Every finding on record at The Cottages

Based on clinical record review, staff interviews, resident interview and policy review the facility failed to ensure resident safety when ambulated and when transferred to a chair without a gait belt for 1 of 3 residents reviewed (Resident #2). The fall resulted in a hip fracture that required surgery. The facility reported a census of 90 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] reflected Resident #2 activity prior to fall documented used a walker, required substantial to maximal assist with sit to stand and lying to sit needed partial to moderate assistance, to lift, hold or support trunk or limb. Resident #2 required supervision or touch assist when walking up to 10 -50 feet. Staff to provide verbal and or touch/steadying and/or contact guard assist throughout activity or intermittently.The Care Plan focus initiated 5/15/24 for Resident #2 revealed is at risk for falls, to use walker through entire transfer, assist of one and a four wheeled walker (4WW) and gait belt.The MDS dated [DATE] for Resident #2 revealed diagnosis of fracture of the left femur. The MDS coding reflected dependence on transfer from a bed or chair and to sit and stand. The Brief Interview of Mental Status (BIMS) assessment scored 14 out of 15 indicated cognitive intact. A Progress Note dated 5/9/26 at 8:19 PM titled incident description relayed Resident #2 was walking to the dining room for dinner, and was about to sit in chair, resident pushed walker away like she was attempting to move it before sitting down and started to fall forward. Registered Nurse (RN) Staff A was walking with Resident #2, pushing the oxygen tank and getting the chair ready for resident to sit in when noticed she was unsteady. Staff A attempted to steady resident and lower her to the ground when resident started to fall sideways. Staff A, went down to the ground. Resident #2 landed on top of Staff A, both landed on their left side. Staff A assessed Resident #2 who was in severe pain and distress when attempted movement of the left leg. The Investigative Summary relating to Resident #2 fall on 5/9/26 documented Resident #2 level of function. Staff assistance of one and a 4WW and gait belt for transfers. Registered Nurse (RN) Staff A reported had the oxygen tank, walked behind Resident #2 to dinner. Resident #2, got ready to sit in the chair and pushed her walker towards end of table and started to fall. When Resident #2 went forward Staff A relayed had grabbed on to correct and we both went on her left. Resident #2 fell on me. The root cause analysis revealed a gait belt was not in use at the time of the event, an expected support measure for assisted ambulation and transfers per the care plan. A Hospital Discharge Summary, admit date [DATE] relayed Resident #2 lost balance, was partially caught by the nurse, did land on her left hip with immediate pain. The x-ray revealed an intertrochanteric (femur) fracture. On 6/2/26 RN, Staff A relayed recollection of Resident #2 fall with fracture. Staff A was asked if she could bring Resident #2 from the bathroom to the dining table. Resident #2 helped Resident #2 in the bathroom and relayed did not see a gait belt while assisting Resident #2 that would be usually in the room. Resident #2 had a 4WW and walked ahead to the dining room. Staff A relayed had the oxygen cannister and walked behind Resident #2. Staff A states Resident #2 went to sit down, thought the resident could back down and do it but instead went forward. Staff A reported grabbed Resident #2 in a panic and both landed on the ground. Staff A stated, knew could have looked at the care plan and did not. Staff A relayed did not think to ask another staff about Resident #2 support needs and did not use a gait belt to assist. Resident #2 was transported out to the hospital following the fall. On 6/3/26 at 12:20 PM Certified Nursing Assistant, Staff B relayed was working in the dining room when Resident #2 fell. Staff B was in the dining room when Staff A assisted Resident #2 to the dining room table, relayed Residents #2 was not wearing a gait belt. On 6/3/25 at 3:00 PM Resident #2 relayed recollection of fall in the dining room, stated it happened so fast that Staff A could not catch her to stop the fall. Resident #2 recalled immediate pain, going to the hospital, having surgery and returning to the facility with therapy to learn to walk again. On 6/3/25 at 3:20 PM Therapy, Staff C relayed Resident #2 had therapy before and after the fall with fracture and required support assistance of one with activities, included with ambulation and transfer with gait belt usage currently as well as before the fall with fracture. On 6/3/26 at 3:30 PM The Assistant Director of Nurses, (ADON) relayed residents requiring assistance of one staff should have a gait belt in use and felt all staff are aware of this gait belt requirement. On 6/4/26 at 10:30 AM The Director of Nurses (DON) relayed awareness of Resident #2 fall with femur fracture and the Staff A should have used a gait belt when Resident #2 ambulated or transferred and thought perhaps Staff A got rushed and was not thinking. The Policy titled, Safe Resident / Client Transfer and Positioning Procedure revised 5/2025 directed gait belt assistance when a resident required supervision or contact assistance when ambulating.

Based on clinical record review, policy review, staff interviews, resident and family interview the facility failed to provide dignity and respectful treatment for 1 of 3 residents reviewed. The facility reported a census of 90. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed required assistance with sit to lye or sit to stand or transfer to chair or toilet. Resident #1 required partial to moderate assistance of staff for lifts, holds, or support of trunk or limb and was dependent on toileting hygiene. The Brief Interview for Mental Status (BIMS) exam Coded a score of 13 out of 15 indicating intact cognition. The Medical Diagnosis, in an electronic record dated 4/3/26 listed Resident #1 had acute cystitis with hematuria referring to bladder inflammation with blood in the urine and had an overactive bladder. A Care Plan with an activity focus area initiated on 4/3/26 documented Resident #1 needs assist of one with toileting and perineal cares and needed assist of one and a front wheeled walker (FWW) to transfer. A Facility Investigation Report documented on 4/22/26 at about 9:52 PM documented the following; The Administrator was notified by the Director of Nursing (DON) of the incident involving Resident #1(R1) had reported he needed to use the restroom a lot the previous night, and had been yelled at by staff. R1eported that Staff D, Certified Nurses Aid (CNA) told him he knew better than to pee in his pants, and R1 made to sleep in a bed when he did not want to. Resident #1as interviewed by the DON and described the staff gender, color of hair and length of the person that yelled. The DON relayed Resident #1 displayed increased anxiety and fidgeting during the recollection. The identified Certified Nurse Aide (CNA) Staff D was called and confirmed she did go into R1's room a couple of times as the resident needed to use the restroom a lot. An Audit Report, Point of Care document revealed on 4/22/26 Certified Nursing Aide (CNA) Staff D provided cares for R1documented times of care included 1:22 AM,1:54 AM,155 AM, 2:50 AM,4:20 AM and 5:33 AM. On 6/2/26 at 1:30 PM R1 reported of the onetime he felt he had frustrated staff because he had to get up alot to go to the bathroom. R1 relayed preferred the recliner instead of the bed and staff did not want to listen to what he needed. R1 relayed staff was frustrated, not nice, yelled and had not seen that staff since that night. On 6/2/26 at 1:36 PM R1s family member who relayed recalled on 4/23/26 when visiting that R1was very upset and relayed the reason was due to treatment received the last night by Staff D. R1had described Staff D and reported had said during care the staff said all you have to do is pee, pee, pee. Family relayed it should not have been said that way. During an interview on 6/2/26 at 4:40 PM Staff D denied assisting R1to the bathroom on 4/22/26 despite the documentation this CNA had provided assistance to R1on 4/22/26. During an interview on 6/3/26 at 7:25 AM with Staff E, CNA reported experiences working with Staff D as a staff that is very negative. Recalled a night when Staff Dexpressed anger because some residents were still up at start of the third shift and StaffDwanted all residents in bed. Staff E relayed felt Staff D did not want to help residents to bed. During an interview on 6/4/26 at 10:45 AM with the DON, relayed all residents are to be treated with respect and reports of negative treatment are taken seriously and anything otherwise would not be tolerated. During an interview on 6/3/26 at 12:40 CNA Staff F recalled on 4/22/26 worked with Staff Dwho came to work all fired up and agitated, relayed at the time was assisting R1from the chair to the bathroom said to R1needed to go to bed and needed to go to bed now. Relayed the attitude was bothersome and did need to console R1 During an interview on 6/4/26 at 12:55 PM CNA, Staff G relayed recollection of what R1relayed on 4/23/26, said the night before, on 5/22/26 the staff, yelled, was not very nice said he knew better than to have to keep going to the bathroom, had to sleep in his bed when he did not want to. The policy titled Resident Rights revised 5/2027 documented, The Resident has a right to a dignified existence. The community will protect and promote the rights of each resident.

Based on record review, facility investigation file, staff interviews, and policy review, the facility staff failed to treat residents with dignity and respect and honor the resident's right when a resident refused to take a shower, and failed to protect residents from abuse by not conducting a thorough investigation of the incident for 1 of 2 residents reviewed for abuse (Residents #2) The facility reported a census of 86 residents. Findings include:A Complaint/Incident Investigation Report revealed the facility self-reported an allegation of abuse to the Department of Inspections, Appeals, and Licensing (DIAL) on 11/03/25 at 5:29 PM. The incident occurred on 10/31/25 at approximately 9:20 AM. Staff A, Certified Nursing Assistant (CNA) notified Staff E, Registered Nurse (RN) that Resident #2 refused to take a shower. Staff E was upset and said she did not have time for this shit and followed Staff A into the resident's bathroom. Staff E told Resident #2 she had to take a shower and the resident said no. Staff E then pried the resident's hand off of the chair and forcefully took off her shirt. Resident #2 was uptight and clenched her hand as Staff E removed the resident's hand and shirt and yelled no stop, stop right now, no, no. On 10/31/25 at approximately 9:45 AM, Staff A reported the incident. Staff E was removed from the unit. Staff B, CNA, reported she was told to tell Resident #2 they are going to take a shower and not to ask the resident, but the resident was very adamant about not taking a shower. Staff B reported she was not in the room when the (resident's) shirt was removed. Resident #2 was assessed from head-to-toe without any injuries noted. The physician was notified on 10/31/25 at 5:00 PM. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses of anxiety disorder, depression, osteoarthritis, and muscle weakness. The MDS recorded the resident had a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition. The MDS indicated the resident required substantial to maximum assistance for upper body dressing and partial to moderate assistance for showering/bathing. The MDS revealed the resident had no behaviors during the seven day look-back period. The Care Plan revealed Resident #2 required assistance with ADL's (activities of daily living). The Care Plan directed staff to cue, reorient and supervise as needed (initiated 12/9/24), present one thought or command at a time (initiated 12/9/24), and leave the resident alone in a safe position and retry the task in a few minutes if the resident was resistive to care (initiated 8/26/24).A Progress Note dated 10/31/25 at 10:32 AM revealed the resident became very agitated during a shower and refused to get in the shower. The nurse assisted resident with removing her clothing. Resident alert and oriented x 3. Staff H documented the Safety Measures implemented at that time included to encourage the resident to take a shower and if refusing, try again at a later time.The facility's investigative file provided to DIAL during the survey revealed the timeline of the incident on 10/31/25: a. At 9:00 AM, Staff A, CNA, and Staff B, CNA, went into Resident #2's room to get her up and assist into the shower. Resident #2 was transferred into the shower chair after she was toileted and was not dressed below the waist. She still had her shirt on. Resident #2 refused to shower at this time stating It's too cold. b. At 9:20 AM, Staff A notified Staff E, RN, that the resident was refusing her shower. Resident #2 continued to refuse a shower at that time. Staff A reported Staff E was upset and said I don't have time for this shit. Staff E followed Staff A into the bathroom and started telling Resident #2 she had to take a shower. The resident said no. Staff E then pried the resident's hand off the chair and then forcefully took off her shirt. Resident #2 was uptight and clenching her hands and saying no, stop this, stop right now, no, no as Staff E removed the resident's hand and shirt. Staff B reported the resident was adamant about not taking a shower The resident said I'm not doing that involves water, this is bullshit. Staff B was not in the room when the shirt was removed. c. At 9:45 AM, Staff A reported the incident. Staff E was removed from the unit and interviewed. A head-to-toe assessment was done on Resident #2 and no injuries were found. d. At 5:00 PM, the physician was notified. An attempt was made to notify the POA (Power of Attorney). The Facility Investigation File also revealed that the facility provided staff education on the right of refusal, and the provision of kind and considerate care. The team member was immediately removed from resident care. Maintenance assessed the bathroom temperature on 10/31/25 at 1:00 PM and found it to be at 74 degrees Fahrenheit.The facility's investigation file revealed a timeline of the incident, separation of staff from the involved resident, and staff education related to resident rights of refusal and treating residents with kindness and consideration. The facility's investigation lacked documentation of follow up with other residents residing at the facility for potential abuse, police notification, and follow up with other staff members working. The Facility's Investigation File contained Investigation Questions for the following: a. On 10/31/25 at 10:30 AM, Staff E, RN, was interviewed by the Director of Nursing (DON) and the Clinical Quality Specialist (CQS). Staff E reported she encouraged the CNA's that morning to get Resident #2 in the shower. Resident #2 typically resisted her showers and that they can't always give a choice, but they could let it go if she really acted out. Staff A approached Staff E and told Staff E you need to come and talk to Resident #2 because she is absolutely refusing the shower and is grabbing onto her arm rests on her shower chair and saying no, no, no to a shower. Staff E said she came in and helped Resident #2 out of her shirt because she would need to be helped anyways. Resident #2 was not upset about Staff E taking her shirt off. The resident was not grabbing at Staff E or yelling or anything. She was just vocal about not wanting a shower. Staff E told her she needed to shower and the shower was running. The agency aide said this is inappropriate, she is absolutely refusing her shower. Staff E said she did get frustrated and said well, okay, do whatever you think is best, and then she left kind of upset. The aide approached Staff E later and said that she was very upset with Staff E and felt like her actions were inappropriate when dealing with Resident #2. Resident #2 ended up getting her shower. Staff E said she told the CNA that she did not have to give Resident #2 a shower. b. On 10/31/25 at 11:08 AM, Staff A, CNA, was interviewed by the CQS and DON and obtained statements to the questions asked. Staff A reported she witnessed the incident. She went to get the resident up for her shower. Resident #2 told her she did not want to take a shower because it was too cold right now. Staff A said she would go talk to the nurse. Staff A told Staff E the resident refused to shower right now because it was too cold. Staff A offered to help the resident later. Staff E said no you have to do it now. Staff B and Staff A went into Resident #2's room. The resident said no over and over again, she did not want a shower. Staff A and Staff B took her to the restroom, turned on the shower to get it warm for her. She still had her shirt on but was nude below the waist. She was gripping the shower chair and when Staff A went to remove the resident's shirt, the resident said you are not going to take my shirt off. Staff A said she was not going to pry her hands off the chair and would go get the nurse. Staff B stayed with Resident #2 while Staff A went and got the nurse. Staff B left the room to assist other residents when the nurse came in. Staff E was upset when Staff A went and spoke with her. Staff E said I don't have time for this shit. Staff E followed Staff B into the bathroom and started telling Resident #2 she had to take a shower. Resident #2 said no, then Staff E pried the resident's hand off the chair and then forcefully took off her shift. Resident #2 was uptight and clenching her hands and saying no stop this, stop right now, no, no, no as Staff E removed the resident's hand and shirt. Staff A told Staff E she could not do this to her, it was the resident's right to refuse the shower. Staff E said no we have to give her a shower. Staff A proceeded to tell the nurse that the resident had the right to refuse. Staff E then got upset and said I'm so over this, dropped the shirt on the ground, and said she would give her a shower but to do whatever the hell she wanted and slammed the bathroom door as she left. Staff A apologized to the resident because she felt so bad. Resident #2 said what's her problem? She is crabby, she's mean. Then the resident said since we are here at the shower already you can just get me in, I'm cold. Staff A told Staff C, Restorative Aide (RA). Staff A inquired as to who she needed to talk to. Staff C told Staff A she would tell someone. Staff A relayed she just felt like Staff E was being forceful because of the way the resident appeared. Resident #2's face was grimacing and she looked scared. Staff A knew she would not want to be treated like that. Staff E cursed and stomped and seemed angry. Her behavior was inappropriate. Staff A spoke with Staff E after the event and told Staff E she did not appreciate how she treated Resident #2 and Staff A, or that Staff E had slammed the door. Staff E said she was so sorry she lost her temper and lost her cool. Staff E said she was very stressed out and overstimulated. c. On 10/31/25 at 11:30 AM, Resident #2 was interviewed by the CQS and DON. Resident #2 remembered taking a shower on the morning of 10/31/25. Resident #2 said the shower was terrible. It was too damn cold in there and they refused to turn up the thermostat. She did not like to take showers at the facility. Sometimes staff are kind to her but they are mouthy and bossy. She did not know if the nurse was kind to her because she did not meet her. Resident #2 responded no when she was asked if any staff had been physically aggressive with her. d. On 10/31/25 at 11:52 AM, Staff B, CNA, was interviewed by the CQS and DON. Staff B signed the document on 10/31/25 at 8:25 PM. Staff B reported she had heard that Staff E forcefully took off Resident #2's shirt for a shower even though the resident refused the shower. Staff B reported she was told that with this resident staff had to tell her she was going to take a shower and not ask but she was very adamant about not taking a shower. The resident said I'm not doing that, that involves water, this is bullshit. Staff B reported she was in the room when Resident #2 refused the shower. Staff B helped Staff A get Resident #2 into the shower chair and that is when the resident did not have her shirt off yet. She used the toilet and then they got her into the shower chair. Staff B said she heard that Staff E was being forceful from Staff A. Prior to this incident, Staff B reported she had an encounter with Staff E when she brought another resident out to the dining area. Resident #1 had a pajama shirt on and Staff E told the resident she could not wear the pajama shirt, she had to put on a shirt. Resident #1 said I don't understand why I cannot wear this. e. On 10/31/25 at 1:30 PM, Staff C, RA, was interviewed by the CQS and DON. Staff C signed the document on 10/31/25 at 1:43 PM. Staff C reported she was in the library with another resident. As she walked the resident, Staff A peeked her head out of Resident #2's room and asked if Staff C worked at the facility. Staff C said yes. Staff A finger motioned Staff C into the room and proceeded to ask what was going on with the nurse, and if the nurse was always like that. Staff C asked Staff A what do you mean? Staff A said she had been by herself for the first hour of the morning and she was told that she needed to make the beds and try to get the residents up first and then do the cleaning afterward. Staff A said when she was getting Resident #2 ready for the shower that Resident #2 grabbed onto the chair sides and did not want to take a shower and then Staff E grabbed Resident #2's hands off the chair and forcefully removed her hands from the chair. Staff A told Staff E not to do that to Resident #2. Staff E said do whatever you want and stormed off. Staff A said she was not sure who she should talk to about the event. Staff C said she would talk to someone about it and then notified Staff D, Social Services (SS). Staff C also shared concerns that Staff E got flustered very easily. Staff C had brought concerns to Staff E before and Staff E responded with I'm so done with this job and seemed very frustrated.f. On 10/31/25 at 1:43 PM, Staff D, SS, was interviewed by the CQS and DON. Staff D signed the document on 10/31/25 at 1:53 PM. Staff D reported Staff C came and told her that Staff A told Staff D that Staff E was very aggressive with Resident #2. Staff D said Staff A gave the example of ripping the resident's hands off the rails and forcefully removed her shirt to get her in the shower after the resident stated she did not want to shower multiple times. Staff A told Staff E that was not right and that Staff E needed to stop. Staff E then left the room and slammed the door. Resident #2 told Staff A that Staff E was mean. Staff D reported she listened to Staff C, and then spoke with Staff E to ask her what had happened that AM with Resident #2's shower. Staff E stuttered and said she may have ripped the resident's shirt off forcefully and then said, it's neglect if we don't give her a shower. Staff E asked Staff D if she should go apologize to the aide. Staff D told her she had to get it figured out, and then went and reported it to the DON and CQS. In an interview on 11/20/25 at 9:30 AM, the DON reported she assisted with interviewing the staff involved in the incident with Resident #2. The stories from Staff E and the CNA's were totally opposite of what happened. Staff E said she did not do anything forcibly. Resident #2 was on the shower chair but she did not want a shower. Staff E got the resident's shirt off. The DON reported when she talked to Resident #2, she did not know anything about what happened. She didn't even know who her nurse was or if she had one. Resident #2 was not concerned, she said she felt safe, and no staff were threatening toward her. In an interview on 11/20/25 at 1:30 PM, Staff D reported Resident #2 could be stubborn but she was with it and could tell staff what she wanted. Staff D reported Staff C, RA, came to her on a Friday (10/31/25) and asked how she should proceed with a situation. Staff A was in the room with Resident #2 and Staff E was in the room. Staff A told her that Staff E removed the resident's hand from the rail and took her shirt off. Staff A told Staff E she needed to stop. Staff E walked out of the room and slammed the door. After that, Staff C told Staff A she would tell the appropriate people. Staff D reported she went and asked Staff E what happened. Staff E started stuttering and said Resident #2 did not want a shower. Resident #2 needed a shower. Staff E claimed it was neglect if she did not get a shower. Staff D asked Staff E what happened and Staff E said she may have removed the resident's shirt forcefully. Staff E asked Staff D if she needed to go apologize to the aide. Staff D told Staff E she was going to figure it out. Staff D reported she then went and talked to the Executive Director and the DON. Staff D reported Staff E was very anxious all of the time and loud. Staff E always told staff how to do things and huffed at her when Staff D wanted to follow the Kardex instead of the paper document that Staff E wanted her to use. Staff D said Staff E also got very frazzled while at work. Staff D reported she had given Resident #2 three showers since the incident and she had not refused a shower. Staff D stated she made another attempt to try at a later time and reported to the nurse whenever a resident refused something or was uncooperative. She did not force anyone to do anything they did not want to do. In an interview on 11/20/25 at 1:50 PM, Staff C, RA, reported Staff A came to her and asked her if she worked at the facility. Staff A explained the situation that they had Resident #2 in the bathroom, Staff E was in the room and pried the resident's hand off of the chair and proceeded to take off her shirt. The CNA (Staff A) told Staff E she should not do that. The nurse left the room and said she was fed up with being there or fed up with the day. Staff A did not know who to tell. Staff C told her she would talk to someone and then went and talked to Staff D, SS. Staff C reported Resident #2 could be negative and staff had to convince her to go do things. Staff C tried to find a way to work around the resident and try again later, tried to offer the resident an alternative, or try to convince the resident to do what was needed. Staff C reported Staff E had a short fuse. Staff E did not snap at anyone, but made statements like I am done for the day or that she was so frustrated.In a call to Staff E on 11/20/25 at 2:30 PM, when the surveyor requested to speak with Staff E, there was a pause and then a question of who was calling. The surveyor identified herself from DIAL. There was another pause and then the surveyor was directed to call Staff E's attorney. At the time, Staff E was advised there had been an allegation of abuse. Staff E responded the surveyor would need to go through her attorney. In an interview on 11/20/25 at 2:45 PM, the Executive Director reported the CQS and the DON were involved in the investigation of the incident with Staff E and Resident #2. In an interview 11/20/25 at 3:55 PM, Staff A, agency CNA, reported Resident #2 was pretty well with it, she conversed but did not remember things. She could tell staff when she wanted to get up or when she wanted something. She could be a little grumpy but that was her demeanor. It depended on how someone approached her. On the day of the incident, the day started off strong. They had a call in so it was just Staff A and Staff E working. Staff A could tell Staff E was upset and frantic. An hour later someone came in to work. Staff E was very adamant about getting the showers done. The incident happened around 8:30 or 9 AM. Staff A told Resident #2 she needed to get a shower sometime that day. Staff A and Staff B sat Resident #2 on the toilet. The shower chair was over the toilet. Resident #2 was already undressed from the waist down. Staff A said let's get into the shower. Resident #2 said no I'm not taking a shower, it's too early, I don't want to take one now, it's cold. Staff A said ok, then tried to ask her one more time, and gently took her hand but she clenched down on the shower chair and said don't take my shirt off. At that point, Staff A realized the resident was not going to take a shower. Staff A went and reported this to Staff E. Staff E said no, I don't have time for this shit. Staff A could tell Staff E was frustrated by the tone in her voice and her throwing her hands above her head, saying I don't have time for this shit. Like she was over it. Staff E came back to the resident's room and told Resident #2 you have to take a shower. Resident #2 said no I don't want to take a shower. Staff E said you are going to take a shower. Resident #2 said no. Resident #2's hands were clenched down on the shower chair. Staff E forcefully pulled the resident's hands off and took her shirt off. Staff A told Staff E that she (Resident #2) doesn't want to take a shower. Staff A could not pull Staff E off of the resident. Staff A told Staff E you can't do this, just leave it alone. Staff A then told Staff E this is like abuse. Staff E finally got the shirt off of Resident #2 and the resident sat in the chair naked. Staff A stated she felt like Staff E violated the resident and she pushed it to the point where she forced the resident. Staff E acted like the resident does this all the time. Staff A told Staff E she did not feel right giving the resident a shower. Staff E yelled do whatever the hell you want, stormed out of the room, and slammed the door. Staff E said she apologized to Resident #2 and told her she did not know what that was all about. Resident #2 said she is just moody, and she's the crabby one. Staff A told Resident #2 she did not have to take a shower now. Resident #2 said now I'm naked, you might as well put me in the shower. Staff A asked Resident #2 what she wanted to do, and Resident #2 said put me in the shower. Staff A told Resident #2 she needed to go report this. Staff A did not have a walkie at that time and did not want to leave the resident alone. Staff A set the shower head by Resident #2 and let the water run. Staff A left the bathroom to get towels located in the room. At that time, another aide walked by the resident's room. Staff A had Staff C come into the room. Staff A told Staff C what happened and wanted to know who she should talk to. Staff C told Staff A she would find someone. Staff C helped Staff A give the resident's shower, then Staff C went to tell someone. The DON talked to Staff A and typed up a statement as Staff A talked about the incident. Staff A reported she believed the way a resident was approached made a difference as far as getting the resident to do things. Staff A felt Staff E took away Resident #2's right to say no. Staff A stated the look on the resident's face was like she wanted to be strong but she was being overpowered by someone who could overpower her. Staff A said she confronted Staff E afterward, and told Staff E she thought what she did was so disrespectful, she did not need to slam the door, and she did not need to cuss. Staff E responded, I lost my cool. I am frustrated, I have a lot of things going on. Staff A told Staff E to not bring things to work and that Staff E needed to give respect. Staff E started to cry. In an interview 11/24/25 at 12:25 PM, Staff B, agency CNA, reported Resident #2 was alert and oriented with what is going on and could let staff know whenever she needed to be changed or needed something. On the day of an incident, she remembered helping get the resident up. Resident #2 was supposed to get a shower but she did not want a shower. The other CNA she was working with (Staff A) went to tell the nurse and Staff B left the room to help another resident. Staff B stated she would let the nurse know when a resident refused something or was resistive to cares, then she waited for the nurse to tell her how to proceed. She would also let the nurse know if the resident had behaviors and document the behaviors in the 24-hour binder at the desk. In an interview on 11/25/25 at 10:55 AM, the CQS reported her impression of the incident that occurred with Resident #2. The CQS believed the agency CNA may not have known the things that the regular staff tried to get the resident to take a shower. The facility also expected the CNA to let the nurse know if a resident refused a shower. The CNA was letting the nurse know the resident refused to take a shower. The nurse was frustrated about that day. The CQS stated she started the investigation on a Friday and got staff statements and then determined they needed to report the incident to DIAL the following Monday. The facility's Abuse Policy and Resident Protection Plan last approved 7/2025 revealed any team member who becomes aware of abuse, mistreatment, neglect, or misappropriation shall immediately report to their immediate supervisor. Dependent Adult Abuse is the willful infliction of any physical, verbal, corporal punishment, or physical restraint. The Administrator and DON notified immediately and other officials in accordance with state law. The Executive Director, Administrator or DON will report the incident immediately, but no later than 2 hours after forming the suspicion. The facility must report allegations of neglect or mistreatment that do not result in serious bodily injury no later than 24 hours after forming the suspicion. Section F revealed the procedure for investigation of an allegation of abuse: a. Protection and care for the resident, including medical interventions as needed. b. Remove the team member implicated in the alleged event immediately. c. Supervisor will interview the team member involved. d. Suspend the team member.e. Notify the Administrator and DON immediately and other officials in accordance with State law. If it appears that there is reasonable suspicion that the maltreatment may involve a crime, the Executive Director, Administrator or DON notifies the police.f. Contact the Medical Director as indicated. g. A root cause investigation and analysis will be completed.The investigation will include: Who was involved Resident's statements For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. A description of the resident's behavior and environment at the time of the incident Injuries present including a resident assessment Observation of resident and staff behaviors during the investigation Environmental considerations.The investigation and written findings are completed and reviewed with the Executive Director, Administrator, and the DON and/or designee. A plan for further action is determined with input from appropriate personnel. Completion of the Investigative Data Summary will ensue to prevent further occurrences as specified per policy. The results of the investigation will be recorded and attached to the report.

Based on clinical record review, facility investigation file review, staff interviews, and policy review, the facility failed to report and allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing within the required time for 2 of 2 residents reviewed for abuse (Residnt#1 and Resident#2). The facility reported a census of 86 residents. Findings include:A Complaint/Incident Investigation Report revealed the facility self-reported an allegation of abuse to DIAL on 11/14/25 at 1:42 PM. The incident occurred on 11/12/25 at approximately 9:40 PM. Resident #1 expressed to Staff F, Certified Nursing Assistant (CNA) anxiety and concerns about an interaction that took place overnight between 11/11/25 to 11/12/25 with Staff I, CNA. Resident #1 told Staff F that Staff I took her bed remote away when she had raised the foot of the bed too high, then Staff I threw the bed remote toward her and struck her wound vac. Staff I was placed on administrative leave on 11/13/25 at 4:30 PM pending the investigation. The Minimum Data Set (MDS) assessment form dated 8/15/25 revealed Resident #1 had diagnoses of Alzheimer's Disease, dementia, left femur fracture, and anxiety disorder. The resident admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognition intact. The assessment revealed the resident had dependence on staff for transfers, dressing, and toileting. The MDS documented the resident had hallucinations but no behaviors. The Care Plan revised on 9/4/25 revealed the resident had impaired cognitive functioning related to Alzheimer's disease and hallucinations, and had a high risk for falls related to confusion. The care plan directed staff to cue, reorient, and supervise the resident as needed, chart any hallucinations in the progress notes, and anticipate the resident's needs. A Head-to-Toe assessment dated [DATE] at 4:34 PM revealed the resident reported to the evening CNA that the overnight CNA on 11/11/25 had yelled at the resident when the resident had raised her bed up high, then the CNA hid the remote to her bed so that the resident could not access it. Resident then pushed her call light so she could elevate the head of her bed and the resident reported that the CNA yelled at the resident and threw the bed remote and the remote hit her wound vac machine. Resident alert and oriented times four (person, place, time, and event). Resident verbally denied any pain or discomfort. The on-call nurse was contacted and notified of the report. A Grievance Report was completed and given to the DON (Director of Nursing). The facility's investigative file provided to DIAL during the survey revealed the timeline of the incident: a. On 11/12/25 at approximately 9:40 PM, Resident #1 told Staff F, CNA, that Staff I, CNA, took the remote away from her so she did not have access to the bed remote. Resident #1 reported the event occurred the night prior to the overnight of 11/11 to 11/12/25. Resident #1 reported that the CNA took the remote away because she had raised the foot of her bed up too high. Staff I then left the room. Resident #1 stated she put her call light on because she wanted her remote back. Resident #1 reported to Staff F that Staff I came back into her room yelling and threw the bed remote and the remote hit her wound vac. b. On 11/12/25 at 9:45 PM, Staff F notified Staff G, Licensed Practical Nurse (LPN) of the incident. Staff G notified Staff H, Nurse Leader, of the incident and completed a Grievance Form. c. On 11/13/25 at approximately 9:00 AM, the Director of Health Services (DOHS) was made aware via a Grievance Form. d. On 11/13/25 at approximately 11:00 AM, DOHS and Staff K, Assistant Director of Nursing (ADON) interviewed Resident #1. Resident #1 stated Staff I came into her room the night before and took away her bed remote control. Resident #1 put her call light on to get her bed remote control back and Staff I tossed the bed control towards her, hitting her wound vac machine. e. On 11/13/25 at approximately 11:30 AM, the DOHS and the Clinical Quality Specialist interviewed Staff I. Staff I stated I did take her remote away from her at the time but if I hadn't done that she would have fallen out of bed. She wasn't in her right mind. She was telling me her husband was in bed with her. I didn't mean that to be a permanent thing. I was just trying to keep her safe. I told my nurse that the resident was confused. I did go back to her room later to check on her. I wasn't doing it trying to be mean. I was doing it for her safety. I don't remember if I gave her the bed remote when I went back into her room.f. On 11/13/25 at 4:30 PM, a head-to-toe assessment was done. g. Physician was notified on 11/13/25 at 5:40 PM, and family was made aware of incident at 5:56 PM. h. Staff I was suspended pending the investigation. The timeline did not include when DIAL was notified. A Grievance Form dated 11/12/25 filled out by Staff G, LPN, revealed the incident reported on 11/12/25 at 9:40 PM but the actual incident occurred on 11/11/25. The Summary of Concern revealed while Staff F was assisting Resident #1 in the bathroom, Resident #1 reported that Staff I had yelled at her because she had raised the foot of her bed up too high. Staff I then took the remote away from her so she did not have access to the bed remote. Resident #1 then pushed her call light because she wanted the head of her bed lowered and wanted the bed remote back. Resident #1 then reported that Staff I came into her room yelling and threw the remote and the remote hit her wound vac. Resident #1 also reported to Staff F that if Staff F said anything she would lie because she didn't want to get Staff I into trouble. During an interview on 11/19/25 at 1:25 PM, Resident #1 reported staff were treating her well but staff could be rougher than she thought they needed to be. Staff needed to know what was wrong with her leg so they knew how to take care of her because she fell and broke her leg. She did not recall how she fell. The surveyor inquired about what happened regarding the aide and remote. Resident #1 reported the CNA took the remote for the bed and she called her back in (to her room). The CNA was not too happy, she threw the remote and it hit her wound machine. The CNA told her not to make the bed go up and down. Resident #1 stated she needed her head and legs raised to make herself more comfortable. Resident #1 said she knew how to run the bed because she had been doing it a long time, since she had lived at the facility over a year. She had operated the bed all along and nobody told her not to. Resident #1 thinks she made the CNA mad when she challenged her. The CNA told her she was not supposed to use the remote but nobody had told her she could not use it before. Resident #1 reported she was surprised when the CNA threw the remote and she thought it was childish and done in anger.In an interview on 11/19/25 at 3:00 PM, Staff F, CNA, reported she was not working on the night of the incident with Resident #1 and Staff I but the resident told her about what happened. Resident #1 was on the toilet and wanted Staff F to stay in the bathroom with her. Resident #1 looked at her and said Can I tell you something but I don't want you to repeat it. Resident #1 told Staff F she had the foot of her bed raised and Staff I came in and was yelling and got angry with her, and took the remote from the bed. Resident #1 said she pushed call light. She wanted her head down but didn't have the remote. Staff I got angry with her again and took the remote and threw it, and it hit the machine on the resident's leg. Resident #1 said if someone came and asked her about it, she would deny and say she forgot. Staff F stated she finished cares with Resident #1 and went and told Staff G what happened. Staff G called the on-call manager and she was told to fill out a form (grievance). Staff F reported she also wrote a statement about the incident. In an interview 11/19/25 at 3:20 PM, Staff G, LPN, reported Staff F came and told her what Resident #1 told her. Staff F told her that the CNA yelled at her for raising her bed up. The CNA came in and took the remote, lowered the bed, and placed the remote out of reach. Resident #1 put the call light on. The CNA yelled at her again and threw the remote and it hit the wound vac. Staff G had Staff F write a statement, and Staff G called Staff H, the on-call nurse, and told Staff H about the concerns. Staff G reported she was told to fill out a grievance report and had Staff F write a statement. Staff G reported she attached the statement to the grievance report, then put the information in a manilla envelope and placed it under the DOHS door. Staff G reported she was going to go talk to Resident #1 but she was resting. Staff G figured the managers would go talk to the resident in the AM and Staff G did not want to irritate Resident #1. In an interview 11/19/25 at 3:45 PM, the Executive Director reported Staff H no longer worked at the facility. In an interview 11/24/25 at 4:00 PM, Staff H, LPN, reported she had received abuse training through Relias (online program). Staff H reported she became aware of a situation with Resident #1 and Staff I when she was notified by Staff G around 10:30 PM about the CNA yelling at or toward Resident #1, and the call light or bed remote was thrown toward Resident #1. Staff H stated she figured at 10:30 PM, there was not much she could do so said she would deal with it in the AM. She told Staff G to just make sure the aide was not working with the resident. She told Staff G to slip something under the DOHS's door regarding the incident. Staff H confirmed she did not call or report the incident to DIAL because she thought they had 24 hours and she would talk to the DOHS in the AM. Staff H reported she spoke with DOHS around 8:15 AM the following day (on 11/13/25). In an interview on 11/20/25 at 9:30 AM, the DOHS, reported she became involved in knowing about the situation with Resident #1 when she came to work and found a grievance form under her door. The DOHS reported she did not get a call from anyone about it. She called the CQS right away after she read the grievance, and went to check on Resident #1 to make sure she was ok. The DOHS reported Staff I was suspended. Staff H got termed because she did not report the incident to management or the State.In an interview11/20/25 10:15 AM, Staff I reported she was doing room checks. Resident #1 had the remote by her bed but she did not think the resident should have it. Resident #1 was sometimes not in her right mind. When she went in to do a room check, Resident #1's bed was high in the air. Staff I reported she took the remote and moved the bed down. Resident #1 was yelling at her. She told Resident #1 not to scream at her when she got the remote, then she shut the door because Resident #1 was yelling. Staff I reported she did not remember where she put the remote. Staff I reported she went to tell the nurse she needed to come help her and that Resident #1 was putting the bed in the air. Staff J went in and gave back the remote. 2. A Complaint/Incident Investigation Report revealed the facility self-reported an allegation of abuse to DIAL on 11/03/25 at 5:29 PM. The incident occurred on 10/31/25 at approximately 9:20 AM. Staff A, Certified Nursing Assistant (CNA) notified Staff E, Registered Nurse (RN) that Resident #2 refused to take a shower. Staff E was upset and said she did not have time for this shit and followed Staff A into the resident's bathroom. Staff E told Resident #2 she had to take a shower and the resident said no. Staff E then pried the resident's hand off the chair and forcefully took off her shirt. Resident #2 was uptight and clenching her hand as Staff E removed the resident's hand and shirt, and yelled no stop, stop right now, no no. On 10/31/25 at approximately 9:45 AM, Staff A reported the incident. Staff E was removed from the unit.The MDS assessment dated [DATE] revealed Resident #2 had diagnoses of anxiety disorder, depression, osteoarthritis, and muscle weakness. The MDS recorded the resident had a BIMS score of 11 out of 15, indicating moderately impaired cognition. The MDS indicated the resident required substantial to maximum assistance for upper body dressing and partial to moderate assistance for showering/bathing. The MDS revealed the resident had no behaviors during the seven-day look-back period. The Care Plan revealed Resident #2 required assistance with ADL's (activities of daily living). The Care Plan directed staff to cue, reorient and supervise as needed, present one thought or command at a time, and leave the resident alone in a safe position and retry the task in a few minutes if the resident was resistive to care (initiated 8/26/24).A Progress Note dated 10/31/25 at 10:32 AM revealed the resident became very agitated during a shower and was refusing to get in the shower. Nurse assisted resident with removing her clothing. Resident alert and oriented x 3. Staff H documented the Safety Measures implemented at that time to encourage the resident to take a shower and if refusing, try again at a later time.The facility's investigative file provided to DIAL during the survey revealed the timeline of the incident: a. On 10/31/25 at 9:20 AM, Staff A, CNA, notified Staff E, RN, that the resident was refusing her shower. Resident #2 continued to refuse a shower at that time. Staff A reported that when she spoke with Staff E, Staff E she was upset and said I don't have time for this shit and she followed Staff A into the bathroom and started telling Resident #2 she had to take a shower. The resident said no. Staff E then pried the resident's hand off the chair and then forcefully took off her shirt. Resident #2 was uptight and clenching her hands and saying no, stop this, stop right now, no, no as Staff E removed the resident's hand and shirt. b. On 10/31/25 at 9:45 AM, Staff A reported the incident. Staff E was removed from the unit and interviewed. The Facility's Investigation File did not list a date and time when the incident was reported to DIAL. In an interview on 11/20/25 at 1:50 PM, Staff C, Restorative Aide (RA), reported Staff A came to her and asked her if she worked at the facility. Staff A explained the situation that they had Resident #2 in the bathroom, Staff E was in the room and pried the resident's hand off of the chair and proceeded to take off her shirt. The CNA told Staff E she should not do that. The nurse left the room and said she was fed up with being there or fed up with the day. Staff A did not know who to tell. Staff C told her she would talk to someone and then went and talked to Staff D, Social Services (SS). In an interview on 11/20/25 at 1:30 PM, Staff D reported Staff C, RA, came to her on a Friday (10/31/25) and asked how she should proceed with a situation. Staff A was in the room with Resident #2 and Staff E was in the room. Staff A told her that Staff E removed the resident's hand from the rail and took her shirt off. Staff A told Staff E she needed to stop. Staff E walked out of the room and slammed the door. After that, Staff C told Staff A she would tell the appropriate people. Staff D reported she talked to the Executive Director and the DOHS. In an interview on 11/20/25 at 2:45 PM, the Executive Director reported the CQS and the DOHS were involved in the investigation of the incident with Staff E and Resident #2. In an interview on 11/25/25 at 10:55 AM, the CQS reported the facility expects the CNA to let the nurse know if a resident refused a shower so the CNA was letting the nurse know. The nurse was frustrated about that day. She started the investigation on a Friday and got staff statements and then determined to report the incident to DIAL the following Monday. In an interview on 11/25/25 at 11:10 AM, the Senior CQS reported they never tried to hide and not report abuse allegation. She attended the Leading Age conference in 5/2025. At that time, the DIAL Bureau Chief (BC) spoke and requested the facilities to gather information to determine if they had enough information to determine if it was really abuse. There had not been any situations that came up until the allegation in 10/31/25. There was confusion. The Leading Age Coordinator reached out to the DIAL BC and then an email was sent out to clarify the information brought up at the conference in 5/2025 related to reporting of abuse. The Senior CQS provided a copy of the email from the Leading Age Coordinator dated 11/18/25 to the surveyor.The facility's Abuse Policy and Resident Protection Plan last approved 7/2025 revealed any team member who becomes aware of abuse, mistreatment, neglect, or misappropriation shall immediately report to their immediate supervisor. Dependent Adult Abuse is the willful infliction of any physical, verbal, neglect, corporal punishment, or physical restraint. The Administrator and DON notified immediately and other officials in accordance with state law. The Executive Director, Administrator or DON will report the incident immediately, but no later than 2 hours after forming the suspicion. The facility must report allegations of neglect or mistreatment that do not result in serious bodily injury no later than 24 hours after forming the suspicion. Failure to report within mandated timeframes are subject to a civil money penalty.

Based on clinical record review, policy review, and staff interviews, the facility failed to create and implement interventions to prevent a fall which resulted in an ER visit for 1 of 3 residents reviewed for falls(Resident #20). The facility reported a census of 95 residents. Findings include:The Minimum Data Set (MDS) assessment tool, dated 5/20/25, listed diagnoses for Resident #20 which included fracture, non-Alzheimer's dementia, and arthritis. The MDS stated the resident sustained a fracture related to a fall in the 6 months prior to admission and stated the resident required partial/moderate assistance for chair and toilet transfers. The MDS listed a Brief Interview for Mental Status (BIMS) score as 11 out of 15, indicating moderately impaired cognition. The facility Accident/Incident Investigation and Reporting Policy and Procedure, revised 4/2025, stated the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision to prevent avoidable accidents. The policy directed staff to initiate new interventions after a fall to attempt to prevent recurrence and to add the interventions to the Communication Board for immediate availability to team members. A 5/12/25 Fall Risk Assessment, dated 5/12/25, stated the resident was at high risk for falls.Nurses Note on 5/18/25 at 2:09 a.m. documented staff found the resident on her left side and the resident stated she went to the bathroom and fell when she tried to get back to the recliner.Care Plan entries, dated 5/20/25, stated the resident was at risk for recurrent falls related to a history of falls, decreased cognition, and decreased safety awareness. The entries directed staff to determine causative factors, keep personal items close, encourage the resident to stay in common areas, and wear non-skid footwear. A 5/22/25 2:45 a.m., Unwitnessed Fall report stated the resident laid on the floor with her knees bent and stated she hit her head and her scalp was tender. The resident was confused and thought it was time to get up. The Care Plan lacked an intervention related to the resident's 5/22/25 fall. Social Services Note dated 5/22/25 at 9:03 a.m. documented the resident admitted to the facility from Assisted Living (AL) on 5/12/25. She had a fall in the AL which resulted in a trip to the ER and therefore was no longer qualified to be at that level of care. A 5/25/25 4:40 p.m. Unwitnessed Fall report stated the resident was wedged between folding chairs and stated she went to the bathroom. The resident had a goose egg on the back of her head. The Care Plan lacked an intervention related to the resident's 5/25/25 fall. A 6/4/25 Orthopedic Clinic report stated the resident had an ankle fracture from an injury 6 weeks ago.A 6/7/25 3:30 p.m. Unwitnessed Fall report stated the resident's call light came on the screen and a Certified Nursing Assistant (CNA) said she had to get to the resident's room right away or she would get up on her own. The CNA was almost to her room when she heard a loud crash. The resident was on the floor with blood everywhere and she stated her head hurt. A 6/7/25 3:50 p.m. Nurses Note stated the resident fell in her room and hit the back of her head and it bled profusely but then stopped. The resident's daughter declined to send the resident to the ER. A 6/7/25 7:45 p.m. Nurses Note stated the resident had a 3.6-centimeter(cm) laceration to the back of her head with a moderate amount of bright red blood. Staff called the resident's daughter and suggested an ER visit. The daughter picked up the resident at approximately 9:00 p.m. and called back at 11:15 p.m. to say the resident was admitted for observation for four brain bleeds. A hospital History and Physical Report, dated 6/7/25, stated the resident presented to the ER due to a fall. The resident sustained a 7 inch gash and the computerized tomography(CT) scan(a scan which used a series of X-ray images taken from different angles to create detailed cross-sectional images of the inside of the body, helping doctors diagnose conditions, plan treatments, and monitor disease progression) showed several areas of intraparenchymal hemorrhages(bleeding directly into the brain's tissue [parenchyma] and often caused by head trauma). A 6/28/25 4:48 p.m. Unwitnessed Fall report stated the resident laid on the floor and stated she was going to the bathroom. She had no injuries. A 6/30/25 Unwitnessed Fall report stated the resident was found on the floor on her back between the recliner and the other side of the chair. The resident stated she hit her head. A 7/1/25 Care Plan entry directed staff to offer the resident toileting assistance before and after meals. A 7/2/25 Unwitnessed Fall report stated staff found the resident on the floor between her chairs in her room. The resident said she had to go to the bathroom. A 7/5/25 Unwitnessed Fall report stated the resident was on the floor and her head hurt and was bleeding. The resident stated she tried to move the table to go to the bathroom. The Care Plan lacked documentation of further interventions related to the above falls using root cause analysis to create preventative measures.On 8/20/25 at 1:28 p.m., Staff A Registered Nurse (RN) stated after a resident fell they had to come up with a new intervention add it to the care plan. On 8/20/25 at 3:27 p.m., the Director of Nursing (DON) stated for each fall, they came up with an intervention and immediately added it to the care plan. She stated with regard to Resident #20, she would do some research to find out which interventions were implemented. On 8/21/25 at 11:22 a.m., Staff K CNA stated Resident #20 got up on her own and fell. She stated they tried to toilet her every two hours but even with this, she got up by herself. When queried regarding any interventions that the facility directed her to carry out in order to prevent the resident from falling, Staff K could not name any. Staff K did say that she closed the bathroom door so the resident was not cued to get up but stated she figured this intervention out on her own. On 8/21/25 at 1:42 p.m., the DON stated she did not find any additional interventions for the resident on the care plan. She stated the team came up with interventions but they did not make it on the care plan. She stated she was not sure why this happened.

Based on clinical record review, observation, staff interview and review of facility policy, the facility failed to give an insulin prior to the meal as ordered for one of one residents observed who received insulin during medication pass (Resident #25). The facility reported a census of 95 residents.The Quarterly Minimum Data Set (MDS) Assessment, dated 7/3/25, revealed Resident #25 had a diagnosis of diabetes. The MDS documented the resident took insulin during the 7-day lookback period. The Medication Administration Record (MAR), dated August 2025, for Resident #25 listed Lispro 100 milligrams (mg)/milliliter (ml), inject subcutaneously (SQ) per sliding scale before meals for blood glucose (sugar) 0-150=zero units (U); 151-200=6U; 201-250=8U; 251-300=10U; 301-350=12U; 351-400=14U and scheduled at 7:00 AM, 11:00 AM and 4:00 PM. The MAR revealed Staff E, Registered Nurse (RN), administered 10 U SQ on 8/19/25 at 5:58 PM.On 8/19/25 at 4:26 PM, observation of Staff E, RN, revealed Staff E obtained Resident #25's blood glucose level which measured 280. Staff E then pushed Resident #25's wheelchair to a table in the dining room. In an interview during the observation, Staff E, RN, reported he planned to hold the administration of the Lispro Insulin until after the resident ate their supper due to concerns with food intake for the lunch and breakfast meals that day (8/19/25). On 8/19/25, continuous observation from 4:26 PM to 5:58 PM revealed the following:a. At 5:04 PM, Staff E, RN, administered Buspar 15 mg, Lorazepam 1mg, Metoprolol 12.5 mg and Nitrofuran 100 mg to Resident #25.b. At 5:07 PM, Resident #25 received her dinner meal of grilled cheese, tomato soup and a sliced fruit cup.c. At 5:31 PM, Resident #25 had finished eating and had consumed 75 percent of her meal.d. At 5:46 PM, Resident #25 was observed to have her eyes closed and neck flexed down while sitting at the table. e. At 5:53 PM Staff E,RN, woke up Resident #25 and pushed her wheelchair to her room.f. At 5:55 PM, Staff E, RN, administered 10 U of Lispro Insulin SQ via a flex pen to Resident #25's left lower outer abdominal area. Review of Resident #25's clinical record including physician orders, MAR and progress notes revealed a lack of documentation of physician orders or notification of the delay in administration of the Lispro insulin on 8/19/25. The nutrition intake record, dated 8/19/25, revealed Resident #25 ate 75 to 100 percent breakfast, lunch and dinner. On 8/21/2025 at 10:19 AM, the Director of Nursing (DON) reported the facility policy to notify the resident's physician if the nurse need to administer a medication outside of order parameters. The DON reported a nurse should not use nursing judgement to change an insulin order; the nurse needed to contact the physician in order to change an insulin order. The DON reported she recently provided education to her nursing staff on this same issue. The DON explained Staff E, RN, would not have received this education due to Staff E working through an agency and not directly through the facility. Review of the facility policy, titled Medication Administration, dated 8/2024, revealed staff administering medications would ensure medications were administered per physician orders and at the right time. According to the American Academy of Family Physicians (AAFP) Insulin Lispro should be injected under the skin within 15 minutes before you eat.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the availability of routine medications for 1 of 4 newly admitted residents(Resident #99). The facility reported a census of 95 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 4/27/25, listed diagnoses for Resident #99 which included rheumatoid arthritis, weakness, and depression and listed the resident's Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The MDS documented that the resident was admitted on [DATE] from a hospital.The undated facility policy Pharmacy-Initiated Order Workflow stated the nurse received a signed order from the prescriber and faxed it to the pharmacy. The pharmacy then processed the medication and delivered it to the facility. The procedure did not address what staff should do if a medication did not arrive from the pharmacy. A 4/25/2025 10:30 a.m. Clinical admission entry stated the resident admitted to the facility. The April Medication Administration Record(MAR) listed the following 4/25/25 orders: a. Alrex suspension 0.2%(an eye drop used to treat allergies of the eye), instill one drop in both eyes. The following doses lacked a checkmark to indicate staff administered the medication and had 9 for the entry which referred to the resident's Progress Notes: 5/25/25 4:00 p.m. and 8:00 p.m. doses, 5/26/25 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. doses, 5/27/25 12:00 p.m. and 4:00 p.m. doses.B. Pregabalin (a medication used to treat nerve pain) 100 milligrams(mg) three times per day. The following doses lacked a checkmark to indicate staff administered the medication and had 9 for the entry which referred to the resident's progress notes: 5/25/25 4:00 p.m. dose, 5/26/25 8:00 p.m. dose, 5/27/25 6:00 a.m. 12:00 p.m., and 8:00 p.m. dosesC. Duloxetine (an antidepressant) 30mgs 1 capsule twice daily. The 5/25/25 4:00 p.m. entry lacked staff initials to indicate staff administered the medication and had a 9 for the entry which referred to the progress notes. Progress Notes entered on the following dates and times stated that the resident's Alrex eye drop was not available: 4/25/25 5:53 p.m., 4/25/25 9:07 p.m., 4/26/25 9:33 a.m., 4/26/25 11:12 a.m., 4/26/25 6:02 p.m., 4/26/25 8:41 p.m., 4/27/25 10:45 a.m. Progress Notes entered on the following dates and times stated that the resident's Pregabalin was not available: 4/25/25 2:18 p.m., 4/26/25 9:11 a.m., 4/27/25 11:05 a.m.A 4/25/25 2:17 p.m Progress Note stated the resident's Duloxetine was not available. The Progress Notes did not contain documentation the facility staff contacted the pharmacy to follow up on the missing medications.A 4/27/25 7:00 p.m., Nurses Note stated the resident left the facility with her spouse Against Medical Advice(AMA). On 8/20/25 at 1:28 p.m., Staff A Registered Nurse(RN) stated when Resident #99 admitted they had trouble getting her Pregabalin. She stated she received education that she should call the provider to obtain the medication. She stated it wasn't appropriate to just wait for the pharmacy. On 8/20/25 at 3:27 p.m., the Director of Nursing(DON) stated if a medication did not arrive from the pharmacy, staff could call for a stat delivery. If the resident didn't come with an order, staff should reach out to the provider and obtain an order for the medication or an order to hold.

Based on clinical record review, observation, staff interview, and policy review, the facility failed to assure a medication error rate of less than 5%. During observation of medication administration, the facility had 3 errors out of 27 opportunities for error resulting in an error rate of 11.11% (Residents #25 and #66). The facility identified a census of 95 residents.1. The Quarterly Minimum Data Set (MDS) Assessment, dated 7/3/25, revealed Resident #25 had a diagnosis of diabetes. The MDS documented the resident took insulin during the 7-day lookback period. The Medication Administration Record (MAR), dated August 2025, for Resident #25 listed Lispro 100 milligrams (mg)/milliliter (ml), inject subcutaneously (SQ) per sliding scale before meals for blood glucose (sugar) 0-150=zero units (U); 151-200=6U; 201-250=8U; 251-300=10U; 301-350=12U; 351-400=14U and scheduled at 7:00 AM, 11:00 AM and 4:00 PM. The MAR revealed Staff E, Registered Nurse (RN), administered 10 U SQ on 8/19/25 at 5:58 PM.On 8/19/25 at 4:26 PM, observation of Staff E, RN, revealed Staff E obtained Resident #25's blood glucose level which measured 280. Staff E then pushed Resident #25's wheelchair to a table in the dining room. In an interview during the observation, Staff E, RN, reported he planned to hold the administration of the Lispro Insulin until after the resident ate their supper due to concerns with food intake for the lunch and breakfast meals that day (8/19/25). On 8/19/25, continuous observation from 4:26 PM to 5:58 PM revealed the following:a. At 5:04 PM, Staff E, RN, administered Buspar 15 mg, Lorazepam 1mg, Metoprolol 12.5 mg and Nitrofuran 100 mg to Resident #25.b. At 5:07 PM, Resident #25 received her dinner meal of grilled cheese, tomato soup and a sliced fruit cup.c. At 5:31 PM, Resident #25 had finished eating and had consumed 75 percent of her meal.d. At 5:46 PM, Resident #25 was observed to have her eyes closed and neck flexed down while sitting at the table. e. At 5:53 PM Staff E,RN, woke up Resident #25 and pushed her wheelchair to her room.f. At 5:55 PM, Staff E, RN, administered 10 U of Lispro Insulin SQ via a flex pen to Resident #25's left lower outer abdominal area. Review of Resident #25's clinical record including physician orders, MAR and progress notes revealed a lack of documentation of physician orders or notification of the delay in administration of the Lispro insulin on 8/19/25. The nutrition intake record, dated 8/19/25, revealed Resident #25 ate 75 to 100 percent breakfast, lunch and dinner. On 8/21/2025 at 10:19 AM, the Director of Nursing (DON) reported the facility policy to notify the resident's physician if the nurse need to administer a medication outside of order parameters. The DON reported a nurse should not use nursing judgement to change an insulin order; the nurse needed to contact the physician in order to change an insulin order. The DON reported she recently provided education to her nursing staff on this same issue. The DON explained Staff E, RN, would not have received this education due to Staff E working through an agency and not directly through the facility. 2. The Electronic Health Record (EHR) Medical Diagnosis list revealed Resident #66 had a diagnoses of dysphagia (difficulty swallowing) and hypothyroidism (low functioning thyroid gland). A faxed Physician Communication and order, dated 1/15/25, included documentation of a request by facility nursing staff to change the administration time of Omeprazole and Levothyroxine. The ordered time had been at 5:30 AM every day, and the physician agreed to change the time of administration to be between 6:00 AM to 10:00 AM, as long as the Omeprazole was administered 20 to 30 minutes before breakfast, and Levothyroxine was administered on an empty stomach 1 hour before food intake. The EHR included an order summary of the following medications: a. Omeprazole 20 mg, take one capsule by mouth daily 30 minutes before meals and an order start date of 1/16/25. b. Levothyroxine 75 micrograms (mcg), take one tablet by mouth on an empty stomach at least 30 minutes before meals and an order start date of 1/16/25. Review of the MAR, dated August 2025, for Resident #66 revealed Staff F, Licensed Practical Nurse (LPN), administered Omeprazole 20 mg, one capsule by mouth 30 minutes before meals, and Levothyroxine 75 mcg one table by mouth on an empty stomach 30 minutes before meals. On 8/20/25 at 8:39 AM, observation of Resident #66 revealed the resident was sitting at a table in the dining room eating hot cereal. On 8/20/2025 at 8:57 AM, observation of Staff F, LPN, revealed Staff F placed the following medications into a pill cup: Aspirin 81 mg one tablet, Omeprazole 20 mg capsule, Levothyroxine 75 mcg one tablet, Calcium-Vitamin D3 600-800 mg one tablet, Gabapentin 300 mg one capsule, Lisinopril 10 mg one tablet, Metoprolol tartrate 50 MG one tablet, Vitamin D3 1000 units one tablet, and Sertraline 50 mg one tablet. Staff F separated out the 2 capsules, crushed the tablets, emptied the contents of the capsules into the crushed tablets. Staff L placed the medications into chocolate pudding. Resident #66 was sitting at the dining room table and had already ate breakfast. Staff L administered the medications by feeding bites of the pudding to the resident. The Assistant Director of Nursing (ADON) was present throughout the medication administration. On 8/20/2025 at 8:59 AM, when asked why the Omeprazole had been administered outside of the physician ordered parameter of 30 minutes before breakfast, Staff L, LPN, explained that she believed the resident was care planned to take Omeprazole with other medications, because the resident a hard time with swallowing and was very confused. On 8/20/2025 at 9:01 AM, the ADON explained that staff had probably not requested to have the before meals statement removed from the medication order. The ADON reported they needed to reach out to the pharmacy to have that statement removed. Review of Resident #66's clinical record including physician orders, MAR and progress notes revealed a lack of documentation of physician orders or notification of the delay in administration of the Omeprazole and Levothyroxine on 8/20/25. Review of the facility policy, titled Medication Administration, dated 8/2024, revealed staff administering medications would ensure medications were administered per physician orders and at the right time. Resident preference would be given for administration time unless the preference contradicted the physician order.

Based on record review, observation, staff interview, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents reviewed for pressure ulcers (Resident #92). The facility reported a census of 95 residents.Findings include:1. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed that Resident #92 had an unhealed, unstageable pressure injury presenting as a deep tissue injury.The Care Plan initiated on 4/8/25 indicated that Resident #92 has a pressure ulcer related to immobility. The Care Plan initiated the focus area with revision date of 4/9/25 documented the resident with self care deficits for activities of daily living related to dementia, and directed the staff to provide two staff to assist with toilet use, and transfers.The Electronic Health Record (EHR) indicated that the location of the pressure ulcer was located on the right dorsum of the first metatarsal.In an observation on 8/19/2025 at 2:44 PM Staff H, CNA Staff I, CNA performed toileting and transfer with Resident #92. Staff G, CMA was present also present. Staff H, CNA cleansed peri area and changed gloves without performing hand hygiene in between. Staff H, CNA then removed old pull-up, placed new pull up and pulled up Resident #92's pants. After Staff H, CNA and Staff I, CNA transferred Resident #92 to her Broda chair with a mechanical lift, Staff H, CNA grabbed Resident #92's water pitcher by the handle and gave Resident #92 a drink with her gloves still on. Finally, personal protective equipment was removed and hand hygiene was performed.In an observation on 8/21/2025 at 10:37 AM Staff D, LPN performed wound care to right inner foot pressure wound on Resident #92. Staff C, LPN was also present. Staff D, LPN took off the old dressing and proceeded to cleanse with wound cleanser without changing gloves. After cleansing and drying, she changed gloves without hand hygiene in between. When she finished with the dressing change, Staff D, LPN put away the cleanser in a cabinet in the room with the same gloves on and threw away her trash. Staff D, LPN then removed her gloves and, without gloves or hand hygiene, changed the trash. She then carried the trash to the door where she used hand sanitizer with the trash still in her hand.In an interview on 08/21/2025 at 11:30 AM the DON stated that hand hygiene should be performed between all glove changes and after removing a dirty dressing. Stated items such as cabinets, sanitizer bottles or water pitchers that were contaminated should be sanitized.In a document titled Infection Control Manual last revised 7/2022, a document titled Hand-Washing Technique indicated staff should always wash hands after handling a source that is likely to be contaminated, such as equipment, dressings, and secretions and excretions from residents. The document lacked information on hand hygiene between changing of gloves.

Based on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility failed to offer the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #25). The facility reported a census of 95 residents.Review of CDC guidelines, dated 10/2024, revealed the following recommendations:Administer Prevnar 20 (PVC20), Prevnar 21 (PVC21), or Vaxneuvance (PVC15) for all adults 50 years or older who have never received any pneumococcal conjugate vaccine, or whose previous vaccination history is unknown.Review of the clinical record for Resident #25 revealed the following:The Quarterly Minimum Data Set (MDS) assessment, dated 7/3/25, identified an admission date of 7/12/24, the resident was over age [AGE], and had diagnoses that included diabetes and dementia. The assessment identified had a severe cognitive impairment. An Informed Consent for Pneumococcal Vaccine, dated 7/12/24, included a signature of authorization by the power of attorney (POA) for Resident #25 to receive the pneumococcal vaccine.On 8/20/25, review of the clinical record for Resident #25's immunization status revealed a lack of documentation on whether Resident #25 had ever received the Pneumovax (PPSV23) vaccine, or any of the pneumococcal conjugate vaccines, Prevnar 20 (PVC20), Prevnar 21 (PVC21), Vaxneuvance (PVC15) per CDC guidelines. On 8/20/2025 at 11:16 AM, the Director of Nursing (DON) explained the facility contracted with a pharmacy to track and oversee the administration of vaccines to the residents. The DON reported she had a spreadsheet with the residents and the vaccines they had received. She was unable to find evidence on the spreadsheet that Resident #25 had received the pneumococcal vaccine. The DON was unsure why the resident would not have received the vaccine.On 8/21/2025 at 10:27 AM, the DON confirmed Resident #25 had not received the pneumococcal vaccine. The DON contacted the pharmacy and the resident would be given the vaccine.Review of the facility policy, titled Infection Prevention Thru Immunization, dated 8/2025, revealed that all residents would be assessed for eligibility per CDC guidelines and offered the pneumococcal vaccine.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure staff attempted non-pharmacological interventions prior to the administration of as needed(prn) anti-anxiety medications for 1 of 3 residents reviewed for anti-anxiety medications(Resident #3). Along with the anti-anxiety medication a opiod analgesic (strong pain med) was also given in most cases at the same time with no non-pharmalogical interventions for relief of pain attempted, or waiting for effectiveness of either medication. The facility reported a census of 95 residents.Findings: The Minimum Data Set(MDS) assessment tool, dated 8/1/25, listed diagnoses for Resident #3 which included depression, mild cognitive impairment, and muscle weakness. The MDS stated the resident had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 1 to 3 days out of the 7 day review period. The MDS stated the resident had inattention and disorganized thinking. The Care Plan for R#3 identified a focus are as an alteration in musculoskeletal status related to left pubic fracture, lumbar disc degeneration, osteoarthritis, and knee pain initiated on 8/12/25 with the following interventions; Give analgesics as order by the physician. Monitor for side effects and effectiveness. Heat/cold applications as ordered and as tolerated.A NADV Clinical admission note dated 7/28/25 at 10:58 a.m. documented the following; Pain: location left hip. pain score: 6 stabbing. Frequency: multiple times a day. Relaxation techniques encouraged. Distraction techniques utilized. Non-medication interventions provided relief. Scheduled medication provided. The facility policy Psychotropic Use Guide-Routine/PRN, dated 3/2025, stated residents who used psychotropic drugs received gradual dose reductions and non-pharmacological interventions in an effort to discontinue these drugs.The August 2025 Medication Administration Record(MAR) listed the following orders:A. A 7/31/25 order for lorazepam(an anti-anxiety medication) 0.5 milligrams(mg) every 4-6 hours as needed for agitation. The MAR documented the resident received the medication at the following times: 8/1/25 at 7:59 p.m., 8/2/25 at 7:48 p.m., 8/4/25 at 7:00 p.m.B. An 8/5/25 order for lorazepam 0.5 mg twice daily as needed for agitation. The MAR documented the resident received the medication at the following times: 8/6/25 at 3:25 p.m. and 8:20 p.m., 8/7/25 at 10:00 a.m. and 8:01 p.m., 8/9/25 at 9:01 a.m., 8/12/25 at 8:23 p.m., 8/13/25 at 9:09 p.m., 8/14/25 at 2:33 p.m., 8/17/25 at 8:45 p.m., 8/1825 at 7:57 p.m.C. A 7/31/25 order for Oxycodone 2.5mg twice a day as needed for pain. The MAR documented the resident received the medication at the following times; 8/6/25 p.m. 8:00 p.m., 8/7/25 at 10:01 a.m., and 8:01 p.m., 8/9/25 at 9:02 a.m., 8/12/25 at 8:23 p.m., 8/13/25 at 9:09 p.m., 8/13/25 at 9:09 p.m., 8/14/25 at 2:36 p.m., 8/17/25 at 8:45 p.m.The MAR lacked documentation of non-pharmacological interventions staff attempted prior to the above administrations, or waiting for effectiveness between giving an additional as needed (PRN) medication. The resident's Progress Notes also lacked documentation of non-pharmacological interventions staff attempted prior to the above administrations. On 8/20/25 at 1:28 p.m., Staff A Registered Nurse(RN) stated prior to the administration of prn anti-anxiety medications, staff should document other non-pharmacological interventions attempted. On 8/20/25 at 3:27 p.m., the Director of Nursing(DON) stated staff should chart non-pharmacological interventions prior to the administration of anti-anxiety medications.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure safe and accurate delivery of oxygen therapy for one of three residents reviewed for respiratory care (Resident #86). The facility reported a census of 95 residents.Findings include:1. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #86 had diagnoses of heart failure, hypertension, respiratory failure, pulmonary hypertension and congestive heart failure with hypoxia.The Care Plan initiated on 7/3/25 indicated that Resident #86 has oxygen therapy related to congestive heart failure (CHF) and gets oxygen via nasal cannula (nc) continuously. It lacked information related to the liters of oxygen flow ordered.The Clinical Physician's Orders dated 6/24/25 directed staff to provide the resident oxygen continuous at 4 liters via nc continuous, and two times a day check oxygen saturation levels with an indefinite end date.The Electronic Treatment Administration Record (EMAR) indicated that Resident #86 was to have the oxygen tubing and humidification unit changed weekly on Tuesdays. It also indicated that they were changed on 8/13/25.The Electronic Treatment Administration Record (ETAR) indicated that Resident #86 was receiving oxygen via nc at 4 liters continuous through the morning of 8/19/25. It was confirmed 2 times daily with an oxygen saturation test.Observations revealed the following:a. On 8/18/25 at 1:43 PM Resident #86 had the oxygen tubing in her nose but the room oxygen concentrator was not turned on.b. On 8/18/25 at 2:18 PM Resident #86 had oxygen on via nasal cannula but unable to see flow rate as visitor in room.c. On 8/19/25 at 9:00 AM Resident #86 was sitting in recliner in room with oxygen off and room concentrator off. Requested this surveyor put on or get staff to help.d. On 8/19/25 at 10:56 AM Resident #86 was sitting in her recliner with her eyes closed. The oxygen tubing and humidification unit for the concentrator were labeled 8/11/25. The oxygen was set at just under 2 liters via nasal cannula.e. On 8/19/25 at 2:29 PM the oxygen tubing and humidification unit for the room concentrator for Resident #86 were still labeled 8/11/25. Picture confirmation taken.f. On 8/20/25 at 8:34 AM Resident #86 was sitting in her recliner with oxygen tubing in her nose connected to the portable concentrator on her wheel chair. The portable concentrator was off. Tubing to portable oxygen concentrator was labeled 8/13/25.In an interview on 08/19/2025 at 9:05 Staff B, CNA stated that Resident #86 can be off of her oxygen when she is out of her room and it is as needed in her room. Stated she will put on Resident #86 if she is requesting it. In an interview on 08/20/2025 at 9:18 AM Staff A, RN stated that Resident #86's oxygen order was just changed to as needed. This surveyor informed Staff A, RN that Resident #86 had her oxygen tubing via nc on but the portable and room concentrators were off. Stated that was no ok and she went to Resident #86's room. She then switched Resident #86 from the portable oxygen concentrator to the room oxygen concentrator and plugged the portable oxygen concentrator in to a wall outlet. Stated the oxygen tubing is changed weekly. Staff A, RN noted that the humidification unit and it's short tubing were dated 8/11/25 and stated that she would change those. Stated current oxygen order is at 2 liters via nasal cannula as needed and can be from 2-4 liters. After questioning what the unit was currently set at, Staff A, RN stated 2 liters. She was looking at the settings from above. Stated that the line had to be in the middle of the bubble. This surveyor reminded Staff A, RN to read the settings from eye level. Staff A, RN looked straight on and stated it was not on 2 liters and increased the rate.In an interview on 8/20/2025 at 10:30 AM Staff C, LPN stated they got the verbal order from Hospice on 8/8/25 for the oxygen to be 4 liters nasal cannula as needed for dyspnea. Stated that staff were aware and they have been following that since then. Stated that they did not change the order under the orders tab in Point Click Care (PCC) as they did not have the signed written order back until 8/19/25. Stated that it is not acceptable for nurses to be charting in the EMAR that Resident #86 is getting 4 liters continuous when she is not. Also stated not acceptable for Resident #86 to be on 2 liters currently since the order says 4 liters as needed.In a document titled Oxygen Therapy and Portable Oxygen Tank, lacked documentation on following doctor's orders related to proper liter flow or correctly reading liter flow on an oxygen concentrator. It also lacked direction on properly documenting oxygen usage.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure that a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for 2 of 20 residents reviewed for care planning (Resident #7 and #8). The facility reported a census of 95 residents.Findings include:1. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #7 had diagnoses of non-Alzheimer's dementia and anxiety. The MDS also indicated that Resident #7 had delusions and rejected care 1 to 3 days in the 7-day look back period. The Physician's Orders revealed that Resident #7 was prescribed 1 milliliter (mL) of a compound ointment topically to inner wrist every 8 hours as needed for agitation. Each mL of compound ointment included: Lorazepam 1 milligram (mg), Diphenhydramine 12.5 mg and Haloperidol 2 mg. In an interview on 8/21/2025 at 9:32 AM Staff C, Licensed Practical Nurse (LPN) stated that she created the care plans for North and South [NAME]. Stated she gets the information for the care plans for new residents from their medications, diagnoses, assessments and through interviews. Staff C, LPN added that she looks at new orders that come in. Staff C, LPN stated that antipsychotic medications should be on the care plan as well. Stated that Haldol, even in a compound ointment, should be on the care plan as an antipsychotic. Staff C, LPN stated that Resident #7 did not have it on her care plan. She also stated she must have missed it as Resident #7 came in with no medications. 2. The Significant Change MDS assessment dated [DATE] revealed Resident #8 had diagnoses of senile degeneration of the brain and cerebral palsy. The MDS indicated the resident was on hospice. The Care Plan revised 7/21/25 revealed Resident #8 was on hospice care services. The care plan lacked information related to oxygen (O2). The Order Summary revealed an order for O2 via nasal cannula (NC) to keep the resident's O2 saturation above 90% (percent) as needed for shortness of breath and for comfort measures. The O2 order had a start date of 8/11/24. The Electronic Health Record (EHR) Weights and Vitals section documented O2 via NC on 5/23/25, 7/4/25, and 7/6/25. Observation on 8/18/25 at 1:32 PM revealed Resident #8 sat in a wheelchair in her room without O2 on. An O2 concentrator sat near the door in the resident's room. In an interview on 8/21/25 at 9:32 AM, Staff C, LPN, stated that she developed the residents' care plans for the North and South [NAME] units. Staff C reported she obtained information for the care plans from the resident's orders, medication list, diagnoses, assessment and through resident and staff interviews. Staff C stated she also looked at any new orders that came in. Staff C stated that oxygen should be on the resident's care plan. 3. The admission MDS dated [DATE] revealed Resident #2 had diagnoses of end-stage renal disease, diabetes mellitus, stage 3 sacral pressure ulcer, and neuromyopathy (damage to both peripheral nerves and muscles, resulting in muscle weakness, sensory loss, difficulty with movements, balance, and coordination). The MDS indicated the resident required substantial/maximal assistance with all transfers. The admission Care Plan dated 6/19/25 revealed Resident #2 is an assist of 1 with front wheel walker (FWW) for transfers. Review of Physician Progress note dated 8/19/25 documented Resident #2's use of EZ stand (mechanical device used to assist to standing position and transfer) for transfers. In an interview on 8/21/25 at 4:10 PM, Staff J, Assistant Director of Healthcare, RN, stated since admission Resident #2 requires the use of an EZ stand for transfers. A Comprehensive Care Plan Process policy last revised 12/2021 revealed the facility must develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to provide additional interventions, and supervision after Resident#1 displayed exit seeking behaviors. The facility also failed to secured the facility's exterior doors so that cognitively impaired residents could not leave the building without staff knowledge. This resulted in Resident #1 leaving the building without the staff's knowledge in 29 degree Fahrenheit weather. The staff only realized Resident #1 had left the building when a visitor found Resident #1 lying on the ground. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident and for 3 of 3 additional cognitively impaired, independently mobile residents with access to this door (Residents #5, #6, #7). The facility identified a census of 93 residents. The State Agency (SA) informed the facility of the Immediate Jeopardy (IJ) on 2/19/25 at 3:35 p.m. The IJ began on 1/26/25, the day Resident #1 left the facility without staff's knowledge. Facility staff removed the Immediate Jeopardy on 2/20/25 through the following actions: -Wanderguard (a system that uses bracelets, sensors, and technology to monitor residents and prevent wandering) placed on Resident #1. -Staff education regarding elopement policy, elopement drills, significant change assessments, response to door alarms. -Elopement assessments on all residents with a Brief Interview for Mental (BIMS) score less than 11. -Sign place on exit doors for families as reminder to not assist someone out the door and to notify team members. -Alarms activated on egress doors in Overijessel (OV) and Utrecht (UT) households -Barrel lock installed on patio door connecting OV/UT -Remote notification alarm installed between the long-term care area and the assisted living area -Door lock installed on Gelderland household dining room door. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: The Significant Change in Status Minimum Data Set (MDS) assessment tool for Resident#1, dated 12/27/24, listed diagnoses which included senile degeneration of the brain, heart failure, and depression. The MDS stated the resident required substantial to maximal assistance for standing and partial to moderate assistance for walking. The MDS listed the residents Brief Interview for Mental Status (BIMS) score as 3 out of 15, indicating severely impaired cognition. Care Plan entries, dated 5/31/23, documented the resident had short and long term memory impairment and had confusion as to date, time, and family members. The facility Elopement Precautions Policy, updated July 2024, stated the facility had electronic door alarms which sounded when opened and should remain activated at all times. The policy also documented that any resident, regardless of location , if consistently exit seeking should have an electronic monitoring device. An 11/13/24 Care Plan entry stated the resident required the assistance of 1 staff with a walker. A 12/1/2024 at 3:36 p.m. Behavior Note stated the resident was very agitated and stated (the facility) was holding him there and he wanted to go outside. The resident kicked below the window in the dining room and tried to pull the window sill out to put the window up. Review of the Care Plan revealed that the facility staff did not identify Resident #1 as displaying potential elopement warning signs on 12/1/24, and the facility staff did not implement any additional nursing supervision interventions to address Resident #1's increased elopement risk. A 12/15/2024 at 4:20 p.m. Nurses Note stated the resident became very confused. He pushed his walker and thought he was driving and was trying to get back to [city name, city where resident currently resided]. Review of the Care Plan lacked additional nursing supervision interventions after Resident#1 displayed potential elopement warning signs on that were documented in a Nurses Note dated 12/15/24. A 12/26/24 at 5:48 p.m. Elopement Evaluation stated the resident was not at risk for elopement. A 1/14/2025 at 8:40 p.m. Incident: Post Follow Up note stated the resident remained confused and not able to sit still. The note stated he could not be trusted to stay in his chair and he tried to stand up and walk without his walker. The resident required constant attention and staff carried out regular checks. A 1/26/2025 Nurses Note stated at 4:45 p.m. a Certified Nursing Assistant (CNA) alerted that the resident was outside and fell in the grass. The resident sat in the grass in front of the sister cottage by the sidewalk. He wore a sweatshirt, white undershirt, knit pants, socks, and shoes. The resident stated he saw an animal outside and went out to get it. The resident had bilateral (referring to both sides) knee abrasions. The facility placed a Wanderguard on the resident's ankle. On 2/19/25 at 10:35 a.m., Staff A Registered Nurse (RN) stated a family member held the door out for Resident #1 as they did not think he lived in the facility. She stated she saw the resident about 5 minutes before the family members left the building. She stated Staff B Certified Nursing Assistant (CNA) informed her that another family member drove by and saw the resident outside. Staff A stated the resident sat in the grass close to the sidewalk. The resident stated he was outside because he went after two hogs. Staff A stated after this incident, staff placed a Wanderguard on the resident and tried not to place him by doorways. On 2/19/25 at 11:15 a.m., Staff B CNA stated a visitor informed her a resident laid outside on the ground. She informed the resident's nurse via radio (Staff A) of this. Staff A assessed the resident and then they assisted him back inside. On 2/19/25 approximately 11:20 a.m., the SA exited the OV household (Resident #1's household) and did not need a code. The door did not alarm when opened and led outside to a patio area and a walkway towards a street in the middle of the facility campus. On 2/19/25 at 12:20 p.m., Staff C CNA stated on the morning of the incident, the resident was a little confused and she got him settled down and reminded him that it was winter. He went to the front door to look outside. She stated she saw the resident 10 minutes before another CNA told her he was outside. On 2/19/25 at 12:26 p.m., Staff D CNA stated towards the afternoon the resident became a little more confused, was looking for his family, and wanted to walk. She stated (prior to him leaving the building) she found him in the breezeway in between the two double doors. He stated he looked for his family. She stopped him and got him turned around and he wanted to sit on the bench located near the door. She and Staff C made sure to cycle past to check him ever 20-30 minutes. She said she last observed him approximately 30 minutes before staff found him outside. She stated the exit doors to the resident's building did not require a code to get out during the day. On 2/19/25 at 1:39 p.m. the Executive Director stated for Resident #1's building, no code was required to exit. She stated there was not another way to lock down that door. She stated if a resident tried to exit the building earlier in the day, she would want staff to monitor them more closely. On 2/19/25 at 3:07 p.m., the Senior Clinical Quality Specialist stated they placed locks on the doors of Resident #1's building. She stated if one did not enter a code, the door would alarm. On 2/19/25 at 3:07 p.m., the Executive Director stated when they reviewed the camera footage, they observed that a visitor did not let the resident out, but he went out independently. An untitled list, provided by the facility on 2/19/25, indicated 3 independently mobile residents with a BIMS less than 11 resided in OV and UT. This list did not indicate Resident #1 met this criteria. A tour of the facility on 2/20/25 revealed the following concerns: a. Staff E Maintenance Staff opened the Gelderland household exterior dining room door at 8:39 a.m. No alarm sounded but Staff E stated the alert would go to staff phones. As of 8:46 a.m., no staff had responded to the door or inquired as to why the door alerted. At 8:46 a.m. a staff member came out to the dining room table and her phone was not with her. Another staff member, Staff E CNA came out of a resident room also at 8:46 a.m. with a pager. She at first said that she did not hear the alert but then said she did not respond to it because she was with a resident. b. The doors to the South [NAME], Gelderland, and Groningen households did not require a code to exit and did not alarm upon exit. Residents had the ability to exit these households and enter a hallway which led toward the Friesland Assisted Living (AL). The AL entry doors were open and no alarm or code system was in place in order to enter the area. Once in the AL, a door to the laundry room was open which led to a hallway and to an unlocked door which led outside. c. A door in a connecting hallway between the OV household and the UT household was unlocked and led out to an enclosed courtyard. The hallway was not locked and residents had access to the door. On 2/20/25 at 1:35 p.m. the door in the connecting hallway between the OV and UT households had a lock installed on it. A tour of the facility on 2/24/25 at 8:00 a.m. revealed a door lock on the Gelderland dining room door and an alert notification on the door leading into the AL. On 2/26/25 at 9:41 a.m. the State Climatologist stated the temperature in [NAME], Iowa at 4:00 p.m. was 29 degrees Fahrenheit.

Based on clinical record review, staff interview, and policy review the facility failed to document an accurate code status for one of four residents sampled for advanced directives (Resident #147). The facility reported a census of 92 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #147 had diagnoses that included multiple sclerosis, thyroid disorder, and a left fibula (a bone in the lower leg) fracture. The Care Plan revised 9/17/24 revealed the advance directives was manifested by the resident and family's specifications. The staff directives included to refer to the IPOST (Iowa Physician's Orders for Scope of Treatment) form on file and review the advanced directives routinely at the care conferences and PRN (as needed). The electronic health record (EHR) (screenshot) revealed Resident #147's code status as a Full Code. The MDS Coordinator entered and confirmed the order on 9/16/24. The EHR Order Details revealed a full code listed under the advanced directives ordered on 9/16/24 at 11:27 AM. The Order Summary Report revealed a prescriber's written active order for a full code ordered on 9/16/24. The IPOST signed by the physician on 9/18/24 revealed a DNR/do not attempt resuscitation. The EHR Resident Detail report printed 9/24/24 at 4:25 PM revealed a DNR entered into the Code Status section. The Order Details revealed on 9/25/24 at 7:53 AM, the MDS Coordinator entered the advanced directives as a DNR order. During an interview 9/24/24 at 3:15 PM, Staff A, Licensed Practical Nurse (LPN) reported the Social Worker (SW) obtained the resident's or resident representative's signature, indicated the choice for a full code or DNR status, then the physician signed the IPOST. The IPOST got scanned into the resident's EHR and placed into a binder located at each household. The SW updated the code status in the computer to reflect if the resident was DNR or full code status. At the time, Staff A confirmed Resident #147's code status was listed as a full code in the EHR. During an interview 9/24/24 at 3:24 PM, the MDS Coordinator reported the SW updated the code status in the EHR after they received the signed IPOST. During an interview 9/24/24 at 4:19 PM, Staff B, SW, reported she presented the IPOST to the resident/representative whenever a resident admitted to the facility. Staff B reported a hard (paper) copy of the IPOST placed in the binder at the nurse's station. She scanned the IPOST into the EHR after the physician signed the IPOST. She also updated the code status in the EHR. During an interview 9/25/24 at 3:03 PM, Staff C, Registered Nurse (RN), reported she looked in the EHR for the resident's code status. Staff C reported the SW updated the code status in the EHR whenever the resident's code status changed. During an interview 9/25/24 at 3:15 PM, Staff D, RN, reported she looked at the EHR to check a resident's code status. Staff D reported they also had a red folder at the nurse's station with all of the residents who had a full code status. Staff D confirmed three residents in the Gelderland Household currently had a full code status. Resident #147's code status information was not contained in the folder. During an interview 9/26/24 at 10:05 AM, the Director of Nursing reported the process for advanced directives was a process they had been working on at the facility to ensure the resident's code status information was correctly entered into the EHR. In an interview 9/26/24 at 10:10 AM, the Clinical Quality RN Specialist reported she went through and reviewed all of the residents' IPOST's but did not compare the IPOST information to each resident's EHR to see that the code status matched. An Advanced Directive Policy revised 9/2024 revealed the IPOST or another document directed the resident's health care and their wishes. The Advance Directive document located in the resident's medical record and readily retrievable by any team member. Changes to the resident's choices for Advance Directives documented in the resident Care Plan, State specific documents (such as the IPOST), and the physician's orders to reflect the new choices as applicable.

Based on clinical record review, resident and staff interviews, and facility document review, the facility failed to evaluate the need for and offer scheduled nutrition interventions related to on-going weight loss and poor intake at meals. The facility also failed to update Resident 72's Care Plan to accurately reflect current staff interventions for weight loss, if any provided, and update the Care Plan for one of three residents reviewed for nutrition (Resident #72). The facility reported a census of 92 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] indicated that the Brief Interview for Mental Status could not be completed and Resident #72's cognitive skills for daily decision making were severely impaired. Diagnoses include Alzheimer's disease, Parkinson's disease, heart failure, anxiety disorder, and depression. The MDS revealed Resident #72 required set-up or clean-up assistance at meals and was independent with walking at least 150 feet. Resident #72 also assessed as independent to move from sit to stand or lying position without the use of assistive devices. The Care Plan with the next scheduled review date of of 12/19/24 documented Resident #72 was able to eat independently after set-up and needed cueing at times. The Care Plan also indicated Resident #72 had a potential problem related to low food intake with a goal to consume 75-100% of diet offered. Interventions include: a. Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food with an initiation date of 7/21/23 b. Invite resident to activities that promote additional intake with an initiation date of 7/21/23 c. Registered Dietitian (RD) to evaluate and make diet change recommendations PRN with an initiation date of 7/21/23 d. Resident would like to have time to consume meals, do not rush with an initiation date of 7/21/23 e. Resident would like to have documented and recorded meal intake with an initiation date of 7/21/23 No interventions related to low food intake identified on the current Care Plan since 7/21/23. The diet card, maintained by the Director of Dining Services, noted on 8/8/24 that Resident #72 had a history of refusing meals and to offer coffee drinks that comply with order. The diet card directed staff to offer plastic silverware as adaptive equipment. No further information regarding intolerances, likes, or dislikes noted. The diet card did not indicate current or past use of oral nutrition supplements or use of fortified foods. The Weights and Vitals summary obtained on 9/26/24 show the following weights from January 2024: 1/4/24 144.8 Lbs 2/1/24 142.4 Lbs 3/1/24 142.0 Lbs 4/1/24 136.0 Lbs 4/3/24 136.0 Lbs 5/1/24 137.6 Lbs 6/5/24 134.8 Lbs 7/5/24 130.6 Lbs 8/1/24 112.8 Lbs 9/1/24 127.8 Lbs The documented weight of 112 Lbs on 8/1/24 was struck out by the RD on 9/18/24 as a technical error. No further documented weight for the month of August identified. The Order Summary Report, obtained on 9/26/24, did not list the use of oral nutrition supplements or the use of fortified foods. The POC Response History for the task related to Nutrition-Amount Eaten obtained on 9/26/24 indicated Resident #72 eating greater than 50% for 70 meals out of 87 meals offered over the past immediate 30 days. The Nutrition/Dietary Notes written by the RD revealed the following: On 3/23/24 at 2:21 PM: Ht: 66 CBW (current body weight): 142.0# BMI (body mass index): 22.9. Wt Hx (weight history): stable x 180 d. General diet, regular textures, thin liquids. Avg meal intakes >50% w/ 120-240 mL fluid q meals. Eats independently w/ plastic silverware. Own teeth w/ no reports of difficulty chewing/swallowing. No PI (pressure injury) or edema present. No GI (gastrointestinal) concerns noted. No recs at this time, continue POC (plan of care). Weight loss, skin breakdown, fecal impaction, and dehydration may be expected/unavoidable outcomes as disease progresses. Continue to encourage intakes/hydration as resident desires on hospice cares. Will continue to monitor. Notify RD of sig changes. On 4/24/24 at 2:26 P: Ht: 66 CBW: 136.0# BMI:21.9. Wt Hx: -4.2% x 30 d, -6.1% x 90 d, -4.1% x 180 d. No sig (significant) wt (weight) changes. General diet, regular textures, thin liquids. Avg meal intakes 50-100% w/ 120-240 mL fluid q meals. Eats independently w/ plastic silverware. No recs at this time, continue POC. Weight loss, skin breakdown, fecal impaction, and dehydration may be expected/unavoidable outcomes as disease progresses. Continue to encourage intakes/hydration as resident desires on hospice cares. Will continue to monitor. Notify RD of sig changes. On 5/29/24 at 5:03 PM: Ht: 66 CBW: 136.0# BMI: 22.2. Wt Hx: stable x 30 d, -3.4% x 90 d, -5.7% x 180 d. No sig wt changes. General diet, Regular textures, Thin liquids ordered. Meal intakes dropping recently, ~2 meal refusals/d x 1 wk w/ 240-480 mL fluid q meals. Eats independently w/ plastic silverware. No recs at this time. Weight loss, skin breakdown, fecal impaction, and dehydration may be expected/unavoidable outcomes as disease progresses. Continue to encourage intakes/hydration as resident desires on hospice cares. Will continue to monitor. Notify RD of sig changes. On 6/19/24 at 11:33 AM: Ht: 66 CBW: 134.8# BMI: 21.8. Wt Hx: -2.0% x 30 d, -5.1% x 90 d, -5.2% x 180 d. No sig wt changes, trending down. General diet, Regular textures, Thin liquids ordered. Meal intakes varied; <50% on avg. x 1 wk w/ 240-480 mL fluid q meals. Eats independently w/ plastic silverware. No noted chewing or swallowing issues. No recent edema, PU, or GI issues noted. No new dietary recs. Weight loss, skin breakdown, fecal impaction, and dehydration may be expected/unavoidable outcomes as disease progresses. Continue to encourage intakes/hydration as resident desires on hospice cares. Will continue to monitor. Notify RD of sig changes. On 8/20/24 at 2:58 PM:Ht: 66 CBW:112.8# BMI: 18.2. Wt Hx: -13.6% x 30 d, -16.3% x 90 d, -20.6% x 180 d. No sig wt changes, trending down. General diet, Regular textures, Thin liquids ordered. Meal intakes remain subpar, <50% on avg w/ 240-480 mL fluid q meals. Eats independently w/ plastic silverware. No noted chewing or swallowing issues. No recent edema, PU, or GI issues noted. No new dietary recs. Weight loss, skin breakdown, fecal impaction, and dehydration may be expected/unavoidable outcomes as disease progresses. Continue to encourage intakes/hydration as resident desires on hospice cares. Will continue to monitor. Notify RD of sig changes. The above note summarized Resident #72's weight loss as non-significant and trending down. The weight loss calculations referenced in the note did meet criteria for significant losses at 30 and 180 days. On 9/18/24 at 11:18 AM: Ht: 66 CBW: 127.8# BMI: 20.6. Wt Hx: -5.2% x 90 d, -10.0% x 180 d (sig). EEN: 1750-1900 kcals/d, 58g pro/d, <1900 mL fluid/d. General diet, Regular textures, Thin liquids ordered. Meal intakes varied; <50% on avg. x 1 wk w/ 240-480 mL fluid q meals. Eats independently w/ plastic silverware. No noted chewing or swallowing issues. No recent edema, PU, or GI issues noted. No new dietary recs. MD notified of sig wt loss; likely unavoidable at this stage. MNA indicates at risk of malnutrition. Form submitted w/ recommendation to add moderate protein calorie malnutrition to Dx AEB sig wt loss x 180 d and intakes <50%. Weight loss, skin breakdown, fecal impaction, and dehydration may be expected/unavoidable outcomes as disease progresses. Continue to encourage intakes/hydration as resident desires on hospice cares. Will continue to monitor. Notify RD of sig changes. All of the above Nutrition/Dietary Notes written by the RD failed to indicate the rationale for the lack of nutritional interventions when non-significant weight loss and/or sub-optimal intake at meals were identified. The Nutrition/Dietary Notes failed to document any previous attempts at nutritional interventions when non-significant weight loss and/or sub-optimal intake at meals identified. During a brief interaction on 09/26/24 10:40 AM, Resident #72 responded I'm hungry when asked how he was doing. In an interview on 9/24/24 at 1:50 PM, Staff H, Certified Nursing Assistant, reported Resident #72's intake had improved recently. Unit snacks may be offered in the afternoon but do not follow any specific menu or diet spreadsheet. Staff H not aware of Resident #72 needed plastic silverware at meals, as outlined on the diet card. In an interview on 9/25/24 at 9:15 AM, the Director of Dining reported weekly weight meetings with the RD and household coordinators attending. During which trending weights are reviewed and interventions discussed, if applicable. She voiced facility-specific dietary interventions may include the use of fortified foods, such as fortified cereals, super mashed potatoes, addition of extra sauce/gravy or double protein The Director of Dining indicated none of the above interventions listed on Resident #72's diet card. In an interview on 9/25/24 at 2:44 PM, the RD reported the weekly meetings are to review resident weight loss and condition. Nutritional interventions are discussed. The RD stated no formal minutes or notes taken. Present staff members may write a Progress Note in the medical record and/or alert the primary care provider if indicated. Regarding Resident #72, the RD was informed by nursing staff that family was not agreeable with nutritional supplements and there should be documentation in a Progress Note. RD could not provide a timeframe of when this information was known. The RD acknowledged no nutritional interventions are currently in place for Resident #72. The RD reported Resident #72 was medically declining at one point but has rebounded. The RD acknowledged that Resident #72 has received hospice services for an extended period, since September '23, and indicated if a resident is receiving hospice services, may let it (weight loss) slide. In an interview on 9/26/24 at 1045 AM, the Director of Nursing (DON) discussed the weekly weight meetings and discussion of possible interventions. The DON was not aware of any documented or scheduled nutritional interventions for Resident #72. The DON voiced family was not interested in supplements but unable to provide a timeframe or further explanation regarding family wishes. In a follow-up interview at 12:30 PM, the DON explained unable to locate further documentation from hospice or facility staff related to family's wishes towards supplement use or further nutritional interventions. The DON reiterated Resident #72's medical decline where interventions were not appropriate in mid to late July. DON acknowledged Resident #72 has medically improved since then and eating better overall. The DON reported facility staff does offer snacks and drinks to Resident #72 frequently but did not note if these were scheduled snacks or if provided as needed. The Nutrition Intervention Program policy, with a revised date of 8/2024, indicated attempts will be made to maintain a high nutritional status and weight acceptable to bodily structure and physical condition. The clinical team will monitor food consumption and weights and will intervene nutritionally on residents experiencing significant weight loss. Procedures include: a. Each resident experiencing a 5% weight loss for one (1) month period, 7 1/2% weight loss for a three (3) month period, or a 10% weight loss for a six (6) month period will be entered into the nutritional intervention program. b. Resident care plans will be adjusted to address the resident's weight loss or gain. c. Dietitian will document an initial nutrition assessment upon notification of a weight loss or gain and at least bi-monthly for those in the nutritional intervention program with appropriate interventions added by the Interdisciplinary Team. Documentation will be maintained in the resident's medical record.

Based on record review, observations, staff interviews, and facility policy review, the facility failed to follow enhanced barrier precautions (EBP) and infection control practices to prevent the potential spread of infection or disease for 2 of 18 residents sampled (Resident #37). The facility staff also failed to appropriately cleanse and disinfect resident care devices after a tube feeding and medications administered through a gastrostomy tube (Resident #69). The facility staff also failed to wash hands or complete proper hand hygiene in-between dirty to clean tasks for 1 of 6 households observed. The facility reported a census of 92 residents. Findings include: 1. The Minimum Data Set (MDS) assessment date 9/23/24 revealed Resident #37 readmitted to the facility from the hospital on 9/23/24. The Medical Diagnosis list in the electronic health record (EHR) revealed the resident had diagnoses of methicillin susceptible staphylococcus aureus (MSSA) (a staph bacteria) infection effective 9/20/24, an extradural (epidural space of the spine or skull) and subdural abscess (a collection of pus that forms in the subdural space between the arachnoid and dura mater of the brain) (added 9/23/24), and elevated white blood cell count (indicating an infection) (added 9/24/24). The Care Plan initiated 9/24/24 revealed the resident had an epidural abscess of the cervical spine at the C2-C3 and MSSA bacteremia (bacteria in the blood). The Care Plan directed staff to administer antibiotics per physician's orders and check the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for PICC line cares to the right upper extremity. The MAR dated 9/2024 revealed cefazolin sodium (an antibiotic used to treat serious bacterial infections) 2 grams intravenously every 8 hours related to MSSA infection. The MAR documented Staff A, Licensed Practical Nurse (LPN), administered the scheduled 4:00 PM dose on 9/24/24. During observations on 9/24/24 at 3:32 PM, Staff A, LPN, obtained supplies and prepared cefazolin 2 grams in 50 milliliters (ml) of dextrose solution. Staff A mixed the powdered medication and the solution in the bag until the medication dissolved. Staff A placed the IV bag on the IV pole with an infusion pump. At the time, an IV tubing was draped over the IV pump and the spike of the IV tubing exposed to air (uncapped) and not attached to an IV bag. Staff A sanitized her hands, donned a pair of gloves, then took an alcohol swab and cleansed the spike on the IV tubing that hung over the IV pump. Staff A then pierced the bag of cefazolin with the spike from the IV tubing, and hung the bag back on the IV pole. Staff A removed an orange cap covering the end of the PICC line, took an alcohol swab and cleansed the PICC line. Staff A flushed the PICC line with 10 ml normal saline, primed the IV tubing, the attached the IV cefazolin to the PICC line. Staff A set the IV pump to infuse the medication over 30 minutes. Staff A removed her gloves and sanitized her hands. Staff A did not utilize a gown while she performed cares and administered medications through the resident's PICC line. During observation on 9/24/24 at 4:34 PM, Staff A, LPN, checked the IV bag and reported the antibiotic medication infused. Staff A sanitized her hands, donned a pair of gloves, and stopped the IV pump. Staff A removed the IV tubing from the PICC line, then took an alcohol swab and cleansed the PICC line port, and flushed the PICC line with 10 ml normal saline. Staff A removed her gloves. Staff A took a black marker and crossed the resident's name and personal information on the IV bag. Staff A threw the IV bag and tubing in the trash, then sanitized her hands. Staff A did not utilize a gown while she handled the resident's PICC line and completed medication administration. The Director of Nursing (DON) stood in the room and observed Staff A during this time. During an interview 9/24/24 at 9:00 AM, Staff A reported the pharmacy sent the IV tubing along with the IV medication infusion. The resident's IV tubing was changed out every 24 hours. During an interview 9/25/24 at 3:03 PM, Staff C, RN, reported personal protective equipment (PPE) such as gown and gloves required whenever she worked with a resident's catheter, a wound, or if the resident had COVID-19. During an interview 9/25/24 at 3:14 PM, Staff E, certified nursing assistant (CNA), reported a gown and gloves worn if a resident was really sick or had COVID, and whenever she emptied a resident's catheter. During an interview 9/25/24 at 3:15 PM, Staff D, RN, reported EBP's consisted of donning a gown and gloves whenever staff worked with a resident with an open wound and tube feeding, but EBP's not necessary when worked with a resident's PICC line. An isolation precautions card placed in the resident's room or on the door and PPE supplies placed inside the resident's room whenever a resident on isolation or EBP's. An email received from the facility's Clinical Quality RN Specialist on 9/26/24 at 8:23 AM revealed the facility did not have an IV medication administration policy. The Clinical Quality RN Specialist wrote the facility's nursing staff just followed the nursing standards of care. During an interview 9/26/24 at 9:45 AM, Staff D, RN, reported the IV tubing came from the pharmacy. IV tubing was changed out every 24 hours. Staff D reported the IV bag discarded after the IV infusion completed, but she recapped the end of the IV tubing in order to use for IV tubing for the next IV medication infusion up to 24 hours. Staff D reported she just found out a gown should be worn whenever staff worked with a resident's PICC line. Staff D reported signage regarding PPE use placed in Resident #37's room. During an interview 9/26/24 at 9:51 AM, Staff F, CNA, reported gown and gloves worn whenever a resident on EBP's. Staff F reported she just found out she needed to wear a gown and gloves if resident had a PICC line. During an interview 9/26/24 at 10:07 AM, the DON reported she would leave the IV tubing connected to the bag and use the IV tubing for the next IV medication administration. She would get a new IV tubing rather than wipe the spike on the IV tubing with alcohol. The DON reported she expected staff wore a gown and gloves for EBP's and whenever working with a resident's PICC line. The facility's IV and PICC Management policy revised 6/2020 lacked information or the procedure for infusion of IV medication through the PICC line. A pharmacy's Medication Administration infusion therapy policy and procedure revised 2023 revealed the sterility of the IV bag and equipment inspected prior to medication administration, and pharmacy called if any problems noted. An Enhanced Barrier Precautions policy revised 4/2024 revealed EBP's is a method for reducing the spread of multi-drug resistant organisms (MDRO). A gown and gloves worn to prevent contamination of healthcare personnel hands and clothing during care activities that have the highest risk of transfer of MDRO's. Residents with risk factors like indwelling medical devices may unknowingly have a MDRO and develop a serious infection and spread MDRO's to others. EBP can effectively reduce the spread of MDRO's. EBP's used whenever a resident had an indwelling device such as a central vascular and central catheter lines. 50500 2. Tube feeding and medication administration for Resident #69 observed on 9/24/24 at 7:00 AM with Staff G, Registered Nurse. Staff G observed washing hands in the bathroom sink prior to the start of administering medications and tube feeding. After medications were given, the tube feeding product was provided as directed via syringe feedings. Once the feedings were complete, Staff G gather the used supplies, which included two graduates (one used for tube feeding product and the other used for water), a 60 cc syringe, and the gastric-tube (g-tube) extension. The graduate used for water was also the same graduate used earlier in the observation to mix and administer medications. Staff G placed the g-tube extension in the bathroom sink. Staff G proceeded to rinse out the two graduates and syringe over the g-tube extension. After the items were rinsed, Staff G removed the g-tube extension from the sink, rinsed and flushed out with water. Supplies were left on the bathroom counter to air dry with the g-tube extension in one of the graduate. During an interview 9/26/24 at 1045 AM, the Director of Nursing (DON) indicated she would have rinsed the g-tube extension first instead of laying it in the sink to reduce the risk of cross contamination. 3. Lunch preparation and service on the Zuid [NAME] unit observed on 9/25/24 at 11:30 AM with Staff I, cook. After pureeing a serving of chicken alfredo with noodles, Staff I proceeded to hand wash the blender for use on the next puree food item. Staff I was observed washing out the blender several times to ensure all food residue was removed. Once the blender was clean, Staff I pureed the zucchini and squash vegetable dish. When the task was completed, Staff I continued to prepare for lunch service up until approximately 12:00 PM when it was time to plate food for resident. No hand hygiene observed during this time frame nor was it observed at the start of plating lunch. During an interview on 9/25/24 at 12:30 PM, the Director of Dining acknowledged the lack of hand hygiene from Staff I as she was present during lunch preparation and service. An email received on 9/26/24 at 11:45 AM, the Clinical Quality RN indicated there was not a separate policy for dietary and hand hygiene. It is all the same hand hygiene policies within the infection control manual. Per the Food and Drug Administration Food Code 2017 (2-301.14 When to Wash), hand washing should be performed before engaging in food preparation, after handling soiled equipment and utensils, and during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Based on clinical record review, resident and staff interviews, the facility failed to ensure a resident had at least 2 baths/showers per week for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 95 residents. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnosis including stroke, osteoporosis and anxiety and required physical assistance with bathing. The Care Plan revised 8/29/23 revealed Resident #1 had a self-care performance deficit related to activity intolerance, impaired balance and stroke, and directed staff to provide assistance with bathing twice a week. Review of the electronic health record (EHR) for Resident #1 revealed showers/baths were offered and provided 3 times between 8/23/23-9/22/23. During an interview 5/16/24 at 9:16 AM, the Clinical Quality Specialist acknowledged showers/baths were documented 3 times during Resident #1's stay. She confirmed it is an expectation residents receive a bath or shower a minimum of 2 times a week or follow the care plan if different and document any refusals. The Clinical Quality Specialist further reported the facility does not have a specific policy related to baths/showers as they follow standards of care.

Based on facility record review, family interview and staff interviews , the facility failed to answer the residents' call lights in less than 15 minutes for 4 of 4 residents reviewed (Resident #30, 42, 57, 75). The facility reported a census of 74 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] of Resident #30 identified a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS revealed the resident required extensive assistance of two staff members for bed mobility, transfers and toileting. The MDS documented diagnoses that included aphasia (difficulty understanding or expressing speech), cerebrovascular accident (stroke) and hemiparesis (one sided paralysis). The Care Plan Focus Area of falls dated 11/7/22 directed staff to have the resident's call light within reach and encourage the resident to use it. The Care Plan documented the resident needed prompt response to all requests for assistance. On 6/27/23 at 10:34 am, a family member of Resident #30 stated it is sometimes as long as 45 minutes for the Resident's call light to be answered. The Device Activity Report for 5/29/23-6/28/23 revealed Resident #30 waited longer than 15 minutes for his call light to be answered 35 times during this timeframe, with the longest wait time of greater than 51 minutes. 2. The Significant Change MDS for Resident #42 dated 4/22/23 identified a BIMS score of 15 which indicated cognition intact. The MDS revealed the resident required total physical assistance of 2 staff for bed mobility, and required extensive physical assistance of 2 staff persons for transfers, dressing and toileting. The Device Activity Report for 5/29/23-6/28/23 revealed Resident #30 waited longer than 15 minutes for her call light to be answered 35 times during this timeframe, with the longest wait time of greater than 29 minutes. 3. The Quarterly MDS for Resident #57 dated 4/18/23 identified a BIMS score of 12 which indicated moderate cognitive impairment. The MDS revealed the resident required extensive physical assistance of 1 person for bed mobility, transfers, ambulating, dressing and toileting. The Device Activity Report for 5/29/23-6/28/23 revealed Resident #57 waited longer than 15 minutes for her call light to be answered 43 times during this timeframe, with the longest wait time of greater than 38 minutes. 4. The Quarterly MDS for Resident #75 dated 6/18/23 identified a BIMS score of 13 which indicated cognition intact. The MDS revealed the resident required limited physical assistance of 1 person for bed mobility, transfers, walking, dressing and toileting. The Care Plan Focus Area of falls dated 6/27/23 directed staff to have the resident's call light is within reach and encourage the resident to use. The Care Plan documented the resident needed prompt response to all requests for assistance. The Device Activity Report for 5/29/23-6/28/23 revealed Resident #57 waited longer than 15 minutes for his call light to be answered 9 times during this timeframe, with the longest wait time of greater than 35 minutes. On 6/29/23 at 11:15 am, the Director of Nursing stated her expectation is for call lights to be answered within 15 minutes. She stated she has ran the call light reports and reviewed camera video and stated some of the extended wait times were due to staff responding to the call for assistance but failing to cancel the call light. On 6/29/23 at 2:07 pm, The Clinical Quality Specialist stated in an email that the facility does not have a policy regarding call lights but the expectation is for call lights to be answered within 15 minutes.

Based on observation, record review, and staff interview, the facility failed to fully review and revise the care plan for 1 of 2 residents (Resident #43) who were sampled for care plan review. The facility reported a census of 74. Findings include: On 6/26/23 at 02:11 PM, Resident #43 stated he had a urinary tract infection (UTI) after the indwelling catheter was inserted. The Resident's Electronic Health Record (EHR) included medical diagnoses of Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms (inflammation of the prostate making it difficult to urinate) and heart failure. The Quarterly Minimum Data Set (MDS) assessment for the resident dated 1/27/23 documented diagnoses which included BPH and heart failure. The MDS indicated no urinary catheter used in the seven-day look-back period. A Progress Note dated 3/16/23 at 2:11 p.m. indicated the resident had urinary retention and increased frequency with urination. Physician Order dated 3/17/23 instructed staff to insert a Foley catheter. A Progress Noted dated 3/17/23 at 6:00 p.m. documented that a Foley catheter was inserted into the resident. The Quarterly MDS dated [DATE] indicated the resident had an indwelling catheter. The Care Plan with initiated dated 12/12/22 included a resolved condom catheter focus as of 2/14/23 but did not include an indwelling catheter entry or interventions. The resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of indwelling catheter care from 3/01/23 to 6/29/23. The MAR's and TAR's dated 3/03/23 to 6/29/23 documented as follows; Record Output per shift two times a day. However, the TAR did not specify output from what. For example catheters, drains, tubes, or ostomy. On 6/29/23 at 12:13 PM, Staff C, Licensed Practical Nurse (LPN), stated the Care Plans are updated by Staff D, Director of Nursing (DON). She stated Staff D is notified by email or a phone call and notification is documented in the resident's progress notes. No documentation was found in the resident's progress notes. On 6/29/23 at 12:38 PM, Staff D stated staff use Hot Charts to communicate information between staff. She stated Care Plans should be updated. On 6/29/23 at 2:30 PM, the Clinical Quality Specialist provided two documents titled <building name omitted> Care Plan updated 3/19/23 and 5/04/23 that included Catheter and Output (help with cath cares). No other indwelling catheter directive was noted. On 6/29/23, the resident's Care Plan was revised and included the resident's indwelling catheter and related catheter care interventions

Based on observation, record review, staff interviews, and facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from self and the environment (Resident #1). The facility failed to develop and institute a comprehensive plan to prevent Resident #1 from eloping from the facility and failed to follow planned interventions to prevent Resident # 4 from falling. The resident sample consisted of 15 residents. The facility reported a census of 60 residents and the facility had 3 residents at risk of elopement. Findings include: 1. The MDS (Minimum Data Set) assessment for Resident # 1 identified the resident had an admitted to the facility on [DATE]. The initial MDS (Minimum Data Set), with a reference date of 02/12/2014 identified the resident had a BIMS (Brief Interview for Mental Status) score of 6. A score of 6 identified the resident as severely cognitively impaired. The MDS documented the resident did wander and at times intruded on the activities and privacy of others. An assessment of the resident's functional status reflected extreme assistance was provided by 1 staff person for dressing, toilet use (not always continent of urine), and personal hygiene. Balance during transfers and ambulation was considered unsteady, but could stabilize without assistance from staff. Resident # 1 utilized a walker when ambulating. The MDS identified the resident ' s [DIAGNOSES REDACTED]. The Care Plan, with a start date of 02/24/14 directed facility staff to assist the resident in acclimating to the facility by showing her/him where her/his room was, provide reality orientation, monitor the resident's whereabouts, and to contact the physician if the resident became more confused. After the elopement of 02/25/14, the Care Plan was updated on 02/26/14 to include a stop sign on the exterior door leading to the outside courtyard, provide Resident # 1 with a roam alert bracelet and ensure it works properly, remind the resident of the yellow flowers on the hand rail outside of her/his room. Staff should also assess the resident for signs and symptoms of urinary tract infections. The initial nursing assessment completed on 02/04/14 at 11:30 A.M by Staff H (registered nurse), identified Resident # 1 as alert to self and able to identify the season, place, and names. Short term memory is documented as a problem, while long term memory was not. For the elopement risk area, Alzheimer ' s dementia was identified giving the resident a score of 1 which did not identify an elopement risk. On the Elopement Risk Assessment sheet, completed on 02/4/14 by Staff H (registered nurse), the family verified the resident had eloped from a facility where he/she had lived in 2012, but had no incidents since that time. The resident was receiving a pain medication and family believed this caused him/her to leave the facility. A score of 4 on the Elopement Risk Assessment identified the resident at risk for elopement and precautions must be initiated. The Elopement Risk Assessment reflected the facility chose to not take the precautions and chose not to implement Care Plan interventions. During an observation on 04/24/14 at 5:45 P.M., Resident # 1 finished eating and ambulated with a wheeled walker down the hall towards her/his room. Resident # 1 went straight to her/his room without difficulty or seeking the outside door to the courtyard. Observations from 04/24/14 until this observation noted no exit seeking behavior. The Nurse ' s Notes reflected from admission on 2/4/14 through 02/12/14 documented assessments of the resident's lungs and cough and frequent or daily visits from family. On 02/13/14 at 4:30 A.M., the night staff documented finding a confused resident ambulating out to the dining room twice and redirected the resident back to her/his room. From 02/13/14 through 02/22/14 the narrative returned to the assessment of the resident's lungs without any other information documented. The Nurse ' s Notes revealed the following: On 2/23/14 at 12:35 p.m. the note reflected the resident ' s family at facility and voiced concerns of the resident ' s incontinent episodes urinating pressure. The staff contacted the physician and obtained an order to obtain a urine specimen to check for infection. At 8:15 P.M. on 2/23/14, the nurse documented the resident had increased confusion and wanting to go home. The results of the urine culture on 02/24/14 identified an organism (infection), Staphylococcus Simulans. The physician ordered Bactrim DS (antibiotic) 1 tablet twice a day for 7 days. On 02/25/14 at 7:00 P.M., Staff F (licensed practical nurse) documented Staff G (registered nurse) from another unit found Resident # 1 outside at approximately 6:00 P.M. Resident # 1 was brought into the dining area. The staff person finding the resident outside had placed a coat over the resident's shoulders. Resident # 1 had been outside with a walker, shoes and light socks, long pants, a sweater, and a light jacket. Staff F placed a roam alert bracelet on the resident. Vitals at 6:10 P.M. were identified as: Temperature 96.1 (normal 98.6) pulse 80 (normal 60-100), respirations 24 (normal 16-20), and blood pressure 120/72. Oxygen saturation was 98% (normal 97-100%). Both of the resident ' s hands were cool. Staff G removed the resident's shoes and checked for skin issues, but found none. Resident # 1 denied any pain in the feet. At 6:20 P.M., vitals were: temperature 97.7, pulse 78, respirations 22, and blood pressure 140/64. Oxygen saturation at that time was 97%. When Staff F escorted Resident # 1 back to her/his room, the resident commented " There ' s my home, I was looking for it. It was bitter cold out there." At 7:00 P.M., Staff F documented observing Resident # 1 ambulating in the hallway and going into her/his room. The Nurse ' s Note dated 02/26/14 at 9:05 A.M. reflected the Director of Nursing visited with the resident's family by phone and offered to move the resident to the secured CCDI (Chronic Confusion Dementing Illness) unit. The family declined. The DON informed the family they would be placing alarms on the doors at the end of the hallways which were not readily visible to the common area. On 2/26/14 at 3:00 p.m. the note identified a late entry of 2/25/14 at 7:00 p.m. The entry reflected the physician was notified of the elopement. After 02/26/14 through 03/05/2014, the Nursing Notes did not reflect any assessments of the resident's condition after the elopement incident. On 03/06/2014 at 6:30 P.M., Resident # 1 attempted to open the front door to the unit, but pressed on the hinged side. On 03/07/2014, Resident # 1 could not find the bathroom and staff redirected the resident. On 04/22/14, Resident # 1 asked staff why she/he could not go home. Staff called the family and asked them to come in to be with the resident. On 02/26/14, Staff J (registered nurse) completed another Elopement Risk assessment on Resident # 1 which again identified the resident as a 4 and at risk for elopement. The assessment reflected the resident would be considered at risk for elopement The interventions listed were a roam alert bracelet placed on 02/25/2014 and flowers placed on the rail outside the resident's room to assist the resident in finding her/his room. Staff J completed a new Elopement Risk Assessment on all residents in the facility except those in the CCDI unit. The CCDI unit exits are all locked. On 04/28/14 at 10:00 A.M., Resident # 1 verbalized not being able to recall much about the 02/25/14 elopement incident. The resident remembered some kids came to help, she/he did not fall, and she/he was not outside long. When asked if the flowers on the railing outside in the hallway helped with finding her/his room, the resident stated no, and she/he just know where her/his room was. On 04/23/14 at 8:00 P.M., an interview with Resident # 1's family revealed this was the third facility for the resident. At an assisted living facility in 2012, Resident # 1 did wander outside. At the time, she/he was on medication for pneumonia and was also on a strong pain medication. Even at that time, the resident showed some memory problems. The resident loved the out- doors and family was concerned with better weather she/he would want to go outside. A concern of so few staff to care for residents was expressed. The family representative verbalized coming to assist the resident on a nightly basis because staff did not have the time to assist the resident. The family member state the yellow flowers on the rail outside of the resident's door might or might not really help the resident find her/his room. The family member verbalized being called by the facility staff to come to the facility and be with the resident while State was there because they thought the resident might be exit seeking. The family representative did not recall telling the facility not to put a roam alert bracelet on the resident on admission, but stated if the facility said she did, then she must have. On 04/23/2014 at 8:45 P.M., Staff G (registered nurse) was interviewed and stated it was a Tuesday around 5:40 P.M. with 2 to 3 inches of snow and in the teens for temperature the day Resident # 1 eloped. She saw the resident with a walker outside of one of the windows of the assisted living cottages. She told her husband to go in and tell someone while she got out and took a coat to the resident. She could not see any evidence that the resident had fallen. On 04/21/2014 at 10; 30 P.M., Staff F (licensed practical nurse) verbalized being the staff nurse on Resident # 1's unit that evening. She stated it was just her and 1 aide for the unit of 14 residents that evening. Resident # 1 did not have an alert bracelet on and must have gone past her room straight out the courtyard door. A facility staff member from the assisted living cottage came to the unit to tell them a lady was pecking on their window. Staff G found Resident # 1 outside as she was coming to work. Staff F estimated the time between seeing the resident in the dining room (around 5:30 P.M.) and the resident being returned to the dining room (around 6:00 P.M. When brought in, Resident # 1 seemed cold but OK (alright). Staff G had placed a coat over the resident's shoulders. Resident # 1 stated it was bitter cold out there and she/he had been looking for her/his room. Vitals were taken and the resident checked over to make sure there were no injuries. An alert bracelet was placed on the resident. The next day, the courtyard door was alarmed. Resident # 1 has had no further incidents that she knows of. On 04/22/14 at 8:00 A.M. Staff I (dietary supervisor) was interviewed and stated she worked in Resident # 1's unit at supper on the evening of 02/25/14. Staff I stated Resident # 1 ate and then got up from the table telling others she/he was going to the other side around 5:35 P.M. About 5 minutes later one of the staff's husband came running in and told them that someone was outside. Staff I ran to get the unit nurse and then headed for the garage. Staff G was bringing Resident # 1 in from outside. On 04/24/14 at 12:15 P.M., Staff E (certified nursing assistant) was interviewed and stated she worked as the only aide on Resident # 1's unit the evening of 02/25/14. She stated sometimes it is 3 or 4 nights in a week that there is only 1 nurse for 2 units and 1 aide on this unit. Staff E saw Resident # 1 leave the supper table about 5:45 P.M. to go back to her/his room. The next time she saw Resident # 1 was when she/he was brought back in from outside around 6:00 P.M. Staff E did not remember the resident shivering or looking flushed with cold. Staff F took the resident to the nursing office and Staff E continued with other resident's cares. Staff E stated she witnessed Resident # 1 have periods of confusion and restlessness, and asking for her/his room at times. The family usually came in and assisted with getting the resident ready for bed. Staff E did not recall Resident # 1 ever setting any alarms off before or since the roam alert bracelet had been applied. On 04/24/2014 at 9:20 P.M., Staff H (registered nurse) stated when she completed the first Elopement Risk Assessment on 02/04/2014; the family did not feel it was necessary to put a roam alert bracelet on the resident even though she/he met the criteria at a score of 4. No interventions were initiated because Staff H went to Staff J (unit manager and registered nurse) who talked to the family and instructed Staff H not to start the Elopement risk precautions. On 04/23/2014 at 9:00 A.M., Staff J (unit manager and registered nurse) stated a score of 4 on an Elopement Risk Assessment identified elopement precautions should be initiated. All residents on the 3 open units had been reevaluated on 02/26/2014 and 3 residents were identified as elopement risks, Resident # 1, # 19, and a new admission Resident # 18. On 04/24/2014, both the Administrator and the Director of Nursing concurred prior to the elopement of Resident # 1 on 02/25/2014, each exit door had a roam alert pad which would sound an alarm if a resident with a roam alert bracelet got near them. The exterior doors have an automatic lock that locks at 9:00 P.M. until 6:00 A.M. After Resident # 1's elopement, a magnetic lock was placed on all exit doors to lock them. Before the magnetic locks were installed, the facility place a temporary alarm on all exits so they would alarm if opened. All staff received an in-service about roam alert use on 02/12, 02/13, and 2/19/14. On 2/20 and 2/28, 2014 all staff again received training on household guidelines, roam alert training, and change of condition documentation guidelines. During the environmental tour on 04/28/14 at 11:00 a.m. it was noted the exit doors in all four cottages of the long term care area of the facility had no alarms to alert staff of possible exit attempts by residents other than those resident who had been deemed elopement risk and had been provided with a roam alert bracelet on their person. The facility director noted that since the facility concept was a home like environment in the cottages, the staff did not believe exit alarms were required. 2. Resident #4 had an MDS assessment due to a significant change in condition, with a reference date of 04/03/2014. The MDS identified the resident had documented both long and short term memory deficits with severely impaired decision-making abilities. The resident required the extensive assistance of 1 to 2 staff for bed mobility, transfers, locomotion, toilet use, and personal hygiene cares. During this assessment reference period, falls prior to admission to the facility and 1 at the facility with no injury was reported. The MDS identified [DIAGNOSES REDACTED]. The Care Plan identified Resident # 4 as being incontinent of urine and facility staff would toilet the resident upon rising, after meals, at the hour of sleep, and as needed. The Care Plan identified a problem on 02/07/14 with Impaired mobility and a high risk of falls. Interventions were the use of a walker for mobility, to provide cues and reminders to use the walker, keep the environment clear of clutter, adequate lighting, and call light in reach at all times. Prior to 03/29/2014, Resident # 4 fell without injury 4 times. The Post Fall Assessment identified on 03/29/2014 at 7:10 A.M, Resident # 4 fell in his/her room. No injuries were assessed and the nurse documented an intervention to have therapy continue to work with the resident. When the Household Coordinator reviewed the fall form, she documented the resident had been discharged from therapy already. Other interventions were a continuation of the chair and bed alarm and to involve Hospice with the fall prevention. On 03/29/2014 at 2:00 P.M., facility staff heard an alarm and found the resident on the floor of his/her room. The resident informed the staff he/she had stood up and fallen. An assessment found the resident to be without any injuries. An intervention of keeping the resident within a supervised area or when in his/room to make sure the alarm was on the resident. On 04/07/2014 at (no time on the fall investigation), Resident # 4 fell . Resident unattended in his/her room and the personal alarm was not in place. No injuries sustained. The interventions documented were to not leave unattended in his/her room when in a wheel chair and to make certain the personal alarm is in place. On 04/10/2014 at 5; 00 P.M., Resident # 4 fell in his/her room and sustained a 4 inch abrasion to the top of the right shoulder. A new intervention for the plan of care was documented as checking the chair alarm and not leaving the resident unattended in the wheel chair. Same interventions. During an observation on 04/22/2014 at 8:30 A.M., Staff C and Staff D (both certified nursing assistants) assisted Resident # 4 from the low bed into the bathroom (the resident had been incontinent). Resident # 4 did have a personal alarm on when in the bed. After providing morning cares, both staff persons assisted the resident to ambulate to the dining area and sit in a wheel chair with a personal alarm attached.

Based on observation, record review, staff and resident interviews and review of the facility policy/procedures, the facility failed to assess and prevent the development of pressure ulcers for 2 residents (Resident #2, #12). The sample consisted of 15 residents and the facility reported a census of 60 residents. Findings include: 1. Resident # 2's quarterly MDS (Minimum Data Set) assessment with a reference date of 03/18/2014, revealed a BIMS (Brief Interview for Mental Status) of 15. A score of 15 identified the resident with no cognitive deficits. The MDS reflected the resident required the assistance of 2 staff persons for bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene cares. Resident # 2 used a wheel chair to propel around the unit. The MDS documentation identified the resident at risk for pressure ulcers with a nonstageable pressure ulcer which was not present upon admission to the facility. The largest pressure ulcer identified measured 3.5 centimeters by 5.5 centimeters with eschar (black/brown crust over the wound surface). The MDS identified the following description of pressure ulcers: Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage 2: Partial thickness loss of dermis presenting as a shall open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling skin. The Care Plan identified venous emboli (obstruction of a vessel due to a blood clot) and [MEDICAL CONDITION] (formation of a blood clot in the vessel and obstructing the flow of blood) of the lower extremity, a [MEDICAL CONDITION] bladder (nervous system affects the bladder) system, chronic ischemic [MEDICAL CONDITIONS] (abnormal heart rhythm of the heart) sleep apnea (abnormal breathing during sleep), and a spinal cord injury. The interventions directed staff to provide Resident # 2 with assistance for toilet use, showers, dressing, turning and repositioning in bed, transfers and ambulation. The Care Plan directed staff to assess and report any sign of skin breakdown. On 02/03/14, the plan identified the need for proper fitting shoes, to apply heel protectors to both heels, and initiate podiatry care. On 02/13/2014, a blister to the right heel was added to the care plan and on 03/11/14; the plan identified the right heel as unstageable. The plan had added treatments to the right heel on 02/25/14 and 03/11/14. Resident # 2's was admitted on [DATE]. The initial nursing assessment was negative for any skin issues. A nursing note in Resident # 2's medical record dated 02/13/14 at 9:20 A.M. identified a right heel blister (6.25 centimeters by 4 Centimeters) filled with liquid. The record did not identify any concerns about the right heel prior to this time. The note on 02/13/14 documented the resident had been to appointments on 02/12/14 with family and wore shoes. The nurse treated the right heel area with skin prep and an abdominal dressing (thick padded rectangular absorbent dressing). The 02/14/14 at 11:00 A.M. (over 24 hours later), the facility faxed the physician to make her aware of the right heel blister and to ask for "bunny boots" (foam boots), informed the physician of the treatment to the heel, and identified Resident # 2 wore shoes considered too small. The telephone order at the bottom of the fax documented an order for [REDACTED]. The facility did not have any orders to provide a treatment to the right heel area except the heel protectors until 02/ 25/2014 (12 days after the ulcer was identified). An "Other Skin Conditions Form" dated 02/13/14 documented the right heel pressure area as 6.25 centimeters by 4 centimeters by 1 centimeter deep, intact and filled with liquid. The form identified the, as yet unordered, treatment as skin prep and cover for protection. On 02/20/14 the area measured 6.25 centimeters by 4 centimeters with 3 centimeters by 3 centimeters of fluid blister, no infection, and treated with the unordered treatment of [REDACTED]. Bunny boots (foam boots with the heel area cut out to keep the pressure off the heels) were applied. On 02/24/14, a telephone order directed the staff to obtain a wound consult to the right heel blister. On 02/25/14, the Wound Nurse identified the right heel area as a pressure ulcer found a couple of weeks ago by the nursing staff at the facility. Resident # 2 was documented as having a history [MEDICAL CONDITIONS] and identified the wound as first discovered on 02/11/14. The wound nurse identified the wound measurements as 5.5 centimeters wide, 9.0 centimeters long, and unable to determine depth due to the area being blistered and intact. The right heel wound was not staged. On 02/25/14, a telephone order identified the staff to use Vaseline gauze to the right heel, a conformed roll (type of rolled padded dressing), and kerlix rolled gauze every day was initiated. The Wound Nurse would see the resident on a weekly basis. A Nurse ' s Notes dated 02/25/2014 at 9:10 A.M., documented the right heel wound as 5.5 centimeters by 9 centimeters with an intact blister. The wound care weekly group meeting identified the following: On 03/04/14, the right heel area measured 6.5 centimeters wide by 8.0 centimeters long with a depth of 0.3 centimeters. The blister was no longer intact and a large amount of serosanguineous (red tinged fluid) was present. The blister tissue was removed with forceps. No wound stage documented. The treatment remained the same with pressure relief to the lower extremities at all times. On 03/03/2014 at 1:40 P.M., Resident # 2's medical record nursing notes documented the right heel area as without drainage and having 3 plus [MEDICAL CONDITION] (swelling) to bilateral feet and legs. On 03/04/2014, the facility nurse documented the area to the right heel as dark purple with no signs of infection, no blister, and no drainage on the "Other Skin Conditions Form". On 03/11/2014, the wound nurse documented the right heel as still unstageable and measuring 3.5 centimeters wide by 5.5 centimeters long and covered with eschar (A brown/black crust) covering the area. Moderate drainage was identified as serosanguineous (bloody drainage). A new order for Santyl [MEDICATION NAME] (removes dead tissue and cleans wound) and gauze was initiated. On 03/11/2014, the nursing staff documented the right heel area as dark purple with slight bleeding, and an irregular border. A nursing note dated 03/03/14 at 1:40 P.M. identified the right heel area as without drainage and with 3 plus [MEDICAL CONDITION] to the lower feet and legs. On 03/18/14, the wound nurse documented the right heel areas as unstageable at 3.5 centimeters wide and 5.3 centimeters long with a wound bed of pale pink, white, and with eschar and a moderate amount of serosanguineous drainage. The eschar was cut across several times with a blade and no change in the treatment. On 03/25/14, the wound nurse documented the right heel area as changed with 3.4 centimeters wide by 5.2 centimeters long with a red, yellow, and eschar colored would bed and a large amount of seosanguineous drainage. The loose eschar was removed with a blade and forceps. On 03/25/14, the nursing staff documented the area as 3.5 centimeters by 5 centimeters with no odor, a black wound bed, and pink and white border. On 03/29/14 at 8:00 A.M., nursing staff documented the right heel wound exuded an odor, brown drainage, and the edges of the wound had a green/blue tint. 03/29/2014 [MEDICATION NAME] (antibiotic) 500 milligrams every day for 7 days was started. On 04/01/14, the wound nurse documented the right heel wound as unstageable, and measuring 3.3 centimeters wide by 4.5 centimeters long, with a yellow slough (signs of infection) wound bed ,a foul odor, and a large amount of purulent (thick pus-like) drainage. The treatment remained the same as before. The facility did not obtain a culture for the right heel area in order to check for possible [MEDICAL CONDITION] which might call for infectious precautions to be established. On 04/01/14, nursing staff identified the right heel area as 3 centimeters by 4.5 centimeters with black eschar, a red border, foul odor, and a greenish/yellow drainage. On 04/02/14 at 8:30 A.M., nursing documented the right heel wound as having an odor with serous drainage. 4/03/14 at 4:330 P.M. nursing staff documented the right heel wound with moderate yellow drainage with a foul odor. On 04/08/14, the wound nurse documented the right heel wound as a Stage III, 3.3 centimeters in width by 4.5 centimeters long with a wound bed of yellow slough and moderate serosanguineous drainage. The area was documented as unstageable and unable to determine depth. No change in treatment. On 04/08/14, nursing staff documented the right heel area as 3 centimeters by 4.3 centimeters, without odor, and with green/yellow drainage. The nurse identified the area as "starting to heal over". On 04/15/14, the wound nurse measured the right heel wound at 3.2 centimeters wide by 4.5 centimeters long, unable to determine depth, and the wound bed as red with slough. Loose slough was removed with forceps and scissors. The treatment remained the same. On 04/15/14, nursing staff documented the right heel wound as 4 centimeters by 5 centimeters, slight odor, and the wound bed as yellow and without drainage. 04/20/2014 at 4:00 P.M., nursing staff documented drainage to the right heel wound drained through the dressing and the resident's sock and boot. The drainage was yellow with a red tinge. On 04/22/14, the wound nurse measured the right heel wound at 3.0 centimeters wide and 4.5 centimeters long, unable to determine depth, a brown, red, yellow slough in the wound bed, and with a large amount [MEDICATION NAME] drainage. The loose slough was removed with forceps and scissors. The treatment remained the same. On 04/22/14, the nursing staff identified the right heel wound as 4 centimeters by 5 centimeters with a yellow bed and a faint odor. Throughout the assessment period from 02/13/14 to present (04/24/14), the facility's documentation of the right heel area and the wound nurse's assessments are not congruent in right heel pressure ulcer for size, description, drainage, and actual condition. The facility did not fully assess and prevent the development of the pressure ulcer. During an observation on 04/23/14 at 10:20 A.M., Staff A (registered nurse) and Staff B (licensed practical nurse) entered Resident # 2's room, washed their hands, and donned gloves. Resident # 2 sat in a wheel chair with both legs down and feet in heel boots. Staff A removed the right heel boot, gripper sock, and the gauze wrapping to the right heel. An observation of the resident's right lower leg and foot revealed at least 2 plus [MEDICAL CONDITION] and the right foot was red in color. Staff A removed the dressing pad on the wound. The dressing pad/gauze was covered with yellow drainage tinged and serosanguinous drainage. The outer area of the wound bed showed a small round white spot which would make this a possible Stage IV. The wound bed's outer area was red in color, the wound bed was covered in 3/4 slough, and an area of red. Staff A verbalized the wound nurse had been [MEDICATION NAME] the wound. After changing gloves, Staff A finished treatment to the right heel wound, removed her gloves, and washed her hands. Resident # 2's gripper socks and boots were applied to both feet. Staff A verbalized the right heel wound area was not present upon admission to the facility. The facility thought it might have been caused by the resident's shoes. Resident # 2 verbalized not realizing his/her shoes were about half a size too small and hard to get on without a shoe horn. The resident only wore the shoes to appointments or when going out of the building with family. Resident # 2 verbalized he/she did not have the pressure area on the right heel when admitted to the facility. The undated facility Policy and Procedure (P/P) for the Prevention and treatment of [REDACTED]. The P/P directed the nursing assistants to observe the skin daily, to turn and reposition residents on a regular basis, and to report any changes. A Braden Scale for skin condition should be completed at admission, a month after being admitted and then quarterly. Resident # 2's Braden Scale completed on 03/14/14 was 16 which represent a high risk for skin issues. A score of 12 or over equals a high risk). When a pressure ulcer is found, nursing staff were to initiate First Aid and initiate a Braden Scale assessment. During an interview with the Director of Nursing on 04/28/14 at 10:20 A.M., First Aid was identified as whatever treatment the nurse felt was best to start. Notifications to the Physician, family, etc. should be completed. The P/P directed nursing staff to initiate weekly documentation and include type of wound, location, date, stage or indicate partial or full-thickness, length, width, depth, wound base and edge description, and drainage, odor, undermining or tunneling, and/or pain. On 04/24/2014 at 10:40 A.M., Resident # 2's Physician verbalized it was the normal procedure for facility nurses to find a skin area and treat it before contacting the Physician. The Physician verbalized she had no problem with this procedure. On 04/28/2014 at 10:50 A.M., the Administrator for the facility presented a protocol the facility was planning to set up for first site care to wounds which would be approved yearly by the Physicians. 2. The MDS (Minimum Data Set) assessment with a reference date of 03/26/14, revealed a BIMS (Brief Interview for Mental Status) score of 10. A score of 10 represented a moderate long and short term memory deficits. Resident # 12 required the limited assistance of 1 staff person for bed mobility, transfers, dressing, toilet use, and personal hygiene. An electric wheelchair provided the resident with propulsion around the unit. The resident ' s [DIAGNOSES REDACTED]. The MDS documented the resident as a risk for skin breakdown and established the number of pressure ulcers present at that time was 1 pressure ulcer. The ulcer was a staged II with no measurements. The Braden Scale of 03/21/14 identified the resident at high risk for skin issues with a score of 21. The Care Plan added the [DIAGNOSES REDACTED]. The Care Plan identified a problem with the resident at risk for developing pressure ulcers dated 02/04/14. The plan directed staff to monitor wound drainage, size, undermining, and progress weekly and notify the physician if any decline. The skin should be monitored daily with cares and biweekly for skin audits. A pressure relief pad for the electric scooter and the recliner along with a pressure relieving mattress was identified for pressure relief. Staff should encourage the resident to turn side to side in bed and to change position every 2 hours. The Braden Scale should be updated quarterly. The plan did not identify any ongoing treatment for [REDACTED]. On the admission to the facility, the physician orders dated 1/21/14, identified Resident #12 displayed a pressure ulcer on the right buttock. The stage was not identified. A telephone order dated 01/21/2014 directed nursing staff to provide daily wound care of Allevyn (a type of dressing pad) with skin prep every Tuesday, Thursday, and Saturday, and as needed for right and left buttock wounds. On 01/25/2014, a telephone order discontinued the treatment to the left and right buttock and identified the wounds as sealed. On 03/05/2014, a FAX (facsimile) to the physician documented an area to the left hip measuring 1 centimeter by 1 centimeter, round, red, with a white center and warm to touch. The nurse applied a transparent dressing. The physician did not give the order for the transparent dressing and ordered the nursing staff to observe the area and apprise him of any changes. On 03/06/14 a FAX was sent to the physician. The physician was informed the resident had requested an Allevyn dressing be placed on the left hip for his/her comfort. The nurse requested and obtained an order for the Allevyn dressing as needed and change every 2 days. On 03/12/14, a telephone order directed staff to apply an Allevyn pad to the decubitus ulcers located on the right and left buttocks and to change every 2 to 3 days. A document titled Other Skin Conditions Forms for assessment and treatment of [REDACTED]. The weekly assessments did not contain all the areas of assessment as described in the policy and procedures for the facility. On 03/14/14 the Other Skin Conditions Form for the left buttock, near the coccyx area, documented an open area with no drainage present or odor and measured 0.25 centimeters. The wound was cleansed with normal saline and covered with an Allevyn dressing. The weekly documentation of the area did not include all the measurements, description as specified in the facility policy and procedures.etc. On 03/17/14 a FAX to the physician identified the left buttock near the coccyx area wound which measured 0.25 centimeters and the treatment consisted of normal saline and Allevyn dressing with the physician ' s approval. On 04/07/14, a FAX to the physician reflected a concern to the left buttock which was being treated for [REDACTED]. A new 2 centimeter by 7 centimeter area next to the original site was also identified. An order to use Allevyn and change every 2 to 3 days was obtained. It was not clear what wound documentation sheet covered these areas. A nursing note on 04/06/14 documented the information faxed to the Physician on 04/07/14, but lacked any further comprehensive assessments. A FAX to the physician dated 04/14/14 concerning a coccyx sore informed the physician of a plan of using the sit to stand mechanical device to better assist the resident with better personal hygiene and toilet use. No assessment of the coccyx "sore" could be found. On 04/22/14, a FAX to the physician documented a wound of 0.3 centimeters by 0.3 centimeters on the right buttock. The areas were cleansed with normal saline and an Allevyn dressing applied. A left coccyx/buttock area of 1 centimeter by 0.4 centimeters, open, with no drainage, redness, or increased warmth also had an Allevyn dressing applied. The physician approved the treatment. A Weekly Wound Documentation Progress Sheet dated 04/22/14 documented the right buttock area. A previous left buttock/coccyx sheet was updated with the treatment. The left buttock/coccyx sheet failed to cover all the areas of assessment such as drainage, size, odor, description of wound base, etc. During an observation on 04/24/2014, Resident # 12 transferred from the electric scooter to the bed and removed his/her slacks. An observation of the resident's left hip/buttock area revealed an Allevyn dressing. Staff B placed a clean pad under the resident and removed the dressing on the left hip/buttock area. The portion of the right hip which displayed a dressing was also removed. The dressing which was to be covering the coccyx area was not on the wound. The left hip/buttock wound displayed a Stage II pressure ulcer with a yellow center and surrounding tissue of pink and a red speckled rash on the rest of the hip/buttock area. The drainage on the dressing pad was yellow with no detectable odor. The right buttock area displayed a shallow red speckled rash. The coccyx area displayed a scabbed surface around 1.5 centimeters long and 0.3 centimeters wide. The wound sheet documentation for these areas was not completed.