Every finding on record at Sunrise Hill Care Center

Based on personnel record review, policy review, and staff interview, the facility failed to implement their abuse policy when the facility failed to complete the required Abuse and Criminal History check within the required 30 days of hire date for 1 of 5 staff reviewed (Staff A, Dietary). The facility reported a census of 53 residents. Findings include: Staff A's personnel record review listed a hire date of 4/14/25. The record review included the Single Contact License and Background Check (SING) with a completion date of 1/31/25. The facility policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, reviewed 4/2024 revealed the following per the Employee Screening section: The facility shall screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of Residents. The policy further instructed the facility to conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code 58.11(3).During an interview 12/2/25 at 2:44 PM, Staff B, Manager, acknowledged Staff A began employment more than 30 days after the facility had completed their background check.

Based on observation, clinical record review, staff and resident interviews, the facility failed to ensure that 1 of 3 residents reviewed were treated with dignity and respect (Resident #3). On 5/23/24 Staff A, Certified Nursing Assistant (CNA) yelled at Resident #3 in a disrespectful and undignified manner using foul language. The facility reported a census of 45 residents. Findings included The quarterly Minimum Data Set (MDS) dated [DATE] revealed short term memory problems and modified independence, some difficulty in making daily decisions in new situations only. The MDS further documented no behaviors or rejection of care and independent for chair to bed transfer and ability to stand from a seated position. The MDS further identified diagnoses that included: Malignant neoplasm of the right breast, chronic kidney disease, and Diabetes Mellitus. The Care Plan dated as initiated on 4/1/24 identified a focus are related to impaired cognitive function/dementia or impaired thought processes and directed staff to ask yes or no questions and cue resident and supervise as needed. Review of an Alleged Abuse Investigation of Resident #3 summary prepared and signed by the Director of Nursing (DON) included: On 5/28/24 Resident #3 reported to her daughter that last week a CNA had come into her room and told her it was time to go to bed. Resident #3 responded that it was too early. Resident #3 went to stand up and the CNA pushed her back down causing her knees to buckle and land on the floor beside her bed. Resident # 3 reported the CNA called her a derogatory name and also called her a princess. Resident #3 described the CNA and positive identification was made by showing a picture of Staff A, CNA to the resident. Resident #3 was checked for any skin markings that may have resulted from the incident and none were identified. Observation and interview on 7/16/24 at 1:45 p.m. Resident #3 was well groomed and sitting in her recliner in a private room. Stated that a staff person, described as a large gal with reddish hair, had pushed her on the chest causing her to fall from her bed to the floor. She was able to get back in bed, but wasn't ready to go to bed at that time. The staff person scared her and yelled at her using foul language and called her a derogatory name. Resident #3 added that she had reported to her daughter. Stated she was shown a picture and was able to identify the staff person who had yelled at her. Resident #3 responded that the staff person had not been back in her room since she reported her concerns, and that she feels safe at the facility but does not feel that she should be treated like that. In an interview on 7/16/24 at 4:09 p.m. Staff A, CNA identified that she had only had difficulty getting Resident #3 to bed on one occasion which was determined to be 5/23/24. Staff A stated she had first approached at 8:30 p.m. and Resident #3 had informed she was not ready to go to bed. Staff A stated she had re-approached at 9:00 p.m. and the resident allowed to toilet and get ready for bed in the bathroom, but wasn't happy about it. Staff A described that she had a gait belt on Resident #3 and walked her back to her bed, but again stated the resident was not happy and didn't want to go to bed. Staff A stated she lifted the bed so that Resident #3 could stand up easily and transferred her with the gait belt to her chair. Staff A denied pushing Resident #3 but did admit to calling her a derogatory name. Staff A stated she realized this was wrong. In an interview on 7/17/24 at 12:04 p.m. the daughter of Resident #3 stated that on 5/28/24 her mother told her that week prior an aide had wanted to put her to bed at 8:00 p.m., but her mom had informed the aide it was too early. Added that her mom reported that the aide had called her a derogatory name and a princess. The family member responded that her mother was calm, not crying or upset but was mad. Did say that her mother stated she had slept with one eye open, but really never brought it up again to her. Her mother had described the stature and hair color of the staff person and stated that she was in the room when her mother confirmed the staff person's identity by looking at a picture provided by the facility staff. In an interview on 7/16/24 at 2:10 p.m., the DON verified that she had completed the investigation The facility had suspended Staff A prior to her next shift. Prior to completion of the investigation Staff A had resigned however the facility had determined that Staff A had violated the abuse policy and that her language and treatment of Resident #3 was not the kind of treatment that is tolerated by the facility. Review of facility Abuse Prevention, Identification, Investigation and Reporting Policy dated as last reviewed 4/24 included: the expectation that all residents have the right to be from abuse. Definition of verbal abuse included: oral, written or gestured language that willfully include disparaging and derogatory terms to residents, or within their hearing distance.

Based on observations, interviews, and record review, the facility failed to provide safety interventions required for 2 out of 4 residents reviewed (Residents #1 and #2). Resident #2 required assist of 1 staff with a gait belt (a belt placed around the waist to aide in safe transfers and ambulation) for transfers and ambulation. A Certified Nurse Assistant (CNA) let go of the gait belt resulting in Resident #2 falling and fracturing her hip. Resident #1 was to not be left unattended in his room unless he was in bed. Resident #1 was found on floor unattended at least twice in his room. The facility reported a census of 47 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #2 required extensive assist of 1 for transfers, ambulation and toilet use. The MDS included diagnoses of a cerebrovascular accident (CVA)(Stroke). A Care Plan Focus initiated on 6/30/22, identified Resident #2 as impulsive and tried to do more than she could safely do. Resident #2 had personal alarms. It directed the staff that Resident #2 required staff assistance of 1 person for toilet use and transfers. It documented Resident #2 received assistance of 1 person with a walker and gait belt for ambulation. Resident #2's Clinical Census reflected she transferred to the hospital on 9/14/23 and then returned from the hospital on 9/18/23. In addition, the list reflected Resident #2 discharged from the facility on 11/6/23. A Progress Note dated 9/14/23 at 4:45 AM, written by Staff B, Licensed Practical Nurse (LPN), documented at 4:00 AM Staff A, CNA reported that Resident #2 fell in her bathroom. Staff B, documented that Resident #2 was laying on her right side on the floor with her head resting on the wall. Resident #2 stated she hit her head on the right side behind her ear. Staff A and Staff B assisted Resident #1 up and placed her on the toilet. Resident #2 complained of sharp pain. Resident #2 was placed into a wheelchair and laid on to her bed for further assessment. Staff B documented that Resident #2's right hip was splayed out wider than normal. Staff B phoned 911. Resident #2's Incident Report dated 9/14/23 described her as sitting/laying on the bathroom floor (on her right side) with her head resting on the wall. Resident #2 had good range of motion, except for her right hip/leg. 2 Staff assisted her to standing with a gait belt. The report indicated Resident #2 had a right hip fracture repaired on 9/14/23. The Nurses Note dated 9/14/23 at 2:49 PM, reflected the facility's physician reported Resident #2 had a right hip fracture and they admitted her to the hospital for right hip surgery. The Nurses Note dated 9/18/23 at 5:15 PM, indicated Resident #2 returned to the facility. The Hospital's Clinical Summary dated 9/18/23, indicated the hospital admitted Resident #2 after undergoing surgical repair for a right hip fracture (intertrochanteric, right femur). The summary included a diagnosis of acute blood loss. The Hospital Progress Notes printed 9/18/23 indicated the provided suspected Resident #2 bled into her surgical site, resulting in Resident #2 receiving 2 units of blood. The note included Resident #2 also had a T12 compression fracture (Fracture in mid-lower back of the vertebrae bone). On 4/3/24 at 10:41 PM, Staff B explained Staff A called her to Resident #2's room. When she arrived, she found Resident #2 sitting in the corner of the bathroom floor. Staff B explained as Staff A threw linen around the corner into the bathroom linen cart. Staff B said when Staff A reached around the corner, Resident #2 fell in that short of period of time. Staff B remarked Staff A took Resident #2 to the toilet. Staff B stated she did not remember if Resident #2 had a gait belt around her waist or not. Staff B stated they lifted Resident #2 off the floor and sat her on the toilet. Staff B stated Resident #2 said that hurts and she wouldn't bear any weight on one leg. Staff B reported she and Staff A when lifting Resident #2 off of the floor and transferring Resident #2 to the toilet, were lifting her up while holding onto Resident #2 under each arm. Staff B stated she wanted to say Resident #2 had a gait belt on when they lifted her but staff B couldn't remember. Staff B reported Resident #1 required assistance for 1 person with transfers. Staff B said of course they are supposed to have a gait belt on Resident #2. She stated they are to use a gait belt on residents that are an assist of 1 for transfers and ambulation. Staff B described Resident #2 as spring loaded, as she would pop up on her own. She always tried to do things like that. She couldn't be left alone on the toilet. Resident #2 had a bed alarm while she slept. Staff B thought that Resident #2 had a bed and a floor alarm. Staff B stated she sent Resident #2 to the hospital. On 4/4/24 at 9:22 AM, Staff A reported Resident #2 washed her hands at the sink of her small bathroom, after having a bowel movement. Resident #2 fell back into the corner of her bathroom. Staff A explained she assisted Resident #2 with standing up from the toilet using the gait belt. Staff A turned to put the dirty towels on to the floor of the bathroom while Resident #2 stood at the sink. Staff A stated she had to use both of her hands to move the towels and at that moment Resident #2 fell . Staff A stated she didn't have time to turn and help Resident #2 before she fell . Staff A said she needed to move the dirty towels to the floor. The towels were in her hand and her clean hand was holding the gait belt. Staff A said she let go (of the gait belt) with her clean hand to use both of her hands to move the towels to the floor. Staff A explained she should have kept a hold of the gait belt as Resident #2 stood. On 4/3/24 at 4:30 PM, the Director of Nursing (DON), stated understanding of concern with gait belt use for Resident #2. This DON acknowledged that a fall with fracture happened a year prior related to a different CNA letting go of Resident #2's gait belt. She stated her expectations would be that a gait belt would be used with transferring off the toilet for Resident #2. The DON stated all residents with assist of 1 needed to have a gait belt and the staff should not let go of that gait belt when a resident is standing, transferring, and/or ambulating. The DON stated the facility provided education that Staff A attended after the last time Resident #2 fell and broke her hip. A Major Injury Determination Form dated 9/14/23, documented that the circumstances of the incident causing the injury was a fall. The description of the injury was a right hip fracture and fracture of T12. The form described the resident's previous functional ability as an assist of one, gait belt and walker. The facility's physician checked that after reviewing the circumstances of the incident causing the injury, the previous functional ability of the patient, and the patient's prognosis, they believed Resident #2 had a major injury, pursuant to 481 Iowa Administrative Code 50.7(1)(a)(3). The Use of Gait Belt Policy dated October 2021, directed the staff to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. 2. Resident #1's MDS assessment dated [DATE], identified a BIMS score of 3, indicating severe cognitive impairment. Resident #1 required substantial/maximal assistance for toilet use and transferring. The MDS included a diagnosis of non-Alzheimer's dementia. A Care Plan Focus regarding Fall/Safety initiated 5/31/23, directed the staff to encourage Resident #1 to stay out of his room unattended unless in bed. If in his bed, ensure he had a bed alarm and pressure pad in chair for safety. The Care Plan included Resident #1 fell on [DATE], 9/8/23, 11/3/23, 11/28/23 (resulting in a right hip fracture), 2/18/24 and 3/16/24. The Nurses Note dated 2/18/24 at 1:55 PM reflected the nurse found Resident #1 laying on the floor on his back in the bathroom. He couldn't say what happened. 2 staff assisted him to standing with a gait belt. The assessment revealed a skin tear on his left hand. The nurse cleaned the area and approximated (put together) with steri-strips. The facility notified the doctor and Resident #1's son of the incident and his new skin area. Resident #1's Incident Report dated 2/18/24 indicated the staff found him on his bathroom floor. The facility reeducated the staff to not leave Resident #1 alone in his bedroom unless he's in bed. The Nurses Note dated 3/16/24 at 3:15 PM, reflected the staff found Resident #1 lying on the floor next to his bed, positioned flat on his back with his legs extended out. He denied pain and his assessment revealed no injuries or skin issues noted. 2 staff assisted Resident #1 to stand and transfer to his wheelchair. Resident #1's Incident Report dated 3/16/24 listed Resident #1 as not to be alone in room unless in bed. He tried to self-transfer from his recliner in his room. The Incident Report directed the staff to have Resident #1 at the nurse's station for closer supervision. On 4/4/24 at 10:05 AM, the DON explained she educated all of the staff including nurses that Resident #1 should not be left alone in his room unless he had his alarms on and laid in bed. She expected them to follow that. She said Resident #1 should sit in in the recliner by the nurses' station when the staff couldn't observe him in his room. The DON acknowledged that on the incident reports indicated Resident #1 fell twice while unattended in his room. She stated the staff received reeducation both times. A Fall Assessment Protocol updated August 2022, directed to complete fall risk assessments with Care Plan reviews and would be reviewed with the QA (Quality Assurance) committee weekly. It directed to review the incidents at the weekly meeting with team input. In addition, the DON monitors all falls and attempts to determine patterns regarding day of the week, time of the day, and where the fall occurs. The form reflected to implement changes and update the written plan of care with input from all members of the interdisciplinary team.

Based on facility and Hospital records review, staff interviews and facility policy review, the facility failed to provide adequate supervision for residents to avoid falls with injuries to occur for 2 out of 3 residents reviewed for falls (Resident #1 and #2). Staff A, Certified Nurse Aide (CNA), let go of Resident #1's gait belt, which resulted in Resident #1 tripping over her walker, falling, and sustaining a fractured hip. Staff B, CNA, stepped out of Resident #2's room to grab an EZ Stand Lift (transferring device) and did not lower Resident #2's bed, which resulted in Resident #2 falling out of a bed that was not in it's lowest position, thus resulting in a fractured leg and rib/s for the resident. The facility reported a census of 53. Findings Include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included unspecified fracture of left femur. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, indicating Resident #1's cognition intact. This resident identified required limited assist of 1 for transfers and ambulation and an extensive assist of 1 for toileting and dressing. A Care Plan initiated on 6/30/22, showed a self care deficit focus area on it, which included a rationale for this problem as a fall with fracture. An intervention directed staff the resident was an assist of one with a walker and a gait belt. A Progress Note dated 9/25/22 at 8:25 p.m., documented Staff A, CNA requested the Nurse to go to Resident #1's room. The Staff A stated the resident was returning from the bathroom using a walker and gait belt. CNA stated the resident stopped and CNA turned to get sleep pants for the resident and heard the sound of the resident falling and yelling. The Nurse entered the room and found the resident behind the door by the night stand on her left side. The Nurse asked this resident how it happened and the resident answered that she did not know but she was still here. Vital signs were blood pressure (BP)190/100, pulse oxygenation (O2 Sat) 97%, Pulse (P)94, temperature (T) 97.9 Fahrenheit (F), and respirations (R) 22. Assisted resident up with 2 staff and a gait belt and the resident immediately had increased pain and discomfort. The resident placed into a wheelchair and transferred to bed where resident was laying flat. Noted the resident's left hip had external rotation, her left heel was shorter and she displayed continued discomfort. The resident given scheduled Tylenol and insulin with snack. A Progress Note on 9/25/22 at 8:50 p.m., documented that the ambulance was at the facility to transport Resident #1 to the hospital. A Progress Note on 9/26/22 at 3:32 p.m., documented that Resident #1 was admitted to the hospital for a left hip fracture. A Progress Note on 9/27/22, documented the Social Worker from the Hospital reported the resident had surgery on her left hip on 9/26/22 and was to return to the facility. A Hospital History and Physical (H&P) showed an admitted [DATE] and documented Resident #1 had a past history of knee replacement, CVA (stroke), atrial fibrillation (A-Fib, irregular rapid heart rate) on Eliquis (blood thinner), diabetes and presented from nursing home facility for evaluation. The H&P documented the resident stated she was ambulating with help of a walker and tripped landing on the left side of her body. The patient was unable to bear any weight on affected extremity and hence the facility called 911. The H&P documented that upon arrival the resident's left lower extremity was seen externally rotated with excruciating pain. The resident underwent x-ray which showed left intertrochanteric femur fracture (hip fracture). The resident was also found to have A-fib with RVR (rapid ventricular (heart chambers) rate) upon presentation for which she was placed on a Cardizem (medication for ventricular rate control in A. fib) drip. In the emergency room (ER) the patient received Fentanyl (synthetic opioid for pain control). Upon further history taking the resident's daughter mentioned that on 6/6 this resident had left knee replacement and transiently had to stop her anticoagulation medication (blood thinner). The resident apparently developed left sided hemiparesis after stopping her anticoagulation and a MRI (imaging test for soft tissues) of her brain indicated ischemic (reduced or blocked supply of blood) stroke. The resident's sensorimotor deficit is back to her baseline as far as stroke was concerned. An X-ray of the resident's hip 2-3 views done on 9/25/22 at 11:42 p.m., revealed an intertrochanteric fracture on the left femur and no dislocation noted. On 4/5/23 at 1:50 p.m., Staff A, CNA Agency, stated she had worked at the facility before the incident but had not worked down Resident #1's hall. When asked how she knew what each resident's Plan of Care was, she stated she knew what the needs of the resident were because staff had given her a list of residents and what they needed for Activities of Daily Living (ADL's) . Staff A stated that day she had taken Resident #1 to the toilet. Staff A reported on the way back from the toilet, she had a gait belt on Resident #1 and Resident #1 was using her walker. Staff A explained Resident #1 wanted her sleep pants and Staff A asked if Resident #1 would sit down first. Resident #1 said she didn't want to sit down and Staff A stated she let go of Resident #1 for just a second. Staff A felt that Resident #1 had been pretty steady on her feet. Staff A stated she had taken 2 steps toward the closet to grab the resident's pants and Resident #1 fell . Staff A stated she felt so horribly bad. She repeated this and also said that she shouldn't have let go of Resident #1. Staff A said it was her fault the resident fell because she should not have let go of the gait belt. Staff A stated she felt bad to this day. Staff A added if she could do it over again, she would not have let go of the gait belt and would have insisted that Resident #1 sit down first prior to going to getting her sleep pants. On 4/6/23 at 2:13 p.m., Staff C, Licensed Practical Nurse (LPN), stated that Resident #1 was pleasantly confused but also can remember your name. Staff C stated she asked Resident #1 what had happened but Resident #1 could not say that she had stumbled over her feet. Staff C stated they assisted her up and she immediately complained of pain, so Staff C assessed her and then sent her up to the ER at the Hospital. Staff C reported Staff A was a CNA from an agency. When Staff A turned around that's when the resident must have done something and she couldn't relay what it was but it resulted in the fall. Staff A didn't say anything about letting go of the gait belt, but she would have had to let go of the gait belt because Staff A was getting things out of the dresser and it was far enough away that she would not have been able to keep a hold of the gait belt. 2. A MDS dated [DATE], documented that Resident #2's diagnoses included Alzheimer's, anxiety and depression. A BIMS documented a score of 11 out of 15, indicated the resident with moderately impaired cognition. Resident #2 required extensive assist of 2 for bed mobility and transfers. A Care Plan initiated on 9/1/22, had a self care deficit focus area with interventions that directed staff the resident was assist of 2 staff for bed mobility and was an assist of 2 staff for transfers with the EZ Stand. A Progress Note on 3/10/23 at 10:56 a.m., documented Staff B, CNA was assisting the resident with morning cares and as she turned her back to get the EZ stand and another CNA to assist, the resident rolled out of bed. The resident was found lying on her back in her room with her head up against the nightstand at 6:45 a.m. The Staff B called for help. The resident's leg was bent at the knee and tucked under her left leg. This resident did state that her leg hurt when asked. Staff D, Registered Nurse (RN) documented they did not attempt to move resident related to unknown injury. A call was placed for an ambulance. Assessment, neurological checks and vital signs were completed and were within normal limits (WNL). The paramedics and staff assisted to get this resident on to the cart and this resident was brought to the hospital. Vital signs were BP 140/84, P-90, R-20, O2 sat 97%, T 97.8 (F). A Progress Note dated 3/10/23 at 2:17 p.m., documented that a call was received from the ER Nurse who stated that the resident had a right femur fracture and was being transferred to another hospital. A Progress Note dated 3/11/23 at 2:51 p.m., documented the writer spoke with the Hospital Staff, whom stated the resident had a full leg brace on at that time and was planning on having surgery for the right femur fracture the following day. A Discharge (DC) Summary (from the 2nd hospital) dated 3/16/23, documented the resident was admitted on [DATE] after a witnessed fall at her Care Facility. Her injuries were documented as right displaced 6 rib and possible 7-8 ribs, and right periprosthetic midshaft femur fracture (fracture of large leg bone above a knee replacement). The DC Summary documented Resident #2 had an open reduction internal fixation of the femoral shaft (surgery to fix severely broken bones). The DC Summary documented the resident was trying to get out of bed and fell to the ground resulting in the above fractures. The DC Summary also documented Resident #2 was initially evaluated at an outside hospital where a local Orthopedics Doctor was not comfortable managing, so Resident #2 was transferred to this hospital. On 4/5/23 at 2:21 p.m., Staff B, CNA, stated she was getting Resident #2 ready and dressed her in the bed. Staff B had the bed up to her waist level so that Staff B wasn't bending over or hurting her back or anything. The EZ Stand Lift was right outside the room. Staff B stated she probably took 3 to 4 steps away from the bed to get to the EZ Stand. Staff B didn't want to bring all the equipment into the room so she left the EZ Stand out in the hall while Staff B did Resident #2's cares. When Staff B was getting Resident #2 dressed, Resident #2 was lying flat on her back in her bed. Staff B stated Resident #2 would roll pretty well in bed, it depended on the day. Staff B stated that Resident #2 would roll but you have to give her assistance or a little bit of a push to have her roll on to her side. Staff B stated that when using the EZ Stand Resident #2 could grab the bar with 1 hand. Staff B stated this resident was not a fall risk at the time. Staff B stated that Resident #2 sat up and flipped around and landed on the floor (when Staff B stepped away from the bed). Staff B stated she watched it happened but she couldn't do anything because Staff B had the EZ stand right in front of her (the EZ stand was between Staff B and the bed as she was pushing it into the room). Staff B stated the Nurse was right out there in the hall and asked what was that? In hind sight, Staff B stated she would have lowered the bed and/or she would have brought the EZ stand into the room instead of leaving it out in the hall. Staff B stated that anytime you are not at the bed the bed needs to be in low position. Staff B stated she had worked with Resident #2 quite a few times as having worked at the facility about a year and a half. Staff B stated that never would she have thought the resident would fall out of bed. On 4/6/23 at 2:24 p.m., Staff D, RN, stated that was her hall for the morning, so she knew the CNA's were getting Resident #2 ready for the day. Staff D stated she was 2 doors down (from Resident #2's room) and 1 CNA was in there (Staff B) and Staff D knew that the other CNA was across the hall. Staff D stated she did not know where the EZ Stand was as Staff D wasn't with Staff B. Staff D stated the bed was up in a higher position and she heard the boom. Staff D stated she then heard Staff B yell for help. Staff D stated that it was obvious that something was wrong with Resident #2's right leg, just the way it was positioned, I didn't want to move her. Staff D stated she didn't know if the leg was dislocated or if there was a break in her hip or leg. Staff D knew Resident #2 required 2 staff for transfer, but did not know how many staff Resident #2 required while in bed. (per MDS Resident #2 required extensive assist of 2 for bed mobility). On 4/6/23 at 10:30, the Director of Nursing (DON), concurred residents' beds in low position before leaving the room, and keeping hold of the gait belt are standards of care and should be followed. She agreed that leaving the bed up further than the lowest position would need to be Care Planned specifically for a resident. The DON stated Staff B had stated that part of the reason Staff B left the EZ Stand out in the hallway was that Resident #2 liked to reach for the stand and Staff B did not want the resident to reach for the EZ Stand while Staff B was providing cares and getting resident ready in bed. Review of the Gait Belt policy updated on 10/2021, directed staff that gait belts were to be used on residents who could not ambulate or transfer independently for the purpose of safety. Review of the Fall Policy updated on 8/2022, directed staff that a Fall Assessment Review will be done with each MDS Assessment with interventions added at that time.

Based on observation, clinical record review, and interview, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 3 of 4 residents reviewed (Resident #1, #2, #3). On 5/20/21, Staff J, Certified Nursing Assistant (CNA) walked with the resident toward the bed without using a gait belt around the resident's waist in accordance with facility policy. As Staff J pulled back the covers on the bed, the resident stumbled backward, fell into a cabinet, and slid to the floor. On 5/22/21, Resident #1 could not bear weight on the right leg and exhibited facial grimacing, and staff sent Resident #1 to the emergency room (ER). The resident subsequently admitted to the hospital with a right [CONDITION(S)]. The facility reported a census of 48 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 4/15/21, Resident #1 had diagnoses that included Alzheimer's Disease and non-Alzheimer's dementia. The MDS documented staff could not administer the Brief Interview for Mental Status (BIMS) test because they could rarely/never understand the resident. The MDS also documented Resident #1 required extensive assist of 1 staff for bed mobility and dressing, and extensive assist of 2 staff for transfers, ambulation (walking), toilet use, and personal hygiene. The care plan initiated 2/5/21 documented Resident #1 required assistance with all activities of daily living (ADLs). An intervention updated on 4/23/21 directed to transfer the resident with assist of 1 staff. The progress notes contained the following entries: a. On 5/20/21 at 7:45 PM - Nurse summoned to unit. Staff reported they were walking the resident to bed and staff stopped to pull back the bedding. The resident then stumbled backward, their left shoulder fell into a cabinet, and the resident slid to floor. Staff assessed the resident's range of motion (ROM) as within normal limits (WNL) and found no signs/symptoms (s/s) of injury or skin issues. Two (2) staff then assisted the resident to transfer from the floor to the bed and noted no facial s/s of discomfort with movement and weight bearing. b. On 5/22/21 at 12:30 PM - Staff reported resident the required assist of 2 staff, needed a wheelchair to transport, and could not to bear weight on the right leg. The nurse documented the resident winced and exhibited facial grimacing with ROM to right leg, but able to perform ROM to left leg without difficulties. c. On 5/22/21 at 2:30 PM - Physician on call ordered staff to send Resident #1 to ER to evaluate and treat. d. On 5/22/21 at 5:48 PM - Staff placed call to hospital ER and spoke with staff: She has a broken hip, we are admitting her. A Fall/Incident Report dated 5/20/21 7:45 PM, documented when staff walked Resident #1 to bed and then pulled the bedding back, the resident stumbled backwards, right shoulder fell against cabinet, and the resident slid to floor. A Radiology Report dated 5/22/21, documented an x-ray of Resident #1's right hip contained findings of a mid-cervical fracture, right femoral neck (fracture of right hip). During an interview on 10/14/21 at 3:16 PM, Staff J, CNA stated she was in Resident #1's room with the resident and was going to assist the resident to bed. Staff J, CNA stated the resident flared with her arms, lost her balance, fell , and landed on her right hip: more on her side than her bottom. Staff J stated she did not have a gait belt on the resident, did not know the resident needed assist of 2 staff. She added she thought Resident #1 needed stand-by assistance only. Staff J, CNA stated, I probably should have put a gait belt on her. The Gait Belt facility policy updated 7/29/06 directed staff to use a gait belt for all residents requiring assistance with transfers and/or ambulation. It serves as a handle to grasp if the resident begins to fall, to help prevent the fall, or control the resident's descent. During an interview on 10/14/21 at 11:25 AM, Staff L, CNA stated prior to fracturing her hip, Resident #1 required assist of 1 staff with a gait belt, for transfers and ambulation. During an interview on 10/14/21 at 11:58 AM, Staff M, CNA stated prior to fracturing her hip, Resident #1 required assist of 1 staff with a gait belt, for transfers and ambulation. During an interview on 10/19/21 at 12:10 PM, Staff K, CNA stated if she needed to know how to transfer a resident, she would review the care plan books located at the nurses' station. Staff K, CNA stated she does not carry a CNA information sheet for her hall. During an interview on 10/19/21 at 12:45 PM, the Assistant Director of Nursing (ADON) stated the facility provides CNAs information hall sheets if they want them, although some CNAs do not carry them. The information sheets contain directives related to whether or not a resident experiences urinary incontinence or uses Ted Hose, glasses, or dentures, how many staff required for assistance. During an interview on 10/18/21 at 12:12 PM, the ADON stated expectation that anytime staff have to help a resident to transfer, the staff are to use a gait belt and if a resident is care planned for assist of 1 or 2 for transfers, should always use a gait belt. Review of statement signed by ADON, dated 10/19/21, documented the ADON spoke with the Director of Nursing (DON) and the DON stated she discussed Resident#1's fall with Staff J, CNA and Staff J, CNA admitted she should not have let go of the resident and did not have a gait belt on the resident. 2. According to the MDS assessment dated [DATE], Resident #2 had diagnoses that included diagnoses of Alzheimer's disease and diabetes. The MDS documented the resident needed extensive assist of 1 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS revealed the resident scored 3 of 15 possible points on the BIMS test, which meant the resident demonstrated severely impaired cognitive abilities. During an observation in the living room on 10/12/21 at 11:22 AM, Staff A, CNA transferred Resident #2 from the couch to a wheelchair by placing their hand/arm under the resident's arm and pulling up on the resident. Staff A, CNA did not use a gait belt to transfer the resident. Review of Resident #2's care plan initiated 7/1/21 documented a focus of ADL/Falls with an intervention updated on 8/19/21 that directed staff to transfer the resident with assist of 1 person. During an interview on 10/19/21 at 2:30 PM, the ADON reported the facility's expectation for staff to transfer Resident #2 with a gait belt and assist of 1 staff. 3. According to the MDS assessment dated [DATE], Resident #3 had diagnoses that included anxiety disorder, depression, and other fracture. The MDS documented the resident needed limited assist of 1 staff for transfers and extensive assist of 1 staff for bed mobility, ambulation, dressing, toilet use, and personal hygiene. The MDS also documented the resident scored 12 of 15 possible points on the BIMS test which meant the resident displayed moderate cognitive impairment. Review of a care plan initiated 8/12/21 documented a focus of self-care/ambulation/falls with a history of left femur (upper leg bone) fracture from a fall prior to admission. A care plan updated 9/2/21 documented Resident #3's has been transferring by themselves and also taking themselves to the toilet, despite education regarding the need for assist and alarm placed for safety. A care plan intervention added 9/2/21 directed staff to ensure placement/functioning of alarms every shift. An observation on 10/19/21 at 10:50 AM revealed Resident #3 sat in her wheelchair in the living room with a pressure alarm pad under her which flashed green. The progress notes contained the following entries: a. 10/4/21 at 1:45 PM - Nurse summoned to Resident #3's room by staff and found the resident on both (bilateral) knees on the floor in front of the bed; resident not sure what she was doing and denies pain or hitting head. Resident placed in wheelchair with alarm on and functioning correctly, and taken to the living room for an activity. b. 10/5/21 at 10:19 AM - Resident noted with intact red/purple bruise which measured 2.5 centimeters (cm) x 8.5 cm to lateral left hip related to fall sustained on 10/4/21. c. 10/6/21 at 8:49 AM - Resident noted with intact purple bruise that measured 8 cm x 4.3 cm to medial right hand related to fall that occurred 10/4/21. Review of the fall/incident report, dated 10/4/21 at 1:45 PM, documented Resident #3 found on bilateral knees in front of bed. During an interview on 10/14/21 at 11:40 AM, Staff L, CNA, stated on 10/4/21 a resident in the hallway reported Resident #3 was on the floor. Staff L reported she went to Resident#3's room with Staff N, CNA and observed the resident on the floor. Staff L reported she was unsure if the resident's alarm positioned in her recliner was going off or not. Staff L stated there is a frequent beep when the alarm battery is going dead and then the battery is replaced. During an interview on 10/14/21 at 2:22 PM, Staff O, LPN stated on 10/4/21, she found Resident #3 on the floor on both of her knees. Staff O stated the alarm was not going off when she found the resident and the alarm did not go off while it was in the recliner. Staff O stated after caring for the resident, she changed the batteries in the alarm and the alarm did work. Staff O stated they check alarms on rounds and at shift change and the nurses sign off to show the alarms are working every shift, because they are supposed to be checked every shift. During an interview on 10/19/21 at 10:53 AM, Staff N, CNA stated on 10/4/21 she was walking by Resident #3's room and observed the resident on the floor on her knees. Staff N, CNA stated the alarm was in the resident's recliner but was not going off, and she reported the alarm not going off to Staff P, LPN. Review of facility's Personal Alarm Monitor Sheet for Resident #3 documented, signature acknowledges alarm is correctly placed and functioning, and appropriate use for this resident with 10/4/21 days initialed by Staff O, LPN. During an interview on 10/14/21 at 2:45 PM, Staff P, LPN stated alarms are checked at the beginning of the shift to make sure in place, but she does not always check to be sure the alarms are turned on. Staff P, LPN also stated she documented in the book every night that alarms were on and present, but she does not always verify the alarms are in working order every shift even though she signs off in the book as completed. During an interview on 10/19/21 at 11:10 AM, Staff O, LPN stated on 10/4/21, she checked Resident #3's alarm at the beginning of her shift (6 AM-10 PM) and heard the alarm going off when staff got the resident up that morning and other times throughout the day. Staff O, LPN stated CNAs from the 2 shifts, at shift change, check the alarms together, then she walks the halls later in her shift to check the alarms and checks the alarms again at bedtime. Staff O, LPN stated she always checks the alarms herself and signs off in the book, as the facility has a policy to check alarms. Review of facility's policy titled Personal Alert Monitors, updated 8/28/06, documented: Purpose to alert staff to any potential risky behaviors a resident may have that could result in a fall. Each shift, the charge nurse documents that the monitor is present and functioning properly. Be aware when the monitor seems to be sounding weaker as this could indicate the battery needs to be changed.

Based on observation, staff interview, and policy review, the facility failed to ensure the staff used acceptable infection control standards of practices to protect from potential infection by not performing hand hygiene between resident contact and after resident care, and failed to comply with current infection control standards for proper use of eye protection. The facility reported a census of 48 residents. Findings include: 1. In an observation on 10/12/21 at 11:25 AM, Staff A, Certified Nurse's Aide (CNA), removed a resident's facemask and placed the facemask on the handle of the resident's wheelchair. Staff A, CNA, without performing hand hygiene, proceeded to remove 2 more residents' facemasks and place them on the handles of the residents' wheelchairs. Without performing hand hygiene, Staff A, CNA then assisted a resident to dine. During an observation on 10/12/21 at 11:31 AM, Staff B, Dietary, cut up food for a resident by touching the fork that had been touched by the resident and then Staff B, Dietary. Without performing hand hygiene, Staff B proceeded to serve another resident and cut up the resident's food. During an observation on 10/13/21 at 12:30 PM, Staff C, CNA applied gloves and provided incontinence care for a resident. While wearing the same gloves, Staff C, CNA, touched the resident's blanket and call light, gathered the trash bag with dirty clothes, exited the resident's room, took the trash bag to the trash room, and then applied hand sanitizer. Review of the Hand Hygiene facility policy dated 4/1/20, documented indications for hand washing with soap and water: a. before serving food and/or assisting residents with eating Indications for hand washing with soap and water or alcohol-based hand sanitizer: b. before having direct contact with residents c. before and after each procedure involving residents or equipment d. when handling dirty or used linen d. if moving from a contaminated body site to a clean body site during resident care e. before applying and after removing gloves 2. During an observation on 10/12/21 at 12:31 PM, Staff D, Social Services wore a facemask only with no eye protection and in a room talking with 2 residents. Staff D exited the room and began talking with another resident with her hand on the resident's back. During an observation on 10/21/21 at 5:00 PM, Staff E, CNA and Staff F, CNA both assisted residents on the unit wearing facemasks, but no eye protection. During an observation on 10/13/21 at 11:26 AM, Staff G, Licensed Practical Nurse, LPN, wearing a facemask only, no eye protection, was assisting 2 residents to dine. During an observation on 10/13/21 at 4:15 PM, Staff H, CNA wearing facemask only and goggles on top of her head, assisted resident to transfer to a recliner. During an observation on 10/13/21 at 4:45 PM, Staff I, CNA, wearing a facemask and goggles on top of his head, pushed a resident, in a wheelchair, down the hallway. Centers for Disease Control and Prevention regulation titled, Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 9/10/21, documented health care personnel working in facilities located in counties with substantial or high transmission should also use personal protective equipment including eye protection(i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. During an interview on 10/18/21 at 3:45 PM, the Assistant Director of Nursing (ADON) confirmed the county's transmission rate was high on 10/12/21 and 10/18/21 and stated the facility's current requirement is for staff to wear facemasks at all times and goggles or side shields (on glasses) within 6 feet of residents. The ADON stated expectation for staff to use hand sanitizer between resident contact and after cares to remove gloves and complete hand hygiene.

Based on observation, clinical record review and staff interviews the facility failed to ensure safety devices in place at all times and ensure safe transfer techniques used for 2 of 6 residents reviewed with a history of falls. (Resident #44 and #64) The facility reported a census of 67. Findings include: 1. The Minimum Data Set (MDS) assessment reference dated [DATE] revealed Resident #64 required extensive assistance with all transfers and mobility. The MDS identified the resident walked in room with extensive assistance of two staff. The assessment documented the resident had a history of [REDACTED]. The MDS identified active [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) revealed a score of 11 which indicated moderately cognitive impairment. The resident's care plan dated [DATE] identified the resident as a fall risk. The care plan informed the staff the resident had fluctuating cognitive ability, is impulsive and personal alarms in place for the resident's safety. The care plan directed the staff to ensure placement and functioning of alarms at all times, answer sounding alarms promptly and to encourage the resident to use his call light to make needs known. The care plan revealed Resident #64 attempted to self transfer from his recliner to wheelchair and staff implemented a pull tab alarm on [DATE]. A document titled Fall Risk Evaluation dated [DATE] revealed the resident received a score of 20 which indicated he had a high risk for falls. Review of Progress notes dated [DATE] at 7:04 a.m. revealed a CNA called Staff O-RN into the resident's room, the CNA reported having difficulty assisting the resident to sit up at the side of the bed requiring assist of 2 to sit up, the CNA also reported to the nurse the resident kept sliding out of bed and required assistance back into wheelchair with the use of a Hoyer Lift (mechanical lift). Review of Progress notes dated [DATE] at 12:50 p.m. the staff reported the resident self transferred from his wheelchair to recliner, reporting to the staff how difficult the transfer was. Review of Progress notes dated [DATE] at 6:50 p.m. revealed the staff found Resident #64 on the floor on his right side, leaning against his wheelchair. The resident stated he went to the bathroom but didn't make it back. The resident complained of discomfort in his knees and staff noted in the progress notes this is a normal complaint for the resident. The staff transferred the resident back into his wheelchair via mechanical lift then into bed. Resident #64 continued to complain of knee discomfort but did not have signs or symptoms of an injury at the time. A fall/incident report dated [DATE] at 6:45 a.m. revealed Resident #64 experienced a fall in his room, he leaned over to pick up something off the floor and fell out of bed. The staff provided fall interventions which consisted of education on use of the call light and to wait for help. A fall/incident report dated [DATE] at 6:50 p.m. Resident #64 experienced a fall while in his bathroom. The resident self transferred to his bathroom and slid off the toilet. The staff provided fall interventions which consisted of education on use of the call light and to wait for assistance. A Progress note dated [DATE] at 7:07 a.m. revealed the staff transferred the resident a local emergency room for evaluation for possible right fractured knee from fall on [DATE]. Review of a progress note dated [DATE] at 10:17 a.m. revealed Staff N-LPN/ADON placed a call to the local emergency room , the staff reported the resident had a fractured right femur. Review of a progress note dated [DATE] at 11:30 a.m. revealed the facility received a call from the local hospital, they reported the resident experienced a serious medical issue during the surgical repair of the hip on [DATE]. The surgeon could not complete the hip repair and placed the resident on a ventilator. The Primary Care Physician ordered the resident to return to the facility and placed on Hospice services. The resident transferred back to the facility on [DATE]. Review of the Progress Notes dated [DATE] at 7:24 a.m. Resident #64 expired. A document titled Fall Risk Evaluation dated [DATE] revealed the resident received a score of 20 which indicated he had a high risk for falls. Review of the North/West nursing report dated [DATE] revealed the staff initiated a pull tab alarm for Resident #64 on that day. Review of a Personal Alarm Monitoring sheet dated [DATE] revealed the staff initiated a pressure pad in the resident's bed and a personal pull tab alarm while in chair recliner. Review of an x-ray report dated [DATE] revealed the resident fell on [DATE] and complained of right knee pain. The resident had a [DIAGNOSES REDACTED]. Review of an internal facility investigation completed on [DATE] revealed Staff C and Staff D-Agency Certified Nurses Aides transferred Resident #64 into a dining room chair during the evening meal and failed to put the pull tab alarm on the resident. During an interview on [DATE] at 1:30 p.m. Staff D-Agency CNA verified she worked on the evening staff found Resident #64 on the floor, she reported being assigned to Resident #64 that evening. Staff D acknowledged knowing the resident utilized alarms but couldn't find the alarm in the resident's room prior to his fall. Staff D stated after the [DATE] fall she found the pull tab alarm behind the blinds in the resident's room. Staff D stated she should have double checked the resident to make sure he had his alarm on. Staff D assisted the resident after the fall on [DATE] and stated the resident did not have an alarm on at the time of the fall. During an interview on [DATE] with Staff C-Agency CNA at 3:25 p.m. she verified she worked and took care of Resident #64 on the evening of [DATE]. Staff C stated when she got Resident #64 up for supper he did not have an alarm on and had no idea he should have an alarm. Staff C verified at the time of the fall on [DATE] the resident did not have an alarm on. During an interview on [DATE] with Staff E-CNA at 2:52 p.m. she verified she worked first shift on [DATE]. Staff [NAME] stated the tab alarm initiated around lunch time on [DATE] due to the self transfer the resident did earlier in the day. Staff [NAME] stated Staff G-LPN communicated they initiated an alarm for the resident. Staff [NAME] said she thought walking rounds were done between first and second shift that day but did not specifically tell second shift the resident now had pull away/tab alarm. During an interview on [DATE] at 4:40 p.m. with the Staff N-LPN/Assistant Director of Nursing she stated she placed the pull away alarm on this resident while he sat in his recliner. She stated she remembered putting the strap for the alarm around the window crank. During an interview on [DATE] with Staff G-LPN at 5:05 p.m. stated she had decided per her nursing judgment to start the pull away alarm on Resident #64. Staff G stated she told first shift she initiated the alarm and the expectation is for first shift to walk the halls with second shift and communicate the changes. During an interview dated [DATE] at 8:00 a.m. the Director of Nursing (DON), revealed the internal investigation concluded the staff failed to put the pull away alarm on the resident. She stated she could not identify a final result of who did not place the alarm. The DON stated that staff are expected to follow the care plans. 2. The MDS assessment dated [DATE] revealed Resident #44 had [DIAGNOSES REDACTED]. The MDS indicated the resident had moderately impaired cognition, and required extensive assistance of two staff for transfers. The Care Plan, revised on [DATE] recorded Resident # 44 had a [DIAGNOSES REDACTED]. The staff directives included use an EZ stand or Hoyer lift per nursing discretion for safety. The physician's orders [REDACTED].>A Physical Therapy (PT) evaluation [DATE] revealed Resident #44 had MS, dementia, muscle weakness, and left hand contracture. PT recommended staff use a Hoyer lift when the resident transferred for staff safety. Nursing progress notes revealed the following: a. On [DATE] at 9:41 a.m., new order from the physician for PT/OT evaluation for transfers. b. On [DATE] at 2:16 p.m., per PT at Medicare meeting, recommended a Hoyer lift used for transfers. The Rehab to Nursing communication form dated [DATE] revealed Resident # 44 required assistance with a Hoyer lift effective [DATE]. During observation on [DATE] at 1:22 p.m., Staff I, Agency CNA, and Staff H, Agency CNA, entered the resident's room and reported they planned to transfer Resident #44 into bed. Resident #44 sat in a high back wheelchair. Staff H questioned why someone removed the Hoyer sling from under the resident. Staff H placed a mesh sling behind the resident's back, then pulled the leg straps under the resident's legs. After they attached the sling straps to the lift, Staff H and Staff I attached the sling straps to the mechanical lift . Staff H took the remote and raised the resident up above the wheelchair using the mechanical lift. Resident #44 said I'm falling. Staff H looked under the resident and said the sling wasn't under the resident properly, then lowered the resident back into the wheelchair, and stated they needed to use a different sling. Resident #44 slid down in the wheelchair with her bottom near the edge of the wheelchair seat. At 1:29 PM, Staff H stated she didn't like how the resident sat in the wheelchair and requested Staff I to help her pull the resident up. Staff H and Staff I reached under the resident and pulled the resident up in the wheelchair. At 1:33 PM, Staff H removed the mesh sling under the resident and placed a light blue sling behind the resident's back, then attempted to push the sling under the resident's legs. Staff H had the resident lean forward and tucked the sling down lower on her back. Staff I brought a Maxi Move mechanical lift into the resident's room. The DON knocked on the door to the resident's room and asked if staff needed anything. Staff H told the DON there wasn't a sling under the resident and questioned how staff had transferred the resident earlier. The DON stated she had to check the care plan as she thought they had upgraded her transfer but then returned to the room and told the CNA's the resident required a Hoyer for all transfers, then left the room. Staff H and Staff I attached the sling straps to the metal buttons on the Maxi Move mechanical lift. Staff H pulled the leg straps between the resident's legs and attached the lower straps to the Maxi Move buttons with much effort. Staff H took the remote and raised the resident up with the mechanical lift, transferred the resident to the bed, and then lowered the resident into bed. Staff H and Staff I started to remove the sling straps from the mechanical lift when the resident yelled ouch. The bar on the mechanical lift struck the resident's right arm. Staff H apologized to the resident, then removed the sling under the resident. On [DATE] at 1:22 PM, Staff I, agency CNA, and Staff H, agency CNA, reported they were assigned to West Hall but came and helped staff in the 200 hall. Staff I reported she had only worked a few shifts at the facility and not familiar with the residents. During an interview [DATE] at 1:55 PM, Staff H reported she had a cheat sheet with information about the residents on her assigned hall (hall 300), but didn't have a cheat sheet for the 200 hall because she was assigned to work the 300 hall that day. Staff H stated if she was not familiar with the resident cares needed or how to use equipment, she just figured it out. Staff H reported she worked as agency staff and had received one day of orientation when she worked her first shift at the facility. The orientation entailed review of emergency procedures, such as if had a fire, and the location of supplies. Staff H acknowledged nobody showed her how to use the resident care equipment such as the mechanical lifts. In an interview [DATE] at 9:14 AM, the MDS Coordinator reported a care meeting held with therapy on [DATE], and therapy recommended staff used a Hoyer lift when they transferred Resident #44. In an interview [DATE] at 10:16 AM, Staff M, Physical Therapist, reported a PT evaluation completed on Resident #44 on [DATE]. Staff M reported they recommended staff used a Hoyer lift for all transfers on Resident #44 because she had a decline in status. Staff M reported she had provided staff education on transfers for all staff a year ago. Staff M stated the staff education pertaining to transfers included agency staff. In a skill set for Hoyer Lift, EZ Lift and EZ stand transfers revealed the following procedural steps: a. Bring Hoyer to bedside. b. Roll resident onto his/her side away from the attendant c. Place wider seat of sling under the resident's thighs, so the lower edge of the seat is in under the knees d. Place narrow part of sling just above the small of the back. e. Roll resident toward attendant and pull slings through, like positioning a draw sheet. f. Position seat sling, elevate head of bed to facilitate placing the back piece. g. Attach S hooks of the chains to the loops on the seat hangers, attach ends of the chains to the swivel bar hooks, attach S hooks on the back in the links as required. Check to see S hooks are hooked all of the way into the chains and the seat is close to the knees for safety. h. Check chains and S hooks to ensure they are properly positioned. i. Position wheelchair and lock brakes. Once resident lifted and cleared from the bed, grasp steering handles and move resident over the chair, then lower the resident slowly and guide his/her descent. j. Detach the S hooks from the seat and back, and remove the chains and back.

Based on clinical record review, resident interview, and staff interview, the facility failed to revise a care plan to include the presence of a pressure sore with measurable goals and interventions for 1 of 21 residents sampled and reviewed for care planning revisions (Resident # 28). The facility reported a census of 67 residents. Findings include: Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status Score (BIMS) of 15 without signs/symptoms of [MEDICAL CONDITION]. A score of 15 indicated intact cognition. The MDS revealed the resident required the extensive physical assistance of 2 persons for bed mobility, transfers, and toilet use. The MDS documented [DIAGNOSES REDACTED]. The MDS revealed the resident did not have pressure sores present at the time of the assessment. The Care Plan dated 2/28/19 identified the resident had moisture related skin alterations with interventions which included: document on wound sheets weekly for skin alterations; provide treatment as ordered for skin alterations; observe for signs/symptoms of [MEDICAL CONDITION] and report to nurse/doctor; and skin inspection to observe for redness, open areas, scratches, cuts, bruises with bathing/cares, and report changes to the nurse. The care plan lacked documentation pertaining to a pressure sore. On 5/9/19 at 11:30 a.m., Resident # 28 stated she had a pressure sore on her bottom and the staff treated it with salve. Resident # 28 commented the staff liked to lay her down once a day to get her off her bottom. On 5/10/19 at 10:59 a.m., Staff L, Licensed Practical Nurse (LPN), stated she applied a cream for treatment to the resident's buttocks area that morning. Staff L stated the area very superficial, pink in color, and did not blanch. On 5/10/19 at 4:40 p.m., the Assistant Director of Nursing (ADON), stated Resident # 28 had a cushion that staff transferred from the wheelchair to the recliner depending on where she sat. The Weekly Pressure Wound Monitoring sheet for Resident # 28 identified a pressure sore on the left inner buttock with onset date of 4/5/19. The ongoing weekly measurements documented the wound remained present 5/9/19 with a measurement of 0.4 cm (centimeters) by 0.2 cm and the resident encouraged to lay down in bed as tolerates. On 5/10/19 at 5:00 p.m., the MDS Coordinator confirmed the care plan lacked a revision to reflect the presence of the resident's pressure sore. The MDS Coordinator stated the care plan revision process included skin condition meetings held on Tuesdays, she would become aware of any new areas, and then she updated care plans to reflect new skin conditions. The MDS Coordinator acknowledged the care plan should have addressed the resident's pressure sore.

Based on clinical record review, observation, resident and staff interviews, and policy review, the facility failed to complete bladder and bowel assessments for an incontinent resident in an effort to maintain or reduce the frequency of incontinence for one of two residents reviewed for bladder and bowel assessments (Resident #40), and failed to provide proper incontinence care to minimize the risk of cross-contamination and infection for one of six residents observed for incontinence care (Resident #44). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 40 had [DIAGNOSES REDACTED]. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded the resident required the extensive assistance of two staff for toileting and transfers and experienced frequent episodes of bladder incontinence. The MDS revealed the resident had no trial or current toileting program such as a scheduled toileting or bladder training since incontinence had been noted to manage the resident's urinary incontinence. The MDS revealed the resident took a diuretic seven of seven days during the look-back period. The care plan revised 3/14/19 revealed the resident needed assistance with cares due to a stroke, right sided [MEDICAL CONDITION], and left side weakness. The resident had bladder incontinence at times and took a diuretic. Staff directives included providing assistance with toileting and peri-care. The physician's orders [REDACTED]. The clinical record lacked documentation of bladder and bowel assessments. During observation on 5/10/19 at 12:20 PM, Staff D, Certified Nursing Assistant (CNA) stood Resident #40 by the toilet. The resident had visibly wet pants and a wet pull up brief. Staff D removed and changed the resident's pants and brief after he sat on the toilet. During an interview 5/9/19 at 10:10 AM, Resident #40 stated he had a stroke and required assistance for cares. The resident reported sometimes it took awhile before staff responded when he placed his call light on and provided assistance when he had to go to the bathroom. The resident reported at times staff told him they would be back to provide assistance, turned his call light off, but then didn't come back. The resident stated he took a diuretic and couldn't always wait a long time for assistance to the BR. During an interview 5/10/19 at 2:08 PM, the MDS nurse confirmed no bowel or bladder assessments done on the residents at the facility. 2. The MDS assessment dated [DATE] revealed Resident #44 had [DIAGNOSES REDACTED]. The MDS indicated the resident had moderately impaired cognition and required extensive assistance of two staff for toileting and hygiene. The resident had a catheter and frequent bowel incontinence. The Care Plan revised on 3/21/19 recorded Resident # 44 had a [DIAGNOSES REDACTED]. The staff directives included provide assistance with pericare. During observation on 5/9/19 at 1:22 PM, Staff H, CNA, and Staff I, CNA, transferred Resident #44 into bed then donned a pair of gloves. Staff H removed the resident's pants and a washcloth in her peri area. At the time, Staff H reported the resident had no brief due to skin breakdown that had occurred when incontinence product worn. At 1:29 PM, Staff H had the resident roll onto her left side, then took a wet washcloth and cleansed between the resident's buttocks. Staff H folded the washcloth and wiped the area again. Staff H had the resident roll onto her back, then took another washcloth and cleansed the peri area and groin area front to back. Staff H folded the washcloth several times between wiping the areas. Staff H rolled the resident onto her left side again, then used another washcloth and cleansed the buttocks area, folding the washcloth twice in-between wipes. Resident #44's had redness to her groin and buttock area, and complained of the area being sore when staff performed peri care. An Incontinence Care Checklist tool revealed the following procedural steps: a. Don gloves b. Remove soiled pads, clothing, linen c. If gloves are soiled, remove and complete hand hygiene, and reapply clean gloves d. Place a towel under the perineum e. For females, use a washcloth and wash the labia from front to back f. Turn resident onto his/her side, wash buttocks, upper thighs, and anal area front to back. g. Remove gloves and perform hand hygiene During an interview 5/11/19 at 11:07 AM, the Assistant Director of Nursing (ADON) reported she performed staff audits for peri care every three months and whenever she noticed a trend in infections. The ADON reported she expected staff cleanse the front then the back side when performed peri care, and changed their gloves when contaminated.

Based on observations and resident and staff interviews, the facility failed to deliver resident Saturday mail for 5 of 67 residents (Resident #20, #40, #41, #42 and #54). The facility census was 67. Findings include: During a Resident Council group interview on 5/09/19 at 1:32 p.m. Resident #40 stated mail sits on the Nurse's Station desk and not delivered to residents on Saturdays. Resident #40 further stated he asked at his Care Conference about Saturday mail delivery but he continues to not receive his mail on Saturday. During Resident Council group interview on 5/09/19 at 1:32 p.m. Resident #20, #41, #42 and #54 stated mail is not delivered on Saturdays. During interview on 5/11/19 at 11:15 a.m. the Acting Administrator (AA) stated business office staff sort mail Monday through Friday and activities staff deliver it to the residents. The AA stated no mail is delivered on weekends because no one is working to sort it. The DON stated no one has voiced concerns about mail not being delivered on week ends. During interview on 5/11/19 at 11:18 a.m. the MDS (Minimum Data Set) Nurse stated Resident #40 was the only resident who voiced concerns regarding mail not being delivered on Saturday particularly his newspaper. The MDS nurse stated she told Resident #40 he could ask staff to get his newspaper on the weekend from the mail.

Based on clinical record review, staff and physician interview, the facility failed to report an injury of unknown origin to the Department as required. The facility census was 64 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The care plan dated 5/10/18, indicated the resident required total staff assistance with the use of the Hoyer lift for transfers. The resident required a left leg immobilize to be in place at all times but bathing due to a [MEDICAL CONDITION] leg. Progress Notes dated 3/26/18 at 8:38 p.m., revealed the resident had complaints of left lower leg pain. The left leg appeared slightly more firm than the right leg. On 3/27/18 at 5:35 a.m., staff noted the resident had a reddened area to the left lower leg with [MEDICAL CONDITION] and notified the physician for further orders. An x-ray report dated 3/27/18, revealed the resident had soft tissue swelling of the medial and lateral ankle and the bones appeared osteopenic. There was a mildly displayed [MEDICAL CONDITION] and a nondisplaced fracture through the left fibula head. During interview on 5/23/18 at 11:30 a.m., the physician stated it was hard to say how the fracture occurred and could not rule out a spontaneous or indeterminate. The physician made it a no major injury as the resident did not ambulate and would remain non-ambulatory. During interview on 5/23/18 at 12:25 p.m., the Director of Nursing stated they did not report the fracture because she did not feel it was a reportable event.

Based on observation, facility policy review and staff interview, the facility failed to ensure staff utilized proper hand/glove technique, failed to ensure dietary staff covered facial hair when in the kitchen and failed to ensure resident food items were properly labeled/dated when opened. The facility census was of 67 residents. Findings include: 1. Observation of lunch preparation on 2/13/18 at 10:30 a.m., revealed Staff D, Cook, donned gloves and touched several surfaces including the outside of a pie box, surface of the counter, the cafeteria tray, plates, knife and spatula. Continued observation revealed Staff D went on to touched ready to serve pie repeatedly by pushing individual pieces of pie off the spatula onto the plate while wearing the contaminated gloves. 2. Observation on 2/13/18 at 11:15 a.m., during the main kitchen lunch preparation revealed Staff A, Cook, donned gloves and repeatedly touched her mouth and forehead and a variety of surfaces including the outside of the bread bag, surface of the steam table and plates. Continued observation revealed bread handled with contaminated gloves and served to residents. 3. During lunch observation on 2/13/18, Staff E Kitchen Aide, entered the kitchen and moved between food preparation and dish wash areas wearing head covering but no beard covering. During interview on 2/13/18 at 2:30 p.m., the Dietary Service Manager stated kitchen employees were to cover facial hair if the beard was noticeable and planned to educate employees. Additionally stated would not expect staff to touch food with contaminated glove and would expect gloves contaminated by touching face, or an unclean surface would be changed and hands washed prior to handling food. 4. During initial observation of the kitchen area on 2/12/2018 at 8:30 a.m., the following food items were not dated or labeled: a. 1 box Hormel thickened milk, opened in refrigerator, undated. b. 1 box apple juice, opened and in refrigerator, undated. c. 1 box prune juice, opened in refrigerator, undated d. 1 box Hormel thick and easy clear water, opened in the refrigerator, undated. e. 1 bottle Hershey's syrup, opened in refrigerator, undated. f. 1 Styrofoam cup of milk unlabeled and undated in refrigerator. g. 1 bag of prunes, opened in refrigerator, undated. During interview on 2/12/18 at 9:10 a.m., the Dietary manager acknowledged all items were to be covered, labeled and dated after opening. A document titled Refrigerator Food Storage Practice, dated 12/28/16 indicated all refrigerated food will be labeled and dated prior to refrigeration. Perishable food will be discarded after 3 days storage

Based on clinical record review and staff interview, the facility failed to ensure the use of non-pharmacological approaches prior to the administration of a [MEDICAL CONDITION] medication for two of 18 residents reviewed. (Resident #24 & #26) The facility census was 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #24 had [DIAGNOSES REDACTED]. Review of a Care Plan with a goal date of 3/15/18 identified resident has a [DIAGNOSES REDACTED]. The Care Plan lists interventions of monitoring for side effects, if refusing or resisting cares or being combative attempt to redirect or reapproach later, observe for increase in behaviors and attempt to redirect, try diversional approaches versus medications such as reading to the resident, strolling in wheelchair, 1:1, back rubs, snack, TV, activities, soft antianxiety blanket. The (MONTH) Medication Administration Record [REDACTED]. A document titled Medication Administration directed prior to the administration of any antipsychotic medication, three non-pharmacological interventions must be attempted. A review of the clinical record revealed lack of documentation of the alternatives attempted prior to administration of PRN [MEDICATION NAME] on 2/1/18. 2. The MDS assessment dated [DATE], documented Resident #26 had [DIAGNOSES REDACTED]. Review of a Care Plan with a revision date of 12/14/17 identified resident received scheduled and PRN (as needed) antipsychotic medications. The Care Plan lists interventions of monitoring for side effects, if refusing or resisting cares or being combative attempt to redirect or reapproach later, observe for increase in behaviors and attempt to redirect, try diversional approaches versus medications such as reading to the resident, strolling in wheelchair, 1:1, back rubs, snack, TV, music, or activities. The (MONTH) Medication Administration Record [REDACTED] A review of the clinical record revealed lack of documentation of the alternatives attempted prior to administration of PRN [MEDICATION NAME] on 2/1/18. A document titled Medication Administration directed prior to the administration of any antipsychotic medication, three non-pharmacological interventions must be attempted. During interview on 2/14/18 at 10:10 a.m., the Assistant Director of Nursing (ADON) stated the expectation for PRN [MEDICAL CONDITION] medication administration was three non-pharmacological interventions attempted before a PRN medication is given.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to utilize infection control techniques while providing incontinence care for two of 11 residents observed. (Resident #48 & #60) The facility census was 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment completed 1/4/18, documented Resident #48 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident was frequently incontinent of bowel and bladder. The Care Plan with a revision date of 1/11/18, revealed the resident required assistance with personal hygiene, toilet use and peri care (perineal care), wears pullups (incontinence briefs) and was incontinent of bowel and bladder. During observation on 2/13/18 at 11:10 a.m., Staff B, certified nurse aide, CNA and Staff C, CNA assisted the resident to transfer from the wheelchair onto the toilet. Staff performed hand hygiene, donned gloves, and assisted the resident to stand using the grab bar near the toilet. The resident had a bowel movement while on the toilet. Staff B wiped from the back to the front of resident's perineal area while the resident stood at the grab bar. Staff B failed to turn the washcloth to a clean area with each swipe. Staff B obtained a second washcloth and washed the anal area from front to back. Staff B used a third washcloth to wipe off both buttocks going over the same area several times without turning the cloth. With the same washcloth, Staff B reached up through the central perineal area from behind reaching through the resident's legs and to the urethral area in the front. Staff B failed to turn the washcloth to a clean area after using the cloth to wipe off the buttocks. Staff C pulled up the resident's clean incontinence product and pants. 2. The MDS assessment completed 1/18/18, documented Resident #60 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident was frequently incontinent of bowel and bladder. The Care Plan with a revision date of 1/25/18 revealed the resident required assistance with personal hygiene, toilet use and peri care (perineal care), wears incontinence briefs, and is incontinent of bowel and bladder During observation on 2/13/18 at 11:00 a.m., Staff B, CNA and Staff C, CNA transferred the resident from the wheelchair to the toilet using a gait belt. Staff washed their hands and donned gloves and Staff C assisted in pulling the incontinence brief and resident's pants down, removed her gloves, washed her hands and donned new gloves. Staff B performed incontinence care after the resident was assisted to a standing position using the grab bar near the toilet. Staff B used one washcloth for the frontal area and urethral opening area, wiping with the same area of the washcloth several times. The CNA failed to turn the washcloth to a clean area with each wipe but did rotate the cloth used to dry the resident's frontal area to a different area for each pat to dry. Staff B did not wash the resident's anal area. Staff B removed her gloves and performed hand hygiene while Staff C pulled up the incontinence brief and pants. Facility policy titled Perineal Care updated 8/12/08 directed staff to follow all principles of medical asepsis, to start at the front of the periarea, wash front to back using soap and water or wash cream. Rinse all areas well and dry. Turn the washcloth to a clean area with each swipe. Cleanse anal area front to back, rinse well, dry. During interview on 2/13/18 at 2:35 p.m., the Assistant Director of Nursing (ADON), stated the expectation for incontinence care was residents will be washed from the front of the perineal area towards the back. The ADON stated staff are trained to turn the washcloth to a clean area after each wipe or use a new washcloth for each wipe to prevent cross-contamination and infection. The ADON stated she would be doing re-education with the CNA's.

Based on facility record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), and the Notice of Medicare Non Coverage (NOMNC) forms within the established timeframes for three of three resident reviewed when skilled nursing services were deemed no longer covered. (Resident #57, #66 & #67) The facility census was 67 residents. Findings include: 1. A review of medicare billing information for Resident # 57 revealed the resident received skilled services from 1/5/18 until 1/18/18. Record review revealed SNFABN and NOMNC with opportunity to request an immediate appeal when services were deemed no longer covered by medicare had been provided to and signed by the resident or residents representative, after services terminated on 1/19/18. 2. A review of medicare billing information for Resident #66, revealed the resident received skilled services from 1/18/18 until 1/25/18. Record review revealed SNFABN and NOMNC with opportunity to request an immediate appeal when services were deemed no longer covered by medicare had been provided to and signed by the resident or residents representative, outside of established time frame on 1/24/18. 3. A review of medicare billing information for Resident # 67, revealed the resident received skilled services from 1/15/18 until 1/31/18. Record review revealed SNFABN and NOMNC with opportunity to request an immediate appeal when services were deemed no longer covered by medicare had been provided to and signed by the resident or residents representative, after services terminated on 2/2/18. On 2/13/18 at 11:00 a.m., the Social Worker stated SNFABN and NOMNC had not been provided timely for the three residents. Acknowledged that expected SNFABN and NOMNC to be presented and signed 48 hours prior to last day of skilled services to ensure residents right to an immediate appeal. SW reported responsibility for the notification process, collaborated by nursing and therapy department.

Based on clinical record review and staff interviews, the facility staff failed to provide adequate supervision and a safe transfer for 1 of 6 residents reviewed (Resident #1). Resident #1 sustained an injury to his head when staff failed to secure him in the whirlpool tub during a bath. The facility reported a census of 72 residents. Findings include: 1. According to Resident #1's Minimum Data Set ((MDS) dated [DATE] the resident had [DIAGNOSES REDACTED]. idiopathic scoliosis. The resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive ability. Resident #1 required extensive assistance of 2 staff for bed mobility, transfers, toilet use and personal hygiene and required physical help with bathing. The resident could stabilize with staff assistance only when standing or transferring between bed and chair. Review of the Care Plan updated on 8/17/17 Resident #1 utilized an EZ Stand as needed for transfers and has a history of leaning forward in the wheelchair. The care plan informed the staff the resident experiences chronic back pain due to scoliosis and back weakness. The care plan directed staff to provide physical assistance with bathing. Review of the Fall Risk Evaluation dated 8/17/17 Resident #1 had a fall risk score of 16, which indicated a high risk for falls. Review of a Fall/Incident Report dated 10/11/17 at 8:40 p.m. Resident #1 had a fall from a raised whirlpool chair after a bath. The resident fell from the whirlpool chair and landed face down on the floor with his head wedged under the open door of the whirlpool. The staff who assisted the resident with the bath indicated she did have the safety belt on but it wasn't tight around the resident's trunk. The staff summoned the local ambulance who transferred the resident to a local hospital for an evaluation and treatment. According to the Progress Notes dated 10/11/17 at 8:40 p.m. Staff A CNA called Staff B LPN into the whirlpool room. Staff A explained to Staff B when she transferred Resident #1 out of the whirlpool, the resident held one hand on the side of the whirlpool and one hand on the whirlpool door. As the staff pulled the resident back the resident fell forward hitting his head on the side of the whirlpool and then fell on to the floor. Staff A indicated the resident sustained [REDACTED]. Staff B summoned the local ambulance for transport to the hospital. Review of a Progress Note dated 10/12/17 at 2:30 a.m. the facility received an update from the local hospital, Resident #1 required 29 sutures to the head and his heart rate in the 30's. Resident #1 admitted to the local hospital for bradycardia. Review of a Progress Note dated 10/14/17 at 6:00 p.m., revealed Resident #1 returned to the facility via ambulance. During an interview with Staff A on 11/21/17 at 2:00 p.m., Staff A stated she gave Resident #1 a whirlpool bath on the evening of 10/11/17. Resident #1 required assistance of 2 staff to sit in the whirlpool chair, he was transferred to the whirlpool room and bath completed. Staff A stated when she and another staff member placed him in the chair she applied the safety belt but it wasn't tight. Staff A stated she could put 2 hands between the belt and the resident's abdomen, indicating she kept the belt loose because it's the way the resident liked it. After she completed the bath, Staff A lifted the mechanical chair up into the air, approximately 28 inches, just enough to clear the resident's feet from the bottom of the whirlpool door. Staff A stated when she lifted the resident up and moved him out of the tub, the resident leaned forward and grabbed the door of the whirlpool and the edge of the tub. Resident #1 fell forward out of the whirlpool chair, struck his face on the tub and landed face down on the floor. The resident struck his head on the floor. Staff A stated she initially thought the chair strap broke but she admitted she had the strap on incorrectly and the belt became unfastened, causing the resident to fall. During an interview with Staff B on 11/21/17 at 1:35 p.m. Staff B stated staff called her to the whirlpool room. Staff B stated she witnessed Resident #1 laying on the floor of the shower room, next to the whirlpool tub with his head wedged under the open whirlpool door. The resident found to be bleeding from the head. The staff called 911, upon arrival to the facility, EMS staff removed his head from under the whirlpool tub and transported the resident to a local hospital. Staff A initially told Staff B the whirlpool belt broke and the resident fell from the whirlpool chair. Staff B stated Resident #1 had a history of [REDACTED]. A review of the Tub Bath Whirlpool Bathing System (Sitting Tub) instructed staff to follow the precautions to maintain the safety of residents. The instructions (#15) directed staff to position the resident in the tub chair designed for the system and ensure the resident is safety secure in the chair. During an interview with Director of Nurses (DON) on 11/21/17 at 10:05 a.m., the DON stated during her investigation it was determined the whirlpool seat belt was not on as tight as it should have been and it was applied incorrectly. The DON stated the facility did re-education with staff on the proper application of the whirlpool seat belt after the resident fall. The facility completed the following: On 10/13/17 the facility identified the root cause as staff failed to secure the buckles, and resident had not been fastened correctly causing the resident to fall and sustain an injury. On 10/13/17 the facility started educating staff (nurses and CNAs) and completed this on 10/16/17 with demonstration of the seat belt placement and securing residents in the whirlpool bath. On 10/13/17, staff would check random belts during showers. The DON conducted random audits to ensure residents were secured correctly. The facility planned to replace the wheelchair belt and shower belts. The investigation identified the facility corrected the noncompliance prior to the arrival of this investigation; and was in substantial compliance on 10/16/17.

Based on observation, staff interview and facility policy, the facility failed to label and date food items stored in a refrigerator/freezer in the kitchen area. The facility reported a census of 70 residents at the time of the survey. Findings include: During initial observation of the kitchen area on 12-12-16 at 9:00am., the following items were not labeled or dated: a) 1 pound of sliced bologna, opened and placed in the refrigerator, undated. b) 2 pounds of fajita chicken, opened and placed in the refrigerator, undated. c) 5 pounds of frozen french fries, opened and placed in the freezer, undated. An interview with the Dietary Manager on 12-12-16 at 9:15am. acknowledged the bologna, fajita chicken and french fries were not labeled nor dated when opened. Dietary Manager verbalized that all items are to be covered, labeled and dated either in the refrigerator or freezer. A Refrigerator Food Storage Practice Policy; dated 1-24-2005 indicated all refrigerated food will be dated and prepared for storage to prevent deterioration or dehydration. Perishable food products will be discarded after 3 days storage with the exception of deli cooked meat, or lunch meat will be discarded 5 days or less and cooked dishes containing eggs, meat, milk, fish or poultry will be discarded in 2 days or less.

Based on observation, record review and staff and resident interviews, the facility failed to provide adequate supervision and assistive devices to protect against accidents and hazards from self (Resident #1). A staff person pushed the resident in the wheelchair without foot pedals and the resident propelled forward onto the floor when the resident ' s foot caught on the floor. The sample consisted of 5 residents and the facility reported a census of 64 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 2/18/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS assessment documented the resident utilized a wheelchair and walker to around the facility. The Resident Care Plan dated 11/25/15, indicated the resident had a fall from the wheelchair on 12/12/15, which required an increase of their toileting schedule. The resident utilized a safety belt as a reminder to not stand up from the wheelchair. An Incident Report dated 3/22/16 at 4:15 p.m., identified the resident sustained [REDACTED]. The resident fell from the wheelchair as a result of staff pushing the resident in the wheelchair without foot pedals on the wheelchair. The report indicated the resident put his/her feet down onto the floor and fell forward from the wheelchair, hitting face on the floor. The Progress Notes dated 3/22/16 at 4:15 p.m., reflected the staff pushed the resident in the wheelchair and the resident ' s foot caught on the carpet. The resident fell out of the wheelchair and hit head on the floor. The resident ' s head was edematous and a purple, ecchymotic area on the center of the forehead. The area measured 5.5 centimeters (cm) by 5.5. cm. Two staff members used a gait belt and assisted the resident to stand and transfer to the wheelchair. The staff were educated about using foot pedals when pushing residents in the wheelchair. The Progress Notes dated 3/22/16 at 10:24 p.m., indicated the resident ' s right 5th finger was bruised and tender with no swelling. The area to the resident ' s middle forehead was observed as swollen and bruised and measured 5.5 cm by 5.5 cm. Observation on 4/6/16 at 8:15 a.m. reflected the resident sitting in his/her wheelchair with facial bruising. The resident had their feet on the floor and moved about in the hall in the wheelchair independently. On 4/6/16 at 12:15 p.m., the Director Of Nursing stated the resident fell on to the floor when staff pushed the resident in his/her wheelchair without having the resident's feet on the foot pedals. On 4/6/16 at 1:15 p.m., Staff B, certified nurse aide, CNA stated they were responsible for the resident's fall and admitted to pushing the resident without the use of the wheelchair foot pedals. The resident put their feet down on the floor and fell forward as a result, hitting face on the floor.

Based on clinical record review, facility policy review and staff interview, the facility failed report a resident to resident altercation to the Department for four of five residents reviewed. (Resident #1, #3, #4 & #5) The facility census was 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had [DIAGNOSES REDACTED]. The Care Plan updated on 12/17/15, directed staff to redirect the resident away from others if the resident became agitated or aggressive with peers, try to distract resident from the activity that causes him/her distress and attempt to redirect the resident from the exit doors when exhibiting exit seeking behaviors. An incident report dated 2/16/16 at 10:50 a.m., documented the resident struck Resident #4 with a closed fist in the face. An incident report dated 3/2/16 at 4: 15 p.m., documented the resident pushed Resident #5 causing the resident to fall onto the floor. An incident report dated 3/12/16 at 9:45 a.m., documented the resident struck Resident #3 with a closed fist on the back. During interview on 3/21/16 at 11:20 a.m. , the Administrator stated they did not report the resident to resident altercations to the Department because Resident #3, #4 & #5 did not receive injuries as a result. An Abuse Policy dated 11/2/15, indicated residents will not be subject to abuse by anyone including other residents. The Policy directed the Administrator or his/her designee to report all alleged violations to the Iowa Department of Inspections and Appeals.

Based on observation and staff interview, the facility failed to ensure dietary staff utilized proper handling of ready to eat resident food items during observation of one meal service. The facility census was 68 residents. Findings include: 1. During observation on 1/5/16 at 8:27 a.m., during the breakfast service Staff B, Dietary Cook donned gloves. Staff B touched a variety of surfaces including the spatula used to turn eggs on the cooking surface, a menu posted on the wall, tongs placed on the surface of the steam table and the aluminum foil that coved eggs on the steam table. Without changing gloves Staff B handled six pieces of toast that was served to residents. During interview on 1/6/16 at 1:30 p.m., the Dietary Supervisor reported dietary staff was trained to safely handle food to prevent food-borne illness. The dietary supervisor stated staff should not to touch ready to eat food with bare hands or contaminated gloves. The Food Code required food employees may not touch ready-to-eat food with their bare hands and must use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves or dispensing equipment.

Based on record review, observation and staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazards to self and failed to plan for and direct the nursing care and services when a resident eloped from the building (Resident #1). The sample consisted of 4 residents. The facility reported a census of 68 residents which included 16 residents living in the CCDI (chronic confusion or a dementing illness) unit. Findings include: According to the annual Minimum Data Set (MDS) assessment with a reference date of 8/22/13, Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had severe cognitive ability with short and long term memory problems. The resident had wandering behaviors daily and resided on the secured (locked) Dementia unit at the facility. Resident #1 did not require staff assistance for ambulation or transfers. The MDS indicated the resident moved from sitting to standing without difficulty and walked with a steady gait without assistive devices. According to the Resident Care Plan updated on 8/29/13, the Care Plan directed the staff to encourage/redirect the resident away from CCDI doors as they will allow. The Care Plan contained a hand written note that Resident #1 exited the unit on 9/8/13 and the staff are to monitor the resident ' s whereabouts every 30 minutes and staff placed a floor sensor mat by the unit East exit door. The Care Plan indicated Resident #1 ambulated about the locked CCDI unit independently but are to offer assistance if needed. According to an Incident Report dated 9/8/13 at 4:30 p.m. revealed Resident #1 eloped out the east door of the Locked Dementia Unit and the staff found her at the campus apartments. The incident report indicated the staff last saw the resident at 3:15 p.m. in their bed. Review of the Nurse's Notes dated 9/8/13 indicated at 4:30 p.m. Staff A, LPN, received a phone call from a female tenant who resides at the facilities apartment complex. The resident reported they saw a person wandering outside, around their apartment. Staff A notified the nursing home staff to walk the halls and check on all the residents in the facility. The staff reported back that all the residents outside of the Locked Unit were accounted for. Staff A reported that when they walked down the south hall, another tenant (male) from the apartment complex arrived in the nursing home and reported a person as sitting outside their apartment on the patio, without wearing shoes or socks and in bed clothing. Staff A and another staff member went to the apartment complex and found Resident #1 sitting on the male tenant's patio. An undated policy titled Missing Resident directed staff if a resident should be determined missing, the immediate actions would be taken: a. The charge nurse will be notified immediately of a resident missing from the unit or the facility. b. The charge nurse will immediately alert the available staff to initiate a facility search for the missing resident. c. The staff will search all rooms, bathrooms, closets; resident care areas, ancillary areas and all locked and unlocked areas of the building will be searched. During an interview with Staff A, LPN (Licensed Practical Nurse), on 9/17/13 at 10:15 a.m. The nurse stated she was the floor nurse on 9/813 and received a phone call at about 4:30 p.m. from a female tenant who resides at the facility apartment complex. The female caller asked if the facility was missing a resident because they saw a person walk by their apartment patio. Staff A directed the staff to do a head count on the residents except those on the locked unit; the staff reported no missing residents outside of the locked unit. Staff A stated a male tenant from the facility apartment complex came to the nursing home shortly after the phone call from the female tenant and reported a person sitting outside their apartment on the patio. The male tenant reported the person on the patio did not wear shoes or socks and wore bed clothes. During an interview with Staff B, C.N.A. (Certified Nursing Assistant) on 9/17/13 at 9:00 a.m. Staff B stated they worked on the Locked Dementia Unit from 2:00 p.m. -6:00 p.m. on 9/8/13. Staff B stated Resident #1 set off the exit door alarms 6 or 7 times on the Locked Unit from 2:20 p.m. until about 3:00 p.m. Staff B stated the Certified Medication Aide gave the resident a medication to ease anxiety at approximately 3:15 p.m. and Staff B escorted the resident to their bed and rest. Staff B stated she did not see Resident #1 again until she returned to the unit at approximately 5:00 p.m. During an interview with a female tenant on 9/17/13 at 10:20 a.m. revealed while sitting in her recliner in her apartment, she witnessed a person walk by the patio door between 3:30 p.m. to 4:00 p.m. The person had a confused look on her/his face. The resident rounded the corner and disappeared. The female tenant stated she called the nursing home to report the walking person. During an interview with a male tenant on 9/17/13 at 10:00 a.m. revealed while he sat in his apartment watching television, he noted a person walk by the apartment patio doors, rounded the corner and then returned and sat on their patio furniture. The male tenant reported when you walk south of his apartment, theirs is the last in the complex and sits next to a large hill. The person walked barefoot on the grass as there isn't a sidewalk on that side of the apartment complex. The male tenant stated he attempted to call the nursing home but call would not go through. The tenant got his motorized wheelchair and came to report the person on his patio to the nursing home staff. The staff went with the tenant to the apartment to obtain the person on his patio. The male tenant stated the distance from his apartment to the facility is about a quarter of a mile. On 9/17/13 at 1:45 p.m. the DON was interviewed and stated when the staff did a head count on 9/8/13, the staff should have checked the Locked Unit but failed to do so. The staff only checked all residents not residing on the unit. The DON stated the East and South exit doors on the unit must be reset by a staff member if a resident activates the alarm on the door. On 9/17/13 at 2:15 p.m. Staff C (Certified Medication Aide) was interviewed and revealed at the change of shift at 2:00 p.m. Staff were told that Resident #1 had extreme anxiety on days 9/8/13 and activated the door alarms on the day shift. Staff C stated they arrived to work at 2:00 p.m. and the resident was at the end of hall setting off the East exit doors. Staff C stated one staff would retrieve the resident from the exit door and the other staff would re-engage (activate) the door alarm. The door alarm on the doors blinks red and the panel behind the nurse ' s station remains a solid red if the alarm is engaged. Staff C stated she administered medication to Resident #1 at 3:00 p.m. and that ' s the last time she saw Resident #1 prior to staff returning the resident to the unit at about 5:00 p.m. Staff C stated she did not receive any direction to do a head count on their unit residents from 3:15 p.m. until 5:00 p.m. During an interview with Staff D on 9/181/3 at 9:00 a.m. revealed she arrived at 2:00 p.m. on 9/8/13 for their shift. Staff D stated the nurse got a call from someone to report a missing resident. Staff D stated the nurse directed the staff to perform a resident count but didn't have the unit staff count the residents. Staff D stated the nurse didn't tell the unit staff to count the resident's because no one heard any alarms go off (sound). Staff D stated she walked down the south hall and a male tenant from the apartment complex arrived and reported a person sitting on the patio. Staff D and Staff A went with the male tenant and found Resident #1 sitting on the tenant's patio furniture outside his apartment. The staff placed the person in a wheelchair and Staff D and Staff A returned the resident to the Locked Dementia Unit. Upon return to the Locked Unit with Resident #1 she checked the Unit exit door alarms and both functioned appropriately. Upon further investigation Staff A and Staff D found the small enclosed area around the cement approach directly outside the East exit door gait open. Observation of the area outside the Locked Unit East exit door revealed a 10 foot by 7 foot cement patio surrounded by a 5 foot fence with a gate. Upon opening the gate, observation revealed 8 concrete like stairs with a concrete sidewalk. The sidewalk winds around to the unit patio area and does not go to the apartment complex. The resident apparently walked out the east exit door, opened the gate and went down the stairs and across the grass lawn. The resident walked by the female tenants apartment which is approximately 300 yards in length and went around the corner to the male tenants apartment which is at the end of the apartment complex. The facility sits on the edge of town and has corn and soybean fields on the south and east side of the apartment complex. The rough terrain of fields could have been hazardous for a wandering resident. Note: At the time of the complaint investigation, the complaint was coded at a "K" immediate and serious jeopardy. By 9/8/2013 the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "E" level. The Administrator had implemented the following interventions following the incident on 9/8/2013: a. Alarmed floor mat placed in front of the CCDI Unit East exit door. b. Staff initiated a 30 minute check sheet in order to monitor the resident. c. Staff initiated a 30 minute door alarm/mat check. d. An in-service was planned for 9/23/2013. The facility policy for missing residents and review of door and mat alarms and the monitoring camera and how to properly reset the alarms. As of the 9/25/2013 exit conference, the facility needed to: . Finish in-servicing all employees regarding the facility policy and procedures for missing residents, .Continue to monitor activation of door and mat alarms and the proper method to reset the alarms, .Monitor the functioning of the security camera outside of the unit east exit door. . Monitor the anti-wandering door system on all exit doors (main entrance/exit, living room patio exit, ambulance entrance/exit, and north, west & South exit doors).