Every finding on record at Tabor Manor Care Center

Based on observations, clinical record review, staff interviews and facility policy review the facility failed to ensure residents were free from significant medication errors. Staff failed to administer Resident #4, #5, #6, #7, #10 insulin as ordered by their physician. Findings included: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/27/2026, documented Resident #4 had a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 indicated mild cognitive impairment. The MDS documented he received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #4: paraplegia, diabetes mellitus, stroke, seizure disorder, and depression.A Care Plan Focus Area with an initiation date of 12/8/2023 documented Resident #4 had a diagnosis of Diabetes Mellitus. The Care Plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness. A second Care Plan Focus Area with an initiation date of 4/15/2025 documented Resident #4 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review revealed Resident #4's blood sugar on 6/7/2026 at 7:41 AM was 91 milligrams per deciliter (mg/dL).Review of Resident #4's June 2026 Medication Administration Record (MAR) revealed the following orders were not signed out as being given on the morning of 6/7/2026: a) toujeo injection (long-acting insulin to treat diabetes mellitus), 31 units (U) daily at 8:00 AM,b) flasp injection solution aspart (fast-acting meal time insulin to diabetes mellitus), inject per sliding scale, three times a day (TID) before meals. If his blood sugar was between 60 and 150, no insulin required to be given.Record review revealed there were no progress notes documented related to why the two insulin orders were not signed out as being given or held.On 6/17/2026 at 7:52 AM Staff C Licensed Practical Nurse (LPN) stated Resident #4's blood sugar was 142 mg/dL and would not require sliding scale. She primed his toujeo injection pen with 3 units (U) then set the pen to 31U. The insulin was administered to his left arm. 2. According to the quarterly MDS assessment tool with a reference date of 4/27/2026, Resident #5 had a BIMS score of 7. A BIMS score of 7 suggested mild cognitive impairment. The MDS documented he received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #5: diabetes mellitus, stroke, anxiety, and bipolar disorder.The Care Plan Focus Area with an initiation date of 9/3/2026 documented Resident #5 had diabetes mellitus. The Care Plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 3/12/2026 documented Resident #5 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review revealed Resident #5's blood sugar on 6/7/2026 at 8:59 AM was 160mg/dL.Review of Resident #5's June 2026 MAR revealed the following order was not signed out as being given on the morning of 6/7/2026:Novolog (treatment of diabetes) injection flexpen, per sliding scale before meals. If the resident's blood sugar is between 151 and 200, staff were directed to give 2U of insulin.Record review revealed there were no progress notes documented related to why the insulin order was not signed out as being given.On 6/17/2026 at 8:07 AM Staff D Registered Nurse (RN) stated Resident #5's blood sugar was 261mg/dL and would need 6U of Novolog insulin. She primed the pen with 3U of insulin the set the pet to 6U. She administered the insulin to his left lower quadrant. 3. According to the quarterly MDS assessment tool with a reference date of 5/11/2026, Resident #6 had severely impaired cognitive skills for daily decision making. The MDS documented he received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #6: diabetes mellitus, cancer, coronary artery disease, stroke, seizure disorder, malnutrition, and depression.The Care Plan Focus Area with an initiation date of 9/3/2026 documented Resident #6 had diabetes mellitus. The Care Plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 3/12/2026 documented Resident #6 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review revealed Resident #6's blood sugar on:a) 6/7/2026 at 7:54 AM was 376mg/dLb) 6/7/2026 at 10:49 AM was 422mg/dLc) 6/7/2026 at 4:26 PM was 450mg/dLd) 6/7/2026 at 4:27 PM was 450mg/dLe) 6/7/2026 at 9:25 PM was 600mg/dLf) 6/7/2026 at 10:11 PM was 600mg/dLg) 6/7/2026 at 11:38 PM at 600mg/dLReview of Resident #6's June 2026 MAR revealed the following orders were not signed out as being given at 6:30 AM and 11:30 AM on 6/7/2026:a) Insulin Glargine 15U daily,b) Insulin Aspart flexpen per sliding scale before meals and bedtime. If the resident's blood sugar is between 350 and 399, staff were directed to give 20U of insulin.The following Progress Notes were documented for Resident #6:a) On 6/7/2026 at 4:44 PM Staff A RN documented resident's blood sugar read HI. His insulin order was checked and administered 24 units of sliding scale insulin. Resident's vital signs were checked and they were within normal limits (WNL). Resident confused, which he has been since he returned from the hospital this last time. Resident was not sweating or clammy, no tremors noted. He was not lethargic or slurring words. Resident #6 was encouraged to drink fluids and resident took in 180 milliliters of water. Will observe and recheck blood sugar.b) On 6/7/2026 at 11:35 PM Staff E LPN documented Resident #6's physician was informed of his blood sugar running HI on this date. Verbal order obtained for 10U of Novolog insulin now, one time only. If continues to run HI send to the emergency room (ER) for evaluation and treatment.c) On 6/8/2026 at 2:57 AM Staff E documented resident's blood sugar was 332mg/dL.d) On 6/8/2026 at 11:08 AM Staff A documented she checked Resident #6's blood sugar and read HI.e) On 6/8/2026 at 11:09 AM Staff A documented she administered 24 U of sliding scale, insulin aspart flexpen.f) On 6/8/2026 at 11:58 AM Staff A documented around 11:10 AM a call was placed to the physician's office and spoke with the nurse regarding resident's increase in confusion, hi blood sugars, and the blood sugars not responding to insulin. Received an order to send to ER. Call placed to son and Power of Attorney (POA) and informed of resident condition and order to send to ER.g) On 6/28/2026 at 3:30 PM the hospital called the facility and reported Resident #6 had a urinary tract infection (UTI); was given antibiotics and fluids and ready to return to the facility.4. According to the admission MDS assessment tool with a reference date of 6/3/2026, Resident #7 had a BIMS score of 11. A BIMS score of 11 suggested mild cognitive impairment. The MDS documented she received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #7: anorexia, diabetes mellitus, UTI, thyroid disease, and schizophrenia.The Care Plan Focus Area with an initiation date of 6/3/2026 documented Resident #7 had diabetes mellitus. The Care Plan directed staff to administer her diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 6/3/2026 documented Resident #7 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer her insulin as ordered and to monitor for adverse effects.Record review revealed Resident #7's blood sugar on:a) 6/7/2026 at 7:11 AM was 237mg/dLb) 6/7/2026 at 10:41 AM was 294mg/dLReview of Resident #7's June 2026 MAR revealed the following orders were not signed out as being given on the morning of 6/7/2026:a) Fiasp flexpen 15U with breakfast,b) Fiasp flexpen 4U with lunch.Record review revealed there were no progress notes documented related to why the insulin orders were not signed out as being given.On 6/17/2026 at 9:52 AM Staff C stated Resident #7's blood sugar was 222 mg/dL. She primed the insulin pen and set the pen to 9U. She administered the insulin to the resident's left lower quadrant.5. According to the quarterly MDS assessment with a reference date of 6/1/2026, Resident #10 had a BIMS score of 8. A BIMS score of 8 suggested mild cognitive impairment. The MDS documented she received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #10: encounter for palliative care, heart failure, renal failure diabetes mellitus, dementia, malnutrition, and depression. The Care Plan Focus Area with an initiated date of 12/202/2024 documented Resident #10 had diabetes mellitus. The Care Plan documented staff are to administer diabetes medications as ordered by the physician. Staff are also to monitor/document for side effects and effectiveness. A second Care Plan Focus Area with an initiated date of 10/10/2025 documented Resident #10 used insulin related to diabetes. The Care Plan documented staff are to administer [NAME] as ordered and to monitor for adverse effects. Record review revealed Resident #10's blood sugar on:6/7/2026 at 7:20 AM was 119mg/dLReview of Resident #10's June 2026 MAR revealed the following order was not signed out as being given on the morning of 6/7/2026:Lantus subcutaneous solution, give 40U once a day.Record review revealed there were no Progress Notes documented related to why the insulin order were not signed out as being given.On 6/17/2026 at 9:54 PM Staff F stated on 6/7/2026 she completed her blood sugars on the medication cart she was working on and gave them to Staff A about 7:30 AM. At about 9:00 AM Staff F noticed the insulin orders were red on the MARs of the residents on her medication cart. She went to Staff A and told her not to forget to give the insulins for those residents. Staff A told her oh I won't. At around 11:00 AM Staff F completed her lunch blood sugars on the same residents. She again reminded Staff A to not forget to give the insulins. At 1:30 PM she noticed the breakfast and lunch insulins were not given. She again approached Staff A about this and she told Staff F she forgot to do them. Staff C stated when her shift ended at 2:00 PM the insulin had not been administered. She let Staff G CMA know when she took over her medication cart. During a follow-up interview on 6/23/2026 at 9:30 AM Staff F stated 6/7/2026 was not a busy day for them, there were no falls, nothing to offset the day. They had one nurse and one CMA doing medications and treatments that day. When asked what Staff A was doing, she was sitting all day. Staff F stated she was in charge of the 100 hall (South), medication cart. Staff A was in charge of the 200/400 hall medication cart. Staff F stated Staff A usually worked the 100-hall medication cart but wanted to be on the 200/400 (West/Southwest) hall so she could learn it. When asked what residents on Staff F's cart did not get insulins on 6/7/2026 she stated Resident #5 and Resident #6. Staff F indicated Staff A had been known to take longer when passing her medications. Staff F stated Staff A had mentioned being on medication for back pain and that she did not feel comfortable working while on the medications. When asked if she reported to anyone about the insulins not being given, she stated she let the Assistant Administrator/Billing Manager know the next day but did not hear anything from him. On 6/18/2026 at 9:11 AM Staff G stated Staff F told her Staff A had not given insulins on the 100-hall medication cart during her shift. Staff G told she would pester Staff A about it. started to check her blood sugars about 3:30 PM on 6/7/2026 and Resident #6's blood sugar read HI. At 4:30 AM Staff A gave Resident #6 24U of his sliding scale insulin, rechecked his blood sugar at 4:45 PM and it continued to read HI. When she told Staff A this, she was gathering the insulin pens. She watched her give the 24U of insulin because she bugged her about doing something. At 8:00 PM his blood sugar still read HI and she reported this to Staff E. She also let Staff E know he had been reading HI all day. Staff E gave him 24U of insulin. Staff G stated every time she told Staff A Resident #6's blood sugar read HI she would advise her to keep rechecking it. Staff G asked then what do we do, Staff A let her know she would have to give him insulin. Staff G said she had to bug Staff A about what to do when it kept reading HI. Staff A did not call that doctor about his HI blood sugars. Staff G stated Resident #6 that day was slurring his words; his vitals were normal but he was just not making any sense at all. She had taken care of Resident #6 to know if he was slurring his words, it was because his blood sugar was either hi or low. When asked how Staff A was a nurse, she stated as a person she is great but as a nurse she would not trust her. She likes to waste time when giving medications, takes forever on breaks in her car. She would go out to her car for an hour when she's supposed to be passing medications, then gets behind on her medication times. Staff G stated she should not be a nurse; she likes to sit around; her medications are late and who knows if they are on time or given all at once. During a follow up interview on 6/23/2026 at 9:40 AM Staff G stated on 6/7/2026 she worked on the 100-hall medication cart and Staff A 200/400 hall medication cart. Staff A usually worked on the 100-hall medication cart. When she worked 2:30 PM until Staff A left at 6:30 PM that day, it was hectic and there were no falls during her shift with Staff A. When asked what it meant when a blood sugar reads HI she stated if the blood sugar is higher than 500mg/dL.On 6/18/2026 at 12:06 PM the DON stated it was brought to her attention by Staff F on 6/8/2026 (Monday) that Staff A had not administered resident's insulins on 6/7/2026. The DON received the MARs and noted the insulins were not signed out as being given. She started her investigation and was able to confirm this because they were not signed out on the MARs. On 6/8/2026 Staff A had approached her because Resident #6's blood sugar was high and had been over the weekend. Staff A stated I don't know what to do and she told Staff A to call the physician to have him sent to the hospital. After this, the DON started to look further in to things. She reviewed camera footage and was able to see Staff F checked resident's blood sugar but did not see Staff A administer their insulins as ordered. She gave all this information to the Administrator and informed him it needed to be reported. The Administrator started to look at blood sugar records and noticed on 6/3/2026, Resident #6's blood sugar was really high but Staff A had documented she gave his ordered sliding scale insulin at 11:30 AM. They reviewed the camera footage and found she had not administered his insulin as she documented. The DON also noted Resident #6 was in a care conference meeting with the DON and his wife during the time she would have given his ordered insulin. Resident #6 did end up going to the hospital on 6/8/2026 and returned to the facility that same day with antibiotics for a urinary tract infection (UTI). The DON stated it was not unusual for Resident #6 to have high and low blood sugar readings. When Staff A came in for her shift on 6/11/2026 they brought her in and asked what happened on 6/7/2026 for her to not give those insulins. Staff A told them she did not remember. That was concerning because she sent Resident #6 to the hospital and she could not remember what happened. When they asked about the falsifying that she gave Resident #6 his insulin on 6/3/2026 while he was in a meeting with staff and she was seen on the camera at the nurse's desk talking. When they looked at the camera footage from 10:00 AM to 2:00 PM that day, she did not cross paths with Resident #6, Staff A just put her head down. They terminated her employment and left her know they would be reporting this to the Iowa Board of Nursing. Staff A became quiet and left the facility. Prior to this Staff A had disciplinary actions related to poor attendance and excessive breaks. The DON reported no concerns with medication administration issues prior to this. When asked what it meant when a resident's blood sugar reads HI, she stated the blood sugar is over 500. The nurse should complete an assessment on that resident and call their physician. The DON verified that when an order is not completed in a resident's EHR, it does turn red. When they completed their investigation the orders for Resident #4, #5, #6 and #7 were red; indicating they were not completed.On 6/18/2026 at 6:25 PM Staff A stated she started at the facility in October 2025. She was asked to talk about what took place during her shift on 6/7/2026. Staff A stated she was working on a hall she never worked on, was overwhelmed and in a lot of pain that day. She took her scheduled hydrocodone medication that day because she has a bad back. When asked what happened that day when four residents did not receive their insulins, she stated I don't know, I don't know what to say. She acknowledged she did forget to give the insulins, she was the only nurse in the building and worked a hall she had been on a lot, I don't know there is no excuse of it. When asked if she saw any orders in red in the EHR of residents, she stated she remembered seeing red orders when she went through to finish things up. She acknowledged the CMA came to her around lunch time asking her not to forget to give insulins and she did not give them. Staff A stated when she was told Resident #6's blood sugar was HI she went down and rechecked it, and gave 24U of insulin per his sliding scale orders. When asked if she called his physician as his order indicated if his blood sugar was over 400, she stated she did not recall then later stated she does not think she did. Staff A stated she looked for parameters but did not see anything on the MAR for that. She then stated she did not know how to get ahold of his physician and that day was crazy. When Staff A was read the orders from Resident #6's MAR she stated she did not remember seeing that. Staff A stated she did send a fax but acknowledged you would normally call the physician but she did not know how to get ahold of them. When asked if the facility had any of their staff on-call that weekend, she stated the MDS Coordinator was on call. When asked if they could have helped locate the physician's contact information, she stated they could have helped her with this. When asked what other residents did not receive their insulins that day, she stated #4, #5, and #7. Staff A was asked why this happened she stated I do not know what to say, she had never done at as nurse. She added, I don't think I will be working as a nurse anymore if that is something I did; I should not be working as a nurse. She again stated it was a rough day, only nurse doing all the things. Did not recall if there were any falls that day, she stated it was just a rough day. The facility provided a document titled Protocol for Medication Administration that was updated on 1/8/2026. The protocol documented the purpose is to ensure that all medications are administered by a qualified individual within state and licensing guidelines/regulations and in accordance with policy and procedures and physician's orders. All medications must be administered by a nurse or a medication aide in accordance with the physician's orders. The nurser is responsible and accountable for all medications that she/he administers (this is also in reference to any medication aide). Routine medications must be administered within 1 hour after the time that it is ordered to be administered. The nurse or medication aide must never document a medication prior to the administration of the medication.

Based on observations, clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to keep residents free from neglect. On 6/7/2026 the nurse on duty failed to administer Resident #4, #5, #6, #7, and #10 insulins as ordered by their physician. Certified Medication Aides (CMAs) reminded the nurse of those resident's orders not completed and the Electronic Health Record (EHR) changed the orders to red, alerting staff the orders had not been carried out. The facility reported a census of 41 residents.1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/27/2026, documented Resident #4 had a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 indicated mild cognitive impairment. The MDS documented he received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #4: paraplegia, diabetes mellitus, stroke, seizure disorder, and depression.A Care Plan Focus Area with an initiation date of 12/8/2023 documented Resident #4 had a diagnosis of Diabetes Mellitus. The Care Plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness. A second Care Plan Focus Area with an initiation date of 4/15/2025 documented Resident #4 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review revealed Resident #4's blood sugar on 6/7/2026 at 7:41 AM was 91 milligrams per deciliter (mg/dL).Review of Resident #4's June 2026 Medication Administration Record (MAR) revealed the following orders were not signed out as being given on the morning of 6/7/2026: a) toujeo injection (long-acting insulin to treat diabetes mellitus), 31 units (U) daily at 8:00 AM, b) flasp injection solution aspart (fast-acting meal time insulin to diabetes mellitus), inject per sliding scale, three times a day (TID) before meals. If his blood sugar was between 60 and 150, no insulin required to be given.Record review revealed there were no progress notes documented related to why the two insulin orders were not signed out as being given or held.On 6/17/2026 at 7:52 AM Staff C Licensed Practical Nurse (LPN) stated Resident #4's blood sugar was 142 mg/dL and would not require sliding scale. She primed his toujeo injection pen with 3 units (U) then set the pen to 31U. The insulin was administered to his left arm. 2. According to the quarterly MDS assessment tool with a reference date of 4/27/2026, Resident #5 had a BIMS score of 7. A BIMS score of 7 suggested mild cognitive impairment. The MDS documented he received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #5: diabetes mellitus, stroke, anxiety, and bipolar disorder.The Care Plan Focus Area with an initiation date of 9/3/2026 documented Resident #5 had diabetes mellitus. The Care Plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 3/12/2026 documented Resident #5 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review revealed Resident #5's blood sugar on 6/7/2026 at 8:59 AM was 160mg/dL.Review of Resident #5's June 2026 MAR revealed the following order was not signed out as being given on the morning of 6/7/2026:Novolog (treatment of diabetes) injection flexpen, per sliding scale before meals. If the resident's blood sugar is between 151 and 200, staff were directed to give 2U of insulin.Record review revealed there were no progress notes documented related to why the insulin order was not signed out as being given.On 6/17/2026 at 8:07 AM Staff D Registered Nurse (RN) stated Resident #5's blood sugar was 261mg/dL and would need 6U of Novolog insulin. She primed the pen with 3U of insulin the set the pet to 6U. She administered the insulin to his left lower quadrant.3. According to the quarterly MDS assessment tool with a reference date of 5/11/2026, Resident #6 had severely impaired cognitive skills for daily decision making. The MDS documented he received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #6: diabetes mellitus, cancer, coronary artery disease, stroke, seizure disorder, malnutrition, and depression.The Care Plan Focus Area with an initiation date of 9/3/2026 documented Resident #6 had diabetes mellitus. The Care Plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 3/12/2026 documented Resident #6 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review revealed Resident #6's blood sugar on:a) 6/7/2026 at 7:54 AM was 376mg/dLb) 6/7/2026 at 10:49 AM was 422mg/dLc) 6/7/2026 at 4:26 PM was 450mg/dLd) 6/7/2026 at 4:27 PM was 450mg/dLe) 6/7/2026 at 9:25 PM was 600mg/dLf) 6/7/2026 at 10:11 PM was 600mg/dLg) 6/7/2026 at 11:38 PM at 600mg/dLReview of Resident #6's June 2026 MAR revealed the following orders were not signed out as being given at 6:30 AM and 11:30 AM on 6/7/2026:a) Insulin Glargine 15U daily,b) Insulin Aspart flexpen per sliding scale before meals and bedtime. If the resident's blood sugar is between 350 and 399, staff were directed to give 20U of insulin.The following Progress Notes were documented for Resident #6:On 6/7/2026 at 4:44 PM Staff A RN documented resident's blood sugar read HI. His insulin order was checked and administered 24 units of sliding scale insulin. Resident's vital signs were checked and they were within normal limits (WNL). Resident confused, which he has been since he returned from the hospital this last time. Resident was not sweating or clammy, no tremors noted. He was not lethargic or slurring words. Resident #6 was encouraged to drink fluids and resident took in 180 milliliters of water. Will observe and recheck blood sugar.On 6/7/2026 at 11:35 PM Staff E LPN documented Resident #6's physician was informed of his blood sugar running HI on this date. Verbal order obtained for 10U of Novolog insulin now, one time only. If continues to run HI send to the emergency room (ER) for evaluation and treatment.On 6/8/2026 at 2:57 AM Staff E documented resident's blood sugar was 332mg/dL.On 6/8/2026 at 11:08 AM Staff A documented she checked Resident #6's blood sugar and read HI.On 6/8/2026 at 11:09 AM Staff A documented she administered 24 U of sliding scale, insulin aspart flexpen.On 6/8/2026 at 11:58 AM Staff A documented around 11:10 AM a call was placed to the physician's office and spoke with the nurse regarding resident's increase in confusion, hi blood sugars, and the blood sugars not responding to insulin. Received an order to send to ER. Call placed to son and Power of Attorney (POA) and informed of resident condition and order to send to ER.On 6/28/2026 at 3:30 PM the hospital called the facility and reported Resident #6 had a urinary tract infection (UTI); was given antibiotics and fluids and ready to return to the facility.4. According to the admission MDS assessment tool with a reference date of 6/3/2026, Resident #7 had a BIMS score of 11. A BIMS score of 11 suggested mild cognitive impairment. The MDS documented she received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #7: anorexia, diabetes mellitus, UTI, thyroid disease, and schizophrenia.The Care Plan Focus Area with an initiation date of 6/3/2026 documented Resident #7 had diabetes mellitus. The Care Plan directed staff to administer her diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 6/3/2026 documented Resident #7 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer her insulin as ordered and to monitor for adverse effects.Record review revealed Resident #7's blood sugar on:a) 6/7/2026 at 7:11 AM was 237mg/dLb) 6/7/2026 at 10:41 AM was 294mg/dLReview of Resident #7's June 2026 MAR revealed the following orders were not signed out as being given on the morning of 6/7/2026:a) Fiasp flexpen 15U with breakfast,b) Fiasp flexpen 4U with lunch.Record review revealed there were no progress notes documented related to why the insulin orders were not signed out as being given.On 6/17/2026 at 9:52 AM Staff C stated Resident #7's blood sugar was 222 mg/dL. She primed the insulin pen and set the pen to 9U. She administered the insulin to the resident's left lower quadrant.5. According to the quarterly MDS assessment with a reference date of 6/1/2026, Resident #10 had a BIMS score of 8. A BIMS score of 8 suggested mild cognitive impairment. The MDS documented she received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #10: encounter for palliative care, heart failure, renal failure diabetes mellitus, dementia, malnutrition, and depression.The Care Plan Focus Area with an initiated date of 12/20/2024 documented Resident #10 had diabetes mellitus. The Care Plan documented staff are to administer diabetes medications as ordered by the physician. Staff are also to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiated date of 10/10/2025 documented Resident #10 used insulin related to diabetes. The Care Plan documented staff are to administer [NAME] as ordered and to monitor for adverse effects.Record review revealed Resident #10's blood sugar on:6/7/2026 at 7:20 AM was 119mg/dLReview of Resident #10's June 2026 MAR revealed the following order was not signed out as being given on the morning of 6/7/2026:Lantus subcutaneous solution, give 40U once a day.Record review revealed there were no progress notes documented related to why the insulin order were not signed out as being given.The facility investigation included the following:Staff G Certified Medication Aide (CMA) handwrote the following statement: on 6/7/2026 I got to the facility around 2:15 PM/2:20 PM. Staff F CMA did tell me that Staff A had not passed insulin. Staff F left the facility at 2:00 PM. I checked Resident #6's blood sugar at 3:30 PM, 4:45 PM, 6:40 PM and 8:00 PM. All the readings said HI. I asked Staff A what we could do. She said check it again in a little bit but I am going him 24U. This was at 4:30 PM. After Staff A left at 6:00 PM, I let Staff E Licensed Practical Nurse (LPN) now what happened. She ended up giving him another 24U at 9:00 PM. Staff G signed and dated her statement on 6/10/2026.Staff F handwrote the following statement: on 6/9/2026 I worked South medication cart while Staff A worked West/Southwest medication cart. I retrieved all blood sugars on South Hall and turned them in to Staff A by 8:00 AM. Around 9:30 AM I noticed zero insulins were charted as administered. I approached Staff A and said don't forget about the insulins on my medication cart and she said I won't. By 11:00 AM when I started retrieving lunch time blood sugars, Staff A still had not signed off any insulin administrations, nor had she asked me for my keys to retrieve the insulin pens. By 11:30 AM, I gave Staff A the lunch time blood sugars, where Resident #6's blood sugar was reading at 422mg/dL. I once again reminded Staff A that insulins had not been done. Around 1:30 PM Staff A approached me and stated she completely forgot to administer insulins on the South Hall medication cart. When I left for the day around 2:05 PM, she still failed to administer a single insulin on the South-Hall cart. Staff F signed and dated her statement on 6/11/2026.On 6/9/2026 an internal investigation into insulin administration revealed the following:-Resident #4 did not receive his toujeo on 6/7/2026 at 8:00 AM, resident is stable, no adverse effects occurred.-Resident #5 did not receive his sliding scale insulin on 6/7/2026 at 8:00 AM for a blood sugar of 160 mg/dL, resident is stable, no adverse effects occurred.-Resident #6 did not receive sliding scale insulin on the following dates: 6/3/2026 at noon for a blood sugar of 168 mg/dL, 6/7/2026 at 8:00 AM for a blood sugar of 376 mg/dL, 6/7/2026 at noon for a blood sugar of 422 mg/dL. Resident did go to the ER on [DATE] for elevated blood sugar. He has been stable since.-Resident #10 did not receive her Lantus on 6/7/2026 at 8:00 AM, resident is stable, no adverse effects occurred.Investigation Summary-Missed Insulin Administration:-an investigation was initiated regarding resident #6 following reports of elevated blood glucose levels over several days, resulting in a transfer to the emergency room for evaluation.-On Monday 6/8/2026 an approximately 8:30 AM, Staff A entered the Director of Nursing's (DON) office and reported that Resident #6's blood glucose readings had remained in the 400's throughout the weekend. Staff A was instructed to contact the resident's primary care provider (PCP) regarding the continued elevated blood glucose levels and obtain further orders. Staff A reported that the resident's vitals were stable, the resident was alert and was eating breakfast at that time.-At approximately 11:15 AM Staff A notified the DON that the PCP had returned the call and ordered the resident to be sent to the emergency room for evaluation. The resident was transported to the hospital, diagnosed with a urinary tract infection (UTI) and sent back to the facility.-An investigation was subsequently initiated after Staff F and Staff G reported concerns that Staff A may not have administered Resident #6's insulin on 6/7/2026 (Sunday). Staff expressed concern that the resident's persistently elevated blood glucose levels may have been related to missed insulin administration.-A review of the electronic medication record for Resident #6 was conducted. Documentation showed that Staff F recorded a before-breakfast blood glucose reading of 376 mg/dL. No documentation was found indicating administration of either scheduled long-acting insulin or sliding scale insulin by Staff A following this reading.-Staff A subsequently documented a before lunch blood glucose reading of 422 mg/dL. Again, no documentation was found indicating administration of sliding scale insulin or scheduled insulin following this blood glucose result. The first documented insulin administration by Staff A occurred at supper time.-Video footage was reviewed for Resident #6. Footage confirmed that the resident was present in the dining room during both breakfast and lunch meal periods. Review of footage did not show Staff A approaching the resident in the dining room to administer insulin or entering the resident's room to administer medications during the corresponding medication administration timeframes.-A broader review of insulin administration records during the same period was conducted. Findings identified additional residents with missing insulin administration documentation: Resident #4 scheduled morning and noon insulin doses not administered/documented, Resident #5 scheduled morning insulin dose not administered/documented, Resident #7 scheduled morning and noon doses not administered/documented.-Video footage for Resident #4 was also reviewed. Footage confirmed that the resident remained in bed during breakfast. Review did not show Staff A entering the resident's room to administer insulin during the morning medication pass. Footage further confirmed that Resident #4 attended lunch in the dining room, however Staff A was not observed administering insulin to the resident in the dining room or entering the resident's room before or after the meal to administer them medication.-Based on MAR review and video surveillance findings, evidence supports that multiple scheduled insulin administrations were not completed and/or documented during the identified medication pass periods. The findings involve resident #6 and additional residents #4, #5 and #7. Further investigation and review of facility policies, medication administration practices, resident outcomes and staff accountability measures are warranted.-Nurse timeline:1. Staff A arrives at 6:30 AM on 6/7/20262. remains at station until 7:00 AM when she starts on the medication cart3. in the dining room until 9:30 AM when Staff A pushed the medication cart back to the front.4. Staff A back in the dining room at 11:50 AM.5. At 12:15 PM Staff A sat down in the dining room and can be seen typing on the computer and writing in the narcotic book.6. Staff A administered insulin to a different resident at 12:42 PM then sat back down.7. Back at the front desk at 1:45 PM.8. Left the building and sat in her car from 1:49 PM until 2:08 PM.Additional Investigation Findings:-During the course of the investigation, an additional concern was identified related to the insulin administration practices by Staff A.-While reviewing blood glucose records, the Administrator identified an unusually elevated blood sugar resident for Resident #6 following a shift worked by Staff A. As a result, the DON conducted a review of camera footage and compared observations to the MAR.-Review of the MAR indicated that on 6/3/2026, Staff A documented a blood glucose check for Resident #6 at 11:58 AM and documented administration of 4U of sliding scale insulin.-Video footage was reviewed for the corresponding timeframe. Footage confirmed that Resident #6 was present in the dining room at the time the blood glucose check and insulin administration were documented. Review of the footage did not show Staff A obtaining the blood glucose reading or administrating insulin to Resident #6.-Additional timeline review revealed the following:1. Staff A was observed outside of the facility from approximately 10:57 AM until 11:24 AM.2. During that timeframe, Resident #6 was with his wife.3. Resident #6 and his wife attended an MDS meeting until approximately 11:46 AM.4. Between 11:42 AM and 11:53 AM Staff A was observed at the nurse's station speaking with coworkers.5. Resident #6 remained near the lobby area until approximately 11:52 AM when he asked his roommate to assist him to the dining room.6. No blood glucose check or insulin administration was observed before, during or after the medication pass.7. Footage was also reviewed to determine whether another nurse may have performed the blood glucose check or administrated insulin. Review confirmed the other nurse on duty did not administer insulin or obtain a blood glucose reading for Resident #6 during the identified timeframe.- Based on review of the MAR documentation and corresponding video surveillance, findings indicate that a blood glucose check and administration of 4U of sliding scale insulin were documented as completed; however, video footage does not support that either task were performed. No evidence was identified to indicate that another nurse completed the blood glucose check or insulin administration on behalf of Staff A.Disciplinary Action: Staff A started employment at the facility on 10/21/2025. On Sunday 6/7/2026 Staff A did not give insulin to Resident #4, #5, #6, and #7. This involved AM and noon insulin, blood sugars were taken and reported to Staff A. Staff F reminded Staff A at 9:30 and when given blood sugars at 11:30 AM she was reminded again; still no insulin given. At 11:30 AM Resident #6's blood sugar was 422 mg/dL and at bed time it was over 600. Monday, 6/8/2026 Resident #6 primary physician was notified of the high blood sugar, and he was sent to the emergency room. The facility watched camera footage to confirm that insulin was not attempted on Sunday 6/7/2026. We also looked at 6/3/3026 as Resident #6's blood sugar was up to 600 at bedtime. Based on camera footage it was marked off as given but based on camera footage it was not given. Due to these concerns the facility is terminating employment.On 6/17/2026 at 9:54 PM Staff F stated on 6/7/2026 she completed her blood sugars on the medication cart she was working on and gave them to Staff A about 7:30 AM. At about 9:00 AM Staff F noticed the insulin orders were red on the MARs of the residents on her medication cart. She went to Staff A and told her not to forget to give the insulins for those residents. Staff A told her oh I won't. At around 11:00 AM Staff F completed her lunch blood sugars on the same residents. She again reminded Staff A to not forget to give the insulins. At 1:30 PM she noticed the breakfast and lunch insulins were not given. She again approached Staff A about this and she told Staff F she forgot to do them. Staff C stated when her shift ended at 2:00 PM the insulin had not been administered. She let Staff G CMA know when she took over her medication cart. During a follow-up interview on 6/23/2026 at 9:30 AM Staff F stated 6/7/2026 was not a busy day for them, there were no falls, nothing to offset the day. They had one nurse and one CMA doing medications and treatments that day. When asked what Staff A was doing, she was sitting all day. Staff F stated she was in charge of the 100 hall (South), medication cart. Staff A was in charge of the 200/400 hall medication cart. Staff F stated Staff A usually worked the 100-hall medication cart but wanted to be on the 200/400 (West/Southwest) hall so she could learn it. When asked what residents on Staff F's cart did not get insulins on 6/7/2026 she stated Resident #5 and Resident #6. Staff F indicated Staff A had been known to take longer when passing her medications. Staff F stated Staff A had mentioned being on medication for back pain and that she did not feel comfortable working while on the medications.On 6/18/2026 at 9:11 AM Staff G stated Staff F told her Staff A had not given insulins on the 100-hall medication cart during her shift. Staff G told she would pester Staff A about it. She started to check her blood sugars about 3:30 PM on 6/7/2026 and Resident #6's blood sugar read HI. At 4:30 AM Staff A gave Resident #6 24U of his sliding scale insulin, rechecked his blood sugar at 4:45 PM and it continued to read HI. When she told Staff A this, she was gathering the insulin pens. She watched her give the 24U of insulin because she bugged her about doing something. At 8:00 PM his blood sugar still read HI and she reported this to Staff E. She also let Staff E know he had been reading HI all day. Staff E gave him 24U of insulin. Staff G stated every time she told Staff A Resident #6's blood sugar read HI she would advise her to keep rechecking it. Staff G asked then what do we do, Staff A let her know she would have to give him insulin. Staff G said she had to bug Staff A about what to do when it kept reading HI. Staff A did not call that doctor about his HI blood sugars. Staff G stated Resident #6 that day was slurring his words; his vitals were normal but he was just not making any sense at all. She had taken care of Resident #6 to know if he was slurring his words, it was because his blood sugar was either hi or low. When asked how Staff A was a nurse, she stated as a person she is great but as a nurse she would not trust her. She likes to waste time when giving medications, takes forever on breaks in her car. She would go out to her car for an hour when she's supposed to be passing medications, then gets behind on her medication times. Staff G stated she should not be a nurse; she likes to sit around; her medications are late and who knows if they are on time or given all at once. During a follow up interview on 6/23/2026 at 9:40 AM Staff G stated on 6/7/2026 she worked on the 100-hall medication cart and Staff A 200/400 hall medication cart. Staff A usually worked on the 100-hall medication cart. When she worked 2:30 PM until Staff A left at 6:30 PM that day, it was hectic and there were no falls during her shift with Staff A. When asked what it meant when a blood sugar reads HI she stated if the blood sugar is higher than 500mg/dL.On 6/18/2026 at 12:06 PM the Director of Nursing (DON) stated it was brought to her attention by Staff F on 6/8/2026 (Monday) that Staff A had not administered resident's insulins on 6/7/2026. The DON received the MARs and noted the insulins were not signed out as being given. She started her investigation and was able to confirm this because they were not signed out on the MARs. On 6/8/2026 Staff A had approached her because Resident #6's blood sugar was high and had been over the weekend. Staff A stated I don't know what to do and she told Staff A to call the physician to have him sent to the hospital. After this, the DON started to look further in to things. She reviewed camera footage and was able to see Staff F checked resident's blood sugar but did not see Staff A administer their insulins as ordered. She gave all this information to the Administrator and informed him it needed to be reported. The Administrator started to look at blood sugar records and noticed on 6/3/2026, Resident #6's blood sugar was really high but Staff A had documented she gave his ordered sliding scale insulin at 11:30 AM. They reviewed the camera footage and found she had not administered his insulin as she documented. The DON also noted Resident #6 was in a care conference meeting with the DON and his wife during the time she would have given his ordered insulin. Resident #6 did end up going to the hospital on 6/8/2026 and returned to the facility that same day with antibiotics for a urinary tract infection (UTI). The DON stated it was not unusual for Resident #6 to have high and low blood sugar readings. When Staff A came in for her shift on 6/11/2026 they brought her in and asked what happened on 6/7/2026 for her to not give those insulins. Staff A told them she did not remember. That was concerning because she sent Resident #6 to the hospital and she could not remember what happened. When they asked about the falsifying that she gave Resident #6 his insulin on 6/3/2026 while he was in a meeting with staff and she was seen on the camera at the nurse's desk talking. When they looked at the camera footage from 10:00 AM to 2:00 PM that day, she did not cross paths with Resident #6, Staff A just put her head down. They terminated her employment and let her know they would be reporting this to the Iowa Board of Nursing. Staff A became quiet and left the facility. Prior to this Staff A had disciplinary actions related to poor attendance and excessive breaks. The DON reported no concerns with medication administration issues prior to this. When asked what it meant when a resident's blood sugar reads HI, she stated the blood sugar is over 500. The nurse should complete an assessment on that resident and call their physician. The DON verified that when an order is not completed in a resident's EHR, it does turn red. When they completed their investigation the orders for Resident #4, #5, #6 and #7 were red; indicating they were not completed. During a follow up interview on 6/23/2026 at 1:01 PM the DON stated they do have staff on call on the weekends: Administration staff for non-nursing related issues and herself and the MDS Coordinator for nursing related issues. They are on call on the week nights and weekends. The weekend of 6/5/2026 the Assistant Administrator/Billing Manager and the MDS Coordinator were on-call.On 6/18/2026 at 6:25 PM Staff A stated she started at the facility in October 2025. She was asked to talk about what took place during her shift on 6/7/2026. Staff A stated she was working on a hall she never worked on, was overwhelmed and in a lot of pain that day. She took her scheduled hydrocodone medication that day because she has a bad back. When asked what happened that day when four residents did not receive their insulins, she stated I don't know, I don't know what to say. She acknowledged she did forget to give the insulins, she was the only nurse in the building and worked a hall she had been on a lot, I don't know there is no excuse of it. When asked if she saw any orders in red in the EHR of residents, she stated she remembered seeing red orders when she went through to finish things up. She acknowledged the CMA came to her around lunch time asking her not to forget to give insulins and she did not give them. Staff A stated when she was told Resident #6's blood sugar was HI she went down and rechecked it, and gave 24U of insulin per his sliding scale orders. When asked if she called his physician as his order indicated if his blood sugar was over 400, she stated she did not recall then later stated she does not think she did. Staff A stated she looked for parameters but did not see anything on the MAR for that. She then stated she did not know how to get ahold of his physician and that day was crazy. When Staff A was read the orders from Resident #6's MAR she stated she did not remember seeing that. Staff A stated she did send a fax but acknowledged you would normally call the physician but she did not know how to get ahold of them. When asked if the facility had any of their staff on-call that weekend, she stated the MDS Coordinator was on call. When asked if they could have helped locate the physician's contact information, she stated they could have helped her with this. When asked what other residents did not receive their insulins that day, she stated #4, #5, and #7. Staff A was asked why this happened she stated I do not know what to say, she had never done that as nurse. She added, I don't think I will be working as a nurse anymore if that is something I did; I should not be working as a nurse. She again stated it was a rough day, only nurse doing all the things. Did not recall if there were any falls that day, she stated it was just a rough day. Staff A stated she remembered seeing Resident #6's order on 6/3/2026 as she went through to finish up her documentation. She signed off the order as being done but did not know why she did that because she knew she did not give the insulin as ordered.On 6/23/2026 at 10:45 AM the Administrator stated Staff A was a mediocre nurse and not one he would consider one of his top nurses. When asked what that meant, he stated she met the criteria as far as medication pass went but had to be re-educated periodically on proper documentation.On 6/23/2026 at 4:50 PM Staff E stated when she worked on 6/7/2026, Staff A did not report to her that Resident # 4, #5, #6, and #7 did not receive their insulins. Had she known that she would have monitored the residents closely; especially Resident #6 because he is brittle. She remembered his blood sugar ran high that night and she had suspicion the resident did not get his insulin, but had no proof. She thought maybe something was going on with him, she ended up get an order to give additional insulin. This brought his blood sugar down but he still went out to the hospital the next and was sent back on an antibiotic for a UTI. When asked how Staff A was as an employee, she stated at times she would get overwhelmed but if you take your time and prioritize you can get a lot of what needs done, done. Staff E stated when orders are not completed in the EHR, they turn red until completed.The facility provided a document titled Protocol for Medication Administration that was updated on 1/8/2026. The protocol documented the purpose is to ensure that all medications are administered by a qualified individual within state and licensing guidelines/regulations and in accordance with policy and procedures and physician's orders. All medications must be administered by a nurse or a medication aide in accordance with the physician's orders. The nurser is responsible and accountable for all medications that she/he administers (this is also in reference to any medication aide). Routine medications must be administered within 1 hour after the time that it is ordered to be administered. The nurse or medication aide must never document a medication prior to the administration of the medication.The facility provided a document titled Abuse Prevention, Identification, Investigation, and Reporting Policy with a revision date of 11/2026. The policy documented all residents have the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, and any

Based on clinical record review, observation, staff interviews and facility policy review the facility failed to notify the physician when Resident #6 had a change in condition. The facility also failed to notify the physician as written per orders for Resident #6. The facility reported a census of 41 residents. Findings include: On 6/19/2026 at 9:15 AM observed a closet across the front nurse's station where the copy/fax machine was located. On the inside of the door are a list of physicians with their address, fax and phone numbers. According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 5/11/2026, it documented Resident #6 had severely impaired cognitive skills for daily decision making. The MDS documented he received insulin injections during the last 7 days of the review period. The MDS listed the following diagnoses of Resident #6: diabetes mellitus, cancer, coronary artery disease, stroke, seizure disorder, malnutrition, and depression.The Care Plan Focus Area with an initiation date of 9/3/2026 documented Resident #6 had diabetes mellitus. The care plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 3/12/2026 documented Resident #6 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review revealed Resident #6's blood sugar on:a) 6/7/2026 at 7:54 AM was 376 milligrams per deciliter (mg/dL)b) 6/7/2026 at 10:49 AM was 422mg/dLc) 6/7/2026 at 4:26 PM was 450mg/dLd) 6/7/2026 at 4:27 PM was 450mg/dLe) 6/7/2026 at 9:25 PM was 600mg/dLf) 6/7/2026 at 10:11 PM was 600mg/dLg) 6/7/2026 at 11:38 PM at 600mg/dLReview of Resident #6's June 2026 Medication Administration Record (MAR) revealed the following order:Insulin aspart flexpen (Novolog, rapid acting insulin) inject subcutaneously per sliding scale before meals and at bedtime. If blood glucose is 400 or greater give 24 units (U). Additional Directions: notify the doctor of blood sugar over 400+. The order had a start date of 1/13/2026.On 6/7/2026 (Sunday) at 4:30 PM Staff A Registered Nurse (RN) documented on Resident #6's MAR a blood sugar of 450mg/dL. She documented she gave the resident 24U of insulin aspart.A Progress Note documented on 6/7/2026 (Sunday) at 4:44 PM by Staff A documented Resident #6's blood sugar read at HI. Checked order and administered 24U of sliding scale insulin. Resident's vital signs were checked and within normal limits (WNL). He is confused which has been since he returned from the hospital this last time. No sweating or clammy skin noted. Resident #6 was not experiencing tremors, not lethargic or slurring his words. He was encouraged to drink fluids and he took in 180 milliliters of water. Will observe and recheck blood sugar.Record review revealed a facsimile (fax) dated 6/7/2026 (Sunday) was sent to Resident #6's physician with the following reason for faxing documented: at 11:30 AM accucheck was 422. Resident has had an increase in confusion and gets agitated easily. Has called his wife multiple times today and requested her to come pick him up so he can get his truck out of the field. On the top left side of the fax a date/time stamp read 6/7/2026 at 11:24 AM. Staff A signed as the sender's signature. On 6/8/2026 (Monday) the physician ordered an urine analysis with culture and sensitivity.On 6/18/2026 at 6:25 PM Staff A stated she started at the facility in October of 2025. She stated on afternoon when Resident #6's blood sugar was reading HI, she went down and rechecked it, gave him his insulin as ordered on his sliding scale order. When asked if she called his physician as his order indicated if his blood sugar was over 400, she stated she did not recall then later stated she does not think she did. Staff A stated she looked for parameters but did not see anything on the MAR for that. She then stated she did not know how to get ahold of his physician and that day was crazy. When Staff A was read the orders from Resident #6's MAR she stated she did not remember seeing that. Staff A stated she did send a fax but acknowledged you would normally call the physician but she did not know how to get ahold of them. When asked if the facility had any of their staff on-call that weekend, she stated the MDS Coordinator was on call. When asked if they could have helped locate the physician's contact information, she stated they could have helped her with this.On 6/19/2026 at 9:15 AM Staff B RN stated each resident's physician is listed in their Electronic Health Record (EHR). When asked about the list located in the closet across from the nurse's station, she stated you can use those too. She stated if you have to call on the weekends, the clinic you are calling will have a message on their machine of who is on call for that person.On 6/23/2026 at 1:01 PM the Director of Nursing (DON) was asked where staff could find a resident's physician's doctor contact information, she stated it would be in the resident's EHR under each under resident profile. They do have the list in the closet across from the nurse's station but it does not list which resident is under each physician. When asked if the fax Staff A sent to Resident #6 would have been the appropriate way to notify him of the resident's status, she stated with a change like that, Staff A should have called especially since the resident had confusion and agitation.The facility provided a document titled Change in Condition Policy with a revision date of 4/23/2026 stated the purpose of this policy is to ensure that residents that have changes in condition have a focused assessment promptly with appropriate interventions and/or notification of the physician.Policy:If it is noted that a resident has a change in condition, nursing staff will promptly acquire a full set of vitals, cognition assessment and focused assessment.Contact the physician with abnormal findings. The physician must be notified by the phone for a change in condition that is life threatening, falls, change in level of consciousness. If it is after hours or on the weekend, the on-call physician must be notified.The facility provided a document titled Nursing assessment dated [DATE]. The purpose is to ensure that proper assessments are completed and documented on chronic illnesses, skin concerns, re-hospitalization and change of condition. When a resident voices a concern, staff brings a concern the nurse will do a full assessment that shall be documented and the physician should be notified of abnormal findings.

Based on clinical record review, a list of discharged residents, staff interviews and Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual the facility failed to complete a death Minimum Data Set (MDS) after 1 of 3 residents (Resident #2) expired. The facility reported a census of 41 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #2 was admitted to the facility on [DATE] from the hospital and had received hospice care. The following diagnoses were listed for Resident #2: palliative care, cancer, coronary artery disease, heart failure, thyroid disorder, and genetic related intellectual disability.A Progress Note dated [DATE] at 1:45 PM documented Resident #2's Power of Attorney (POA) called the nurse to his room stating he had expired. Time of death was called at 12:52 PM. On [DATE] at 9:29 AM the facility provided a document titled Admission/Discharge To/From Report with range date of [DATE]-[DATE]. The document listed Resident #2 expired on [DATE].Review of the MDS tab in Resident #2's Electronic Health Record (EHR) on [DATE] at 8:09 AM revealed two MDS assessments had been completed and accepted: [DATE] Entry assessment and [DATE] admission Assessment. The MDS tab lacked a Death in Facility MDS assessment. On [DATE] at 12:06 PM the Director of Nursing (DON) stated MDS assessments are a collaborative thing completed between herself, the MDS Coordinator, Social Worker and Dietary Manager. The DON was shown the MDS tab for Resident #2 and she acknowledged the Death in Facility MDS assessment had not been completed. She added it should be completed within the following day.On [DATE] at 12:46 PM the MDS Coordinator stated she just completed Resident #2's Death in Facility MDS assessment, she is waiting for the DON to sign off on it. She acknowledged she forgot to complete it after he passed away.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1, updated [DATE] revealed a Death in Facility should be completed no later than 7 calendar days after the death.

Based on clinical record review, staff interviews and facility policy review the facility failed to ensure 1 of 7 residents' (Resident #6) records were accurate. The facility reported a census of 41 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 5/11/2026, Resident #6 had severely impaired cognitive skills for daily decision making. The MDS documented he received insulin injections during the last 7 days. The MDS listed the following diagnoses of Resident #6: diabetes mellitus, cancer, coronary artery disease, stroke, seizure disorder, malnutrition, and depression.The Care Plan Focus Area with an initiation date of 9/3/2026 documented Resident #6 had diabetes mellitus. The Care Plan directed staff to administer his diabetes medication as ordered by the doctor. Staff are to monitor/document for side effects and effectiveness.A second Care Plan Focus Area with an initiation date of 3/12/2026 documented Resident #6 used insulin related to his diabetes diagnoses. The Care Plan directed staff to administer his insulin as ordered and to monitor for adverse effects.Record review of Resident #6's June 2026 Medication Administration Record (MAR) revealed the following orders signed out as being completed by Staff A Registered Nurse (RN):Accucheck before meals and at bed time: on 6/3/2026 at11:30 AM his blood sugar was 168.Insulin Aspart Flexpen, inject subcutaneously per sliding scale before meals and at bed time. Staff were directed to give 4U of insulin if the blood sugar is between 150-199.Review of the facility's investigative file revealed the following:-Review of the MAR indicated that on 6/3/2026, Staff A documented a blood glucose check for Resident #6 at 11:58 AM and documented administration of 4U of sliding scale insulin.-Video footage was reviewed for the corresponding timeframe. Footage confirmed that Resident #6 was present in the dining room at the time the blood glucose check and insulin administration were documented. Review of the footage did not show Staff A obtaining the blood glucose reading or administrating insulin to Resident #6.-Additional timeline review revealed the following:1. Staff A was observed outside of the facility from approximately 10:57 AM until 11:24 AM.2. During that timeframe, Resident #6 was with his wife.3. Resident #6 and his wife attended an MDS meeting until approximately 11:46 AM.4. Between 11:42 AM and 11:53 AM Staff A was observed at the nurse's station speaking with coworkers.5. Resident #6 remained near the lobby area until approximately 11:52 AM when he asked his roommate to assist him to the dining room.6. No blood glucose check or insulin administration was observed before, during or after the medication pass.7. Footage was also reviewed to determine whether another nurse may have performed the blood glucose check or administrated insulin. Review confirmed the other nurse on duty did not administer insulin or obtain a blood glucose reading for Resident #6 during the identified timeframe.- Based on review of the MAR documentation and corresponding video surveillance, findings indicate that a blood glucose check and administration of 4U of sliding scale insulin were documented as completed; however, video footage does not support that either task were performed. No evidence was identified to indicate that another nurse completed the blood glucose check or insulin administration on behalf of Staff A.On 6/18/2026 at 6:25 PM Staff A stated she remembered seeing Resident #6's order on 6/3/2026 as she went through to finish up her documentation. She signed off the order as being done but did not know why she did that because she knew she did not give the insulin as ordered.On 6/18/2026 at 12:06 PM the Director of Nursing (DON) stated staff had reported a concern about Staff A not administering insulins to residents on 6/7/2026. The DON received the MARs and noted the insulins were not signed out as being given. She started her investigation and was able to confirm this because they were not signed out on the MARs. She reviewed camera footage and was able to see Staff F Certified Medication Aide (CMA) checked resident's blood sugar but did not see Staff A administer their insulins as ordered. She gave all this information to the Administrator and informed him it needed to be reported. The Administrator started to look at blood sugar records and noticed on 6/3/2026, Resident #6's blood sugar was really high but Staff A had documented she gave his ordered sliding scale insulin at 11:30 AM. They reviewed the camera footage and found she had not administered his insulin as she documented. The DON also noted Resident #6 was in a care conference meeting with the DON and his wife during the time she would have given his ordered insulin. When Staff A came in for her next scheduled shift, when they brought up her falsifying documentation on 6/3/2026. They let her know they saw the camera footage of her at the nurse's station and Resident #6 being in a care conference. They let her know they were able to see she did not cross paths with Resident #6 from 10:00 AM until 2:00 PM. Staff A did not say anything, she just put her head down.On 6/23/2026 at 10:45 AM the Administrator stated the DON completed an investigation in to another issue with Staff A not administering insulin to residents. She brought the information to him and he dug a little deeper and noticed on 6/3/2026 Resident #6's blood sugar started to elevate after Staff A had signed out as giving his insulin that afternoon. After they review camera footage, they noted she did not give Resident #6 his insulin even though she had signed it out as being given. The facility provided a document titled Protocol for Medication Administration that was updated on 1/8/2026. The protocol documented the purpose is to ensure that all medications are administered by a qualified individual within state and licensing guidelines/regulations and in accordance with policy and procedures and physician's orders. All medications must be administered by a nurse or a medication aide in accordance with the physician's orders. The nurser is responsible and accountable for all medications that she/he administers (this is also in reference to any medication aide). Routine medications must be administered within 1 hour after the time that it is ordered to be administered. The nurse or medication aide must never document a medication prior to the administration of the medication.

Based on observation, staff interviews, and policy review the facility failed to transport food in accordance with professional standards by stacking food uncovered in bowls on top of each other contaminating the uncovered food. The facility reported a census of 40 residents.Findings include:On 2/24/26 at 11:15 AM an observation of Staff O, Assistant Dietary Manager / [NAME] preparing pureed chocolate gooey cake revealed Staff O obtained chocolate gooey cake from the walk in refrigerator from trays stacked on each other in styrofoam bowl with clear plastic wrap cover, Staff O removed bowls of cake from trays, stacked 2 cakes on each other in one hand, stacked 3 cakes on top of each other in the other hand, cakes had no cover when brought to the table to be processed, cake processed to appropriate consistency and utilized appropriate scoop to replace puree cake in styrofoam bowl.On 2/24/26 at 11:25 AM Staff O acknowledged she should not have stacked the chocolate cakes on top of each other without a protective cover between each. Staff O stated the outside of the bowl should not have come in contact with the item of food. On 2/25/26 at 1:12 PM Staff N, Certified Dietary Manager (CDM) stated when the food was removed Staff O she should not have stacked because the bottom of the bowl would contaminate the food item. Staff N stated she expected the food would have been covered if it was going to be stacked with a lid or a plastic wrap cover. Staff N acknowledged the food should not come in contact with any surfaces that would contaminate the food.Review of an undated policy titled, Meal Preparation documented the purpose of the policy was to establish procedures that ensure food was prepared, handled, and stacked in a manner that maintained food safety, prevents contamination, and complies with Iowa Food and Drug Code requirements. Stacking food items during preparation must follow safe practices to prevent cross contamination and ensure temperature control. If foods are plated and stacked before service, stacking must not compromise hygiene.

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 40 residents.Findings included:On 2/25/26 at 3:38 PM, a medication cart was observed unlocked at the nurses' station facing the lobby. Staff A, Registered Nurse (RN) was on the opposite side of the lobby, facing a resident with her back partially positioned toward the medication cart. A vase of flowers was blocking the line-of-site between Staff A and the medication cart. The cart contained gabapentin (anticonvulsant), escitalopram (antidepressant), and multiple blood pressure medications.At 3:40 PM, a confused resident wandered toward the nurses' station as Staff B, RN approached the nurses' station from the other side and confirmed she was not assigned to the cart. She redirected the resident's attention to an activity device on the counter and stated she wasn't going to leave the medication cart unsecured.At 3:42 PM, Staff A stated the medication carts are not typically left unlocked when staff walk away from the cart. She stated she was giving medications to a resident who was yelling that her taxi was waiting on her to go to an appointment. She admitted the cart should not have been left unlocked.On 2/26/26 at 11:28 AM, the Director of Nursing (DON) stated staff should lock the cart if they are going to leave it unattended.An undated document titled Protocol for Medication Administration indicated the carts must be in possession of the Nurse or Medication Aide at all times. When unlocked, the cart must be within eyesight of the nurse or medication aide at all times.

Based on observations, resident interview, staff interviews and policy review the facility failed to provide food at an appetizing temperature to 1 of 10 residents reviewed (Resident #24). The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #24 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment.On 2/23/26 at 11:03 AM Resident #24 stated the food was served very cold most of the time. Resident #24 explained she had asked the staff to reheat the food and the staff say they would get the food reheated and the staff would not return. On 2/24/26 at approximately 12:15 PM an observation of the lunch meal room tray plating and delivery revealed:The first room tray was an alternate meal. At 12:16 PM the second room tray was plated with a regular lunch meal.Test plate plated at 12:18 PM and replaced with the second plate that was placed on the delivery cart.Test plate picked up by CNA at 12:20 PM.The plate was delivered to the room for the Resident who originally had the second plate placed on the delivery cart. The test plate was immediately removed from the delivery cart as staff took the residents tray into the room at 12:24 PM and returned to the lunch service to check the temperature of the food by the Staff O who was still serving the lunch meal. One room tray remained on the delivery cart to still be delivered at the time the test plate was removed and taken for temperature check (the second plate that was plated was the second to last plate delivered during room tray delivery). Test plate temperature checked at 12:25 PM.Temperatures of test tray food items: pulled pork 114, french fries 105 and green beans 108On 2/24/26 at 12:40 PM Staff O, Assistant Dietary Manager / [NAME] acknowledged all of the food from the test tray was under temperature. Staff O explained she would like the food to be delivered to the residents room at 135 degrees or higher.On 2/24/26 at 11:32 AM Staff L, [NAME] 1 PM shift stated Resident #24 had complained about cold food and not getting enough food. Staff L explained these concerns were reported by Staff N, Certified Dietary Manager (CDM).On 2/24/26 at 1:15 PM Staff M, [NAME] 1 PM shift stated the holding temperature for food was 145 degrees. Staff M explained there were usually 4 room trays. Staff M stated the temperature of the food arriving in the residents room should also be 145 degrees. On 2/25/26 at 1:12 PM Staff N, CDM stated the temperature of the items of food should be out of the danger zone. Staff N explained the facility does temperatures on test trays frequently. Staff N stated she checked the temperature of the tray for the food that had to travel to the furthest resident room away. Staff N stated she would like the temperatures above 135 degrees when delivered to the residents in the room. Review of policy with effective date of 5/19/16 titled, Meal Delivery / Room Trays documented the purpose was to ensure all residents receive meals that are safe, palatable, and served in a dignified manner by maintaining CMS-compliant food temperatures during tray service, serving meals on plates rather than disposable containers when appropriate and promoting resident dignity and quality of life. Hot foods must be greater than or equal to 135 degrees when served to residents. Trays must be delivered to resident rooms within 5 minutes of plating. If delivery exceeds, temperatures must be rechecked.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to maintain medical records that are complete and accurately documented for 1 of 14 residents (Resident #4). The facility also maintain confidentiality of residents' records during medication administration. The facility reported a census of 40 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating severe cognitive impairment. The document included resident diagnoses of Alzheimer's, Non-Alzheimer's Dementia, and depression. The resident did not have any falls in the previous reporting period. Resident #4's Care Plan last revised 2/13/26 contained a focus of high risk for falls (10/30/25) with interventions of call light within reach and follow facility fall protocol (10/30/25). A focus area of having an actual with no injury dated 10/30/25 contained staff interventions of chair/bed alarm (12/12/25), continue interventions on the at-risk plan (10/30/25), and hospice fall mat (2/13/26). The clinical record's Progress Notes entry on 2/24/26 at 9:05 PM revealed Staff V, Licensed Practical Nurse (LPN) was summoned to Resident #4's room and observed the resident sitting on the floor with her back against the bed. Temperature, pulse and respiration checks 97.5-68-18 and the resident refused blood pressure (B/P). The staff noted approximately 1 inch x .25 inch abrasion to mid left side of back, area cleansed with soap and water. The entry included the resident was assisted onto her bed with dependent full body lift and 3 staff assistance, the bed was in lowest position prior to fall, and neuro checks were initiated due to fall being unwitnessed. Staff V entered the note on 2/24/26 at 10:55 PM.Staff V completed the facility's Un-witnessed Fall document with indication of a fall on 2/25/26 at 9:05 PM. The document provided a Certified Nurse Assistant (CNA) summoned the nurse to the room at 9:05 PM and the resident was observed sitting on the floor next to the bed, back to the mattress with legs extended. The staff noted a 1 x .25 abrasion-like area to the mid left back which was cleansed with soap and water, full range of motion (ROM) to extremities and no complaints of pain. The resident refused B/P, temperature, pulse and respiration checks 97.5-64-18. The document included the resident was lifted from the floor with a dependent mechanical lift with the assistance of 2 staff, the bed was in the lowest position at the time of the fall, a fax was sent to the physician for notification and neuro checks were initiated. The Neurological Flow Sheet provided the following:Staff V completed the first entry at 9:05 PM with pupil size equal and reactive equally, hand grasp equal and strong, speech clear, refused B/P and pulse, respiration 18, and temperature 97.5.Staff V's entry at 9:20 PM included refusal of B/P, pulse 68, respiration 18, and temperature 97.5.Entries beginning at 10:50 PM for level of consciousness indicated the resident was sleeping until 7:00 AM with hand grasps, pupil size, reaction and speech assessed and documented. Entries beginning at 11:20 PM for speech, B/P, Pulse included the resident was sleeping and not assessed. On 3/3/26 at 2:52 PM Staff V stated she did not actually respond to the call for assistance as she was down the hall. The staff stated Staff W, LPN, responded to the call. Staff V stated by the time she got there, Staff W had completed the assessment, got Resident #4 back into bed and gave the report of what had happened. Staff V stated she did not witness the fall or assess Resident #4.On 3/3/26 at 3:10 PM Staff W stated she was notified by Staff S, CNA, of need for assistance as Resident #4 was on the floor. The staff stated upon entry the resident was seated on the floor mat with her back against the bed and the bed was in a low position. Staff W stated she completed the assessments of ROM and pain with no abnormal findings. The staff stated then she and 2 CNAs assisted the resident back into bed. Staff W acknowledged she had Staff V complete the documentation of the assessment and fall, but could not give justification as to why. On 3/3/25 at 4:22 PM Staff S stated she heard Resident #4's bed alarm going off with the resident calling for help. The staff stated she found the resident seated on the floor mat with her back against the bed with her legs stretched out. Staff S stated she did observe the bed control on the bed and the bed higher than what she had placed it around 8:00 PM when she put the resident to bed. The staff stated when putting the resident to bed she placed the bed in the lowest position with a fall mat present and upon entry into the room the resident was no longer in that position. Staff stated she called for assistance with Staff W and Staff X, CNA, responding. Staff S stated Staff W did some assessment while the resident was on the floor, and then the 3 staff assisted the resident back into bed. Staff S stated Staff W left the room and came back and completed vital assessments. Staff S stated Staff V did not assess the resident at the time of the fall. Staff S stated she witnessed Staff V talking with Staff W at the nurses station discussing the documentation of the fall. On 3/3/26 at 4:26 PM Staff X stated she could not remember all the details of the fall but did acknowledge she, a nurse and CNA S picked the resident up and put her into bed. On 3/4/26 at 9:40 AM the Director of Nursing (DON) reviewed the neuro assessments and stated if the resident was documented as sleeping the staff should not have documented hand grasp and pupil size/reaction as the resident would need to be awake for those assessments. The DON stated the documentation in the medical record needs to be completed by the nurse who is completing the assessment.On 3/4/26 at 12:00 PM the Administrator stated he felt a licensed nurse would want to complete the documentation of her assessments and not depend on someone else to document correctly what was completed. 2. Continuous observation of Staff A, Registered Nurse (RN), on 7/24/26 beginning at 7:00 AM - 7:35 AM completing medication administration. Observed the staff enter Resident #22's room leaving the laptop computer on the medication cart open and the screen not locked. Observed the nurse's paper notes face up on the cart with documentation readable. Staff A entered Resident #27's room not locking the computer and leaving documentation papers readable to others on the medication cart. On 2/26/26 at 12:30 PM the Administrator acknowledged that computers were not to be left open and nurse's documentation papers were not to be left open and viewable by others.On 2/26/26 at 1:15 PM the DON stated nurses cannot leave computers unlocked and documentation pages uncovered on the medication carts when walking away from the carts. The facility's Health Insurance Portability and Accountability Act (HIPAA)/Privacy Safeguarding and Storing Protected Health Information Policy and Procedure revealed active medical records should not be left unattended in any areas where residents, visitors and unauthorized individuals could easily view the records.

Based on clinical record review, observations, interviews, and policy review, the facility failed to monitor a pressure area in a manner to reduce the risk of wound development and failed to implement offloading procedures to decrease pressure for 1 of 1 residents reviewed (Resident #4). The facility reported a census of 40 residents.Findings include:Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating severe cognitive impairment. The document included resident diagnoses of Alzheimer's, Non-Alzheimer's Dementia, and depression. The document disclosed the resident had an unstageable pressure ulcer due to coverage of the wound bed by dead hard tissue. The MDS included skin treatments including a pressure reducing device for chair, bed, pressure ulcer/injury care, application of dressings to feet and the resident utilized a wheelchair (w/c)The resident's Care Plan dated 2/13/26 contained a focus area of potential/actual impairment to skin integrity revised on 11/8/25 with staff interventions of monitoring/documenting location, size and treatment of skin injury, dependence on staff for wound care, assistance to apply protective garments (cushion boot) dated 11/8/25. The 2/26 Treatment Administration Record (TAR) contained an order to apply Betadine to the right lateral heel every night shift with a start date of 12/2/25 at 10:00 PM. The document provided the following entries for the order:No documentation on 2/3/26 indicating the treatment was completed. The M line contained 10 entries with measurements, 7 entries with Y, 8 entries with X, 2 entries with NA.The Note line contained 22 entries of yes or Y, 3 entries of no or N, 2 entries with NA.The Night line contained staff initials with completion indicated, 1 entry for refused, 2 entries for sleeping. The clinical record document Skin Issues dated 2/19/26 - in progress disclosed the resident had a new issue on the right heel, pressure - Kennedy terminal ulcer/End of Life that was improving and unstageable. The document included it was inhouse acquired, chronic over 3 months and measured length .75 cm x width 1.16 cm, no depth and area .65 cm squared. The clinical record document Skin Issues dated 2/27/26 - in progress disclosed the resident had a new issue to the right heel, pressure ulcer/injury that was improving and unstageable. The document included it was inhouse acquired, chronic over 3 months and measured length 1.5 cm x width 3.5 cm, no depth, no area. The clinical record Skin and Wound - Total Body Skin assessment dated [DATE] identified a new wound but did not provide measurements. The clinical record Skin and Wound - Total Body Skin assessment dated [DATE] did not identify a pressure ulcer or provide measurements. The clinical record Skin and Wound - Total Body Skin assessment dated [DATE] did not identify a pressure ulcer or provide measurements. The clinical record Skin and Wound - Total Body Skin assessment dated [DATE] did not identify a pressure ulcer or provide measurements.The clinical record Progress Notes reviewed from 10/15/25 - 3/3/26 contained the following entries: 10/15/25 2:37 PM Resident #4 had a deep tissue injury to the right lateral heel measuring 1.5 cm x 3 cm; the heels were floated in bed and a boot was applied. The entry included notification to the physician for treatment orders.10/29/25 9:00 AM the resident continued to wear a pressure relieving boot.11/21/25 11:47 AM the right lateral heel measured 1.5 inches x1 inch and was hard, dark black/brown.1/10/25 5:16 AM dark coloring of the heel and measured 1.5 inches x1 inch.2/9/26 4:17 AM the right lateral heel is brown, flaky in appearance and measured 2 cm x 1.5 cm circular in shape. 2/19/26 at 3:43 PM light brown scabbed area on right heel, no pain 0.75 cm x 1.16 cm. 3/3/26 at 4:55 AM the right heel measured 2 cm x1.5 cm. Observed on 2/23/26 at 1:36 PM the resident's picture cue card above the bed indicated a pressure boot for the right foot. The resident was seated in her w/c. Observed on 2/24/26 at 2:05 PM Staff D, Certified Nurse Assistant (CNA)/Restorative Nursing Assistant (RNA) and Staff J, Certified Medication Aide (CMA) bring the resident in her w/c wearing only socks to her room for personal care and repositioning. Following personal care, the resident was positioned in bed without the use of heel protector/boot. Observed on 2/25/26 at 10:55 AM observed a heel protector (blue foam bootie) on the resident's recliner. Observed on 2/25/26 at 11:13 AM observed the resident seated in her w/c wearing only socks with her feet touching the footrests. Observed on 2/25/26 at 2:39 PM the resident was wearing only socks while seated in her w/c. Observed on 2/26/25 at 12:22 PM 2 foam heel protectors on the resident's recliner and the resident seated in her w/c without a foot protector. Observed on 3/4/26 at 10:35 AM the resident seated in her w/c without wearing a heel protector. On 2/25/26 at 11:10 AM Staff D stated she did not typically work with Resident #4. The staff stated to know about a resident she would look at the Care Plan. The staff stated the picture diagram on the walls in the residents' rooms assists the staff know what kind of assistance a resident needs with transfers, care. Staff D stated Resident #4 had had a heel protector and did not know if one was still required. The staff stated she was not aware of any pressure areas on the resident and had not observed any pressure areas when completing care the previous day. On 2/25/26 at 11:30 AM Staff B, Registered Nurse (RN), stated she was not sure if orders were obtained for the use of pressure relief boots. The staff stated it would make sense to be on the TAR to ensure they were used. The staff stated she did not know if Resident #4 had heel protectors and could not speak to the resident's treatment as it was completed on the night shift. On 2/25/26 at 1:50 PM Staff A, RN, stated if a resident had a heel protector it would typically go on the Medication Administration Record (MAR)/TAR ensuring nursing could monitor the protective equipment being used with the staff giving examples of other residents who utilized pressure relieving devices. On 2/25/26 at 3:44 PM Staff R, CNA, stated she would know if a resident needed a heel protector by looking at the picture diagram/chart posted in a resident's room.On 2/26/26 at 9:10 AM Staff H, CNA/RNA, stated she would know if a resident required a heel protector by the picture system on a resident's wall. When asked when the device would be used, the staff stated she would assume on in the morning and off at night or would ask the nurse. On 2/26/26 at 9:30 AM Staff C, CNA, stated she would know to use the heel protectors if it was represented on the wall. The staff stated she would think the heel protectors would be used when the resident is in bed. On 3/3/26 at 9:50 AM and 12:15 PM the Director of Nursing (DON) stated the resident's heel initially was all black and covered the heel. The DON indicated she would look at the Progress Notes for monitoring the progress of the heel with the notes coming from the Electronic Medical Administration Record (EMAR). The DON stated she had recently started completing Skin Issues Assessments in the past few weeks due to concerns raised by herself and the Administrator regarding the consistency of measurement and documentation of the wounds. The staff stated the assessments she completed included photos of the wounds and with a recent update to the electronic record it showed documents that contained photos as in progress versus completed. The DON stated with the use of the photo program it automatically completed the measurements of the wound and was still working to get the consistency with the program. The staff stated the resident's pressure ulcer was improving and not regressing as indicated by the most recent automated measurement. The DON stated interventions for the pressure ulcer included the iodine treatment, no shoes and heel cushion. The staff stated the heel cushion was supposed to be on the right foot and the resident had a history of messing with it. The DON stated it was suspected the issue with Resident #4's heel came from either her shoe or hitting her foot on the w/c pedal. The DON stated the resident was supposed to wear the heel boot while she was up in her w/c. The DON indicated the boot was referenced on the Care Plan, but acknowledged it did give staff directions on when to use it. The DON further concurred the picture system on the resident's wall did not give directions as to what times the boot should be worn. The DON stated the facility did not typically get physician orders for use of pressure devices as they were considered nurses orders. The staff stated without it being on the TAR it would be difficult for staff to monitor the use of the device and other residents did have pressure devices on their TARs. The DON stated she could not speak to why Resident #4 did not have her boot placed on the TAR and the boot should still be used. The DON stated her expectation was the treatments be completed as ordered and the resident's TAR was to have daily measurements of the wound, and a note entered. On 3/3/26 at 12:45 PM the Administrator stated he had been made aware of the concern with Resident #4's pressure ulcer. The Administrator stated the facility was making a change in monitoring of the wounds and would continue to complete audits to improve this area of concern. The facility's Policy and Procedure for Skin Inspection and Pressure Injury Prevention, updated 11/25, provided there would be documentation of all assessments in the resident's medical record with inclusion of date, time, interventions, reassessment schedule and staging. The document included the daily dressing changes required descriptive wound note from the nurse and interventions included repositioning schedules based on the risk level, use of pressure relieving devices, skin care protocols and nutrition/hydration support. The facility's Protocol for Wound Assessments, updated 2/28/24, included that wound and skin concerns were tracked and evaluated to ensure interventions were working in a timely manner and to prevent further breakdown. The document included skin assessment would be completed in the clinical record weekly with measurements.

Based on clinical record review, resident and staff interviews, and policy review the facility failed to develop programs maintaining residents strength, range of motion (ROM), mobility needs based on the comprehensive assessment and under the direct guidance of a Registered Nurse (RN) for 2 of 14 residents reviewed (Resident #26, #45). The facility reported a census of 40.Findings include:1. The Minimum Data Set (MDS) admission for Resident #26 dated 1/2/26 provided a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The document revealed the resident had diagnoses of stroke, anxiety, depression, bipolar disorder, psychotic disorder and schizophrenia. The document included the resident had functional limitations of ROM in both the upper and lower extremities. The document further disclosed the resident received 4 days of passive range of motion (PROM), 3 days of active range of motion (AROM), 2 days of splint or brace assistance, 5 days of bed mobility, 5 days of transfers and 1 day of dressing and/or grooming of least 15 minutes in the last 7 calendar days.Resident #26's Care Plan dated 1/27/26 contained a focus area related to the Restorative Nursing Program initiated and revised on 1/5/26 by the Director of Nursing/RN. The interventions for staff to follow included specific resistive exercises, bed mobility, PROM, splint/brace,and transfers revised by Staff Y, Restorative Nursing Assistant (RNA) on 1/19/26. On 2/23/26 at 3:02 PM Resident #26 stated she wanted to be walking more and she was supposed to be getting a new leg brace and the staff had told her they would work with her on the uneven bars.On 2/26/26 at 8:33 AM Staff D, Certified Nurse Assistant (CNA)/RNA stated Resident #26's Restorative Nursing Program included PROM to the left upper extremity (LUE) and left lower extremity (LLE), splint for the LUE, brace for LLE, attending morning group exercise, and use of the NuStep (low impact seated upper and lower extremity exercise machine). The staff stated she was not aware of the resident getting a new brace for her leg. Staff D stated she created Resident #26's Restorative Nursing Program on 12/28/25 when the resident re-admitted to the facility. The staff stated if a resident presented without AROM of an extremity, she would immediately go to PROM. When asked how far she would passively stretch a resident, Staff D replied go until you feel resistance. Staff D stated the training she had received for completing Restorative Nursing Programs was by Staff Y and Staff U, Administrative Assistant, who used to complete Restorative Nursing Programs. The staff stated she had been working in Restorative Nursing for almost a year. The staff stated she referred to the resident's Care Plan for the Restorative Nursing Program. 2. Resident #45's MDS Export Ready dated 2/21/26 revealed a BIMS score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of severe life threatening blood infection, diabetes and a rare flesh eating bacterial infection. The document disclosed the resident was independent with dressing, toileting, bed mobility, transfers and required supervision for walking distances of 150'. The document included the resident did not have limitations in ROM. The document disclosed the resident received at least 15 minutes of AROM 3 days, bed mobility 4 days, transfers 4 days and dressing and/or grooming 4 days in the last 7 calendar days. The resident's Care Plan dated 2/24/26 included a focus for restorative initiated 2/18/26 with staff interventions of ambulation, AROM, bed mobility, dressing and/or grooming, and transfers initiated and revised by Staff Y on 2/18/26. The self-care performance deficit focus area initiated and revised 2/23/26 included staff interventions of independence with bed mobility, dressing, toileting, and personal hygiene initiated and revised 2/23/26.The clinical record provided the resident was admitted on [DATE].On 2/25/26 at 12:51 PM Resident #45 stated he had only attended Restorative Nursing 1 time since his admission on [DATE]. The resident stated he had an exercise band in his room that he had brought with him that he used for independent exercise and that the facility staff had given him a stronger resistance band for him to use and could get a stronger one if he wanted. On 2/26/26 at 8:27 AM Staff D stated Resident #45 used overhead pulleys for 1-5 minutes, bicep curls with and without weights (1-2#), and AROM for his LEs. The staff stated the resident was independent in his room. The staff stated Staff Y wrote the Restorative Nursing Program on the Care Plan on 2/18/26. On 2/26/26 at 9:45 AM Staff Y stated if a resident came into the facility with skilled orders for therapy, Restorative Nursing would wait until the resident was finished and then therapy would give directions on what the resident could do. Staff Y stated if a resident did not have therapy orders, she would do an assessment to determine what the resident can and can't do for basic exercises, ambulation. The staff stated she would give the ideas to the MDS Coordinator or the DON if the MDS Coordinator wasn't available, and then start the program. The staff stated she received training on the completion of Restorative Nursing Programs from Staff U. On 2/26/26 at 1:20 PM Staff U stated she was self taught on the Restorative Nursing Program many years ago. The staff stated she did a lot of internet searches to learn about exercises and ROM. The staff stated when she was completing Restorative Nursing therapists were more prevalent in the building and she may observe them. However Staff U stated her primary knowledge was obtained from books and the internet without any formal training on Restorative Nursing. On 3/3/26 at 10:10 AM the DON stated the MDS Coordinator works more directly with the RNAs and oversees the staff. The DON acknowledged the MDS Coordinator was a Licensed Practical Nurse (LPN). The DON stated the RNA will write the programs, take to the MDS Coordinator and then give to the DON. The DON stated the RNAs can write programs and put them in the residents' Care Plans. The staff stated when developing the programs they use feedback from the RNAs and the residents. When asked about residents who may not be able to provide feedback, the DON indicated that more of the feedback was taken from the RNAs. The DON stated if a resident had specific needs, the facility would request therapy orders for assistance in developing a program. When asked for documentation indicating the DON had been actively involved with the program development and not done by a RNA, the DON acknowledged the documentation did not provide that information. The DON stated she reviewed the Care Plans quarterly. The DON stated she was not aware of the training the staff had for working in the Restorative Nursing Program. The DON stated RNA's should not be assessing residents for program development and changes, and there needed to be more formal training for RNA staff.The facility's Restorative Policy dated 1/24/23 revealed a restorative program would be started upon admission for AROM, PROM, strengthening and self care. The document disclosed the programs would be set up by the restorative supervision and MDS/Care Plan Coordinator. The programs will include 3 days a week and 7 days a week upon Care Plans and Skilled Care.

Based on observations, clinical record review, policy review, resident interview and staff interviews the facility failed to provide respiratory services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #24) who required the use of a Continuous Positive Airway Pressure (CPAP) machine. The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #24 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS documented Resident #24 had a diagnosis of obstructive sleep apnea.On 2/23/26 at 11:03 AM Resident #24 stated none of the facility's staff have ever cleaned her CPAP machine. Resident #24 stated she had not had her CPAP mask or machine cleaned at all since admission to the facility.On 2/23/26 at 11:10 AM an observation of Resident #24's CPAP machine revealed speckled white sediment covered the outside of the machine. [NAME] haze colored water present in the reservoir. The CPAP machine's mask had cloudy white sediment and film on the inside with dry red [NAME] on areas of the mask.Review of Resident #24's Care Plan revealed no documentation that Resident #24 would clean her own CPAP machine or mask.Review of Resident #24's Treatment Administration Record (TAR) revealed no orders for cleaning of Resident #24's CPAP machine or maskOn 2/26/26 at 12:00 PM Staff A, Registered Nurse (RN) stated she had never cleaned Resident #24 CPAP machine or mask. Staff A stated she thought that Resident #24 cleaned her own machine. Staff A acknowledged if Resident #24 cleaned her own CPAP that would be documented on the care plan and the TAR. Staff A stated she thought CPAP masks were cleaned every am shiftOn 2/26/26 at 12:15 PM Staff P, Licensed Practical Nurse (LPN) stated she had never cleaned Resident #24 CPAP machine or mask. Staff P stated she thought that Resident #24 cleaned her own machine. Staff P stated Staff B usually worked with Resident #24 in the morning.On 2/26/26 at 2:03 PM Staff B, RN stated she had never cleaned the CPAP machine. Staff B stated Resident #24 does all of that herself. Staff B explained typically for all the other residents she would complete that task for them on the am shift every morning. Staff B stated if the resident completed her own cleaning of the CPAP it would be in the care plan. Staff B acknowledged she worked with Resident #24 frequently. On 2/26/26 at 12:57 PM the Director of Nursing (DON) stated Resident #24 told her that she would clean her own CPAP machine and did not need nursing staff help. The DON stated the resident should have a care plan that indicated Resident #24 would complete the cleaning of the CPAP machine on her own. The DON acknowledged Resident #24's care plan did not have any documentation that she would clean her own CPAP machine. The DON explained the TAR would also have an order to clean Resident #24's CPAP mask if facility staff were going to clean it. The DON acknowledged the TAR did not have an order.Review of policy revised on 6/26/23 titled, CPAP and Nebulizer Cleaning and Storage documented the policy was developed to ensure all CPAP and nebulizer equipment was cleaned and disinfected according to manufacturer instructions for use. Stored in a manner that prevents contamination. Assigned to individual residents when required. Maintained and documented per CMS and facility Infection Prevention and Control Program.

Based on clinical record reviews, resident interviews, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards for 2 of 14 residents (Residents #26, #1). The facility failed to complete neurological assessments post falls, and failed to complete wound assessments to ensure healing. The facility reported a census of 40 residents. Findings include:1. The Minimum Data Set (MDS) admission for Resident #26 dated 1/2/26 provided a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The document revealed the resident had diagnoses of stroke, anxiety, depression, bipolar disorder, psychotic disorder and schizophrenia. The document revealed the resident had a fall in the last month prior to admission, a fall in the last 2-6 months prior to admission, fracture related to a fall in the 6 months prior to admission, and no falls since the admission to the facility. The MDS Discharge Return Not Anticipated dated 12/21/25 revealed the resident had sustained 2 falls without injury since the prior assessment. The MDS Quarterly dated 11/10/25 provided the resident scored 14/15 on the BIMS, indicating normal cognition. The document revealed the resident sustained 2 falls without injury during the previous reporting period. Resident #26's Care Plan dated 1/27/26 contained a focus area of high risk for falls dated 1/25/26 with interventions of call light within reach and encouraged the resident to use it for assistance as needed and prompt response to all requests for assistance. A focus area of actual fall with no injury related to poor balance, poor communication/comprehension and psychoactive drug use dated 1/4/26 contained interventions of previous Care Plan interventions of staff education/re-education, 2 assist with toileting, use of call light for assistance, resident education on reclining chair prior to attempting to reposition or use of the call light, anti-slide mat in recliner, seat belt on the wheelchair (w/c) and grabber initiated 1/5/26 and revised 1/17/26). The clinical record Progress Notes contained the following entries: 2/11/26 at 10:30 PM the resident put pillows on the floor and lowered herself to it. 12/4/25 at 5:22 PM the resident had an unwitnessed fall at the bedside. 12/3/25 at 11:12 AM the resident slid from her w/c while outside in a supervised smoking environment. 11/13/25 at 10:27 PM the resident fell from her recliner when attempting to recline. The resident had significant pain in her left shoulder and hip and was sent to the emergency room. 11/13/25 at 12:25 AM the resident had an unwitnessed fall transferring herself from her w/c to her bed. 11/10/25 at 10:30 AM the resident fell while staff was assisting with a toileting transfer in the bathroom. 11/9/25 at 1:57 AM the resident had an unwitnessed fall in her bedroom and was found beside the bed. 10/28/25 at 11:20 PM the resident had an unwitnessed fall when she put herself on the floor in an attempt to take herself to the bathroom. The clinical record Neurological Check List in the Assessment tab provided assessments were completed on the following dates: 2/11/26 at 10:30 PM, 12/5/25 at 4:39 PM, 11/16/25 at 10:10 PM, 11/13/25 at 12:25 AM, 11/9/25 at 1:48 AM, 10/28/25 at 11:20 PM. The facility provided documents related to falls on the following dates: 2/11/26 at 10:30 PM un-witnessed fall by placing pillows on the floor and placing self on the floor. 12/4/25 at 3:00 PM un-witnessed fall by reaching for the call light that was laying on the bed. 12/3/25 at 10:00 AM witnessed fall slide from w/c while outside smoking. 11/16/25 at 10:10 PM un-witnessed fall when the resident was using a reaching device while seated in the recliner to obtain a pillow from her bed. 11/13/25 at 12:25 AM un-witnessed fall self transferring from the w/c to the bed. 11/13/25 at 9:50 PM un-witnessed fall pushing back in recliner and falling. 11/10/25 at 8:00 AM witnessed fall transferring with staff in the bathroom. 11/8/25 at 11:50 PM un-witnessed fall reaching for call light and slipped from the side of the bed. The clinical medical record contained physician notifications for falls on the following dates: 2/11/26 notification of un-witnessed fall. 12/3/25 order for x-ray for resident thinking toes were broken. 12/3/25 notification for a witnessed fall outside. 11/16/25 notification for un-witnessed fall from a recliner. 11/10/25 notification for witnessed fall. 10/28/25 notification for un-witnessed fall. The clinical medical record contained an emergency room report following the fall sustained on 11/13/25 with an increase in pain. The document revealed no acute injuries. The clinical medical record contained neuro assessments for 2/11/26, 12/3/25, at 12/4/25. The clinical medical record contained 15 minute checks without assessments for 11/16/25. The medical clinical record did not contain neuro assessments for fall on 11/16, 11/13, 11/8 and 10/28/25. On 3/2/26 at 2:54 PM Staff Q, MDS Coordinator/Licensed Practical Nurse (LPN), stated she had looked through the medical record and acknowledged neuro assessments had not been completed on 11/16/25, first fall on 11/13 and 11/8/25. The staff stated she expected the staff to complete neurological assessments following unwitnessed falls. On 3/2/26 at 3:55 PM the Director of Nursing, DON, stated her expectation was for staff to complete Risk Assessments, Neurological Assessments, and notification to the physician following falls with the Neurological Assessments for unwitnessed falls. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS documented diagnoses of chronic venous hypertension with ulcer and inflammation of the right lower extremity. On 2/23/26 at 12:36 PM Resident #1 said a van ran over him before he got to the facility and broke his leg in 9 places. Resident #1 pulled his sock on the right foot down to reveal wounds on inner ankle. On 2/23/26 at 12:40 PM an observation of Resident #1's inner right lower extremity revealed 5 areas with dark red scab covering the wound all approximately 0.3cm in diameter. Review of Resident #1's document dated 5/21/25 titled fax documented to send Resident #1 to a wound care clinic. Review of Resident #1's document dated 5/23/25 titled Physician's Orders Wound Care Clinic documented the wounds on Resident #1's right lower extremity probes down to the hardware. Resident #1 needs ortho. Request for Ortho consult for exposed hardware. Review of Resident #1's document dated 7/3/25 titled Physician's Orders Ortho Consult documented to continue current wound care with chronic implant related infection to right leg. Review of Resident #1's wound assessments for the last year in EHR titled, Assessments documented no assessments with measurements or descriptions of the wound on the right lower extremity. Review of Resident #1's Electronic Health Records (EHR) titled, Progress Notes for last 12 months documented wound assessment with measurements on 2/19/26, 6/21/25, 5/30/25 and 5/25/25. Progress Notes documented only monthly skin assessment on 2/3/26, 1/19/26, 12/22/25, 9/21/25, 8/4/25 and 7/21/25 with no wound description or measurement. On 2/26/26 at 12:00 PM Staff A, Registered Nurse (RN) stated she did not know when a skin assessment was supposed to be completed. Staff A acknowledged she cared for Resident #1 frequently. Staff A explained she was the nurse that completed the treatment to Resident #1's wound to the lower right extremity most days that she had worked since September of 2025. Staff A stated since caring for Resident #1 his wound had not gotten any worse. Staff A stated the wound remained about the same. Staff A explained stated if the wound had gotten worse she would have notified the DON and Resident #1's physician. On 2/26/26 at 12:15 PM Staff P, Licensed Practical Nurse (LPN) stated the skin assessments were to be completed weekly and should contain both measurements and a description of the wound. Staff P stated she completed the treatment today and had measured the wound then and entered the measurements. Staff P stated she would put the assessment under weekly skin assessments and would contain measurements and a description. On 2/26/26 at 12:32 PM the Director of Nursing (DON) presented 2 photo assessments that determined the wound had been resolving over the last 6 months. On 2/25/26 at 10:59 AM the DON stated there were no progress notes with regards to an assessment to Resident #1's right leg since 2/19/26. The DON explained she would like to see a wound assessment every time a dressing was changed. The DON acknowledged there was not the amount of assessments she would expect to see in progress notes for Resident #1's wound on his right lower leg. Stated she would expect s/s of infection, dressing, measurements and description of the wound on the wound assessments. The DON explained Resident #1's wound comes and goes and he has had them for years. The DON acknowledged assessments were not completed appropriately by the nursing staff. On 2/26/26 at 10:41 AM Resident #1's Primary Care Physician (PCP) stated he could not tell for sure if the wound was resolving or worsening as he had not looked at the area recently. Resident #1's PCP stated in July of 2025 Resident #1 had right ankle pain and the AFO was rubbing. Resident #1's PCP stated on 5/21/25 at fax he sent to refer Resident #1 to a wound care clinic. Resident #1's PCP stated Resident #1 was having more problems with the wound. Resident #1's PCP stated once the referral was sent he assumed the wound care clinic would complete the determination. Resident #1's PCP stated he has no notes from the wound care clinic. Resident #1's PCP stated he would expect the facility would notify the wound clinic if there was any change. Review of a policy updated 3/18/25 titled, Protocol for Documentation documented the purpose was to ensure all patients information was being documented. Wound care notes should state the treatment provided, the appearance of the wound in detail, and any new concerns noted during treatment. Review of a policy updated 2/28/24 titled, Protocol for Wound Assessments documented the purpose was to ensure that wound and skin concerns are tracked and evaluated to ensure that interventions are working in a timely manner and to prevent further breakdown. When a skin concern arises, the nurse shall complete skin assessment in the EHR, physician notification for ongoing treatment/intervention, EHR updated to reflect current treatment/intervention, weekly measurements obtained by a nurse and reflected in the residents EHR. The policy was to ensure all patient information was being documented. The document disclosed that telephone orders were to be documented in the nurse's notes with any clarification required as well as additional notifications made. The document included all wound care notes that would state the treatment provided, appearance of the wound in detail and any new concerns regarding the wound.

Based on clinical record review, resident and staff interviews, and provider interview, the facility failed to assist the resident to obtain hearing devices through possible available resources for 1 of 1 resident (#29). The facility reported a census of 40 residents.Findings include:On 2/23/26 at 11:48 AM, Resident #29 stated she was hard of hearing and has been trying to get hearing aids but her insurance would not cover them.The Care Plan dated 3/31/25 included a hearing deficit focus category and directed staff to validate the resident's message by repeating aloud.The Appointment Note dated 10/21/25 at 2:33 PM revealed the facility was waiting for the resident's Ear, Nose, and Throat (ENT) provider to supply a phone number for the facility to contact the resident's insurance company about hearing aids.Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of heart failure, depression, and bilateral hearing loss. It indicated she required supervision with bathing and shower transfers, dressing, personal hygiene, and ambulating 150 feet and was independent with all other Activities of Daily Living (ADLs) and mobility. It documented she had adequate hearing without hearing aids or other hearing appliances.The Appointment Note dated 12/17/25 at 11:49 AM revealed the facility was waiting for a mobile hearing service response to schedule a hearing test.On 2/24/26 at 8:44 AM, Staff D, Certified Nurse Aide (CNA) stated Resident #29's insurance would not pay for her hearing aids.On 2/24/26 at 1:37 PM, the Assistant Administrator (Asst Admin) stated he was not aware of the hearing aid process delay in the aforementioned progress note until he spoke to the Director of Nursing earlier in the day. He also stated the process for insurance related communication was for staff to notify him directly.On 2/24/26 at 1:52 PM, Staff E, Certified Medication Aid (CMA) stated the resident's ENT provider did not state they could not provide the resident with hearing aids but supplied her with a list of hearing aid providers contracted by the resident's insurance. Staff E stated she made multiple attempts to contact the resident's insurance provider on 12/17/25 and was informed they would call her back, but never did. She further stated she forgot about it until the date and time of this communication. She revealed she usually talks to the Director of Nursing (DON) or the MDS Coordinator when she is communicating with insurance providers and is expecting return calls. She also stated she does not know of any official process in place for communication of insurance barrier situations.On 2/24/26 at 2:02 PM, the MDS Coordinator stated she knew the resident had gone for a hearing test but was not aware of the hearing aid insurance barrier until the DON asked her to contact the hospital on 2/24/26.On 2/24/26 at 2:13 PM, the DON stated she was not aware of the hearing aid insurance barrier until 2/24/26.On 2/24/26 at 2:20 PM, Staff C, Certified Nurse Aide (CNA) stated she has to talk to Resident #29 with an elevated voice because she doesn't think the resident can hear very well.On 2/26/26 at 11:32 AM, the DON stated staff should've notified her or the MDS coordinator of the ongoing hearing aid communication attempts.

Based on clinical record reviews, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards for 1 of 14 residents (Residents #45). The facility failed to complete/document wound treatments per physician orders and failed to administer oxycodone per physician orders. The facility reported a census of 40 residents. Findings include:The Minimum Data Set (MDS) admission for Resident #45 dated 2/21/26 provided a BIMS score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of severe life threatening blood infection, diabetes and a rare flesh eating bacterial infection. The document revealed the resident had an open lesion and had the interventions of a pressure reducing device for the bed, repositioning program and application of nonsurgical dressings. Resident #45's Care Plan dated 2/24/26 contained a focus area of wound management dated 2/20/26 with interventions of measuring wound on regular intervals, monitoring for signs of infections, and wet to dry dressing changes twice daily dated 2/20/26.The clinical record contained a verbal order on 2/18/26 at 8:40 AM for wet to dry dressing 2 times daily to affect area and wound care clinic referral. The order was signed by the physician and noted on 2/18/26. The clinical record's Physician Orders revealed wet to dry dressing 2x daily to perianal. Pack wound with wet (Dakins/[NAME]) kerlix/gauze, cover with ABD secure with tape every day and night shift for perianal wound. The document disclosed entry at 4:53 PM with a start of 2/18/26 at 5:00 PM.The clinical record's Progress Notes did not contain the verbal order received from the physician for wound care/dressing changes that occurred on 2/18/25 at 8:40 AM. The Progress Notes contained an entry at 2/18/26 at 4:56 PM indicating receiving the returned fax from the physician for the wound care treatment. The entry further contained an entry regarding treatments provided and the appearance of the wound, as well as its size. The Treatment Administration Record (TAR) 2/26 revealed the entry for the order of dressing changes for day and HS (evening). The document disclosed the following:2/18 hour of sleep (HS) no entry for treatment.2/19 day and HS no entries for treatment.2/20 day and HS no entries for treatment.2/25 HS no entry for treatment.2/26 HS no entry for treatment.The Medication Administration Record (MAR) 2/26 revealed an order for Oxycodone/APAP Tab 5-325 mg, 1 tab twice daily as needed. The order disclosed on 2/20/26 Resident #45 received the medication at 4:23 AM, 3:54 PM, and 8:23 PM for a total of 3 doses in 1 day.On 2/25/26 at 11:30 AM Staff B, Registered Nurse (RN) stated as staff she cannot see all missed treatments/medications on clinical record (electronic). The staff acknowledged she had seen items in red when opening the Medication Administration Record (MAR)/TAR meaning something had not been completed on the previous shift. Staff B stated she did not see Resident #45 for the first few days he was in the facility past the day of admission as she was off. The staff stated the day of admission the resident did not have wound orders. Staff B stated when she returned she knew the resident did not have orders on his TAR for wound treatments. The staff stated she did provide a treatment for the resident as she had been told to do a wet to dry dressing with saline on the resident. The staff then stated she saw the resident for the first time with the DON as the DON was going to complete the treatment and take measurements of the area. The staff acknowledged she should have put an order onto the TAR when she saw there wasn't one present but she didn't. The staff stated the resident should not have gotten the pain medication 3 times in a day when only ordered for twice as needed. On 3/2/26 at 11:06 AM Staff T, RN, stated she recalled entering the order for the dressing change and was then off for the next couple of days. The staff stated when she returned she noted the order was not on the TAR as it had not been populated. Staff T stated she was able to go into the medical orders and populate the order to the TAR.On 3/4/26 at 9:50 AM the DON stated she did not know why the documentation was not completed for Resident #45 on the TAR for wound treatments for the 18th-20th as she had been present for one of the treatments and no entries for the 25th and 26th. The staff stated the resident should not have been provided 3 Oxycodone when the order was written for 2. The DON stated the expectation was to provide and document orders as written.On 3/4/26 at 11:15 AM the Administrator stated that orders should be followed and documentation should be completed without holes reflected in the record. The policy titled Protocol for Medication Administration dated 1/8/26 documented the purpose is to assure all medication is administered within state and licensing guidelines/regulations and in accordance with policy and procedures and physician orders. Review of a policy updated 3/18/25 titled, Protocol for Documentation documented the purpose was to ensure all patients information was being documented. All new orders shall be documented in the nurses notes along with the following information: any clarifications that may need to be made, notification of responsible party, notification of the pharmacy, notification of therapy or other documentation if applicable. Wound care notes should state the treatment provided, the appearance of the wound in detail, and any new concerns noted during treatment.

Based on resident interview, clinical record review, staff interviews, and policy review, the facility failed to complete an accurate comprehensive assessment for 1 of 1 resident (#29). The facility reported a census of 40 residents.Findings include:On 2/23/26 at 11:48 AM, Resident #29 stated she was hard of hearing and has been trying to get hearing aids but her insurance would not cover them.The Baseline Care Plan dated 3/27/25 revealed the resident was hearing impaired.The Care Plan dated 3/31/25 included a hearing deficit focus category and directed staff to validate the resident's message by repeating aloud.The Appointment Note dated 10/21/25 at 2:33 PM revealed the facility was waiting for the resident's Ear, Nose, and Throat (ENT) provider to supply a phone number for the facility to contact the resident's insurance company about hearing aids.Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of heart failure, depression, and bilateral hearing loss. It indicated she required supervision with bathing and shower transfers, dressing, personal hygiene, and ambulating 150 feet and was independent with all other Activities of Daily Living (ADLs) and mobility. It documented she had adequate hearing without hearing aids or other hearing appliances.The Appointment Note dated 12/17/25 at 11:49 AM revealed the facility was waiting for a mobile hearing service response to schedule a hearing test.On 2/24/26 at 2:07 PM, the MDS Coordinator stated she coded the MDS as adequate hearing because the resident did not say she had a hard time hearing her and resident responded as though she was able to hear. She confirmed her assessments are based solely on her interactions with the residents unless there is something in the progress notes. She stated she did not catch the prior notes about the resident's hearing deficit.On 2/24/26 at 2:20 PM, Staff C, Certified Nurse Aide (CNA) stated she has to talk to Resident #29 with an elevated voice because she doesn't think the resident can hear very well.On 2/26/26 at 11:32 AM the DON stated the MDS should be accurate and follow the diagnoses.An undated policy titled Minimum Data Set (MDS) Accuracy and Documentation Integrity indicated every MDS item must accurately reflect the resident's status during the defined look-back period (observation period) ending at 11:59 PM on the Assessment Reference Date (ARD). It also directed staff before transmission, the RN Coordinator will verify that encoded data matches clinical documentation. Any discrepancies must be corrected during the 7-day encoding period.

Based on clinical record review, facility document review, and staff interviews, the facility failed to report suspected abuse between two (2) residents (#2 & #37) to the State Agency after being made aware of the incident. The facility reported a census of 40 residents. Findings include:A grievance form dated 11/08/25 at 10:00 AM revealed Resident #37 informed Staff H, Restorative Aide (RA) that Resident #2 came in Resident #37's room and was bumping into everything. When he tried to stop Resident #2, Resident #2 grabbed Resident #37's shirt so Resident #37 grabbed Resident #2's shirt. Resident #2 let go of Resident #37's shirt and slapped at his hands. When Resident #37 let go of Resident #2's shirt, Resident #2 left the room.A document dated 11/08/25 titled Incident with <Resident #37 name> and <Resident #2 name> revealed the administrator interviewed Resident #37 and documented Resident #37 stated Resident #2 came in in his room and startled him and he spilt his coffee. He stated he tried to stop him by grabbing his merry walker (specialized walker with a seat to prevent falls while walking). He also stated Resident #2 grabbed his shirt and Resident #37 grabbed Resident #2's shirt tail and Resident #2 let go and swatted at Resident #37's hands with no contact.On 11/08/25 AM at 11:45 AM, Staff H entered a Restorative Program Note that documented Resident #37 stopped Staff H in the hallway to report that another resident came into his room bumping into everything. Resident #37 tried to stop him by grabbing his merry walker since there was coffee spilt everywhere he didn't want the other resident to fall. The other resident grabbed this resident by the shirt. This resident reacted by also grabbing the other resident by the shirt. The other resident began slapping at this resident's hands stating he's allowed to be in this room. This resident let go of the other resident and the other resident left the room. This resident also stated how upset he was since he's not able to stand or defend his self that he felt threatened. The nurse <Staff A, Registered Nurse (RN)> was notified by staff immediately.A document titled Self Reports did not include a facility reported incident dated within 48 hours of the aforementioned incident.On 2/25/26 at 5:00 pm, the Administrator stated the aforementioned resident-to-resident interaction was not reported to the state agency because there was no physical contact.On 2/26/26 at 8:29 AM, Staff H confirmed the resident reported the aforementioned events and she notified the Assistant Administrator. She stated she was instructed to complete the grievance form and asked her to provide close supervision for Resident #2 for the remainder of her shift, 2:00 PM.On 2/26/26 at 8:49 AM, Staff J, Certified Medication Aide (CMA) stated she was not present during the incident but was told about it. She also stated she was instructed to keep a closer eye on him when she came to work.On 2/26/26 at 8:55 AM, Staff K, CNA stated staff were instructed to keep eyes on Resident #2 as a collective group more vigilantly.On 2/26/26 at 9:31 AM, Staff I, Certified Nurse Aide (CNA) stated, when she came to work, the nurse told her to keep the two residents apart as best she could during her shift.

Based on clinical record review, observations, resident interview, policy review, and staff interview the facility failed to provide the residents with a homelike environment by serving meals on Styrofoam flatware to residents. The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #24 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment.On 2/23/26 at 11:03 AM Resident #24 stated the staff in the evening serve most of the meals on Styrofoam plates and bowls. Resident #24 explained she does not like being served on Styrofoam plates. Resident #24 stated she did not know why the facility does not use actual plates. On 2/24/26 at 11:32 AM Staff L, [NAME] stated she worked 3-4 days a week serving dinner meals of the day. Staff L stated if the dish machine was broken the cook would use Styrofoam for that meal. Staff L stated the dish machine had not been out of order when she had worked but she had heard the dish machine was down at least one day in the last 3 months. Staff L explained Staff M, PM shift [NAME] worked as the other evening shift cook. Staff L said she never used Styrofoam for meals. Staff L said Resident #24 had complained about cold food and not getting enough food. Staff L explained these concerns were reported to her by Staff N, Certified Dietary Manager (CDM).On 2/25/26 at 12:51 PM Staff E, CNA/CMA/Transport Driver stated she had heard residents complain about meals served on Styrofoam. Staff E stated Staff M was the cook that served meals on Styrofoam. On 2/24/26 at 1:15 PM Staff M stated residents had not voiced any concerns to him about the kitchen. Staff M acknowledged Staff L was the only other cook on pm shift and she had worked at the facility for about 6 months. Staff L stated he thought the dish machine had been down a couple of times in the last 3 months. Staff L explained he got his butt chewed today about serving all the room trays on Styrofoam plates. Staff L stated Staff N told him everything was supposed to be on regular plates and bowls. Staff L explained he served room trays and the assisting dining room with Styrofoam flatware. Staff L said there was no real reason he used Styrofoam for meal service.On 2/25/26 at 1:12 PM Staff N, (CDM) explained there was a sit down with Staff M a little while back about serving with Styrofoam plates and he acknowledged he understood not to use Styrofoam for meal service. Staff N stated she had spoken with Staff M yesterday about use of Styrofoam and he admitted to continued use of Styrofoam. Staff N explained the use of Styrofoam was a dignity issue. Staff N explained her expectation was meals would be served on regular plates and not utilize Styrofoam for resident meal service unless there was a need such the dish machine was not working appropriately or during a quarantine. Review of an undated policy titled, Disposable Dishware Use Policy documented the purpose of the policy was to define appropriate circumstances for the use of paper plates and other disposable dishware in order to maintain resident dignity, infection control standards and regulatory compliance. The facility will use reusable dishware for routine meal service. Disposable dishware may be used only under the conditions outlined below and shall not be used for staff convenience. Disposable dishware may be used for infection control during outbreaks or when directed by the Infection Preventionist and for residents on transmission-based precautions, as clinically indicated. During emergency situations such as during water service interruptions, dishwasher malfunction, or other utility failures and during natural disasters or other events impacting normal kitchen operations. During special events such as outdoor events or large facility-sponsored gatherings where reusable dishware is impractical and to meet individual care plan needs when identified by the interdisciplinary team as necessary for resident safety or behavioral reasons and documented in the care plan.Review of policy with effective date of 5/19/16 titled, Meal Delivery / Room Trays documented the purpose was to ensure all residents receive meals that are safe, palatable, and served in a dignified manner by maintaining CMS-compliant food temperatures during tray service, serving meals on plates rather than disposable containers when appropriate and promoting resident dignity and quality of life.

Based on clinical record review, interviews and policy review the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN), Form Center for Medicare Services (CMS)-10055 or Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123-NOMNC, for 2/3 residents reviewed (Resident #26, #11). The facility failed to provide the residents notification of the changes as soon as the change in coverage was made available. The facility reported a census of 40. Findings include:1. The Discharge Notification from therapy dated 8/31/25 for Resident #26 indicated the last treatment date for therapy would be on 9/4/25 and the discharge date would be 9/5/25. Resident #26 signed a NOMNC, Form CMA 10123-NOMNC approved 12/31/11, on 9/2/25 indicating coverage of therapy services would end on 9/5/25. Resident #26 signed the SNF-ABN form on 9/5/25 indicating the resident would begin occurring costs for therapy on 9/6/25 if electing to continue therapy services. The facility failed to provide the resident the document the charges that would occur prior to the last date of covered services. The facility failed to provide consistent dates on the last date of therapy services and discharge based on the notification from the therapy department. 2. The Discharge Notification from therapy dated 1/13/26 for Resident #11 indicated the last treatment date for therapy would be on 1/20/26 and the discharge date would be 1/20/26 as all goals were met and the resident was discharging home at prior level of function.Resident #11 signed a NOMNC, Form CMA 10123-NOMNC approved 12/31/11, on 1/20/26. The facility failed to provide the resident with the documentation of notification of ending of services prior to the discharge date . On 3/3/26 at 12:25 PM the Assistant Administrator/Billing Manager stated he had been completing audits since the last annual survey to improve the process, and had begun to decrease the audits. On 3/3/26 at 12:45 PM the Administrator stated audits were being completed in several areas with hopes to improve the processes in the facility.On 3/3/26 at 4:00 PM the Assistant Administrator/Billing Manager acknowledged documents regarding NOMNC and SNFABN needed to be provided as soon as notification for discontinuation of therapy services was made. The facility's ABN Policy, revised 3/25/25, revealed the facility must issue a SNFABN before providing services may not be covered ensuring the resident understands their financial liability. The document further included that the ABN must be given before reducing services that the facility believes Medicare will not pay for and allow the beneficiary time to sign the form and ask questions.

Based on observation, clinical record review, policy review, resident interviews and staff interviews the facility failed to provide dignity and respect by video recording a resident without notifying the resident or asking permission and by failing to remove food from the resident's face and cover the resident's right shoulder in a public area to 2 of 40 residents reviewed (Resident #36 and #24). The facility reported a census of 40 residents.Findings include:1.On 2/23/26 at 12:27 PM, Staff F, Certified Nurse Aide (CNA) transported Resident #36 to her room after eating lunch and positioned the resident beside her bed facing the room door. Resident #36 had mashed potatoes below her left lower lip. Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of a stroke with reduced right side muscle strength, non-Alzheimer's dementia, and seizure disorder. It revealed she required supervision with eating, maximal assistance with upper body dressing and rolling left-to-right in bed, and was dependent with all other Activities of Daily Living (ADLs) and chair-to-bed and shower transfers. The Care Plan revised 12/11/25 revealed the resident required assistance with eating on days she was more tired. It also revealed the resident required staff to perform oral hygiene. On 2/23/26 at 1:06 PM, observed the resident sitting in her wheelchair, in her room, facing the door with mashed potatoes still on her face. On 2/24/26 at 8:27 AM, observed Resident #36 sitting in her wheelchair at the dining conference room table with 2 other residents while Staff F assisted her with eating. Resident #36's gown was positioned in a way which allowed full exposure of her right shoulder, collar-bone, and the nape of her neck. At 8:29 am, Staff F transported Resident #36 back to her room, faced the resident toward the opened door, pulled her gown over her right shoulder, and left the room. The resident's gown slipped back down and re-exposed her right shoulder, collar-bone, and the nape of her neck. On 2/24/26 at 9:16 AM, Staff F transported Resident #36 to the lobby in her wheelchair to participate in a group activity. Her gown was positioned below her right shoulder exposing her shoulder, collar-bone, and the nape of her neck with other residents in the lobby. On 2/25/26 at 1:51 PM, Staff G, Certified Medication Aide (CMA) stated it is a dignity concern to leave food on a resident's face because it could easily be removed when they are put in their room. She also stated a female's shoulder, collar-bone, and neck exposed in a public setting is a dignity concern. On 2/25/26 at 1:54 PM, Staff C, CNA, stated food left on a resident's face is a dignity concern. She also stated a female's shoulder, collar-bone, and neck exposed in a public place is also a dignity concern. On 2/26/26 at 11:30 AM, the Director of Nursing (DON) stated staff should have assisted the resident to clean her face and help her readjust her clothing to cover her shoulder. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #24 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. On 2/23/26 at 11:03 AM Resident #24 explained on 2/16/26 the Director of Nursing (DON) and Staff Q, MDS Coordinator came into her room. Resident #24 stated the DON and Staff Q got into an argument with her about and continued to accuse her of having cameras in the room and recording the staff. Resident #24 stated the facility staff accused her of having recording devices but they did not tell her that she could not have them. Resident #24 stated the Administrator came into her room and asked what time the incident occurred. Resident #24 stated she replied to the Administrator the incident happened around 1:20 PM and she told him he could just check the camera. Resident #24 stated the Administrator told her that he knew he had already reviewed the facility's video footage. Resident #24 said the police officer stated the DON had recorded their interaction. Resident #24 said if the DON had recorded her it was very upsetting to her. Resident #24 stated recording her without her knowledge was very disrespectful and the DON would not have been treating her with dignity. On 2/25/26 at 3:44 PM Staff R, Certified Nurse Assistant (CNA) stated on 2/16/26 Resident #24 had requested to speak with Staff Q and the DON. On 2/25/26 at 4:35 PM Staff Q, MDS Coordinator stated Staff R received a note from Resident #24 requesting for Staff Q to come talk to her. Staff Q explained staff had to enter Resident #24's room in pairs. Staff Q explained she entered the room with the Director of Nursing (DON) around 1:30 PM on 2/16/26. Staff Q stated the DON recorded the encounter with Resident #24. Staff Q stated the DON revealed to Staff Q as they were walking in the door. Staff Q stated she thought the DON should have told Resident #24 or asked Resident #24 if they could record the incident. On 2/25/26 at 10:27 AM the DON stated Resident #24 had sent a handwritten note to talk to Staff Q. The DON explained that Staff Q asked her to be the second staff to enter the room. The DON acknowledged she put her phone on record, placed it in her pocket and recorded the entire interaction. The DON stated she does not record residents frequently. The DON stated she did not ask Resident #24 if she could record their interaction. The DON explained there was not a policy at the facility for staff recording residents. The DON stated she did see an issue with dignity when she recorded Resident #24 without her knowledge. On 2/26/26 at 4:01 PM the DON sent the video recording from her personal phone of the incident between her, Staff Q and Resident #24 to the survey team. Review of a policy revised 11/16 titled, Abuse Prevention, Identification, Investigation, and Reporting Policy documented all residents have the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Review of a policy with an effective date of 11/26/13 titled, HIPAA / Privacy Safeguarding and Storing Protected Health Information documented the purpose of the policy was to ensure, to the extent possible, that Protected Health Information (PHI) is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulation governing confidentiality and privacy of health information. The procedure was designed to prevent improper uses and disclosure of PHI that is or would be, contained in a resident's medical record.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to protect residents from accidents and injuries for 2 of 2 residents (Resident #33, and #193) reviewed for falls. Resident #33 fell on [DATE] and sustained a right greater tuberosity of humerus fracture (right upper arm) when his alarm failed to go off alerting staff that he had gotten up without staff assistance. Resident #193 fell on [DATE] when he got up out of bed and walked across his room without staff assistance, fell , and sustained a left intertrochanteric fracture (left hip fracture). The facility reported a census of 43. Findings include: 1. The Minimum Data Set (MDS) for Resident #33 dated 7/29/24 identified a Brief Interview of Mental Status (BIMS) score of 7/15 indicating severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's Dementia and depression. The document revealed the resident was substantial assistance for toileting hygiene and lower body dressing. The resident required partial to moderate assistance for sit to stands, chair/bed to chair transfers, toilet transfers, and walking distances up to 50 feet. The document revealed the use of bed and chair alarms used daily. The MDS revealed the resident had 1 fall without injury, and no falls with injury or major injury. Resident #33's Care Plan revised 2/3/25 revealed focus areas for risk for falls and actual falls with injury. The document revealed the interventions at the time of the fall on 9/18/24 included pressure pad alarm at all times (12/13/23), call light within reach at all times and prompt response (11/2/23), ghost alarm to be added to the recliner and alarm to stay in the dining chair (6/10/24), and nurses to check alarms every shift and staff re-education on alarm placement (9/9/24). The Care Plan identified an ADL self-care performance focus with interventions at the time of the fall with transfers requiring the assistance of 2 staff and a walker (11/1/23), toileting with the assistance of staff and staff to perform peri care as needed (11/1/23), and dressing with minimal assistance for the upper body and staff to assist with the lower body (11/1/23). The Morse Fall Scale assessment dated [DATE] revealed a score of 80. A score above 45 indicated a high risk for falls. The Electronic Medical Record (EMR) revealed there was no documentation of the alarms being checked every shift by the nurses to ensure they were functioning from 9/9/24 to 2/5/25. The Risk assessment dated [DATE] revealed the resident sustained an unwitnessed fall in his bedroom. The document revealed the chair alarm did not go off. Intervention from the fall was nurses to check the alarm system and placement every shift, and staff re-education. The Emergency Department (ED) Summary dated 9/18/24 revealed the resident seen for an unwitnessed fall with chief complaint of right hip pain, right shoulder pain, resident holding his head and in a c-collar, and has a skin tear to his left wrist. The discharge diagnosis from the ED was charted as greater tuberosity of humerus fracture. The Orthopedic Note dated 9/20/24 revealed the resident is no weight bearing to his right upper extremity, may remove the sling for elbow, wrist and hand range of motion and hygiene. Observations of Resident #33 revealed the following: -On 2/4/25 at 10:00 AM the resident lying in bed with an alarm cord visible, and 1 alarm on the dining chair. No alarm on the recliner. -On 2/4/25 at 1:56 PM an alarm present on the dining chair, no alarm on the recliner. -On 2/5/25 at 11:15 AM a ghost alarm on the dining chair and no alarm on the recliner. -On 2/6/25 at 10:45 AM a ghost alarm on the dining chair and no alarm on the recliner. -On 2/6/25 at 2:35 PM with the Director of Nursing (DON) a ghost alarm on the dining chair and no alarm on the recliner. On 2/4/25 at 3:00 PM the DON stated the resident's alarm did not go off on 9/18/24. The DON stated the resident had both audible and ghost alarms. The staff stated the resident had a ghost alarm in his recliner, a pressure pad alarm in his dining chair, and a pressure pad alarm in his bed. The DON stated the alarms were checked twice weekly by the restorative nurse and maintenance. The staff stated it was everyone's responsibility to make sure the alarms were working, and to notify nursing if they were not. The DON stated the ghost alarm is attached to the call light system, and if the system were to go down the resident would be switched to a pressure pad alarm. On 2/5/25 at 1:25 PM the DON stated the Care Plan did not have interventions related to the failure of an alarm as it was part of the policy and everyone knew what to do. The DON stated there was never an instance on overnights or weekends when there was not at least 1 regular staff on duty who would know what to do. On 2/5/25 at 3:00 PM the DON acknowledged she was not aware of an intervention on the Care Plan related to nursing completing alarm checks every shift and did not know about the documentation. On 2/6/25 at 10:53 AM the MDS Coordinator acknowledged that documentation had not been completed for the alarm checks, and the checks were not completed. The staff stated there wasn't a link developed to place it in the EMR for documentation. The MDS Coordinator concurred that according to an intervention on the Care Plan the resident should have 2 separate alarms for his chairs - 1 ghost alarm for the recliner and an alarm for the dining chair. On 2/6/25 at 2:32 PM the DON reviewed the Care Plan and indicated there should be a ghost alarm on the recliner and an alarm on the dining room chair. The DON observed the Resident #33's room and chair alarms, and concurred there were not 2 separate alarms as per the Care Plan intervention; there was a ghost alarm on the dining chair and no alarm present on the recliner. 2. The MDS for Resident #193 dated 1/24/25 identified a BIMS score of 8/15 indicating moderate cognitive impairment. The document revealed diagnoses that included: urinary tract infection, white matter disease, unspecified, and mild cognitive impairment of uncertain or unknown etiology. It further disclosed the resident required partial/moderate assistance for dressing, and supervision or touching assistance for toileting hygiene, toilet transfers, and walking distances up to 150 feet. The document indicated the resident utilized a walker during the previous 7 days. The MDS also documented the resident had fallen in the last month. The Baseline Care Plan dated 1/22/25 in the Assessment tab of the EMR was not completed and did not contain interventions or assistance levels related to self care, mobility or mobility devices. The Baseline Care Plan also lacked any safety risks or interventions related to his history of falls. The Morse Fall Scale assessment dated [DATE] revealed a score of 80. Any score above 45 indicated a high risk for falls. The Care Plan dated 2/5/25 revealed a focus related to ADL self-care performance deficit was initiated on 2/2/25 and had a revision of 2/5/25. The interventions did not provide instructions for direct care staff for assistance for toileting, transfers, or use of side rails until 2/5/25. The document contained a focus area related to impaired cognitive function or impaired thought process initiated 1/23/25 with interventions of supervision with all decision making, and task segmentation to support short term memory deficits. The Care Plan revealed a moderate risk for falls focus with interventions including call light within reach at all times with prompt response, and use of appropriate footwear initiated on 1/23/25. The Physical Therapy (PT) Evaluation dated 1/24/25 identified decreased safety with ambulation demonstrated by forgetting to use a walker and bringing his catheter, increasing his risk for falls. The PT Notes dated 1/24/25 to 2/4/25 revealed focus of therapy included strengthening, dynamic balance, endurance, safety education and ambulation. The entry on 2/3/25 indicated the resident required the use of a front wheeled walker and close standby assistance (SBA), the resident was within arm's reach. The 2/3/25 entry further revealed the resident transferred with contact guard assistance (CGA), hands on assistance, with cues required for use of the front wheeled walker (FWW) and safety. Occupational Therapy (OT) Evaluation dated 1/23/25 identified the resident required CGA for toileting, hygiene/grooming, and functional mobility (ambulation) during ADLs. It further revealed decreased standing dynamic balance and safety. OT Notes dated 1/23/25 to 2/4/25 revealed focus of therapy included safety training during transitional movements, dynamic reaching activities in standing position, and ADLs. The note dated 1/31/25 indicated Resident #193 required CGA assistance during dynamic standing activities. A PT Note provided by the facility dated 1/29/25 revealed during the Medicare Meeting the Clinical Team discussed a trial of removing the bed and chair alarms for the resident as he was demonstrating increased agitation and decreased non-compliance with all transfers and mobility. It revealed the staff was in agreement. A recommendation was made for Speech Therapy order to address memory and cognition. Review of the EMR revealed an order dated 1/29/25 for Speech Therapy to evaluate and treat. The record lacked any documentation of Speech Therapy starting and lacked any other interventions being put into place when the alarms were removed. The EMR Progress Notes dated 1/22/25 to 2/5/25 revealed the resident ambulated with a walker and SBA. The Risk assessment dated [DATE] at 11:00 PM revealed Resident #193 sustained an unwitnessed fall in the resident's bedroom. The document revealed the resident did have gripper socks on his feet and his walker nearby. It indicated the resident had stated he was using his walker to get up and turn a light on over his sink. The document identified poor lighting with the resident exhibiting predisposing confusion and gait imbalance. The EMR Point of Care documented care provided by staff on 2/4/25 at 8:37 PM for limited assistance of transfers. The record lacked any documentation of care provided after 8:37 PM. On 2/5/25 at 11:25 AM the Administrator stated Resident #193 sustained a nonwitnessed fall the previous night and sustained a hip fracture. The Administrator stated therapy had wanted the resident independent in his room. The Progress Notes for Resident #193 documented the following: On 2/5/25 at 3:40 AM this nurse notified of resident unwitnessed fall with hip pain on 2/4/25 at 11:14 AM. On call doctor notified and obtained order to send the resident to the hospital. On 2/5/25 at 5:52 AM notified by hospital that the resident was admitted with left hip fracture and ortho was to evaluate. On 2/6/25 at 8:13 AM Staff Y, Certified Occupational Therapy Assistant (COTA), revealed he was a contract therapist for the facility. The staff stated the focus of OT included safety, balance, weight shifting, and functional mobility. The staff stated on 2/4/25 during treatment the resident required CGA for dynamic balance tasks with reaching outside away from the body. On 2/6/25 at 9:46 AM Staff Z, Certified Nurse Assistant (CNA), stated Resident #193 required SBA for ambulation. The staff stated the resident would stand up and move around his room whether he had an alarm or not. On 2/6/25 at 9:51 AM Staff N, CNA/Restorative Aide (RA), stated the resident required SBA for ambulation to the dining room using a walker, the distance is approximately 350 feet. The staff stated the resident would stand with or without the alarm present. Staff N stated that upon standing the resident would take off and walk using the walker. On 2/6/25 at 2:41 PM the DON stated the Baseline Care Plan was utilized until the actual Care Plan was developed. The DON concurred the Care Plan was opened on 1/23/25, and neither the Baseline Care Plan nor the Care Plan provided interventions for staff regarding the resident's transfer abilities until 2/5/25. The DON further concurred the assistance level placed on the Care Plan on 2/5/25 indicated the resident was independent by therapy recommendation. On 2/6/25 at 3:15 PM Staff S, Occupational Therapist Registered (OTR), revealed was a contract therapist for the facility. Staff S stated during his treatment with the resident on 1/28/25 the resident had staggering balance in standing when challenged. The staff stated the resident required CGA>SBA for standing and mobility using the FWW. On 2/6/25 at 4:07 PM Staff AA, Physical Therapist Assistant (PTA)/Program Coordinator (PC), revealed she was a contract therapist for the facility. The staff stated the resident was admitted to the facility for skilled therapy services. The staff stated treatment emphasized strengthening, leg exercises, walking, safety, balance, endurance. Staff AA stated the resident was discussed at the weekly Medicare Meeting on 1/29/25. The staff stated the Medicare Team, which is the clinical team, meets weekly to discuss the residents. The staff stated during the Medicare Meeting on 1/29/25 the clinical team decided to discontinue the bed and chair alarms as they were not effective in preventing the resident from standing and moving around in the room. Additionally Staff AA stated she had observed the resident exhibit signs of agitation with the alarms during therapy by punching the bed when the alarm sounded. Staff AA stated CNAs were part of the team decision to trial no alarms in the room. The staff stated the decision by the team was a 48 hour trial beginning on Wednesday the 29th, and there were no concerns raised during the 48 hour trial. The staff stated the therapy department did not recommend the resident be independent in his room, but discontinue the alarm. On 2/10/25 at 10:10 AM the MDS Coordinator stated the Baseline Care Plan should reflect the resident's ability to transfer within the ADLs portion of the Care Plan. The staff stated the Care Plan should provide information for staff on the resident's assistance needs. The MDS Coordinator stated during the Medicare Meeting it was discussed discontinuing the use of the alarms due to therapy stating it caused increased agitation, and the alarms did not stop the resident from standing or moving around in his room. The MDS Coordinator stated the resident was considered contact guard at a minimum for transfers and ambulation. The staff stated the resident had not been made independent for mobility and transfers. On 2/10/25 at 10:12 AM the Certified Dietary Manager (CDM) stated the alarms for Resident #193 had been discontinued but the resident continued to require assistance for transfers and ambulation. The facility's policy, Resident Information to be Used for Care Plan, dated 1/24/23 revealed sources for generating the Care Plan. The document did not contain information regarding the updating the Care Plan, development of the Baseline Care Plan within 48 hours, or use of the MDS/Resident Assessment Instrument.

Based on record review, staff interviews, and facility policy review, the facility failed to provided adequate nursing supervision and assistance devices to prevent accidents for 1 of 1 residents (Resident #141) reviewed for elopement (when a resident leaves the facility without staff knowledge or permission). On the afternoon of 7/11/22, a facility employee heard knocking and found Resident #141 outside asking to be let back into the facility. The resident had exhibited increased confusion, voiced her intention to leave the facility, and demonstrated exit-seeking behavior, but staff failed to increase supervision or complete an elopement risk assessment in an attempt to keep her from leaving the facility unattended. This constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 06/06/22 revealed Resident #141 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident demonstrated moderately impaired cognitive abilities. The MDS identified the resident had diagnoses of heart failure (heart does not pump blood effectively), hypertension (high blood pressure), diabetes mellitus, and chronic obstructive pulmonary disease (COPD, air is obstructed from the lungs). The door alarms systems in the facility are as follows: Front Door: The front door immediately alarms overhead when opened, and staff turn of the alarm at the nurse's station. The alarm immediately resets upon closing of the door. The alarm takes approximately 35-40 seconds to alarm once opened. The Wanderguard alarm sounds overhead when the front door threshold is breached. The Wanderguard alarm is turned off at the nurse's station. Cognitively impaired residents at risk for elopement (determined by a wandering or elopement assessment, see policy) must be wearing a wanderguard or have it on their person for the wanderguard system to activate once they reach the door to leave the facility. North and South Door: Both doors contain 2 alarms that alarm immediately upon opening. One alarm sounds overhead and is turned off at the nurse's station. The other alarm is located on the door and sounds at the door. The alarm is turned off by a key at the door. There is also a stop sign banner across each door. Southwest and Courtyard Door: There are 2 alarms for both doors, and both alarm immediately when opened. One alarm sounds overhead and is shut off at the nurse's station. The other alarm sounds at the other nurse's station near the doors and is shut off at that location. There is a stop sign banner across both doors. Service Door: This door requires a key code to open. The Progress Notes from 07/01/22 to 07/10/22 contained documentation that showed the resident displayed confusion and attempted to exit the facility 8 times. Review of the clinical record revealed it lacked a wandering or elopement assessment. The record also failed to contain documentation to show the facility increased nursing supervision or implemented other safety measures after Resident #141's episodes of increased confusion, multiple attempts to leave, and escalated exit -seeking behavior in attempt to keep her from eloping from the facility. A Progress Note on 07/11/22 at 2:34 PM, revealed Resident #141 propelled herself up and down the halls and wandered in and out of other residents' rooms while disrupting the other residents. She also told staff she intended to leave. She told the staff person that documented the progress note (the writer) to get out of the way, attempted to exit the facility via the south door, turned around, then pointed at the writer, and stated, You're fired. Resident #141 also pointed to a resident in another room and said, So are you. Nurse aware of the resident's behavior. A Progress Note dated 7/11/22 at 3:20 PM, documented a staff person heard a knock while walking to the vending machine and saw Resident #141 at the window outside in her wheelchair, looking into the building. When the resident saw the employee, she yelled, Hey, let me back in. When the writer and the Administrator exited the building to escort her back into the facility, they asked Resident #141 how she got outside and what was she doing out there. She replied well, I wanted to go outside, so I went out the front door. Staff assisted the resident assisted into the facility - assessment and skin check revealed no injuries. The resident denied falling, injuries, or pain. Staff then placed a wanderguard bracelet on her wheelchair because she refused to let staff apply a bracelet to her wrist. Resident #141 warned, if you put that on me I will just cut it off. Staff called the resident's medical doctor to report her increased agitation, confusion, and behaviors: she threatened to fire multiple staff and yelled, what the hell are you doing here? You've been here all day too? She also yelled, get out of here! At an x-ray technician in the facility to see another resident. Resident is not easily re-directed and continues to be confused. Staff waiting for response from medical doctor. Hazards include: a. The State Climatologist reported at the time of the elopement revealed the temperature on the afternoon of 7/11/22 measured 81 degrees Fahrenheit (F). relative humidity: 74%, heat index temperature of 85 F, with winds out of the north at 10 mph and no cloud cover or precipitation detected b. Hwy 275 runs parallel to the facility with a speed limit of 45 MPH. An undated report provided and completed by the facility, tiled The (Resident #141) Self Report Elopement identified staff took the following actions after they found the resident unattended outside on 7/11/22: 1. Facility management investigated and reviewed camera footage, which showed that a visitor helped Resident #141 through the glass door. She stood upright by the punch pad for a few moments, then pushed on the door right after the hospice nurse exited the building. 2. The resident remained outdoors for a total of 13-15 minutes. 3. To avoid reoccurrence, the facility staff applied a wanderguard, reduced the time the door remained open during green mode (related to the punch pad) to 25-30 seconds, and also removed the 8.5 in x 11 in placard that contained the door passcode to the nurse's station. In an interview on 12/06/22 at 01:36 PM, Staff H, Administrative Assistant, reported that she found the resident knocking on the window asking for assistance to enter the facility. The window was low enough that the resident could be seen in her wheelchair. Staff H was not certain if the resident had her oxygen with her or not. In an interview on 12/06/22 at 03:47 PM, Staff D, Certified Nursing Assistant (CNA) and Restorative Aide, reported that the resident was very confused with multiple attempts to exit the facility around that time. One day the resident would exhibit a calmer demeanor and then the next, she had extreme changes in behavior in say that she needed to get on a train. In an interview on 12/06/22 at 03:48 PM, Staff I, Registered Nurse (RN), reported she remembered the resident's elopement and that it was uncertain exactly how the resident exited the building, but no harm came to the resident while outside. The undated Elopement Policy directed staff to complete an elopement risk assessment. If resident scores 7 or higher, consider the resident at risk for elopement until further information can be obtained. The Elopement Protocol with a revision date of 02/17/15 directed upon admission to the facility, any resident suspected of being at risk for elopement shall have an evaluation completed. Staff will re-evaluate on a regular basis to correspond with the quarterly MDS schedule or with any change in condition. Any resident deemed at risk for elopement shall have a wander guard placed. Additional interventions to implement through assessment include: wander guard bracelet, picture on Medication Administration Record (MAR), and location away from exit doors if possible. In an interview on 12/07/22 at 06:13 PM, the Administrator verified the resident's record failed to contain an elopement or wandering risk assessment. The facility was notified of the Immediate Jeopardy (IJ) situation on 12/5/22. The IJ was removed on 12/7/22 when the facility implemented the following actions: 1, Completed Elopement Assessments for 8 residents to increase supervision for these affected residents in accordance with their policy. 2. Re-educated all staff regarding the missing resident policy and elopement policy, and stressed the importance of the elopement risk assessments to all nurses. 3. They posted a sign to alert visitors and hospice staff to be aware of residents near the door and alert staff if they suspect a resident is trying to leave. The IJ was lowered from a scope and severity of K to an E.

Based on record review and staff and physician interviews, the facility failed to adequately assess the respiratory status of Resident #5 and notify the physician per facility standards and failed to assess and follow the physician's orders [REDACTED]. The sample consisted of 8 current and 4 discharged residents and the facility reported a census of 57 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 10/13/13, identified pertinent [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) revealed a score of 3 which represented the resident to be severely impaired cognitively. Review of the Care Plan for Resident #5 included an admission date of [DATE] and a most recent date of 10/15/13 revealed no problem identifying the resident had difficulty with respiratory systems or the need for oxygen. A second typed Care Plan included an admission date of [DATE] and revealed no problems of respiratory status or the need for oxygen. Additionally, 10/27/13 is the date of the resident's death. Review of the facsimile dated 9/20/13 for Resident #5 revealed an order for [REDACTED]. Review of the Physician order [REDACTED]. Review of the Departmental Notes for Resident #5, 9/20/13 through 10/26/13 revealed the resident continued to refuse oxygen. The oxygen saturations revealed are as listed: On 9/20/13- 77% oxygen at 4 liters, then sent to the emergency room , orders given for oxygen continuously (resident returned to facility at 6:14 p.m.), On 9/27/13-resident refusing to wear oxygen. The facility did not notify the doctor or family On 9/28/13-77% refusing to wear oxygen. The facility did not notify the doctor or family, resident continued to refuse to wear oxygen through 10/2, neither doctor or family were notified On 10/2/13-oxygen saturation 89-91% on room air, refusing oxygen, On 10/3/13- resident refused to wear oxygen this shift. The facility did not inform the physician or family. On 10/5/13- 85% oxygen saturation, refused oxygen, failed to notify doctor or family, On 10/6/13-78% oxygen saturation, refused oxygen, facility failed to notify doctor or family, On 10/9/13-86% oxygen saturation, refused oxygen, facility failed to notify doctor or family, On 10/10/13-87% oxygen saturation, refused oxygen, facility failed to notify doctor or family, On 10/11/13-81% oxygen saturation, refused oxygen, facility failed to notify doctor or family, On 10/13/13-76% oxygen saturation, refused oxygen, facility failed to notify doctor or family, On 10/14/13-86% and 88% oxygen saturation, refused oxygen, facility failed to notify doctor or family, On 10/18/13-82% oxygen saturation, refused oxygen, failed to notify doctor or family, On 10/19/13-87% oxygen saturation, refused oxygen, facility failed to notify doctor or family, On 10/20/13-86% & 89% oxygen saturation, refused oxygen, failed to notify doctor or family, On 10/26/13 at 7:25 AM, the resident had a medium sized yellow emesis, temperature at 99.2 (normal 98.6), pulse 108 (normal 60-100), respirations 20 (normal 16-20), blood pressure 110/62, oxygen saturation at 82% on room air, refused oxygen and head of bed elevated. At 9:38 AM, the resident had a temperature of 102.1, pulse 64, respiratory rate at 22 and blood pressure at 140/76. The resident ' s oxygen saturation at 71% on room air and using accessory muscles to breathe, oxygen placed. At 9:40 AM, Tylenol given. The physician was notified and staff received orders to administer [MEDICATION NAME] treatment, increase the oxygen, send to ER if oxygen saturations remain low, otherwise send the resident to the clinic if oxygen saturation increases, oxygen increased to 5 liters, at 10:50 AM, family notified and the resident gave approval to send to ER. The ambulance transported the resident to the ER. At 1:30 p.m., the nurse contacted the hospital to check the resident ' s status. The ER nurse stated the resident was admitted with [DIAGNOSES REDACTED]. The hospital ER report reflected the resident presented with difficulty breathing, cough and wheezing. The laboratory tests revealed the resident had abnormal results. The white count registered at 14.1 (elevated), red blood count 3.23 (low), hemoglobin 11.3 (low), po2 71 (low), oxygen saturation read 93 (low). The chest x-ray report identified left lower lobe consolidation. The resident ' s condition was identified as guarded due to dyspnea (difficulty breathing), pneumonia and [MEDICAL CONDITION]. On 10/27/13 at 4:30 AM, the resident's family member telephoned the facility and informed the facility the resident had passed away. Review of the Discharge Summary dated 10/27/13 for Resident #5 revealed the admission [DIAGNOSES REDACTED]. 1. Pneumonia 2. [MEDICAL CONDITION] with rapid ventricular response 3. [MEDICAL CONDITION] with [MEDICAL CONDITIONS] and fluid overload 4. [MEDICAL CONDITION] 5. [MEDICAL CONDITION] 6. Dementia 7. Do Not Resuscitate. During an interview on 12/19/13 at 9:15 AM, the Resident's Primary Care Physician stated from looking through his electronic record, he could not find any notation that he was notified regarding the resident refusing oxygen. He stated the resident would have been a candidate for Hospice and the resident was not on Hospice. He stated he would have expected to be informed of this refusal and the oxygen saturations that ran below 90. The physician stated this did lead to hospitalization . After reviewing all of the oxygen saturations with the physician, he did not state this caused the resident's death but it led to his/her transfer to the hospital. During an interview on 12/18/13 at 1:15 PM, Staff H, LPN (licensed practical nurse) stated whenever a resident is sick and having symptoms she is expected to notify the physician immediately, by phone first since symptomatic. She stated whenever there are changes with a resident, that involves the care plan to be reviewed she is to let the MDS person know. She stated as far as she knew, the resident did not receive Hospice services or comfort cares and if h/she had been having symptoms, then yes the physician should be called right away. She further stated as far as she knew, she thought the doctor knew the resident's oxygen saturations were running low and the resident refused to use it (oxygen) all the time. During an interview on 12/18/13 at 1:42 PM, Staff I, LPN stated if she has an emergency with a resident then she will always call the physician, otherwise she will send a fax. It also depended, for example, if the resident had signs of a cold or something like that. She stated with any change with a resident they are to notify the physician. She then stated they can add interventions to the resident care plan like if they fall then they have to try new interventions and they can also let the care plan team know. She stated she was not aware of the resident's doctor not being aware of the resident's oxygen saturations running low. She stated, no she never told the doctor either, and yes she would have. She stated she would have told the doctor that the resident had been refusing oxygen too. During an interview on 1/14/14 at 8:53 AM, the MDS Coordinator stated she completes the section O of the MDS from visiting with their own therapists. She stated she has never gone through the information obtained from the hospital when completing her sections and further stated no she does not refer to the History and Physical much either. 2. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 revealed pertinent [DIAGNOSES REDACTED]. The same assessment further revealed one fall since admission with no injury. The resident required extensive assistance of 2 for bed mobility, transfers, assistance to the toilet and the extensive assistance of 1 for dressing and personal hygiene activities. Section O of the assessment documented the resident received no oxygen. Review of the Face Sheet dated 11/13/13 revealed additional [DIAGNOSES REDACTED]. Review of the care plan dated 11/15/13 for Resident #11 revealed no identified problem or interventions for the cardiac/respiratory problems in his/her immediate history and no approaches for the administration of oxygen when discharged from the hospital into the facility. Review of the hospital Clinical Discharge Instructions dated 11/7/13 revealed discharge [DIAGNOSES REDACTED]. Review of the History and Physical dated 10/30/13 revealed the following impression and plan: #1 [MEDICAL CONDITION] secondary to acute left heart systolic failure-bilateral pleural effusion #2 Urinary tract infection secondary to chronic indwelling Foley catheter #3 Hypertension #4 Dementia #5 [MEDICAL CONDITION] Review of the Departmental Notes revealed the oxygen saturations completed routinely each shift from 11/8/13 through 12/13/13 with documentation of the resident on room air and without oxygen. On 12/13/13 at 3:10 p.m., staff documented the resident became red in the face and with blue lips after breakfast. The resident became unresponsive and staff measured an oxygen saturation of 77% on room air. Staff placed the resident on 2 liters of oxygen and the resident's oxygen saturation rose to 96% and s/he began to respond again. Review of the only oxygen order provided by the facility revealed a date of 12/13/13 for oxygen as needed (PRN) to keep saturations above 90 % and to obtain a chest X-ray. Review of the radiology report dated 12/13/13 of final impression to be at least a small left pleural effusion (fluid build-up in the lung and the chest cavity) with left basilar compressive atelectasis (collapsed lung) versus consolidation. Review of the Departmental Notes for Resident #11 dated 12/14/13 at 6:43 AM revealed the oxygen saturation at 90 % and the resident on room air. According to the documentation the facility failed to follow the order written on 12/12/12 for oxygen PRN to keep oxygen saturation above 90 %.

Relates to # -I: Based on record review and staff interviews, the facility staff failed to adequately supervise Resident #1 to ensure against hazards from elements in the environment and failed to transfer the resident with proper safe technique for 1 of 9 residents reviewed. The facility identified a census of 54 residents. Findings include: 1. Resident #1 had an annual MDS (Minimum Data Set) assessment with a reference date of 7/08/12 which identified [DIAGNOSES REDACTED]. The assessment reflected Resident #1 depended on 2 people for physical transfer assistance, bed mobility and the resident required a wheelchair. The resident had not experienced a fall since admission to the facility. The care plan dated 7/12/12 directed the staff to use 2 person assistance with transfers when using an EZ stand lift. The resident also used a wheelchair for long distances. A sign located in the resident ' s room (placed prior to the fall) directed staff to use 2 people when using the E-Z stand for transfers with the resident. An in-service meeting held on 2/3/2012 directed staff to know the resident ' s method of transfer and follow the signs posted in the rooms above the beds. The Incident/Accident Report dated 7/13/12 at 9:30 p.m. revealed the resident slid out of the lift sling while being transferred to her/his bed. The resident expressed pain upon movement. The rescue unit arrived at the facility on 7/13/12 at 10:10 p.m. and transferred the resident to the hospital. The Nurse ' s Notes dated 7/13/2012 at 11:45 p.m. indicated the nurse informed the physician that the resident slid out of the lift sling and was lowered to the floor. The ambulance transferred the resident to the hospital at 10:45 p.m. for evaluation and treatment. The hospital transfer form indicated Resident #1 returned to the facility on [DATE]. The form indicated the resident had a fractured left femur (thigh bone) which was repaired. The transfer form indicated the resident had an incision on the left hip. The former Staff K, Certified Nursing Assistant (C.N.A), documented on 8/7/12 at 2:55 p.m. that he proceeded to put the resident into bed. Staff K wrote that he hooked the resident up in the E-Z stand harness and waist belt and thought he had the resident ' s legs locked in the stand support. Staff K documented he lifted the resident to a standing position and then heard a click. Staff K stated he noticed the resident ' s legs had come loose from the lift so he tried to put the resident ' s legs back into the support. Staff K documented he could not get the legs supported so he called for help on the Walkie Talkie device but obtained no response so he opened the door of the resident's room and saw Staff J C.N.A., going outside. Staff K yelled for help and Staff J entered the room and attempted to help support Resident#1. Staff J left the room to obtain additional help, with Staff K with the resident. No assistance arrived to the room so Staff K looked out the room door and yelled for help. A temporary nurse came to help him to finish lowering the resident to the floor. Staff K continued to express he knew he should have had assistance but he had been told a month or so before by the MDS Coordinator to " do what it took to get the resident to bed " . Staff K documented he could use the harness by himself because of his strength but she (MDS coordinator) doubted the girls could. On 8/7/12 at 2:20 p.m. Staff J C.N.A. was interviewed and documented she had just come out of another resident's room. Staff K had opened the door to the resident's room and voiced he needed help. Staff J stated she went to help and saw the resident up in the E-Z stand so she pushed the wheelchair behind the resident. Staff J stated she thought she had locked the breaks on the wheelchair and left to get some help because she had paged on the walkie-talkie and no one arrived to help. Staff J stated she did notice the leg strap not on the resident to help with support. She stated she left the room to answer another resident ' s light. Staff J stated she ran into another resident's room and told Staff L, C.N.A. that Staff K needed help right away and Staff L replied " okay Staff J stated that after she got the other resident back to bed, she saw the nurses run to Resident #1's room. Staff J stated she had not heard over the Walkie Talkie that Staff K paged for assistance. Staff J again stated when she entered the resident ' s room, the resident was in the air with the waist belt around her/him but did not notice it the belt was loose or sung. Staff J stated the strap that was supposed to hold her feet was undone. The facility Skills Competency For Use of the Sit Stand Lift (E-Z stand lift, i.e. sit stand lift) identified and directed staff to apply sling around the resident ' s truck and apply strap around the resident ' s feet, buckle and tighten. A document from the maintenance department dated 7/13/2012 identified the EZ stand lift was inspected. The inspection identified all parts, straps, slings and locking devices all in good operating condition.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self or elements in the environment and plan for and direct the nursing care so the resident ' s needs are met (Resident #4). The sample consisted of 5 residents and the facility reported a census of 57 residents. Resident #4 had spastic movements and required assistance by staff with eating. Resident #4 had severely impaired cognition due to intellectual disabilities. A staff member left Resident #4 unattended at the dining room table with access to a hot bowl of soup. The staff member left to assist another resident. Another staff member had left the dining room for up to 30 minutes during meal time and so was not available to assist with resident needs. With the resident ' s spastic movements and cognitive impairment, the resident put right hand into the hot soup which caused the resident to yell out in pain and experience a burn to the right hand. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/14/2011 which identified [DIAGNOSES REDACTED]. The MDS indicated the resident required total dependence of two staff members for bed mobility, transfers, toileting, dressing, personal hygiene and total dependence of one person for assistance with eating. The MDS revealed severely impaired cognition, rarely or never understood and unclear speech-slurred or mumbled words for communication. The MDS indicated the resident had upper and lower extremity impairments. The clinical record Face Sheet identified Resident #4 had a [DIAGNOSES REDACTED]. The Care Plan dated 6/22/2011, with the last review on 9/15/11, revealed the facility failed to complete a comprehensive assessment due to no problem or interventions identified for the [DIAGNOSES REDACTED]. The Incident/Accident Report dated 11/11/11 at 5:45 PM indicated Resident #4 laid hand in a bowl of stew at the dining room table. Staff immediately applied ice. An assessment included the following vital signs take: temperature 98 (normal 98.6) degrees, pulse 74, respiratory rate 22 (normal 16-20), blood pressure 156/84 (normal 120/60). The staff notified the resident's primary care physician and received orders for treatment. The injury consisted of a burn on the posterior and anterior portion of the right hand. The Telephone Physician order [REDACTED]. The physician ordered staff to administer Tylenol with Codeine one tablet by mouth every 8 hours as needed for pain and to give a tetanus toxoid 1/2 cubic centimeter (cc) injection. Record review of the Nutritional assessment dated [DATE] indicated Resident #4 required a diet of puree foods. On 11/2/11 at 2:40 PM, observation revealed Resident #4 in bed with arms flailing aimlessly and hands in mouth at times. A sock covered the gauzed wrapped right hand. On 11/14/11 at 4:30 PM, observation revealed the resident positioned in bed and staff provided perineal care. During the cares, the resident continuously moved both arms and placed hands in mouth at various times. When the cares were completed, the staff transferred the resident from the bed into the wheelchair by a mechanical lift with the assistance of 2 staff members. . Staff A, Certified Nursing Assistant (CNA) assisted the resident with cleansing the hands, combing hair, feet positioned on foot rests, head rests supports head and a seat belt fastened due to spastic movements of the upper trunk and extremities. The staff assisted the resident to the dining room table. Observation revealed no food on the tables and staffs continue to bring residents' into the dining room. At 5:43 PM, the staff served the supper meal and staff noted to assist the residents. During observation on 11/15/11 at 10:00 AM, Staff E, Licensed Practical Nurse (LPN) removed the dressing on the right hand. The right hand had superficial burns on the two middle fingers and at the base of the right thumb. The skin of the right hand was found to be pink in color with no signs or symptoms of infection. Staff C, CNA assisted by holding the resident's right arm to prevent the resident from placing right hand into mouth during the dressing change. Record review of the Food Temperature Check Sheet revealed no temperatures of food taken the evening on 11/11/11 until after the incident occurred. At that time the stew temperature found to be 168 degrees Fahrenheit. On 11/15/11 at 11:15 AM, the resident's primary care physician was interviewed and stated the burn was not a major injury and minimal. The physician stated it ' s common sense, to move the hot food to the side and this to be an unfortunate accident On 11/14/11 at 2:15 PM, Staff A, CNA stated she left the resident at the dining room table, to help another resident. When helping the other resident, she heard Resident #4 yell out. Staff A stated she quickly turned and saw the resident ' s right hand with puree food on it. Staff A stated she went to the resident right away and gently removed the hot food and found the entire right hand red. Staff A called for Staff F, LPN and the nurse instructed her to take the resident to the nursing station and she put on the hand immediately. Staff A stated she did not see who put the food on the table but Staff G, served the food. Staff A stated she saw 3 blisters form quickly. On 11/15/11 at 2:30 PM, Staff G stated she worked as a cook II that night, setting up the resident's drinks and other dietary duties. Staff G stated she had served the resident the meal food while Staff A sat with the resident. Staff A had begun to feed the resident and then saw Staff A get up to get another resident a cup of coffee and another resident a clothing protector. Staff G stated when Staff A helped another resident, she heard Resident #4 yell out. Staff G stated she saw the resident swinging her/his arms around and the right hand land in the food; then the resident yelled out. Staff G stated she grabbed a clothing protector and her and Staff A cleansed the residents hand and placed another clothing protector over the food to avoid another problem. Staff F came with a bag of ice to put on the resident's hand. Staff G stated Staff H; DA had gone to the restroom around 5:25 PM to 5:45 PM. This absence caused a disruption in service which caused Staff A to assist a resident when it had been the job of Staff H to do so. Staff G stated two other CNA's were in and out at that time assisting residents to the tables and stated they had begun serving around 5:30 PM. On 11/15/11 at 12:25 PM Staff F was interviewed and stated she was in the dining room administering medications and did not see who placed food on the table or see who had yelled. Staff F stated she told Staff A to call Staff I, LPN immediately and took the resident from the room and placed the resident ' s hand on ice. Staff I called the primary care physician, obtained physician's orders [REDACTED]. Staff F stated from the time she heard the resident yell out to having the hand treated it was not more than 10 minutes. She stated she did not see any food on the resident's hand, the hand red with no blisters. She stated the blisters started when the treatment had been completed. The burn area mostly involved the two middle fingers. She stated she did not pay attention to whom else had been in the dining room, she knew Staff G and J had been working but not their location at time of incident. Staff F stated the kitchen started serving around 5:30 PM; two CNA's would be at the assist table. They had three CNA's and a float. The float leaves and helps in the west dining room when all the residents are up to the east dining room. She stated she didn't know why Staff A was away from the assist table unless a resident had requested something. On 11/15/11 at 2:15 PM Staff J, DA/Cook stated she saw an aide with the resident, she had asked Staff A if she would be staying with the resident and she replied yes. She stated she prepared the resident's food and was not aware of when Staff A had gotten up from the table. She stated she then heard a resident yell out. She stated she did not see when Staff A got up from the table or how the resident had burned self. She stated Staff H had gone to the restroom just before they began to serve and he had been gone for 30-45 minutes. Staff J stated the Administrator checked the temperature of the stew and found it to be 168 degrees. On 11/15/11 at 3:00 PM, Staff H was interviewed and stated his job is to serve the food to the residents. Staff H stated he had gone to the restroom and when he returned to the dining room the incident had already occurred. Staff H stated he had visited with an employee in the hall and then had gone on to the restroom and had been gone for 10-15 minutes. Staff H stated it had been no more than 30 minutes

Relates to revisit of # -I and # -I: Based clinical record review, observation and staff interview, the facility failed to ensure that safety alarms on and functioning for 2 of 4 residents reviewed for nursing supervision (Residents #3 & #5). The facility identified a census of 58. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] documented that Resident #3 had [DIAGNOSES REDACTED]. The resident required limited assistance of 1 person for transfers and walking and s/he had unsteady balance but could stabilize without human assistance. The assessment documented the resident fell since admission or the prior assessment. The undated Care Plan updated on 7/21/11 documented Resident #3 had the risk for falls with interventions prevent injuries related to falls. Interventions included the assistance of 1 staff member for all ambulation, to keep their walker within reach at all times, a PPD (Personal Protection Device) alarm while in the chair or in bed. An intervention dated 7/3/11 directed staff to replace alarm box with one that the resident could not disassemble or prevent from sounding. An intervention dated 7/22/11 directed that alarm be switched to one without a button. The Care Plan had a problem dated 9/23/11 that Resident #3 had been removing the alarm with an Intervention which directed staff not to allow more than 2 books in the resident's room at a time due to using to put on alarm to keep from going off. Review of the Incident/Accident Report dated 1/11/12 at 9:45 PM identified Resident #3's call light to be on, his/her body alarm off and in the chair and a pressure pad in chair not sounding. Staff found the resident on the floor behind the door on his/her buttocks. The incident report described injuries as a .3 cm (centimeters) skin tear to the right elbow with purple bruising. Review of the Nurse's Notes dated 1/11/12 at 9:45 PM documented staff found the resident on the floor on their buttocks and the call light on. The resident's ghost pad alarm lay on the chair not sounding and the body alarm had been removed by the resident. Nurse's notes identified a .3 cm skin tear to right elbow. The nurse's notes also documented that resident stated he/she tried to go to the wheelchair to go to the bathroom. During an interview with the Administrator on 1/26/12 at approximately 5:00 PM the Administrator stated that the facility had been checking all alarms 2 times per week. The Administrator indicated the Maintenance Department responsible for 1 check per week and the Restorative Aide responsible for 1 check per week. 2. Review of the MDS assessment dated [DATE] for Resident #5 documented [DIAGNOSES REDACTED]. The MDS did not document a BIMS score, but identified the resident had short and long term memory deficits and severely impaired decision making skills. The MDS documented Resident #5 required the extensive assistance of 1 person for transfers and walking, with unsteady balance which required human assistance to stabilize. Review of a Care Plan for Resident #5 dated 12/8/12 identified a problem with falls and listed interventions which included a pressure pad alarm at all times, a gripper pad under the alarm pad, a personal body alarm, and to rotate between wheelchair with lap buddy and a geri-chair. Observation of Resident #5 on 1/25/12 at 10:40 AM found him/her in the front lounge in a wheelchair. Resident #5 had a lap buddy (a device to prevent rising from the chair) on which the resident removed 2 times during the observation. Resident #5 had a personal body alarm which had a string attached to the alarm and and the string hung down between the resident back and the back of their wheelchair. Upon investigation, the string which hung down had baby safety pin attached to the other end but it did not attach to the resident's clothing. Observation of Resident #5 on 1/25/12 at 10:43 AM revealed Staff B, CNA (Certified Nurse Aide) and Staff C, CNA taking the resident to his/her room to lay down. Staff C removed the wheelchair foot pedals and the lap buddy. Staff B asked Resident #5 if he/she was 'un-pinned' as she leaned the resident slightly forward. Staff B found the baby safety pin unattached from the resident. During an interview on 1/25/12 at 10: 47 AM with Staff B and Staff C both acknowledged the baby safety pin to be unattached and that neither of them had unpinned the alarm string from Resident #5. Staff B and Staff C proceeded to transfer the resident to his/her bed. Observation of Resident #5 on 1/25/12 at 3:00 PM found Resident #5 in bed. Upon investigation Resident #5 had a string attached to his/her right shoulder with a baby safety pin and the string hung down over the bed with the magnet attached to metal of bed frame and the personal safety alarm box hung on the top to the back of the headboard. The alarm did not appear to be functional as a fall prevention device. The surveyor informed the DON (Director of Nursing) following the discovery and the DON talked with the South Hall Nurse and South Hall Aides and showed them the location of the magnet. The DON stated that they should have caught that on rounds.