Every finding on record at Story Medical Senior Care

Based on clinical record review, staff interviews, family interview and policy review, the facility failed to complete a thorough investigation and take steps to ensure resident safety after alleged abuse for 1 of 3 residents reviewed for abuse (Resident #1). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented diagnoses to include debility, cardiorespiratory conditions, heart failure, renal insufficiency, diabetes mellitus, unspecified macular degeneration, anxiety disorder and depression. The resident was dependent on toileting hygiene and required substantial/maximal assistance with toilet transfer. The Care Plan for Resident #1, revised on 4/11/25, included a focus area: resident unable to complete Activities of Daily Living (ADL's) independently. The Care Plan instructed staff under interventions: the resident required an assistance of 1 staff into the bathroom to transfer to the toilet and the resident has very poor eyesight and wears glasses. She uses a lighted magnifying lens. When staff enter her room, she prefers staff to tell her their name, so she knows who she is talking to.Review of facility document Grievance Form dated 7/20/25 (Sunday), for Resident #1, completed by Staff A, Registered Nurse (RN), documented a family member reported that resident said someone that works there and it does not happen very often, pushes her, shoves her and yells at her and they get into shouting matches sometimes. Resident unable to say who it was but did say they sounded young. Under the Facility follow up section of the document, investigation by staff: Staff B, Director of Households, to talk to the resident. The section Findings of Dept. Heads documented see attached sheets. The section Follow Up Action Taken documented: 5 minute meeting about appropriate approaches, education to staff both facility and agency. The document was signed by Staff B and the Administrator on 7/22/25. Review of the attached sheets to the Grievance Form, undated, documented Staff B followed up with Resident #1 about how the weekend went, the resident stated well, it was good until I got into a yelling match with a CNA (Certified Nursing Assistant). Staff B documented the resident made it a point to say that she did all of the yelling, that the CNA didn't yell. She told Staff B that it happened on Saturday, during the day, unfortunately she is unable to identify who the CNA was. She said that the CNA entered her room saying, Well, I don't know your routine which made the resident mad/sad/feel bad. The resident told Staff B that she was shoved and plopped down on the toilet. The resident stated, well, maybe she didn't mean anything by it, maybe she didn't know how she made me feel, it's all over now, I'm not worrying about it, nothing like this has ever happened before. Staff B then asked the resident other than this incident, do you feel safe here to which the resident replied yes, I like most of the people that work here. Staff B documented she followed up with the resident and the Power of Attorney (POA) about the reported grievance from the weekend. The resident reported there was a misunderstanding between her and a staff member, she felt the CNA was a little rough with her and the CNA also stated to the resident she was new and did not know the resident's routine. There is no further documentation by Staff B related to the grievance. The additional sheets attached to the Grievance form included interviews of 11 residents on the unit where Resident #1 resided, no documentation as to who is conducting the interviews, and an email sent by Staff A to the DON, the Administrator, Household Coordinator and Household mentors, dated 7/20/25 at 4:16 PM. The email included what was reported to Staff A by the family member regarding Resident #1. The email documented Staff A was in with the resident a few times in the morning and once in the afternoon and there was nothing said about this. The resident was upset this morning when Staff A went over there because no one answered her light, it had been 16 minutes. At 4:00 PM, Staff A went to the resident's room to follow up to see how she was feeling, a CNA was in the bathroom with the resident getting ready to assist to the bathroom, Staff A asked resident how she was feeling or if there was anything she could get for her. The resident denied any needs at this time, was smiling and said still had some nausea but much better. During an interview 10/13/25 at 12:30 PM, the Administrator stated Staff A, RN, followed up on 7/20/25 after being informed by the family member of the concerns of abuse to Resident #1 by contacting the Director of Nursing (DON) and by going to see the resident who said she was good and had no concerns. The facility followed up with their full investigation starting on Monday, the 21st of July, 2025. The resident was never able to say who the staff person was, she said she was the one who yelled at the staff when the staff came into her room and said she did not know the resident's routine, which upset the resident. The resident did not know exactly when it happened, but thought it was on Saturday, the 19th of July. The facility had an agency staff working on the unit where the resident resides on that Saturday (the 19 of July), a CNA, Staff C. During their investigation they did not interview Staff C, separate Staff C from the resident or interview other staff working that day. They narrowed it down that it was more than likely Staff C Resident #1 was referring to. The Administrator stated a report was not made to the State Agency regarding the reported concerns of abuse to Resident #1. The Administrator acknowledged the facility did not interview any staff during their investigation into the reported concerns. During an interview 10/13/25 at 12:40 PM, Staff B, Director of Households, stated she followed up on the reported concern with Resident #1, she interviewed the resident on 7/21/25. Staff B stated residents on the unit where Resident #1 resided in July who had a BIMS 13 and over were interviewed on 7/20/25 and 7/21/25. Staff B stated neither she nor other team members interviewed staff working that weekend, she stated there was an agency staff working that weekend as well. Staff B stated the resident does not do well with strangers and she does not like it when staff do not know her routine. Staff B stated she was notified of the grievance regarding Resident #1 on the 21st of July, 2025. On that date, she interviewed the resident who said she yelled at a Certified Nursing Assistant (CNA) over the weekend when she was asked how her weekend went. She said she was the one who yelled at the CNA. The resident stated there was a misunderstanding between her and a staff member, she said she yelled at a CNA, it was on Saturday, but she did not know who the CNA was. She said the CNA entered her room and said she did not know her routine and this upset the resident. The resident told Staff B she was shoved and plopped on the toilet, and then said maybe she (the staff) did not know how it made her feel, and then said she isn't worried about it and said nothing like this happened before and she was over it. Staff B stated she did not question the resident more about her statement that she was shoved and plopped on the toilet, but asked her about feeling safe. Staff B stated she had an intention of following up with the resident with regard to her statement of being shoved and plopped on the toilet, however this did not take place. Staff B stated she believed the resident had the impression she was shoved and plopped, but did not believe that is what happened as the resident said maybe the staff did not know how she made her feel. The resident advised Staff B the incident took place on Saturday of that weekend, the 19th of July. Staff B acknowledged there are no dates or times on her documentation related to the grievance and facility investigation. Staff B acknowledged staff were not interviewed related to the reported concern in the grievance. During an interview 10/13/25 at 1:45 PM, Staff A, RN, stated she recalled working on the 20th of July, she was the RN and charge nurse working a 6:00 AM to 6:00 PM shift. A family member of Resident #1 came up to her (unsure the exact time, but it was right around lunch time) and started yelling and swearing. The family member told her that Resident #1 just reported she had been pushed by a staff member, the family member did not know who the staff member was. Staff A stated she went to check on the resident and she was good and did not need anything. Staff A stated the resident cannot see well and can get frustrated with staff at times, she has yelled at staff before. Staff A stated she did not hear any staff yell at the resident, however she was not working on the unit where the resident resides that weekend. The resident did not report to Staff A that anything happened to her by a staff member, however Staff A did not interview the resident about the reported concern. Staff A did not know the specific time the family member came to her to report the concerns, she said it was after lunch, around 1:30 PM. Staff A then contacted the DON by phone. The DON instructed her to fill out a grievance form and assess the resident. Staff A went down to the resident's room later in the afternoon, at 4:00 PM, and asked her if she was okay and if she needed anything. The resident said she was okay, she was smiling. Staff C was assisting the resident in the bathroom one of the times Staff A went to check on the resident, this was after the report was made to Staff A by the family member. During an interview 10/13/25 at 2:00 PM, the Administrator and DON stated Resident #1 does not like it when a new staff member comes into her room, or someone she does not know. She does not like it when staff say they are new and say they do not know her routine. The Administrator and DON stated they believed Staff B was going to follow up with the resident again later in the week. They thought she did. The Administrator acknowledged there is no further documentation of another follow up to the resident's statement to Staff B that she was shoved and plopped down on the toilet. The Administrator stated an expectation this kind of statement is followed up on, and reported if needed. The Administrator acknowledged there needed to be a more thorough investigation and better documentation. The Administrator stated the facility did not make a self report to the State agency regarding the reported concerns. They did not separate the resident from any staff. The Administrator stated they care planned not to have agency staff work with the resident. Review of the Care Plan for Resident #1 revealed a lack of intervention or planning to include agency staff not providing care or working with the resident. Review of the staffing schedule for the 19th and 20th of July 2025 revealed Staff C worked on the 19th from 6:00 AM to 10:00 PM on the unit where Resident #1 resided. On the 20th of July Staff C worked a 6:00 AM to 2:00 PM shift on the unit where the resident resided. Further review of the staffing schedule for July and August of 2025 revealed Staff C worked at the facility on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/25/25, 7/28/25, 7/29/25, 7/30/25, 7/31/25, 8/1/25, 8/4/25, 8/5/25, 8/6/25, 8/7/25, 8/12/25, 8/13/25, 8/14/25, 8/15/25, 8/18/25, 8/19/25, 8/20/25, 8/21/25, 8/22/25, 8/25/25 and 8/26/25. These additional dates were not on the unit where Resident #1 resided. During an interview 10/14/25 at 10:00 AM, the DON stated she received a telephone call from Staff A on 7/20/25 (unsure of the exact time) advising her that the family came to her and said something happened with a staff member where she talked loudly to Resident #1, but it was not recently. The DON stated she instructed Staff A to do education with staff to go slow with the resident and that staff did not need to talk loudly to her because she can hear. She instructed Staff A to fill out the grievance form and then to send an email to the team about the situation. The DON stated she read the email the next morning from Staff A which included the family member stating the resident said she was shoved, pushed and yelled at by a staff member. The DON then had Staff B go talk to the resident. The DON stated she also instructed Staff A to check on the resident on 7/20/21. The DON stated she would have done things differently if she knew up front that there was a report of the resident being pushed and shoved and yelled at, she would have called the Administrator and discussed other steps. The DON stated an understanding that if there are suspected abuse concerns with a staff member, steps need to be taken to ensure the resident's safety and a report of suspected abuse would need to be made to the State within two hours. The DON stated after reading the email the following morning and noting the report of a staff member at the facility pushed, shoved and yelled at the resident, she had Staff B interview the resident. The DON acknowledged a report was not made to the State agency regarding the resident stating she was shoved, pushed and yelled at by a staff member. The DON acknowledged staff were not interviewed, including Staff C, and no other steps were taken regarding the reported concerns of suspected abuse. Review of the Electronic Health Record (EHR) revealed 14 of the 21 residents on the unit where Resident #2 resided in July of 2025 required assistance of 1 or more staff for completion of cares, such as toileting and transferring. During an interview 10/14/25 at 10:30 AM, a family member of Resident #1 stated on 7/20/25 a visit took place at the facility with the resident, in the early afternoon. While the family member stepped out of the resident's room, the resident talked to another family member still in the room. When the family member returned to the room, the resident was crying and holding the hand of the other family member. The family member asked if everything was okay and the other family member said something happened. The resident then stated a CNA was mean to her and yelled at her, they got into a yelling match. The resident said she had used her call light to go to the bathroom and when the CNA came into her room she had gone in her brief. She said the CNA screamed that she had to clean up the resident. The resident said the CNA jerked her up out of her recliner chair and the resident yelled at her that she was hurting her. The resident said the CNA pushed her back into her chair. The family member asked the resident who the CNA was, the resident said she did not know her name, it was a staff member who did not work at the facility very often. The resident told the family member the CNA then got her up out of the recliner and took her to the bathroom and then dropped her down on the toilet. The resident said she told the CNA she was hurting her and the CNA yelled at her. The family member asked the resident more questions about the staff member and the resident said she had been working over the past few days, but did not work there very often. The resident said it happened within the last day or two. The family member said the resident was crying while reporting what happened. The resident said maybe the staff member was having a bad day and didn't know what she was doing, the resident said she felt helpless. The family member went to find the charge nurse and reported this to the charge nurse. Review of the facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, with a revision date of November 2024, documented it shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. The facility will identify, through ongoing assessment, high-risk situations where abuse, neglect, or misappropriation of resident property may occur and provide appropriate intervention in such occasions. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring 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.

Based on clinical record review, staff interviews, family interview and policy review, the facility failed to report an allegation of alleged abuse to the State survey and certification agency for 1 of 3 residents reviewed for abuse (Resident #1). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented diagnoses to include debility, cardiorespiratory conditions, heart failure, renal insufficiency, diabetes mellitus, unspecified macular degeneration, anxiety disorder and depression. The resident was dependent on toileting hygiene and required substantial/maximal assistance with toilet transfer. The Care Plan for Resident #1, revised on 4/11/25, included a focus area: resident unable to complete Activities of Daily Living (ADL's) independently. The Care Plan instructed staff under interventions: the resident required assistance of 1 staff into the bathroom to transfer to the toilet and the resident has very poor eyesight and wears glasses. She uses a lighted magnifying lens. When staff enter her room, she prefers staff to tell her their name, so she knows who she is talking to.Review of facility document Grievance Form dated 7/20/25 (Sunday), for Resident #1, completed by Staff A, Registered Nurse (RN), documented a family member reported that resident said someone that works there and it does not happen very often, pushes her, shoves her and yells at her and they get into shouting matches sometimes. Resident unable to say who it was but did say they sounded young. Under the Facility follow up section of the document, investigation by staff: Staff B, Director of Households, to talk to the resident. The section Findings of Dept. Heads documented see attached sheets. The section Follow Up Action Taken documented: 5 minute meeting about appropriate approaches, education to staff both facility and agency. The document was signed by Staff B and the Administrator on 7/22/25. Review of the attached sheets to the Grievance Form, undated, documented Staff B followed up with Resident #1 about how the weekend went, the resident stated well, it was good until I got into a yelling match with a CNA (Certified Nursing Assistant). Staff B documented the resident made it a point to say that she did all of the yelling, that the CNA didn't yell. She told Staff B that it happened on Saturday, during the day, unfortunately she is unable to identify who the CNA was. She said that the CNA entered her room saying, Well, I don't know your routine which made the resident mad/sad/feel bad. The resident told Staff B that she was shoved and plopped down on the toilet. The resident stated, well, maybe she didn't mean anything by it, maybe she didn't know how she made me feel, it's all over now, I'm not worrying about it, nothing like this has ever happened before. Staff B then asked the resident other than this incident, do you feel safe here to which the resident replied yes, I like most of the people that work here. Staff B documented she followed up with the resident and the Power of Attorney (POA) about the reported grievance from the weekend. The resident reported there was a misunderstanding between her and a staff member, she felt the CNA was a little rough with her and the CNA also stated to the resident she was new and did not know the resident's routine. There is no further documentation by Staff B related to the grievance. The additional sheets attached to the Grievance form included interviews of 11 residents on the unit where Resident #1 resided, no documentation as to who is conducting the interviews, dated 7/21/25 and 7/22/25, and an email sent by Staff A to the DON, the Administrator, Household Coordinator and Household mentors, dated 7/20/25 at 4:16 PM. The email included what was reported to Staff A by the family member regarding Resident #1. The email documented Staff A was in with the resident a few times in the morning and once in the afternoon and there was nothing said about this. The resident was upset this morning when Staff A went over there because no one answered her light, it had been 16 minutes. At 4:00 PM, Staff A went to the resident's room to follow up to see how she was feeling, a CNA was in the bathroom with the resident getting ready to assist to the bathroom, Staff A asked resident how she was feeling or if there was anything she could get for her. The resident denied any needs at this time, was smiling and said still had some nausea but much better. During an interview on 10/13/25 at 12:30 PM, the Administrator stated Staff A followed up on 7/20/25 after being informed by the family member of the concerns of abuse to Resident #1 by contacting the Director of Nursing (DON) and by going to see the resident who said she was good and had no concerns. The facility followed up with their full investigation starting on Monday, the 21st of July, 2025. The resident was never able to say who the staff person was, she said she was the one who yelled at the staff when the staff came into her room and said she did not know the resident's routine, which upset the resident. The resident did not know exactly when it happened, but thought it was on Saturday, the 19th of July. The facility had an agency staff working on the unit where the resident resides on that Saturday (the 19 of July), a CNA, Staff C. During their investigation they did not interview Staff C, separate Staff C from the resident or interview other staff working that day. They narrowed it down that it was more than likely Staff C Resident #1 was referring to. The Administrator stated a report was not made to the State Agency regarding the reported concerns of abuse to Resident #1. During an interview on 10/13/25 at 12:40 PM, Staff B, Director of Households, stated she followed up on the reported concern with Resident #1, she interviewed the resident on 7/21/25. Staff B stated residents on the unit where Resident #1 resided in July who had a BIMS of 13 and over were interviewed on 7/21/25 and 7/22/25. Staff B stated neither she nor other team members interviewed staff working that weekend, she stated there was an agency staff working that weekend as well. Staff B stated the resident does not do well with strangers and she does not like it when staff do not know her routine. Staff B stated she was notified of the grievance regarding Resident #1 on the 21st of July 2025. On that date, she interviewed the resident who said she yelled at a Certified Nursing Assistant (CNA) over the weekend when she was asked how her weekend went. She said she was the one who yelled at the CNA. The resident stated there was a misunderstanding between her and a staff member, she said she yelled at a CNA, it was on Saturday, but she did not know who the CNA was. She said the CNA entered her room and said she did not know her routine and this upset the resident. The resident told Staff B she was shoved and plopped on the toilet, and then said maybe she (the staff) did not know how it made her feel, and then said she isn't worried about it and said nothing like this happened before and she was over it. Staff B stated she did not question the resident more about her statement that she was shoved and plopped on the toilet, but asked her about feeling safe. Staff B stated she had an intention of following up with the resident with regard to her statement of being shoved and plopped on the toilet, however this did not take place. Staff B stated she believed the resident had the impression she was shoved and plopped, but did not believe that is what happened as the resident said maybe the staff did not know how she made her feel. The resident advised Staff B the incident took place on Saturday of that weekend, the 19th of July. Staff B acknowledged there are no dates or times on her documentation related to the grievance and facility investigation. Staff B acknowledged staff were not interviewed related to the reported concern in the grievance. During an interview on 10/13/25 at 1:45 PM, Staff A stated she recalled working on the 20th of July, she was the RN and charge nurse working a 6:00 AM to 6:00 PM shift. A family member of Resident #1 came up to her (unsure the exact time, but it was right around lunch time) and started yelling and swearing. The family member told her that Resident #1 just reported she had been pushed by a staff member, the family member did not know who the staff member was. Staff A stated she went to check on the resident and she was good and did not need anything. Staff A stated the resident cannot see well and can get frustrated with staff at times, she has yelled at staff before. Staff A stated she did not hear any staff yell at the resident, however she was not working on the unit where the resident resides that weekend. The resident did not report to Staff A that anything happened to her by a staff member, however Staff A did not interview the resident about the reported concern. Staff A did not know the specific time the family member came to her to report the concerns, she said it was after lunch, around 1:30 PM. Staff A then contacted the DON by phone. The DON instructed her to fill out a grievance form and assess the resident. Staff A went down to the resident's room later in the afternoon, at 4:00 PM, and asked her if she was okay and if she needed anything. The resident said she was okay, she was smiling. Staff C was assisting the resident in the bathroom one of the times Staff A went to check on the resident, this was after the report was made to Staff A by the family member. During an interview on 10/13/25 at 2:00 PM, the Administrator and DON stated Resident #1 does not like it when a new staff member comes into her room, or someone she does not know. She does not like it when staff say they are new and say they do not know her routine. The Administrator and DON stated they believed Staff B was going to follow up with the resident again later in the week. They thought she did. The Administrator acknowledged there is no further documentation of another follow up to the resident's statement to Staff B that she was shoved and plopped down on the toilet. The Administrator stated an expectation this kind of statement is followed up on, and reported if needed. The Administrator acknowledged there needed to be a more thorough investigation and better documentation. The Administrator stated the facility did not make a self report to the State agency regarding the reported concerns. They did not separate the resident from any staff. The Administrator stated they care planned not to have agency staff work with the resident. Review of the staffing schedule for the 19th and 20th of July 2025 revealed Staff C worked on the 19th from 6:00 AM to 10:00 PM on the unit where Resident #1 resided. On the 20th of July Staff C worked a 6:00 AM to 2:00 PM shift. During an interview on 10/14/25 at 10:00 AM, the DON stated she received a telephone call from Staff A on 7/20/25 (unsure of the exact time) advising her that the family came to her and said something happened with a staff member where she talked loudly to Resident #1, but it was not recently. The DON stated she instructed Staff A to do education with staff to go slow with the resident and that staff did not need to talk loudly to her because she can hear. She instructed Staff A to fill out the grievance form and then to send an email to the team about the situation. The DON stated she read the email the next morning from Staff A which included the family member stating the resident said she was shoved, pushed and yelled at by a staff member. The DON then had Staff B go talk to the resident. The DON stated she also instructed Staff A to check on the resident on 7/20/25. The DON stated she would have done things differently if she knew up front that there was a report of the resident being pushed and shoved and yelled at, she would have called the Administrator and discussed other steps. The DON stated an understanding that if there are suspected abuse concerns with a staff member, steps need to be taken to ensure the resident's safety and a report of suspected abuse would need to be made to the State within two hours. The DON stated after reading the email the following morning and noting the report of a staff member at the facility pushed, shoved and yelled at the resident, she had Staff B interview the resident. The DON acknowledged a report was not made to the State agency regarding the resident stating she was shoved, pushed and yelled at by a staff member. During an interview on 10/14/25 at 10:30 AM, a family member of Resident #1 stated on 7/20/25 a visit took place at the facility with the resident, in the early afternoon. While the family member stepped out of the resident's room, the resident talked to another family member still in the room. When the family member returned to the room, the resident was crying and holding the hand of the other family member. The family member asked if everything was okay and the other family member said something happened. The resident then stated a CNA was mean to her and yelled at her, they got into a yelling match. The resident said she had used her call light to go to the bathroom and when the CNA came into her room she had gone in her brief. She said the CNA screamed that she had to clean up the resident. The resident said the CNA jerked her up out of her recliner chair and the resident yelled at her that she was hurting her. The resident said the CNA pushed her back into her chair. The family member asked the resident who the CNA was, the resident said she did not know her name, it was a staff member who did not work at the facility very often. The resident told the family member the CNA then got her up out of the recliner and took her to the bathroom and then dropped her down on the toilet. The resident said she told the CNA she was hurting her and the CNA yelled at her. The family member asked the resident more questions about the staff member and the resident said she had been working over the past few days, but did not work there very often. The resident said it happened within the last day or two. The family member said the resident was crying while reporting what happened. The resident said maybe the staff member was having a bad day and didn't know what she was doing, the resident said she felt helpless. The family member went to find the charge nurse and reported this to the charge nurse. Review of the facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, with a revision date of November 2024, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. 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 (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Based on clinical record review, staff interview and policy review, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASSR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis and initiation of a psychotropic medication (Resident #17). The facility reported a census of 54 residents. Findings include: Resident #17's Minimum Data Set (MDS) assessment dated [DATE] included a diagnosis of delusional disorder. The MDS reflected Resident #17 received an antidepressant on a routine basis during the lookback period. The Care Plan initiated 5/24/24 indicated Resident #17 received the antidepressant Lexapro due to his diagnosis of delusions and anxiety. The Care Plan goal indicated Resident #17 would not have any adverse effects from the medication. Resident #17's Medical Diagnoses reviewed 4/1/25 included a diagnosis of delusional disorders effective 5/24/24. Resident #17's PASRR completed 9/25/23 listed a completed negative Level 1 screening. The PASRR lacked documentation of a known o r suspected mental health diagnosis. The clinical record lacked a Level II PASRR evaluation submission following the new mental health diagnosis of delusional disorder effective 5/24/24. The PASSR Screens/Level I and Level II Evals policy, revised November 2024 directed changes in status are required when a resident receives a new mental health diagnosis. During an interview 4/1/25 at 2:23 PM the Director of Nursing (DON) acknowledged she had not completed a Level II evaluation for Resident #17 with her new diagnosis of delusional disorder and initiation of Lexapro (antidepressant). During an interview 4/2/25 at 1:40 PM the Administrator revealed the expectation that a Level II PASSR evaluation needed to be submitted for residents with a significant change, psychotropic medication change or a new diagnosis related to mental health.

Based on personnel file review, facility policy, and staff interview, the facility failed to assure 3 of 5 staff met the requirements for Mandatory Adult Abuse Training (Staff D, Staff E, and Staff F). The facility reported a census for 48 residents. Findings include: The New Hires Since Last Survey Form provided by the facility listed the following staff with hire dates: a. Staff D, Certified Nursing Assistant (CNA): 5/22/23. b. Staff E, Food Nutrition Services (FNS): 6/13/23. c. Staff F, FNS: 7/7/23. Staff D's personnel file lacked a two-hour Dependent Adult Abuse Mandatory Reporter Training until 1/24/24. Staff D's Dependent Adult Abuse Mandatory Reporter Training required completion by 11/22/23. Staff E's personnel file lacked a completed two-hour Dependent Adult Abuse Mandatory Reporter. Staff E's Dependent Adult Abuse Mandatory Reporter Training required completion by 12/13/23. Staff F's personnel file review lacked a 2-hour Dependent Adult Abuse Mandatory Reporter training. Staff F's Dependent Adult Abuse Mandatory Reporter Training required completion by 1/7/24. Th Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, reviewed 5/23/23, instructed each employee required an initial two-hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse within six months of hire for each employee. In an interview on 5/8/24 at 5:07 PM the Administrator acknowledged they expected each staff member receive Dependent Adult Abuse Mandatory Reporter training within 6 months of their hire date.

Based on observation, facility staff interview, and facility policy the facility failed to meet professional standards of food service sanitation during meal service. The facility reported a census of 48. Findings include: On 5/8/24 at 11:45 AM during an observation of the meal service on first floor dining room, witnessed Staff B, Cook, remove the stainless steel covering off the food and placed the lids upright, alongside the cabinet, behind the steam table. The lids touched the floor. Interview on 5/8/24 at 12:30 PM Staff A, Dietitian, reported the covers are usually set alongside the food on the table. Staff B didn't place the lids appropriately. Staff A explained the Dietary Manager ensured training on food service and sanitation. Interview on 5/8/24 at 5:00 PM with the Administrator who said the staff should keep the lids sanitary and not touch the floor. Interview on 5/9/24 at 8:30 AM Staff B explained the steam table didn't have enough room for the lids and she didn't know where else to place them. Interview on 5/9/24 at 8:47 AM Staff C, Certified Dietary Manager (CDM), reported the staff should keep the lids on the steam table and if there is not room, she expected them to place them back in the hot box. The Infection Control Plan, Department, Food Nutritional Services policy revised 4/7/23 identified employee orientation included safe food handling procedures and prevention of cross contamination.

Based on observations, staff interviews, and clinical record reviews, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 12 residents reviewed (Residents #34) for administration of medications and supplements. The facility reported a census of 46 residents. Findings include: Resident #34's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. Resident #34's MDS included diagnoses of cancer, gangrene (death of tissue due to infection or lack of blood flow), and necrosis (dying tissue) of the lung. On 2/1/23 at 10:48 a.m. observed Staff D, Licensed Practical Nurse (LPN), providing an Ipratropium Bromide HFA (Atrovent inhaler) to Resident #34. Staff D administered the inhaler to Resident #34. Resident #34 took one puff from the inhaler, exhaled, then took the second puff within 5 seconds of the first. Staff D did not wait the manufacturer's recommended 15 seconds between the two puffs. On 2/1/23 at 11:36 AM, Staff D verbalized there should be a couple of minutes between each inhaled puff when administering oral inhalers. Staff D also stated that she did not believe Resident #34 received an accurate amount of the inhaler medication. During an interview on 2/2/23 at 7:45 AM, Staff E, LPN, verbalized the process of administering oral inhaler medications as shaking the medication to mix the contents, count to 3 to alert the resident when to inhale, wait a second, then repeat shaking the medication and counting to 3 to alert the resident when to inhale. Afterwards rinse the resident's mouth out with water. On 2/2/23 at 8:15 AM, the Director of Nursing (DON) revealed the facility did not have a policy about inhaler administration but provided a data sheet from the pharmacist dated 2/1/23 at 5:09 PM. A Physician ' s Order dated 10/24/22 for Ipratropium Bromide HFA instructed to provide 2 puffs inhaled orally four times per day related to a personal history of nicotine dependence. Resident #34's electronic medication record (EMAR) for January 2023 and February 2023 listed that he received the Ipratropium Bromide HFA inhaler four times per day. On 2/2/23 at 9:09 AM the DON explained that she expected the staff administering oral inhalers to follow the manufacturer's instructions, such as rinse out the resident's mouth after using steroid inhalers and clean with an alcohol swab when finished.

Based on observations, staff interview, clinical record review, and policy review the facility failed to provide appropriate catheter care for 1 of 1 residents reviewed (Resident #41) to prevent urinary tract infections. The facility placed Resident #41 ' s catheter bag on a garbage can and on the floor. The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #41 dated 1/16/23 identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified that Resident #41 required extensive assistance of one person with bed mobility, toilet use, and extensive assistance of two persons with transfers. The MDS indicated Resident #41 had an indwelling catheter. Resident #41's MDS included diagnoses of benign prostatic hyperplasia, obstructive uropathy, renal disease, and feeling of incomplete bladder emptying. The Care Plan revised 1/20/23 identified Resident #41 required an indwelling foley catheter due to the inability to empty the bladder. A Physician Order dated 10/12/22 instructed to change the indwelling urinary catheter monthly and as needed for build up, leakage, and pain. On 1/30/23 at 1:02 p.m. observed Resident #41 ' s catheter bag in a dignity bag placed on the side of a garbage can next to the recliner. On 1/31/23 at 1:23 p.m. observed Resident 41 ' s catheter bag in a dignity bag placed on the side of a garbage can next to the recliner. On 2/1/23 at 8:55 a.m. watched Staff B, Certified Nursing Assistant (CNA), and Staff C, CNA, assist Resident #41 from the wheelchair to the edge of the bed using a sit to stand lift. Staff A removed the catheter bag without a dignity bag from the sit to stand machine and placed the catheter bag along with the catheter tubing directly on the floor. Staff A then picked up the catheter bag and tubing off the floor, and placed the catheter bag into a dignity bag hanging on the edge of the bed. No one cleaned or disinfected the catheter bag and tubing after being on the floor. A facility policy titled Catheter Care effective date April 2019 stated the purpose of the policy was to prevent infection and reduce irritation. The policy directed staff to place the catheter bag inside the dignity bag and keep it off the floor. During an interview on 2/1/23 at 9:15 a.m. the Director of Nursing (DON), agreed the catheter bag and tubing should not be on the floor or placed on the garbage can.The DON reported she would provide education to the staff.

Based on clinical record review, staff interview, and policy review the facility failed to review and revise care plans for 1 of 13 residents reviewed (Residents #34). The facility reported a census of 46 residents. Findings include: Resident #34 ' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7, indicating moderately impaired cognition. The MDS identified Resident #34 required extensive assistance of one person with bed mobility, transfers, ambulation and toilet use. The MDS indicated Resident #34 used a walker and a wheelchair. The MDS included diagnoses of cancer, anemia, Alzheimer's disease, and anxiety disorder. A Physician Order dated 1/16/23 directed staff to administer lorazepam, (Ativan) an antianxiety medication, 0.25 ml (milliliters) by mouth at bedtime for increased anxiety related to malignant neoplasm (cancerous abnormal growth of tissue) of the esophagus. Review of Resident #34 ' s Comprehensive Care Plan dated 1/9/23 lacked the use of an antianxiety medication, potential side effects, and what to monitor for while taking the high risk medication. The facility policy titled Care Plan- Comprehensive effective April 2019 stated it is the policy of the facility to develop a comprehensive person centered Care Plan for each resident that included measurable objectives and timetables to meet the resident ' s medical, nursing, and psychosocial needs. The policy further stated Care Plans are revised as changes in the resident ' s condition dictate. During an interview on 1/31/23 at 2:30 p.m. Staff A, MDS Coordinator/Assistant Director of Nursing, verified Ativan was not addressed on the Care Plan and agreed that it should be. Staff A stated she would add it to the Care Plan.

Based on clinical record review, staff interview, and policy review the facility failed to complete assessments before and after outpatient hemodialysis treatments for 1 of 1 resident reviewed that required dialysis (Resident #28). The facility reported a census of 46 residents. Finding include: The Minimum Data Set (MDS) assessment for Resident #28 dated 12/19/22 identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #28 as independent with bed mobility, transfers and toilet usage. The MDS indicated Resident #28 received dialysis while a resident at the facility. Resident #28 ' s MDS included diagnoses of stage four chronic kidney disease and dependence on renal dialysis. The Care Plan revised 12/23/22 identified a need for hemodialysis (the process of running the blood through an external machine to rid the blood of toxins) on Mondays, Wednesdays, and Fridays. The Care Plan directed the staff to weigh Resident #28 per doctor ' s orders, assist Resident #28 to get ready for dialysis, and to only use the right arm for blood pressure readings. Resident #28 ' s January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to direct staff to complete a daily assessment or pre/post hemodialysis assessments on Mondays, Wednesdays, and Fridays. Review of 2023 calendar revealed Resident #28 should have attended hemodialysis on the following dates in January 2023: 1/2/23, 1/4/23, 1/6/23, 1/9/23, 1/11/23, 1/13/23, 1/16/23, 1/18/23, 1/20/23, 1/23/23, 1/25/23, 1/27/23, and 1/30/23. The clinical record lacked documentation of a completed pre and post dialysis assessmentfor Resident #28 on the following dates: 1/2/23- pre and post 1/4/23- pre and post 1/9/23- pre and post 1/11/23- pre and post 1/13/23- post 1/16/23- pre and post 1/18/23- pre and post 1/23/23- pre and post 1/25/23- pre and post 1/27/23- pre and post 1/30/23- pre and post Review of the documentation in the clinic record revealed no dialysis evaluation on non-dialysis days in the month of January 2023. Review of facility policy titled Dialysis Policy effective April 2019 stated the facility will ensure that residents who receive dialysis are provided care and assistance, consistent with professional standards. The policy directed staff to complete ongoing assessments that included vital signs with site checks prior to leaving and upon return from dialysis. During an interview on 2/1/23 at 4:26 p.m. the Director of Nursing (DON) acknowledged that Resident #28 ' s pre and post dialysis assessments did not get completed consistently.

Based on observations and staff interviews, facility staff failed to store drugs in accordance with currently accepted professional practices, in one of two medication (med) carts (Hall 200). The facility reported a census of 50 residents. Findings include: 1. Observation on [DATE] at 08:05 AM revealed an outdated stock supply of acetaminophen (Tylenol). The bottle contained an open date of [DATE] written with black marker. The manufacturer's labeled expiration date was stamped as [DATE]. The bottle was labeled by the manufacturer as having 1000 tablets packaged. Approximately 50 tablets remained in the bottle when observed. On [DATE] at 08:07 AM, Staff A confirmed the stock bottle of acetaminophen contained an expiration date of [DATE] and should be removed from the cart. Staff A then stepped to the phone on the wall next to the med cart and called the pharmacy to request a replacement bottle. Staff A then placed the expired bottle in the medication room on Hall 200 for disposal. On [DATE] at 08:42 AM the DON (Director of Nursing) stated it is common nursing knowledge to check for expiration dates. On [DATE] at 09:01 AM, the Associate Administrator reported there is no facility policy addressing the inspection of medications for outdates. She stated it is best nursing practice to monitor outdates and discard medications as indicated.

Based on observation, staff interview, and record and policy review the facility failed to provide appropriate incontinence care for one (Resident #24) of three residents reviewed. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) for Resident #24, dated 7/12/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident was total dependence on two staff for bed mobility, transfers, dressing, and toilet use. The MDS identified the resident as always incontinent of urine and bowel. The MDS identified the resident as rarely/never understood and no BIMS (Brief Interview for Mental Status) test performed, indicating severe cognitive impairment. Observation showed on 8/25/21 at 9:07 AM, Staff D, Certified Nurse's Aide (CNA) and Staff E, CNA apply hand sanitizer and gloves. With resident lying in bed, Staff D, CNA and Staff E, CNA lowered resident's pants, brief, and acknowledged brief was wet. Staff D, CNA wiped between the perineal area and right leg/thigh with a wipe, then wiped between the perineal area and left leg/thigh with the same wipe and same side of the wipe. Staff D, CNA used a new wipe for each swipe to cleanse the middle perineal area, right hip, and both buttocks. Staff D, CNA failed to cleanse the left hip. Staff E, CNA applied new brief while Staff D, CNA removed gloves, applied hand sanitizer, and donned new gloves. Staff D and Staff E, CNA pulled up resident's pants, transferred resident to wheelchair, doffed gloves, and washed hands. Review of facility policy titled Perineal Care, dated 11/30/17, documented: a. Separate labia and wash with peri wash/soap and water from front to back toward rectum. Use a new section of the washcloth for each stroke, repeating strokes until the area is clean. b. Wash the outer labia and inner thighs the same way, with front to back strokes using a clean washcloth. The policy did not direct staff to wash the hips. On 8/31/21 at 11:05 AM, the Associate Administrator stated she expected staff to use 1 swipe with each wipe and to cleanse the hips with incontinent care.

Based on observation, record review and staff interview the facility failed to follow the physician ordered treatment to a Stage II pressure ulcer for one (Resident #26) of three residents reviewed. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #26 dated 7/19/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident needed extensive assist of 1 staff for transfers, dressing, toilet use and personal hygiene, with extensive assist of 2 staff for bed mobility. The MDS documented the resident with an unhealed pressure ulcer and at risk of developing pressure ulcers. A Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment for decision-making. The State Operations Manual identified a Stage II pressure sore as: Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [CONDITION(S)], intertriginous [CONDITION(S)] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Resident's skin evaluation dated 3/11/2021 documented: Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: left lateral foot Pressure Ulcer / Injury Stage: Stage II - Partial thickness skin loss. Length: .8 Width: 1 Depth: 1 millimeter (mm) Wound Bed: Necrotic. Wound Exudate: None. Peri Wound Condition: WNL (within normal limits). Dressing Saturation: None. No wound odor. No tunneling. No undermining. Tissue: Painful. Physician's progress note for resident, dated 3/11/21, documented lower extremity ulcer located on left lateral foot. Physician's progress note for resident, dated 8/26/21, documented lower extremity ulcer located on left lateral foot. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Left foot: Puracol (collagen dressing to promote natural healing while absorbing the wound drainage) to lateral foot wound, 4X4 gauze, abdominal pad (ABD), kerlix (dressing wrap), coban (sticky dressing wrap to hold dressing in place). Observation showed on 8/30/21 at 9:34 AM, Staff A, Licensed Practical Nurse (LPN) washed hands, donned gloves, and on left foot cleansed 3 toes and lateral wound with wound wash. Staff A, LPN doffed gloves, washed hands, donned new gloves, and applied [MEDICATION(S)], 2 X 2 gauze, and tube gauze on the 3 toe wounds. Staff A, LPN applied [MEDICATION(S)] and ABD pad to left lateral foot wound and wrapped with kerlix and coban. Staff A, LPN removed gloves and washed hands. Staff A, LPN failed to apply Puracol to left lateral foot ulcer as ordered. On 9/01/21 at 1:59 PM, the Director of Nursing identified the left lateral wound as a pressure ulcer. On 9/01/21 at 12:25 PM, the Associate Administrator stated she expected staff to follow physicians orders.

Based on record review and staff interview the facility failed to update the resident's care plan with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #26 dated 7/19/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident received an antidepressant and had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment for decision-making. Resident #26's Order Summary Report dated 6/28/21, contained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26's care plan, with last review date of 7/23/21, lacked documentation of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The MDS assessment for Resident #27 dated 7/19/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident received an antidepressant and had a BIMS score of 11, indicating moderate cognitive impairment for decision-making. Resident #27's Order Summary Report dated 6/28/21, contained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27's care plan with last review date of 7/23/21, lacked documentation of new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 3. On 8/31/21 at 11:05 AM, the Associate Administrator stated she expected staff to update care plans with new antidepressant medication orders.

Based on clinical record review and staff interview the facility failed to develop a care plan to address pain medication, goals and interventions for 1 out of 18 sampled residents reviewed for comprehensive care plans (Resident #25). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 showed the Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. The MDS documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] revealed Resident #25 received pain medication 7 out of 7 days during the review period. An Order Summary Report dated 8/26/21 revealed the following orders signed by the physician: a. [MEDICATION(S)] (muscle relaxant for pain caused by muscle stiffness and tightness). Give one tablet by mouth three times a day with a start date of 1/14/21. b. [MEDICATION(S)] (used to treat nerve pain) 600 mg. Give one tablet by mouth three times a day with a start date of 1/14/19. c. [MEDICATION(S)]-Acetaminophen Tablet (used for pain) 5/325 mg. Give one tablet by mouth every 8 hours as needed for pain and fever with a start date of 1/14/21. d. Tylenol Capsule 325 mg. Give 2 capsules by mouth every 8 hours as needed for pain, fever/ e. Tylenol Tablet 325 mg. Give 650 mg by mouth at bedtime for shoulder pain, chronic pain related to pain to the left knee and age related [CONDITION(S)]. f. Assess pain every shift using the 1-10 pain scale or the Wong Baker Faces pain scale three times a day per policy with a start date of 5/7/21. The care plan last revised on 7/22/21 lacked any documentation pertaining to the residents usage, goals, and interventions related to pain. On 08/31/21 at 12:20 PM, Associate Administrator, Director of Nursing (DON) and Assistant DON, confirmed the care plan should contain information regarding pain medications, goals and interventions. On 09/01/2021 at 10:01 AM, Associate Administrator stated they developed a process to track medications for care plans and staff is currently working to update the care plans using this process.

Based on personnel and policy review and staff interview, the facility failed to request a Department of Human Services (DHS) evaluation for misdemeanor convictions, with a finding of guilty by a court of law, for 2 of 5 employees reviewed. The facility reported a census of 50 residents. Findings include: 1. Employee records documented a start date of 03/10/20 for Staff B, cook. Staff B's SING (Single Contact License and Background Check) dated 02/26/20 revealed the need for further research for criminal history. An undated Criminal History Record Check Request Form was submitted to the DCI (Department of Criminal Investigations) The results dated 03/02/2020 documented 4 arrests and convictions including 1st and 2nd OWI and 2 convictions of Possession of Controlled Substances. There was no documentation of a DHS submission for review and determination of eligibility for hire. 2. Employee records documented a start date of 01/30/20 for Staff C, LPN (licensed practical nurse). Staff C's SING report dated 01/22/20 revealed the need for further research for criminal history. Staff C signed a Record Check Evaluation request dated 01/28/19. The Associate Administrator stated HR informed her the 1/28/19 date was a typo and reflected the Record Check Evaluation request for the date of hire of 01/30/20. An Iowa Record Check Result dated 01/27/20 documented a Misdemeanor conviction of Criminal Mischief 5th Degree. There was no documentation of a DHS submission for review and determination of eligibility for hire. 3. On 09/01/21 at 11:50 AM the associate Administrator stated Human Resources (HR) could not provide any documentation of the the DHS findings from the record check evaluation requests for Staff B and Staff C. She stated the prior HR director was terminated and the new HR director in place since March 2021 and stated the current practices are to receive the DHS findings and determination before hiring an employee. The Associate Administrator stated she expected the HR department to complete all required background checks and clearances prior to hire. 4. The facility policy titled Background Checks, effective 12/01/17 directed the facility to conduct background checks in order to determine if individuals should not be granted employment. It instructed that DHS would evaluate and determine the employee's eligibility for continued employment.

Based on observation, clinical record review and staff interview, the facility failed to follow proper infection control technique in order to prevent infection for three residents observed. (Resident #3, #38 & #17) The facility census was 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment date 10/28/19, documented Resident #3 had [DIAGNOSES REDACTED]. During a nebulizer breathing treatment on 11/6/19 at 11:10 a.m., observation revealed the oxygen tubing and breathing mask were not dated to reveal when the items were last replaced. During interview at the time, Staff F, Certified Medication Aide, CMA stated she was not sure of how the tubing and mask was labeled to identify when they were replaced with new ones. During interview on 11/6/19 at 11:50 a.m., the Director of Nursing (DON) stated the mask and tubing are changed out the 7th and 23rd of each month and acknowledged they should have been dated on 10/23/19 when done. 2. The Admission Record Face Sheet for Resident #17 listed a [DIAGNOSES REDACTED]. During observation of a blood sugar check on 11/4/19 at 11:00 a.m., Staff G, Licensed Practical Nurse, LPN entered Resident #17's room to check a blood sugar using the unit glucometer. Staff G did not place a barrier underneath the machine when she laid it on the sink counter in the resident's room before obtaining blood sample. After the blood sample was obtained on the glucose strip, Staff G set the glucometer back on the sink while she obtained a cotton ball and then carried the glucometer to the med cart and laid it down without a barrier under it. Staff G removed her gloves and sanitized her hands. Staff G wiped only the front of the glucometer off with a Clorox bleach wipe. Staff G went on to complete the next resident's blood sugar check (Resident #38). Upon return to the medication cart Staff G placed the glucometer on top of the medication cart without a barrier underneath it. Staff G wiped off the glucometer with a Clorox Bleach wipe before placing it back in the glucometer case and putting it away in the medication cart. Review of a document labeled Equipment Cleaning with a revision date of 2/22/18 directed if the Accu check machine (glucometer) was brought into a patient/client room the portion of the machine that had come into contact with the patient/resident was to be cleansed. Care is used to avoid all window portions of the Accu check machine. Alcohol swabs or Stat III sheets may be used on the interior portion of the Accu check machine. During interview on 11/6/19 at 4:15 p.m., Staff H and Staff L, Registered Nurses, stated nurses are expected to clean the entire glucometer with the Oxivir wipes between each resident's use. Staff L stated the facility does not specifically require the use of a barrier under the glucometer during use. During interview on 11/7/19 at 8:30 a.m., the Administrator stated the facility has not had Stat III wipes for a long time and part of the Equipment Cleaning policy must have gotten overlooked. She stated the glucometers are to be disinfected with the facility approved Oxyvir wipes and not Clorox Bleach wipes.

Based on observation and staff interview, the facility failed to ensure dietary staff secured their hair properly while in the food service area. The facility census was 62 residents. Findings include: During observation of the noon meal service 11/4/19 from 11:45 a.m. to 12:20 p.m., Staff B, Dietary Aide was wearing a black uniform-type hat that partially covered the top of their head. Approximately 4 inches of hair (bangs over forehead) was unrestrained and uncovered. Staff B had an approximate 12 inch long braid of hair down her back, uncovered. During interview on 11/7/19 at 9:15 a.m., Staff I stated bangs, ponytails and braids should be covered with a hairnet as well.

Based on observation, clinical record review and staff interview, the facility failed to complete an assessment for a significant change for one of 18 residents reviewed. (Resident #6) The facility census was 62 residents. Findings include: 1. The Minimum Data Set (MDS) completed 5/6/19 documented [DIAGNOSES REDACTED]. The MDS documented the resident needed extensive assistance of one person for dressing and bathing, and was continent of both bowel and bladder function. A Brief Interview for Mental Status (BIMS) score of 15 out of 15 documented no cognitive impairment for decision-making. Review of the MDS with a completion date of 8/5/19, listed [DIAGNOSES REDACTED]. The MDS documented the resident needed extensive assistance of one person with transfers, bed mobility, ambulation in the room, dressing, toileting and personal hygiene. Ambulation outside of the room did not occur during the seven day assessment period. The MDS documented the resident as totally dependent on one person for locomotion off of the unit and as being frequently incontinent of bladder. The resident's health record did not reveal a completion of an MDS for the resident's significant change in physical ability. During interview on 11/5/19 at 3:30 p.m., Staff H, MDS Coordinator, stated the resident had fallen in the time period between (MONTH) 2019 and (MONTH) 2019 and they were not sure if she was going to get back up to her usual level of independence again. Staff H stated Physical Therapy had completed an evaluation and deemed her as being able to be independent in her room. The MDS nurse reviewed Physical Therapy notes brought to the surveyor which revealed documentation on 8/1/19 that the resident's rehab program was on hold at that time. Staff H acknowledged she had missed completing the significant change MDS in August.

Based on clinical record review and staff interview, the facility failed to provide notice to the resident and/or representative of the facility's bed-hold policy prior to and upon transfer to the hospital for one of three residents reviewed. (Residents #55) The facility census was 62 residents. Findings include: 1. Clinical record review lacked documentation of notification to Resident #55 or family regarding bed-hold when the resident transferred to the hospital on [DATE]. During interview on 11/6/19 at 10:48 a.m., the Director of Senior Care stated they did not have a bed hold notification for the discharge and did not implement the bed hold policy until 2/21/19.

Based on observation, clinical record review and staff interviews, the facility failed to provide adequate supervision to ensure one residents safety resulting in the resident eloping from the facility without staff knowledge. (Resident #1) The facility census was 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The plan of care dated 8/7/17, revealed the resident had disturbed thought processes with intermittent confusion but did not wandering until 9/18/18 when staff applied a wanderguard bracelet on the resident. Progress Notes dated 9/28/18 at 12:10 a.m., revealed staff found the resident outside knocking on the first floor dining room window. Staff A went outside and escorted the resident back into the facility. The notes indicated the resident was dressed in a night gown with a long sleeve shirt under it and gripper socks. The nurse applied a wanderguard bracelet to the resident's left ankle. During interview on 11/14/18 at 10:30 a.m., Staff A, certified nurse aide, stated she was working in the dining room setting up for breakfast on 9/27 at about 11:45 p.m. while in the dining room she heard a knocking on the large dining room window. Staff A observed the resident outside knocking on the window. Staff A ran thru the front door and escorted the resident back into the facility. During interview on 11/14/18 at 10:00 a.m., Staff B, licensed practical nurse, LPN stated she worked as the charge nurse the night of 9/27 until the morning of 9/28/18. Staff B was alerted of the residents elopement after the incident occurred. Staff B came to the unit and assessed the resident and the dining room exit doors. At 2:00 a.m., Staff B found the right side of the double exit door slightly ajar and a piece of white translucent tape over the alarm to silence it. Staff B removed the tape from the right door jam and pulled the door shut. Staff B stated she assumed this was how the resident eloped from the facility but could not be certain. During interview on 11/14/18 at 11:15 a.m., the Assistant Director of Nurses reviewed the video clip of the resident attempting to get into the building. She believed the resident spent approximately 20 minutes in the vestibule of the main building entrance before she exited and knocked on the dining room windows. During interview on 11/8/18 at 2:30 p.m., the Director of Nurses, DON stated the main floor dining room right side exit door was found slightly ajar with a piece of tape over the alarm sensor. She did not know how long the alarm had been silenced or who put the tape over the alarm sensor. The DON stated the resident eloped from the facility sometime after 10:00 p.m. on 9/27/18, staff found the resident outside the dining room, knocking on the window. The resident was clothed in a long sleeve white shirt under her pink nightgown and with gripper socks on. The DON stated staff were checking the door alarms daily but since the elopement has increased the door alarm checks to every shift, initiated on 9/27/18. The (MONTH) (YEAR) every shift door alarm audits revealed staff failed to check door alarms on 10 shifts, review of the (MONTH) (YEAR) door alarm check form on 11/8/18 revealed staff failed to complete the daily door alarm checks 3 shifts from 11/1-11/8/18.

Based on observations, interviews, record reviews and the Food & Drug Administration's Guide, the facility failed to ensure the correct dimensions were used on the bed rails to prevent entrapment for 15 out 59 bed rails, which resulted in an immediate jeopardy. (Residents #15, 18, 44, 47, and 54 were specific residents who resided in beds which had the incorrect dimension for bed rails). Facility reported a census of 62. Findings include: 1. Observation on [DATE] at 10:30 a.m. nine of the thirty-four resident beds on the second, floor unit contained bed rails that failed to meet the federal requirements for safety. The rooms included; ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE],,[DATE], and 227. Observation on [DATE] at 11:30 a.m. six of the twenty-five resident beds on the first floor unit contained bed rails that failed to meet the federal requirements for safety. The rooms included; ,[DATE], 103, 104, ,[DATE], 109, and ,[DATE]. Review of the Food & Drug Administration's (FDA) Hospital Bed Safety Workgroup (HBSW) article, Clinical Guidance For the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated (MONTH) 2003, indicated, impertinent part, Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team .Bed rail use for patient's mobility and/or transferring, for example, turning and positioning within the bed and providing a hand-hold for getting into of out of bed, should be accompanied by a care plan .Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment of patient needs, considering all relevant risk factors .If it is determined that bed rails are required .the mattress and bed. Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist item .should be ongoing. According to the FDA's Guidance for Industry and FDA Staff article, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued [DATE], For [AGE] years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment' describes an event in which a patient/resident is caught, trapped or entangled in the in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. FDA received appropriately 691 entrapment reports over a period of [AGE] years from (MONTH) 1, 1985 to (MONTH) 1,2006. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. These entrapment events have occurred in opening within the bed rails, and between the bed rails and head or footboards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement Entrapments have occurred in a variety of patient care settings. A. The FDA recommended dimensional limit for zones 1 through 4, and suggested if any alternative approach be least stringent as the ones describe below: a. Zone 1- within the rail. Zone 1 is any open space within the perimeter of the rail. Opening in the should be small enough to prevent the head from entering. The recommend space is less than 4 and ,[DATE] inches, representing head breath. The HBSW considers a resident to be at high risk to injury when he or she cannot move safely from a bed to a wheelchair, cannot move safely from the toilet without assistance, had previous entrapment episode, had previous bed-related injuries, or had fallen from a bed, or had difficulties using call alarms. 2. The Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. According to the MDS the resident scored a fourteen out of fifteen on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS indicated the resident required extensive assistance with one staff for bed mobility, transfer, and toilet use. The care plan with a problem onset date of [DATE] revealed the resident has potential for injury related to weakness and forgetfulness. Interventions include left side rail (upper) to assist resident with repositioning while in bed. A Bed Rail/Assist Bar Evaluation dated [DATE] revealed the residents uses the side rails to promote independence while in bed for assistance and repositioning. An observation on [DATE] at 10:39 PM Resident # 15's bedrails looked larger than the required dimensions. 3. The MDS dated [DATE], identified [DIAGNOSES REDACTED]. According to the MDS the resident scored a fifteen out of fifteen on the BIMS indicating intact cognition. The MDS indicated the resident was independent with bed mobility and transfers but required extensive assistance of one staff for toilet use. The care plan with a problem onset of [DATE] revealed the resident had potential for injury from falls related to mobility issues, obesity, arthritis, and pain. Interventions include side rails up at head of bed (HOB) to assist with repositioning when in bed. A Bed Rail/Assist Bar Evaluation dated [DATE] revealed the resident uses half rails on the left, right, and head. Observation on [DATE] at 11:13 AM, Resident # 54 noted laying in bed with bilateral upper side rails up and the bottom left side rail up. The bed rail appeared larger than required. 4.The quarterly MDS dated [DATE] for Resident # 18 included [DIAGNOSES REDACTED]. The MDS reported a BIMS score of 9 out of 15 a score of ,[DATE] indicated moderately impaired cognition for daily decision making. Resident #18's Care Plan dated [DATE] included a problem for potential for injury related to a history of frequent falls and included an intervention for use of side rails to be up on both sides at the head of the bed to assist with positioning when in bed. The facilities Bed Rail Assist Bar Evaluation dated [DATE] reported Resident #18 requested bed rail while in bed and they were an enabler to promote independence. During an observation on [DATE] at 10:49 AM revealed Resident # 18 had ,[DATE] side rails at the head of her bed that the openings looked larger than allowed for safety. 5. The quarterly MDS dated [DATE] for Resident #44 included [DIAGNOSES REDACTED]. The MDS reported a BIMS score of 14 out of 15 a score of ,[DATE] indicated intact cognition for daily decision making. Resident #44's Care Plan dated [DATE] included a problem for potential injury related to history of falls and increased weakness with decreased safety awareness. The care plan lacked an intervention to use side rails. The facilities Bed Rail Risk Data Collection Tool dated [DATE] for Resident #44 listed he used the side rails for assisting with repositioning. The form contained information that there is a risk for a resident to trap their head, neck or limbs between the mattress and the bed frame or mattress or bedrail. When the resident is in the bed, the gap must be smaller than: 4 ¾ inches inside the rail under the rail and between the rail and the mattress. The facilities Bed Rail Assist Bar Evaluation dated [DATE] reported that Resident #44 had requested bed rail while in bed and they were indicated and served as an enabler to promote independence. During an observation on [DATE] at 11:57 AM the bed rails in Resident #44's room were larger than allowed for safety. During an interview on [DATE] at 3:15 PM with Resident #44 explained he became upset with staff over the bedrails. Resident #44 acknowledged he had fallen before and the bedrails gave him boundaries he further explained the facility is working on getting a new bed for him. 6. A quarterly MDS dated [DATE] for Resident #47 reflected a BIMS score of 9 which was indicative of mild cognitive impairment. Bed mobility how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture is coded which indicated the resident was independent with set up help only. [DIAGNOSES REDACTED]. The care plan dated [DATE] reflected siderails were to be up on both sides to assist resident with repositioning. The bed rail assist evaluation dated [DATE], summary of findings reflected resident used siderails to assist with repositioning. The bed rail risk data collection tool dated [DATE] reflected side rails were requested by resident for positioning assistance. The resident used siderails at the head of bed for repositioning while in bed to promote independence. The bed rail safety noted there was a risk for a resident to trap head, neck or limbs between the mattress and the bed frame or mattress or bedrail. When the resident was in bed, the gap must be smaller than: 4 ,[DATE] inches inside the rail, under the rail and between the rail and the mattress or 2 ,[DATE] inches at the end of the rail between the rail and the headboard or footboard. An observation on [DATE] at 10:30 AM, the side rails on the bed were larger than requirements. The measurements were 7 inches wide x 7 inches long x 9 inches diagonal. During a telephone call with CEO (Chief Executive Officer) of the hospital and DON (Director of Nursing) on [DATE] at 1:37PM, they agreed 15 beds out of 59 total beds were out of compliance and measuring 7 inches wide by 7 inches long by 9 inches diagonal. The maintenance staff was notified to rectify the situation and will notify us when completed. An invoice was submitted dated [DATE] for the purchase of 6 beds and those beds have not arrived. An interview with the DON on [DATE] at 3:15 PM acknowledged a plan had been submitted to the Board of Directors for the purchase of beds that would meet federal regulations. The Board approved the purchase of 6 beds. On [DATE], the facility abated the immediate jeopardy (IJ) after all 15 beds had the bottom rails removed and top two rails have been zip-tied under the bed frame so staff would not be able to raise. The facility submitted a purchase order for 3 additional new bed frames to the 6 already ordered. These findings lowered the IJ from a K severity level to an E with ongoing monitoring to ensure facility monitors dimensions of bed rails.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff utilized assistive devices as planned for one of five residents reviewed for proper/safe transfers. (Resident #15). The facility census was 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #15 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident utilized a walker and wheelchair for mobility devices. The care plan dated 5/23/18, revealed the resident had the potential for injury related to weakness and forgetfulness. Interventions included to keep the call light within reach, transfer with assistance of one and proper footwear. A care tool undated documented the resident required the assistance of one for transfers. The fall risk assessment indicated a resident with a score of 10 or greater would be at high risk for falls. The fall risk assessment dated [DATE], documented the resident scored an 18, indicating they were at high risk for fall. Observation during tour on 8/20/18 at 11:07 a.m., revealed the resident laying on floor with staff present. At 11:11 a.m., the director of nursing stated the resident fell and had pain and paramedics were enroute. Progress notes dated 8/20/18 at 10:55 a.m, documented Staff A, certified nurses aide, CNA stated she needed Staff B, license practical nurse, LPN in the resident's room. The resident was lying on her right side, beside the bed and Staff A stated the resident was holding onto the end of the bed and she started to fall. Staff A could not quite reach the resident. Both the resident and Staff A stated the resident did not hit her head. The resident complained of right hip pain. Staff B placed a pillow under the residents head and the resident slid herself to her back. Staff B noted the resident's right foot rotated outward. A call was placed to the physician and an order was obtained to transfer the resident to the emergency room . An incident report dated 8/20/18 at 10:55 a.m., revealed the resident had a witnessed fall. Staff A reported the resident was holding on to the end of the bed and Staff A reached for the garbage can and the resident stated her right knee gave out so she started to fall and Staff A could not quite reach her and the resident landed on her right side on the floor. The resident complained of right hip pain. The incident report revealed the intervention was to complete immediate education with Staff A regarding the use of gait belt on every resident who was not care planned as independent. A radiology report dated 8/20/18, revealed a displaced right femoral neck fracture with mild angulation. During interview on 8/22/18 at 1:32 p.m., Staff A, CNA stated the resident had her call light on and when she entered the room the resident was seated in her recliner. Staff A stated the resident needed to get her brief changed and she assisted the resident to stand and did not use a gait belt or any assistive device. The resident was standing at the end of the bed and Staff A left the resident standing there and went to get the garbage can. Staff A stated after she obtained the garbage can she noticed the resident falling. Staff A verified no gait belt was used and stated she was told by other staff that she did not need a gait belt. Staff A stated if she had a question about a resident and how they transferred she asked other staff. During interview on 8/22/18 at 1:47 p.m., Staff B, LPN indicated she was the charge nurse on duty at the time of Resident #15's fall on 8/20/18. Staff B entered the resident's room and found the resident laying sideways on her right side towards the end of the bed. Staff B stated the resident rolled herself to her back and staff placed a pillow under the resident's head. The resident was complaining of right hip pain. Staff B stated there was no gait belt around the resident. Staff B stated the CNA's have a care tool available to them that indicates each resident and how they transfer. The pocket care plans are updated as needed with any changes. Staff B stated Resident #15 requires assist of one staff and gait belt for transfers. In an interview on 8/23/18 at 9:46 a.m., the director of nursing, DON verified Staff A did not use a gait belt while transferring the resident on Monday, 8/20/18. The DON stated it was the standard of care for staff to use a gait belt for all residents requiring assistance with transfers and ambulation. The DON stated CNA's have a care tool available for reference and the care tools are updated as needed. The DON would expect staff to reference the care tool if questions regarding the transfer technique and expected all staff to use a gait belt while transferring and ambulating residents who require assistance. A policy titled Use of Gait Belt on Senior Care dated 11/30/17, revealed gait belts are to be used for all transfers and ambulation activities that require assistance. Gait belts will be provided to each employee upon initial hire and additional gait belt will be stored in the nurse's station on each floor. Each staff member shall have a gait belt on their person. The purpose is to transfer and ambulate residents in a safe manner for both residents and employees and to prevent injuries from falls, sprains and strains from lifting. The policy procedures indicate to explain the procedure to the resident. When transferring or walking a resident, the belt shall be placed snugly around the resident's waist and securely fastened. Avoid lifting resident's by placing your hands under their arms or around their waist. Use the gait belt to provide a handle for secure grip and greater control.

Based on record review and staff interviews, the facility failed to adequately assess a resident with a change of condition following a fall and failed to provide appropriate interventions (Resident #2). The staff found Resident #2 on the floor. The nurse did not adequately assess the resident and had the nursing assistants transfer the resident with a mechanical lift to bed. The sample consisted of 4 residents and the facility reported a census of 60 residents. Findings include: 1. Resident#1 had a MDS (Minimum Data Set) assessment with a reference date of 12/28/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated Resident #2 experienced a fall since admission to the facility on [DATE] but had no injury. The Care Plan, initiated 12/22/15, identified the resident to be at risk for injury due to dementia and forgetting to remember his/her walker. The Care Plan had interventions which included and directed the staff to utilize a personal and floor mat alarm and ensure proper functioning of the alarms. The Physical Therapy notes, dated 1/6/16, indicated Resident #2 had gone downhill significantly since his/her prior visit. On 1/21/16 the physical therapist discontinued services with goals met and noted Resident #2 required assistance of one staff for activities of daily living. The Nurse's Notes dated 2/19/16 at 7:23 a.m. (recorded) indicated the staff responded to a sounding alarm and discovered Resident #2 in his/her room lying on right side on the floor between the bed and bathroom. Resident #2 complained of right hip pain when the nurse palpated (touched) the hip. The staff transferred Resident #2 into bed with the use of a mechanical lift and the nurse administered Tylenol ([MEDICATION NAME]) 650 milligrams for pain. The Nurse's Note indicated at 6:15 a.m. the facility had the resident transferred via ambulance to the hospital emergency room . The resident's neurological checks and vital signs (pulse temperature, blood pressure, respirations, remained within normal limits. The record did not reflect the nurse had performed a complete assessment (range of motion, to extremities, external or internal rotation of leg, lengthening or shortening of extremities or a complete pain assessment). A hospital History and Physical report dated 2/19/16, indicated Resident #2 climbed out of bed at 4:30 a.m., fell and sustained a [MEDICAL CONDITION] which required surgical intervention. On 3/9/16 at 6:15 a.m. Staff J, certified nursing assistant (CNA) stated at approximately 4:25 a.m. she and Staff K, CNA, completed cares and exited a resident's room. Upon entering the hallway, she heard an alarm sounding and ran towards Resident #2's room. Resident #2 was lying on his/her left side facing the bathroom. The bed alarm sounded, however, the floor alarm did not sound at the time of the fall. Staff J stated 3 side rails were up on the resident's bed, two at the head of the bed and the lower side rail near the wall/heater, and the side closest to the bathroom was down. Staff J asked Staff K to get Staff P, licensed practical nurse (LPN). Staff P entered the resident's room and stated the resident complained of pain when Staff P touched his/her hip. Staff P directed Staff J and Staff K transfer the resident into bed per mechanical lift. Staff J stated she did not want to move Resident #2 because he/she complained of pain and indicated she did not observe Staff P complete an assessment of the resident's extremities except touch the resident's leg. Staff rolled Resident #2 from side to side to place the lift sheet then transferred Resident #2 per mechanical lift. Staff J stated Resident #2 yelled ouch, ouch, ouch and said he/she could not move his/her leg because it hurt. The resident was positioned in bed and ensured he/she was cleaned. Staff P directed Staff J and Staff K cover Resident #2 and allow rest until the paramedics arrive. Staff J stated she continued with resident rounds. Staff J stated she observed the paramedics arrive at approximately 6:00 a.m. (nearly 1.5 hours after discovered on the floor. On 3/9/16 at 12:36 p.m. Staff K, CNA, stated at approximately 4:20 a.m. she and Staff J exited a resident's room. Upon entrance to the hallway, Staff J heard an alarm, ran down the hall and discovered Resident #2 on the floor. Staff K notified the nurse (Staff P). Staff P entered Resident #2's room and asked the resident if he/she was hurt. Resident #2 reported his/her leg hurt and held his/her hip. Staff K stated Resident #2 complained of pain with even slight movement. Staff K stated Staff P directed Resident #2 to be transferred into bed per mechanical lift. Resident #2 yelled it hurts, please stop however they were directed to continue transfer by Staff P. After Resident #2 was placed in bed, staff rolled Resident #2 from side to side in bed to remove the lift sheet and Resident #2 cried and yelled, it hurts! Staff K stated at approximately 5:30 a.m. the aides observed Resident #2 in his/her room. Staff P stated she had not notified the ambulance because she had paperwork to complete. Staff K stated the 3 side rails of the bed were in an up position (two at the top of the bed and one on the lower end, wall side). Staff K stated if Resident #2 crawled over the footboard, the floor alarm would not sound. Staff K stated she felt badly about transferring Resident #2 the following day and contacted her manager regarding her concerns and lack of assessment prior to transferring the resident from the floor. On 3/9/16 at 1:04 p.m. Staff P, LPN, was interviewed and stated at approximately 4:25 a.m. she was at the nurse's station doing paperwork when a nursing assistant informed her that Resident #2 was found on the floor. Staff P did not hear an alarm sounding. Upon entering Resident #2's room, she observed the resident lying on his/her left side and the resident appeared to have been attempting to get to the bathroom. Resident #2 complained of pain when rolled onto back, and said, oh my leg, my leg as he/she held the leg. Staff P confirmed the resident guarded the affected extremity. A mechanical lift was utilized to transfer the resident from the floor onto his/her bed. Staff P stated as she assessed the resident's range of motion and the resident complained of pain. She then directed staff transfer the resident per mechanical lift from the floor to bed. Staff P stated Resident #2 was unable to move his/her leg so staff rolled him/her from side to side, placed a lift sheet and transferred the resident per mechanical lift. Staff P stated the resident's affected leg was immobilized while in the mechanical lift. Staff P stated she stood near the top of the mechanical lift. Staff P stated Resident #2 held his/her leg, was unable to lift the affected leg and said oh my leg! Staff P stated when Resident #2 was in bed, she completed her assessment to include vital signs and neurological signs with a flashlight in the presence of Staff J and Staff K. Initially, Staff P stated she did not have a flashlight present to assess pupil response, then recanted and stated oh yes I did, it was on the vital sign machine. Staff P stated Resident #2 complained of pain when staff rolled him/her from side to side in bed to change his/her incontinent brief. Staff P completed an assessment of the resident's vital signs every 15 minutes after the fall, and administered Tylenol ([MEDICATION NAME]) for complaints of pain as evidenced by the resident guarding his/her hip. The clinical record lacked evidence of the assessments. Staff P completed paperwork and notified the resident's physician. The ambulance arrived near change of shift at 6:00 a.m., and again stated the fall occurred at approximately 4:25 a.m. Staff P stated she documented the resident's complaints of pain and range of motion to the resident's arms and left leg only because when she slightly moved the right leg, he/she complained of pain. Staff P stated Resident #2 was unable to lift or move the affected extremity and kept his/her hand near the side of his/her right hip. Staff P stated she did not attempt to do further range of motion in order to not aggravate the injury more. Staff P stated in nursing school, she learned a resident could be moved (by staff) if a fracture is suspected. Staff P stated the signs or symptoms of a fracture include pain or if one extremity was longer than the other. Staff P stated she as not certain a fracture occurred, however, Resident #2 complained of pain. On 3/9/16 at 7:19 a.m. the interim Director of Nursing (DON) stated when she learned Resident #2 fell and sustained a fracture, she immediately initiated an investigation. Upon review of Staff P's nursing assessment at the time of the fall/fracture, the DON stated she had a concern regarding Staff P's Nurse's Note, The DON stated the assessment was missing a significant assessment information. The DON completed a verbal counseling session with Staff P regarding the importance of documentation of nursing assessment and provided education on the role of nurses. On 3/10/16 at 8:50 a.m. the DON stated she expected staff to complete a head to toe assessment to include pain, range of motion, mobility, vital signs, and complete body check and if a fracture is suspected, then an immediate transfer for an x-ray.