Every finding on record at Stratford Specialty Care

Based on personnel record review, staff interview and policy review the facility failed to provide appropriate screening prior to employment for 1 of 5 employees reviewed for background checks. The facility reported a census of 39 residents. Findings include:The personnel file for Staff D, (Registered Nurse) documented a start date of 6/24/25. The personnel file lacked documentation that a Single Contact License and Background Check (SING) was completed prior to hire. Review of current nursing schedules revealed Staff D was an active RN at the facility and was working during the survey. On 7/8/26 at 4:30 PM, the Administrator reported the facility could not locate the SING for Staff D. He said he sent Staff D home as a precautionary.The facility policy titled Background Screening Investigations revised March 2019 documented the facility would conduct employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. The policy documented background and criminal checks are initiated two days of an offer of employment or contract agreement, and completed prior to employment.

Based on clinical record review, facility investigative file review, staff interviews, and facility policy review the facility failed to document on the Controlled Drug Count Record and the electronic Medication Administration Record (MAR) when liquid Morphine (opioid medication) was administered for 1 of 1 resident reviewed for controlled substance use (Resident #1). The facility also failed to consistently and accurately reconcile controlled medications. The facility reported a census of 39 residents. Findings include:The Facility Self Report to the Department of Inspections, Appeals and Licensing (DIAL) by the Administrator on 5/15/26 revealed Resident #1 lacked Morphine (strong pain medicine). The report documented a staff member notifying the Director of Nursing (DON) and the Administrator at shift change about the liquid Morphine (strong liquid pain medicine) count differing from the record, with the time of the last correct count remaining unknown. The Facility 5-day Investigation documented on 5/15/26 revealed a report to the DON showing a shortage of 6.75 milliliters (ml) in Resident #1's liquid Morphine count. The Care Plan with a target date of 8/13/26 documented Resident #1's use of opioid (strong pain reliever) medications for chronic pain and metastatic cancer (cancer spreading). The Care Plan directed staff to administer opioid medication as the physician ordered and monitor Resident #1 for side effects. The May 2026 Medication Administration Record (MAR) directed staff to administer Morphine Sulfate Concentrate Oral Solution 20 milligrams/milliliter (mg/ml), 0.25 ml every 2 hours as needed for pain. Resident #1's Individual Narcotic Records from March 28, 2026 to June 30, 2026 revealed:Staff signed out Morphine Sulfate on the Individual Narcotic Record but failed to record the administration on the MAR on 4/16/26, 4/20/26, 4/21/26, 4/30/26 twice, 5/3/26, 5/15/26, 5/31/26, 6/5/26, 6/6/26 twice, 6/7/26, 6/8/26, 6/20/26, and 6/30/26 (15 times).Staff documented Morphine Sulfate on the MAR as administered on 4/18/26 but failed to record it on the Individual Narcotic Record.Staff documented a subtraction error on 4/15/26. On 4/14/26 at 12:46 PM, staff administered 0.25 ml, leaving 18.75 ml. On 4/15/26 at 4:54 AM, staff administered 0.25 ml and recorded 18 ml remaining, creating a 0.5 ml discrepancy.Staff documented a subtraction error on 5/1/26. On 4/30/26 at 1:41 PM, staff administered 0.25 ml, leaving 14 ml. On 5/1/26 at 8:15 AM, staff administered 0.25 ml and recorded 14 ml remaining.Staff documented a medication discrepancy on 5/15/26. On 5/14/26 at 4:29 PM, staff administered 0.25 ml, leaving 7.5 ml. On 5/15/26 at 12:30 PM, staff administered 0.25 ml and recorded 0.25 ml remaining, creating a 7.25 ml discrepancy. On 5/15/26 at 5:00 PM, staff administered 0.25 ml, leaving zero remaining. The facility document titled Controlled Drugs- Count Record required staff signatures to acknowledge counting the controlled drugs on hand and verifying agreement with the quantity stated on the Controlled Drug Administration Record. Review of the count record for both medication carts revealed a lack of staff signatures, indicating staff failed to reconcile controlled medications on the following dates and shifts:6 AM - On: 4/14/26, 4/17/26, 4/27/26, 5/12/26, 5/28/26, 5/31/26, 7/2/26, and 7/4/26.6 AM - Off: 4/29/26.2 PM - On: 4/16/26 and 4/20/26.2 PM - Off: 5/1/26.6 PM - Off: 4/14/26, 4/16/26, 4/20/26, 5/3/26, 5/4/26, 5/7/26, 5/11/26, 5/12/26, 5/23/26, 5/24/26, 5/28/26, 5/31/26, 6/8/26, 7/2/26, and 7/4/26.5 PM - Off: 5/5/26.10 AM - Off: 7/5/26.4:47 PM - Off: 7/5/26. On 7/6/26 at 9:49 AM, the DON expected staff to document completion of the narcotic count. On 7/7/26 at 12:49 PM, Staff C, Registered Nurse (RN), reported Resident #1's liquid Morphine count differed from the records since her employment began around 5/5/26. Staff C stated other staff reported the count as correct. Other nurses informed Staff C of potential liquid medication volume fluctuations causing discrepancies. Staff C couldn't recall the exact shortage, estimating a difference of 3 to 4 milliliters. Staff C admitted failing to report the discrepancy to the DON. Staff C reported completing the count with another person but acknowledged failing to sign the form in the back of the book, noting if it wasn't documented it wasn't done. On 7/7/26 at 2:13 PM, Staff D, RN, reported Staff C approached her the Sunday prior to 5/15/26 regarding concerns Resident #1's Morphine bottle appeared short compared to the narcotic record log. Staff D inspected the bottle and found it acceptable, attributing a minor discrepancy to observed leakage around the bottle. Staff D didn't recall the exact shortage amount. Staff D recalled a telephone call 3 to 4 days later from the DON inquiring about Staff C's report. Staff D informed the DON the discrepancy appeared minor and non-urgent, noting bottle leakage. Staff D reported completing the count at shift change, acknowledging the expectation to sign the back of the book. Staff D admitted occasionally forgetting to sign or signing during the subsequent count. Staff D stated the facility expected staff to sign the MAR and narcotic record immediately following medication administration. On 7/7/26 at 2:02 PM, Staff F, Certified Medication Aide (CMA), reported Resident #1's liquid Morphine bottle felt damp and the box showed pink markings. Staff F noted a missing stopper under the lid and wet residue trickling from the bottle. Staff F didn't recall whether she discovered the discrepancy during administration or the count. Staff F didn't recall the exact shortage amount but reported finding the bottle nearly empty. On 7/7/26 at 6:51 PM, Staff E, RN, reported the narcotic count required two nurses. Staff E stated staff compared medication cards to the narcotic record and signed the back of the book to verify accuracy. Staff E reported attempting to count at shift change, admitting she occasionally forgot or skipped the count when the other nurse remained busy, though she denied habitual omissions. Staff E stated the facility expected staff to sign the narcotic log and MAR immediately after administering medication. Staff E reported the subsequent narcotic count would catch any undocumented doses. On 7/8/26 at 3:41 PM, the DON expected staff to notify her of any narcotic count discrepancies. The Controlled Substance Record Book (Protocol) policy effective 2/14/22 directed:Conducting a Controlled Substance Count: Begin the narcotic count with the oncoming shift by counting the cards, ensuring the count matches the non-yellowed lines on the index sheet. Verify each medication card against the proper page number, counting each card bubble and the actual medication.Signing out a Controlled Substance:When administering a controlled substance, staff must document the date, time, dose, signature, and remaining quantity on the Individual Narcotic Sheet in the Controlled Substance Book.Staff must sign the MAR in the electronic medication record with the administration date and time to match the entry in the Controlled Substance Record Book.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past 2 surveys, and staff interview, the facility failed to correct their own deficiencies for 3 of 3 areas of concern. The facility reported a census of 39 residents. Findings include: The facility had the following concerns identified at the current recertification survey, which matched citations from the previous complaint survey and the previous recertification survey:Infection Prevention and ControlReporting of Alleged ViolationsInvestigate/Prevent/Correct Alleged Violation The Quality Assurance and Performance Improvement (QAPI) Program policy revised March 2020 directed the QAPI committee to:Collect and analyze performance indicator data and other information;Identify, evaluate, monitor and improve facility systems and processes supporting the delivery of care and services;Identify and help resolve negative outcomes or care quality problems identified during the QAPI process;Utilize root cause analysis to help identify where identified problems point to underlying systematic problems;Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care;Establish benchmarks and goals to measure performance improvement;Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; andCommunicate all phases of the QAPI process to the Administrator and governing body through sharing meeting minutes, committee activities and results of QAPI activities. On 7/9/26 at 2:30 PM the Administrator stated the QAPI committee reviews prior surveys and prior deficiencies to determine root cause and develop a plan to address and correct prior and repeat deficiencies. The Administrator acknowledged the repeat concerns with the repeat deficiencies during this survey and prior surveys and advised the QAPI committee must complete more extensive audits to address them.

Based on observation, interview, and record review, the facility failed to ensure a safe environment and protect residents from inappropriate sexual behaviors for 2 of 2 residents reviewed (Residents #3 and #31). The facility reported a census of 39 residents. Findings include:1. Resident #3's Minimum Data Set (MDS; clinical assessment) admission assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS; cognitive test) score of 3, indicating severely cognitively impaired. Resident #3 displayed physical behavioral symptoms, including hitting, kicking, pushing, scratching, grabbing, and sexually abusing others, and verbal behavioral symptoms, including threatening, screaming, and cursing, directed toward others for 1 to 3 days during the lookback period. Resident #3 had diagnoses of metabolic encephalopathy (temporary brain malfunction), Alzheimer's disease (progressive brain disorder causing memory loss) with late onset, and a psychotic disorder (mental illness causing detachment from reality) other than schizophrenia. The Care Area Assessment (CAA; care review area) Summary indicated Resident #3 triggered care areas for cognitive loss or dementia and behavioral symptoms. Resident #3's MDS assessment dated [DATE] showed a score of 3, indicating severely cognitively impaired. Resident #3's MDS significant change in condition assessment dated [DATE] showed a score of 0, indicating severely cognitively impaired. Staff rarely or never understood Resident #3. The Staff Assessment for Mental Status showed short-term and long-term memory problems. Resident #3 couldn't recall the current season, room location, staff names and faces, or the nursing home setting. Resident #3 possessed severely impaired cognitive skills for daily decision-making. Resident #3 exhibited physical behavioral symptoms directed toward others for 1 to 3 days during the lookback period. The CAA Summary indicated Resident #3 triggered care areas for delirium (sudden severe confusion), cognitive loss or dementia, and behavioral symptoms. Resident #3's Care Plan Focus revised 5/22/26 and 7/7/26 stated that Resident #3 had a behavior problem, could act sexually inappropriate due to dementia, and experienced a resident-to-resident altercation. Resident #3's Care Plan Focus revised 3/10/26 and 7/6/26 stated that Resident #3 had impaired cognitive function or thought processes related to dementia, an involvement in a resident-to-resident altercation, and an involvement in inappropriate sexual behavior with another resident. A care plan intervention dated 5/26/26 directed that Resident #3 would engage with another male resident at times with affectionate behavior. A progress note dated 7/6/26 at 5:14 PM indicated staff noted Resident #3 in a consensual relationship with another resident in the CCDI (memory care) unit, which progressed to an intimate touch. Staff spoke with Resident #3 Representative, who maintained awareness, stated the relationship fell within Resident #3's rights, and lacked concerns or questions. A progress note dated 7/6/26 at 5:32 PM stated that both residents experienced cognitive impairment and fluctuating behaviors related to Alzheimer's disease. 2. Resident #31's MDS assessment dated [DATE] showed a score of 11, indicating moderately impaired cognition. Resident #31 exhibited physical behavioral symptoms directed toward others for 4 to 6 days during the lookback period. Resident #31 displayed verbal and other behavioral symptoms not directed toward others, including hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, and throwing or smearing food or bodily wastes, for 1 to 3 days during the lookback period. Diagnoses included other sexual disorders, adjustment disorder with depressed mood, and anxiety. Resident #31 received an antidepressant medication during the lookback period. Resident #31's Care Plan Focus revised 5/22/26 stated that Resident #31 had a behavior problem involving sexually inappropriate actions related to dementia. A care plan intervention dated 5/26/26 stated Resident #31 would engage with another male resident at times with affectionate behavior. A care plan intervention dated 6/3/26 stated Resident #31 took medication to help decrease sexual inhibition, which carried a black box warning (strict safety alert). An incident, accident, and unusual occurrence note late entry dated 5/3/26 at 7:15 PM summarized that staff reported finding Resident #31 and another resident kissing lip-to-lip in the dining area. Resident #31 sat in a chair at the table while the other resident stood and leaned toward Resident #31 with a walker nearby. Staff separated both residents. The facility Director of Nursing (DON; chief nursing executive) and Administrator (facility manager) received notification. Staff called the sheriff and updated Resident #31 Representative. Staff sent notifications on 5/3/26 at 7:23 PM to the DON, 5/3/26 at 7:25 PM to the Administrator, 5/3/26 at 8:01 PM to the sheriff, and 5/3/26 at 8:20 PM to Resident #31 Representative. A nurses note dated 5/4/26 at 11:29 AM indicated the facility received orders from the medical provider for a psychiatry (mental health) consultation, with consideration for Depo-Provera (hormone medication) use to regulate sexual behaviors. Staff planned to call Resident #31 Representative to obtain permission for the consultation while the plan of care remained ongoing. A psychiatry encounter note dated 5/4/26 at 6:00 PM for a date of service on 5/5/26 detailed an initial psychiatric evaluation. Resident #31, a [AGE] year-old male with a history of dementia with mood disturbance and major depressive disorder, sat in a wheelchair during the evaluation. Resident #31 appeared calm and lacked acute distress. Due to cognitive impairment, Resident #31 experienced difficulty focusing and answering questions, stating life felt terrible because Resident #31 didn't get Cheerios. Staff reported consistent verbal aggression consisting of yelling and screaming, but denied sleep concerns, recent depression, or anxiety symptoms. Current psychiatric medications included Paroxetine 20 milligrams daily and Trazodone 50 milligrams nightly. Resident #31 Representative signed a consent form for evaluation and treatment. The clinician noted poor impulse control, impaired cognition, impaired attention, impaired concentration, impaired memory, minimal insight, and poor judgment. Diagnoses included major depressive disorder, unspecified dementia with mood disturbance, psychophysiological insomnia (sleep disorder), and inappropriate sexual behavior. The plan directed continuing Paroxetine to monitor depression, noted Resident #31 resided in the memory care unit with verbal but not physical aggression, and addressed the inappropriate sexual behavior toward staff and other residents by increasing Paroxetine to 30 milligrams daily to see if it helps, with future consideration for a Trazodone increase. An alert note dated 5/17/26 at 7:28 AM documented sexually inappropriate behavior where Resident #31 asked another resident if he had a gay orientation. Resident #31 sat at the far table in the dining room when the other male resident walked over. Staff heard the comment, turned from the medication cart, and witnessed the two men kiss. Staff immediately called the other resident over, and he cooperated. Staff reported neither resident displayed anger, and both appeared to enjoy themselves. Staff assisted Resident #31 to a bedroom via wheelchair for care and bed placement per request, leaving the call light within reach. On 7/9/26 at 9:12 AM Staff H, Certified Nursing Assistant (CNA), stated during an interview that Resident #3 and Resident #31 liked each other and held hands, which represented the extent of the witnessed behavior. On 7/9/26 at 9:15 AM Staff I, Certified Medication Aide (CMA), stated during an interview that Resident #3 and Resident #31 kissed and expressed mutual love. Staff I once found Resident #3 fondling Resident #31 through clothing. Staff I kept them separated to prevent this behavior in the dining room. Staff I noted Resident #3 declined recently, experienced episodes of unresponsiveness, and staff previously thought Resident #3 faced active death. On 7/9/26 at 10:45 AM Resident #31 stated during an interview that Resident #31 lacked friends but recognized Resident #3 as a friend. Resident #31 denied a romantic relationship or any instances of inappropriate touching or kissing. On 7/9/26 at 10:48 AM Resident #3 rested in bed during an observation with eyes closed, and Resident #3 didn't awaken when staff called Resident #3's name. On 7/9/26 at 10:45 AM Staff J, Program Coordinator, stated during an interview that reports indicated Resident #3 and Resident #31 kissed and engaged in mutual touching in the dining room. Staff J never witnessed the behavior directly but heard about it, noting Resident #3 usually initiated the encounters. Staff J reported management instructed staff they couldn't keep the residents separate anymore, though groin touching in the dining room or entry into each other's rooms remained restricted. Staff J believed management held awareness of the reports. Staff J noted Resident #3 experienced a significant decline recently and could hardly speak. On 7/9/26 at 11:10 AM the DON stated during an interview that awareness existed regarding Resident #3 and Resident #31 kissing and holding hands. The DON noted only a physician could determine Resident #3's capacity to consent. The DON stated Resident #31 had a Power of Attorney (POA) that remained un-enacted because the primary care provider hadn't declared Resident #31 incompetent. The DON contacted the primary care provider and Resident #3 Representative about the relationship; the provider didn't state Resident #3 lacked the capacity to consent, and Resident #3 Representative stated Resident #3 had the right to do what he wanted. The DON held awareness that Resident #3 placed a hand on Resident #31's inner thigh recently, and that Resident #31 pulled his pants down while Resident #3 touched Resident #31's penis in the dining room before staff intervened. The DON stated reporting would only occur for true sexual contact or if either resident demonstrated resistance. The facility restricted contact to common areas and disallowed anything beyond holding hands in those spaces. On 7/9/26 at 12:45 PM Staff K, Registered Nurse (RN), stated during an interview that although she didn't work in the locked unit often, she heard reports about sexually inappropriate behaviors between Resident #3 and Resident #31. The interactions didn't appear nonconsensual, though both residents had Alzheimer's disease. Staff K witnessed kissing and heard of fondling. Resident #3 and Resident #31 only interacted with each other. On 7/9/26 at 12:55 PM the DON stated during an interview that she charted the behavior as consensual because no reports indicated otherwise. The DON and the Administrator decided the residents could make their own decisions, and they didn't request capacity evaluations, though they reported the relationship to the primary care provider. The DON recognized regulatory changes occurred and didn't know if future consent evaluations would take place, noting she would seek higher guidance today. The facility allowed the relationship to naturally evolve without intervention. The DON added that Resident #31 walked independently for the first time on Monday. On 7/8/26 at 1:27 PM the DON stated during an interview that corporate communication indicated consent for residents with dementia relies on body language and visible pleasure, based on a presentation by the Iowa Departments of Inspections, Appeals, and Licensing (DIAL) Bureau Chief. On 7/9/26 at 1:30 PM the Administrator stated during an interview that he functioned as the abuse coordinator. The Administrator determined consent occurred because the interactions progressed from light kissing to a hand on the thigh, and staff intervened when Resident #31 pulled his pants down or when Resident #3 touched Resident #31's penis in the dining room to ensure decency. The Administrator referenced a corporate presentation on F600 on May 12th of this year, which indicated that residents with lower capacity could engage in sexual contact without reporting if they showed signs of enjoyment. Because both residents showed enjoyment, the facility categorized the behavior as consensual and didn't report it as abuse. The Chief Nursing Officer informed them of the presentation by the DIAL Bureau Chief. The Administrator lacked handouts or knowledge of capacity assessments, focusing only on whether the behavior appeared enjoyable. The Abuse and Neglect - Clinical Protocol revised March 2018 defined sexual abuse as non-consensual sexual contact of any type with a resident. The Identifying Types of Abuse dated April 2021 directed as part of the abuse prevention strategy volunteers, employees, and contracts hired by the facility are expected to be able to identify the different types of abuse that may occur against residents. The policy defined sexual abuse as non-consensual sexual conduct of any type with a resident. The policy listed the following:Sexual contact with a resident who lacked the cognitive ability to consent is considered non-consensual and therefore, constitutes abuse.The resident's capacity to consent to sexual conduct is carefully evaluated as part of the initial assessment and care planning process.The interdisciplinary team consults with the ethics committee or legal counsel whenever there is a question of capacity to consent.The resident's capacity to consent is monitored and re-evaluated over time, as needed, based on changes to his or her physical, mental, and/or psychosocial status.

Based on observations, interviews, clinical record reviews, and facility policy review the facility failed to report an allegation of sexual abuse for a resident with an unknown capacity to consent for 2 of 2 residents reviewed (Residents #3 and #31). The facility failed to report the allegation of sexual abuse after the residents progressed to fondling each other over clothing and then to touching without clothing. The facility reported a census of 39 residents. Findings include:1. Resident #3's Minimum Data Set (MDS; clinical assessment) admission assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS; cognitive test) score of 3, indicating severely cognitively impaired. Resident #3 displayed physical behavioral symptoms, including hitting, kicking, pushing, scratching, grabbing, and sexually abusing others, and verbal behavioral symptoms, including threatening, screaming, and cursing, directed toward others for 1 to 3 days during the lookback period. Resident #3 had diagnoses of metabolic encephalopathy (temporary brain malfunction), Alzheimer's disease (progressive brain disorder causing memory loss) with late onset, and a psychotic disorder (mental illness causing detachment from reality) other than schizophrenia. The Care Area Assessment (CAA; care review area) Summary indicated Resident #3 triggered care areas for cognitive loss or dementia and behavioral symptoms. Resident #3's MDS assessment dated [DATE] showed a score of 3, indicating severely cognitively impaired. Resident #3's MDS significant change in condition assessment dated [DATE] showed a score of 0, indicating severely cognitively impaired. Staff rarely or never understood Resident #3. The Staff Assessment for Mental Status showed short-term and long-term memory problems. Resident #3 couldn't recall the current season, room location, staff names and faces, or the nursing home setting. Resident #3 possessed severely impaired cognitive skills for daily decision-making. Resident #3 exhibited physical behavioral symptoms directed toward others for 1 to 3 days during the lookback period. The CAA Summary indicated Resident #3 triggered care areas for delirium (sudden severe confusion), cognitive loss or dementia, and behavioral symptoms. Resident #3's Care Plan Focus revised 5/22/26 and 7/7/26 stated that Resident #3 had a behavior problem, could act sexually inappropriate due to dementia, and experienced a resident-to-resident altercation. Resident #3's Care Plan Focus revised 3/10/26 and 7/6/26 stated that Resident #3 had impaired cognitive function or thought processes related to dementia, an involvement in a resident-to-resident altercation, and an involvement in inappropriate sexual behavior with another resident. A care plan intervention dated 5/26/26 directed that Resident #3 would engage with another male resident at times with affectionate behavior. A progress note dated 7/6/26 at 5:14 PM indicated staff noted Resident #3 in a consensual relationship with another resident in the CCDI (memory care) unit, which progressed to an intimate touch. Staff spoke with Resident #3 Representative, who maintained awareness, stated the relationship fell within Resident #3's rights, and lacked concerns or questions. A progress note dated 7/6/26 at 5:32 PM stated that both residents experienced cognitive impairment and fluctuating behaviors related to Alzheimer's disease. 2. Resident #31's MDS assessment dated [DATE] showed a score of 11, indicating moderately impaired cognition. Resident #31 exhibited physical behavioral symptoms directed toward others for 4 to 6 days during the lookback period. Resident #31 displayed verbal and other behavioral symptoms not directed toward others, including hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, and throwing or smearing food or bodily wastes, for 1 to 3 days during the lookback period. Diagnoses included other sexual disorders, adjustment disorder with depressed mood, and anxiety. Resident #31 received an antidepressant medication during the lookback period. Resident #31's Care Plan Focus revised 5/22/26 stated that Resident #31 had a behavior problem involving sexually inappropriate actions related to dementia. A care plan intervention dated 5/26/26 stated Resident #31 would engage with another male resident at times with affectionate behavior. A care plan intervention dated 6/3/26 stated Resident #31 took medication to help decrease sexual inhibition, which carried a black box warning (strict safety alert). A psychiatry encounter note dated 5/4/26 at 6:00 PM for a date of service on 5/5/26 detailed an initial psychiatric evaluation. The plan directed continuing Paroxetine to monitor depression, noted Resident #31 resided in the memory care unit with verbal but not physical aggression, and addressed the inappropriate sexual behavior toward staff and other residents by increasing Paroxetine to 30 milligrams daily to see if it helps, with future consideration for a Trazodone increase. On 7/9/26 at 9:15 AM Staff I, Certified Medication Aide (CMA), stated during an interview that Resident #3 and Resident #31 kissed and expressed mutual love. Staff I once found Resident #3 fondling Resident #31 through clothing. Staff I kept them separated to prevent this behavior in the dining room. Staff I noted Resident #3 declined recently, experienced episodes of unresponsiveness, and staff previously thought Resident #3 faced active death. On 7/9/26 at 11:10 AM the DON stated during an interview that awareness existed regarding Resident #3 and Resident #31 kissing and holding hands. The DON noted only a physician could determine Resident #3's capacity to consent. The DON stated Resident #31 had a Power of Attorney (POA) that remained un-enacted because the primary care provider hadn't declared Resident #31 incompetent. The DON contacted the primary care provider and Resident #3 Representative about the relationship; the provider didn't state Resident #3 lacked the capacity to consent, and Resident #3 Representative stated Resident #3 had the right to do what he wanted. The DON held awareness that Resident #3 placed a hand on Resident #31's inner thigh recently, and that Resident #31 pulled his pants down while Resident #3 touched Resident #31's penis in the dining room before staff intervened. The DON stated reporting would only occur for true sexual contact or if either resident demonstrated resistance. The facility restricted contact to common areas and disallowed anything beyond holding hands in those spaces. On 7/9/26 at 12:45 PM Staff K, Registered Nurse (RN), stated during an interview that although she didn't work in the locked unit often, she heard reports about sexually inappropriate behaviors between Resident #3 and Resident #31. The interactions didn't appear nonconsensual, though both residents had Alzheimer's disease. Staff K witnessed kissing and heard of fondling. Resident #3 and Resident #31 only interacted with each other. On 7/9/26 at 12:55 PM the DON stated during an interview that she charted the behavior as consensual because no reports indicated otherwise. The DON and the Administrator decided the residents could make their own decisions, and they didn't request capacity evaluations, though they reported the relationship to the primary care provider. The DON recognized regulatory changes occurred and didn't know if future consent evaluations would take place, noting she would seek higher guidance today. The facility allowed the relationship to naturally evolve without intervention. The DON added that Resident #31 walked independently for the first time on Monday. On 7/8/26 at 1:27 PM the DON stated during an interview that corporate communication indicated consent for residents with dementia relies on body language and visible pleasure, based on a presentation by the Iowa Departments of Inspections, Appeals, and Licensing (DIAL) Bureau Chief. On 7/9/26 at 1:30 PM the Administrator stated during an interview that he functioned as the abuse coordinator. The Administrator determined consent occurred because the interactions progressed from light kissing to a hand on the thigh, and staff intervened when Resident #31 pulled his pants down or when Resident #3 touched Resident #31's penis in the dining room to ensure decency. The Administrator referenced a corporate presentation on F600 on May 12th of this year, which indicated that residents with lower capacity could engage in sexual contact without reporting if they showed signs of enjoyment. Because both residents showed enjoyment, the facility categorized the behavior as consensual and didn't report it as abuse. The Chief Nursing Officer informed them of the presentation by the DIAL Bureau Chief. The Administrator lacked handouts or knowledge of capacity assessments, focusing only on whether the behavior appeared enjoyable. The Abuse and Neglect - Clinical Protocol revised March 2018 defined sexual abuse as non-consensual sexual contact of any type with a resident. The Identifying Types of Abuse dated April 2021 directed as part of the abuse prevention strategy volunteers, employees, and contracts hired by the facility are expected to be able to identify the different types of abuse that may occur against residents. The policy defined sexual abuse as non-consensual sexual conduct of any type with a resident. The policy listed the following:Sexual contact with a resident who lacked the cognitive ability to consent is considered non-consensual and therefore, constitutes abuse.The resident's capacity to consent to sexual conduct is carefully evaluated as part of the initial assessment and care planning process.The interdisciplinary team consults with the ethics committee or legal counsel whenever there is a question of capacity to consent.The resident's capacity to consent is monitored and re-evaluated over time, as needed, based on changes to his or her physical, mental, and/or psychosocial status. The Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating policy revised April 2021 directed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility. The policy defined immediately as within 2 hours of an allegation of abuse.

Based on clinical record review, observations, interviews, and policy review the facility failed to separate residents with the unknown capacity to consent in sexual relations for 2 of 2 residents reviewed (Residents #3 and #31). See F600 for additional information regarding Resident #3 and #31. The facility reported a census of 39 residents. Findings include:1. Resident #3's Minimum Data Set (MDS; clinical assessment) admission assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS; cognitive test) score of 3, indicating severely cognitively impaired. Resident #3 displayed physical behavioral symptoms, including hitting, kicking, pushing, scratching, grabbing, and sexually abusing others, and verbal behavioral symptoms, including threatening, screaming, and cursing, directed toward others for 1 to 3 days during the lookback period. Resident #3 had diagnoses of metabolic encephalopathy (temporary brain malfunction), Alzheimer's disease (progressive brain disorder causing memory loss) with late onset, and a psychotic disorder (mental illness causing detachment from reality) other than schizophrenia. The Care Area Assessment (CAA; care review area) Summary indicated Resident #3 triggered care areas for cognitive loss or dementia and behavioral symptoms. Resident #3's MDS assessment dated [DATE] showed a score of 3, indicating severely cognitively impaired. Resident #3's MDS significant change in condition assessment dated [DATE] showed a score of 0, indicating severely cognitively impaired. Staff rarely or never understood Resident #3. The Staff Assessment for Mental Status showed short-term and long-term memory problems. Resident #3 couldn't recall the current season, room location, staff names and faces, or the nursing home setting. Resident #3 possessed severely impaired cognitive skills for daily decision-making. Resident #3 exhibited physical behavioral symptoms directed toward others for 1 to 3 days during the lookback period. The CAA Summary indicated Resident #3 triggered care areas for delirium (sudden severe confusion), cognitive loss or dementia, and behavioral symptoms. Resident #3's Care Plan Focus revised 5/22/26 and 7/7/26 stated that Resident #3 had a behavior problem, could act sexually inappropriate due to dementia, and experienced a resident-to-resident altercation. Resident #3's Care Plan Focus revised 3/10/26 and 7/6/26 stated that Resident #3 had impaired cognitive function or thought processes related to dementia, an involvement in a resident-to-resident altercation, and an involvement in inappropriate sexual behavior with another resident. A care plan intervention dated 5/26/26 directed that Resident #3 would engage with another male resident at times with affectionate behavior. A progress note dated 7/6/26 at 5:14 PM indicated staff noted Resident #3 in a consensual relationship with another resident in the CCDI (memory care) unit, which progressed to an intimate touch. Staff spoke with Resident #3 Representative, who maintained awareness, stated the relationship fell within Resident #3's rights, and lacked concerns or questions. A progress note dated 7/6/26 at 5:32 PM stated that both residents experienced cognitive impairment and fluctuating behaviors related to Alzheimer's disease. 2. Resident #31's MDS assessment dated [DATE] showed a score of 11, indicating moderately impaired cognition. Resident #31 exhibited physical behavioral symptoms directed toward others for 4 to 6 days during the lookback period. Resident #31 displayed verbal and other behavioral symptoms not directed toward others, including hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, and throwing or smearing food or bodily wastes, for 1 to 3 days during the lookback period. Diagnoses included other sexual disorders, adjustment disorder with depressed mood, and anxiety. Resident #31 received an antidepressant medication during the lookback period. Resident #31's Care Plan Focus revised 5/22/26 stated that Resident #31 had a behavior problem involving sexually inappropriate actions related to dementia. A care plan intervention dated 5/26/26 stated Resident #31 would engage with another male resident at times with affectionate behavior. A care plan intervention dated 6/3/26 stated Resident #31 took medication to help decrease sexual inhibition, which carried a black box warning (strict safety alert). An incident, accident, and unusual occurrence note late entry dated 5/3/26 at 7:15 PM summarized that staff reported finding Resident #31 and another resident kissing lip-to-lip in the dining area. Resident #31 sat in a chair at the table while the other resident stood and leaned toward Resident #31 with a walker nearby. Staff separated both residents. The facility Director of Nursing (DON; chief nursing executive) and Administrator (facility manager) received notification. Staff called the sheriff and updated Resident #31 Representative. Staff sent notifications on 5/3/26 at 7:23 PM to the DON, 5/3/26 at 7:25 PM to the Administrator, 5/3/26 at 8:01 PM to the sheriff, and 5/3/26 at 8:20 PM to Resident #31 Representative. The Facility's Self Report submitted 5/3/26 identified the staff found Resident #3 and Resident #31 sitting at the table kissing. The facility immediately separated the residents. The Intervention directed the facility would have the residents sit at separate tables while in the dining room. On 7/9/26 at 9:15 AM Staff I, Certified Medication Aide (CMA), stated during an interview that Resident #3 and Resident #31 kissed and expressed mutual love. Staff I once found Resident #3 fondling Resident #31 through clothing. Staff I kept them separated to prevent this behavior in the dining room. Staff I noted Resident #3 declined recently, experienced episodes of unresponsiveness, and staff previously thought Resident #3 faced active death. On 7/9/26 at 10:45 AM Staff J, Program Coordinator, stated during an interview that reports indicated Resident #3 and Resident #31 kissed and engaged in mutual touching in the dining room. Staff J never witnessed the behavior directly but heard about it, noting Resident #3 usually initiated the encounters. Staff J reported management instructed staff they couldn't keep the residents separate anymore, though groin touching in the dining room or entry into each other's rooms remained restricted. Staff J believed management held awareness of the reports. Staff J noted Resident #3 experienced a significant decline recently and could hardly speak. On 7/9/26 at 11:10 AM the DON stated during an interview that awareness existed regarding Resident #3 and Resident #31 kissing and holding hands. The DON noted only a physician could determine Resident #3's capacity to consent. The DON stated Resident #31 had a Power of Attorney (POA) that remained un-enacted because the primary care provider hadn't declared Resident #31 incompetent. The DON contacted the primary care provider and Resident #3 Representative about the relationship; the provider didn't state Resident #3 lacked the capacity to consent, and Resident #3 Representative stated Resident #3 had the right to do what he wanted. The DON held awareness that Resident #3 placed a hand on Resident #31's inner thigh recently, and that Resident #31 pulled his pants down while Resident #3 touched Resident #31's penis in the dining room before staff intervened. The DON stated reporting would only occur for true sexual contact or if either resident demonstrated resistance. The facility restricted contact to common areas and disallowed anything beyond holding hands in those spaces. On 7/9/26 at 12:55 PM the DON stated during an interview that she charted the behavior as consensual because no reports indicated otherwise. The DON and the Administrator decided the residents could make their own decisions, and they didn't request capacity evaluations, though they reported the relationship to the primary care provider. The DON recognized regulatory changes occurred and didn't know if future consent evaluations would take place, noting she would seek higher guidance today. The facility allowed the relationship to naturally evolve without intervention. The DON added that Resident #31 walked independently for the first time on Monday. On 7/9/26 at 1:30 PM the Administrator stated during an interview that he functioned as the abuse coordinator. The Administrator determined consent occurred because the interactions progressed from light kissing to a hand on the thigh, and staff intervened when Resident #31 pulled his pants down or when Resident #3 touched Resident #31's penis in the dining room to ensure decency. The Administrator referenced a corporate presentation on F600 on May 12th of this year, which indicated that residents with lower capacity could engage in sexual contact without reporting if they showed signs of enjoyment. Because both residents showed enjoyment, the facility categorized the behavior as consensual and didn't report it as abuse. The Chief Nursing Officer informed them of the presentation by the Department of Inspections, Appeals, and Licensing (DIAL) Bureau Chief. The Administrator lacked handouts or knowledge of capacity assessments, focusing only on whether the behavior appeared enjoyable. The Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating policy revised April 2021 directed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for initiating a thorough investigation and determining what actions (if any) are needed for the protection of residents.

Based on record review, observation, and interview, the facility failed to ensure staff administered medications in accordance with physician orders for 1 of 2 residents reviewed for skin conditions (Resident #9). The facility reported a census of 39. Findings include:Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severely cognitively impaired. The MDS listed diagnoses of hypertension (high blood pressure), diabetes mellitus (high blood sugar), and non-Alzheimer's dementia (brain decline). Resident #9 had moisture associated skin damage (skin irritation from moisture) and received applications of ointments or medications other than to feet. The Care Plan Focus dated 5/5/26 identified Resident #9's potential or actual skin impairment. Resident #9 had a rash to the scrotum and buttocks. The Nurses Note dated 6/10/26 at 12:09 PM indicated the facility received new orders from Advanced Registered Nurse Practitioner (ARNP) 2 to discontinue Nystatin cream, start miconazole 2% cream twice a day for 2 weeks, and apply a thin layer over affected areas. The orders instructed staff to apply Triad paste three times a day and as needed after incontinence (loss of bowel or bladder control) episodes, reassess after 14 days, and consider an oral antifungal if not effective. The Orders - Administration Note Text dated 6/12/26 at 7:49 PM specified instructions to apply Micatin Cream 2% topically two times a day for a rash for 14 days per additional directions. The Communication - with Physician Note Text dated 6/15/26 at 9:50 AM detailed verbal orders ARNP3 to start Resident #9 on Nystatin Cream, discontinue Micatin, start 10 mg prednisone PO (by mouth) daily in the AM for 5 days, and provided an order for a dermatology referral. The Nurses Note Text dated 6/18/26 at 5:08 PM documented a new order for Nystatin cream BID (twice daily) and Triad paste. The note indicated Resident #9's appointment with a dermatologist on the 24th for skin issues, noting the rash spread to Resident #9's face, eyelid, and ears. The Dermatology Visit Note dated 6/24/26 included the following orders:a. Fluconazole 150 mg tablet by mouth, give one and may repeat up to 2 additional doses for a total of 3 days.b. Econazole Nitrate 1% topical cream apply to rash in groin, on thighs, and buttocks twice a day until areas resolve. Resume application for an additional 1 week thereafter to minimize reoccurrence.c. Nystatin-Triamcinolone 100,000 units/gram - 0.1% topical ointment. Apply to rash in groin, buttocks, and thighs twice daily for up to 2 weeks. Take a 2 week break from applications, then resume course as directed until areas resolve.d. Follow-up rash and medication progress in 1 month. The Order Note Text dated 6/25/26 at 5:11 PM noted a new order for Nystatin-Triamcinolone 100,000 unit/gram 0.1% topical ointment to apply to the rash on the groin, buttocks, and thighs BID for 2 weeks, take a 2-week break, then resume the cycle until healed. The Nurses Note Text dated 7/2/26 at 1:55 PM indicated a provider saw Resident #9 that morning. New orders changed the duration of Fluconazole to once daily, updating the order to read as 150 mg daily for 14 days total. Staff administered the first dose on 6/28/26 and updated the order to include doses for the next 10 days to reach the 14-day duration. Resident #9's July 2026 MAR included the following orders:a. Fluconazole Oral Tablet 150 MG (Fluconazole) Give 1 tablet by mouth one time a day for rash for 10 administrations with a start date of 7/3/26 at 7:00 AM.b. Nystatin-Triamcinolone External Ointment 100000-0.1 UNIT/GM-% (Nystatin-Triamcinolone) Apply to groin, buttocks, and thigh topically every shift for rash for 2 weeks, apply up to 2 weeks then take a 2-week break then continue cycle until healed with a start date of 6/29/26 at 5:00 AM.c. Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to buttocks and groin topically three times a day for incontinence episodes, reassess after 14 days, and consider an oral antifungal if not effective with a start date of 6/10/26 at 4:00 PM.d. Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to groin and buttocks topically every 3 hours as needed for affected areas with a start date of 6/10/26 at 12:15 PM. On 7/7/26 at 9:12 AM, Staff L, Certified Medication Assistant (CMA), and the Director of Nursing (DON) completed incontinence care and ointment application to Resident #9. Staff L removed the brief, cleansed the front area, and applied ointment and powder. Staff L applied the ointment to the backside as well, utilizing Econazole Nitrate 1% and Nystatin powder. On 7/7/26 at 11:47 AM, the Pharmacist stated during a telephone call the pharmacy held orders for two ointments for Resident #9, specifically Nystatin/Triamcinolone 100,000/0.1 Unit/GM every shift and Econazole 1% topical. The Pharmacist noted the medications differ and the Electronic Medication Administration Record (eMAR) lacked the Econazole 1% order. The Pharmacist also stated orders from the nurse practitioner discontinued the Nystatin powder on 6/1/26. On 7/7/26 at 11:55 AM, the DON stated the facility received no paperwork or orders when Resident #9 returned from the dermatology clinic. The DON noted the Assistant Director of Nursing (ADON) called the clinic and verified the order for Nystatin/Triamcinolone ointment but not for the Econazole ointment. On 7/7/26 at 12:15 PM, Staff L stated she shouldn't have administered the Econazole without an order but thought she held the Nystatin ointment. Staff L noted she shouldn't have documented the Nystatin ointment since she administered the other ointment, and she shouldn't have administered the Nystatin powder since the provider discontinued it. On 7/7/26 at 12:22 PM, the ADON stated she received paperwork from the dermatology clinic ordering oral Fluconazole for 3 days and a topical antifungal. The ADON noted Resident #9 showed no improvement, leading to an extension of the Fluconazole duration, though she couldn't remember if the clinic prescribed two ointments. Following a review of the morning observation, the ADON stated Staff L shouldn't have administered the Econazole without an order, shouldn't have signed for the Nystatin ointment since she didn't administer it, and shouldn't have administered the Nystatin powder since the provider discontinued it. On 7/7/26 at 1:40 PM, ARNP2 stated she routinely evaluated Resident #9 for a groin rash. She noted Resident #9 previously received Nystatin, but it failed to work, prompting a change to a different topical antifungal medication. She didn't start Diflucan due to a potential reaction with Eliquis increasing bleeding risks. ARNP2 stated another provider evaluated Resident #9 when the rash still showed no improvement and restarted Nystatin despite its previous failure. She noted the dermatology clinic started Diflucan for 3 days, and the physician subsequently extended the Diflucan to 14 days. The dermatologist attributed the condition to poor perineal care (cleansing the genital area), but ARNP2 disagreed because the rash spread to Resident #9's face as well. She believed the medication failed to work, noting moisture didn't help. On 7/8/26 at 2:20 PM, Advanced Registered Nurse Practitioner (ARNP) 1 stated she provided orders for Diflucan and two ointments. The orders specified Nystatin/Triamcinolone as the first ointment and Econazole as the second ointment.

Based on observation, staff interviews, and policy review the facility failed to prepare and serve pureed food to meet the nutritional needs of 2 of 3 residents reviewed (Residents #17 and #28). The facility reported a census of 39 residents. Findings include:A facility form titled Diet Type Report dated 7/7/26 identified three residents (Residents #6, #17 and #28) who received a pureed texture diet.During an observation on 7/8/26 at 10:57 AM Staff A, Cook, prepared 4 servings of puree. She placed 4 servings (2 scoops with a 4 ounce number #8 scoop) of beef and bean casserole into the blender with 2 buns and blended to pureed texture. She then put the mixture into a container for service without measuring and stated that the serving size would be 2 #8 scoops for service. Next, she put 4 servings (1 scoop of 4 ounce #8 scoop) of green beans with 2 buns and blended to pureed texture. She then put the mixture into a container for service without measuring and stated that the serving size would be 1 #8 scoop for service. Finally, she placed 4 servings (1 scoop of 4 ounce #8 scoop) of rice and added tomato juice and blended to puree texture. She then put the mixture into a container for service without measuring and stated that the serving size would be 1 #8 scoop for service.In an observation 7/8/26 at 12:15 PM Staff A, [NAME] used a #8 scoop to serve the pureed meat, vegetables and rice to 2 of the 3 residents who received a pureed diet. Resident #6 declined to eat lunch. In an interview on 7/8/26 at 1:22 PM Staff B, Dietary Manager stated that when doing puree they always do an extra serving. They add butter or sauce to the food when blending. They should measure the final blend and use the chart to find out the final scoop to use for service. She stated that Staff A, [NAME] should have measured the puree after blending to get the correct serving size but she did not. When she noticed it was too late.In an undated document titled Care Initiatives Puree Process hanging on the wall next to the steamer indicated the steps in the puree process.Measure out desired number of servings into container for pureeing.Puree the food.Add any necessary thickener or appropriate liquid of nutritive value and flavor to obtain desired consistency.Measure the total volume of the food after it is pureed.Measure the total volume of the pureed food by the original number or portions. See the Puree Scoop Chart for reference.Heat or chill the puree food to safe serving temperatures. In a policy titled Kitchen Weights and Measures revised April 2007 it indicated that Cooks and Food Services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes. It also indicated that staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (e.g., color-coded) on utensils will be prominently displayed for reference and the Food Service Supervisor will ensure cooks prepare the appropriate amount of food for the number of servings required.

Based on observation and interview, the facility failed to ensure staff followed dietary orders for Resident #27. The facility reported a census of 39 residents. Findings include:The Diet Type Report printed 7/7/26 listed Resident #27 had a diet order for a mechanical soft texture. The Diet Spreadsheet for Cycle Day 32 included a vegetable of corn relish. The spreadsheet directed to give regular texture diets 1/2 cup corn relish, but directed to give 1 each puree corn to mechanical soft texture. On 7/8/26 at 12:30 PM watched Staff A, Cook, serve corn relish to Resident #27 and sent the item with other meal trays to the locked unit. On 7/8/26 at 12:40 PM Dietary Manager (facility nutritional services director) clarified Resident #27's dietary restrictions regarding a mechanical soft diet (foods altered to a soft texture for easier chewing). She stated Resident #27 could not consume corn relish. Following notification regarding the delivery of the corn relish to Resident #27, she walked to the locked unit to inspect the meal. On 7/8/26 at 12:42 PM witnessed the staff distribute meal trays to the residents. The meal tray for Resident #27 contained corn relish. Dietary Manager removed the item prior to delivery to Resident #27. She obtained another tray and provided the correct diet. On 7/8/26 at 12:43 PM the Dietary Manager acknowledged the improper delivery of corn relish to Resident #27 and termed the occurrence a mistake. On 7/8/26 at 1:22 PM the Dietary Manager explained the standard food preparation protocol of producing an extra serving during the pureeing process. Kitchen staff members add butter or sauce to the food during blending. The protocol required measuring the final blend and utilizing a reference chart to determine the correct scoop size for meal service. She noted Staff A failed to measure the pureed food after blending to ensure the correct serving size. She discovered the omission too late for correction.

Based on clinical record review, staff interviews and policy review, the facility failed to have a complete and accurately documented medical record for 2 of 13 residents reviewed (Residents #33 and #4). The facility reported a census of 39 residents.Findings include:Resident #33's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of diabetes mellitus (high blood sugar). The July 2026 Medication Administration Record (MAR) directed staff to administer Pregabalin (nerve pain medicine) 100 milligrams (mg), 1 capsule three times a day for fibromyalgia (chronic pain disorder). Resident #33's Individual Narcotic Record revealed a late entry on 6/30/26 at 1:11 PM documenting Staff D, Registered Nurse (RN) administered 1 capsule of Pregabalin. On 7/7/26 at 12:49 PM Staff C, RN reported witnessing Staff E, RN sign another nurse's name, Staff D, on Resident #33's individual narcotic record to correct the count for the Pregabalin medication a few days prior. Staff C reported notifying the Director of Nursing (DON), who promised to handle the situation. Staff C didn't know what steps the facility took to address the matter. Staff C reported saying nothing directly to Staff E to avoid an argument. Staff C stated the forgery bothered her. Staff C felt the facility dismissed the concern and didn't feel Staff E should continue working at the facility. Staff C questioned what other records Staff E signed out. Staff C didn't know the facility policy on forging. On 7/7/26 at 6:51 PM Staff E acknowledged signing Staff D's signature on Resident #33's individual narcotic record. Staff E stated the MAR documented the Pregabalin dose as given. Staff E reported checking with Staff D before leaving the shift, and Staff D confirmed administering the medication and instructed her to log it on the narcotic record. Staff E stated the DON provided verbal counseling and warned further actions would result in a written warning and increased supervision. On 7/8/26 at 10:30 AM Staff D verified the signature on Resident #33's Individual Narcotic Record for the Pregabalin medication on 6/30/26 at 1:11 PM didn't match her handwriting. Staff D stated she administered the medication to Resident #33. Staff D didn't recall any issues with the narcotic count that day. Staff D reported she didn't give consent or instruct Staff E to log the medication. Staff D stated she'd never ask another nurse to document for her. The Disciplinary Action Form dated 7/1/26 documented a written warning for Staff E. The form revealed Staff E noted an unsigned narcotic medication, verified its administration on the MAR by a previous nurse, and logged it out for that nurse. The DON signed the form on 7/1/26, and Staff E signed it on 7/8/26. On 7/8/26 at 3:41 PM the DON stated she expected staff to notify her regarding any narcotic count discrepancies. The DON reported Staff E should've notified her when the medication lacked recording on the narcotic log. The Charting and Documentation policy revised July 2017 directed documentation in the medical record to be objective, complete, and accurate. Resident #4's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of diabetes mellitus (high blood sugar), heart failure (poor heart pumping), and peripheral vascular disease (poor blood flow). The MDS documented Resident #4 had a stage three pressure ulcer (deep skin sore) and received treatments. The Care Plan with a target date of 9/23/26 documented Resident #4 had a history of diabetic foot ulcers (foot sores) and wounds to his buttocks. The Care Plan directed staff to complete treatments as ordered. Review of the May 2026 Treatment Administration Record (TAR) revealed missing documentation for the following treatment orders:Betadine (antiseptic medicine) and offloading bandage (pressure-relieving wrap) to left foot daily - 4 timesDiabetic foot checks daily - 5 timesResident #4 to wear post-op (after surgery) shoe to left foot until obtaining diabetic shoes - 4 timesApply Triad cream (skin barrier ointment) to wound on right buttocks three times a day and as needed until healed - 10 times Review of the June 2026 TAR revealed missing documentation for the following treatment orders:Betadine and offloading bandage to left foot daily - 7 timesDiabetic foot checks daily - 6 timesResident #4 to wear post-op shoe to left foot until obtaining diabetic shoes - 6 timesApply Triad cream to wound on right buttocks three times a day and as needed until healed - 10 times On 7/8/26 at 2:00 PM the DON reported nurses didn't click over to the TAR from the MAR to complete documentation based on similar experiences at a previous facility. The DON stated Resident #4 had a history of occasionally refusing treatments but expected staff to document refusals in the electronic medical record (EMR). On 7/8/26 at 11:35 AM the DON acknowledged the missing documentation on Resident #4's TARs. The DON stated she expected staff to complete and document treatments on the TAR or MAR.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 resident reviewed (Resident #33 and #18) during medication administration. The facility reported a census of 39 residents.Findings include:1. Resident #33's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of diabetes mellitus (high blood sugar). The July 2026 Medication Administration Record (MAR) directed staff to administer Lantus (long-acting insulin), inject 25 units subcutaneously (under the skin) every morning and at bedtime due to type two diabetes mellitus (high blood sugar). The MAR instructed staff to notify the physician if blood sugar fell below 60 or rose over 400. On 7/8/26 at 8:15 AM Staff D, Registered Nurse (RN), entered Resident #33's room to complete a blood sugar test. Staff D wore gloves and cleansed Resident #33's finger with an alcohol swab. Staff D poked Resident #33's finger with an Assure lancet and then threw the lancet into the garbage can. Staff D stated that another nurse told her she could throw the lancets into the garbage can because they're single-use devices. On 7/8/26 at 8:22 AM Staff G, Licensed Practical Nurse (LPN), put on gloves without performing hand hygiene and prepared Resident #33's Lantus insulin at the medication cart, touching multiple surfaces. After preparing the insulin, Staff G entered Resident #33's room wearing the same pair of gloves and administered the insulin into Resident #33's abdomen. Review of the Assure Lance Safety Lancets box instructions directed staff to dispose of used lancets in approved sharps containers in accordance with state or local biohazard regulations. On 7/8/26 at 8:35 AM Staff D acknowledged the directions on the lancet box. Staff D stated that another nurse told her that staff could throw lancets in the garbage can to avoid using up space in the sharp containers. Staff D stated she'd start reading the boxes. On 7/8/26 at 9:00 AM the Director of Nursing (DON) reported she expected staff to discard lancets in a sharp's container. The DON walked to Resident #33's room and removed the lancet from the garbage can. Additionally, the DON stated she expected staff to perform hand hygiene when putting on, removing, or changing gloves. 2. Resident #18's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of diabetes mellitus (high blood sugar) and anemia (low red blood cells). On 7/8/26 at 8:40 AM Staff G put on gloves to prepare Resident #18's morning medications and eye drops. During the preparation, Staff G touched multiple surfaces on the medication cart, including the computer, medication cards, eye drop box, and pill cup. After preparing the medication, Staff G entered Resident #18's room and administered the medication and eye drops while wearing the same gloves. Staff G then exited the room, removed the gloves, and performed no hand hygiene. Staff G pushed the medication cart down the hallway to another resident's room and documented the medication administration on the computer. The Handwashing/Hand Hygiene policy dated August 2019 directed staff to perform hand hygiene as the primary means to prevent the spread of infection. The policy instructed staff to perform hand hygiene before applying non-sterile gloves and after removing gloves. Additionally, the policy specified that glove use doesn't replace handwashing or hand hygiene. The policy identified the integration of glove use with routine hand hygiene as the best practice for preventing healthcare-associated infections.

Based on resident interviews, staff interviews and policy review, the facility failed to provide care for 2 out of 8 residents reviewed (Resident #5 and #7) in a manner to promote dignity and respect. The facility reported a census of 37 residents. Findings include:1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.On 12/1/25 at 12:42 PM, Staff A, Certified Nursing Assistant (CNA), reported Staff C, Registered Nurse (RN), told Resident #5 he needed to follow the rules, so he didn't fall. She said Resident #5 would say that Staff C was a bitch.On 12/1/25 at 1:12 PM, Staff B, CNA, reported he didn't like the way Staff C talked to and treated some of the residents. He reported Resident #5 liked to stand and stretch his legs in the mornings, but he was not supposed to stand unless staff were present. He said Resident #5 liked to stand in the morning when the staff were busy. He said Staff C would yell at Resident #5 and they would get into screaming matches. He said Staff C belittled Resident #5 to his face and called him dumb on many occasions. He said Staff C told Resident #5 that she would not feel sorry for him when he fell and broke his hip, as it would be his own fault.On 12/2/25 at 8:23 AM, Staff D, CNA, reported Staff C liked to agitate Resident #5 by some of the questions she asked him, which would escalate his behaviors. She said Staff C liked to put a lot of wet floor signs around the nurses' station to prevent Resident #5 from standing up at the nurses' station. She said Resident #5 required staff assistance with standing. She said Resident #5 would then go down the hallway and use the rail to stand up. Staff D reported Staff C on one occasion took a memory blanket and tied the blanket to Resident #5's wheelchair pedals behind his legs so when he put his feet down, they would not touch the floor preventing him from standing up.On 12/2/25 at 9:07 AM, Staff E, CNA, reported she was in the memory care unit and heard Staff C arguing with Resident #5 and telling him to sit down. She said she looked out the window in the memory care unit door and saw the wet floor signs around the nurses' station. 2. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.On 12/2/25 at 8:23 AM, Staff D reported Staff C would keep Resident #7 from going back to his room due to his attempts to take himself to the bathroom. She said she would tell Resident #7 she was going to move his bed into the hallway. On 12/2/25 at 12:50 PM, Resident #7 described Staff C as loud and smart-alecky. He said Staff C would yell at him all the time, but he didn't think she meant to. He said Staff C was afraid that he was going to fall. He said Staff C would tell him to watch what he was doing. He said it would make him feel rough, but he could give it right back. When asked if anyone told him they were going to move his bed in the hallway, he said yes, Staff C had. When asked why she would do that, he stated because he didn't obey and was getting up by himself. On 12/2/25 at 1:40 PM, the Administrator reported he would expect the staff to treat residents with the utmost respect and dignity. The facility policy titled Dignity revised February 2021 documented each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy documented the following:Residents are treated with dignity and respect at all times.Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with the facility. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents.

Based on interviews, clinical record reviews, and policy review, the facility failed to notify the physician following an allegation of abuse for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 37 residents.Findings include:The Minimum Data Set (MDS) for Resident #1 dated 11/10/25 assessment identified a Brief Interview for Mental Status (BIMS) score was a 6, indicating severe cognitive impairment. The MDS identified Resident #1 required substantial/maximal assistance with bed mobility and transfers. The MDS documented Resident #1 was non-ambulatory and was dependent on staff for locomotion in a manual wheelchair. Resident #1's MDS included diagnoses of anemia, hypertension (high blood pressure), diabetes mellitus, thyroid disorder, traumatic brain injury (TBI) and alcohol abuse with alcohol induced mood disorder.An Incident Report (IR) titled Allegation of Abuse dated 11/20/25 documented it was reported to the Administrator that Resident #1 sat with two dining room chairs placed behind his wheelchair in the common area. The nurse stated that it was, so he did not tip backwards in his wheelchair. The IR lacked documentation of the facility notifying the Physician of the allegation of abuse.Resident #1's Clinical Record lacked documentation of the facility notifying the Physician of the allegations of abuse. On 12/1/25 at 1:28 PM, the Director of Nursing (DON) reported no one notified the Physician of the incident until the morning of 12/1/25. The DON reported she called the ARNP (Advanced Registered Nurse Practitioner) and the ARNP reported no one notified her of the incident. The DON said there was some miscommunication with the Assistant Director of Nursing (ADON) regarding the Physician notification. The DON reported the ARNP knew of the incident as of 12/1/25 and she documented the notification in the progress notes. On 12/2/25 at 11:20 AM, the Administrator reported he would expect the Physician to be notified of any incident. He said with the ADON being suspended the facility missed notifying the physician.The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating revised April 2021 documented the Administrator or the individual making the allegation should immediately report to the resident's attending physician and the facility medical director.

Based on clinical record review, staff interviews, and facility policy review the facility failed to protect a resident from the use of physical restraints for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 37 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score was a 6, indicating severe cognitive impairment. The MDS identified Resident #1 required substantial/maximal assistance with bed mobility and transfers. The MDS documented Resident #1 was non-ambulatory and was dependent on staff for locomotion in a manual wheelchair. Resident #1's MDS included diagnoses of anemia, hypertension (high blood pressure), diabetes mellitus, thyroid disorder, traumatic brain injury (TBI) and alcohol abuse with alcohol induced mood disorder.The Care Plan with a target date of 2/5/25 revealed Resident #1 had a risk for falls. The Care Plan directed to have Resident #1 within line of sight of staff at all times for his safety. The Care Plan documented Resident #1 didn't ambulate and used a mechanical stand with assistance of one staff member for transfers. An Incident Report (IR) titled Allegation of Abuse dated 11/20/25 documented the Administrator received a report of Resident #1 sitting with two dining room chairs placed behind his wheelchair in the common area. The nurse stated it was so Resident #1 didn't tip backwards in his wheelchair. The IR documented the immediate removal of the chairs from behind Resident #1 and suspension of the nurse. The facility form titled Internal Investigation Witness Statement dated 11/20/25 for Staff C, Registered Nurse (RN), documented they placed a dining room chair sideways behind Resident #1's wheelchair at the dining room table, with several inches between the resident, the dining room chair and the wall. The statement documented Resident #1 could freely move his wheelchair forward and he moved the table with his hands several feet in front of him. Staff C reported she didn't wedge the chair behind him. Staff C reported she just didn't want Resident #1 to wheel his wheelchair back too far so that he'd fall forward out of it as he constantly stood up and walked. On 12/1/25 at 10:30 AM, Staff F, Maintenance Supervisor, reported on Wednesday, November 19th at 6:59 AM, he arrived at work and observed Resident #1 sitting in his wheelchair in the front dining room. He said there were two chairs behind Resident #1's wheelchair, keeping him behind the table so he could not back up. He said he moved the chairs and notified the Dietary Manager. Staff F reported at the daily quality assurance (QA) meeting on 11/19/25 around 9:15 AM, he reported the concern to the Assistant Director of Nursing (ADON). He said the Administrator was not at the meeting. He said the ADON said she would take care of it. He said the next day around 3:30 PM he sent the Administrator a text and a picture regarding the concern. Staff F reported he had taken a picture of Resident #1 the morning of 11/19/25 to show the Administrator what had occurred.On 12/1/25 at 11:42 AM, the Regional Director of Clinical Services provided the photo that Staff F had taken of Resident #1 on 11/19/25. The photo showed Resident #1 sitting in a wheelchair at the dining room table in the front common area with two dining room chairs lined up (one in front of the other) behind his wheelchair in between the wheels of the wheelchair with the second chair touching the wall.On 12/1/25 at 12:50 PM, Staff G, Certified Nursing Assistant (CNA), reported the weekend before 11/19/25 she saw a chair behind Resident #1's wheelchair a few times in the common area. She said he was sitting at a table facing the nurses' station with a wall behind him. She said she believed Staff C did it. She said the staff were busy and didn't have time to sit with Resident #1. She said she removed the chair from behind his wheelchair each time she saw it. She said she thought the chair was put there to prevent Resident #1 from pushing himself back so he couldn't stand up.On 12/1/25 at 1:12 PM, Staff B, CNA, reported on the morning of 11/19/25 Resident #1 was being himself and trying to stand up. He said Staff C sat Resident #1 over at the far table in the common room and put two chairs behind him. He said the chairs were stopping Resident #1 from backing up so he would not stand up. He said the wheelchair was locked and Resident #1 was pushed up to the table with his chest almost touching the table. Staff B said he asked Staff C why it was okay and she said that was all she could do at the time. Staff B said there was no one to sit with Resident #1. Staff B reported he told Staff C he thought the chairs should be removed and she walked off. He said he was headed over to remove the chairs but got called into another resident's room. He said when he came out of the room, the chairs had been removed. He said it happened during breakfast time. He said when he came to work at 6:00 AM Resident #1 sat at the table but didn't have chairs behind him. He said he thought maybe Resident #1 had the chairs placed behind there for about 45 minutes to an hour. He said Staff C reported she put the chair there and Resident #1 hadn't moved since. He said he didn't report it to management and he was told it was already being handled. He said a picture had been taken and the chairs removed by a management staff member. On 12/2/25 at 9:07 AM, Staff E, CNA, reported on the morning of 11/19/25, she saw two chairs behind Resident #1's wheelchair preventing him from getting his wheelchair out. She said Resident #1 was pushed up to the table and Staff C said she did that because he kept standing up.On 12/2/25 at 8:23 AM, Staff D, CNA, reported Resident #1 had a tendency to stand up on his own. She said he used a mechanical stand for transfers and needed constant reminders to stay seated. She said on Sunday, 11/16/25, she saw Staff C push Resident #1 up against the wall/heater vent with his wheelchair and pushed the table up to him. On 12/2/25 at 11:20 AM, the Administrator reported the facility didn't allow any physical or chemical restraints. The facility policy titled Use of Restraints revised April 2017 documented restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls.The facility policy titled Identifying Involuntary Seclusion and Unauthorized Restraint revised April 2021 documented as part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify involuntary seclusion and/or unauthorized restraint of residents. The policy documented the following:Residents are free from the use of any physical restraints not required to treat their medical condition. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:Is attached or adjacent to a resident's body.Cannot be removed easily by the resident (in a manner as it was applied by the staff); andRestrict the resident's freedom of movement or normal access to his/her body.Inappropriate or unauthorized use of a restraint occurs when it:Is used for discipline or convenience.Unnecessarily inhibit a resident's freedom of movement or activity.Is not the last restrictive option or used for the least amount of time needed; and/[NAME] not accompanied by ongoing re-evaluation of the need for the restraint.Sometimes the use of restraints is not intentional, but this does not absolve the staff of the responsibility to recognize and report unauthorized use of a restraint. Example of a physical restraint include:Placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or getting out of bed.Using devices in conjunction with a chair such as trays, tables, cushions, bars or belts, that the resident cannot move and prevents the resident from rising.

Based on staff interviews, personnel record review, facility investigation review, and policy review the facility failed to notify DIAL (Department of Inspection, Appeals and Licensing) of an allegation of abuse for Resident #1 that occurred on 11/19/25 at 6:59 AM in a timely manner. In addition, the facility failed to notify the police of the allegation of abuse. The Maintenance Supervisor reported he told the ADON (Assistant Director of Nursing) of the allegations of abuse on the morning of 11/19/25 at 9:15 AM. The facility investigation for the alleged abuse was initiated on 11/20/25 after the Maintenance Supervisor reported it to the Administrator. The facility reported the incident to DIAL on 11/20/25 at 8:16 PM. The facility reported a census of 37 residents. Findings include:An Incident Report (IR) titled Allegation of Abuse dated 11/20/25 at 4:30 PM documented the Administrator received report of Resident #1 sitting with two dining room chairs placed behind his wheelchair in the common area. The nurse stated that it was so Resident #1 didn't tip backwards in his wheelchair. The IR documented the staff immediately removed the chairs from behind Resident #1 and suspended the nurse. Review of document titled Self Report Summary revealed the facility filed the allegation of abuse with DIAL for Resident #1 on 11/20/25 at 8:16 PM. On 12/1/25 at 10:30 AM, Staff F, Maintenance Supervisor, reported on Wednesday, November 19th at 6:59 AM, he arrived at work and observed Resident #1 sitting in his wheelchair in the front dining room. He said there were two chairs behind Resident #1's wheelchair, keeping him behind the table so he could not back up. He said he moved the chairs and notified the Dietary Manager as she was another department head at the facility at the time. Staff F reported at the daily quality assurance (QA) meeting on 11/19/25 around 9:15 AM, he reported the concern to the Assistant Director of Nursing (ADON). He said the ADON reported she was aware and would take care of the concern. He said the Administrator was not at the meeting. He said the next day around 3:30 PM he sent the Administrator a text and a picture regarding the concern. He said the Administrator reported it should not have happened and would start the process of a self-report. He said he didn't think the self-report process/investigation had been started before then.On 12/1/25 at 12:29 PM, the Administrator reported he didn't notify the police of the allegations of abuse. He said normally he did but didn't know why he didn't, but he should have.On 12/1/25 at 11:50 AM, Staff H, Dietary Manager, reported she walked into the facility between 7:10-7:15 AM. She said Staff F showed her a picture of Resident #1 and told her what was going on. She said the picture showed Resident #1 in his wheelchair up against the table with two chairs behind him. She said the chairs had been removed by the time she got to work. When asked what her reaction was to the picture, she said you can't do that. When asked if she gave any direction to Staff F, she said no. She said Staff F had already done what he was supposed to do by moving the chairs. She said Resident #1 was not being harmed. She said she thought it was a restraint and didn't think it was abuse. When asked if she reported it to anyone, she said no. She said Staff F brought it up that day at the QA meeting at 9 AM. She said there really was not a lot of comment or a whole lot of discussion around it. She said the Administrator was not at the meeting and could not recall where he was.On 12/2/25 at 11:20 AM, the Administrator reported he was out of the facility on 11/19/25. He said he was back in the office on 11/20/25 until 10 AM. He said on 11/20/25 around 3:48 PM he got a text message from Staff F with a picture. He said he didn't read the text message until around 4:30 PM. He said he called the ADON to see what was going on and instructed her to call the Regional Nurse to figure out the next steps since the facility was already late with reporting to DIAL. He said in the text message Staff F reported he brought up the concerns to the team on 11/19/25 and he didn't feel the concerns were being addressed. The Administrator reported he got home around 4:45 PM and the Regional Nurse called him at 5:00 PM. He said there was a rapid response call with the regional team. He said approximately 8 PM he suspended Staff C, Registered Nurse, the ADON and Staff F. He reported he completed the self-report to DIAL at 8:16 PM. A facility form titled Disciplinary Action Form dated 11/21/25 for the ADON documented a written warning given due to the failure to notify the Administrator of an allegation of abuse. The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating revised April 2021 documented the Administrator or the individual making the allegation immediately reports to the state licensing/certification agency responsible for surveying/licensing the facility within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. In addition, the policy directed to notify Law enforcement officials of the allegations.

Based on staff interviews, personnel record review, facility investigation review, and policy review the facility failed to separate a staff member from dependent residents accused of alleged abuse that occurred on 11/19/25 at 6:59 AM for Resident #1. The Maintenance Supervisor told the Assistant Director of Nursing (ADON) of the allegations of abuse on 11/19/25 at 9:15 AM. The ADON did not inform the Administrator of the allegations, did not start an investigation and did not separate the staff member from the resident. On 11/20/25 around 3:48 PM, the Maintenance Supervisor reported the allegations of abuse to the Administrator via text. The staff member worked full shifts on 11/19 and 11/20. The facility reported a census of 37 residents. Findings include: An Incident Report (IR) titled Allegation of Abuse dated 11/20/25 at 4:30 PM documented it was reported to the Administrator that Resident #1 had been sitting with two dining room chairs placed behind his wheelchair in the common area. The nurse stated that it was so Resident #1 did not tip backwards in his wheelchair. The IR documented the chairs were immediately removed from behind Resident #1 and the nurse was suspended. The facility form titled Internal Investigation Witness Statement dated 11/20/25 for Staff C, Registered Nurse (RN) documented Staff C placed a dining room chair sideways behind Resident #1's wheelchair at the dining room table, there were several inches between the resident, the dining room chair and the wall. The statement documented Resident #1 was able to freely move his wheelchair forward and he was also moving the table with his hands several feet in front of him. Staff C reported she did not wedge the chair behind him. Staff C reported she just didn't want Resident #1 to wheel his wheelchair back too far so that he'd fall forward out of it as he was constantly standing up and walking. Review of the Employee Time Entry Report from 11/15/25 to 11/20/25 revealed Staff C worked full shifts on 11/19/25 (14.25 hours) and 11/20/25 (13.63 hours). On 12/1/25 at 10:30 AM, Staff F, Maintenance Supervisor reported on Wednesday, November 19th at 6:59 AM, he arrived at work and observed Resident #1 sitting in his wheelchair in the front dining room. He said there were two chairs behind Resident #1's wheelchair, keeping him behind the table so he could not back up. He said he moved the chairs and notified the Dietary Manager as she was another department head at the facility at the time. Staff F reported the concern to the Assistant Director of Nursing (ADON) at the daily Quality Assurance (QA) meeting on 11/19/25 around 9:15 AM. He said the ADON reported she knew and would take care of the concern. He said the Administrator was not at the meeting. He said the next day around 3:30 PM he sent the Administrator a text and a picture regarding the concern. On 12/2/25 at 11:20 AM, the Administrator reported he was out of the facility on 11/19/25. He said he was back in the office on 11/20/25 until 10 AM. He said on 11/20/25 around 3:48 PM he got a text message from Staff F with a picture. He said he did not read the text message until around 4:30 PM. He said he called the ADON to see what was going on and instructed her to call the Regional Nurse to figure out the next steps since the facility was already late with reporting to DIAL. He said in the text message Staff F reported that he brought up the concerns to the team on 11/19/25 and he did not feel the concerns were being addressed. The Administrator reported he got home around 4:45 PM and the Regional Nurse called him at 5:00 PM. He said there was a rapid response call with the regional team. He said approximately 8 PM he suspended Staff C, Registered Nurse, the ADON and Staff F. He reported he completed the self-report to DIAL at 8:16 PM. He reported with any allegation of abuse he would expect the staff member to be separated/suspended right away. He verified the facility should have suspended/separated Staff C on 11/19/25.A facility form titled Disciplinary Action Form dated 11/21/25 for the ADON documented a written warning given due to the failure to notify the Administrator of an allegation of abuse. The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating revised April 2021 documented any employee accused of resident abuse will be placed on leave with no resident contact until the investigation is complete. If the investigation reveals that the allegations of abuse are founded, the employee will be terminated.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of concern. The facility reported a census of 36 residents. Findings include: The Quality Assurance and Performance Improvement (QAPI) Program revised March 2020 is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and governing body. The Administrator, whether a member of the QAPI Committee or not, is ultimately responsible for the QAPI program and for interpreting its results and findings to the governing body. The governing body is responsible for ensuring that the QAPI program is implemented and maintained to address identified priorities; is sustained through transitions of leadership and staffing; is adequately resourced and funded, including the provision of money, time, equipment, training and staff coverage sufficient to conduct the activities of the program; is based on data, resident and staff input and other information that measures performance and focuses on problems and opportunities that reflect processes, functions and services provided to the residents The facility had the following concerns identified at the current survey, previously cited at surveys in the past year: a. Sufficient Nursing Staff On 5/21/25 at 1:22 PM the Administrator reported they did interviews with the residents. The Administrator stated that we all have community connections and the residents didn't tell the staff their concerns with the call lights. The Administrator explained the residents tell the surveyors their concerns. Even if they had one time six months ago the staff didn't get to their call light soon enough, some residents didn't forget. The Administrator verbalized the one thing that residents don't bring up anymore is call lights. The Administrator stated regarding staff, she felt they would never say they had enough help. The more you have, didn't necessarily mean the work got done faster or more efficiently, and the staff have proved that. The Administrator stated she did call light audits within the last year. The Administrator stated any deficiency they received for staffing, resulted because of resident's interviews and not observation.

Based on clinical record review, Payroll Based Journal (PBJ) data, staff, and resident interviews, the facility failed to provide enough staff to care for residents in a timely manner. The facility reported a census of 36 residents. Findings include: 1. Resident #9 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. On 5/18/25 at 11:29 AM, Resident #9 reported staff could take 30 to 45 minutes and sometimes longer to answer his call light because the facility being short staffed. He reported staff will either quit or have gotten fired. Resident #9 reported he used the clock on the wall to know the length of time of the call light response. Resident #9 said sometimes staff came in, shut off the call light, say they will be back, and then forget to come back. He said the staff run around like their heads are cut off trying to take care of the people. The PBJ Fiscal Year Quarter 1 2025 (October 1 - December 31) date reflected excessively low weekend staffing. A facility form titled Grievance/Concern Investigation dated 2/5/25 documented Resident Council reported call light times between 15 - 30 minutes. The form documented the action and follow up as to continue to audit times and educate on times. The Administrator reviewed the form on 2/5/25. 2. On 5/20/25 at 9:28 AM, Resident #19 reported the facility had more staff than they normally had related to the annual survey and surveyors being present in the building. On 5/20/25 at 10:28 AM, Staff A, CNA (Certified Nursing Assistant), reported the facility was very short staffed and the management staff did not help out. She said there have been times when there was 1 Nurse and 1 CNA for almost 40 residents. She said the facility had a lot of bullying and finger pointing between the staff without any consequences, because of this the staff leave. She said some of her co workers struggled with the DON (Director of Nursing). She said the DON would be on call and when no one shows up or calls in, she would tell the staff to figure it out. She said the DON told the staff they have to find their own replacements. On 5/20/25 at 3:45 PM, Staff B, CNA, reported being mentally and physically exhausted due to the lack of staff on the evening shift. She reported the facility had a lot of times with only 2 aides between 2:00 PM - 4:00 PM and after supper in the main area. She said she tried to get baths done from 2:00 PM - 4:00 PM but that it was very difficult at times. She reported having the memory care unit open made staffing more difficult. She said it could get stressful at bed time as they had a lot of call lights on and residents wanting to go to bed. She said some of the residents exhibited behaviors and yelled at her. Staff B described the shift as overwhelming and overstimulating because of everything going on. She reported she talked to the DON about the staffing and the DON responded all shifts hurt for help. She said the facility hired staff but some of them don't stay and then others are not reliable. She reported she thought the facility's location made it difficult to find staff. She said on weekends it could be worse when the management staff are not there. She said the staff are more likely to call in on the weekends because they can get away with it. She said it is left up to the nurses to find replacements when the facility had call ins and at times the nurse can't find replacements. She said some staff will come in an hour early. On 5/20/25 at 9:57 PM, Staff C, RN (Registered Nurse),, reported usually on the evening shift there are 2.5 CNAs in the main area and once in a while if they are lucky they will have 3 CNAs. She reported staffing was challenging at times. She reported sometimes it can be hard to get to the call lights in a timely manner. She said she tried to respond and help as much as possible but if the resident required the assistance of 2 people she couldn't do it by herself. When asked if any residents had complaints regarding long call lights, she said, I'm sure we do. On 5/21/25 at 11:15 AM, the DON reported they expected the staff to answer call lights within 15 minutes per the policy. She reported when the facility had a call-in during business hours, the ADON and herself help find replacements. She said on the schedules they have a designated staff member scheduled stay over 4 hours if the facility had a call in on the next shift. The DON gave an example: if they have a call in on the 2 - 10 shift, a designated day shift aide would have to stay over until 6 PM. She reported staff members who call in are to try to find their own replacement but it didn't always happen. When asked about after hours or on the weekend, she said the nurses are to attempt to try to find replacements and if they're not able, then they must notify the on call nurse. When asked about the expectation of the on-call nurse, she said it depended on the staffing situation at the time. She said if the facility had 2 or less CNAs, then they expect the on call nurse to come in. She reported 1 nurse and 2 CNAs in the main area was not ideal but manageable. She said she has worked the shift herself and it was doable. When asked about getting baths done with 2 CNAs, she said they usually only have 4 - 5 baths scheduled. She said if they have a call in on the evening shift then the day shift would try to help out to get the baths done. She said her ideal staffing pattern is 3 CNAs in the main area with 1 CNA in the unit on the day and evening shift. For the overnight shift, 2 CNAs in the main area and 1 CNA in the unit. The facility policy titled Answering the Call Light revised March 2021 documented the purpose of the policy as to ensure timely responses to the resident's requests and needs.

Based on clinical record review, staff interviews and review of Medicare guidelines, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) form for 2 of 2 residents (Resident #33 and #27) whose skilled stay ended and they continued to reside in the facility. The facility reported a census of 36 residents. Findings include: 1. Resident #33's Minimum Data Set `MDS` assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. The MDS included diagnoses of hypertension, cerebrovascular accident (CVA), aphasia (difficulty speaking) and dysphagia (difficulty swallowing). The MDS documented Resident #33 used a feeding tube while a resident in the last 7 days. The Clinical Census revealed Resident #33 was admitted to the facility for a Medicare Part A skilled stay on 10/4/24, was discharged from Medicare on 1/6/25 and remained in the facility private pay. The Clinical record lacked documentation a SNFABN form was given to Resident #33 or a resident representative when Resident #33 was discharged from Medicare Part A to private pay. 2. Resident #27's Minimum Data Set `MDS` assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, which indicated severely impaired cognition. The MDS included diagnoses of pneumonia, urinary tract infection, depression, coronary artery disease and hypertension. The Clinical Census revealed Resident #29 was admitted to the facility for a Medicare Part A skilled stay on 3/7/25, was discharged from Medicare on 4/3/25 and remained in the facility private pay. The Clinical record lacked documentation a SNFABN form was given to Resident #33 or a resident representative when Resident #27 was discharged from Medicare Part A to private pay. On 5/19/25 at 12:59 PM, the Administrator reported she could not locate a SNF ABN Form CMS 1055 for Resident #33 or Resident #27 when they were discharged from Medicare Part A and remained in the facility. On 5/19/25 at 2:22 PM, the Administrator reported it was an expectation for the SNF ABN Form CMS 105 to be completed when a resident was discharged from Medicare Part A and remained in the facility. The facility policy titled Medicare Advanced Beneficiary Notice dated April 221 documented it was the facility policy to inform residents in advance when changes will occur to their bills. The policy directed that if the admission coordinator or business office manager believed that Medicare would not pay for an otherwise covered skilled service, the resident or representative would be notified in writing why the service may not be covered and the resident's potential liability for payment of the non covered service. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage CMS 105 to the resident prior to providing care that Medicare usually covers, but may not pay for because the care was considered not medically reasonable and necessary, or custodial. The resident or representative may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well being for 1 of 1 residents reviewed (Resident #13). The facility failed to immediately assess Resident #13 after she was lowered to the floor and scraped her back on the wheelchair. Findings include: Resident #13's Minimum Data Set `MDS` assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #13 required substantial/maximal assistance with bed mobility, transfers and ambulation. The MDS included diagnoses of hypertension (high blood pressure), viral hepatitis (infection affection the liver), diabetes mellitus, bipolar disorder and anxiety disorder. The MDS revealed Resident #13 had 2 or more falls without injury since the last assessment. On 5/18/25 at 2:43 PM, Resident #13 reported she fell all the time. She said her legs didn't work and she kept trying. She reported she last fell about a week ago. She said 2 staff members need to help her transfer and she only had 1 staff member. She reported the staff member dropped her. She added she wouldn't fall if the staff member had more help. She explained she scratched her back on the wheelchair, but the scratch didn't hurt. The Incident Report (IR) dated 5/15/25 at 8:10 PM documented a staff member was assisting Resident #13 with peri care after toileting and asked Resident #13 to sit back down so she could get assistance to help with the transfer. The IR documented Resident #13 was impatient and attempted to transfer herself back into the wheelchair, misjudged the distance and staff had to assist Resident #13 to the floor to prevent falling. The IR documented an injury post incident that included an abrasion of the vertebrae. A Progress Note dated 5/16/25 at 5:48 AM revealed Resident #13 was assisted to the floor to prevent falling. The progress note documented Resident #13 was assessed but the note lacked any documentation or an assessment regarding an abrasion to Resident #13's back. A facility form titled Wound Evaluation dated 5/16/25 at 10:15 PM documented Resident #13 had an abrasion to the spine that measured 6 cm (centimeters)(width) x 18.39 cm (length). The form documented that the area occurred on 5/15/25. A Progress Note titled Communication with Physician dated 5/17/25 at 2:39 AM documented on 5/16/25 nurse was notified that Resident #13 received skin area to back during the 5/15/25 incident. The note documented the nurse assessment skin head to toe and noted an abrasion/scratch and bruise to Resident #13's back. On 5/20/25 at 10:28 AM, Staff A, CNA (Certified Nursing Assistant) reported she was going down the hallway and Resident #13 roommate came out of the room without her pants on and told her that Resident #13 needed help. She said she went into the room and Resident #13 had transferred herself onto the toilet. She said there was bowel movement (BM) everywhere on the floor all the way to the bathroom. She reported she cleaned up the floor and then proceed to help Resident #13. Staff A said Resident #13 reported she had transferred herself from the wheelchair to the toilet but she thought Resident #13 may have ambulated to the toilet because of all the BM on the floor. She said she put a gait belt on Resident #13 and stood her up to clean up her bottom and then had her sit back down on the toilet. She said Resident #13 required assistance of 2 for transfers so she stepped out of the bathroom, went to check the room number on the outside door and walkie for assistance. She said she was gone maybe a minute and when she went back into the room, she saw Resident #13 was already transferring herself from the toilet and her knees were buckling. She said the gait belt was still in place and she tried to assist Resident #13 but could not get her back into the wheelchair so she lowered her to the floor. She said Resident #13 had scraped her back on the wheelchair and there were two small skin tears that were bleeding a little bit so she knew the nurse would need to take pictures. She said she found the nurse passing medications in the center hall. She said the nurse did not come to Resident #13's room for at least 30-40 minutes. She said the nurse finished passing medications in the center hallway and the right hall before she came to assess Resident #13. Staff A reported she kept trying to walkie for the nurse but the nurse's walkie talkie was dead. She said after waiting 15-20 minutes for the nurse to come and assess Resident #13 and she did not come so herself and two other aides got Resident #13 off the floor and into her wheelchair. She said one staff member stayed with Resident #13 until the nurse came and the other two staff members went to lay other residents down. When asked how she knew how long it took for the nurse to come she said she knew it was a long time as the staff was able to lay down several residents while waiting for the nurse to come. She said after the nurse came and assessed Resident #13, she left her in the wheelchair and did not tell the staff and Resident #13 tried to self-transfer again. She reported she had tried to call the DON (Director of Nursing) regarding the nurse but the DON did not answer. On 5/20/25 at 3:45 PM, Staff B, CNA reported Resident #13's call light had been on and she had transferred herself to the toilet and then was lowered to the floor. She said the aide who lowered her to the floor used the walkie talkie for help. She said the nurse's walkie was on but was not sure where the walkie was located. She said she did not know if the walkie talkie was with the nurse or at the nurses' station. She said the staff used the walkie talkie multiple times asking the nurse to come and also went in person and told the nurse Resident #13 was on the floor. Staff B reported the nurse said she was coming. She said the nurse was at the table in the living room with her lap tap. She said they waited about 10 minutes before herself and two other aides got Resident #13 off the floor. She said she was not going to leave Resident #13 sitting on the floor. She said they lifted her with a gait belt into the wheelchair. She said they left Resident #13 in her wheelchair for a while for the nurse to check her out. She said they put Resident #13 to bed right before 10 PM and that she was the last one to go to bed. She said she did not witness the nurse going into the room. She said the nurse could have and she was not aware of it. On 5/20/25 at 9:57 PM, Staff C, RN (Registered Nurse) reported on the evening of 5/15/25, she was down the center hall passing medications. She said Staff A, CNA approached her and told her that Resident #13 had taken herself to the BR, had a BM and Staff A had cleaned her up on the toilet. Staff C said Staff A told her that she had gone to check the room number and call for assistance. She said in the meantime Resident #13 decided to self-transfer from the toilet to the wheelchair and Staff A saw that Resident #13 was not going to make it so she assisted Resident #13 by lowering her to the floor to prevent a fall. Staff C reported she was in the middle of passing medication along with giving insulin and she did not want to make a medication error so she finished up with that resident before going to Resident #13's room. She acknowledged and reported that there was a delay in response. She said she made the decision based on the facts that she knew Resident #13 was lowered to the floor, did not actually fall and had not hit her head. She reported when she completed the medications for the one resident, she secured her lap top and med cart and went to Resident #13's room. She said by then there was a 2nd staff member present (Staff B) and the staff had gotten Resident #13 up off the floor and into the wheelchair. She verified Resident #13 had not been assessed before she was moved off the floor. When asked how much time had passed from when she was first told Resident #13 was on the floor by the time she got to the room, she said she did not feel like it was longer than 10 minutes. She said she assessed Resident #13 which included her vital signs and range of motion. She reported she had been notified Resident #13 had an injury on her back. She said she did not look at her lower back at that time. She said she was going to go back when Resident #13 was in bed to look at her back and she did not. She stated she had forgotten and got busy. She said the next day the day shift nurse evaluated Resident #13's back. On 5/21/25 at 11:15 AM, the DON reported she would expect the nurse to complete a nursing assessment before the resident was assisted off the floor. In addition, the DON reported she would expect the nurse to assess Resident #13 back after the fall. The DON said she had identified Resident #13 did not have an assessment completed of her back until the following day. She acknowledged when a staff member lowers a resident to the floor that it was still considered fall and the staff would complete the required fall documentation. The DON reported she was aware and acknowledged there had been a delay in the nurse assessing Resident #13 after a fall. She said she expected the nurse to stop the medication pass and assess the resident after the fall. She said she was in the process of completing a write up for the nurse and would provide the surveyor with a copy. A facility form titled Corrective Action Form dated 5/21/25 documented Resident #13 had a witnessed fall on 5/15/25 in which she was lowered to the floor by Staff A. The form documented that it was reported Staff C did not respond to the fall to complete an assessment timely on 5/20/25 to the DON. The form documented Resident #13 was found to have an abrasion to her spine on 5/16/25 by the day shift nurse. The form revealed the corrective action documented, it was an expectation that Staff C do a full head to toe assessment including skin checks and vital on any resident that has a fall prior to the resident being moved from the position they are in. In addition, if Staff C was completing the medication pass, it was an expectation that Staff C stop what she was doing and attend to the resident. The facility policy titled Change of Condition/Hot Chart Protocol dated January 2015 documented the purpose of the policy was to provide care to residents through nursing assessment, interventions and appropriate follow up. The policy documented a change in condition was an alteration from normal status with could include but not limited to an accident, incidents with or without injury, and skin changes.

Based on clinical record review, facility policy review, provider guidelines, staff, and nurse practitioner interview the facility failed to notify the provider on a resident that had a decline in condition after a fall on 9/3/23, for which the resident started to present with changes in altered mental status, unstable vital signs, and vomiting. The resident passed away at the facility on 9/5/22. (Resident #1). This failure put the facility into an Immediate Jeopardy to the health, safety, and security of the resident. The facility also failed to notify a provider of a resident that contacted the Suicide Hotline and required 1-1 supervision. (Resident #9). The facility identified a census of 37 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on January 30, 2023 at 3:16 PM. The facility removed the Immediate Jeopardy on January 30, 23 through the following actions: a. The need to assess and intervene on vitals that are not within normal parameters must be addressed with interventions per provider direction - if the intervention is not effective this information must be relayed to the provider and further directions will be given per the provider. b. Low oxygen levels with saturation of oxygen intervention that is not effective must have another conversation with the provider. c. Education on Acute Condition Changes - Clinical Protocols The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Include: 1. Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of coronary artery disease, renal insufficiency, diabetes mellitus, non-Alzheimer's dementia, depression, and a history of falling. The MDS identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate decision-making abilities. The MDS documented the resident with adequate hearing, vision and had the ability to be understood and understand others. The MDS indicated that Resident #1 required supervision with bed mobility, transfers and personal hygiene. In addition, Resident #1 required limited assistance with dressing and toilet use. The Care Plan Focus dated 8/15/22 listed transitional Care Planning. The Focus included an Intervention to transition home with goals met. The Care Plan Focus dated 8/15/22 identified Resident #1 as a risk for falls. The Focus included the following interventions: *Encourage Resident #1 to use his call light for assistance. *Resident #1 needs a safe environment without clutter. *Monitor Resident #1 for unsteady gait. The Care Plan Focus dated 8/15/22 indicated that Resident #1 had a defibrillator related to atrial fibrillation. The Focus included an intervention to monitor, document, and report as needed any signs and symptoms of altered cardiac output or pacemaker malfunction, dizziness, syncope, difficulty breathing (dyspnea), pulse rate lower than programmed rate, lower than baseline blood pressure. The Care Plan Focus dated 8/15/22 listed that Resident #1 had an impaired cognitive function/dementia or impaired thought processes related to Lewy Body Dementia. The Focus Intervention that directed staff to monitor, document, and report as needed any changes in cognitive function, specifically changes in: decision making abilities, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Review of Progress notes documented on: *9/4/22 at 12:08 AM, Incident, Accident, Unusual Occurrence Note, indicated the nurse heard Resident #1 yell for help. The nurse observed him sitting on the floor with his left leg bent at the knee and lying on the floor. His right leg bent at the knee and his foot on the floor. Sitting on his right butt cheek. He was able to straighten his legs with no rotation noted, he denied pain. He helped get up by placing his feet flat on the floor. Two staff lifted him and sat him on the bed. The floor was wet with urine. His blankets were on the floor with him and half on the bed. He leaned on the pillow between him and the bed while resting his head on the pillow. He was barefoot, with his brief off and on the floor next to him. His urinal was on the other side of the bed on the table with urine in the urinal. He tells the nurse that he was trying to sit in the recliner. Blood pressure 114/74 (average range 90/60 to 120/80), temperature (temp) 98.8 degrees Fahrenheit (average temperature 98.6), Pulse 92 (average 80 to 100), Respirations 16 (average 12-20), pulse oximetry 93% (average 90 to 100%), blood sugar is 72 (average 80-130) which is low for this resident. The nurse gave him chocolate milk and pudding, then rechecked his blood sugar and remained at 72. Vital Signs, blood pressure 176/71 (elevated), temperature 98.7 degrees Fahrenheit, pulse 90, respirations 16 and 90% for pulse oximetry, he is very shaky but his speech is clear and he could feed himself. Continued with cheese, Graham crackers and grape juice. Temperature 98.4, blood pressure 154/72 (elevated), pulse 100, respirations 16, pulse oximetry 91% and Blood sugar is 122. The nurse added a note in the Doctor's book to update him on the fall and low blood sugar. The nurse planned to call the wife in the morning. *9/4/22 at 1:20 AM, Administration Note: Tylenol, Tablet 325 Milligrams (MG), give 2 tablets by mouth every 6 hours as needed for pain. *9/4/22 at 3:06 AM, Alert Note: BLOOD PRESSURE WARNING: Value: 164/77 (high of 150 exceeded), after a fall and has a fever. *9/4/22 at 3:09 AM, Alert Note: BLOOD PRESSURE WARNING: Value: 176/71 (systolic high of 150 exceeded), after a fall and a low blood sugar. *9/4/22 at 3:10 AM, Alert Note: pulse oxygenation (ox) 87.0, (Low of 89.0 exceeded), breathing through his mouth and a low blood sugar *9/4/22 at 3:14 AM, Alert Note: TEMPERATURE, WARNING: Value: 100.7, (High of 99.0 exceeded) *9/4/22 at 3:28 AM, Administration Note Text: Tylenol Tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain as needed (PRN) Administration was ineffective Temp 100.2 from 100.8. *9/4/22 at 3:37 AM, Alert Note Text: BLOOD PRESSURE, WARNING: Value: 151/68, (Systolic High of 150 exceeded), after a fall and has a temperature. *9/4/22 at 3:38 AM, Alert Note Text: TEMPERATURE, WARNING: Value: 100.2, (High of 99.0 exceeded), after the Tylenol *9/4/22 at 9:19 AM, Administration Note: Tylenol Tablet 325 MG, give 2 tablets by mouth every 6 hours as needed for Pain, Temp 100.3 Tylenol repeated. *9/4/22 at 10:21 AM, Administration Note: Atorvastatin calcium Tablet, give 10 mg by mouth one time a day for lower cholesterol, held due to vomiting. *9/4/22 at 10:22 AM, Administration Note: Cholecalciferol Tablet 50 micrograms (MCG) (2000 UT) give 2 tablets by mouth one time a day for supplement, held due to vomiting. *9/4/22 at 1:27 PM, Alert Note: BLOOD PRESSURE WARNING: Value: 127/58, (Diastolic low of 60 exceeded).] No adverse effect noted. *9/4/22 at 1:30 PM, Alert Text: TEMPERATURE WARNING: Value: 99.4 (High of 99.0 exceeded). Noted resident currently ill. *9/4/22 at 2:48 PM, Focused Evaluation Text: Reason for Evaluation: Incident/Accident/Unusual Occurrence Follow-up Charting: Vitals Temp - 99.4, Route: Forehead (non-contact) Blood pressure (BP) - 107/65 - Position: Lying left/arm Pulse (P) - 61, Regular Respirations (R) - 16 Resident lying in bed with eyes closed. Skin pale warm to touch. Temperature (T)- 100.3 other Vital signs at 9:19 AM Resident status post falls this early AM, Tylenol given per PRN order. At 9:30 AM assisted the resident to the side of the bed for breakfast. Resident was awake and conversing normally. Took a few bites of breakfast and vomited undigested food. Denies abdominal pain, assisted resident to lie down abdomen soft with active bowel sounds x four quadrants. tested for COVID as resident has clear nasal drainage and elevated temp but the test negative. Blood sugar 225 but insulin held due to emesis, Resident #1 not eating, and retaining food. At 10:30 AM Resident #1 retained his Tylenol and other meds. Temp down to 99.4. Blood sugar went up to 309 so insulin is given. Resident resting in bed. At 11:30 AM, Resident temp remains at 99.2 with no further nausea or vomiting. Cares given and assisted to the recliner by two staff for lunch. Resident sluggish at first but then fully awake and able to feed himself his lunch with staff supervision. Resident #1 able to take his fluids well. *9/4/22 at 3:26 PM, Focused Evaluation Note: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vitals T 99.4 Route: Forehead (non-contact) BP 107/65 Position: Lying left/arm P 61 Regular R 16. Oxygen Saturation (O2) at 91.0% on room air Changes in Condition At 2:00 PM, Resident #1 rested quietly in bed. Retained all of his lunch and medications. Skin pink, warm, and dry. Resident #1 responds readily to stimuli. *9/4/22 at 8:34 PM Nurses Note: Hour of sleep (HS) pills given. Resident #1 appeared soaking wet. The nurse changed him, cared for him, and changed his sheets. Resident #1 wet again and the nurse changed him again. Blood Sugar 127 at the time. *9/4/22 at 10:35 PM, Nurses Text: Blood Sugar is 86 with a temperature of 100.8 at the time. Tylenol given. Resident #1 could talk with clear speech. Resident #1's skin felt warm and dry. Resident #1 did not shake at the time. At the time Resident #1 was incontinent of urine and the staff changed his bedding. *9/4/22 at 11:07 PM, Nurses Note: Resident states he feels fine. Skin is warm to touch, Tylenol given to him. Blood pressure 78/61 (below normal), temperature 100.9, pulse 98, respirations 18, pulse ox 87%. No use of accessory muscles to breathe. Denies shortness of breath. Respirations are even and unlabored. His oxygen does go up to the 90% when he breathes in through his nose and out his mouth. He is a mouth breather. He did not have a fever until 10:00 PM. *9/5/22 at 12:24 AM, Nurses Note: Note left in the doctor's book to update the two nights in a row he had low blood sugars and spiked a fever. *9/5/22 at 1:08 AM, Focused Evaluation Note: Reason for Evaluation: Hot Charting & Incident/Accident/Unusual Occurrence Follow-up Charting Vitals Temperature 100.0 Route: Forehead (non-contact) BP 78/61 (low blood pressure) P 84 Type: Regular R 18 O2 89.0% Method: Room Air Changes in Condition Other, No injuries from his fall. Denies pain. The nurse received a report that Resident #1 had a fever, could not stand with help, or feed himself off and on through the day. He did sit up on the edge of the bed and ate a portion of his supper. Resident #1's blood sugar stayed good that day. That night his blood sugar dropped again and he needed help to eat, but he could eat and swallow. Resident #1 could talk with clear speech. Resident #1's temp spiked to 100.0 and the nurse gave him Tylenol. Resident #1 had 24 hours and two nights of his temp spiking and his O2 in the high 80's. Respirations are even and unlabored. Denies pain in his ribs and/or pain with breathing. He had a blood sugar of 122. Resident #1 was very incontinent throughout the day. Resident #1 required two assist at times with his care. The nurse put a note in the doctor's book to update on his temp and low O2 at HS although he breathes with his mouth. FYI related to his blood sugars dropping. *9/5/22 at 2:44 AM, Alert Note: Low of 89. oxygen saturation, bounces between 91% and 86%. Resident #1 breathes through his mouth. Respirations are even and unlabored. Resident #1 denied shortness of breath. *9/5/22 at 2:46 AM, Alert Note: TEMPERATURE WARNING: Value: 100.0, (High of 99.0 exceeded) LITTLE ELEVATED. blood sugar WAS LOW. *9/5/22 at 2:47 AM, Alert Note: TEMPERATURE WARNING: Value: 100.9, (High of 99.0 exceeded). Tylenol given. *9/5/22 at 2:49 AM, Alert Note: BLOOD PRESSURE WARNING: Value: 78/61, (systolic Low of 90 exceeded). Resident #1 also had a low blood sugar at the time. *9/5/22 at 2:49 AM, Alert Note: BLOOD PRESSURE WARNING: Value: 83/65, (systolic Low of 90 exceeded). Resident #1 laid most of the day, on his left side. He did sit up on the edge of the bed for supper without any dizziness or feelings of being light-headed. *9/5/22 at 12:54 PM, Administration Note: Obtain weight upon admission then for three weeks for a total of four weekly weights, every Monday day shift. Resident #1 refused to get out of bed that shift, the nurse documented that they would continue to attempt to get his weight. *9/5/22 at 3:08 PM, Focused Evaluation Note: Reason for Evaluation: Hot Charting & Incident/Accident/Unusual Occurrence Follow-up Charting Vitals T 97.5 Route: Forehead (non-contact) BP 113/50 Position: Sitting right/arm Pulse 95 pulse Type: Regular R 16 O2 91 % Method: Room Air Resident post fall follow up with neuros. Resident #1 appeared restless that shift, with incontinence of bowel and bladder. The staff assisted Resident #1 to get changed and provided peri-cares. Resident #1 then rested in bed. The nurse noted a small pinpoint abrasion to the right forehead. Resident #1 denied pain or discomfort. *9/5/22 at 5:16 PM, Administration Note: when the nurse entered the room to administer medications resident noted without pulse, without respirations, and fixed pupils. During an interview on 1/26/23 at 3:02 PM, the regional corporate nurse confirmed and verified that the clinical record lacked any documentation of the provider being notified of Resident #1's change in condition. The Regional Nurse explained that it is the expectation of the nurses to notify a provider of mental status changes, vital sign changes, and to follow the guideline and policy and procedure for changes in condition. During an interview on 1/26/23 at 4:37 PM, Staff A, Registered Nurse (RN), explained that Staff B, Licensed Practical Nurse (LPN), told Staff A that Resident #1 had a fall on 9/3/22 around 11:30 PM. Staff B explained they started a neurological (neuro) flow sheet in the clinical record. Staff A continued with the neuro flow sheet per the facility policy. Staff A verified that Staff A failed to notify the provider of the changes in the resident's condition, for which included abnormal vital signs, vomiting, changes in blood pressures, and holding his medications. Staff A confirmed that they failed to notify the provider. Staff A stated it is expected that the nurses notify the provider of any changes in mental status and abnormal vital signs. Staff A acknowledged that the resident had a change in condition while doing neuros and was shocked when the resident had passed away. Staff A verified that they failed to notify the provider or call 911 to have the resident sent out after the change of condition. During an interview on 1/26/23 at 5:00 PM, Staff B, said that Resident #1 had an unwitnessed fall in his room and neuros were started according to the facility policy and procedure. Staff B said that Resident #1's vital signs started to become abnormal during the morning hours on 9/4/22. Staff B confirmed that they failed to notify the provider with the change in resident vital signs and his change in condition. Staff B explained that it is expected that nurses follow the facility policy and procedure for notifying a provider of a resident's change in condition. During an interview on 1/30/22 at 10:30 AM, the facility Administrator verified that the clinical record lacked documentation of the provider being notified of Resident #1's change in condition. The Administrator reported that she expected the nurses to inform the provider of any changes in a resident's condition and to follow the facility policy and procedures. During an interview on 1/30/23 at 1:40 PM, Staff C, Advanced Registered Nurse Practitioner (ARNP), stated that they did not know of Resident #1's change in condition. Staff C explained that at the nurses' station is a binder that has guidelines on when to notify the provider on an urgent and non-urgent notification. Staff C explained that it would be expected by the facility nurses to notify a provider of a change in resident condition. Staff C explained that the health clinic didn't have an opportunity to take care of the resident to assess or intervene as needed to see if there was something else going on that changed his mental status and his change in condition. Staff C explained that it was unfortunate that no one notified the provider to transfer Resident #1 from the facility to determine the change in the resident or to do any interventions while the resident was still at the facility. Review of the undated Guidelines directed that *ensure to call the correct Provider for the patient *be prepared to take orders This is meant to serve as a general guideline. However, please do not hesitate to call if you have concerns for your patient. CALL IMMEDIATELY FOR: *any unstable patient *falls with injury *altered mental status *unstable vital signs *chest pain *fever *hypoxia *shortness of breath *syncope (fainting) 2. Resident #9's Admission MDS assessment dated [DATE], included diagnoses of anemia, osteoporosis, multiple sclerosis, seizure disorder or epilepsy, malnutrition, anorexia nervosa, chronic pain syndrome and adult failure to thrive. The MDS identified a BIMS score of 15, indicating no impairment for decision making abilities. The MDS documented Resident #9 had adequate hearing, vision, with the ability to understand and be understood. The MDS indicated that Resident #9 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS explained that over the last 2 weeks the resident had trouble falling or staying asleep, feeling tired, having little energy, no thoughts of being better off dead, hurting herself in some way, feeling down, depressed, or hopeless. The Care Plan Focus reviewed on 2/2/23 at 3:33 PM stated that Resident #9 has a behavior problem of manipulation. The Care Plan Focus reviewed on 2/2/23 at 3:33 PM indicated that Resident #9 felt down, depressed, or hopeless. The Interventions included: * One-on-one (1:1 (line of sight)) until cleared by doctor or ARNP for safety concerns. * 1:1 visit with Resident #9. * Activities to visit with me and provide brief opportunities for me to share in common activities. * Allow me to verbalize my feelings and listen in a non-judgmental manner. * Psychiatric talk therapy evaluated for new on-set signs or symptoms of depression. * Monitor Resident #9 for suicidal ideations. * Observe Resident #9 for changes in her mood status. * Refer Resident #9 to a psychological counseling/mental health specialist. Activities staff to visit with her and provide diversional activities. * Administer medications as ordered. Monitor for and document any side effects and effectiveness. * Anticipate and meet Resident #9's needs. * Assist Resident #9 with a selection of appropriate coping mechanisms. * Do not argue with her. * Explain all procedures to Resident #9 before starting and allow her a couple minutes to adjust to changes. * Resident #9 has a history of telling one staff member something and then telling another staff member something different or denying her original comments. * Resident #9 has started calling the All-purpose Talk line. Resident #9 tells different staff different stories as to what she is doing, who she is calling, and why she called. Review of Progress notes documented on: *1/30/23 at 5:22 AM, Focused Evaluation Note Text: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vitals T 97.3 Route: Forehead (non-contact) BP 122/75 P 72 Pulse Type: Regular R 18 O2 96.0 % Method: Room Air Behaviors Other (specify) Monitoring for issues with eating solids. Resident #9 needs much encouragement to get up in her wheelchair or chair for supper. The staff offered it multiple times. After the start of supper getting served Resident #9 wanted to get up after multiple refusals or simply not answering staff when asked. Resident #9 had no issues with eating or drinking. The staff reported that night they overheard a resident on the phone talking to someone. Later Resident #9 told another staff she used the phone to call the suicide hotline. The nurse spoke with Resident #9 regarding the phone call. Resident #9 reported that she called them twice that day. She reported that she felt like she is too fat, that everyone hates her, that she makes everyone upset all the time, and that she didn't want to be here. Resident #9 reported no plan in action to harm herself and that she had no thoughts of self-harm. While speaking with the nurse, Resident #9 appeared tearful at times then fine. Would frequently look at the nurse and not answer for a minute, then she would repeat herself. Resident #9 could not stay on the current subject she was talking about without changing the subject and asking can you do this, I need this. On 1/30/23 at 5:04 PM, Focused Evaluation Note Text: Reason for Evaluation: Incident/Accident/Unusual Occurrence Follow-up Charting, Vitals T 97.3 Route: Forehead (non-contact) BP 122/75 P 72 Pulse Type: Regular R 18 O2 96.0 % Method: Room Air Resident #9 appeared very argumentative and cross that day. She argued about her shower, the food, what was brought, not brought, who would bring her shot, her medications, her water, her milk, on and on. She refused to come to the dining room for meals and refused a shower as she didn't want to be wet. Resident #9 just wanted to call the facility over and over again and have the staff come to her room to assist her frequently. She doesn't like the noise her roommate makes. Asks that she be medicated. She has made no comments as to suicide or feeling down/depressed, even when asked. The nurse would continue to monitor. On 1/31/23 at 1:53 AM, Focused Evaluation Note Text: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vitals T 97.3 Route: Forehead (non-contact) BP 122/75 P 72 Pulse Type: Regular R 18 O2 96.0% Method: Room Air No choking noted this evening, Resident #9 went out to the dining room for the supper meal. No observed coughing, on auscultation (listening) Resident #9's lungs sounded clear. Resident #9 appeared to seek attention per her baseline. The staff did not report that Resident #9 called the suicide hotline. On 1/31/23 at 10:08 AM, Note Text: call placed to physician's office to get Psychological services ordered, the provider was out of office, so the nurse asked to speak to another provider nurse that resident has seen. The office reported that they didn't have anyone available and voiced it was alright to go through the facility's Medical Director. The staff reported that Resident #9 has called the suicide hotline. The nurse went to talk to Resident #9 regarding the report to check on her to see if she still had thoughts of hurting herself. Resident #9 denied ever calling the line or having those thoughts. The nurse reached out for orders on talk therapy and will have the Psychiatrist see her. On 1/31/23 at 1:16 PM, Focused Evaluation Note Text: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vitals T 97.3 Route: Forehead (non-contact) BP 122/75 P 72 Pulse Type: Regular R 18 O2 96.0 % Method: Room Air Behaviors: Residents declined to eat breakfast today. Did come to the doctor's for lunch but immediately afterward wanted to go back to her room after eating only bites. She began crying out for help and acting out. The doctor's staff attempted to calm and redirect her, but in the end, it was better to appease her and allow her to return to her room. She was changed and happy. Resident #9 is very manipulative and requires more of the staff's time than is necessary. Resident #9 can be argumentative at times, she denied suicidal ideation, or thoughts, and she does not have a plan or want to hurt herself. The nurse would continue to monitor. On 1/31/23 at 1:13 PM, Resident #9 continued to call the suicide hot line, while denying that she did. The staff could hear her on the call with the person's responses to her. During an interview on 1/30/22 at 5:22 PM, Staff D, LPN, stated that they overheard a conversation between staff that Resident #9 was on the telephone with the suicide hotline. Staff D explained that they went into Resident #9 room and proceeded to ask the resident if they were going to harm themselves or if she had a plan to harm herself, but she reported no. Staff D verified that they failed to notify the provider of the phone conversation and that is it the expectation of the nurses to notify the provider of resident change in status. During an interview on 1/31/22 at 4:30 PM, the facility's Regional Corporate Nurse Consultant confirmed that the clinical record lacked documentation of notification to the provider of Resident #9's phone call to the suicide hotline. The Regional Corporate Nurse Consultant explained that she expected the nurses to notify the provider of changes in a resident condition according to the facility's policy and procedure. During an interview on 1/31/23 at 4:30 PM, the Administrator confirmed that the clinical record lacked documentation that the provider got notified of Resident #9's phone call with the suicide hotline. The Administrator reported that she expected the nurses to notify the provider of changes in a resident's condition according to the facility's policy and procedure. During an interview on 1/31/23 at 5:15 PM, Staff E, LPN, stated that the provider did not get notified of Resident #9's calling the suicide hot line. Staff E reported that it is expected that the nurses follow the facility policy and procedure for notifying the provider of a change of condition with a resident. During an interview on 2/1/23 at 12:00 PM, Staff F, certified nursing assistant (CNA), overheard the lady on the other end of the phone telling Resident #9, that if she continued to have suicidal thoughts to call them back. During an interview on 2/1/23 at 2:28 PM, Staff G, RN, said that she checked the call logs and there is not a phone call from the facility to inform the provider that Resident #9 called the suicide hotline. Staff G said that it is the expectation for the nurses to notify the provider on call or at the office of the phone conversation. During an interview on 2/2/23 at 2:15 PM, Staff H, RN, said that Staff F, notified them that they heard the tail end of a phone conversation between Resident #9 and someone else for which the person on the other end of the phone told Resident #9 that if she continued to have suicidal thoughts to call back. Staff H confirmed that they failed to notify the provider of the phone conversation and that it is expected to notify the provider of a change in resident condition. Review of the facility policy for Change in Residents Condition or Status dated March 2021, explained that the facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or statute (changes in level of care). 1. The nurse will notify the resident's attending physician or physician on call when there has been a *accident or incident involving the resident *discovery of injuries of unknown source *significant change in the resident's physical/emotional/mental conditions *specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: *will not normally resolve itself without intervention by staff or by implementing standard disease-relate clinical interventions *impacts more than one area of the resident's health status.

Based on observations, clinical record reviews, employee time card reviews, facility policies reviews, and staff interviews, the facility to provide appropriate education related to the sounds of the door alarms to ensure safety for one of three residents reviewed (Resident #1). Interviews determined that the staff reported that they could not hear the alarms or they heard the alarms but did not know what the sound meant. In the afternoon of 9/5/22, Resident #1 became anxious after becoming incontinent. Some of the staff reported that Resident #1 turned on his call light but when no one answered it, he exited the facility through the left, or west, exit door. As he exited the door, the door alarm sounded but due to the lack of knowledge the staff did not know that the sound meant a resident exited the facility. As two employees went to leave the facility for the end of their shift they heard the alarm sounding and immediately responded to action. Due to the remainder of the staff reporting that they either did not hear the alarm or did not know the door alarm sound, the resident managed to leave the building unattended for an undetermined amount of time. Based on interviews and time card reviews, the resident exited the building after 2:45 PM and returned to the facility around 3:00 PM. Resident #1 managed to leave the building, made his way to the frequently traveled highway and got approximately to the second house on the next block on the north side of the road. Resident #1 walked past the county highway along the state highway. Since the staff did not notice Resident #1's escape from the facility and his walk on the state highway this resulted in immediate jeopardy to the resident's safety. On 9/28/22 at 2:20 PM the Administrator received notification of the immediate jeopardy. The facility reported a census of 34 residents. Findings include: Resident #1's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS indicated that Resident #1 did not wander in the assessment period. The MDS included Resident #1's staff assessment of his daily and activity preferences that indicated he enjoyed spending time away from the nursing home and spending time outdoors. The MDS documented that Resident #1 required extensive assistance of one person with transfers, walking in his room, walking in the corridor, and toilet use. Resident #1's balance during transitions and walking indicated that he remained steady at all times and that he had an impairment with one upper extremity. Resident #1 did use a mobility device. The MDS section related to Functional Abilities and Goals recorded that Resident #1 could walk ten feet independently, walk 50 feet with two turns, and walk 150 feet in a corridor with supervision or touching assistance on admission. Resident #1 did not have a toileting program and always had incontinence of urine and frequent incontinence of bowels. The MDS included diagnoses of myopia, otherwise known as nearsightedness, first degree atrioventricular block, and [CONDITION(S)]. The section labeled restraints and alarms included that Resident #1 used a wander/elopement alarm every day. The Incident, Accident, Unusual Occurrence Note dated 9/5/22 at 5:07 PM documented that Resident #1 eloped out the left hall door near his room. He frequently attempts to exit the facility. At the time of the incident both nurses working the floor helped other residents in their rooms. One of the nurses recently started at the facility did not know the wander guard tones. The other nurse could not hear the alarm while she changed a catheter and The staff located Resident #1 and returned him to the facility by two certified nurse aides (CNA's) unharmed, unhappy but unharmed. The resident appeared happy after the CNA's cleaned him up. The Care Plan focus initiated on 12/27/21 recorded Resident #1 as an elopement risk/wanderer related to impaired safety awareness. The Goal indicated that Resident #1 would not wander into unsafe situations. The Care Plan included the following interventions: a. Distract Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversation, TV shows and books that he prefers. Date Initiated: 12/27/21 b. Place Resident #1 in an area with the ability to provide frequent observation. Date Initiated: 12/27/21 c. Wander Alert bracelet to left wrist. Date Initiated: 12/27/21 On 9/27/22 at 2:43 PM observed Resident #1 resting in his room. Observed Resident #1's room halfway down the C hall on the west side of the hall. On 9/27/22 at 2:52 PM noted each exit door in the facility closed with its alarm set. On 9/27/22 at 2:53 PM, noted a door in the restorative room locked to the courtyard. The door had a sign that said the door must be locked at all times. Outside of the door showed an enclosed courtyard area. On 9/27/22 at 3:19 PM Staff A, Cook, reported that her friend Staff D, Cook, found Resident #1. Staff A explained that she worked the second shift in the kitchen. When Staff D, Cook, and Staff C, Dietary Aide, walked out of the kitchen door she heard the sound of the door alarm. Staff C immediately went to look because he was good at looking if he heard the alarm. She said that from what she heard, while the staff ran to get him off the highway, Staff D got into her car. She said that Staff D picked him up and brought him back inside. On 9/27/22 at 3:23 PM Staff B, Registered Nurse (RN), reported during the incident she changed a catheter on a resident and couldn't hear the alarms. Staff B explained that Staff E, Agency CNA, found him and brought him back inside. Staff D picked him up when she found him on the highway. She said she didn't witness any of the incident, she only heard from others. Staff B said that he had his call light on and he had an accident. She reported that when he had an accident, he gets upset and that is when he wants to elope. When questioned if the facility did anything to make the alarms louder to hear inside resident rooms, she explained that due to him being in isolation it muffled the alarm due to the plastic barrier from the novel Coronavirus 2019 (COVID) hall. Staff B explained that he went out the left door and not the front door. On 9/27/22 at 3:35 PM Staff C explained that he vaguely remembered the incident with Resident #1 due to it being a little while ago. Staff C added that he heard the alarm when he opened the kitchen door. After he left the kitchen he yelled, doesn't anyone else hear the alarm going off? Then he ran down the left hall because he heard the alarm sounding from there and where the panel at the nurses' station showed because he said he looked at it. He said no one responded until someone came out of a room. One was caught up in a room and that was the one who came out to look when they started to look for him. Staff C said that the agency staff usually just stand around. It wasn't until a facility staff started to do something that the agency staff started to move. He believed that the rest of the staff were in rooms. All of the rest of the facility staff knew to answer the alarms. Staff C reported that nothing this severe has happened, they usually open the door, but they are able to get to them quickly. He doesn't believe that the facility has done anything to make the door alarms louder so they can be heard in the kitchen. On 9/27/22 at 3:42 PM heard the door alarm sounding. Upon entering the hall, observed the staff redirecting Resident #1 back into the facility. Resident #1 redirected easily and went with the staff without issues. On 9/27/22 at 3:49 PM Staff E confirmed that she remembered when Resident #1 left the facility. Staff E reported that Resident #1 stayed in the COVID hall and he went out that door, she thought left the hall. She didn't see him so she ran out the front door as two other staff went out that door. Then she saw him walking down the street and so she started running after him. He has gotten out of the building but he never has gone down the street. The alarm is what alerted her so that is when she went looking. Usually he just opens the door and then goes somewhere else like another room. She was in a room helping a resident and when she finished helping the resident, she heard the alarm. At that time she immediately started looking for the sound. She didn't hear the alarm until she got into the hallway. She honestly did not remember someone else getting out as she honestly hasn't been back to the facility in a month. The Wandering and Elopements policy revised 3/19 included that the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy instructed that if a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, c. initiate a search of the building(s) and premises; d. If the resident is not located, notify the Administrator and the Director of Nursing (DON) Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). When the resident returns to the facility, the DON Services or Charge Nurse shall: - Examine the resident for injuries; - Contact the Attending Physician and report findings and conditions of the resident; - Notify the resident's legal representative (sponsor); - Notify search teams that the resident has been located; - Complete and file an incident report; and - Document relevant information in the resident's medical record. On 9/28/22 at 10:10 AM Staff F, Licensed Practical Nurse (LPN), explained that during the incident, she helped another resident who had a big mess. She reported that she could hear the alarm but not the wander guard alarm. Staff F reported that she was in room L0 to give that resident medications. Upon entering that room, the resident was a big mess and she could not leave him alone. Staff F reported that she couldn't hear anything about who started the search because the door was shut but could hear stuff over the walkie. Staff F said she didn't see anything but heard that he got a block and a half away before someone got him. She knew that there were many of the staff members looking for him, like the aide when he got back to the facility and the dietary aide who picked him up. She said that the residents attempt to go out the door but they can usually redirect him. Staff F reported that Resident #1 generally goes out the front door while another resident attempts to go out the right door. She said that they are both usually easily redirected. Staff F reported that day was her first day back in six years to the building. On 9/28/22 at 11:21 AM Staff C reported that he was the one who found him and got to him first. He said that the resident walked on highway 175, passed the intersection of the county road R26 and highway 175, passed the trees west of the facility, and then an additional two houses before he got to him. During an interview on 9/28/22 at 12:04 PM Staff D said that she picked Resident #1 up in her car. Staff E and Staff C went out roaming around the building. She said that she saw him down the road two houses down. Staff E and Staff C ran to him while Staff D got her car. She said that he was very particular about who he went with so she drove up to him and asked if he'd like to go for a ride. She drove him down towards the gas station, then brought him back into the facility. When she first heard the alarms as she came out of the kitchen she noted that Staff E and Staff B were in rooms, while the agency nurses stood around. As everyone started looking around, Staff D suggested, if anyone checked on Resident #1. They went to check on him but they did not find him. So then the staff all went walking looking for him. Staff B, Staff E, and two or three other staff who were with the agency were the nursing staff on duty at that time. During a follow-up interview on 9/28/22 at 2:00 PM Staff A reported that the incident happened sometime around 2:30 PM and 3:00 PM. She said that Staff D and Staff C were leaving at the time they heard the alarm. That was why they left the kitchen. On 9/28/22 at 2:20 PM the facility received the notice of an IJ template presented. The Administrator reported that no one told them they couldn't hear the alarms, all of the staff said they heard them but they were just busy and couldn't get to them. She said that she felt some of them could get to the alarm but didn't. The Administrator said the plastic barrier was only up at the end of the hallway as Resident #1 and another resident had COVID at that time. The Administrator said the other resident left the unit and Resident #1 got moved to get him away from the door. The Administrator reported that they removed the plastic barriers the next day. She explained that the facility's current plan if COVID happened again, was to have the residents isolated in place. The Administrator explained that the alarms are already loud enough they can't make them any louder without upsetting the residents. On 9/28/22 at 2:35 PM Staff A reported that Staff C and Staff D had just clocked out and were heading to their cars when they heard the alarm. Staff D's time card documented that she started her shift on 9/5/22 at 5:57 am and ended her shift at 2:45 pm. Start C's timecard documented that he started his shift on 9/5/22 at 6:41 am and he ended his Shift at 2:21 pm. On 9/28/22 at 3:15 PM the Administrator and the DON came into the office to discuss their investigation the day of the elopement. They reported and showed documentation of Staff H, Agency CNA, still working at the time of the incident. Staff H documented and told them that she stood at the nurses' station. She didn't do anything until Staff C asked her what she was doing. Review of undated typed statements regarding Resident #1's incident on 9/5/22 a. Staff H reported that she heard the door alarm sound around shift change. Shift change occurred around 2:45 PM - 2:50 PM that day. Staff H explained that as the dietary aide exited the kitchen, she stood at the nurses' station. He headed down the left hallway responding to the alarm. Staff H reported that Staff C immediately responded to the alarm and all available staff responded at that time. Staff H said that she went out the main entrance and looked around to the east and west of the building. She stated that she did not see the resident, but she did see Staff C Staff E with the resident at that time. So she returned to the building at that time. Staff H added that she last saw Resident #1 an hour prior to the event. He did not need assistance at that time. He sat in his room smiling and declined needing any care at that time. b. Staff C stated that at the end of his work day approximately 2:40 PM on 9/5/22 as he left the kitchen area, he heard the door alarm sounding. He looked at the door alarm panel and noticed that it indicated the left hall door alarm. Both primary and secondary alarm sounded. He opened up the left hall exit door and looked around the surrounding outside area but he did not see any residents outside. He explained that he then went through the building and went out the right hall door with Staff E. Staff C reported that they looked both ways outside the exit door and did not see any residents outside. Staff D also intended to leave for the day at that time and went out the front door to investigate the sounding alarms and noted Resident #1 to be two houses away. Staff D notified other staff of Resident #1's location, and returned him to the facility. The application referred to as Google Maps reviewed on 9/28/22 at 3:18 PM indicated that the distance Resident #1 walked 0.2 miles or about five minutes to get to the second house on the north side of Highway 175 west of the facility. On 9/28/22 at 3:20 PM The Administrator and The DON went with the Maintenance Director and redid the alarm sounds. The alarm sounded at the nurses' station with a fine buzz and an overhead alert. We then went into C1 and closed the door. The alarm was faintly audible and took a couple seconds to notice it. From there we went to C5 and closed the door. The alarm could be heard the same as in C1 faint but still audible. After this, an aide pulled a call light to distinguish the sound between the door alarm and the call light. The call light was a beeping sound mostly heard at the nurses' station. On 9/28/22 at 3:23 PM the Administrator reinitiated the alarm. Upon entering the kitchen and shutting the door the alarm could not be heard. One staff member turned off the ice cream machine and the alarm still could not be heard. The staff reported they are unable to hear announcements in the kitchen as well. On 9/28/22 at 4:09 PM the Administrator brought in Staff H and Staff J's time that they left the facility. Staff H clocked out at 3:01 PM. On 9/29/22 at 9:38 AM Staff G said that depending on where you are in the building you can hear the alarms in the rooms. She said that the new plan now is to keep the doors open a crack and they added stop signs to all of the exit doors of the building. On 9/29/22 at 10:29 AM during a follow-up interview with Staff D, she reported that she can clock out either behind the kitchen or on her phone. She wasn't sure which one she clocked out on. She reported that the lobby had two to three staff just standing around. They just stood there until Staff C came out running asking them what they were doing. Then she saw Staff E come out of a resident's room and then they all started running for him. She said that she can't run very well so she got into her car and went to get him because he was down there. She said she knew it was actively happening when they came out of the kitchen but she didn't know for sure how long. She said that they don't normally leave the kitchen until they need to go to the bathroom, it is time for meals, or they are leaving. On 9/29/22 at 10:50 AM Staff H said that they were all standing at the nurses station waiting to leave because it was time for the next staff to come that day. She said that she thought it was Staff I, Staff E, and her standing there. She heard a buzzing sound but did not hear the door alarm. Then Staff C came out of the kitchen and they realized it was the door alarm at that time. She said that the facility never showed them the door alarms before that but definitely did after that. She said that she didn't remember how long it buzzed. Staff H reported that she only started at the facility with the Staffing Agency at the end of August. She was on maternity leave and then came back to work at the Staffing Agency. She reported that she never worked at the facility before being on maternity leave. The state agency notified the facility of the IJ on 9/28/22 at 2:20 p.m. The Immediate Jeopardy (IJ) to the residents' health and safety was abated on 9/6/22, after the facility completed the following a. Scoring report ran for knowledge of high risk residents b. The facility moved Resident #1 from a room near an exit door to a room in the center of the facility. c. 9/6/2022 Education completed to all staff on the alarms systems and who are the high risk residents in the building. d. 9/6/2022 Signage posted at the front door to educate visitors to alert staff if a resident is near or trying to exit to get staff immediately.

Based on observations, facility policies reviews, clinical record reviews, staff, and physician interviews the facility failed to appropriately provide assessment and interventions for the necessary care and services related to a change in condition for one of five residents reviewed (Resident #11). The facility failed to address Resident #11's weight after a 12 pound weight gain in three weeks with abnormal lab values. Despite the provider visiting Resident #11 multiple times, the increase of weight failed to get assessed. At the time of Resident #11's admission to the hospital on 8/18/22 he did not have a weight for over a month. When the hospital weighed Resident #11, he weighed 391 pounds and had a lab result of NT-Pro B Natriuretic Pep (BNP) 3471 high (a test that determines how well the heart is working). The facility reported a census of 38 at the time of the investigation. Findings include: Resident #11's Minimum Data Set (MDS) dated 6.24.22 identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition for daily decision making. Resident #11 required extensive assistance of two persons for bed mobility, toilet use, and personal hygiene. The MDS indicated that Resident #11 did not transfer, walk, move around the unit, or move around off the unit. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 had shortness of breath with exertion. Resident #11 weighed 328 pounds (#) and had no significant changes in weight. The Care Plan Focus initiated 3/3/22 indicated that Resident #11 experienced Sleep Apnea. The Care Plan included the following interventions. Assist Resident #11 with his [CONDITION(S)] (a device worn to assist with breathing)/[CONDITION(S)] (a machine used as treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Ensure Resident #11 that he is using his equipment appropriately. Evaluate him each morning for signs of decreased oxygen, (confusion). Resident #11 chose not to use his [CONDITION(S)] as directed by his doctors, even after receiving education. Monitor him for worsening symptoms of sleep apnea and notify the physician as needed. The Order Review History Report reviewed on 8/25/22 included an order dated 6/11/22 for [CONDITION(S)] with 2 liters (L) of oxygen (O2) bled in as needed. The Weight Summary reviewed on 8/25/22 documented the following weights completed with a mechanical lift: 2/28/22 at 2:36 PM 350.9 # 3/14/22 at 12:39 PM 329.5 # 3/38/22 at 4:05PM 319.9 # 4/6/22 at 8:46 PM 323.1 # 6/9/22 at 12:12 PM 324.1 # 6/16/22 at 11:34 AM 327.8 # 7/6/22 at 3:27 PM 339.3 # The Task for Vitals-Weight reviewed on 8/25/22 for the previous 14 dates included only one weight charted as not applicable on 8/14/22. The Chemistry Report Results collected on 7.26.22 at 11:45 AM listed the following results flagged as abnormal: Glucose 57 low, range 70-199 mg/dl. BUN 43 high, range 8-21 mg/dl. Creatinine 1.63 high, range 0.44-1.21 mg /dl. Carbon [MEDICATION(S)] 24 normal, range 21-32 mmol/L. The Appointment/Visit Note dated 8/5/22 at 1:35 PM documented that Resident #11 saw the provider during the house rounds. The provider saw Resident #11 to follow-up on his dark sediment urine. The provider gave a new order to check a urinalysis (UA) with a culture and sensitivity (C&S) if indicated and to obtain a basic metabolic panel (BMP) that day. The Progress Note form dated 8.5.22 recorded that the provider saw Resident #11 in his room that day. The nursing staff requested Resident #11 to be seen due to dark urine, sediment, and possible pus present. Resident #11 has an indwelling urinary catheter due to chronic urinary issues and retention. Patient denies any urinary discomfort or urge to void (urinate). Patient states he drinks a lot of juice and his liquid supplements but denies drinking any water because he gets too full. The provider ordered a UA and BMP to check for a urinary tract infection ([CONDITION(S)]) and to assess his renal function. The provider noted that Resident #11's had a stable blood urea nitrogen (BUN)/Creatinine when last evaluated. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note form dated 8.10.22 recorded that the provider evaluated Resident #11 in his room. The nursing staff requested the provider to see Resident #11 the week before due to dark urine, sediment, and possible pus present in his urinary catheter. Resident #11 had an indwelling urinary catheter due to chronic urinary issues and retention. Resident #11 denied any urinary discomfort or urge to void. The provider ordered a UA and BMP to check for a [CONDITION(S)] and assess his renal function, as of that day those had not been completed. The nursing staff would obtain a UA that day. The provider reordered his BMP as indicated. The provider noted that Resident #11's had a stable blood urea nitrogen (BUN)/Creatinine when last evaluated. The Chemistry Report Results collected on 8.11.22 at 2:50 PM listed the following results flagged as high: Glucose 143 high, range 70-199mg/dl. BUN 37 high, range 8-21 mg/dl. Creatinine 1.84 high, range 0.44-1.21 mg /dl. Carbon [MEDICATION(S)] 35 high, range 21-32 millimole (mmol)/L. The Progress note form dated 8.12.22 included that the provider evaluated Resident #11 in his room. The Provider ordered a UA and BMP to check for a [CONDITION(S)] and assess his renal function. The UA remained pending, but noted the BUN/Creatinine as slightly increased but stable. The Patient Report documented that Resident #11 had a chest x-ray on 8/17/22. The report included findings from a portable image of the chest demonstrating cardiac silhouette to be within normal limits and no mass seen in the pulmonary hila (supporting structures that connect the lungs to their supporting structures) bilaterally. The lungs noted as clear with no consolidation, no pleural effusion, and no pneumothorax (collapsed lung) visualized. The bilateral Interstitial opacities (scarring in the lungs) may be chronic. The Order Note dated 8/18/22 at 2:03 AM documented Resident #11's vital signs as temperature of 97.0, pulse of 90, respirations of 20, and blood pressure of 107/65, and 92% on 2L of O2 (reference 90-100%). Resident #11 observed to be a little lethargic that shift, but he denied complaints. Vitals obtained and with an oxygen saturation of 44%. He displayed no shortness of breath or increased respirations. Obtained a different device that showed the same reading. O2 applied with nasal cannula and saturation noted in the low 90s. Resident #11's lungs sounded diminished on auscultation (listening). The nurse notified the on call provider who gave orders for a two view chest x-ray. The nurse notified the x-ray provider who reported that they would arrive in the morning. The SPN - Focused Evaluation dated 8/18/22 at 4:24 PM recorded a respiration rate of 12.0 with an O2 rate of 84.0% on room air. Resident #11 noted to have changes in his condition of a headache, ER visit, nausea and vomiting, with decreased urinary output in his catheter. Resident #11 had a low O2 sat and wouldn't keep his O2 on. The nurse noted a bluish color around his mouth. Without O2 he had a saturation level of 55%, after applying O2 his O2 sat came up to 87%. Resident #11 denied having shortness of breath. Upon auscultation his lungs were diminished through all lobes. The nurse changed his catheter and observed a small amount of bright red blood from his penis. He complained of discomfort when the balloon inflated. The nurse deflated the balloon, readjusted the catheter, and inflated the balloon again. Resident #11 continued to complain of pain and discomfort. After changing the catheter, Resident #11 had no immediate return of urine even though he reported that he had to urinate. Approximately a half hour after, the nurse rechecked on his catheter and observed a small amount of blood tinged, amber urine. The nurse called the on-call provider who gave orders to send Resident #11 to the ER. A telephone order from the Physician dated 8/18/22 indicated the nurse could send Resident #11 to the emergency room for evaluation and treatment. The emergency room ED Physician Documentation dated 8/18/22 documented that Resident #11 presented to the ER for low oxygen saturation. The nurse reported that Resident #11 had O2 saturations in the 70s since the previous day that did not respond to application of oxygen. He had a negative COVID test and had an outpatient x-ray that morning which showed normal results. Resident #11 explained that he came for a medical evaluation but he did not really know why. Resident #11 reported that he vomited the day before, but not that day, and stated that he did not have an appetite. He denied any significant chest pain. The section related to Resident #11's vital signs documented the following: Temperature 99.2 Non-labored normal Respiratory rate 22, Oxygen 60% on room air Weight 391 pounds. Resident #11's lab results listed below Carbon [MEDICATION(S)] (CO2) 31 normal BUN 77 high Creatinine 3.33 high Glucose 110 high BNP 3471 high The document included that while awake, Resident #11's had O2 sats in the high 90s, but while lying flat on his back and if no one talked to him, he fell asleep. When asleep his O2 sats go down to the low 80s. According to his chart, Resident #11 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . His wife reported that since he got moved to a different room at the care center, he did not have plug-ins for his [CONDITION(S)] machine and oxygen concentrator so he could not use those. The note dated 8/18/22 at 6:24 PM included in the document indicated that he had an end tidal (a simple graphic measurement of how much CO2 a person is exhaling) CO2 of 59-60. The ER physician recorded that he seemed to be retaining CO2 due to untreated sleep apnea and would definitely benefit from a [CONDITION(S)] or a [CONDITION(S)]. His BUN/creatinine level elevated most likely due to dehydration. BNP at baseline, will gently hydrate. At 6:50 PM per a discussion with another physician, Resident #11 received an order to be admitted to the hospital. The undated B-Type Natriuretic Peptide Plasma document retrieved from mayocliniclabs.com indicated a BNP aided in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interpretation of the lab result indicated the following - Normal to less than 200: likely compensated CHF - Equal to 200 or less than 400: likely moderate CHF - Greater than 400: likely to moderate-to-severe CHF The document labeled Heart Failure retrieved from mayoclinic.org listed symptoms as a. Shortness of breath with activity or when lying down b. Very rapid weight gain from fluid buildup c. Nausea and a lack of appetite. The section when to see a doctor indicated that if a person had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This may also be the case if they gain five pounds or more within a few days. The document included the following risk factors: a. [CONDITION(S)] b. Diabetes c. Sleep Apnea d. Obesity e. hypertension The EMR reviewed from lacked documentation to show if Resident #11 had [CONDITION(S)]. On 8/24/22 at 10:00 AM observed Resident #11's room with two wall plugs with one empty space on each. On 8/23/22 at 8:37 the emergency room physician reported that the facility did not take care of their residents. He acknowledged concerns about the residents from the nursing home that came in last Friday. Resident #11 had a high CO2 (carbon [MEDICATION(S)]), BUN, and creatinine levels. Resident #11 reported that he could not plug his [CONDITION(S)] in. The Communication with Family note dated 8/25/22 at 9:05 PM documented that Resident #11's wife called and voiced that he passed away that morning. On 8/25/22 at 9:28 AM Staff A, Licensed Practical Nurse (LPN), explained that ever since Resident #11 admitted to the facility, she only knew that he wore his [CONDITION(S)] only a few times and then the order changed to as needed (PRN). Staff A added that Resident #11 had a low oxygen saturation with diminished lungs (difficult to hear air moving in the lungs) and applied oxygen. Staff A called the physician and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/22 at 3:03 PM the Director of Nursing (DON) acknowledged that she could not find the order to change the [CONDITION(S)] from nightly to PRN. During an interview on 8/29/22 at 10:10 AM the Administrator acknowledged that she would expect physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Weight Assessment and Intervention policy revised September 2008 directed that the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for the residents. The section Policy Interpretation and Implementation instructed the following: 1. The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter, unless otherwise ordered by a physician or determined by the Interdisciplinary Team (IDT). 2. Weights will be recorded in each resident's electronic medical record (EMR). 3. Any weight change of 5% or more since the last weight assessment will be retaken as soon as possible for confirmation. If the weight is verified, nursing will notify the Dietitian. 4. The Dietitian will respond and make recommendations as necessary. 5. The Dietitian will review the resident's weight monthly to follow individual weight trends over time. Negative trends will be evaluated by the dietician whether or not the criteria for significant weight change has been met. The section labeled Analysis indicated the following: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The policy included a section labeled Interventions that directed the following: a. The Dietitian/Designee will discuss undesired weight gain with the resident and/or family. b. Interventions for undesired weight gain should consider resident preferences and rights. c. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. d. If a resident declines to participate in a weight loss goal, the Dietitian will document the resident's wishes, and those wishes will be respected. The Medication Orders policy updated November 2014 indicated the purpose of the procedure is to establish uniform guidelines in the receiving and recording of medication orders.

Based on observation, record review, staff and physician interview, the facility failed to provide adequate nursing supervision of residents when using the facility's courtyard patio, for 1 of 7 residents reviewed for inadequate nursing supervision (Resident #1). On 6/23/20, the facility began unlocking the courtyard patio door in the morning and locking it at night to allow residents to use the courtyard independently during the daytime. The facility failed to maintain adequate supervision of Resident #1 and did not know the resident entered the courtyard on 7/11/20. Staff last saw the resident at approximately 9:44 a.m. and did not see her again until staff found the resident at 10:20 a.m. on the ground following a fall. The heat index was 90 degrees outside at the time and when found, the resident's temperature was 101.4 degrees. It took 1 hour and 15 minutes for the resident's temperature to return to normal (98.4 degrees). The resident was also assessed with [REDACTED]. The incident resulted in an immediate jeopardy situation. The facility abated the concern on 7/18/20. The facility reported a census of 38 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified the resident with long and short term memory impairment. The resident's cognitive skills for daily decision making severely impaired. The MDS recorded the resident exhibited wandering behavior one to three days of the seven-day look back period. The MDS revealed the resident independent without set up for bed mobility and transfers. The MDS revealed the resident required extensive physical assistance of one person for toileting and frequently incontinent of urine, always incontinent of bowel. The MDS documented [DIAGNOSES REDACTED]. The care plan focus area initiated 5/25/18 identified the resident with difficulty making her own decisions. Care plan interventions revised on 10/12/18 included: give the resident verbal cues or reminders when she could not remember; the resident could follow simple directions, redirected easily; and sometimes the resident spoke words or sentences that made sense and other times she spoke jumbled words. Additional revisions to the care plan included: a. On 12/18/19, a key lock placed on the resident's closet doorknob as the resident used the closet as a bathroom and an alarm placed on the bathroom door as the resident flushed things down the toilet. b. On 2/1/19, the resident's clothes kept in the shower room because of her dementia and trying to flush them in the toilet. c. On 2/8/19, staff to redirect the resident as needed from wearing multiple layers of clothes at a time. A care plan focus area dated 5/25/18 identified inappropriate behaviors related to [MEDICAL CONDITION]. On 6/22/20, a care plan revision documented the resident resided on the securely locked CCDI (Chronic Confusion and Dementing Illness) unit and a 30-day trial to occur of opening the CCDI unit doors. A care plan focus area revised 7/12/20 identified the resident at risk for falls related to dementia and the resident fell without injury on 9/22/19, 10/16/19, 2/15/20, and on 7/11/20 with injury. The care plan interventions included: a. On 10/12/18 the resident on the falling leaf program, used a walker in her room and hallways, and at times needed reminders to use the walker. Staff to monitor for changes in the resident's condition that warrant increased supervision or assistance and notify the physician. b. On 7/11/20, a secondary alarm placed on the patio door and the alarm to be on at all times when the door unlocked. On 7/16/20, the intervention resolved. c. On 7/16/20 the door to the patio to be locked unless the patio used with supervision. Resident #1's order list revealed that on 12/24/18 the physician ordered CCDI unit placement for the resident. A fall risk evaluation dated 6/3/20 revealed the resident scored a 15; a score of 10 or higher equaled high risk for falls. A wandering risk evaluation dated 12/12/19 identified a score of 14.0; the 3/12/20 evaluation scored the resident at a 9.0; and the 6/3/20 evaluation scored the resident at 9.0. The score of 10 or higher indicated a high risk for wandering. Under 10 equaled low risk. Resident #1's supplemental documentation records documented the resident displayed wandering behavior on the following days: a. May 2020 - 5/1, 5/2, 5/3, 5/4, 5/5, 5/7, 5/8, 5/9, 5/10, 5/13, 5/14, 5/15, 5/18, 5/19, 5/22, 5/23, 5/25, 5/27, 5/28, 5/31 b. June 2020 - 6/1/, 6/2, 6/3, 6/5, 6/6, 6/7, 6/8, 6/10, 6/11, 6/13, 6/15, 6/16, 6/17, 6/19, 6/20, 6/22, 6/24, 6/25, 6/26, 6/27, 6/28, 6/29, 6/30 c. July 2020 - 7/3, 7/5, 7/8, 7/9, 7/13 Progress Notes included the following documentation: a. On 6/10/20 at 10:37 a.m., a care plan conference summary note under the nursing section recorded the resident continued to require assistance to meet ADL (Activities of Daily Living) needs and remained on the CCDI unit ambulating independently with a walker. b. On 6/22/20 at 7:04 p.m., the resident shut the memory lane doors after the doors opened two times. The resident stayed back in the TV room and did not go past the doors. c. On 6/23/20 at 7:05 p.m., the resident urinated in the recliner one time and staff assisted her to use the restroom to clean and change clothes. The resident later incontinent in bed and wandered into others rooms, slamming the door to her own room. d. On 6/24/20 at 1:10 p.m., the resident visibly upset, confused, resisting care, and spit her medication out. e. On 6/24/20 at 10:34 p.m., the resident redirected multiple times throughout the shift due to wandering into other peers rooms and taking items from their rooms. f. On 6/25/20 at 11:52 a.m., the resident in and out of every room taking all toilet paper off the rolls putting things in toilets. g. On 6/26/20 at 2:42 p.m., the resident wandered in other's rooms and went through their things, urinated on the bed two times, undressed two times, and behaviors increased since memory care unit doors opened. h. On 6/27/20 at 12:32 p.m., the resident incontinent and stripped off her clothes in the TV room, naked in the recliner. i. On 6/28/20 at 6:32 p.m., the resident wandered in halls and into others rooms. j. On 7/4/20 at 4:07 p.m., the resident slammed doors and wandered in the hallways. k. On 7/9/20 at 8:00 p.m. and 7/10/20 at 12:53 a.m., the resident up in hallway wandering halfway naked and went into other residents' rooms. The unwitnessed fall incident report dated 7/11/20 at 10:20 a.m. revealed staff found Resident #1 outside of the memory care unit dining room, on the patio. A CMA (certified medication aide) found the resident lying on her back in the mulch with the walker on top of her stomach. The nurse assessed two red lines on the resident's abdomen measuring in 15 cm (centimeters) by 2 cm, 7 cm by 2 cm, and a 10 cm diameter circle of redness on the resident's coccyx. The report recorded the resident's skin flushed and temperature 101.4 degrees (high). The resident assisted to her feet by three staff members. The resident could not give a description of the event. The incident report revealed the facility locked the door to the outside courtyard following the incident. The incident report revealed the facility notified the family and the physician. A Progress Notes dated 7/11/20 at 8:12 pm., written by Staff A, Registered Nurse (RN), documented Staff A called to the courtyard outside the memory unit dining room. Staff A recorded the resident found by a CMA laying on her back in the mulch with the walker on top of her stomach. Staff A assessed the resident as alert, awake, responsive to verbal stimuli, skin flushed, and sweating. Staff A measured vital signs that included temperature of 101.4 degrees and heart rate of 104 beats per minute. Staff assisted the resident to her feet then the resident walked with assistance of two persons to the restroom. Staff A documented the resident's temperature remained high, a cool washcloth place on the resident's neck but the resident refused to keep it on her forehead, and the resident refused to void at that time. Staff assisted the resident to change her clothes as the clothes sweaty, and the resident assisted to ambulate to her bed. Staff A further assessed 2 red lines on the resident's abdomen where the walker rested; the top line 15 cm by 2 cm and the bottom line 7 cm by 2 cm, which started to fade. Staff A assessed a 10 cm circle of redness on the resident's coccyx area from laying on the warm mulch that was fading around the edges. Staff A measured the temperature at 10:28 a.m. at 101.0 degrees and at 10:35 a.m. at 100.7 degrees. Staff A offered the resident a glass of water, which she drank. Staff A initiated an intervention to keep the doors to the outside courtyard locked unless supervision available. Resident #1's Temperature Summary printed 7/17/20 documented the following temperature readings: a. 7/11/20 at 2:39 a.m. 98.0 degrees b. 7/11/20 at 10:21 a.m. 101.4 degrees c. 7/11/20 at 10:28 a.m. 101.0 degrees d. 7/11/20 at 10:39 a.m. 100.7 degrees e. 7/11/20 at 10:50 a.m. 99.6 degrees f. 7/11/20 at 11:03 a.m. 98.9 degrees g. 7/11/20 at 11:23 a.m. 98.8 degrees h. 7/11/20 at 11:36 a.m. 98.4 degrees The Progress Notes dated 7/13/20 at 8:32 a.m. documented a fax received from the resident's physician stated the physician would review the incident in-person on Wednesday (7/15/20). A physician fax form dated 7/11/20 documented a FYI (For Your Information) notification of Resident #1's unwitnessed fall in the courtyard off memory lane. The fax recorded the resident found on her back in the mulch, flowerbed, with no injuries. The fax documented the resident's temperature elevated initially but went down to normal. Then intervention implemented to have the doors closed to outside unless supervised. The physician responded 7/13/20 that she would discuss the incident on Wednesday (7/15/20) to review the incident report and policy. The Internal Quality Assurance Investigation Form, signed by the Director of Nursing (DON) and Administrator on 7/13/20, identified the possible contributing factors to Resident #1's fall on 7/11/20 as the cement higher than the ground. The facility implemented the following preventative measures: patio door to remain locked at all times unless supervision provided outside and staff educated about locking the patio door. Physician visit notes dated 7/15/20 identified the resident with a couple of significant events recently. The notes revealed the resident wandered out onto the patio that weekend and staff found the resident in the flowerbed. The entry documented apparently the resident's walker hit the edge of the sidewalk, which caused her to tumble. The resident did not have obvious injuries but did have an elevated temperature of 101.0 degrees Fahrenheit and the temperature managed in the facility. The physician found out about the incident by fax on Monday morning (7/13/20) and as of the 7/15/20 exam, the resident did not appear to have any injuries and appeared at baseline mentally. Progress Notes dated 7/16/20 at 10:17 a.m. documented after QA (Quality Assurance) discussion an intervention dated 7/11/20 of a secondary alarm to be on the courtyard patio door at all times when the door unlocked changed to the door locked unless supervision provided. Observations Observation showed on 7/15/20 at 10:30 a.m. the facility's courtyard located on the Memory Lane unit, off the unit's dining room. Observation also revealed the facility's CCDI unit doors open. Observation of the patio revealed uneven areas from the sidewalk to the mulch with drop of 2 to 3 inches. Observation also showed chairs present, small landscaping ornaments in the center circle, plants and shrubbery around the edges of the patio in mulch areas. On 7/15/20 at 1:36 p.m., the surveyor checked the doors for alarms and found the courtyard door locked. Observation on 7/16/20, revealed the resident's room located approximately four rooms down from the CCDI unit dining room which contained the entrance to the courtyard patio. Staff Interviews On 7/15/20 at 3:21 p.m., Staff A, RN, reported the resident occasionally wandered but tended to stay in her room and kept the door shut most of the time. Staff A, RN, recalled the incident of Resident #1 on 7/11/20. Staff A reported she assessed Resident #1 at 10:20 a.m. as she laid on the ground. Staff A stated prior to going on break at 9:45 a.m., Staff B, CMA, reported seeing the resident in bed. Staff A reported Staff B reported finding the resident at 10:20 a.m. on the ground of the courtyard upon returning from her break. Staff A stated there was no way the resident outside for more than a half hour. Staff A stated she observed skin issues on the resident which disappeared by the time she left the facility at the end of her shift. Staff A reported even though there was a staff member assigned in the CCDI unit, staff tried to help all over the building and cover where they could. However, at the time of the incident the CMA went to break. On 7/16/20 at 2:10 p.m., the DON identified the resident's general routine as walking in the hallway, the dining hall, and the TV room. The DON reported when the facility first opened the CCDI unit doors, the resident would actually shut them. The DON reported the resident loved to go outside, and went outside before. The DON reported the resident with no previous elopement events in the facility prior to the event. The DON stated the resident never tried to open doors or tried to leave the facility. The DON reported staff recalled seeing the resident 30 minutes prior to the fall. The event occurred around 10 a.m. The DON identified Staff B as the one to discover the resident down outside in the patio area. The resident's abdomen and buttock contained marks but the DON reported those skin issues now resolved. The DON reported before the incident, the door not alarmed. The DON reported staff checked door alarms daily and times for the checks varied The DON stated during the weekends, the weekend manager or scheduled department heads checked the doors. The DON identified the Dietary Manager as the department head working the weekend of 7/11/20. The DON stated night shift did not always open the doors in the morning for residents. The DON reported when the department heads did the door checks, typically in the morning around 8:00 a.m., they unlocked the patio door at the same time so residents could utilize the courtyard. The DON reported the facility applied a secondary alarm which proved to not work so staff now locks the patio door and staff must be supervise residents while outside. On 7/16/20 at 2:39 p.m., the DON reported she called Staff A at 2:30 p.m. and got a statement from Staff A. The DON reported Staff A said she chose to fax the doctor due to the resident not having any major injuries and because all skin issues resolved before Staff A left the facility. The DON reported Staff A said the resident wore slacks and a short sleeve shirt when found. The DON reported the facility did not have a facility policy for use of the courtyard. The time sheet for 7/11/20 revealed Staff B clocked out for break at 9:44 a.m. and returned at 10:15 a.m. On 7/16/20 at 4:45 p.m. Staff B, CMA, recalled Resident #1's fall on 7/11/20. Staff B reported she checked on the resident previously and observed the resident in her room, in bed and awake. Before going to break at 9:44 a.m., Staff B informed other staff the residents doing okay. Staff B reported she left for break and returned to find the resident outside in the courtyard around 10:20 a.m. Staff B stated she observed the resident damp from sweat and wearing beige pants, a t-shirt and shoes. Staff B reported Resident #1 normally wandered and wandered in and out of resident rooms. Staff B reported she felt staff should be in the CCDI unit at all times to supervise the residents. Staff B reported residents like Resident #5 and Resident #6 tried to elope. Staff B stated she felt the facility had residents who were high acuity and required more help. In a follow-up interview on 7/20/20 at 12:50 pm, Staff B reported she did not feel it safe for Resident #1 to be outside unsupervised. She stated she used to take the resident out to the patio all the time and would always supervise her. Staff B reported she didn't know the door was unlocked to the patio. Staff B identified the patio door as unlocked by the time the resident went out in the courtyard. Staff B stated she found the resident outside and the resident stated, oh good you came. Staff B reported the resident appeared alert and laid flat on her back in the center of the patio, which was covered in mulch and lawn ornaments. The resident laid with her walker but did not appear to be laying on any of the landscaping ornaments located in the center of the patio. In a follow-up interview on 7/21/20, Staff B reported the resident also outside on 7/11/20 at around 9 a.m. Staff B let Resident #1 out to the patio and the resident stayed out there for about 5 to 10 minutes before wanting to come back in. On 7/21/20 at 10:38 a.m. Staff D, CMA, recalled the fall on 7/11/20 for Resident #1. Staff D reported she first saw Resident #1 on 7/11/20 around 9 a.m. when Staff B asked her to let Resident #1 inside from the patio while Staff B worked on medications. Staff D reported the resident outside and waved to get back in. Staff D reported she knew the door unlocked but did not know when the door became unlocked. Staff D reported, later she headed to lunch when she heard a page overhead for urgent help in CCDI unit. Staff D put her items down and went to help in the unit. Staff D reported she arrived to see Resident #1 on her back in the middle of the courtyard in the mulch area. Staff D stated the resident didn't seem to be in any distress or complain of pain. Staff took the resident's vitals and staff assisted her up. Staff D reported the resident had red areas to the resident's backside, which appeared to be from lying on the mulch. Staff D didn't recall seeing the resident's abdomen for marks but the resident's arms appeared pink. Staff D reported she assisted the resident to her feet. On 7/15/20 on 3:12 p.m., Resident #1's physician reported she received a fax 7/13/20 about Resident #1's fall in the courtyard 7/11/20. The physician stated she understood the courtyard was unlocked and staff found the resident outside on the mulch area of the patio. The physician reported she called the doctor on call over the weekend to find out whether or not the facility reported the incident to them and the doctor stated the facility did not report it to them. The physician reported she felt the facility should have notified the on-call physician about the incident. The physician commented she discussed with the facility that they needed to make changes regarding physician notification. In a follow up interview on 7/16/20 at 4:13 p.m., Resident #1's physician reported she came to the facility on [DATE] and assessed the resident with no signs of skin breakdown or wounds from the fall. The physician reported she expected the facility to call if a resident temperature 101.4 degrees but she felt okay to treat the resident within the facility since hospitals battling COVID-19. The physician stated she would not want the resident to risk exposure. The physician stated if the temperature had been 103 degrees, she would have expected a call and a transfer to the hospital. On 7/16/20 at 1:48 p.m., the climatologist reported the temperature for the nearest city, Webster City, recorded on 7/11/20 at 9 a.m. as 82 degrees with a humidity of 66%, heat index 86 degrees. At 10 a.m. on 7/11/20 the temperature 84 degrees with a humidity of 70%, heat index 90 degrees. On 7/15/20 at 1:40 p.m., the Maintenance Director stated the gate outside in the patio didn't lock but identified it as alarmed. The Maintenance Director stated he was not in the facility when staff found the resident outside. The Maintenance Director stated on days he worked he checked the doors to make sure they were functioning properly and would unlock the patio door during the daytime for the residents. On 7/15/20 at 3:45 pm, the Dietary Manager (DM) reported night staff should lock the doors and when she came in the mornings, she did the patio door check and unlocked it for the residents. The DM stated after the incident occurred with Resident #1 on 7/11/20, she checked the patio door at 10:30 a.m. The DM stated she did not unlock the door that morning. The DM identified it as likely the overnight staff left the door unlocked. The DM reported the door now contains a secondary lock or alarm so when residents go outside the alarm goes off. Observation with the DM at the time of the interview showed now a secondary lock on the patio door. The Dietary Manager showed when the door unlocked, the alarm would sound which required a staff member to shut it off with use of a key. On 7/16/20 at 4:30 p.m., Staff E, CNA (Certified Nurse Aide), reported when the facility first opened the doors to the CCDI unit, Resident #5, attempted to leave through the front door of the facility. She stated the facility since started opening the door to the patio for Resident #5 to go outside instead of trying to escape through the front door. Staff E stated management preferred to have the CCDI unit doors open. Staff E reported the night staff supposed to lock the patio door at 10 p.m. Staff E reported even though there was a schedule with designated areas for staff to work in, they technically floated all over the facility to help where they could. Review of the facility staff schedule revealed there were usually two nurses on in the morning with four CNAs to cover the building. On the morning of 7/11/20 (day of incident) the schedule revealed one nurse scheduled for the whole facility and four CNAs, one acting as a med aide. This indicated the facility was short one staff. Facility Educations The Five Minute Meeting for Employees dated 6/22/20 contained 22 staff signatures and recorded the following information: Memory Lane doors are now open for the 30-day trial period. The first week we will keep operations the same. Medication aide will work in memory lane and continue to do meds. Start of the second week we will make the transition of the nurse responsible for the medications down memory lane. The CNA/CMA in memory lane work the right hall and memory lane (also known as left hall) CNA duties. The Five Minute Meeting for Employees dated 6/23/20 contained 22 staff signatures and recorded the following information: Memory lane patio doors will be unlocked by maintenance or whoever is checking door alarms for that day. If they forget to unlock nursing, please unlock. Also, relock the doors during inclement weather. Nurses are responsible for ensuring the door is locked at 10 p.m. Additional Staff Interviews On 7/16/20 at 1:50 p.m., the MDS Coordinator reported the facility began the trial of opening the CCDI memory care doors on 6/22/20. The MDS Coordinator stated she made note of the trial on all residents care plans who resided on the CCDI unit. The MDS Coordinator responded all staff could work everywhere in the building and not just dedicated to the memory care hall. At 3:00 p.m., the MDS Coordinator responded to the question what actions the facility took to increase supervision of residents who resided on the memory care unit when the facility opened the memory care doors on a trial basis. The MDS Coordinator stated they mostly kept a CMA on the unit with the doors locked and then when they opened doors that directed an aide to focus on that hall. The MDS Coordinator reported when the memory care doors locked and secured there were three residents who ambulated independently and utilized the courtyard: Resident #5, Resident #6, and Resident #1. The MDS Coordinator stated they placed a wander guard on Resident #5 when they opened the doors. The MDS Coordinator stated they tried to figure out what to do with the patio door located on the memory care unit that lead outside to a locked courtyard. The MDS Coordinator stated in the past, the facility tried several different approaches from having the patio door unlocked thru the day then locked at night and a time when they had a secondary alarm on the door. The MDS Coordinator stated the med aide could work on the unit and would lock the door. Then they went to having the door locked at all times. The MDS Coordinator responded the actions taken to increase supervision when they decided to open the CCDI doors included updating the care plans that a trial of opening the doors took place and if a resident went outside to the courtyard they needed supervised. At this point in the interview, the DON joined the conversation. The DON stated in preparation for opening the CCDI unit doors the facility notified all physicians, notified families, and completed elopement assessments for the six residents who resided on the CCDI unit. The DON stated the outside doors of the facility contained wander guard alarm systems. The DON commented the facility took baby steps when opening the doors. The DON stated they first kept someone staffed on that hall the whole time. Then they had a couple of residents who never crossed the line and Resident #1 as one of those residents who still did not come off that hall. The DON said eventually as the residents began to venture off that hall so did the staff assigned to the hall. The DON responded to what led the facility to trial opening the memory care doors. The DON identified the population on the CCDI unit as only six residents. The facility did not get referrals or admits to the unit, they did not feel those six residents presented as elopement risks, and they wanted the hall available to place residents if they had an outbreak of COVID-19 infection in their building. The DON stated those residents who scored higher on the elopement risk assessments had a wander guard placed on them. The MDS Coordinator responded to why the facility scored Resident #1 a low risk on 6/3/20 when she previously had been high risk on 12/19/19 quarterly assessments. The MDS Coordinator and DON stated the resident did not leave her room anymore and typically just went to the commons area to watch her westerns on TV and at one time resided with the general population after a hip injury . They stated Resident #1 got better and then wandering progressed so went back to the unit. Therefore, at that time, Resident #1 score a higher elopement risk score. The DON added the increased supervision when opening the doors was just like any other monitoring of residents they did and they gave adequate supervision. They kept the same daily staffing ratios--- that did not change. On 7/17/20 at 2:06 p.m., the Nurse Consultant stated the facility did not have a policy or procedures available for the use of the courtyard or expectations on the locking of the courtyard patio door. On 7/17/20 at 2:10 p.m., the Administrator stated she did not know the date the courtyard patio door opened. The Administrator said that in the winter the facility kept the door locked at all times. The Administrator recalled the QA team discussed unlocking the courtyard patio door about a month or two prior related to the previous summer they unlocked the door to give residents secured access to the outside. The Administrator commented they decided to unlock the door in the mornings. The Administrator responded anyone with a key could unlock the door, nurses or anyone who checked door alarms. The Administrator stated during the week, first thing in the morning, the Maintenance Director unlocked the door, and on weekends, the manager on duty unlocked the door. The Administrator identified no set time to lock the courtyard door at night but revealed the night nurse as responsible to lock the door. The Administrator reported the DON talked to the nurses and did not know whether she provided the education verbally or written. The Administrator responded the facility did use temporary staffing agencies for CNA help but not for nurses and the Administrator did not know if the DON educated them. The Administrator voiced only the medication aides and nurses would have keys to the door. The Administrator responded she had no expectation for staff to provide supervision when the residents went in the courtyard. The residents who ambulated independently did not need supervision. The Administrator stated she started working at the facility in November 2019 and she did not know of Resident #1 having a fall since then. At this point in the interview, the DON joined the conversation. The Administrator then confirmed the facility unlocked the courtyard patio door on 6/22/20 at 8:00 a.m. and did not believe they made any changes to policies. The Administrator stated on 7/11/20 when Resident #1 fell , the facility locked the patio door unless staff provided supervision when a resident went outside. The Administrator stated she believed before that a resident did not need supervision when using the courtyard. The DON stated when the facility opened the memory care unit doors the supervision remained one staff member staffed on that hall, staff completed shift and behavior charting, and the facility did not feel any of those residents met the criteria for a locked unit. The DON stated it would not matter if the memory care doors opened or closed, Resident #1 could always go outside to use the courtyard patio. The Administrator responded she first became aware of Resident #1 falling outside on 7/11/20 when she read notes in risk management the morning of 7/13/20. The Administrator stated they discussed initially just locking the door then thought maybe they could put on a secondary alarm, however, the alarm went off too many times from residents opening the door. The Administrator said they then changed protocol for the courtyard patio door locked at all times and they made all those changes on 7/13/20. On 7/17/20 at 3:36 p.m. Staff F, Licensed Practical Nurse (LPN), recalled working with Resident #1 on 7/11/20 in the evening. Staff F identified Resident #1 as agitated when she tried to get vitals, the resident did not complain of pain, but its hard to say with dementia residents. Staff F stated the resident usually wandered at night into peoples' rooms and took stuff out. Staff F reported that night the resident stayed in her room. Staff F could not identify if the resident was a fall risk. Staff F recalled a 5-minute meeting about keeping the patio door open. Staff F voiced she did not agree with that as it was hard to keep track of residents with the doors opened and residents wandered a lot when sundowning. (According to mayoclinic.org, sundowning refers to a state of confusion occurring in the late afternoon and spanning into the night. Sundowning can cause a variety of behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning can also lead to pacing or wandering.) Staff F responded facility management knew of the concern as they talked about it a lot. Staff F stated management staff never asked the floor staff about what they experienced at night with some residents up in the middle of the night several times. Staff F voiced yes the residents from the CCDI unit wandered and with the CCDI doors opened, residents appeared more confused and some really exit seeking. Staff F commented when the CCDI doors were shut, there was less risk as they always had a staff member assigned to that area. Staff F stated the person assigned the memory care hallway is now expected to help on other halls for people who need more care. Staff F identif (TRUNCATED)

Based on observation, staff interview and record review, the facility failed to properly identify risk factors for pressure ulcers upon the admission survey and failed to implement adequate interventions to prevent the development of an avoidable heel ulcer (Resident #2). The sample consisted of 4 residents and the facility identified a census of 49 residents. Resident #2 required a surgical repair of the left hip due to a fracture. Nine days after readmission into the facility, the staff identified a wound as a Stage I and a week later then an unstageable wound (unable to view wound bed) which resembled a (DTI) deep tissue injury. The resident required extensive assistance of 2 people for bed mobility and transfers which placed the resident at risk for pressure ulcers. Observation identified the resident moving feet back and forth and up and down in bed and preventive devices were on the heels to avoid pressure, friction or shearing. Review of the nursing assessment identified inaccuracy with describing the wound bed. The nurses described the wound as unstageable but with granulation tissue. The nurses always staged the wound as unstageable but listed granulation tissue and at times eschar. Findings include: Resident #2 had a MDS (Minimum Data Set) assessment, with a reference date of 3/9/17. The assessment reflected a significant change in condition. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had short and long term memory problems and showed no mood or behavior problems during the assessment period. The MDS activity of daily living portion of the assessment described the resident needing extensive assistance of 2 or more people for bed mobility and depended upon 2 or more staff for transfers and toileting needs. The resident used a wheelchair and did not ambulate. The MDS indicated the resident had no pressure ulcers but did have a moisture associated area (MASD and a surgical wound (due to [MEDICAL CONDITION]). The resident at pressure reducing devices on the bed and chair. A form titled Resident Assessment-Data Collection Form identified an admission date of [DATE] at 2:30 p.m. to the facility via an ambulance. The [DIAGNOSES REDACTED]. The skin condition identified no pressure ulcers and identified only incisional staples and 2 skin wounds on the forearms. The skin condition was described as dry and warm and no appearance of reddened, cyanotic, ashen color or [MEDICAL CONDITION] (swelling). The assessment identified the resident's functional status as total assistance and wheelchair only. The psychological aspects described the resident as alert, combative, hyperactive and disoriented to time and place. A form titled: Braden Scale-For Predicting Pressure Sore Risk, dated 3/5/17 identified a score of 16. A score of 15-18 reflected a mild risk for the development of pressure ulcers; however, the initial assessment on 3/5/17 did not coordinate with the Braden Scale. The scale showed errors with the resident's mobility and friction shear which changed the scoring to a moderate risk for the development instead of a mild risk. The Braden Scale dated 3/16/17 identified the resident as a moderate risk for the development of pressure ulcers and a score of 14. The MDS reflected the resident required extensive assistance of 2 people for bed mobility and transfers. The Braden Scale on 3/16/17 identified the resident as only slightly limited and makes frequent though slight changes in body or extremity position independently. The MDS assessment identifies descriptions of pressure ulcers as the following: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. A deep tissue damage could lead to the appearance of a Stage III or IV pressure ulcer or progression of a Stage I pressure ulcer to an ulcer with eschar or exudate within. A deep tissue ulcer has pre-existing signs (such as a purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION], or induration) suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. The Nurse's Notes included and indicated the following: On 3/5/17 at 2:30 p.m. the resident arrived per ambulance. The resident pinching nurse and grabbing the nurse's stethoscope and threw oxygen set. The resident denied pain and alert to self only. The nurse administered [MEDICATION NAME] per IM (intramuscular) injection. The resident transferred with Hoyer (mechanical) lift. On 3/8/17 at 10:30 a.m. the resident agitated with cares and pinching and yelling at staff. Seemed better after cares completed. On 3/14/17 at 8:30 a.m., the nurse noted a dark purple/black area to the left heel (same leg side as [MEDICAL CONDITION]). The area felt boggy and the surrounding area to skin reddened. The resident had no signs or symptoms of discomfort. At 10:00 a.m., heel booties (non-suspension of heels) placed on left heel when in bed as tolerated. A fax sheet dated 3/14/17 indicated the physician was notified of the heel area. The physician ordered [MEDICATION NAME] barrier to the left heel twice a day and staff are to apply heel booties. On 4/25/17 at 3:00 p.m. the resident had a 2.2 cm (centimeters) by 2 cm purple bruise to the bottom of the left foot. The staff noted the resident moving legs in air continuously during an assessment. The facility placed a pillow on the foot buddy of wheelchair. The Wound/Skin healing record identified the following: The Wound/Skin healing record identified on 3/14/17, the resident had a Stage I pressure ulcer located on the left heel that measured 3 cm by 3 cm. On 3/15/17 the nurse described the area as unstageable and measured 3.5 by 3.5. The entire area measured 5 cm by 8 cm which included surrounding redness. On 3/22/17 the nurse documented the wound assessment as unstageable and measured 2.5 cm by 2.8 cm. The wound bed was described as normal for skin and the surround skin color dark red/purple but normal for skin. The overall measurement was 5 cm by 6 cm. (larger) On 3/29/17 the nurse documented the wound as 2 cm by 2 cm unstageable with normal wound bed and the overall area measured 3.5 by 3 cm. On 4/5/17 the stage remained as unstageable, however, the wound bed marked as normal for skin. The entire area measured 4.5 by 3 cm and the wound itself measured 1.5 by 2 cm. The dates of 4/12/17 and 4/19/17 identified the same stage and measurements. On 5/17/17 the area remained unstageable and measured 1.8 by 1.8 cm. The wound bed had granulation tissue present. On 5/31/17 and 6/1/17, the area remained unchanged in size and continued to have eschar present. The eschar remained present at the 7/5/17 wound assessment and measured 2 cm by 2 cm (no change). On 5/24/17 the heel measured as 1.8 by 1.6 and unstageable. The assessment determined the wound bed had granulation (no eschar identified). On 5/31/17 the area had eschar present and measured 2 cm by 2 cm. On 6/7/17 the area was unstageable due to eschar and measured 2 cm by 2 cm. The note identified no change On 6/17/17 the area measured 2 cm by 2 cm with granulation on the wound bed (no eschar identified. On 7/5/17 the heel area measured an unstageable 2 cm by 2 cm pressure sore with eschar present. The Care Plan identified a problem onset on 1/24/12 with the resident with a history of bruises and scabbed areas. The problem identified a problem with a history of excoriation under the abdominal fold and under the breast. The goal date of 6/15/17 identified a plan that the problem would be reviewed every quarter. The interventions indicated a pressure reduction mattress to the bed. On 5/17/17 the staff placed sheep skin padding on each side of the wheelchair bars by the foot buddy (a foot buddy does not prevent pressure on the heels). On 3/14/17, the facility placed a blue heel elevator boot on the resident's foot and to be kept on at all times except when bathing. On 4/25/17, the facility added an intervention to have a pillow on the foot buddy when in the wheelchair. Observation on 7/5/17 at 11:45 a.m. identified the resident in bed and laid on right side. The resident had blue boot on left foot. The resident seemed agitated with interventions, and moved both legs up and down and back and forth in bed. In an interview on 7/6/17 at 11:40 a.m., the Nurse Consultant confirmed Resident #2 did not have a pressure area on the left heel when readmitted on [DATE]. The Consultant confirmed the area on the left heel was identified on 3/14/17 and then the facility implemented heel lift boot to the left foot at all times. The Consultant stated on 7/10/17 at 9:20 a.m. she expected the staff to observe the skin with cares and showers and then report to the nurse if any issues. The Consultant provided documentation titled, Monthly-March 2017 Bath Record, which identified Resident #2 hospitalized until 3/5/17, received a shower on 3/7/17 (no issues identified), 3/11/17- skin tear reported and on 3/14/17 a bruise noted on the heel by Staff C, certified nursing assistant. On 7/10/17 at 11:20 a.m. Staff C (nursing assistant) was interviewed and confirmed she found a purple area on the resident's heel during a bath on 3/14/17 and reported this to the nurse. Staff C stated she had regularly cared for the resident on the day shift and had not noticed this before 3/14/17. Staff C stated she would have noticed it if had been there prior as the resident lifted legs in the air frequently and then down. Staff C confirmed the resident on a regular turning schedule and would get up for meals.

Based on record review, staff interviews and facility policy, the facility failed to ensure one (1) of four (4) residents were free from resident to resident abuse. Record review identified resident to resident physical altercations between Resident #1 and Resident #4. Record review identified Resident #1 lacked the ability to express his/her emotions or possible fear of Resident #4's aggressive actions; and a reasonable person would find Resident #4's actions towards Resident #1 as abusive. The facility reported a census of 47 residents during the investigation. Findings include: The facilities Dependent Adult Abuse policy updated 5/16 section revealed each resident had the right to be free from abuse. The policy indicated Residents must not be subjected to abuse by anyone including but not limited to other residents. The policy included the abuse definition as the willful infliction of injury, intimation, pain or mental anguish. Physical abuse included hitting and slapping. Mental abuse included but not limited to harassment. When resident to resident physical contact occurred, which included but was not limited to resident hitting or slapping which is considered resident to resident abuse. The facility will presume that instance of abuse caused physical harm, pain or mental anguish in residents with cognitive and or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish in the absence of evidence to the contrary. The policy listed an example of a resident slapping another resident who is physical or cognitively impaired even though the resident showed no reaction; it is presumed the resident experienced pain. The policy for resident to resident altercations indicated the facility will do whatever possible to control resident to resident altercation in order to prevent mental, physical, sexual and verbal abuse from occurring. 1.The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1's cognitive skills for daily decision making as moderately impaired with decisions poor. The MDS identified the resident had [DIAGNOSES REDACTED]. Resident #1's care plan up dated 12/20/16 reported that the resident will reach out to other with his/her hands once someone holds them the resident becomes agitated and yells out. a). Incident/Accident/Unusual Occurrences Form dated 11/19/16 at 9:10 a.m. reported Resident #4 held on to Resident #1's hand and pulled his/her arm straight forward. Resident #4 continued to pace up the hallway. Nurses Notes date 11/19/16 at 10:10 a.m. late entry for 9:40 a.m. revealed the panic button sounding on Memory Lane (the locked unit). The staff reported that Resident #4 had been pacing in the hallway while Resident #1 was holding on to the handrail in the hallway. Resident #4 held onto Resident #1's hand and Resident #1 tried to lift Resident #4's hand off his/hers. Resident #4 pulled Resident #1 arm straight out and continued to pace in the hallway. b). Incident/Accident/Unusual Occurrences Form dated 12/9/16 at 4:40 p.m. revealed Resident #4 had been ambulation in the hallway in staffs view when Resident #4 grabbed a hold of Resident #1's hand. The Certified Nursing Assistant (CNA) and Certified Medication Assistant (CMA) separated the two residents immediately. Nurses Notes dated 12/9/16 at 4:40 p.m. revealed Resident #1 reported the resident ambulating in the hallway when staff witnessed Resident #4 grab a hold of Resident #1's hand. The residents were separated and head to toe assessment done. c). Nurses Notes dated 12/18/16 late entry for 12/17 16 at 8:30 p.m. for Resident #4 reported that Resident #4 was walking in the hallway with CNA providing one to one. Resident #4 got close to Resident #1 and reached out to touch his/her hand. The CNA stepped between the two residents causing Resident #4 to tighten his/her grip. Resident #1 yelled and hit Resident #4 CNA called for assistance and the staff were able to separate the two residents. During an interview on 1/19/17 at 11:50 a.m. with Staff A CNA explained that Resident #4 was a very busy and would not sit down for a minute. He/she had been very resistive to cares and had even head butted her. Staff A acknowledged that once Resident #4 came to Memory Lane the other residents were kind of afraid, before they would walk up and down the hallway. Once Resident #4 came he/she was always in the hallway. Resident #4's room and Resident #1's room were on the same side of the hallway right next door to each other. Resident #4 was in the last room in the hallway on the south side. During an interview on 1/19/17 at 4:21 p.m. with Staff F CNA explained she worked in the Memory unit with one other CNA on 12/17/16 and had been assigned one to one ' s with Resident #4. That night he/she punched me in the mouth. Later, walking down the hallway toward his/her room Resident #1 was walking in the hallway and Resident #4 started to walk toward Resident #1 and Staff F got between the two residents. Resident #4 reached around and grabbed Resident #1's hand and pulled. Resident #1 started to yell and hit Resident #4. Staff F pushed the panic button and it took 10 to 12 minutes for a nurse to respond. It had been a very hectic night in the unit and out front. Staff F reported that Resident #4's room had been at the end of the hallway and Resident#1's room right next door to him/her. During an interview on 1/23/17 at 3:45 p.m. with Staff G CNA explained she worked on 12/17/16 out front as a float. Staff G acknowledged she heard Resident #1 yelling and went back to Memory Lane. Staff G explained all four were standing there at the time Staff F, Staff E and Resident #4 had Resident #1 hand. Staff G at that time redirected Resident #1. 2. The 11/29/16 quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4's cognitive skills for daily decision making as moderately impaired with decisions poor. The MDS identified the resident had [DIAGNOSES REDACTED]. The 11/23/16 care plan recorded Resident #4 had difficulty making decisions and communication and required checked on every 15 minutes. The 12/9/16 update to the care plan recorded the resident required one to one with staff at all times. The 12/17/16 update to the care plan recorded the resident requires one to one with staff at all times with staff between resident and others at all times. a). The Incident/Accident/Unusual Occurrences Form dated 11/19/16 at 9:10 a.m. reported that Resident #4 held on to Resident #1's hand and pulled his/her arm straight forward and then continued to pace up the hallway. Nurses Notes for Resident #4 on 11/19/16 at 10:40 a.m. documented the panic button sounding on Memory Lane (the locked unit). The staff reported Resident #4 had been pacing in the hallway while Resident #1 was holding on to the handrail in the hallway. Resident #4 held onto Resident #1's hand and Resident #1 tried to lift Resident #4's hand off his/hers. Resident #4 pulled Resident #1 arm straight out and continued to pace in the hallway. Record review of Resident #4's behaviors included the following: Nurses Notes dated 11/26/16 at 9:00 p.m. documented 15 minute checks continued, but the one (1) to one's (1) were done most of the 2p.m.-10 p.m. shift pacing and moving chairs unable to redirect the resident while pushing right through a person. The resident began to run into the walls banging his/her head attempted to elbow and hit staff getting aggressive and agitated. Nurses Notes dated 11/27/16 at 3:30 a.m., revealed staff assisted the resident back to bed he/she grabbed the staff's neck. Nurses Notes dated 11/27/16 at 2:30 p.m. identified staff notified the nurse that when assisting Resident #4 with toileting he/she made contact with staff three times. Nurses Notes dated 11/27/16 at 10:00 p.m. noted the resident pacing and wandering into room one to one most of the evening. The resident attempted to kick the door at the end of the hallway able to redirect from the exit. In the dining room the resident picked up a table and attempted to tip it over. Earlier in the day the CNA reported the resident stabled her with a fork one to ones during dinner. Nurses Notes dated 11/29/16 at 4:00 a.m. reported upon entering Memory Lane noted resident with increased anxiety and ponding on walls, turning tables over in dining area and gritting teeth. One to ones done and attempted to direct to sit or lay down resident combative and attempting to it staff. Nurses Notes dated 11/29/16 at 1:040 p.m. revealed the resident very anxious, moving and tipping furniture over. Nurses Notes dated 11/29/16, 11/30/16, and 12/2/16 and 12/5/16 and 12/9/16 documented Resident #4 paced up and down the hallway and staff continued 15 minute checks. Nurses Notes dated 12/3/16 at 1:30 p.m. revealed the resident very restless and pacing and turning tables and chairs over in the dining room. b). The Incident/Accident/Unusual Occurrences Form dated 12/9/16 at 4:40 p.m. reported that Resident #4 had been ambulation in the hallway in staffs view Resident #4 grabbed a hold of Resident #1's hand. The Certified Nursing Assistant (CNA) and Certified Medication Assistant (CMA) separated the two residents immediately. The Nurses Notes dated 12/9/16 at 4:40 p.m. Resident #4 reported the resident ambulating in the hallway when staff witnessed Resident #4 grab a hold of Resident #1's hand. The residents were separated while doing a head to toe assessment on Resident #4 he/she became agitated and attempted to head butt staff while taking blood pressure. Resident #4 one to one at this time for an intervention and continued to pace the hallway. Nurses Notes dated 12/9/16 at 5:20 p.m. revealed the resident remained agitated pacing the hallway. Nurses Notes date 12/10/16 at 3:00 p.m. identified one to one with resident unable to redirect will reach out and grab staff while pacing and not rest. Nurses Notes dated 12/10/16 at 3:30 p.m. revealed the resident continued pacing moving chairs attempted to tip over tables and trying to enter other resident's rooms. Nurses Notes dated 12/10/16 at 8:00 p.m. identified the resident punched the nurse in the stomach and snapped the toothbrush in half when in the shower. Nurses Notes dated 12/11/16 at 10:30 p.m. Resident #4 reported the resident up and down the hallway attempted entering other resident's rooms and continued one to one with staff. Nurses Notes dated 12/11/16 at 3:30 p.m. reported the resident agitated and pushing and swinging at staff. The resident will not stop pacing up and down the hall and attempted to hit staff twice. Nurses Notes dated 12/11/16 at 10:30 p.m. revealed the resident stopped for approximately 20 minutes to eat diner. Then the resident got back up pacing again and will not stop walking when other people are in front of him/her and will try to walk through them. Nurses Notes at 12/12/16 at 9:40 p.m. revealed the resident pacing all evening unable to redirect moving chairs and tables and being aggressive with staff. Nurses Notes dated 12/14/16 at 1:25 p.m. revealed while doing cares the resident became combative grabbing staff by the hair and head butted staff. Nurses Notes dated 12/14/16 at 3:30 p.m. identified the resident aggressive turning chairs over and pacing up and down the hallway. Nurses Notes dated 12/14/16 at 9:30 p.m. revealed the resident very resistive with cares and punched the nurse in the ribs. Then the resident hit nurse on top the head with his/her fist. Nurses Notes dated 12/15/16 at 6:00 a.m. reported the resident with increased aggression and anxiety when staff attempts to assist. Nurses Notes dated 12/15/16 at 10:00 a.m. reported the resident continued one to one with staff up and down the hallway and redirected out of other resident's rooms. Nurses Notes dated 12/16/16 at 4:20 p.m. the resident head butted the CNA while attempting to do cares. Nurses Notes dated 12/16/16 at 4:30 p.m. the Resident #4 reported the resident became agitated wand head butted the nurse while doing cares. Later, the resident was in chair with foot rest up and attempted to climb out. Nurse put hand on the resident's leg to wait till the foot rest was down and the resident became agitated and punched the nurse in the head. The resident stood up walked toward the nurse out of the TV room. Three female residents were in the hallway and Resident #4 walked toward them. This nurse stood between Resident #4 and the female residents encouraging them to backup, which they did not do. Resident #4 became aggressive and punched this nurse grabbing and scratching the right side of nurse's neck. The nurse immediately backed up the 3 female residents into a room for safety. Nurses Notes dated 12/17/16 at 8:00 a.m. revealed the resident hit staff in the head two times during cares. This nurse attempted to do cares and the resident head butted, kicked and punched at staff. Nurses Notes dated 12/17/16 at 12:00 p.m. while doing cares the resident attempted to head butt staff and hit them in the stomach. The resident continued to be very agitated and combative toward staff. The resident attempted to stand on chairs and difficult to redirect. Nurses Notes dated 12/17/16 at 2:20 p.m. reported the resident hit a CNA in the face. At 3:00 p.m. Resident #4 paced the hallway. Nurses Notes dated 12/17/16 at 7:00 p.m. the resident alternates between pacing from the family room to his/her room and the end of the hallway by exit doors. c). Nurses Notes dated 12/17/16 at 8:30 p.m. the resident walked in the hallway with CNA providing one to one. Resident #4 got closer to Resident #1 and reached out to touch his/her hand. The CNA stepped between the two residents causing Resident #4 to tighten his/her grip. Resident #1 yelled and hit Resident #4, the CNA called for assistance and the staff were able to separate the two residents. Incident/Accident/Unusual Occurrences Form dated 12/17/16 at 8:30 p.m. reported Resident #4 had been ambulating in the hallway with CNA one to one with resident. Resident #4 got closer to Resident #1 and reached out and touched Resident #4. Staff F CNA stepped between the residents causing Resident #4 to tighten his/her grip. Resident #1 started to yell and hit Resident #4 while Staff F attempted to block and redirect Resident #4. Nurses Notes dated 12/18/16 at 5:00 a.m. the resident pacing up and down the hallway agitated. The resident continued to move furniture, pushing and attempting to hit staff. Nurses Notes dated 12/18/16 at 5:20 a.m. reported the resident hit staff in the head with his/her fist and had increased agitation. Nurses Notes dated 12/18/16 at 5:30 a.m. reported the resident hit staff and continued pacing up and down the hallway. Nurses Notes dated 12/18/16 at 9:45 a.m. the resident combative hitting and pushing staff. Nurses Notes dated 12/18/16 at 10:30 a.m. revealed the resident continued pacing up and down the hallway combative and pushing staff. Nurses Notes dated 12/18/16 at 1:15 p.m. revealed the panic button sounding in Memory Lane. Two CNA's were with Resident #4 while doing cares, the resident head butted one CNA and then stood up and head butt the other one. Nurses Notes dated 12/18/16 at 2:30 p.m., revealed the resident up pacing the hallway and agitated. The resident pounding on walls and pushed staff. Nurses Notes dated 12/19/16 at 1:20 p.m. documented the resident up and down the hallway with some increased agitation. The resident attempted to pick up and move dining room table and chairs. Nurses Notes dated 12/19/16 at 7:30 p.m. the ambulance here to transport resident to the hospital for psychiatric evaluation.

Based on observation, record review, resident, staff and physician interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 4 resident records reviewed for assessment/intervention concerns. Resident #2 complained of abdominal pain and requested to see the physician. The facility failed to conduct an abdominal assessment and refused to allow the resident to see the physician when requested. Facility reported a census of forty-five (45) residents. Findings include: A Minimum Data Set (MDS) with assessment reference date of 11/13/14 assessed Resident #2 with a brief interview for mental status (BIMS) score of "15" (no cognitive impairment). Resident #2 required supervision with dressing and personal hygiene and extensive assistance with bathing and used a wheelchair for mobility. Resident #2 was occasionally incontinent of urine. Resident #2 ' s [DIAGNOSES REDACTED]. A pain assessment identified the resident with occasional pain with a numeric rating of "4" (on scale of 00-10 with 10 being the worst pain). Resident #2was 67 inches tall and weighed 220 pounds. A care plan dated 5/15/14 revealed staff should allow Resident #2 opportunities to make choices about his/her schedule and monitor for worsening of pain symptoms and report to physician. A hospital discharge date d 1/6/15 revealed Resident #2 received [DIAGNOSES REDACTED]. Resident #2 returned to the facility with orders for [MEDICATION NAME] (antibiotic) 500 milligrams (mg.) three times a day, [MEDICATION NAME] (antinausea) as needed for nausea and vomiting and [MEDICATION NAME] (for GERD) 40 mg. The nurse ' s noted dated 1/6/15 at 6:30 p.m. revealed Resident #2 returned from the hospital emergency room (ER) with a [DIAGNOSES REDACTED]. Resident #2 returned with a nursing order note for [MEDICATION NAME] 500 mg by mouth three times daily and [MEDICATION NAME] 40 mg, one tablet by mouth daily. Nurses notes, dated 1/9/15 at 1:40 p.m. revealed staff administered Tylenol ([MEDICATION NAME]) for abdominal pain and urinary pain with no further complaints voiced. Resident #2's temperature was 98.8 degrees. On the same date at 6:30 p.m. the resident's temperature was 99.3 degrees. Resident #2 complained of extreme coldness and his/her abdominal region hurting. Staff offered Tylenol for pain and Resident #2 refused because Resident #2 stated he/she took some earlier and it did not help. None of the 1/9/15 entries identified that staff conducted an abdominal assessment and/or assessment for bowel sounds. The clinical record and documentation failed to include vital signs assessed other than Resident #2's temperature. There was no further documentation until 1/10/15 at 5:20 a.m. On 1/10/15 at 5:20 a.m., Resident #2's temperature was 100.4 degrees. Staff administered Tylenol and encouraged resident #2 to get up and drink more fluids. Resident #2 stated he/she would not get up. At 6:45 a.m. Resident #2's temperature was 100.5 degrees. At 9:00 a.m. Resident #2's temperature was 99.3 degrees. Staff administered Tylenol 650 mg. At 10:15 a.m. Resident #2's temperature was 99.1 degrees and staff encouraged him/her to get up. At 2:00 p.m. Resident #2 got up in the wheelchair and ate 25% of lunch. Staff reminded Resident #2 to drink liquids. Resident #2 complained of stomach upset. Staff explained to Resident #2 that he/she was on an antibiotic and with Resident #2 not eating and other medications could upset his/her stomach. Resident #2 stated his/her bowels didn't move and staff again explained Resident #2 needed to eat and drink. At 3:30 p.m. Resident #2's niece arrived at the facility and insisted Resident #2go to the ER. Staff called the physician assistant (PA) and Resident #2's daughter and all agreed Resident #2 should go to the ER. Resident #2's temperature was 101.4 degrees. Resident #2 vomited green bile. Resident #2's niece took Resident #2 to the ER via car. Nurses notes dated 1/10/15 at 10:30 p.m. revealed Resident #2 was admitted to the hospital with [REDACTED]. None of the 1/10/15 entries identified that staff conducted an abdominal assessment and/or assessment for bowel sounds. No vital signs other than temperature were assessed until Resident #2 prepared to transport to the hospital at 3:30 p.m. Hospital emergency room and history and physical reports dated 1/10/15 revealed Resident #2 complained of pain in the epigastric area, especially the upper right quadrant with no bowel sounds. The abdomen was protuberant with no organomegaly. There was guarding of the upper right quadrant with positive Murphy's sign. On 1/11/15 the resident transferred to a larger hospital in Des Moines with ischemic enteritis and septic shock. Resident #2 underwent laparotomy with small bowel resection on 1/11/15. Nurse ' s notes on 1/13/15 documented Resident #2 in the hospital for necrotic bowel and had emergency surgery for [REDACTED]. According to review of the nurse ' s notes Resident #2 returned to the facility on [DATE] at 4:45 p.m. and was placed on Hospice care upon admission to the facility. Observation and interview revealed, on 3/4/15 at 10:50 a.m., Resident #2 in bed. Resident #2 stated they took 15 inches of small intestine out because it was rotting. Resident #2 stated it got to the point he/she vomited and Staff K (registered nurse) didn't act on his/her condition concerns. Resident #2 told Staff K that he/she wanted to see the physician and Staff K told Resident #2 he/she could not. Resident #2 stated his/her roommate (Resident #14) even tried to call the physician for him/her. Staff K told Resident #14 (roommate) to go back to his/her room because it was none of his/her business. On 3/4/15 at 3:50 p.m. Resident #14 confirmed Resident #2 was asking to go to the physician on 1/10/15. Resident #14 asked Staff K to call the physician after lunch that day and Staff K said she was not calling anyone. Staff K said Resident #2 had stomach pain because he/she did not eat. Staff K was very rude and also rude to Resident #2's niece when she arrived that afternoon. Resident #14 stated Staff K came up over the desk at Resident #14 and commented, I am not calling the doctor for someone not eating with stomach pain. On 3/4/15 at 3:25 p.m. Resident #2's niece stated Staff K got belligerent and told her there was nothing wrong with Resident #2 and there was no reason to call the physician. She stated she had to take Resident #2 by car because no ambulance was offered. Before they even left the driveway, Resident #2 vomited in the niece's car so she turned around and went in and requested an emesis basin. She stated Resident #2 should have gone via ambulance. When she got Resident #2 to the ER, the physician told her it was touch and go and serious. Resident #2 was transferred to a hospital in Des Moines. On 3/9/15 at 11:15 a.m., the physician stated anytime a resident has abdominal pain, staff needs to conduct an assessment of the abdomen. If a resident asks to go to the doctor, they need to go or have the Physician Assistant (PA) come and check the resident. The PA is just 3 minutes away from the facility. On 3/9/15 at 10:30 a.m. Staff K confirmed Resident #2 asked to see the physician after lunch and Staff K encouraged Resident #2 to get up and drink fluids. She also confirmed she did not assess Resident #2's abdomen or check for bowel sounds. When asked why she didn ' t call the ambulance for Resident #2, she stated the niece told her she was taking Resident #2 in the car

Based on observation, clinical record review and staff interview, the facility failed to direct nursing services to ensure Resident #4 received adequate supervision against hazards and failed to implement care plan directives to meet the resident ' s safety needs for one of four residents reviewed. Resident #4 fell during lunch in the dining room. The dining room was unattended due to 2 staff toileting a resident that required 2 staff assistance. The care plan identified the resident should use an alarm at all times. The alarm was not in place and therefore did not sound when the fall occurred. A physical therapy aide (PTA) failed to reapply the alarm after therapy. Staff interviews identified there were prior instances of PTA failure to reapply or activate resident alarms. The facility census was fifty-two (52) residents. Findings include: 1. A Minimum Data Set (MDS), with assessment reference date of 5/21/13, identified Resident #4 with a brief interview for mental status score of "3" (severe cognitive impairment). The resident had the following indicators of delirium: inattention and disorganized thinking. The resident required extensive staff assistance with transfers and ambulation. A "balance during transitions and walking" test identified the resident as not steady while moving from seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet and surface to surface transfers. The resident was able to stabilize without staff assistance. Nurses notes, dated 8/25/13 at 6:30 a.m., documented staff found the resident on the floor in his/her room. The resident tripped on his/her blankets and fell . Staff observed a skin tear to the resident's left elbow measuring 2 centimeters (cm) by 3 cm. The resident could not bear weight on the left lower extremity, cried out and his/her face grimaced with pain. The facility notified the physician and the resident transported to the emergency room (ER) for evaluation. The resident admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE] at 4 p.m. A care plan dated 5/30/13, contained an addendum dated 8/29/13, which directed staff to apply a clip alarm to the resident at all times. Nurses notes dated 9/2/13 at 12:15 p.m. and documented by Staff A (licensed practical nurse) identified staff summoned Staff A to the CCDI (Chronic Confusion Dementing Illness) Unit observed the resident on the floor by a table. Staff A observed external rotation and shortening to the left leg. Staff notified the physician and the resident transported to the emergency room for evaluation. Nurses notes dated 9/3/13 at 1:45 p.m. documented the hospital called and informed the facility the resident had a crack below the left hip hardware used to repair the 8/25/13 hip fracture. The resident was admitted to the hospital. A fall investigation for nurses dated 9/2/13 and completed by Staff A (licensed practical nurse) identified the resident got up from his/her wheelchair while in the dining room for the meal. The investigation form identified the resident's alarm intervention was not in place because it was not placed on the resident after therapy. Prior to the fall, the resident was seen eating lunch. An internal quality assurance investigation form dated 9/2/13 identified staff left the dining room unattended. Staff education provided included: Do not leave dining room unattended and check all alarms. A hospital transfer report with admission date of [DATE] contained an entry dated 9/3/13 which identified the resident sustained [REDACTED]. The additional fracture was nondisplaced. The physician and family opted not to surgically treat the new fracture and the resident returned to the facility with 10% weight bearing and bed to chair transfers. The surgical option was not pursued due to the risk of surgery. On 9/23/13 at 2:10 p.m. the Administrator identified the facility had a contract with a therapy company that comes in and provided therapy to residents. She provided the contract to the surveyor. Page 2 of the therapy contract contained a category that identified "duties and obligations of the facility". Under "administrative responsibility" the contract documented the facility and/or its agent shall retain administrative and professional responsibility for control over and supervision of the provision of services rendered to patients in all respects, as required by state and federal laws. On 9/23/13 at 11:05 a.m. Staff I (physical therapy aide) stated on 9/2/13 he got the resident up from bed and detached the resident's clip alarm. He saw the resident for therapy for 65 minutes from 10:15 a.m. to 11:20 a.m. He stated at 11:20 a.m. a nurse came and told him it was time for the resident to go to lunch. He brought the resident to the CCDI lunch room. Staff were present in the dining room when he returned the resident. He stated he saw another resident for 45 minutes when he heard a lot of commotion and found out Resident #4 fell . He stated he forgot to reapply the alarm after therapy. He left the alarm in the resident's bed. He stated his normal practice was to "leave a patient how they were" when he took them to therapy. In other words, it would be normal practice to reapply the alarm after he removed one. He stated the facility now has a communication sheet that contains information about residents and their alarms. The communication sheet started after Resident #4's fall. On 9/24/13 at 11:20 a.m. Staff D (certified nurse aide) stated she worked in the CCDI with Staff H (certified nurse aide) on 9/2/13. They were the only staff present on the CCDI when the fall occurred. She stated during lunch, a resident's alarm sounded and the resident tried to self-transfer. That resident required two staff for assistance and that resident needed the commode. Both staff left the dining room to assist that resident to the commode. While in that resident's room, a visitor knocked on the door and informed them a resident was on the floor in the dining room. Staff D stated no alarm sounded prior to Resident #4's fall. She stated when she left the dining room, the majority of residents finished eating but some were still finishing their meals. She estimated she was gone from the dining room 1 to 2 minutes-just long enough to get to the resident's room and sit the resident on the commode. She stated the resident's room was 3 doors down from the dining area. Staff D stated therapy did not activate a resident's alarm after therapy in the past. She did not report it to anyone, she just turned the alarm on and made a mental note about the incident. She stated she was not sure if staff could have made it to the dining room in time even if the alarm was in place. On 9/23/13 at 10:45 a.m. Staff H (nurse aide) stated on 9/2/13 she and Staff D worked on the CCDI unit. As they assisted residents with lunch, a resident attempted to self transfer to the toilet. That resident required 2 staff to assist him/her. As she and Staff D assisted that resident, a visitor knocked on the door and said someone was on the floor in the dining room. Staff H identified no staff present in the dining room when the fall occurred. She stated when she left the dining room residents ate lunch. She stated was only gone a few minutes. She stated after Resident #4 fell , she saw the resident's clip alarm was not in place. She stated if the alarm sounded, she thought they could have reached the resident in time to prevent the fall. She stated she recently shortened the resident's alarm cord so it would have sounded right away. She estimated the resident ambulated about ten feet prior to falling. She stated therapy failed to reattach alarms after therapy in the past but no resident fell . She just discovered them not reapplied. She stated she informed the charge nurse but could not remember who she told. On 9/24/13 at 12:50 p.m. Staff H stated all 12 residents were still in the dining room when the fall occurred other than the resident they toileted. On 9/23/13 at 11:47 a.m. Staff G (certified nurse aide) stated there was a few times therapy did not reattach/activate alarms after therapy. The last time prior to the 9/2/13 incident was approximately 4 to 5 months. Staff G stated she informed charge nurses but could not recall who she told. On 9/24/13 at 9:35 a.m. Staff A (licensed practical nurse) stated staff paged her to the CCDI unit and she observed the resident on the floor with his/her leg rotated. The resident did not complain of pain. Staff A stated they reported no one was in the dining room when the fall occurred. They took a resident to the toilet and during that time, the resident got up and fell . The resident also did not have an alarm attached because therapy failed to reapply it after therapy. Staff A stated she thought staff could have prevented the fall if someone would have been in the dining room. After the incident Staff A put out a staff education to call for someone out in the main area so someone will always be in the dining room. She stated the resident always tried to stand. She stated hindsight is 20/20 so maybe the incident couldn't have been prevented. On 9/24/13 at 10:33 a.m. the Director of Nursing (DON) stated she was not aware of past issues with therapy not reattaching/activating alarms after therapy. Since being informed, she stated she asked 2 charge nurses who were also not aware. After the incident on 9/2/13, the DON informed staff to page the main area of the facility so someone could cover the dining room if staff needs to toilet a 2 person resident. She also stated therapy personnel were more than welcome to check the resident's chart for care plan directives. Since the incident, the DON implemented a communication form for therapy that identified the residents' alarm needs. The DON wants to be 100% sure they know of alarms in the future. On 9/24/13 at 12:30 p.m. the Director of Nursing stated it is not a policy for a staff to remain in the dining room during meal time. They would like a staff in the dining room at all times but also understand things happen that may not always make that possible. On 9/24/13 at 12:38 p.m., Staff C (food service manager) stated there are 2 residents on pureed diets in the CCDI. One was the resident the staff left the dining room to toilet and the other resident received puree because it made it easier for that resident to swallow. On 9/23/13 at 12:12 p.m., the surveyor interviewed the visitor that observed the resident on the floor. The visitor stated she arrived to visit a family member and always looks in the CCDI dining room before proceeding to the family member's room to see if they are still eating. When she looked, she saw a resident on the floor so she knocked on a resident's door and informed the staff. She confirmed there were no staff present in the dining area when she observed the resident on the floor. Observation showed, on 9/23/13 at 8:25 a.m., the resident in bed with a laser alarm at the bedside and a pressure alarm in place. Two staff assisted the resident from bed to the wheelchair. The resident denied pain. On the same date at 10:40 a.m., the resident finished therapy. The resident sat in a wheelchair with an alarm on. Observation showed, on 9/23/13 at 12:12 p.m. two staff assisting residents with eating their meals in the CCDI dining area.

Based on observation, record review and interviews, the facility failed to plan for and implement services to ensure residents received adequate supervision from others. Resident #2 was known to become agitated and aggressive with residents that entered his/her room. The facility failed to implement interventions to increase supervision of the resident until after the resident pushed Resident #1 to the ground causing a hip fracture and then failed to ensure implemented interventions were effective. The facility identified a census of fifty-four (54) residents with five residents reviewed for supervision. Findings include: A Minimum Data Set (MDS), with assessment reference date of 3/22/12, assessed Resident #2 with a brief interview for mental status (BIMS) score of 3 (severe cognitive impairment). The MDS did not identify behavior symptoms. The resident required supervision transfer and was independently ambulatory. The resident had [DIAGNOSES REDACTED]. admission orders aggression" and "dementia". The resident admitted with an order for [REDACTED].) injection into the vein 0.25 ml. every 4 hours as needed and Haldol (antipsychotic) 5 mg. per milliliter 1 ml. intramuscularly every 6 hours as needed. A social service progress note, dated 12/20/11 at 4:25 a.m., identified the resident admitted to the facility CCDI (Chronic Confusion and Dementing Illness) unit from the hospital where the resident's behavior fluctuated from compliant to agitated. A MDS departmental note, dated 12/31/11, revealed the resident admitted to the facility following hospitalization for belligerent, combative and physically aggressive behavior. Nurses notes, dated 12/29/11 at 9:03 a.m. documented Resident #2 received a shower and then thought he/she could go home. The notes indicated Resident#2 very agitated and pushed at staff. Staff provided one to one and the resident calmed down. On the same date at 9:49 a.m., the physician assistant (PA) increased the resident's Risperdal (antipsychotic) medication to 0.5 milligrams (mg.) twice a day. At 12:10 p.m., Resident #2's agitation continued and he/she indicated he/she wanted out of here. The resident made calls on a cell phone and stated he/she did not understand why he/she needed to reside at the facility. A facsimile to the PA, dated 12/29/11, stated Resident #2 had behaviors starting around 9 a.m. on that date, staff listed the behavior as wanting to go home and trying to push others to get out of the CCDI unit. Nurses notes, dated 1/7/12 at 9 p.m., stated the resident complained of wrist pain and stated he/she twisted or sprained the wrist while pushing Resident #1 out of his/her room. Nurses notes, dated 2/14/12 at 8:15 a.m., identified the resident as agitated stating "that guy steals". One to one provided and resident yelled at staff. A February 2012 behavior/intervention monthly flow record identified an intervention for agitation and refusing care as "remove others from room" added to the intervention list as an addendum on 2/10/12. On 5/8/12 at 12:35 p.m. Staff O (registered nurse) stated she added the addendum, to the intervention list after a state surveyor questioned why the intervention was not on the list. After the surveyor questioned her, Staff O stated she then added the addendum to the list. The behavior record identified staff removed others from Resident #2's room due to agitation on 2/23/12, 2/2712, 2/28/12. March 2012 behavior/intervention monthly flow record identified staff removed others from the resident's room on the following dates: 3/3/12, 3/4/12, 3/7/12 and 3/8/12. The behavior record did not identify behaviors on 3/24/12 other than "multiple health complaints". Nurses notes, dated 3/24/12 at 3:50 p.m., stated the resident became very upset when another resident came into his/her room and refused to leave. The resident raised his/her arms up and accidentally hit other resident in face without injury. An incident/accident/unusual occurrences form, dated 3/24/12 at 3:50 p.m. and written by Staff N (registered nurse), revealed the nurse heard a commotion coming from Resident #2's room. When Staff N entered the room she noted Resident #5 just inside the doorway of Resident #2's room yelling at the resident and stating Resident #2 hit him/her in the face. Resident #2 then identified the incident as an accident. Resident #2 stated the other resident attempted to use his/her bathroom and Resident #2 told the other resident to leave. The other resident refused to leave and Resident #2 became very upset and raised both arms and hit the other resident in the face. The incident report indicated the facility notified the PA of Resident#2's role in the incident on 4/30/12 (over one month later). A Minimum Data Set (MDS), with assessment reference date of 2/2/12, assessed Resident #5 with a brief interview for mental status (BIMS) score of 8 (moderate cognitive impairment). The MDS identified the resident as independent with ambulation. The resident had [DIAGNOSES REDACTED]. On 5/3/12 at 2:30 p.m. observation showed Resident #5 in bed. The resident denied anyone pushed or hit him/her and stated he/she just arrived at the facility yesterday. Nurse's notes revealed, on 3/28/12 at 12:35 p.m., PA reduced Resident#2's Risperdal by discontinuing the morning dose. Nurse's notes revealed, on 3/31/12 at 12:40 p.m., after lunch another resident opened Resident #2's door. Resident #2 yelled and raised his/her hand up but staff intervened before Resident #2 made contact with the other resident. Staff separated the residents and provided one to one and Resident #2 stated he/she didn't care and "no one better come here again". Nurses notes revealed, on 4/10/12 at 10:15 a.m., another resident opened Resident #2's door and Resident #2 almost pushed the other resident but staff intervened before Resident#2 made contact with the other resident (Resident #3). On the same date at 12:56 p.m., Staff O asked Resident #2 if he/she would take a shower. Resident #2 pushed Staff O and grabbed Staff O's thumb and pulled it back. While doing this the resident almost lost his/her balance. Staff O provided one to one and the resident calmed down. Staff O updated the physician. April 2012 behavior records identified staff removed others from Resident #2's room on the following dates: 4/1/12, 4/5/12, and "all" interventions used (which included removing other from room) on: 4/6/12, 4/9/12. 4/10/12, 4/11/12, 4/13/12, 4/14/12, 4/15/12, 4/19/12, 4/24/12, 4/25/12, 4/26/12, 4/28/12, 4/29/12. Resident #2's Nurse's notes dated 4/16/12 at 12:40 p.m., documented a PA visit due to weight loss and decreased appetite. The PA initiated Zoloft (antidepressant) 50 mg. every morning and Ranitidine (for ulcers and heartburn) 150 mg every night. Nurses notes, dated 4/18/12 at 4:45 p.m., documented Resident #2 pushed another resident (Resident #1) and the resident fell in the hallway. Staff did not witness the event. Resident #4's spouse witnessed the incident. Resident #2 stated he/she felt bad about the incident and denied pushing Resident #1. Resident #2 stated he/she merely took Resident #1 by the shoulders and walked Resident #1 to the door like he/she had done 4 or 5 times before. Resident #2 stated when Resident #1 got to the door he/she got wobbly and lost their balance. On 5/7/12 at 5:16 p.m., Resident #4's spouse, who visited at the time of the incident, identified self as a witness to the 4/18/12 incident. He/She stated he/she observed Resident #1 leaving Resident #2's room when Resident #2 came behind Resident #1 and very forcefully pushed Resident #1 in the back causing Resident #1 to go into the wall and down to the floor. Resident #1 information: A fall risk assessment, dated 2/29/12, identified Resident #1 with a fall risk of "16". A score of 10 or above represents high risk. A Minimum Data Set (MDS), with assessment reference date of 2/23/12, assessed Resident #1 with impaired long and short term memory and moderately impaired decision making skills. The MDS identified the resident to require limited staff assistance with ambulation. A "balance during transitions and walking test" revealed the resident was not steady but could stabilize without human assistance. The resident had [DIAGNOSES REDACTED]. Resident #1's nurses notes, dated 4/18/12 at 5 p.m., documented another resident shoved Resident #1 causing Resident #1 to fall in the hallway. The resident transported to the hospital via ambulance where x-rays identified a fractured right hip. A patient transfer form, dated 5/2/12, indicated the resident returned to the facility on Hospice care with [DIAGNOSES REDACTED]. Observation showed, on 5/3/12 at 11:05 a.m., Resident #1 in bed. The resident did not respond to verbal stimuli. Review of Resident #2 care plan and observations: A care plan, dated 4/5/12, did not identify the resident with aggression towards other residents that entered his/her room until after the 4/18/12 incident. On 4/20/12 the facility added the following problem to the care plan "Gets upset when other residents wander into room". At this time, the facility placed a Velcro stop sign across Resident #2's room door to discourage other residents from entering. On 5/1/12 the facility placed an infrared alarm at Resident #1's door entrance to identify in and out traffic. On 5/3/12 at 10:25 a.m., observation showed Resident #2's door shut with stop sign across door and alarm in place on door frame. The alarm sounded. Observation showed the resident in bed. The resident stated he/she did not feel well. The resident denied any residents entered his/her room. When asked if he/she would like it if others entered, Resident #2 replied it ' s up to them "I do not hold them back". Observation showed, on the same date at 5:42 p.m. after supper, the resident in the room resting in the recliner with stop sign across the door with the door shut. Observation of the alarm showed it in the "off" position. Staff J (acting director of nursing) confirmed this observation. An incident/accident/unusual occurrence form, dated 5/5/12 at 12:30 p.m., and documented by Staff N revealed staff heard a commotion from Resident #2's room. A nurse aide (Staff R) reported she observed Resident #2 shouting at Resident #3 who was in Resident #2's room. Observation also showed Resident #2 pushing Resident #3. Staff R intervened and removed Resident #3 from the room. Staff R observed the door to Resident #2's room wide open with stop sign down and the alarm in the "off" position. Staff notified the physician of the incident. Resident #3 did not sustain injury. Observation showed, on 5/8/12 at 10:12 a.m., Resident #2 in their room. The resident stated he/she did not have a good weekend. When asked what occurred the resident replied, "Nothing serious". Observation showed a staff seated outside the resident's room. Staff identified her job was to watch the resident and stated if the resident gets up, we get up and if the resident goes down the hall we go down the hall. At 10:35 a.m. an ambulance arrived to take the resident to a geriatric psychiatric unit for evaluation. Staff Interviews: On 5/3/12 at 2:38 p.m., Staff N (registered nurse) stated Resident #2 has gotten angry with others going in the resident's room before the 4/18/12 incident in which Resident #1's hip fractured. She stated she worked when Resident #2 and Resident#5's incident occurred. Staff N stated Resident #5 had a urinary tract infection at the time and this resulted in increased confusion. Resident #5 went into Resident #2's room to use the bathroom. Staff N stated she was in the dining room around 4 p.m. the day of the incident (3/24/12) when she heard a commotion. Resident #5 stated Resident #2 hit him/her. Staff N did not see any marks. At that time, Resident #2 told Staff N that Resident #5 would not leave Resident #2's room so Resident #2 threw up his/her hands and accidentally hit Resident #5 in the face. Staff N separated the residents and told Resident #2 to keep the room door closed. Staff N stated Resident #1 and Resident #2 used to share a room but it didn't work out because Resident #1 got up and tried to get in Resident #2's bed. Later Resident #1 moved out of the room. She stated Resident #1 often went in everyone's room. She stated usually they would hear a commotion or they would see Resident #1 head down towards Resident #2's room and staff would intervene. Staff N stated staff has intervened before anything physical could occur in the past. On 5/8/12 at 12:42 p.m., Staff N stated she worked when the incident occurred on 5/5/12. She stated it was a Saturday after lunch when staff heard a commotion. Staff R went to the room, and saw Resident #2 pushing Resident #3 in the chest. Staff N stated the alarm did not sound and staff found it in the "off" position. Staff N stated the resident took themselves out to lunch and she did not know if the door alarm sounded when the resident went to lunch. Staff N stated they caught the resident turning the alarm off after installation on 4/20/12. On 5/9/12 at 11:25 a.m., Staff R (nurse aide) stated she worked on 5/5/12 when the incident occurred. She stated she was in the dining room when she heard yelling. She went to Resident #2's room and saw him/her standing behind the recliner with Resident #3 a few steps in the room. She observed Resident #2 push Resident #3 in the chest causing Resident #3 to stumble back. Staff R removed Resident #3 from the room. Staff R stated she did not observe any of the interventions in place. The door was wide open, the stop sign was down and the laser alarm did not sound. Staff R stated when the facility installed the alarm the resident got frustrated and figured out how to turn it off. The resident saw others turn it off so many times that he/she figured it out. Staff R stated she saw the resident turn it off a couple times before the 5/5/12 incident. The resident would take the Velcro stop sign down and not reattach it. Staff R stated she switched the alarm on after breakfast but following that she does not know what occurred. She denied taking the resident out for lunch and stated he brought his/her self out. On 5/7/12 at 4:42 p.m. Staff B (nurse aide) stated she had seen Resident #1 try and get in Resident #2's room in the past. Resident #2 starts yelling but Staff B had not seen anything physical before. Staff B stated Resident #2 has gotten more irritated recently thinking others are "out to get him/her". Staff B stated staff was probably busy in the dining room when the incident between Resident #1 and Resident #2 occurred but Staff B feels staff does watch the residents and monitor them adequately. Staff B stated there were no interventions in place regarding residents entering Resident #2's room prior to the 4/18/12 incident. On 5/7/12 at 9:33 a.m., Staff G (nurse aide) stated Resident #2 gets very irritated when people get in the resident's room. She stated she saw Resident #2 gently remove a resident from the room once by taking the resident's shoulders and turning the resident around. Staff G stated staff tried to keep residents out of Resident #2's room. She stated Resident #2 would walk up and down the hall and get angry if someone interfered with the walking. On 5/8/12 at 10:38 p.m., Staff I (nurse aide) documented in March 2012 she heard yelling from Resident #2's bathroom and found Resident #1 and Resident #2 both in the bathroom. It appeared Resident #1 used the toilet because the resident's pants were not all the way up. Resident #2 had a hold of Resident #1's wrists and shoved Resident #1 making Resident #1 unsteady. Staff I tried to separate the two residents and in doing so, Staff I got shoved against the wall by Resident #2. The nurse on duty had to assist with the incident. Also within the past couple months Staff I heard Resident #2 yelling and went to see what was wrong. Resident #3 was confused and wandered into Resident #2's room. When Staff I arrived, Resident #2 had his/her fists drawn back as if he/she would strike Resident #3. Staff I attempted to calm the resident but Resident #2 kept cursing. Staff I took Resident #3 from the room. Staff I stated she tells the nurse on duty when incidents occur. On 5/8/12 at 10:50 a.m., Staff J (acting director of nursing) stated staff notified her of the incident on 5/5/12 between Resident #2 and Resident #3. Staff J stated she did not know how it occurred but the alarm was off. The facility sent Resident #2 to the emergency room (ER) that day but they did not keep the resident. Staff J researched geriatric psych units on Sunday over the Internet and the physician also increased Resident #2's Risperdal (antipsychotic) that day. No staff stated they turned the alarm on after lunch on 5/5/12. On 5/3/12 at 12:15 p.m. Staff K (nurse aide) stated Resident #2 pushed her in the past and said, "Leave me alone". As Staff K left the room, the resident pushed her into the closet. It was a hard push and enough that Staff K lost his/her balance. Staff K stated because of this incident involving herself and the resident, she was not surprised when the incident occurred on 4/18/12 between Resident #1 and Resident #2. She stated the incident with her occurred about a month ago. Staff K stated Resident #2 shoved Resident #3 in the past and she estimated the date as 4/15/12. She stated she may have reported it to Staff N. Staff K stated Resident #3 did not fall because she was right there to assist the resident out of the room. She stated she had said "it ' s an accident waiting to happen" and thought the resident could end up hurting someone. On 5/3/12 at 10:20 a.m., Staff M (nurse aide) stated, before the 4/18/12 incident, she saw Resident #2 get agitated when other residents would get in his/her room. On 5/3/12 at 10:37 a.m. Staff O (registered nurse) identified Resident #1 as very unsteady with a history of falls, especially when turning around. Resident #2 became angry when residents would enter his/her room and it had gotten worse. The resident was getting more aggressive. Before the incident on 4/18/12 , there was an incident between Resident #2 and Resident #3 on 4/10/12. Staff O heard Resident #2 tell the other resident to get the hell out. Resident #3 turned around and Resident #2 had his/her hands up as if to push the resident in the back. Staff O yelled at Resident #2 not to touch Resident #3 because the resident did not know what they were doing. Resident #2 stopped and said, "Oh I didn't know". Staff O stated she informed the Director of Nursing (DON) of the incident and that it looked like Resident #2 might push someone. She stated Resident #2 ducks under the stop sign so staff implemented the laser alarm which agitated the resident. Staff O stated, on 5/8/12 at 12:50 p.m., she observed Resident #2 disable the alarm one time. On 5/8/12 at 2 p.m. Staff P stated she was on break when the 4/18/12 incident occurred between Resident #1 and Resident #2. Other staff informed Staff P that Resident #2 pushed Resident #1. Staff P sat with the resident until the ambulance arrived. Staff P stated Resident #2 did not like anyone in his/her room. Resident #2 has been aggressive with resident in the past. Resident #2 pushed other residents before and even pushed staff. Afterwards, the resident is immediately sorry. Staff P observed Resident #2 grab Resident #3's arms and moved Resident #3 backwards. This occurred month ago and Staff P reported it to the nurse. Staff P stated the alarm does not always work on the door of the resident's room because the resident knows how to turn it off. Staff P identified Resident #2 as gradually getting more aggressive about others going into his/her room. On 5/8/.12 at 2:43 p.m. Staff Q (medication aide) stated she was with someone, on 4/18/12 when she heard a scream. Resident #2 does not understand why other residents wander into his/her room. Resident #2 pushed Resident #1. Resident #2 did not like other residents in his/her room and would get agitated. The resident might firmly push them out but not violently. Staff Q stated she observed Resident #2 "be firm" with Resident #3 and Resident #1 before. Resident #2 would push others in the chest or put his/her hand on their chest. Staff Q stated she could see it coming at some point because the resident was "a little firm". On 5/9/12 at 11:15 a.m., Staff S (nurse aide) stated Resident #2 had exhibited anger, before the 4/18/12 incident, when others would enter the room uninvited. The resident would get upset and his/her voice changed and the resident would throw his/her arms in the air. On 5/10/12 at 10:21 a.m. during phone exit, the Administrator and Staff J stated they spoke with Staff R about observing the resident turn the alarm off prior to the 5/5/12 incident. They stated Staff R did not work in the CCDI unit often and when asked when she saw the resident turn the alarm off, Staff R stated she may have viewed it just the morning of the incident. They stated Staff N also stated she may have only observed the resident turn the alarm off that morning. Following the 4/18/12 incident, the facility held a five minute meeting for employees, dated 4/18/12 regarding resident to resident behavior and interventions.