident #5 attempting to exit the bed when Staff C, CNA entered the resident's room without knocking, flipped on the light, failed to introduce herself then flung the resident's feet in bed and told her to stay in bed. 2. The MDS assessment dated [DATE] for Resident #44 documented diagnoses of Alzheimer's Disease, anxiety disorder and pain unspecified. The MDS showed the BIMS score assessment unable to be completed. The MDS also showed Resident #44 dependent for toilet hygiene, bathing, and dressing. In an interview on 8/27/25 at 11:29 AM Staff I, CNA reported while transferring Resident #44, she became incontinent of bowel movement which Staff C, CNA commented, in the presence of the resident, Are you fucking kidding me? 3. The MDS assessment dated [DATE] for Resident #54 documented diagnoses of heart failure, dementia and seizure disorder. The MDS showed the BIMS score of 6, which indicated severe cognitive impairment. The MDS also showed Resident #52 dependent for toilet hygiene and lower body dressing. On 2/10/25 at 12:00 PM Staff I, CNA reported Resident #54 voiced she felt another CNA was upset at her because they didn't get her up for supper. While Staff I and Staff C, CNA worked to get the resident up for supper, in the presence of the resident, Staff C talked about why staff didn't like the resident.4. The MDS assessment dated [DATE] for Resident #80 documented diagnoses of heart failure, dementia and malnutrition. The MDS showed the BIMS score of 4, which indicated severe cognitive impairment. The MDS also showed Resident #80 required substantial/maximal assistance for hygiene and dressing. On 2/10/25 at 12:00 PM Staff I, CNA reported while in the presence of Resident #80, Staff C stated that she believed the resident would pass away soon. In an interview on 8/27/25 at 11:29 AM Staff I, CNA witnessed Staff C, CNA rapidly removed Resident #80's shirt which caused the resident to elevate her voice. Staff C informed Staff I the resident suffered from gout. Staff I reported Staff C, knowing the condition of the resident, failed to use a method that could have possibly avoided discomfort. Staff C then stated to the resident, you're fine. Staff I reported, Staff C didn't ask the resident if she was okay. In an interview on 8/27/25 at 11:29 AM, Staff I, CNA reported the same day she witnessed the allegations, and additional allegations, she typed a note and submitted the note under the office doors of the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON). When asked if allegations were reported to other staff, Staff I stated, I didn't report it. I was new. I didn't know what nurse to trust. I didn't want the story to go around differently than what happened. When asked what she would do if she witnessed possible abuse today, Staff I reported she didn't know because she reported to all three administration staff and no one did anything. Staff I reported no one followed up with her. Approximately a week later, I went to the Administrator's office. Staff I stated, the Administrator said he had six days to follow up. No one followed up.Observation on 8/27/25 at 2:57 PM of Staff C's, CNA personnel file showed an untitled document dated February 21, 2025 recorded the following:We have received some complaints concerning the care you are providing to the residents. Careful on how you talk to residents or about them in front of the residents and your co-workers. It is my experience that all residents are treated in a kind and considerate manner, and that they are always treated with dignity and respect in all interactions. You need to explain what you are doing to the resident while providing cares so they know what you are doing and so you don't come across as being rude or rough. The document was signed by the Administrator and ADON.In an interview on 8/28/25 at 9:50 AM, the ADON reported she didn't recall all the details of the meeting with the Administrator and Staff C, CNA. The ADON stated, it was all the way back in February, that's hard to remember. The ADON reported meeting with Staff C about her gruff voice, then made plans for Staff C's work assignments to be in the same hall as the ADON's office. When asked to provide documentation related to resident care incidents and the meeting with Staff C, the ADON reported she doesn't keep documentation of any incident. The ADON explained once she reported to the Administrator or DON, she destroys her documentation. In an interview on 8/28/25 at 10:28 AM, when asked if the Administrator received any typed letter in February regarding Staff C, CNA and concerns with resident care. The Administrator stated, I remember getting something but I don't know if it was one of the letters we already gave you, or something else, or I may have gotten rid of it. When asked if he is required to keep documentation, the Administrator stated, I don't know am I? When asked if the [DATE] documentation concerning Staff C occurred in reaction to receiving a concern, the Administrator stated, yes but I don't remember what was said. I looked through my notes and I didn't see anything. In an interview on 9/2/25 at 3:06 PM, the DON reported submitting all information regarding Staff C, had no further documentation regarding Staff C, and couldn't recall if other incidents were reported. The DON stated, I know we are supposed to report allegations of abuse within two hours, but I already gave you all the documentation I had. I don't remember anything else that was reported. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 identified all allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting allegations of abuse to the Administrator, or designated representative. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Based on observation, infection control policy and staff interview, the facility failed to wear Enhanced Barrier Precautions (EBP) with catheter care and failed to perform hand hygiene between glove changes with 1 of 1 residents (Resident #41). The facility reported a total census of 68 residents.Findings include: Observation on 8/27/2025 at 10:11 a.m., of Staff E, Licensed Practical Nurse assisted Resident #41 to empty her catheter bag. Staff E was in the residents room walking around in the room with gloves on and no other EBP and had a graduate in her left hand. Resident wheeled herself into her room and Staff E closed the door behind her. Staff E with the same gloves on opened the spout on Resident #41's leg bag. Staff E emptied the contents and set the graduate with urine in directly onto the floor and with soiled gloves on, took alcohol swabs out and cleaned the end of the catheter bag opening. Staff E then picked up the graduate off of the floor with the same soiled gloves on and emptied the graduate into the toilet. With the same soiled gloves on got soap out of the soap dispenser and added it into the graduate and rinsed it out with water and dumped contents into the toilet. Staff E then removed the soiled gloves and without performing hand hygiene applied clean gloves and applied the leg strap to her leg, pulled resident pant leg back down, applied her boots and then removed the gloves and performed hand hygiene prior to opening the room door. Review of the facility provided policy titled Enhanced Barrier Precautions dated 3/27/24 revealed Enhanced Barrier Precautions can be applied to residents with any of the following, chronic wounds or indwelling medical devices, regardless of MDRO colonization status. Examples of indwelling medical devices include urinary catheters and suprapubic catheters. Review of facility provided policy titled Handwashing Hand Hygiene with a reviewed date of 3/10/2020 revealed perform hand hygiene before applying non-sterile gloves and perform hand hygiene after removing soiled gloves. Interview on 9/2/2025 at 2:44 p.m., with the Director of Nursing (DON) revealed when staff are working with a resident with a catheter they are to be using EBP in the room especially when emptying a catheter bag.

Based on clinical record review, observation, staff interview and facility policy review the facility failed to provide privacy of a body during personal cares (Resident #11 and #54). The facility reported a census of 27 residents.Findings include: 1. Observation on 8/27/2025 at 12:43 p.m., Staff C, Certified Nursing Assistant (CNA) and Staff D, CNA assisted Resident #11 into bed. During the transfer with the mechanical lift, staff failed to close the curtains to provide privacy during the transfer. 2. Observation on 8/27/2025 at 9:57 a.m., revealed Staff A, CNA and Staff B, CNA assisted Resident #54 into bed. During the transfer with the mechanical lift staff failed to close the curtains to provide privacy during the transfer. Review of the facility policy titled Resident Right Guidelines undated revealed close the door to the room when privacy is appropriate. Draw window curtains as well as the privacy curtain between beds. Provide privacy for the resident during cares. Interview on 8/27/2025 at 1:54 p.m., with the Director of Nursing (DON) revealed staff should have the curtains closed when performing transfers.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notices were signed by the residents and or the resident's responsible person when residents transferred out of the facility. The chart also lacked documentation regarding notification and residents or resident's responsible person's decision to enact a bed hold for 2 of 2 residents reviewed (Residents #3 and #23). The facility reported a census of 68 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented reentry to the facility on 8/19/25 for a short term hospital stay. Review of the Clinical Census report for Resident #3 revealed the following information:a. 4/28/25 - discharged to acute care hospital b. 4/29/25- readmission c. 8/15/25- discharged to acute care hospital d. 8/19/25- readmission Review of the Progress Notes for Resident #3 revealed the following:a. 4/25/25 at 12:19 PM- admitted to the hospital for dehydrationb. 8/19/25 at 2:18 PM- admitted to the hospital Review of Resident #3's chart on 9/2/25 at 9:14 AM showed the bed hold form for 4/28/25 lacked a signature of the residents or resident's responsible person. The facility also lacked a bed hold form for 8/15/25. The Nurse's Notes lacked documentation regarding bed hold communication of the resident or resident's responsible person for 4/28/25 and 8/19/25. 2. The MDS assessment dated [DATE] for Resident #23 documented diagnoses of coronary artery disease, hypertension and Non-Alzheimer's Dementia. The MDS showed the BIMS score of 5, indicating severe cognitive impairment. Review of Resident #23's Census listing revealed the following information: 8/25/25- transfer date 8/24/25 8/26/25- readmission date 8/26/25 Review of Progress Notes revealed the following: 8/24/25 at 11:17 p.m., Resident transferred to the emergency room (ER) for assessment. 8/25/25 at 2:26 a.m., admitting resident to local hospital for monitoring. 8/26/25 at 2:15 p.m., resident returns from the hospital. Review of the medical chart contained a bed hold but the bed hold lacked any decision on if the resident representative wanted the bed hold or not. The Progress Notes lacked information obtained from the family regarding if they contacted for a bed hold for the resident and lacked any signatures of receipt of notification. Review of facility provided policy titled Bed-Holds and Returns dated 4/21/25 revealed all residents or representatives are provided written information regardless of the facility and stated bed-hold policies which address holding or reserving a resident's bed during periods of absence including hospitalizations. Multiple attempts to provide the resident representative with notice should be documented in cases where staff were unable to reach and notify the representative timely. Interview on 9/2/2025 at 2:44 p.m., with the Director of Nursing (DON) revealed the facility sends a bed hold with the resident to the hospital with the paperwork the facility prints out. The next day the Business Office Manager prints off a bed hold and mails it to the family. The facility then scans the bed hold into the chart. The DON verifies the chart lacks notification of the family regarding the bed hold. The DON verifies if the bed hold is scanned in then the notification has been sent to the family but does not know if the bed hold was ever completed for this resident. The DON revealed it was her fault that nothing was charted on the day after the resident went to the hospital.

Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) Assessment for 2 of 3 residents reviewed (Resident #6 and #10). The facility reported a census of 68 residents.Findings include: 1. Resident #6's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of anxiety disorder, depression, and schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves). The MDS coded the resident as a no for a Preadmission and Resident Review (PASRR) Level II (a comprehensive evaluation that follows a positive Level I screening to determine if an individual has a mental Illness (MI) or intellectual/developmental disability (IDD) and whether they need a nursing facility (NF) placement and specialized services for their condition). Resident #6's current PASRR dated 4/21/23 documented Level II approved with specialized services. On 8/28/2025 at 8:45 AM Staff F, Unit Manager reported Resident #6 is a Level II PASSAR. She reported it should be coded on the MDS as a Level II and is an error if not. On 8/28/2025 at 9:54 AM the Director of Nursing (DON) reported it should be coded on the MDS for Resident #6's Level II PASSAR. She reported the facility does not have a policy for MDS assessments. She reported the facility follows the RAI Manual. The RAI manual dated October 2025 documented in Chapter 3 page A-32 to code yes if the PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition. 2. Resident #10's MDS assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of seizure disorder or Epilepsy, bed confinement status and malnutrition. The MDS further documented the bed rails used as a physical restraint (any manual method, physical, or mechanical device, material or equipment attached or adjacent to the resident's body the individual cannot remove easily which restricts freedom of movement or normal access to one's body). Resident #10's Care Plan documented she could not complete her own cares due to right sided weakness. The intervention documented Resident #10 requested a transfer assist rail for the left side of the bed so she may use her right arm for transfer assistance, mobility, care and increase in independence.On 8/28/2025 at 8:46 AM Staff F , Unit Manager reported the bedrail for Resident #10 is not a restraint. Staff F reported it said bedrail on the MDS so she marked it. She further verbalized it does not restrict Resident #10's movement. Staff F reported it is not a restraint then it should not be coded on the MDS. The RAI manual dated October 2025 documented in Chapter 3 page P-6 that bed rails are used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint.

Based on clinical record review, observations, facility policy review and staff interviews the facility failed to protect residents from the use of physical restraint that the resident could not remove on their own (Resident #54). The facility reported a census of 68 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 documented diagnoses of Alzheimer's Disease, heart failure and anemia. The MDS showed a Brief Interview for Mental Status (BIMS) score was not completed as resident is rarely or never understood. Observation on 8/25/2025 at 1:32 p.m., revealed a positioning device behind Resident #54's left side of her back under the fitted sheet. Observation on 8/27/2025 at 9:57 a.m., revealed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA assisted Resident #54 into bed. After Resident #54 was laying in bed. Staff B removed a positioning device from the closet and placed it under the fitted sheet and pressure relieving device behind her left side of her back. Staff finished assisting the resident and left the room. Review of Facility provided policy titled Use of Restraints dated 11/1/19 revealed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's condition and this restricts his or her typical ability to change position or place, that device is considered a restraint. Interview on 9/2/2025 at 2:44 p.m., with the Director of Nursing revealed the wedge should not have been under the sheet.

Based on observation, interviews, video and record review, the facility failed to account for the whereabouts of 1 of 1 resident reviewed (Resident #16), and failed to ensure that the door alarms were activated. The facility failed to transfer correctly 1 of 1 resident reviewed for a transfer with a sit to stand lift, (Resident #23). On the evening of 5/7/24, Resident #16 used the handicap button, that did not trigger an alarm, to exit through the front door at 7:20 PM. A staff member from the assisted living facility returned him to the nursing home at 10:10 PM. Nursing home staff were unaware that he had been gone for over 2 hours and that he had fallen during his time outside. Staff later found that the alarm to the front door had been turned off earlier that evening. This failure caused an Immediate Jeopardy to the health, safety and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 7, 2024 on August 21, 2024 at 2:15 PM. The facility staff removed the Immediate Jeopardy on August 21, 2024 through the following actions: a. Contractor Knight Protection called to install new alarm system at front door with a key pad and code for anyone exiting the facility. b. Wanderguard System (WGS) was always in working order for those residents assessed to be at risk for elopement. c. Education: Wandering and Elopement in Long-Term Care was assigned to employees. d. Color placard placed at alarm panels at both Nurses' Stations regarding shutting off alarms. e. Employee that turned off the alarm on date of incident was disciplined. f. Director of Nursing had a private message via private FaceBook to nursing employees regarding elopement. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 67 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficit). He was independent with eating, toileting, dressing, hygiene and walking with the use of a walker. His diagnosis included; seizure disorder, traumatic brain injury, anxiety disorder, and bradycardia. The Care Plan updated on 7/23/24, showed Resident #16 preferred to spend time in his room. Staff were to offer to take him outside to tend to the garden when appropriate. The resident had a history of a traumatic brain injury and had periods of confusion and difficulty organizing his thoughts and communicating needs. Resident #16 had the potential to fall down and get hurt, staff were directed to remind him to ask for help. He tended to lose his balance and would fall or bump into things. On 5/7/24 he had a WG placed to his right ankle and it was removed on 6/19/24. Staff were to monitor for attempts to leave facility and replace if needed. Encourage him to ask for staff assistance if he wants to go outside. Encourage to let staff know when leaving facility with family or friends not to leave facility on his own without staff knowledge. On 8/19/24 at 12:41 PM, Resident #16 was sitting in a recliner in his room. He pointed out at the bird feeder outside his window, and talked about migration of different birds. He said that the staff treat him well, but got in trouble when he went outside without them knowing. He said he wanted to put seed in the bird feeder but nobody wanted to go with him. It was 7:00 at night I sat out there and listened to the birds. He said that he was outside for about 2 hours and then he decided that he better come in because it was getting dark. He said that he was able to leave through the front entrance undetected by hitting the button so the alarm wouldn't go off. A facility investigation showed that on 5/7/24, Staff C Licensed Practical Nurse (LPN) reported that she gave Resident #16 medication at 7:04 PM and he asked her to fill up his bird feeder outside his window. She said she would put in a maintenance request to have that done in the morning. At 10:10 PM, Staff G, Personal Assistant (PA) from the Assisted Living (AL) building brought Resident #16 back to nursing home. He had entered the front door of AL and told Staff G that he needed help finding his room. She then walked him back to the nursing home. At 10:15 PM, Staff C noted that he did not have his walker and he commented to the staff that he went to fix his bird feeder. He was found to have an abrasion to left face, left wrist and both of his knees. At 11:00 PM Staff C went around the nursing home and checked exits and alarms and noted that the front door alarm was bypassed. The resident's walker was found by the front door. A Nursing Note dated 5/8/24 at 2:06 AM, showed that, initially, Resident #16 told the nurse that he hadn't fallen while he was outside. Later, when the nurse noticed a small abrasion to the left side of his face, under his glasses frame, he admitted that he had fallen and had a difficult time getting back up. He also had small abrasions to the left wrist, left knee above and below the knee cap and one to the right knee. An Elopement Risk assessment dated [DATE], showed Resident #16 was not at risk for elopement. An intervention was later added to the document reading: resident did have a WG in place after he went out of the facility without notifying staff, it was intentional that he went outside, and staff is aware to keep track of his whereabouts, WG had been removed. The following signed, written staff statements were included in the facility investigation of the incident from the evening of 5/7/24: a. Staff V, Certified Nurse Aide (CNA) was working that night, giving baths and putting residents to bed. She did not see the resident before he left the building and did not hear any alarms. b. Staff U, CNA did not see the resident or hear alarms. c. Staff W, RN did not see the resident or hear alarms. d. Staff X, Certified Med Aide (CMA) did not hear an alarm or see the resident before he left the building. Further investigation revealed that a family had left the facility around 8:00 PM, and the front door alarm went off. Staff E, CNA, indicated to Staff A that it was all clear and it was okay to turn the alarm off so she switched it off. Staff A thought she had turned it back on. Staff were educated and reminded that door alarms were to be turned on at all times, and hourly rounding was to be completed on resident per facility policy. On 8/20/24 at 6:05 PM, Staff G Personal Assistant (PA) in the AL building said that she was just starting her shift (10p-7a) when Resident #16 came to the South door. She said that it was dark outside, he was able to enter by pushing the handicap button. She asked him if he needed help and he said that he needed help finding his room so she walked him over to the nursing home. The only thing he said to her was it's buggy out there. He didn't say that he fell or what he was doing outside. It was chilly, and he was wearing a short-sleeved shirt, pants and shoes. One of his shoes was untied so she tied it for him. He had glasses on, and seemed to be walking okay without assistance. In an observation on 8/21/24 at 8:49 AM, it was found that the outside area from the front door of the nursing home to the assisted living door was about 500 feet through the grass. There were a couple of hills and a valley with rough, uneven ground. A review of a video from the front door of the facility revealed that on 5/7/24 at 7:20 PM Resident #16 walked to the door with his walker, pushed the handicap button and exited the building. On 8/19/24 at 7:20 PM Staff F LPN said that Resident #16 knew that he could just hit the handicap button and the front door would not alarm. He would go out with family quite often so he knew the routine. He wasn't a risk before, didn't wander or check doors, and he was pretty independent around the facility. On 8/20/24 at 8:45 AM, Staff C, LPN said she didn't know how long Resident #16 may have been outside or where he actually went during that time. She didn't think he ever made it to the bird feeder. When Staff G brought him over from Assisted Living, he said that he hadn't fallen. She took him to his room and helped him into the recliner. That's when she noticed he had a scratch near his eye, it was difficult to see behind his glasses. She noticed his knees were dirty and that's when he admitted that he had fallen. Staff C did not remember hearing an alarm. When the resident had been brought back to the facility, she called the supervisor on duty, and she directed her to go around and check all of the alarms. The northeast nurse station alarm for the front door had been turned off. She did not know how long it could have been off, someone cleared it and didn't turn the switch back on. On 8/21/24 at 5:50 AM, Staff A, CNA, said that she worked the night that Resident #16 got out. She did not see him leave or know that he was gone. Earlier in the evening, the alarm had gone off and another employee had told her it was clear so she shut the alarm off. I thought I turned it back on but apparently not. The other staff member could see the front door and the nurses' station where Staff A was standing, and she gave her the okay to turn it off. On 8/21/24 at 4:30 PM, the Director of Nursing (DON) said that after the incident with Resident #16, she reinstituted the hourly rounding. This was a process where the staff document that all residents are accounted for on an hourly basis. She said that they had used in the past, but most recently, it hadn't been followed. On 8/22/24 at 6:58 AM, the DON said that they had a process for residents and families to sign out so they know where they are, but it wasn't being used and they needed to reeducate staff and families about using that. On 8/21/24 at 3:49 PM Staff Z CNA works PRN. she has worked some evening shifts and from 6-9 PM, most of their time is spent getting residents to bed and it's a very busy time. They try to get to the rounding but sometimes there was just one CNA per hallway and one floater. On 8/21/24 at 3:45 PM, Staff X said that on the overnight/evening shift is a very busy time with getting residents too and from meals, and then getting them ready for bed. From 7 PM-10 PM was the busiest time for resident cares. According to a facility policy titled: Wanderguard System/Door Alarm System, Revised on 8/20/24. The front door was alarmed and you must push the red button to get into the facility. When exiting a code must be punched in before exiting. All door alarms need to physically be checked when sounding to assure that a resident was not leaving and not just turned off at the nurses' station. The policy indicated that staff would perform hourly rounding on residents. 2) According to the MDS dated [DATE], Resident #23 had a BIMS score of 14 (intact cognitive ability). She required substantial assistance with dressing, toileting hygiene, sit to stand and toilet transfers. Diagnosis included diabetes mellitus, anxiety disorder, muscle weakness and chronic pain. The Pare plan updated on 2/7/24, showed Resident #23 used a power scooter for mobility and an EZ stand mechanical lift for transfers. On 8/19/24 at 12:54 PM, Staff Y, CNA prepared to transfer Resident #23 from the wheel chair to the recliner with the Sit to Stand mechanical lift. She attached the sling and strapped the resident's legs to the platform. Several times, she reminded the resident to stand up straight. Once she was in the standing position, Staff Y failed to tighten the belt around the torso. On 8/21/24 at 10:12 AM, the DON said that the staff were taught upon orientation on safe transfers. She acknowledged the risks if/when the buckle on the Sit to Stand was not tightened, especially with a weaker resident. According to the user [NAME] for the Sit to Stand mechanical lift, page 6; as the patient is being raised, simultaneously tighten the safety strap buckled around the torso.

Based on record review, interview and policy review the facility failed to obtain complete resident records. A facility form titled: Authorization for Withholding CPR (Cardiopulmonary Resuscitation) did not include a date, or physician signature and/or a witness signature for 4 of 27 reviewed, (Residents #3, #23, #2 and #121) . The facility reported a census of 67 residents. Findings include: 1. According to the Face Sheet for Resident #3, he was admitted to the facility on [DATE] with a Do Not Resuscitate (DNR). Do not attempt to restore heartbeat and breathing following a cardio pulmonary arrest. A form titled; Authorization for Withholding CPR signed by the resident, included a handwritten note, I want CPR and the writing was scribbled out. The resident's signature and witness signature were not dated. Staff failed to include the code status in a request for signature fax to the doctor dated [DATE]. Item #8 was written: request (blank space) status. 2. The Face Sheet for Resident #23 showed that she was admitted on [DATE] with a code status of DNR. The Authorization for Withholding CPR was signed by the resident and a witness, but it was undated. 48004 3. Review of Resident #2 ' s Electronic Health Record (EHR) revealed a document titled, Face Sheet that indicated Resident #2 had an advanced directive for do not resuscitate. Review of a facility provided undated document titled, Authorization for Withholding CPR, revealed Resident #2 ' s Guardian had signed the form and was the only signature on the form with no date. This document further revealed that the form had no physician signature and no witness signature or dates. 4. Review of Resident #121 ' s EHR document titled, Face Sheet, revealed that Resident #121 had an advance directive for do not resuscitate. Review of a facility provided document titled, Authorization for withholding CPR, revealed Resident #121 ' s Durable Power of Attorney (DPOA) had signed the form with no witness signature or physician ' s signature present. This document further revealed a date of [DATE] was written on the date space by the witness signature. Review of a facility provided document titled, Authorization for Withholding CPR dated [DATE] revealed: a. Upon admission the facility will ask about the resident ' s directives. b. They will be given the opportunity to determine whether they wish for CPR or to withhold CPR. c. After signing the document, it will be sent to the physician for signature. d. The CPR request will be placed in the resident ' s chart and replaced when the signed physician sheet is returned to the facility. e. Code status will be documented in E.H.R. as well as the document will be scanned into the record. g. The Unit Managers/Social Service Director will be in charge of obtaining the resident signature and dating it.

Based on clinical record review, observations, resident interviews, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 4 of 4 residents reviewed (Residents #11, #21, #33, and #41) requiring the use of oxygen. The facility reported a census of 67 residents. Findings include: 1. Review of Resident #11 ' s Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS further revealed diagnosis of chronic obstructive pulmonary disease, and dyspnea (shortness of breath). During an interview 8/20/24 at 9:27 AM with Resident #11 revealed that the Resident could not recall when the oxygen tubing was last changed for her. Resident #11 further revealed that it felt as if it had been awhile since it was last changed. On 8/20/24 at 9:28 AM an observation revealed Resident #11 ' s oxygen tubing was dated 6/2/24. 2. Review of Resident #33 ' s MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Review of Resident #33 ' s Electronic Health Record (EHR) document titled, Physician ' s Orders dated 6/20/24 revealed an order to apply oxygen 1-2 Liters (per nasal cannula), as needed to keep oxygen levels equal to or greater than 90%. During an interview on 8/19/24 at 12:02 PM with Resident #33 revealed the Resident could not recall when the tubing was changed. Resident #33 further revealed it had been a while ago. During an observation 8/19/24 at 12:02 PM Resident #33 was observed to be wearing a nasal cannula. Oxygen tubing was observed to have no date on it at this time. 3. Review of Resident #41 ' s MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. The MDS included diagnoses of coronary artery disease, and heart failure. Review of Resident #41 ' s EHR document titled, Physician ' s Orders dated 6/20/24 revealed an order to apply oxygen 1-2 liters per nasal cannula. Keep oxygen levels greater than 90% every shift. During an observation 8/19/24 at 11:43 AM Resident #41 was observed to be on oxygen via nasal cannula. It was observed at this time that the oxygen tubing was dated 3/2/24. Review of Resident #41 ' s Treatment Administration Record (TAR) dated August 2024 showed an order to change oxygen cannula one time per week on Tuesday nights. The TAR further revealed that this was not signed on 8/17/24. During an interview on 8/20/24 at 9:32 AM with Staff N Licensed Practical Nurse (LPN) revealed oxygen tubing is to be changed once a week. Staff N stated that she personally dates the tubing, and the TAR has areas to initial when completed. Staff N then revealed the tubing is usually changed on overnights on Saturdays. Staff N stated her expectation would be for the oxygen tubing to be changed weekly per the orders. During an interview on 8/20/24 at 9:41 AM with the Director of Nursing (DON) stated oxygen tubing should be changed, labeled, and dated as ordered. The DON then revealed the facility does not have a policy related to oxygen tubing being changed, but the facility does follow professional standard. 49628 4. The MDS assessment dated [DATE], documented Resident #21 had a BIMS score of 12/15 indicating moderate cognitive impairment. The MDS documented diagnoses that included coronary artery disease (CAD), heart failure, neurogenic bladder, and benign prostatic hyperplasia. Resident #21 required oxygen. The Medication Profile Report Dated 5/29/24 revealed Resident #21 had orders for 2 Liters (L)/Nasal Cannula (NC) or mask to keep saturations above 90%; oxygen 1-5L/minute (min) per NC as needed for comfort - intermittent or continuous. Resident #21 ' s MAR/TAR revealed an order for changing nebulizer mask/tube/tubing 1x week with the first date 8/27/24, entered on 8/20/24. The document further revealed administration of oxygen 1.0 L/min - 5.0 L/min (per nasal cannula)>or equal to 90% as needed on the first date 5/29/24 (for comfort), entered on 5/29/24. The document revealed no signatures by staff for the resident needing oxygen for the month of August. Resident #21 ' s Care Plan revealed an approach of application of oxygen per primary care provider ' s orders, allow rest periods and to notify the nurse if the resident complains of shortness of breath. Observation on 8/19/24 at 12:51 PM revealed the resident on oxygen via nasal cannula. The oxygen tubing from the concentrator showed a changed date of 7/28/24. Observation on 8/20/24 at 9:37 AM revealed oxygen tubing on the concentrator dated 7/28/24 and nebulizer tubing dated 8/14/24. On 8/20/24 at 10:24 AM and at 1:58 PM Staff M, LPN, stated oxygen tubing and nebulizers were changed once a week on nights. The staff stated it is the facility protocol that the tubing is to be changed weekly and it should be noted on the TAR. Staff M stated it did not matter whether or not the resident received hospice services. On 8/21/24 at 12:50 PM the Director of Health Services (DHS) stated oxygen tubing was to be changed weekly. The DHS acknowledged that earlier in the week that some tubing had not been changed, and the facility had gone through and changed tubing. The DHS stated the facility ordered bright colored stickers for easier notification of dates on the tubing. The staff stated the tubing will now be changed on Tuesdays and it would be noted on the TAR.

Based on observations, clinical record review, staff interviews and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares (Resident #21, Resident #64). The facility further failed to diminish the risk of spreading SARS-CoV-2 (COVID-19) during an active outbreak. The facility reported a census of 67. 1. The MDS assessment dated [DATE], documented Resident #21 had a BIMS score of 12/15 indicating moderate cognitive impairment. The MDS documented diagnoses that included coronary artery disease (CAD), heart failure, neurogenic bladder, and benign prostatic hyperplasia. The assessment section entitled Functional Abilities and Goals (GG) revealed Resident #21 required extensive assistance to dependent assistance with activities of daily living (ADLs), mobility and transfers. The resident had an indwelling catheter. Resident #21's Care Plan revealed approaches for staff to follow including the resident having a catheter, following enhanced barrier precautions, taking care of catheter equipment, and monitoring output. Observation on 8/21/24 at 9:25 AM Staff H, Certified Nursing Assistant (CNA), and Staff O, CNA, donned appropriate personal protective equipment (PPE) and entered Resident #21's room for catheter and personal cares. Staff O completed catheter care using the left (L) hand to move the resident's skin, testicles, penis, and catheter tubing, while the right (R) hand obtained new disposable wipes from a package multiple times during catheter care. Staff O threw the used wipes across the resident into the trash can. During the same time period Staff H donned the resident's pants and non-skid socks. Staff H and Staff O assisted the resident to reposition to the R and L sides for completion of peri cares. Staff O completed peri cares obtaining wipes and cleaning with the R hand. Resident #21 was incontinent of bowel. Staff O completed removal of the dirty brief, closed it, and handed it to Staff H, who threw it in the trash can. Staff O initiated donning of the adult dependent brief and then removed her gloves. Staff O handed Staff H the dirty gloves, who threw the gloves away, and then handed Staff O clean gloves. Staff O donned the clean gloves without hand hygiene. Staff H and Staff O completed dressing, and transferred the resident to the wheelchair. Resident #21 blew his nose and handed Staff O the dirty tissue. Staff O threw the tissue away, assisted the resident complete upper body dressing, and made the resident's bed. Staff H emptied the resident's catheter, cleaned the urine graduate, placed the catheter in the dignity bag, brushed the resident's hair and cleaned his glasses. Staff H removed her gloves, applied Resident #21's oxygen, removed her gown, and pushed the resident towards the dining room. There was no hand hygiene. Staff O removed her gloves, wound up concentrator tubing, removed her gown and then washed her hands. On 8/21/24 9:58 AM the Infection Preventionist (IP) stated it was expected that every time gloves come off the staff need to complete hand hygiene. The IP stated following peri cares and catheter cares she would expect changing of gloves with hand hygiene before proceeding with other cares. On 8/21/24 at 12:53 PM the Director of Health Services (DHS) stated she would expect gloves to be changed during peri cares when hands became contaminated and before continuing on to other tasks. The DHS stated hand hygiene should occur prior to glove application, between gloves, and at the removal of gloves. The facility document, Infection Control Guidelines for All Nursing Procedures reviewed 1/30/20, revealed all direct control staff must have training on general infection and exposure control issues prior to having direct-care responsibilities for residents. The document further revealed employees must wash their hands with antimicrobial or non-antimicrobial soap and water or use alcohol-based hand rub containing 60-95% ethanol or isopropanol after removing gloves, after handling items potentially contaminated with blood, bodily fluids, or secretions, and before moving from a contaminated body site to a clean body site during resident care. The facility document, Handwashing/Hand Hygiene reviewed 3/10/20, revealed all staff will follow the procedures to prevent the spread of infection. The document also revealed alcohol-based hand rub with at least 62% alcohol or soap and water should be used after removing gloves, before and after handling an invasive device, and is the final step after removing and disposing of personal protective equipment (PPE). 2. Observed on 8/19/24 at 10:30 AM upon entry into the facility a sign posted that stated the facility was in outbreak status and masks must be worn by all healthcare providers and visitors. On 8/19/24 at 2:41 PM Staff R, Infection Technology, entered the conference room from the main hallway, dropped off a computer, and exited the room without wearing a mask. Observed on 8/20/24 at 7:00 AM the Laundry Supervisor and Staff P, laundry, working together without wearing masks. Observed on 8/20/24 at 7:29 AM the Maintenance Director and multiple maintenance/grounds staff gathered in the Maintenance Director's office talking. None of the staff were wearing masks. Observed on 8/20/24 at 11:35 AM the Office Manager walking in the main hallway into the business office without wearing a mask. Observed on 8/20/24 at 4:05 PM Staff Q exiting a room and walking in the hallway with her mask down below her chin. Observed on 8/20/24 at 4:15 PM the IP sitting at a table with the DHS in the DHS's office without a mask. On 8/20/24 at 10:37 AM the IP stated the facility has had 14 residents and 9 staff test positive for COVID-19 with the first resident testing positive on 8/6/24. The IP stated on 8/19/24 the facility had 2 residents and 2 staff test positive for COVID-19. The staff stated the facility is encouraging visitors to wear masks and staff were to wear masks. The IP stated if staff are in offices, they were OK to not wear masks, but they were to wear masks in the halls. The IP voiced that she was not worried about staff not wearing masks around others in an office if there was enough distance. The staff would not elaborate on what enough distance constituted, but would encourage separation. On 8/20/24 at 12:58 PM the DHS stated masks were to be worn in all resident care areas, including hallways and residents' rooms. The DHS expected staff to wear masks when around other staff even when in offices. The facility document, Coronavirus Disease (COVID-19) - Source Control dated 8/1/23, revealed source control measures are utilized as part of COVID-19 prevention and control measures. Source control included use of well-fitting masks that cover the mouth and nose, and prevent the spread of respiratory secretions when individuals were breathing, talking, coughing, or sneezing. The document disclosed source control may be implemented more facility-wide targeting higher risk areas or resident populations. The document also revealed those working in a facility experiencing an outbreak the universal use of source control may be discontinued as a mitigation measure once no new cases have been identified for 14 days. 41785 3. According to the Minimum Data Set (MDS) dated [DATE], Resident #64 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). She required partial assistance with toileting, dressing, and transfers. Resident #64 had an unhealed, unstageable pressure open area on her left foot and staff were to apply a dressing on the foot. The Care Plan last updated on 8/8/24, showed the resident had pain related to cancer and was having a hard time moving. She was an assist of one, and was admitted to Hospice services on 8/8/24. Staff were to follow wound care orders for a stage 3 pressure to left heel, and to follow recommendations. The heel protector boot was to be applied when in chair and bed, remove when up. A Nursing Note dated 8/19/24 at 8:27 AM showed Resident #64 tested positive for COVID-19. She was experiencing shortness of breath, chills, and muscle pain. On 8/19/24 at 2:58 PM the entrance to the room for Resident #64 was covered with plastic and there was a bin outside the door with Personal Protection Equipment (PPE). The resident was in bed sleeping on her back and did not respond when addressed. On 8/20/24 at 9:25 AM, Staff T, Certified Nurse Aide (CNA) provided a bed bath for the resident. Staff T cleaned the residents face, arms, back legs and peri area with disposable clothes. She provided the entire bed bath without having changed her gloves, she pulled the covers back over resident and touched many surfaces before removing gloves and gown. Staff T left the room without washing her hands and used the hand sanitizer in the hallway.

Based on observations, staff interview, clinical record review, and policy review the facility failed to review and revise the care plan for 1 of 24 residents reviewed (Resident #30). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #30 scored 3/15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident completed rolling in bed independently. Section J revealed Resident #30 had occasional pain. Section M of the MDS revealed the resident had 1 or more pressure ulcers/injuries that were not healed. The document indicated the resident had 1 unstageable pressure injury presenting as deep tissue injury. Resident #30's Care Plan revealed the resident has the potential to bruise easily and is at risk for skin breakdown. The document provided approaches for staff including: ensuring heels are placed in boots to prevent pressure. Resident #30's Medication Administration Record (MAR)/Treatment Administration Record (TAR) for 8/24 revealed application of skin prep to the right heel twice daily. The nursing staff signed off on the treatment for 39/41 opportunities. The document also revealed the placement of heels in inflatable boot(s), both heel(s), to prevent pressure with the first date of 6/1/24. Review of the document further revealed staff signed off on the treatment for 39/41 opportunities. Observed on 8/19/24 at 12:55 PM Resident #30's right (R) foot in a boot and the left (L) foot in a regular shoe. Observed on 8/20/24 at 10:02 AM Resident #30's R foot in a boot and regular shoe on the L foot. Observed on 8/21/24 at 6:54 AM Staff L, Registered Nurse (RN), complete wound care to Resident #30's R heel. Upon removal of Resident #30's bed covers observed a single boot on the resident's right foot. Staff L completed the appropriate wound care, replaced the R boot and left the room. Staff L stated Resident #30 came back with the wound to the heel and only wears a boot on the R foot. On 8/20/24 at 10:20 AM Staff M, Licensed Practical Nurse (LPN), stated Resident #30 came back from the hospital with spots on his heels. The staff stated the L heel had healed and the R heel is close. Staff M stated the resident only wears the R boot during the day when he is up and just sitting. The resident may wear regular shoes when ambulating with staff. On 8/20/24 at 12:50 PM the Director of Health Services stated the Care Plans and the TARs should correlate together. If a resident had a positioning device referenced on the TAR it would be expected to be on the care plan. The facility provided document, Care Plans, Comprehensive Person-Centered revised March 2022, revealed the MAR/TAR will be considered part of the ongoing Care Plan. The document further revealed the care plan should include services required to attain or maintain the resident's highest level of physical well-being.

Based on observations, interviews, clinical record review, and facility policy, the facility failed to provide dignity by consistently knocking on residents ' doors before entering. The facility reported a census of 67 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #4 scored 14/15 on the Brief Interview for Mental Status (BIMS) indicating the resident is cognitively intact. Resident #4 on 8/19/24 at 1:50 PM stated staff do not knock prior to entering her room or announce themselves. The resident stated staff just walk in, do whatever they want, and give orders. Continuous observation on 8/20/24 at 9:49 AM identified Staff H, Certified Nursing Assistant (CNA), Staff I, CNA/Certified Medication Aide (CMA), and Staff J, CNA, delivering towels. The staff were entering rooms on the East Hallway without consistently knocking on the residents ' doors or announcing their entrance. On 8/21/24 at 7:58 AM observed Staff K, CNA, enter a resident ' s room without knocking or announcing her entrance. On 8/21/24 at 12:45 PM the Director of Health Services (DHS) indicated staff should knock on all resident doors prior to entering. The DHS stated staff should wait for response from a resident before entering. The facility provided document, Residents ' [NAME] of Rights revised 11/16, revealed the facility must treat each resident with dignity, respect and care. The facility must provide a homelike and comfortable environment, and the residents have a right to personal privacy.

Based on observation, interviews and record review the facility failed to follow the interventions and physicians' orders to prevent worsening of pressure ulcers for 2 of 3 residents reviewed, (Residents #64 and #30). Resident #64 had a treatment order for a chronic heel ulcer and the treatment was not followed. Resident #30 had an order to place boots on both feet to prevent worsening of ulcers. Staff were applying a boot to the right foot only. The facility reported a census of 67 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #64 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). She required partial assistance with toileting, dressing, and transfers. Resident #64 had an unhealed, unstageable pressure open area on her left foot and staff were to apply a dressing on the foot. The Care Plan last updated on 8/8/24, showed the resident had pain related to cancer and was having a hard time moving. She was an assist of one with the wheeled walker, and was admitted to Hospice services on 8/8/24. Staff were to follow wound care orders, as she was being treated by wound care nurse for stage 3 pressure to left heel, and to follow recommendations. Heel protector boot was to be applied when in chair and bed, remove when up. A review of the electronic chart revealed the following Physicians' Orders: a. On 4/16/24, apply waffle boots bilateral at all times except while walking. b. On 6/11/24, cleanse left heel ulcer with sterile saline apply small amount of iodosorb (gel containing substance that helps clean wounds) into the wound. Apply calcium alginate, cover with polymem, (soft absorbent dressing with moisturizing and wound cleansing properties) secure with roll gauze and tape. c. On 7/24/24, cleanse left lateral foot ulcer with sterile saline, apply polymem and secure with medipore (soft, surgical tape) daily. On 8/19/24 at 2:58 PM, Resident #64 was in bed sleeping on her back, she had gripper socks on her feet, and there was a blue heel protector boot in the recliner on the opposite side of the room. On 8/20/24 at 5:59 AM, the blue boot was still in the recliner. The resident was in bed on her back sleeping. On 8/20/24 at 6:20 AM, Staff S, Licensed Practical Nurse (LPN) said that the order was to leave the left heel Open To Air (OTA) so she wouldn't be doing any treatments to the residents foot. On 8/20/24 at 9:25 AM, Staff T, CNA, prepared to give the resident a bed bath. She was sleeping and did not respond when addressed. The boot was still in the recliner. The resident did not have anything on her feet and as Staff T lifted her left foot, it was revealed that she had two sores; one just below the small toe and spot on the heel. A review of the Treatment Administration Record (TOA) showed that in the month of August, the treatment was not completed and the foot was left open to air. On the 6th and 7th of August the treatments were not signed off as having been completed. On 8/21/24 at 10:15 AM, the Director of Nurse (DON) said she would expect staff to complete orders as written. 49628 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #30 scored 3/15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident completed rolling in bed independently. Section J revealed Resident #30 had occasional pain. Section M of the MDS revealed the resident had 1 or more pressure ulcers/injuries that were not healed. The document indicated the resident had 1 unstageable pressure injury presenting as deep tissue injury. Resident #30's Physician Orders revealed skin treatment: placing heels in inflatable boot(s), both heel(s) to prevent pressure with the first date 6/1/24. The document also revealed to apply dry dressing to the right hip for drainage as needed with the first date of 6/4/24. Resident #30's Medication Administration Record (MAR)/Treatment Administration Record (TAR) for 8/24 revealed staff signing that both boots were in place on AM and HS shifts for 39/41 opportunities with 2 blanks on the document. The document also revealed no documentation for dressing on the right (R) hip for the month of August. Observed on 8/19/24 at 12:55 PM Resident #30's R foot in a boot and the left (L) foot in a regular shoe. Observed on 8/20/24 at 10:02 AM Resident #30's R foot in a boot and regular shoe on the L shoe. Observed on 8/21/24 at 6:54 AM Staff L, Registered Nurse (RN), complete wound care to Resident #30's R heel. Upon removal of Resident #30's covers observed a single boot on the resident's right foot. Staff L completed the appropriate wound care, replaced the R boot and left the room. Staff L stated Resident #30 came back with the wound to the heel and only wears a boot on the R foot. Staff L stated there was no wound on the R hip. On 8/20/24 at 10:20 AM Staff M, Licensed Practical Nurse (LPN), stated Resident #30 came back from the hospital with spots on his heels. The staff stated the L heel had healed and the R heel is close. Staff M stated the resident only wears the R boot during the day when he is up and just sitting. The resident may wear regular shoes when ambulating with staff. Staff M stated there was no wound care for the hip as it had been healed. On 8/20/24 at 12:50 PM the Director of Health Services stated if a resident had a positioning device referenced on the TAR it would be expected to be followed.

Based on interviews, record review, and policy review, the facility failed to ensure call lights were answered in under 15 minutes for 4 out of 4 residents reviewed (Resident #2, #5, #6 and #7). The facility reported a census of 75 residents. Findings include: 1. Interview on 4/24/24 at 12:42 with Resident #2 revealed she waits a long time when she uses her call light and has waited over 2 hours for her call light to be answered. When Resident #2 told the facility about the long call light wait time, they went back and looked at the call light times and told her she was right about waiting so long. Resident #2 revealed she has had incontinent episodes of bowel movement and it makes her feel terrible. Resident #2 further revealed she has a catheter but there are times she has even been wet because staff does not come in and empty the bag enough so the urine backs up and her clothing gets wet with urine. Review of the facility provided document titled Device Activity Report dated 4/24/24 with report dates from 4/22/24- 4/24/24 revealed the following: a. On 4/22/24 the call light turned on at 7:05 a.m., and was on for 64 minutes. b. On 4/22/24 the call light turned on at 4:27 p.m., and was on for 24 minutes. c. On 4/23/24 the call light turned on at 6:14 p.m., and was on for 44 minutes. 2. Interview on 4/24/24 at 11:41 a.m., with Resident #5 revealed she has to wait a long time for her call light to be answered. Resident #5 further revealed she doesn't feel there is enough staff here to take care of all the residents and when she uses her call light sometimes no one ever comes. Resident #5 revealed she worries at times if she will make it to the bathroom when she has to wait so long for the staff to answer her call light. Review of the facility provided document titled Device Activity Report dated 4/24/24 with report dates from 4/22/24- 4/24/24 revealed the following: a. On 4/23/24 the call light turned on at 1:40 p.m., and was on for 15 minutes. 3. Review of the facility provided document titled Device Activity Report for Resident #6 dated 4/24/24 with report dates from 4/22/24- 4/24/24 revealed the following: a. On 4/22/24 the call light turned on at 1:56 p.m., and was on for 15 minutes. b. On 4/23/24 the call light turned on at 7:20 p.m., and was on for 39 minutes. c. On 4/23/24 the call light turned on at 8:10 p.m., and was on for 24 minutes. d. On 4/23/24 the call light turned on at 9:27 p.m., and was on for 23 minutes. e. On 4/24/24 the call light turned on at 8:45 a.m., and was on for 27 minutes. 4. Interview on 4/24/24 at 9:50 a.m., with Resident #7 revealed she has to wait a long time for her call light to be answered. Resident #7 further revealed she feels there is not enough staff here to take care of her. Review of the facility provided document titled Device Activity Report dated 4/24/24 with report dates from 4/22/24- 4/24/24 revealed the following: a. On 4/22/24 the call light turned on at 8:40 a.m., and was on for 16 minutes. b. On 4/22/24 the call light turned on at 9:03 a.m., and was on for 16 minutes. c. On 4/23/24 the call light turned on at 6:22 p.m., and was on for 20 minutes. d. On 4/24/24 the call light turned on at 7:05 a.m., and was on for 35 minutes. Review of Licensed Nurse Orientation Checklist provided by the facility dated 5/17/23 revealed no call light should go beyond 15 minutes. Interview on 4/25/24 at 10:27 a.m., with Staff A, Assistant Director of Nursing (ADON) revealed she expected call light to be answered in less then 15 minutes.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was covered before leaving the dining area and served to residents in their rooms. The facility identified a census of 75 residents. Findings include: During an ongoing observation on 4/24/24 at 12:04 p.m., in the dining room revealed the following: a. Staff D, Certified Nursing Assistant (CNA) took Resident #10 ' s meal tray to their room. The meal tray left the dining area with the cake and drinks uncovered and exposed as the tray went to Resident #10 ' s room. b. Staff D took Resident #11 ' s meal tray to their room. The meal tray left the dining area with the cake, a cup of ranch dressing and drinks uncovered and exposed as the tray went to Resident #11 ' s room. c. Staff E, CNA took Resident #12 ' s meal tray to their room. The meal tray left the dining area with the juice and coffee uncovered and exposed as the tray went to Resident #12 ' s room. d. Staff F, CNA took Resident #13 ' s meal tray to their room. The meal tray left the dining area with cake, ice water and coffee uncovered and exposed as the tray went to Resident #13 ' s room. e. Staff D took Resident #14 ' s meal tray to their room. The meal tray left the dining area with the cake, juice and milk uncovered and exposed as the tray went to Resident #14 ' s room. Review of the facility provided policy titled Resident Nutrition Services with a revision date of November 2009 revealed if a resident is receiving a room tray, all food and beverages must be covered before transport. Interview on 4/24/24 at 12:17 with Staff B, Dietary Manager revealed she expected all staff to cover all items leaving the dining room area.

Based on clinical record review, staff interviews, and facility record review, the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals (DIA) within 24 hours for 1 of 1 residents reviewed for abuse (Resident #5). The facility reported a census of 75 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of diabetes mellitus, heart failure and arthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Progress Notes dated 3/29/24 at 10:46 p.m., revealed the following note: During the aide report nurse overhears aides talking about a physical altercation involving resident and aide. Aides state that at 2:00 p.m., the report for day shift stated the resident was swinging at the aide and giving her a hard time. Aide also states that it was reported by the resident that the aide hit her. Called the nursing supervisor on call phone and spoke with them regarding the situation. The aide is to work in the morning. On call supervisor states to speak to the aide tomorrow and anyone else who was present and let her know. When the resident was asked about what happened during the day she stated I don't remember we just didn't get along. When asked directly if there was an hitting resident stated no there was no hitting. Review of document titled Interview with Resident #5 dated 4/2/24 revealed feel no hitting of resident took place based on interview with Staff G, Certified Nursing Assistant and Resident #5 also the charting in the Nurses Notes on 3/29/24 support this. Review of facility provided policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 revealed the following: a. All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting allegations of abuse to the administrator or designated designee. b. All allegations of resident abuse shall be reported to the State Agency no later than 2 hours after the allegation is made. c. All allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the State Agency, no later than 2 hours, if the events that cause the allegation result in serious bodily injury, or not later than 24 hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. Interview on 4/25/24 at 11:54 a.m., with the Administrator revealed he does not feel it should have been reported as the resident saying she was not hit when she was directly asked if anyone hit her.

Based on record review, resident and staff interviews, and facility policy review the facility failed to investigate allegations of abuse and separate resident from staff alleged of abuse during the investigation for 1 of 1 resident reviewed (Resident #5). The facility reported a census of 75 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of diabetes mellitus, heart failure and arthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Progress Notes revealed the following note: a. On 3/29/24 at 5:28 p.m., Resident was upset with Certified Nursing Assistant (CNA) as she was talking with her hands. Resident was yelling at staff member and made her upset. Nurse suggested that they use 2 aides while helping resident. b. On 3/29/24 at 10:46 p.m., During the aide report nurse overhears aides talking about a physical altercation involving resident and aide. Aides state that at 2:00 p.m., the report day shift stated that the resident was swinging at the aide and giving her a hard time. Aide also states that it was reported by the resident that the aide hit her. Called the nursing supervisor on-call phone and spoke with them regarding the situation. The aide is to work in the morning. On-call supervisor states to speak to the aide tomorrow and anyone else who was present and let her know. When the resident was asked about what happened during the day she stated I don't remember we just didn't get along. When asked directly if there was an hitting resident stated no there was no hitting. Interview on 4/24/24 at 2:25 p.m., with Staff G, CNA revealed she was assisting Resident #5 to the bathroom and when assisting her back into her wheelchair resident swung at Staff G. When Staff G asked why she swung at her she accused Staff G of hitting her when she was assisting her into the wheelchair. Staff G revealed she went and reported to Staff H, Registered Nurse (RN) that Resident #5 accused her of hitting her and Staff H told her not to go in there and if Staff G had to to make sure that there were 2 staff present. Staff G further revealed she was never suspended or had disciplinary action in regards to this incident. Interview on 4/24/24 at 1:25 p.m., with Staff H, RN revealed no one had reported anything to her on her shift about Resident #5 accusing Staff G of hitting her. Staff H said Staff G talked a lot and used her hands when she talked and Resident #5 was upset with Staff G. Staff H told Staff G to make sure she had 2 people in the room with her as Resident #5 was upset with Staff G. She heard the next day during shift report from Staff I, Licensed Practical Nurse (LPN) that Resident #5 accused Staff G of hitting her. Interview on 4/24/24 at 1:43 p.m., with Staff I, LPN revealed when she came onto her shift she had been told by Staff H, RN that Resident #5 didn't get along with Staff G. Staff I stated she didn't think much of it and went about her duties on her shift and at shift report at 10:00 p.m., overheard the CNA's reporting to the oncoming that Resident #5 had accused Staff G of hitting her. Staff I doubled checked with the CNA giving report and she revealed she had been told by the dayshift Resident #5 accused Staff G of hitting her. Staff I immediately called on-call nursing supervisor Staff J, Registered Nurse. Staff J asked Staff I if she had talked to the resident or the aides. Staff I was directed to talk to the aide when she came in for her morning shift. In the morning the aide told Staff I that she talked with her hands and Resident #5 thought she was swinging at her. Staff I told Staff G to stay away from Resident #5. Staff I reported information off to the dayshift nursing staff to tell Staff J when she came in. Staff I assumed Staff J was coming in to do an investigation into the situation. Interview on 4/24/24 at 3:26 p.m., with Staff J, RN revealed she was called by Staff I and stated that she had overheard the aides giving report and was told Resident #5 accused Staff G of hitting her. Staff J asked Staff I if she had talked to the aides or Resident #5. Staff J advised Staff I to talk to the aide in the morning when she came in. Staff J further revealed if something happened to Resident #5 she would have let everyone know and she had not heard anything about it so she wasn't too worried it happened. Staff J revealed she did not hear back from Staff I or anyone else from the building so she just left it at that. Staff J revealed Staff A, Assistant Director of Nursing had done an investigation on it either Monday or Tuesday after the report of the incident. Interview on 4/24/24 at 3:51 p.m., with the Administrator revealed he thought he knew about the incident but it didn't happen so they didn't do anything further but would check with nursing to see if there was an investigation. Review of document titled Interview with Resident #5 dated 4/2/24 revealed Staff A, ADON interviewed Resident #5. The document revealed feel no hitting of resident took place based on interview with Staff G, Certified Nursing Assistant and Resident #5 also the charting in the Nurses Notes on 3/29/24 support this. Review of document titled Interview of Staff G, CNA dated 4/2/24 revealed Staff A, ADON interviewed Staff G. Staff G talks with her hand and that upset Resident #5. Staff G states that Resident #5 swung at her and also that Resident #5 said she swung at Staff G because Resident #5 thought Staff G was swinging at her. Staff G stated there was no contact between Resident #5 and her other then when Staff G removed the EZ stand sling. Review of untitled document and undated signed by Staff J, RN revealed she had received a call on the on-call nursing cell phone on 3/29/24 at 10:27 p.m., from Staff I, LPN stating she had overheard in CNA report that Staff G had hit Resident #5. She also stated she had overheard Resident #5 had swung at Staff G during cares. Staff J asked if Staff I had talked to the aides or nurses and she states she would talk to them the next morning as the ones that worked on 3/29/24 would be here the next day. Staff J also told Staff I that if Resident #5 would have gotten hit by a CNA she would have made sure the nurses knew it had happened. She is very vocal and in the past if anything happened she told staff right away. Staff I was going to talk with the staff in the morning and let the on-call nurse know. Staff J did not get any updates regarding this after that phone call. It is noted in Resident #5's chart during the day Staff G had taken Resident #5 to the toilet and Staff G talks with her hands and this upset Resident #5 in turn she was yelling at Staff G. Day shift nurse encouraged CNA's to use 2 staff. Staff I spoke with Resident #5 and she has stated that there was no hitting involved. Review of facility provided policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated October 2022 revealed the following: Should an incident or suspected incident of resident abuse be reported or observed, the administrator or his designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident. a. Review documentation in the resident record. b. Assess the resident for injury if the allegation involves physical or sexual abuse. c. Provide proper notification to primary care provider, responsible party, ect. d. Attempt to obtain witness statements (oral and or written) from all known witnesses. e. If there is physical evidence that can be preserved, attempt to do so, and maintain it in a safe location to minimize risk of evidence being tampered with. Following investigation the Administrator or designated agent will be responsible for forwarding the results of the investigation to the State Agency. This written report shall be forwarded to the State Agency within 5 days of the initial report. Initial and or immediate protection during facility investigation revealed upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment the facility shall immediately implement measure to prevent further potential abuse of residents from occuring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following if practicable: 1. Suspending the employee 2. Segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility and in rare instances 3. Separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with residents. Following completion of the facility investigation, if the facility concludes that the allegation of resident abuse are unfounded, the employee may return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the State Agency concludes its investigation and issues the written results of its investigation. Interview on 4/25/24 at 11:54 a.m., with the Administrator revealed he does not feel the staff should have been separated pending investigation since the resident denied being hit by the staff member.

Based on record review and staff interview, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 residents reviewed (Resident #133). Resident #133 had a history of [REDACTED]. to prevent further falls. The resident transferred/ambulated independently, fell and sustained a [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The motion sensor was not on. The facility reported a census of 82 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #133 scored 8 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. The resident required limited assistance with activities of daily living (ADL's) including bed mobility, transfer, ambulation toilet use and personal hygiene. The resident had 2 falls with no injury and 1 fall with a minor injury. An Incident Report dated [DATE] at 8:15 PM documented the resident fell in her room. The resident took her shoes off getting ready for bed. A Diagnostic Imaging report dated [DATE] documented the findings from an x-ray included the resident had left rib fractures, likely rib 7 and 8, possibly including rib 6 as well. An Incident Report dated [DATE] at 1:30 PM documented the resident fell in her room when transferring without assistance. The resident sustained [REDACTED]. A Nursing Home to Hospital Transfer Form dated [DATE] documented the reason for the transfer a gash to the back of the head and goose egg from a fall. A hospital report dated [DATE] documented the resident's after care instructions regarding a laceration included to keep the wound clean and dry. (MONTH) shower and wash hair but do not scrub too hard over the staples, place ice as needed, follow up with family doctor in ,[DATE] days to have staples removed. An Incident Report dated [DATE] at 6:15 PM documented the resident fell in her room transferring without assistance, with no apparent injury. A document dated [DATE] reviewing the incident documented the care plan was updated to have a motion sensor alarm when in her room, take the resident to the toilet before and after meals, and allow time for a bowel movement. A Physician Visit report dated [DATE] documented the resident seen for status [REDACTED]. The progress note documented the resident to have staples removed from scalp laceration and the nurses also noted she had increased confusion and anxiety lately. The Care Plan dated [DATE] identified the resident at risk for falls. The interventions included a motion sensor when in room for safety, offer toilet every ,[DATE] hours while awake, take to the bathroom before and after meals, and allow time for a bowel movement. An Incident Report dated [DATE] at 6:30 PM documented the resident fell in her room self transferring, the motion sensor off. A CNA Quality Assurance Fall and Injury assessment dated [DATE] documented the resident had a fall and found lying on the left side with blood on the floor. The resident self transferred and the motion sensor not on. A History And Physical dated [DATE] documented the resident fell and hit her head sustaining a laceration. She had a lot of pain in the left hip. An x-ray revealed an intertrochanteric [MEDICAL CONDITION] hip. The scalp laceration repaired in the ER. Orthopedics recommended admission and surgical intervention. A Consultation report dated [DATE] documented the recommendations included surgical stabilization to facilitate ambulation and pain relief. The resident had a high risk of morbidity (medical problems) due to the fracture. Leaving her without surgery would likely leave her with worse outcomes and pain. A Discharge Summary dated [DATE] documented the resident fell at the nursing home and found to have a left [MEDICAL CONDITION]. The resident was post-op day 4 from a left hip short gamma nail for fixation. The resident disoriented to time and place. The resident refused most medications by mouth and resisted feeding. The resident tolerated [MEDICATION NAME] for pain. Hospice care discussed. The resident had acute blood loss [MEDICAL CONDITION] in the setting of an open reduction and internal fixation of a left [MEDICAL CONDITION]. The resident's hemoglobin 9.9 on admit, dropping to 6.9 after surgery. The resident received 2 units of blood. A Physical Therapy (PT) Evaluation and Plan of Treatment dated [DATE] documented the resident unable to participate and not appropriate for PT. The resident unable to tolerate any activity and no restorative program indicated. The resident grimaced and yelled when the leg moved. Nurse's Notes documented the following: On [DATE] at 1:07 PM resident readmitted from the hospital. At 1:59 PM the resident did cry out and moan when touched or moved. At 4 PM the resident cried out when touched. On [DATE] at 7:33 AM the resident received [MEDICATION NAME] for moaning. At 10:43 AM the resident received [MEDICATION NAME] for moaning and saying help me. At 11:26 PM the resident unable to rate pain due to cognitive function but moaning and given pain medication. On [DATE] at 12:47 AM as needed pain med given. At 2:52 AM med ineffective, resident given another dose of [MEDICATION NAME]. At 9:24 AM resident given pain med for pain all over. At 11:48 AM [MEDICATION NAME] given for pain all over, moaning out. At 1:52 PM the resident received [MEDICATION NAME] for crying and moaning out. At 5:07 PM the resident received [MEDICATION NAME] for crying out. At 5:44 PM the resident admitted to hospice. At 7:32 PM [MEDICATION NAME] given for pain all over. At 8:03 PM [MEDICATION NAME] given for crying out/restlessness. At 8:31 PM [MEDICATION NAME] given for pain. At 9:37 PM [MEDICATION NAME] given for pain all over. At 11:02 PM [MEDICATION NAME] given for pain all over. On [DATE] at 12:22 AM the resident cried and repeated help me. The resident was restless and moaned with facial grimacing with any movement. At 2:44 AM [MEDICATION NAME] given for pain all over. At 3:53 AM [MEDICATION NAME] given for pain. At 4:51 AM [MEDICATION NAME] given for pain, resident began crying/moaning with repositioning. At 9:34 AM [MEDICATION NAME] given for crying out. At 10:36 AM [MEDICATION NAME] given for pain/crying out. At 11:44 AM [MEDICATION NAME] given for crying out. At 1:17 PM hospice request to give [MEDICATION NAME] every 1 hour and [MEDICATION NAME] every 2 hours to keep comfortable. Staff informed hospice nurse the resident rested comfortably and didn't see any agitation or restlessness. Hospice instructed to hold off on [MEDICATION NAME] unless sees in need, but to keep up with [MEDICATION NAME]. The Nurse's Notes dated [DATE] at 4:23 PM documented the resident died at 4:10 PM. An Employee Counseling/Warning Report dated [DATE] documented Staff A Certified Nursing Assistant (CNA) received an oral warning with written notice related to the resident sustaining a fall in her room at 6:30 PM. The motion sensor was not sounding and turned off. The resident was having loose stools at assessment and the care plan not followed for taking the resident to the restroom after meals and the alarm not on. During an interview by phone on [DATE] at 11:33 AM Staff A (no longer works at the facility) stated she was assigned to the resident's hall the day of the incident ([DATE]). She stated she had asked the resident if she needed to use the bathroom prior to supper. She took a tray to the room and the resident consumed very little. She asked her again if she needed the bathroom and she again said no. She was not sure what time she left the room but was sure she turned the alarm on. She said it was placed near the television (TV) and at an angle. She said it allowed the resident to move in the chair without setting it off, but if she got up it would sound. She said she walked by the resident's room numerous times after that and she was always in the recliner. She reported seeing the resident last when she went by her room with another resident. She said she did not hear an alarm go off, but not sure she would. She said the resident could shut the alarm off herself and staff were aware of it. She said she placed the alarm so it would not be in the resident's reach, but she could have walked a few steps and turned the alarm off. She said she had not heard the resident's alarm sound that shift. She stated she signed the write up because she doesn't like to argue so she just signed it. In a written statement dated [DATE] Staff B, Registered Nurse (RN) documented the resident sat in her recliner when he walked by her room to go do a treatment in another room. When he came out from doing the treatment he heard the resident yelling for help. When he entered the room he saw the resident laying on her left side with her hand up to her head and blood on the floor. He looked at the motion sensor and the switch was in the center position. Additionally he wrote the alarm had sounded earlier in the day. He had seen the resident try to shut the alarm off before, and she laid right in front of the motion sensor. During an interview on [DATE] at 1:27 PM Staff B stated he worked a 12 hour day shift and was getting ready to be off. He had a few treatments he needed to finish up and walked by the resident's room and she sat in the recliner. He went in the other resident's room and shut the door. He did not hear an alarm go off, but did not know if he would. He said the motion sensor alarms were softer. He said the resident did like to shut the alarm off herself and they had it sitting on a table out of reach. When they found her on the floor she was in the general direction of where the alarm sat, rather than toward the bathroom. During an interview on [DATE] at 6:05 AM Staff C, CNA stated he saw the resident in her recliner as he walked down the hall to the other resident's room. It did not appear she needed anything at that time. He did not see the aide working that hall as he walked down to the other resident's room. Not long after he assisted the other resident into bed he heard the nurse yelling for help. He said the resident was on the floor and the resident's alarm was not turned on. He stated he had no knowledge the resident would turn the alarm off herself. He stated the resident would stop if the alarm sounded and would wait for someone. He said the resident would never say no to going to the bathroom. He said he would not force her to go, he would just take her to the bathroom. During an interview on [DATE] at 6:34 AM Staff D, Licensed Practical Nurse (LPN) stated she started the ([DATE]) shift at 6 PM. She did not recall any alarms sounding. She went down A hall with the day shift nurse to look at a skin condition and they passed the resident's room. She sat in the recliner watching TV in no distress. After looking at the skin she went back to the nurse's station and the day shift nurse stayed to do a treatment. While at the nurse's station getting things ready she heard Staff B call her name. She went to the resident's room and she was on the floor. She could see she had a [MEDICAL CONDITION] and would need to be seen in the ER. She said the resident had 3 diarrhea stools before the paramedics arrived. She said the resident could tell you if she needed to go to the bathroom. She said if she had gone to the bathroom earlier, it probably would not have changed the fact she had the loose stools at the time and directly after the fall. She said she thought the resident had turned the alarm off before, but had not actually seen her do it. She had turned the alarm on herself and returned to find it off when no one else had been in the room. She said the alarm was sitting on the TV stand out of reach of the resident when sitting in the chair. She said it would have been about 3 steps away from the recliner and would have been in reach of the resident where she fell . She said she did write the staff member up, although the staff member said she had turned the alarm on. During an interview on [DATE] at 2:43 PM Staff E, RN, Nurse Manager stated she was unsure if the resident could shut the alarm off. She said if she could, they should have notified her so they could look at other interventions to prevent the resident from falling.

Based on observation, record review, staff interview, and facility policy, the facility failed to assure residents received care, consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and prevent new ulcers from developing for 2 of 4 residents reviewed (Residents #1 and #11); and failed to notify a physician in regards to a deteriorated pressure ulcer for 1 of 4 residents with pressure ulcers reviewed (Resident #2). The facility reported a census of 85 residents. Findings include: 1) A Care Area Assessment (CAA) dated 5/11/17 regarding pressure sores documented Resident #1 had a high risk for a heel ulcer. A Care Plan Goals form dated 5/11/17 documented Resident #1 may have skin breakdown or pressure ulcers (including heel ulcers) because of diabetes, [MEDICAL CONDITION], impaired circulation and incontinence. A list of care plan interventions showed the intervention to use heel protectors to both Resident #1's feet while in bed initiated 5/9/17. According to the Minimum Data Set (MDS) assessment, dated 8/4/17 Resident #1 demonstrated long and short term memory problems and moderately impaired skills for daily decision making. Resident #1 required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use, and bathing. Resident #1's [DIAGNOSES REDACTED]. Resident #1 had a risk for developing pressure sores, but had no pressure sores. The MDS defined a Stage 1 pressure ulcer as intact skin with non-blanchable redness of a localized area. A Stage 2 area as partial thickness skin loss of dermis presenting as a shallow crater with a red or pink wound bed without slough, or an intact or open/ruptured serum filled blister. An unstagable pressure ulcer is a known ulcer but not stageable due to coverage of wound bed by slough/eschar (dead tissue). A Braden Scale dated 9/19/17 scored Resident #1 at 14 indicating moderate risk for skin breakdown. A hospital Discharge Summary documented Resident #1 admitted [DATE] and discharged [DATE]. Resident #1 had a history of [REDACTED]. Resident #1 was getting more short of breath and gain 10-15 pounds of weight and appeared to be in an exacerbation of her [MEDICAL CONDITIONS]. Resident #1's [DIAGNOSES REDACTED]. A Readmission assessment dated [DATE] at 1:02 p.m. documented Resident #1 arrived from the hospital at 11:39 a.m. Resident #1 experienced weakness, and transferred with the mechanical lift and 2 assist. Skin problems noted on the readmission did not include any concerns with the heels. Resident Bruise/Skin Tear Injury Reports dated 9/25/17 documented Resident #1 had a fluid filled blister on the right heel measuring 7 by 4.6 cm., and had a red, soft (left ) heel. A Incident Report dated 9/25/17 at 11:25 a.m. documented Resident #1 had a blister, possibly caused by shoes with an insole causing a seam at the heel while in the recliner. A hand written note by Staff F Registered Nurse (RN) dated 9/25/17 documented on reviewing the incident, Resident #1 noted with a fluid filled blister on the right heel, and slightly soft left heel. The resident could not say how it occurred, and denied pain. Resident #1 had a BIMS of 5 (severely impaired cognition) and [DIAGNOSES REDACTED]. He/she took [MEDICATION NAME] and [MEDICATION NAME] which can affect the skin. He/she had a care plan intervention to wear bilateral heel protectors when in bed, but had no heel protectors in his/her room. The Certified Nursing Assistants (CNA's) were provided with a mini inservice to use heel protectors. The care plan not updated, due to non-use of heel protectors. An addendum on 10/13/17 documented the care plan was not followed. Two Mini-Inservice forms dated 9/25/17 regarding 6 p.m. to 6 a.m. shift 9/23/17 and 9/24/17 documented a diabetic resident care planned for heel protectors on both feet while in bed. Resident developed a blister and no heel protectors in his/her room [ROOM NUMBER]/25/17 when blister noted. During an interview on 10/18/17 at 4:05 p.m. Staff F stated they had no boots in Resident #1's room on 9/25/17. One of the CNA's signed the mini inservice form and stated she didn't know Resident #1 needed to wear boots. The other CNA did not sign the form. She heard the CNA wrote a note about it, but did not know what it contained. During an interview on 10/18/17 at 4:15 p.m. the Director of Nursing (DON) stated the other CNA said she did not put the protective boots on (9/23-24/17) because the resident was not care planned for boots. The DON confirmed the boots were on the care plan. Care Plan Change Alerts notified staff of the addition of care plan interventions: a. 9/25/17 No shoes until blister resolved, wear slipper socks, skin prep right heel until resolved, left heel every day. Assure bilateral heel protectors are on in bed. b. 9/26/17 Waffle boot right leg at all times, heel protector to left heel at all times, and continue no shoes until resolved. A fax dated 10/3/17 notified the physician Resident #1's right heel blister revealing a 3 by 2.4 cm reddened area with dark purple/black 0.8 by 3.2 cm with a moderate amount of serous drainage. Non-adherent dressing placed initially, and the current treatment skin prep 2 times a day until healed. Waffle boot on at all times, please advise. The physician responded to consult wound nurse for evaluation and treatment. In a report dated 10/5/17 the wound nurse documented Resident #1 referred for bilateral heel pressure ulcers. The left heel a stage 2 pressure ulcer, with a blister measuring 4 by 2.7 cm. The periwound (surrounding skin) had slight [DIAGNOSES REDACTED] (redness). They would continue with skin prep and keep heels up. The right heel blister with deep tissue injury. The area measured 6 by 4.2 cm. The blister starting to deflate with serous exudate (drainage). Dark purple discoloration at the center measuring 3 by 1 cm. They would continue with skin prep and keep covered with telpha and kling, and continue EHOB (to reduce pressure) boot to keep heels pressure free. A significant change Dietary Note dated 10/9/17 lacked any documentation of Resident #1's pressure ulcers or nutritional needs related to them. During an interview on 10/17/17 at 11:20 a.m. Staff E MDS Coordinator stated she did not know if the dietician assessed Resident #1's nutritional needs. At 11:30 a.m. Staff E stated the dietician had not addressed the pressure ulcers, and did not know if the Dietician had been notified of the pressure ulcers. On 10/18/17, the dietician informed the physician in a note: due to Resident #1's current ulcer, (she) does have increased protein needs and recommended [MEDICATION NAME] BID with lunch and supper. A follow-up on bilateral heel pressure ulcers dated 10/12/17 documented the right heel with an unstagable ulcer. Loose skin from the blister conservatively removed with pickups and scissors. Black eschar noted under the blister measuring 3 by 1 cm. The periwound skin denuded measuring 7 by 4.5 cm. Left heel pressure ulcer, a deflated blister measured 4 by 3 cm with the area drying. New dressing orders received for the right heel and recommended waffle boots bilaterally at all times. Care Plan Change Alerts notified staff of the addition of care plan interventions: c. 10/11/17 bilateral waffle boots at all times, free float heels at all times (including a picture showing a pillow under the legs, not under the heel). d. 10/12/17 discontinue heel protectors. Waffle boots bilaterally at all times. During an observation on 10/17/17 at 1:25 p.m. Staff C RN and Staff D RN provided treatment of [REDACTED]. The right heel had black eschar measuring 2.5 by 1.4 cm and the red open area surrounding it measured 4 by 2.5 cm. The left heel ulcer measured 3.5 by 2 cm brown tissue. During an observation on 10/18/17 at 10:32 a.m. Resident #1 sat in the recliner (by the nurse's station) with a pillow under his/her heels. Staff B Registered Nurse (RN) readjusted Resident #1's waffle boots and pillow so his/her heels free floated, after confirming they were not free floating. During an interview on 10/18/17 at 8:40 a.m. Staff E stated they did not (initially) do the waffle boot on the left foot because (the heel) was just red and blanchable. It did become a Stage 2 and they put waffle boots on both heels (6 days after the wound nurse documented a blister and staged the left heel at a 2). She said they had communication sheets they put out when there were intervention changes (see care plan change alerts previously documented). She said staff were educated when areas developed for not using the heel protectors as care planned. On 10/19/17 at 8:50 a.m. Staff E confirmed Resident #1 did not have a specialty mattress on his/her bed. She said Resident #1 had a standard pressure reduction mattress. During an interview on 10/18/17 at 7:25 a.m. the Dietician stated they did not make her aware of Resident #1's pressure ulcers until yesterday. She stated she would have assessed Resident #1's needs for increased protein/nutrition. A fax dated 10/18/17 notified the physician Resident #1 had increased protein needs due to pressure ulcer. The Dietician recommended 4 ounces liquid with 1 scoop [MEDICATION NAME] 2 times a day with lunch and supper. Dietary staff updated on protein requirements and would offer protein pancakes with a side of eggs at breakfast. The facility policy, Prevention of Pressure Ulcers reviewed 8/15/15 identified the risk factor of immobility and included when in bed every attempt should be made to float heels by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. The facility policy, Pressure Ulcer Risk Assessment reviewed 8/15/15 documented because a resident can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk residents need to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. 2). According to the MDS assessment, dated 6/9/17 Resident #11 scored 7 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #11 required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use, and bathing. Resident #1's [DIAGNOSES REDACTED]. Resident #11 had a risk for developing pressure sores, but had no pressure sores. A facsimile dated 8/2/17 notified the physician Resident #11 readmitted to the facility with a reddened coccyx and bilateral buttocks. The coccyx had a Duoderm on to change 3 times a week. Resident #11 had 2 small open areas to the left hip covered with polymem and tape to change 3 times a week. Bilateral heels were pink. The wound nurse saw Resident #11 on 8/10/17 with recommendations. A progress note dated 10/6/17 documented Resident #11's return from the hospital, from an admission on 9/28/17 for pneumonia. An initial assessment on readmission documented pressure ulcers on admission: a. Right mid buttock redness measuring 0.6 by 0.4 cm stage 2 pressure ulcer. b. Penile meatus with 0.5 by 0.9 cm open ulcer with a white/yellow base. Other skin conditions: a. Left heel, slightly mushy, red intact. b. Right heel mushy intact. c. Entire scrotum red and [MEDICAL CONDITION]. d. Dorsal scrotum with 0.4 by 0.2 cm open area with white/yellow base, and 0.8 by 0.3 cm open area present anterior to the other area. e. Left buttock 13 by 4 cm reddened. f. Right mid buttock reddened 6 by 3.4 cm. The wound nurse saw Resident #11 on 10/12/17 with recommendations. The most recent dietary assessment found for Resident #11 was done on 6/9/17. During an interview on 10/19/17 at 7:55 a.m. the Dietician stated she was not aware of Resident #11's skin issues, and she would have assessed nutritional status if she had known. The facility policy, Prevention of Pressure Ulcers reviewed 8/15/15 identified nutrition. The policy indicated the dietician would assess nutritional status and hydration and make recommendations based on the individual resident assessment. Lab values would be monitored. Administer vitamins, minerals and protein supplements in accordance with physician orders [REDACTED]. 3. According to a [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment with a reference date of 9/29/17, documented Resident #2's Brief Interview Mental status (BIM's score) as an 8, indicating moderate impairment in his/her mental status. The MDS revealed the resident required extensive assistance from staff with bed mobility, transfer, toilet use and personal hygiene and assessed the resident with a Stage 2 pressure ulcer. The MDS identified the resident's admission to the facility as 8/22/17. Review of a skin assessment dated [DATE], revealed the resident had a Stage 1 pressure ulcer on his/her coccyx area. Staff described the area as intact skin, with a 5 by 3 centimeter (cm) deep redness on each inner buttock and an approximate 1 cm of attached rolled skin in the center of the redness. The assessment documented a [MEDICATION NAME] dressing, without tape, covered the area. A Braden Scale (assessment to predict pressure sores) form dated 8/22/17 , revealed staff assessed the resident to be at high risk for skin breakdown. Resident #2's Care Plan, dated 9/1/17, included a problem for a Stage 1 pressure ulcer. The Care Plan included approaches to look at and record the resident's ulcer weekly and let a Physician know if the ulcer got worse or not healing. The Care Plan included an update 10/10/17 with a problem for a Stage 2 pressure ulcer. The approach remained on the care plan to let the Physician know if the pressure ulcer got worse or failed to heal. A facsimile to a Physician dated 8/22/17 (same day as admission to the facility), revealed staff requested the resident's dressing cover over his/her coccyx pressure ulcer be changed from a [MEDICATION NAME] dressing PRN (whenever necessary) to a Duoderm dressing change on bath days (2 times a week) and PRN until healed. According to a facility Pressure Ulcer Treatment form with a review date of 8/15/15 a description of a Stage 1 pressure ulcer included an intact non-blanchable redness, usually over a bony prominence and a description of a Stage 2 pressure ulcer included a partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. Review of weekly skin assessment forms revealed the following: 9/1/17 at 5:52 P.M.- Reddened areas left and right inner buttocks bilaterally. Each area measured the same at 0.9 by 0.3 cm. Staff also noted an open area to his/her bilateral buttock. 9/8/17 at 9:03 P.M.- Staff documented the resident refused any type of assessment and told staff the assessment could be done in the morning. Review of skin assessment forms revealed staff failed to attempt to assess the resident's coccyx area until 9/15/17. 9/15/17 at 9:20 P.M. - Left upper buttock and right upper buttock coccyx measured 0.4 by 0.2 cm. Staff documented the area as healing with fragile tissue noted in the base of the open area. 9/22/17 at 4:10 P.M.- Left upper buttock and right upper buttock coccyx, area is reddened around edges, granulation continues in base, measured 1.4 cm by 0.4 cm and worsening. 9/26/17 at 5:36 P.M. - Left upper buttock and right upper buttock coccyx measured 1.7 cm by 0.3 cm., granulation continues in base. 10/4/17 at 1:46 A.M. - Coccyx ulcer measured 2 by 0.2 cm., staff described the area as moist and light /pale pink in color. 10/6/17 at 10:14 P.M. - Open area on the left upper buttock and right upper buttock, measured 1.9 by 0.3 cm and granulation continued in the base. 10/10/17 at 11:29 P.M. - Coccyx ulcer measured 2.2 by 0.2 cm. 10/13/17 at 8:08 P.M. - Open area left upper buttock and right upper buttock measured 1.9 by 0.2 cm. (Note: During interview on 10/19/17 at 8:00 A.M., the facility Director of Nursing confirmed the times of the skin assessments completed above outside of normal sleep hours re: 11:29 P.M., 1:46 A.M. etc, were documented at the time the nurse documented the skin assessment rather than the time the skin assessment was completed). The resident's pressure ulcer changed from a closed Stage 1 ulcer to an open Stage 2 ulcer and the facility failed to notify the resident's Physician of the change. Review of a Client Coordination Note Report dated 10/14/17, revealed Resident #2 was admitted to Hospice Services. Review of a facsimile to Hospice services dated 10/17/17, revealed nursing staff advised the Hospice staff of the measurements of the resident's coccyx pressure ulcer as 1.9 cm by 0.2 cm and 0.1 cm in depth. A facility Pressure Ulcer Risk Assessment form, with a review date of 8/15/15, included direction for staff to document in the medical record Physician notification if noted a new skin alteration with a change in the plan of care. During interview on 10/17/17 at 1:30 P.M., Staff A, MDS Registered Nurse, stated she notified the facility wound nurse assigned to completed Resident #2's skin assessment and the skin nurse confirmed she had not notified the resident's Doctor in regards to the change in the resident's coccyx pressure ulcer. During interview on 10/17/17 at 3:00 P.M., Staff A confirmed she expected nurses to notify a Resident's doctor if assessed a change in a Resident's pressure ulcer.

Based on record review and staff interviews, the facility failed to ensure Resident #1 was free from abuse. The sample consisted of 4 residents. The facility identified a census of 92 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 6/9/16. Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had behaviors the included Physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others. According to the MDS the resident required limited assistance with bed mobility and toilet use and extensive assistance with transfers. The care plan dated 6/2/16 directed staff to assess for behavior changes and provide moderate stimulation; avoid under stimulation and over stimulation. On 6/13/16 the care plan updated to identify triggers and/or underlying causes of behavior. Review of the form identified as Behavior Record dated 7/19/16 at 5:27 AM revealed the resident had behaviors that included wandering. The interventions included one on one and talking. Review of the Nurses Notes dated 7/19/16 at 4:27 AM revealed the as needed medicated result at 12:04 AM effective with no further complaints. No further medications administered to the resident during the 6:00 PM to 6:00 AM shift. During an interview on 8/12/16 at 10:00 AM with Staff B, CNA (certified nursing assistant) she stated the resident had a tough night on 7/17/16 and required one on one care. The CNAs were taking turns with the resident. She brought the resident to N/W hall with Staff N, LPN (licensed practical nurse) at approximately 1:45 AM. She then brought the resident back to the A/B/C/D hall near Staff I, RN (registered nurse) and explained she did not have time to spend with the resident. Staff I yelled at Staff N. The resident then said What did I do? Staff I told the resident; It's because of you she's (Staff N) treating me this way. The resident stated, But what did I do? . During an interview on 8/12/16 at 10:30 AM with Staff C, CNA she stated at approximately 1:45 AM on 7/19/16, she brought the resident to N/W wing after Staff I instructed her to do so. Staff N brought the resident back to the A/B/C/D wing and told Staff I We're not doing this; you need to spend time with your resident and not send to our end. Staff N went back to N/W wing. Staff I yelled at the resident. You go right over there, your causing problems . The resident wheeled his/her chair to the table and sat with the CNAs. Staff C stated she informed the resident that she would report this to administration tomorrow. On 8/16/16 at 4:45 PM, the DON (Director of Nursing) was interviewed and stated Staff C reported the incident the morning of 7/19/16. The DON stated after the night shift was completed and confirmed she did not receive a phone call at home of the incident. The DON stated she started the investigation and suspended Staff N on 7/19/16. On 8/16/16 at 6:20 AM, Staff J, RN (Registered Nurse), was interviewed and stated she sat at the nurse ' s station and oriented another nurse who had not been in the area. Staff N brought the resident to the A/B/C/D unit and told Staff I she needed to take care of her resident and she needed to go into the unit. That sparked friction between the 2 nurses and Staff I returned to D unit. The resident ' s anxiety increased and said What did I do? Staff N told the resident to be quiet; you ' re causing problems on the other end and now go over there. The resident then sat with the CNAs. On 8/23/16 at 12:40 PM, Staff N, LPN (licensed practical nurse), was interviewed and stated the staff brought the resident to her unit (N/W) to look after. Staff N stated she did not have time because she had to go to the dementia unit and did not want to leave the resident alone. She brought the resident back to A/B/C/D unit and told Staff I she needed to go to the dementia unit. Staff I yelled at Staff N and said What is your problem tonight? You've had an attitude towards me. Staff N felt it all had been directed towards her and not the resident. There were 3 other staff members there at the time, and she felt the resident had been safe. Staff N did not want to cause a bigger problem and walked away. She further stated she did not hear Staff I say anything to the resident and did not know about it until after her shift the following morning.