Every finding on record at The Highlands

Based on observation, United States (US) Food and Drug Administration (FDA) Food Code, document review, and staff interview, the facility failed ensure staff washed hands prior to applying gloves and between glove changes. The facility also failed to prevent dirty gloves from coming into contact with food served to residents. The facility reported a census of 74 residents.Findings include:During an observation on 7/20/26 at 11:01 AM Staff B, Cook, reported she planned to prepare 16 servings of spinach, three moist and minced and thirteen puree. Staff B applied gloves without washing her hands, then opened the oven, removed a steam pan of spinach, touched a scoop, touched the blender, and continued to place sixteen, 4 ounce (oz) serving of spinach into the blender and blended. Staff B then removed three of the servings to a small steam pan for the moist and minced diets. Staff B then opened a bread bag and removed 5 slices of bread with her dirty gloves. Staff B and placed into the blender with hot water. Then, Staff B continued to prepare the spinach puree. Staff B then changed her gloves without washing her hands. The pureed spinach was served out during the lunch meal. Observation on 7/20/26 at 11:16 AM revealed Staff B verbalized she planned to prepare 16 servings of barbeque (BBQ) chicken, three servings of minced and moist and 13 servings of pureed chicken. Staff B applied gloves without washing her hands prior to food preparation. Staff B placed sixteen, 3 1/4 oz of BBQ chicken into the blender and blended. Staff B touched a scoop and removed three, 3 1/4 oz servings to a steam pan, then touched a measuring cup of chicken broth. Staff B added the chicken broth to the bottom of the steam pan. Staff B placed plastic wrap over the small steam pan of moist and minced chicken and placed the pan in the warmer. At 11:23 AM, Staff B returned to the preparation table and continued to wear gloves. Staff B obtained a bag of bread, removed the tie on the bread, opened the bread bag and pulled 13 slices of bread out of the bread bag with the dirty glove and placed it in the blender with the remaining chicken. Residents #1, #4, #10, #15, #18, #21, #28, #40, #54, #64, #69, #73, and #75 received the pureed BBQ chicken at the lunch meal. During the provision of the lunch service on 7/20/26 from 12:23 PM to 1:00 PM, Staff B changed her gloves without washing her hands, then proceeded to plate resident meals. Staff B plated four resident meals touching plates, scoops and steam pans with her gloves, then plated Resident #33 and #42's minced and moist BBQ chicken into divided plates, and tapped the top of the chicken down with her dirty right gloved hand. Staff B placed tater tots onto Resident #24's plate and proceeded to touch the top of the tater tots with her left dirty glove and handed the plate to the Nutritional Services Supervisor (NSS) to finish plating the vegetable, then was set up on the resident's lunch tray. On 7/20/26 at 1:00 PM, Staff B explained they had to use clean gloves or utensils to touch food. On 7/20/26 at 1:27 PM, Staff C, Dietary Aide reported if they had a solid food item, they could use gloves to handle the food. For other foods, they were to use a spatula or other serving utensil. On 7/21/26 at 9:20 AM, Staff D, Dietary Aide (DA) explained they were to wash their hands all the time. Staff D specified staff were to wash their hands before they put gloves on, after they took gloves off, and any time they changed gloves. On 7/21/26 at 1:00 PM, the Food Service Supervisor reported the staff were expected to use gloves for handling food and change gloves with handwashing directly after touching the food item. The facility's Glove-ology Vendor Guidance and Glove Use Best Practices for Food Safety both mandate thorough handwashing before and after wearing or changing gloves and emphasize that a fresh set of gloves should be used when changing tasks. Furthermore, the FDA Food Code 2017 (Chapter 2-301.14 and 3-301.11) mandates handwashing before donning gloves to initiate food preparation tasks and prohibits contact with ready-to-eat foods with bare hands.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Resident Assessment Instrument (RAI) Manual review, and staff interview the facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within 14 days of hospice election for 1 of 2 residents receiving hospice services (Resident #30). The facility identified a census of 74 residents. Findings include:Resident #30's Hospice Certification and Plan of Care documented hospice care services started 12/31/25. Resident #30's SCSA MDS dated [DATE] documented he received hospice services.The MDS Summary Page documented the 1/6/26 SCSA MDS was completed on 1/15/26. During an interview on 7/21/2026 at 2:38 PM, the MDS Coordinator reported a SCSA has to be completed within 14 days of the admission to hospice including the day of admission to hospice. The MDS Coordinator verbalized she missed it and probably completed it late. She further reported she followed the RAI manual for completing the MDS. The CMS LTC RAI User Manual, Chapter 2, page 2-17 directed a SCSA MDS must be completed within 14 calendar days after the determination that a significant change in resident's status has occurred. Page 2-25 directed a SCSA was required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home.

Based on clinical record review, document review, and staff interview, the facility failed to perform a new Preadmission Screening and Resident Review (PASRR, a federal mandate requiring all states to screen individuals before they are admitted to a Medicaid-certified nursing facility, ensuring they are placed in the most appropriate setting and receive necessary care) as required for 1 of 2 residents sampled (Resident #60). The facility reported a census of 74 residents.Findings include:An Electronic Health Record (EHR) Clinical Census showed Resident #60 admitted to the facility on [DATE]. The Hospital Discharge summary dated [DATE] documented a Secondary Diagnosis of intellectual disability (ID). The Baseline Care Plan dated 3/31/26 documented Resident #60 as cognitively impaired. A 3/25/26 Notice of Preadmission Screening and Resident Review (PASRR) Level I Screen Outcome documented no Level II was required due to no ID. The PASRR documented a reliable source, such as a family member, confirmed the presence of an ID prior to the age of 18 by answer the question, yes. The Clinical Reviewer Comments documented ID was not noted in the documentation (provided). Under Medical Conditions the documents available for review were the History and Physical Exam, Medication List and Medication Administration Records (MARs). The 3/25/26 PASRR Outcome Rationale documented a Level I screen indicated that a PASRR disability was not present because there was no evidence of a PASRR condition of an intellectual/developmental disability condition. If changes occurred or new information refuted the findings, a new screen must be submitted. The admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #60 was not currently considered a level II through the PASRR process and did not have a ID. The MDS documented a diagnosis of mild intellectual disabilities in the diagnosis section of the assessment. A Clinic Note, Encounter Date 5/14/26, documented the Patient Active Problem List included a diagnosis of mental retardation, dated 5/7/19.The Care Plan, revised 7/10/26, documented Resident #60 was independent in meeting his own emotional, intellectual, physical and social needs. During an interview on 7/21/26 at 2:04 PM the Social Worker (SW) reported he completed or reviewed the PASRRs as part of the admission process. He was still learning the PASRR process and had recently received more education regarding the PASRRs. He reviewed Resident #60's PASRR and reported the PASRR was not correct as Resident #60 did have an ID condition. He verbalized he had not read the PASRR thoroughly or correctly and the PASRR needed to be re-screened. The Preadmission Screening for Mental Illness/Mental Retardation Level II Policy, revised 3/2026, failed to address when a PASRR should be re-screened.

Based on clinical record review, document review, policy review, and staff interview the facility failed to ensure the Iowa Physician Orders for Scope of Treatment (IPOST) matched provider's orders on the electronic health record (EHR) for Do Not Resuscitate (DNR) for 1 of 2 residents sampled (Resident #6). The facility identified a census of 74 residents. Findings include: Resident #6's Electronic Healthcare Record (EHR) Census showed he was hospitalized [DATE] and returned to the facility on [DATE]. The After Visit Summary (hospital) dated [DATE] documented Resident #6 as a Do Not Resuscitate (DNR) status. A Clinic Note, Encounter date [DATE] documented after discussion with the Power of Attorney (POA), Resident #6 was changed to a DNR code status. A Nurses Note dated [DATE] at 4:40 PM written by the Director of Nursing (DON) documented the family had discussed due to the resident's continued decline, they would like to switch him to a DNR. The DON reached out to the Medical Director and received a verbal order for a DNR. The Physician Order dated [DATE] revealed, DNR.The Advanced Directives Care Plan included an updated intervention [DATE] for DNR status. During an interview on [DATE] at 8:27 AM Staff A, Registered Nurse (RN) reported they had an IPOST book they would refer to for a resident's code status. A review of the Hallway's IPOST Book revealed Resident #6's IPOST signed by the Healthcare POA on [DATE] stated if no pulse and not breathing cardiopulmonary resuscitation (CPR) to be provided. During an interview on [DATE] at 8:34 AM, Staff A verified the IPOST listed a full code status. Staff A checked Resident #6's EHR and verbalized Resident #6 was listed as a DNR. She stated in the situation, she didn't know what she would do. She would probably follow the IPOST as it was listed in the book to perform CPR. On [DATE] at 9:53 AM, the Administrator reported generally the IPOSTs were completed upon admission by the Social Worker (SW). If there were changes in the IPOST, those were usually completed as part of the care conferences and the DON would address those. During an interview on [DATE] at 11:43 AM, the DON explained the SW completed the IPOST with the family as part of the admission process. The SW and the MDS Coordinator also went over the IPOST as part of care conferences and updated the IPOST as needed. On [DATE] at 2:05 PM, the SW explained he completed the IPOST with the resident or the family at the hospital prior to admission to the facility or as part of the admission process. They reviewed the IPOST at each care conference and if there were changes requested, they would fill out a new IPOST and get a verbal order to change the code status. He further stated it would fall to him or the DON to ensure the correct IPOSTs (forms) were in the hallway books.The Advanced Directives Policy, revised 3/2026, directed upon return from a hospital or other facility, staff shall verify that any advance directives and IPOST forms on file are still current and that no revocations or amendments were made during the resident's absence. Updated documents shall be obtained and filed in the medical record. The Policy lacked direction on ensuring IPOSTs were updated in the hallway books.

Based on clinical record review, facility document review, and staff interview, the facility failed to provide adequate supervision for residents with wandering behaviors for 2 of 3 residents reviewed for supervision (Residents #1 and #2). The facility failed to ensure staff from the area of the facility where the Resident #1 resided responded to a door alarm, resulting in Resident #1 eloping from the facility on 3/7/26 via the front door of the facility. A staff member from assisted living responded and assisted Resident #1. The facility failed to prevent Resident #2, who had a history of entering other resident's rooms, from entering Resident #3's room without staff knowledge, resulting in a physical altercation between Resident #2 and Resident #3. The facility reported a census of 71 residents.Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Resident #1's Face Sheet recorded an admission date of 3/2/26.The Wandering Risk Scale dated 3/2/26 identified the resident as a high risk for wandering.The Progress Note written on 3/2/26 at 6:00 PM documented the resident was anxious and agitated with placement, wanting to leave, saying he would walk if he had to.Review of the Care Plan focus area dated 3/3/26, revised on 3/7/26, revealed the resident was an elopement risk/wander resident has eloped from building r/t (related to) Dementia. The Intervention dated 3/3/26 revealed, Has a [wander alert device] watch that will lock doors/sound when close to or attempting to leave the health center. The Progress Note dated 3/3/26 at 1:23 AM documented the resident was talking about going home. The Progress Note dated 3/3/26 at 9:44 PM documented the resident was a wanderer and had been redirected from the front door x6 (times six). The Progress Note written on 3/4/26 at 4:32 PM documented the resident became argumentative with staff, looked for his car, and requested to go home. The Progress Note written on 3/5/26 at 9:02 PM documented the resident was anxious, confused, and constantly wanted to leave the facility.The Progress Note written on 3/7/26 at 1:17 PM documented the resident was found in the assisted living parking lot by a staff member from the facility's assisted living. He was assisted back into the facility. The resident explained he was trying to go home.The facility provided [wander alert device] log recorded the resident left the faciity on 3/7/26 at 12:26 PM, and reentered the facility at 12:29 PM.The State Climatologist reported the temperature in [City Name Redacted] around the time the resident left the facility was 39 degrees Fahrenheit (F) and the wind chill at that time was 31 degrees F.During an interview on 6/16/26 at 3:19 PM, Staff A, assisted living universal worker, explained she was returning dishes to the kitchen from the assisted living. She heard the door alarm for exit A sounding. She quickly walked to the door and went outside. She observed Resident #1 walking toward the Assisted Living (AL). The resident was fully dressed but did not have a coat on. No staff from the care center responded to the alarm. Staff A explained she called a Certified Nursing Assistant (CNA) from the care center to come get the resident.During an interview on 6/11/26 at 12:05 PM, Staff B, CNA explained she worked the resident's unit on 3/7/26. She explained she left her co-worker on the unit and went to another unit to assist with the noon meal. She reported she received a text message from the AL worker that the resident had been outside and she needed to come get him. She reported her cell phone did not alert her to the door alarm going off.Review of Staff B's Staff Investigation Questionnaire for the resident's incident on 3/7/26 revealed Staff B believed the alarms didn't go off. During an interview on 6/11/26 at 12:11 PM, Staff C, CNA explained she worked on the resident's unit on 3/7/26. She explained she was assisting another resident in their room and when she was done with that, she observed the nurse assessing the resident. She explained she did not see the resident go out or come back in. She reported she did not recall the cellphone alerting her the door alarm had gone off, was beeping the call lights. Review of Staff C's Staff Investigation Questionnaire for the resident's incident on 3/7/26 revealed Staff C didn't hear any alarm from their call light phone around the time that the incident occurred. During an interview on 6/16/26 at 4:21 PM, the Administrator and the Director of Nursing (DON) explained the [wander alert device] alarms go to the cellphones the CNAs carry with them. The [wander alert device] alarm sounds different than the call lights that go to the cellphones as well. They reported the exit A door alarm has gone off before, being set off by someone not entering the code, and staff from the care center have responded to the alarm. They were unable to explain why staff from the care center did not respond this time.The facility policy titled Elopements and Wandering Residents last revised 12/2025 explained the facility was equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The policy also explained adequate supervision would be provided to help prevent accidents or elopements.2. Resident #2's Face Sheet recorded an admission date of 2/5/26.The MDS assessment dated [DATE] revealed Resident #2 had severely impaired cognition, and identified a short term and long term memory problem. Per this assessment, the resident wandered 1 to 3 days of the review period. The resident used a walker and wheelchair, and was independent to wheel 150 feet in her wheelchair. Resident #2's Care Plan focus area dated 3/19/26 revealed the resident was an elopement risk/wander r/t (related to) Dementia. The interventions included distract from wandering by offering pleasant diversions (initiated 3/19/26) and [wander alert device] placement on 3/19/26.The Progress Note for Resident #2 written on 5/19/26 at 7:30 PM documented the resident was wandering into other resident's rooms, bathrooms and closets.The Progress Note for Resident #2 written on 5/20/26 at 4:03 PM documented the resident enjoyed wheeling around the facility to see what everyone is up to.The Incident Report dated 5/22/26 at 3:45 PM documented an occurrence of Resident #2 and Resident #3 having a loud verbal interaction in the dining area. Once the residents were separated, Resident #3 reported Resident #2 had been in the doorway of his room, in his things. He explained he asked her to leave the room and she said something smart like him going to h*ll. He reported grabbing her wrist, told her it was his room and get out. They then had the loud verbal interaction in the dining area. Resident #2 reported that Resident #3 had grabbed her wrist. Per the Incident Report, three CNAs and a Nurse were in rooms providing cares at the time, and there were no witnesses to the altercation in Resident #3's room. The Progress Notes for both residents lacked an entry related to the occurrence.During an interview on 6/11/26 at 1:42 PM, Staff D, Activity Aide, explained on 5/22/26 she heard a woman's voice yelling something, help maybe. She then heard a man with a raised voice. She entered the dining room and observed Resident #3 standing with his walker and Resident #2 in her wheelchair. She separated the residents, encouraging Resident #3 to sit down and guiding Resident #2 to her room.3. Resident #3's Face Sheet recorded an admission date of 12/22/25.The MDS dated [DATE] revealed Resident #3 scored 13 out of 15 on a BIMS exam, which indicated intact cognition. The facility policy titled Elopements and Wandering Residents last revised 12/2025 explained adequate supervision will be provided to help prevent accidents or elopements, and interventions to increase staff awareness of the resident's risk, modify behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated with appropriate staff.

Based on observation, clinical record review and staff interview, the facility failed to properly position resident clothing while positioned in bed for 5 of 5 residents reviewed (Resident #2, #3, #4, #5 and #6). The facility identified a census of 68 residents. Findings include: An observation 9/18/25 at 2:48 p.m. revealed Resident #2 positioned in bed with his sweatpants positioned around his ankles. Review of Resident #2's Medical Diagnoses included Alzheimer's Disease. During an interview 9/18/25 at 2:53 p.m. Staff A, Certified Nursing Assistant (CNA) confirmed the resident's sweatpants as positioned around his ankles and indicated staff should not have positioned the pants around the resident's ankles as she proceeded to remove them. During an interview 9/24/25 at 9:22 a.m. the resident's wife confirmed she observed the resident's pants positioned around his ankles at various time while in bed, she had not liked that at all, and directed the staff to have removed them. The resident's wife indicated the resident had not slept with his pants around his ankles while he resided at home. Random observations 9/18/25 at 2:54 p.m. with Staff A included the following: a. Resident #3 positioned in bed with a brief on and sweatpants positioned around his ankles, confirmed and removed by Staff A. b. Resident #4 positioned in bed with a brief on and sweatpants positioned around her ankles, confirmed and removed by Staff A. c. Resident #5 positioned in bed with a brief on and sweatpants positioned around his ankles, confirmed and removed by Staff A. d. Resident #6 positioned in bed with a brief on and jeans positioned around her knees.During an interview 9/18/25 at 3:00 p.m. Staff B, CNA confirmed staff positioned residents in bed with their pants around their ankles so they could have easily checked and changed them. During an interview 9/23/25 at 11:21 a.m. Staff E, CNA confirmed it had not been acceptable to have positioned residents in bed with their pants around their ankles and/or knees. The staff member indicated she observed pants around resident's ankles and/or knees at various times.

Based on observation, clinical record review and staff interview the facility failed to properly monitor and intervene when an air conditioning unit became non-operational. The facility identified a census of 68 residents. Findings include: During an interview on 9/23/25 at 1:54 p.m. Staff C, Registered Nurse (RN) confirmed on 6/21/25 on the 10 p.m. - 6 a.m. shift the Chronic Confusion or Dementing Illness (CCDI) unit was warm, with a build up of quite a bit of humidity. Per Staff C, caused the floors to have been wet and slippery as the residents wandered throughout the unit. Staff C indicated Staff D, Certified Nursing Assistant (CNA) periodically dry mopped the floors as a means to have minimized the moisture build up. The staff member confirmed staff failed to notify members of management, to have included the maintenance department, related to the warm temperatures the evening and night of 6/21/25 into 6/22/25. During an interview 9/23/25 at 2:08 p.m. Staff H, Licensed Practical Nurse (LPN) confirmed she worked 6/21/25 from 6 p.m. - 10 p.m. or 6 p.m. - 6 a.m. in the CCDI unit. The staff member described the unit as a big unit which got to the point of condensation on floors in the hallways and dining room when the air went out, so she became worried residents would have fallen. The staff member described the unit at that time as hot, extremely hot, which had never been repaired while she worked. During an interview 9/23/25 at 11:08 a.m. Staff E, CNA confirmed she worked 6/21/25 on the 6 a.m. - 2p.m. shift in the CCDI unit and the T have been really warm and humid, without any air flow. The staff member confirmed she observed water on the floors in the resident rooms. The staff member also confirmed staff failed to have informed management of the high temperatures in the CCDI unit. During an interview 9/23/25 at 12:06 p.m. the Director of Human Resources (HR)/Interim Administrator (ADM) indicated she had been called on 6/21/25 by Staff F, Housekeeping who informed her it had been hot in the CCDI unit, the floors wet with humidity and staff had not been able to keep them dry so the Director of HR/Interim ADM called Staff G, Maintenance. During an interview 9/23/25 at 1:31 p.m. the Director of HR/Interim ADM indicated she thought the staff got ahold of her on 6/21/25, but the staff could have called her on 6/22/25. During an interview 9/23/25 12:34 p.m. Staff G confirmed he received a call from the facility staff on 6/22/25 at 6:30 a.m., and when he arrived at the facility he knew something had been wrong. Staff G explained he looked at the air unit, cleaned it, changed the filters, and went home. On 6/22/25 at 12:30 p.m. he received another call from Staff F who informed him the floors had been sweaty so he returned to facility and brought more fans and dehumidifiers. The staff member indicated the facility had fans and humidifiers in-house but on Monday, the next day, he purchased more dehumidifiers and portable air units for the CCDI unit and part of assisted living as they were the only units affected by the malfunction of the air unit/units. During an interview 9/23/25 at 1:43 p.m. the Director of Operations confirmed the Charge Nurses should have called and informed him of the situation and the direct care staff should have called if the nurses failed to follow through as expected. A Local Climatological Data v2 Daily Summary form dated June 2025 described the maximum temperature (T) on 6/21/25 as 91 degrees Fahrenheit (F), minimum T 77 degrees F, and the average T 84 degrees F.

Based on personnel file review, facility assessment review, facility policy review, and staff interview, the facility failed to provide dependent adult abuse training, within 6 months of hire for 4 of 5 employee personnel files reviewed (Staff A, Staff B, Staff C, and Staff D). The facility identified a census of 64 residents. Findings include: The employee personnel file review for Staff A, Licensed Practical Nurse (LPN), documented a date of hire of 10/17/24. Staff A's employee personnel file lacked documentation of Dependent Adult Abuse required training. The employee personnel file review for Staff B, Food Service Supervisor, documented a date of hire of 11/13/24. Staff B's employee personnel file lacked documentation of Dependent Adult Abuse required training within 6 months of hire. The facility provided a certificated titled: DS 168 Dependent Adult Abuse Mandatory Reporter Training Course dated 6/12/25. The employee personnel file reviews for Staff C, Certified Nursing Assistant (CNA), documented a date of hire of 8/1/24. Staff C's employee personnel file lacked documentation of Dependent Adult Abuse required training within 6 months of hire. The facility provided a certificated titled: DS 168 Dependent Adult Abuse Mandatory Reporter Training Course dated 6/12/25. The employee personnel file reviews for Staff D, Cook, documented a date of hire of 11/11/24. Staff D's employee personnel file lacked documentation of Dependent Adult Abuse required training within 6 months of hire. The facility provided a certificated titled: DS 168 Dependent Adult Abuse Mandatory Reporter Training Course dated 6/12/25. A review of the Facility Assessment updated on 3/5/25 documented required training for all positions included mandatory reporter training. A review of the facility policy titled: Abuse Prevention Policy, with a revision date of 11/22/24 revealed the facility require staff training/orientation programs that include such topics as abuse prevention, identification and reporting abuse, stress management, and handling verbally or physically aggressive resident behavior. The policy lacked detailing the timeframe of required training of 2-hour training within 6 months of hire and 1 hour of training annually. During an interview on 6/12/25 with Staff E, Personnel Director/Provisional Administrator, revealed the facility had no system in place for tracking completion for dependent adult abuse training. Staff E, acknowledged the required training had not been completed within 6 months of hire for 4 of 5 employees reviewed. Staff E, revealed 3 staff members had completed the required training on 6/12/25.

Based on record review and staff interviews the facility failed to provide 48 hour notice before the end of Skilled Nursing Care stays for 2 of 3 residents reviewed for Skilled Nursing Care (Residents #28 and #62). The forms the facility failed to provide timely were Notice of Medicare Non-Coverage (NOMNC) (Form CMS 10123-NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) (Form CMS-10055). The facility reported a census of 64 residents. Findings include: 1. Record review of Resident #28 Census in his Electronic Health Record (EHR) on 6/12/25 documented he started Skilled Nursing Care on 2/28/25 and transitioned to private pay on 3/20/25. Record review of Resident #28 Progress Notes on 6/12/25 revealed no documentation regarding advance notice of NOMNC and SNFABN forms were reviewed with the resident or his Power of Attorney (POA) 48 hours or greater prior to his discharge from skilled services and transition to private pay on 3/20/25. Record review of Resident #28 NOMNC and SNFABN revealed they were not signed until 3/30/25. 2. Record review of Resident #62 Census in his EHR on 6/12/25 documented he started Skilled Nursing Care on 12/1/24 and transitioned to private pay on 1/14/25. Record review of Resident #28 Progress Notes on 6/12/25 revealed no documentation regarding advance notice of NOMNC and SNFABN forms were reviewed with the resident or his Power of Attorney (POA) 48 hours prior to his discharge from skilled services and transition to private pay on 1/14/25. Record review of Resident #28 NOMNC and SNFABN revealed they were not signed until 1/15/25. During an interview on 6/12/25 at with Medical Records revealed she talked with Resident #28 POA before he discharged from Skilled Nursing Care, but must have forgotten to document it. She informed she would normally give notice prior to them going off Skilled Nursing Care. During an interview on 6/12/25 at 11:19 AM with Staff G, Nurse Manager, revealed they have a process in place to make sure Skilled Nursing Care notice forms are updated.

Based on record review and staff interviews the facility failed to complete a Discharge Minimum Data Set (MDS) and Reentry MDS for 1 of 1 residents reviewed for hospitalizations (Resident #41). The facility reported a census of 64 residents. Findings include: Record Review of Resident #41 Census in his Electronic Health Record (EHR) on 6/11/25 documented a discharge to the hospital on 4/5/25 and a return to the facility on 4/7/25. Record Review of Resident #41 MDS log in his EHR on 6/11/25 at 10:21 AM revealed the facility has not opened, started, or completed a 4/5/25 Discharge MDS and a 4/7/25 Reentry MDS as required. On 6/11/25 at 10:41 AM, Staff E, Personnel Director/Provisional Administrator informed they a are working on Resident #41 4/5/25 Discharge MDS and his 4/7/25 Reentry MDS. On 6/11/25 at 10:46 AM, Resident #41 MDS log in his EHR revealed a 4/5/25 Discharge MDS and a 4/7/25 Reentry MDS are in progress. During an interview on 06/11/25 at 1:24 PM with Staff G, Nurse Manager, revealed Resident #41 4/5/25 Discharge MDS and a 4/7/25 Reentry MDS are done. He informed the computer did not flag it for their MDS Coordinator to see it for some reason, he then informed the MDS Coordinator is hybrid and currently not onsite. He then informed they follow the Resident Assessment Instrument (RAI) manual for completing MDS assessments.

Based on record review, staff and medical professional interviews the facility failed to promptly identify and intervene for an acute change in a resident's condition related to dehydration for 1 of 3 residents reviewed (Resident#2), resulting in Resident #2 being transported and admitted to the hospital via ambulance [DATE] with severe dehydration and sepsis. Resident #2 died on [DATE]. Resident #2's Electronic Health Record (EHR) documented he had acute changes in condition noted as follows with lack of follow up assessments and notification to the physician with the condition changes: [DATE] increased blood pressure [DATE] No assessment completed [DATE] slightly elevated pulse [DATE] increase in pulse, blood pressure and mental status change. [DATE] No assessment completed [DATE] prior to being seen by psych via telecare in the early afternoon no assessment completed. On [DATE] at 4:45 PM, the Iowa Department of Inspections, Appeals, and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. This Immediate Jeopardy situation started on [DATE], the day Resident #2's documentation noted an acute change in condition with no physician notification and no follow up assessment completed. The facility staff removed the immediacy on [DATE] after the facility staff completed the following: Corrective Action: a. Immediate in-service for nurses on identifying acute changes in resident conditions, conducting complete assessments, and notification of providers of changes in condition in a timely manner. b. Attestation of these procedures for all shifts prior to caring for the residents c. Immediate review of all resident documentation going back 72 hours to ensure there were no current changes of condition that may require follow-up, further assessment, or provider notification. d. Any identified concerns will be assessed and the proper notifications made prior to clinical leadership leaving for the day. e. Started Daily auditing of all resident records to ensure that there are no current changes of condition that may require follow-up, further assessment, or provider notification. The scope lowered from a J to G (harm that is not immediate) on [DATE] after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had moderate impaired cognition. The MDS further revealed during the 7 day look back period he had not exhibited any rejection of care. The MDS documented he needed Supervision or touch assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating. The MDS documented diagnoses of diabetes, hip fracture, Alzheimer's disease and hypertension. Resident #2's Care Plan with a focus for potential for unplanned weight changes related to variable oral intake of meals and fluids, diabetes mellitus, Alzheimer's Disease with confusion, history of hip fracture and hospitalization . The interventions for the focus were to provide and serve diet as ordered, he needs assistance with feeding, and weight weekly and as needed. Review of the EHR for Resident #2 documented the following: Resident #2's discharge summary from the hospital on [DATE] documented he was initially taken to the local ER where imaging revealed a right displaced femur fracture. He had a hip replacement on that side in 2022. Workup aside from hip fracture was unremarkable aside from mild thrombocytopenia. The resident was medically stable for discharge. Review of the skilled assessments documented the following findings: [DATE] increased blood pressure with no follow up or notification to the physician. [DATE] No assessment completed that 24 hour time period last completed on 5:27 AM on [DATE]. [DATE] slightly elevated pulse with no follow up or notification to the physician. [DATE] increase in pulse, blood pressure, and mental status change. with no follow up or notification to the physician. [DATE] No assessment completed since assessment completed since 10:42 AM on [DATE] [DATE] prior to being seen by psych provider via telecare in the early afternoon no assessment completed. Review of Resident #2's Progress Notes document the following: [DATE] 10:38 PM : The resident was sleepy during supper. It is noted that resident is pocketing food, Licensed Practical Nurse (LPN) attempted to offer resident Ensure and it ran out of resident's mouth. Pain medication and other medications were administered prior to supper with no issues. We will continue to monitor. [DATE] 6:35 PM : The resident returned, from supper, clammy, not very active, eyes closed, drooling. The resident had been like this at the start of shift although not clammy until after supper. vitals taken, BS 196. afebrile. was reported that he attempted to hit the Certified Nursing Assistant (CNA) as she was trying to feed him. Will continue to monitor him. [DATE] 7:05 PM CNA's alerted this nurse to bloody drainage noted on sweatpants, when laying resident in bed, right side along the incision site. This nurse did not see any openings along the incision, no fluids were noted after palpating the incision area. Drainage is a serosanguinous (watery fluid and blood), moderate amount. Positioned resident on the right side, pillow between his legs to keep hip aligned. [DATE] 5:15 AM The resident has a fever of 100.1 Fahrenheit (F), Tramadol was given earlier and at this time cool compress to forehead temp 99.2 F at beginning of shift. [DATE] 1:32 PM Resident is lethargic, responds to verbal stimuli, when asked a question he is not able to answer, he is noted to be grimacing occasionally, and occasionally makes jerking movements. The writer called the resident's Power of Attorney (POA) with an update and voicemail left on the ARNP's nurse phone. We will continue to monitor. [DATE] 3:43 PM Resident transferred to ED via ambulance. Review of the Psych Telehealth note written on [DATE] documented: Today, staff report Resident #2 has had a change in mental status over the past 24 hours, blood pressure is slightly elevated, and running a low-grade temperature. Resident #2 is brought into a private office for an exam. He appears in distress - grimacing and respirations mildly elevated. He does not open his eyes or engage in conversation. Appointment concluded. Nursing staff instructed to notify PCP immediately as he appears to need urgent medical evaluation. During an interview on [DATE] at 2:36 PM Staff A, Registered Nurse (RN) reported for the [DATE] change in condition she passed it on in report to the next shift nurse to monitor. She reported at that time she did not notify the physician of changes. She reported she should have. For the change of condition on [DATE] she left a voicemail on the Advanced Nurse Practitioner's nurse phone on the condition change at 1 PM. She reported she then got a call back at 2:55 PM that recommended sending to the ED if the family was okay. She called the Power of Attorney and she didn't answer so called the second emergency contact which is a daughter and she wanted him sent to the ED. She then called the ambulance and the resident was sent out. During an interview on [DATE] at 10:20 AM, the Nurse Consultant reported the Nurse Practitioner reported she was not aware of any condition change or concerns with Resident #2 until [DATE] when the nurse called after he was seen by Psych. She reviewed the chart and no one was notified in the office. He reported staff should have notified the physician or the Nurse Practitioner. During an interview on [DATE] at 12:52 PM the Psychiatric-Mental Health Nurse Practitioner (PMHNP) reported she had been following Resident #2 for a year and a half via telehealth (the use of digital technology to access health care services remotely via video) for psych care and so she knows the resident. She reported on his appointment on [DATE] he was slumped over and not responding to her questions like he normally would. He would answer yes/no questions in the past. She noted he had been grimacing and respirations were mildly elevated. She noted the mental status change and staff reported he had this change for 24 hours, that he was running a low-grade fever and that his blood pressure was slightly evaluated. She immediately stopped the visit and told the nurse to notify his primary care physician and as he appeared to need urgent medical evaluation. During an interview on [DATE] at 3:55 PM Resident #2's Advanced Registered Nurse Practitioner (ARNP) reported her and her office were not aware of any change in condition prior to the notification on the afternoon of [DATE]. Resident #2's emergency room (ED) Notes dated [DATE] at 4:14 PM: Resident #2 with significant dementia and a recent right femur surgical repair on ,d+[DATE] who is a resident at [NAME] home. Presents today from the nursing home with fever, tachycardia (elevated heart rate), and decreased responsiveness. History is per nursing staff who spoke with nursing home staff as well as Emergency Medical Staff providers. Staff report he started to have a fever today which was controlled with Tylenol. They report his mental state has not been the same since he was hospitalized for his femur fracture. He appears profoundly dehydrated in the bed, dry mucus membranes and dry skin, and opens his eyes to voice. He is not verbally responsive. IV was established by EMS and Normal Saline was started. admitted with sepsis and dehydration. Hospital Physician Progress Note dated [DATE] documented Resident #2 discharged from the hospital on [DATE] after sustaining a femur fracture and Sodium level was 143 upon discharge. He was transferred to the nursing home after discharge from the hospital. - Per chart review, it was noted that Resident #2 was having mental status changes, fever, and minimal urine output with possible 1 episode of urination per shift for a week prior to this admission. Nurse Practitioner documented conversation on [DATE] he was admitted on [DATE] with a 7 Liter water deficit. Resident #2's Progress Notes documented the following: [DATE] 11:11 AM The resident returned from hospital stay. [DATE] 11:31 AM The resident admitted to hospice level of care. [DATE] 12:29 AM The resident passed. Resident #2's Death Record documented immediate cause of death was dehydration due to or as a consequence of sepsis.

Based on observation, clinical record review, facility policy review, and staff interview the facility failed to assess a bruise after identification for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 61 residents. Findings include: A Progress Note written on 9/21/24 at 9:38 PM for Resident #2 documented a bruise on the resident's right forearm. The documentation identified a larger red/purple area and multiple smaller bruises at various stages of healing. The documentation lacked measurements or a picture of the bruising. During an observation on 9/24/23 at 1:02 PM a purple/red area was noted on right forearm of Resident #2, approximately 2 centimeters (cm) by 3 cm. Two smaller purple/red areas measuring approximately 0.5 cm by 0.5 cm each. During an interview on 9/24/24 at 12:28 PM, Staff A Licensed Practical Nurse (LPN) explained skin concerns would be documented in Point Click Care (PCC, Electronic Health Record) in a skin assessment or in the skin/wound tab. During the same interview Staff B confirmed skin concerns found during off hours would be documented in a skin assessment or in the skin/would tab. Staff A and Staff B agreed there is no paper documentation for skin concerns. Staff B further explained Staff D, Registered Nurse (RN) is the wound nurse and follows up on all skin concerns and takes the pictures for measurements. During an interview on 9/24/23 at 2:30 PM, Staff C LPN explained she identified the purple/red area on Resident #2's arm on 9/23/24. She acknowledged she did not take measurements and did not take a picture. She acknowledged she did know she could document skin tears in the skin/wound tab of PCC but did not know how to document skin areas that were not skin tears. During an interview on 9/24/23 at 2:45 PM, Staff D RN, explained she would expect the person finding the skin concern to take a picture. She further explained that she does 1:1 education with nurses on how to take a picture and frequently they do the first picture together. She explained this education is not a part of on-boarding new nurses but something she does with them individually. The pictures provide length and width measurements. On 9/25/24 at 11:24 AM, Staff E, RN Supervisor reported the facility did not have a published policy for staff use regarding skin alterations.

Based on clinical record review, facility policy review, and staff interview the facility failed to notify the family and primary care provider (PCP) of bruising for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 61 residents. Findings include: A Progress Note written on 9/21/24 at 9:38 PM for Resident #2 documented a bruise on the resident's right forearm. The documentation identified a larger red/purple area and multiple smaller bruises at various stages of healing. The documentation lacked family or PCP notification. The clinical record lacked any documentation on 9/22/24 and 9/23/24. A Progress Note written on 9/24/24 at 12:26 PM documented the resident's PCP was notified. The incident report included a note explaining the family would be visiting this day (9/24/24) and would be informed of the skin alteration. During an interview on 9/24/23 at 2:45 PM, Staff D explained she would expect staff to follow the skin protocol. She further explained she would expect the family and PCP to be notified no later than the next morning. A facility document titled Physician and Family Notification of Resident Changes Policy, dated 6/29/23 directed staff to notify the family and attending or on call physician for any abnormal skin issues, including bruising. The policy also directed staff to contact the PCP and family the next morning for non-emergent issues.

Based on clinical record review, facility documents, and staff interviews the facility failed to prevent accidents and hazards for 1 of 3 residents reviewed (Resident #41). The facility reported a census of 62 residents. Findings include: Review of the MDS (minimum data set) dated 5/2/24 revealed Resident #41, was non-verbal, had a BIMS (Brief Interview for Mental Status) score of 0, indicating the resident is rarely understood, and a cognitive pattern of 2, indicating moderately impaired (decisions poor; cues/supervision required). Resident #41 had diagnoses of Dementia with other behavioral disturbance, mood disturbance, and anxiety disturbance. Review of Resident #41's Care Plan, revision date 7/9/24, indicated resident had limited physical mobility, Resident #41 did not ambulate, ADL self-care performance deficit required two staff for all transfers and may use mechanical lift at nurses discretion. Review of a Progress Note dated 7/17/24 at 4:05 PM, Staff K, LPN, was called down to resident's room, on arrival he was found lying flat on the floor underneath the mechanical lift sling, which was still attached to the lift. Staff stated that he fell out of the sling backwards, the strap that goes on his left shoulder was off of the metal bars. Staff also stated that he had hit his head. Neurological assessment started, range of motion with in normal limits, skin was assessed and noted to have a skin tear to his left elbow. Resident was assisted x 3 with lift into bed. The doctor was notified and Nurse K was informed as long as there was no active bleeding, continue to monitor and send Resident #41 to ER if symptoms worsen. Resident's family and DON (Director of Nursing) were notified. Progress Note date 7/17/24 at 9:26 PM revealed, at 5:48 PM, Staff L, LPN, called the on call provider to informed them, Resident #41 was not using his left hand as he normally would, he was not able to feed self and he had a red spot on the back of his head. Resident #41's right pupil was reactive and sluggish measuring 3 mm and left pupil reactive and brisk measuring 3 mm. Per the provider, if the family agreed, the Staff L was to send Resident #41 the ER (emergency room ) to be evaluated. At 5:55 PM, Staff L contacted Resident #41's family who indicated due to insurance and financial concerns not to send and make him comfortable, if any changes to his condition to notify the family. Staff L, notified the DON and Provider that Resident's family did not want him sent to ER at this time. Progress Note dated 7/18/24 at 3:33 PM, revealed Resident #41 was seen by Facility provider per nursing request following the incident 7/17/24. Resident #41 noted to have a hematoma on left side of his head and upper extremity discomfort. Facility provider was notified of family request not to send to ER. As needed order for ice received and continued with neuro assessments, pupils equal and reactive to light. Facility Provider Clinic Note, dated 7/18/24, revealed Resident #41 was reported to have an episode of emesis after breakfast this morning and was taken back to his room. He is resting quietly in his bed at the time of my assessment. I did press on all of his extremities and he cried out in pain with palpation to the left should and distal clavicle. He was also crying out in pain when I palpated left side of his head, with a moderate hematoma noted. Pupils equal, reactive. No active bleeding, no other significant bruising noted. No signs of increased discomfort in the lower extremities, hips, or pelvis. Would recommend further evaluation in the ER if any new changes or worsening in condition although this has been previously declined by Resident #41's Power Of Attorney as she prefers to monitor him and just keep him comfortable in the facility as able. I did also order a cold compress to be applied to the left shoulder and left scalp as needed three times daily for 20 minutes at a time. Progress Note dated 7/18/24 8:50 PM revealed, the author, DON, was updated on Resident #41's general demeanor change, he was difficult to arouse from waking, and screams out in pain with light palpation to left shoulder. He had emesis this AM and had been lethargic this shift, difficult to arouse and generally appears off his baseline cognitively, however difficult to assess due to resident being non-verbal. He was evaluated by Facility Provider with recommendation to evaluate at the ER, family declined ER evaluation at that time. This author (DON) called and Resident #41's family on 7/18/24 at 8:30 PM to update on Resident #41's current change in level of consciousness and intense pain to left shoulder. DON explained to family the indication to be seen in ER to qualify for hospice for palliative care support for pain management. Family confirms concerns with insurance and financial burden, DON assured family further financial burden will not occur due to ER visit. Family verbally gave consent to sent Resident #41 via ambulance to ER to be evaluated. Progress Note dated 7/18/2024 at 9:46 PM revealed, family was in agreement to send Resident #41 out to ER due to resident noted to be sluggish when responding to this nurse and yelling out in pain when touched on left side. Paper work completed and ambulance called at 9:43 PM for ambulance. Ambulance arrived at 10:05 PM, resident was assisted to stretcher and left accompanied with 2 EMT's. Progress Note dated 7/19/2024 12:00 AM, indicated call was received from ER, Resident #41 was discharged , X-ray of left should revealed no fracture, some separation of the ac joint. Review of Incident Report dated 7/17/24 at 1:15 PM, revealed the following: A.) On 7/17/24 the mechanical lift and sling was inspected by DON without issues. Root cause determined the left shoulder strap was not hooked into mechanism completely and gave away. B.) On 7/17/24 Education was provided to staff, competencies performed with no concerns. C.) On 7/19/24 Resident #41 was evaluated in ER, diagnosed with AC separation. Witness Statement dated 7/17/24, Staff N, CNA, stated Staff M, CMA and I hooked up mechanical lift to transfer Resident #41 as Staff N controlled the lift, I, Staff N, CNA, was behind Resident #41's chair. Once Resident #41 was lifted to clear the chair, I (Staff N, CNA) proceeded to pull the chair back and in the process of doing so, Resident #41 began to fall from the sling onto the floor, that's when I (Staff N, CNA) stepped out of the room and called for the nurse. Witness Statement dated 7/17/24, Staff M, CMA, stated Staff N, CNA and I went and hooked up Resident #41 to transfer into bed, I (Staff M, CMA) was operating the lift, as the lift was going up in the air I checked to make sure the straps were still attached and getting tight, went to turn him around and Staff N, CNA, moved the chair out of the way and I saw the strap dropped down and he fell to his left side, hitting his head on the floor and right leg was still in the lift when he landed. I (Staff M, CMA) yelled for the nurse to come to room and sit next to Resident #41 and try to reassure him it was going to be okay. Review of Major Injury Determination Form dated and signed 7/17/24 at 1:15 PM, indicated by Facility Provider, after reviewing circumstances, injury and prognosis of patient, the injury Resident #41 sustained was not a major injury. Hoyer lift Transfer Training Education, signed by attended staff, dated 4/12/24 at 2:00 PM, indicated the following: 1.) Inspect mechanical lift prior to use- any concerns? [NAME] tip guards in place? Report to DON and maintenance if missing. 2.) Inspect lift sling prior to use- correct size per resident's weight? Any wear on straps? Report to DON and maintenance if so. 3.) 2 nursing staff must be present at all times during mechanical lift transfers: CNAs, Med Aides, LPNs, RNs only- no dietary/housekeeping/maintenance staff. 4.) 1 nursing staff to run lift, while paying attention to resident's arms (inside sling at all times) and legs to prevent feet from bumping mechanical lift. 5.) 2nd staff to have at least 1 hand on resident at all times, guiding body and pulling back/adjusting as necessary to prevent foot contact with mechanical lift. 6.) 2nd staff must not be preparing bed/room/linens etc. during transfer. 7.) When in wheelchair, remove mechanical lift sling and tuck away to prevent skin breakdown on appropriate residents. (per care plans) Those unable to completely remove, tuck leg straps in and pull top straps around to maintain dignity. 8.) Our current fall protocol states to use the mechanical lift whenever a resident has fallen and need assist up. If resident is able to get up on own, mechanical lift not needed, but they must be able to do 100% themselves. Competency Testing of Hoyer (mechanical lift) completed by Staff M, CMA, Staff N, CNA, and other nursing staff on 7/17/24 indicated the following steps during mechanical lift transfer procedure: Step 10: The caregiver ensure loops to be hooked up to the lift are uniform. Step 11: Both caregivers agree the clips and loops are secured to the lift and in proper position prior to moving the resident and the resident is safely positioned in the sling. Step 12: The lead uses the controls to raise the resident. The helper assures the sling is secured and may need to hold the resident's head. Interview with Staff M, CMA on 7/25/24 at 9:34 AM, revealed Staff M, CMA, hooked up Resident #41 to mechanical lift, as the operator, she always watches as the residents go up, watching that all straps go up together, guiding Resident #41's legs to rotate into the right position, then she noticed the top strap slipped off and resident fell down to his left side, hitting his head on the floor. Staff M, CMA stated there are always two staff when transferring residents by mechanical lift. Training was received for mechanical lift transfers following the incident. Interview with Staff O, CNA, on 7/25/24 at 9:37 AM, indicated CNAs/CMAs had received mechanical lift training and competency testing a week ago. Interview with Staff J, RN Supervisor on 7/25/24 at 10:47 AM, revealed Staff J would expect to have 2 staff members during mechanical lift transfer and perform the set up and transfer according to the training guidelines including making sure straps are secured. One staff is to run controls and watch the sling and mechanical lift while the other is to guide and move the resident as little as possible while moving the mechanical lift to the transfer location.

Based on record review, staff interviews, and policy review the facility failed to have a qualified and educated dietary staff provide food service to residents. The facility reported a census of 62 residents. Findings include: Record review of an untitled and undated document provided by the facility instructed meal times are: Breakfast 7:30 AM Lunch 11:30 AM Supper 5:00 PM During an observation on 7/22/24, noon meal service started in the dinning room at 12:04 PM and was completed at 12:40 PM. During an observation on 7/24/24, noon meal service in the dinning room started at 12:02 PM and completed at 12:45 PM. Record review of the the facilities Job Description for [NAME] updated 7/24/24 instructed requirements for completion of a state approved safety and sanitation, and modified diet courses. Record review of the the facilities Job Description for [NAME] updated 7/24/24 instructed requirements for completion of a state approved safety and sanitation course. During an interview on 7/24/23 at 11:45 PM with Staff F, Cook, revealed he has been trained on different types of diets and how to prepare them. During an interview with Staff J, Registered Nurse (RN) Supervisor on 7/25/24 at 10:15 AM revealed no Dietary staff have food service training completed for safety and sanitization course or modified diets.

Based on observation, staff interviews, and policy review the facility failed to ensure during meal service, ready to eat food was not touched by contaminated gloves for multiple residents that were served chicken sandwiches. The facility reported a census of 62 residents. Findings include: During intermittent observations of meal service on 7/24/24 at 12:05 PM to 12:32 PM revealed Staff F, [NAME] put on gloves and touched multiple surface items including handles, trays, counter tops, his clothing, his arm, serving utensils, exterior portion of bread bags and would preceded to touch sandwich buns with the same gloves. The facility provided an undated policy, Dietary Sanitary Conditions that lacked instruction to staff on when gloves should be worn, but did instruct staff to complete good hand washing prior to preparing, serving, and distributing food. During an interview with Staff J, Registered Nurse (RN) Supervisor on 7/25/24 at 10:15 AM revealed he had instructed staff to remove gloves and wash their hands when in doubt.

Based on observation, staff interview, and policy review the facility failed to ensure 10 of 10 residents received a well-balanced diet that met their nutritional needs. The facility reported a census of 62 residents. Findings include: During an observation on 7/24/23 at 11:00 AM - 11:45 AM of the puree process for chicken sandwiches revealed the following: Staff F, Cook, had ten (10) cooked and breaded chicken patties in a large mixer that was being ground, Staff F added in chicken broth and milk to get to proper consistency. Staff F, decided the consistency was about correct and was going to transfer into a serving dish to serve. The Surveyor intervened and asked if the buns have been added to the pureed chicken and Staff F informed they had not been and went and proceeded to add three (3) buns to the purred chicken, and continued the process, Staff F was checking consistency and about ready to remove to serve and the Surveyor intervened again and informed that if there are ten (10) servings of chicken there would need to also be ten (10) buns to ensure residents get the same amount of calories as a non-pureed diet would get one (1) patty and one (1) bun to make a sandwich. Staff F then proceeded to add seven (7) more buns. Staff F, finished mixing and was going to transfer into the serving dish without measuring the pureed food. The Surveyor intervened asking what their process was for measuring to ensure correct portions are served for all ten (10) residents and Staff F was not sure, Staff F then utilized resources found in the kitchen to ensure accurate portions were given to all ten (10) residents During non meal food service observation on 7/24/23. The facility provided accurate portions to puree residents. During an interview with Staff J, Registered Nurse (RN) Supervisor on 7/25/24 at 10:15 AM revealed he would expect puree diets to get the same amount of food as non pureed diet residents. Review of the facility policy, Therapeutic Diets, dated 7/1/24 lacked instruction to staff on the process of how to complete the puree process and ensure, puree diet residents get the same portions as regular diets.

Based on observation, clinical record review, policy review and staff interview, the facility failed to properly secure medication and assess resident safety for medication administration for 1 of 1 residents sampled (Resident #53). The facility identified a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive loss. The MDS listed a diagnosis of mild cognitive impairment of uncertain/unknown etiology. A review of the Order History Report signed by the Provider on 7/02/24 lacked physician orders to self-administer medications or orders for Pepto Bismol or vitamin D. A 7/23/24 review of Resident #53 Care Plan and Kardex lacked documentation Resident #53 could store and self-administer medications. During an observation on 7/23/24 at 10:23 AM Resident #53 lay in a low bed watching television. Observation at this time revealed, a half full bottle of Pepto Bismol and a half full bottle of vitamin D, 1000 international units (IU) on the second shelf of the residents double mirrored cabinet above his dresser. He reported he didn't think he had used the vitamin D in a while, but he verbalized when he has an upset stomach after eating, he comes back to his room and takes a few swigs of the Pepto and that does the trick. Resident #53 reported he needs that often. A 7/23/24 10:48 AM review of Resident #53 Point Click Care (PCC) Assessment tab in the electronic health record for the past 6-9 months lacked documentation of an assessment to self-administer medications. On 7/23/24 at 7/23/24 at 1:18 PM observed Resident #53 leave his room with the door open approximately one foot and walk up toward the dining room out of sight. During an observation on 7/23/24 at 1:31 PM the half full bottle of Pepto Bismol and the half full bottle of vitamin D remained on Resident #53 second shelf of his cabinet above his dresser. On 7/24/24 at 9:47 AM Staff B Licensed Practical Nurse (LPN) verbalized she hadn't seen any physician orders for any resident's to self-medicate on the electronic medication administration record. If she had any questions about medication in resident rooms, she would ask the Assistant Director of Nursing (ADON). On 7/24/24 at 9:57 AM Staff C CMA reported there are no residents that self-administer medications on the Woodlands hallway. If she found medication in a room, she would report to the Director of Nursing (DON) as she thought it would need to be assessed. Interview completed on 7/24/24 at 9:59 AM revealed Staff D Registered Nurse (RN) voiced the facility has an assessment form they complete. All bedside stands have a locked drawer on them. The resident, cognition wise, has to know when to take the medication, how often to take the medication, be able to write down when they take the medication, and how to keep the medication locked up. They get a physician order for the resident to have the medication at the bedside and the resident is assessed and has to demonstrate proper medication administration. Staff D verbalized she did not know where the medication self administration form was kept. After thinking further, she voiced she thought the assessment form was in PCC under assessments. Staff D checked and the Medication self-administration safety screen assessment form came up in PCC. During an observation on 7/24/24 at 10:02 AM Resident #53 room door observed open all the way approximately four feet. A half full bottle of Pepto Bismol and half bottle of vitamin D 1000 IU sat on the second shelf of his cabinet above his dresser. The sliding glass door of the cabinet was completely open. Staff D stood at the medication cart approximately 28 feet from Resident #53 room. On 7/24/24 at 10:11 AM Staff E ADON entered Resident #53 room to look for another resident and walked out of the room. Resident #53's room door remained wide open. During an interview on 7/24/24 at 10:27 AM Staff D reported Resident #53 went on a bus trip this morning and would be back a little later. Resident #53's room door remained wide open. The half full bottle of Pepto Bismol and half-full bottle of vitamin D 1000 IU sat on the second shelf of the cabinet above the dresser. The sliding glass door to the cabinet was wide open. Observation on 7/24/24 at approximately 11:05 AM revealed the facility bus returning from the morning outing. Resident #53 returned to his room. During an interview on 7/24/24 at 10:36 AM the DON reported they have not run into the situation where a resident wanted to self administer their own medications. She would have to look into what the facility policy entailed. She reported from her past experience, usually they have to get a physician order for the resident to keep the medications at their bedside, ensure the resident can keep the medication locked up and do assessments to ensure the resident is safe to administer the medication. On 7/24/24 at 12:22 PM Resident #53 door remained open approximately 10 inches. The half bottles of Pepto Bismol and vitamin D3 1000 IU remained on the second shelf of the residents cabinet above his dresser in clear view with the sliding glass door open. Resident #53 was out to lunch in the main dining room at this time. On 7/24/24 at 1:57 PM Staff G Certified Nursing Assistant (CNA) voiced she had never seen any medications in resident rooms that should not be there. During an interview on 7/25/24 at 8:41 AM the DON reported She didn't think Resident #53 would be safe to administer his own medication. The DON further verbalized it is typically more highlighted in the memory unit for residents not to have medications at the bedside. They don't do any formal training for staff to recognize and report on medications in resident rooms, but she would expect staff to report to the charge nurse if they saw medications in the resident's room (that was not administered by the nurse). The Self-Administration of Medication Policy, revised 1/14/24 directed the following: 1. As part of their overall evaluation, the staff and practitioner will assess the resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for the medications. c. Ability to remove medications from container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of the medications. 3. Self-Administered medications must be stored in a safe and secure place, which is not accessible by other residents. 4. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.

Based on observation, resident, family, and staff interviews the facility staff failed to submit a new Preadmission Screening and Resident Review (PASRR) for 2 of 2 residents sampled (Residents #29 and #56). The facility reported a census of 62 residents. Findings include: 1. Resident #29 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS included diagnoses of bipolar disorder, anemia, orthostatic hypotension, and non-Alzheimer's dementia. Resident #29 current PASRR Level 1 Screening Outcome dated 3/12/2021 reflected a PASRR Level 1 Determination, No Level II required. The bipolar disorder diagnosis was not listed on the submitted form. A Monthly Medication Therapy Review - Prescriber Notification Form for GDR (Gradual Dose Reduction) signed by the Nurse Practitioner on 6/27/23, listed diagnoses of bipolar disorder, anxiety, dementia with behavioral disturbance, and major depressive disorder. During an interview on 7/24/24 at 10:15 AM, Staff H social worker, stated the clinical team reviews referral packets and the clinical nursing team advises him when a PASRR for Level II determination will be required. During an interview on 7/24/24 at 10:21 AM, Staff I DON indicated that diagnoses are reviewed and the MDS nurse will advise the social worker when a PASRR will need to be submitted. The Maximus PASRR manual dated 2/8/23 directs PASRR evaluations are referred to as Level II evaluations to distinguish them from their counterpart Level I screens; the Level I screen is a brief screen used to identify persons applying to or residing in Medicaid certified nursing homes that are subject to the Level II process. Once a person with a suspected or known diagnosis is identified through that screen, a Level II evaluation must be performed to determine whether the individual has special treatment needs associated with the MI and/ or ID/RC. 2. Resident #56 MDS assessment dated [DATE] identified a BIMS score of 2 indicating severe cognitive impairment. The MDS included diagnoses of atherosclerotic heart disease, coronary artery disease, hypertension, non-Alzheimer's dementia, and post-traumatic stress disorder. Resident #56 current PASRR Level 1 Screening Outcome dated 7/21/23 reflected a PASRR Level 1 Determination, No Level II required. The post-traumatic stress disorder diagnosis was not listed on the submitted form, which would trigger the need for a Level II PASRR to be submitted. A 7/24/24 review of the Point Click Care medical diagnosis list documented a diagnosis of post-traumatic stress disorder with an active diagnosis on 7/25/23.

Based on record review, staff interviews, and job description review the facility failed to have a qualified professional serve as the Dietary Manager. The facility reported a census of 62 residents. Findings include: Record review of the Dietary Managers employee file on 7/23/24 lacked documentation they had completed a state approved food service supervisor's course as required. During an interview with Staff J, Registered Nurse (RN) Supervisor on 7/25/24 at 10:15 AM revealed the Dietary Manager had been employed by the facility since roughly February, 2024 and did not have a state approved food service supervisor's course completed. Record review of the the facilities Job Description for Dietary Managers updated 7/24/24 instructed they are to complete a state approved food service supervisor's course.

Based on clinical record review, hospital record review, policy review, and former and current staff interviews the facility failed to use safe transfer techniques for 1 of 4 (Resident #3) residents reviewed for gait belt transfers, resulting in a hip fracture. The facility failed to provide adequate supervision for a resident with dementia (Resident #1) who accessed a potentially hazardous area through a locked door. The facility reported a census of 64 residents. Findings include: The Face Sheet for Resident #3 documented an admitted [DATE]. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS documented diagnoses including displaced intertrochanteric fracture of the left femur, anemia, and osteoporosis. The Progress Note written on 10/19/23 at 1:00 PM documented a mobility score of 9 indicating moderately impaired mobility. The Progress Note written on 10/19/23 at 5:05 PM documented the resident was assist of 1 with a walker and gait belt with weight bearing as tolerated to the left leg. The Occupational Therapy (OT) note dated 10/19/23 directed staff to use 1 assist with all self-cares, and to ambulate with a walker to the bathroom. The Baseline Care Plan signed on 10/19/23 directed staff to use one assist, a walker, and a gait belt. The Progress Note written on 10/29/23 at 9:50 PM documented Staff A, Registered Nurse (RN) was called to Resident #3's bathroom following a fall. The note documented Staff B, Certified Nursing Assistant (CNA) was transferring the resident to the bathroom when the resident fell and hit her head on the corner of the wall. The resident complained of pain 10/10 to her left leg. The resident was sent to the Emergency Department (ED) for evaluation. The Progress Note written on 10/29/23 at 10:30 PM documented Staff A, RN provided verbal 1:1 education to Staff B, CNA regarding the use gait belts for all transfers and ambulation, and not let go of the gait belt until the resident is seated on a safe surface. The Progress Note written on 10/30/23 at 12:47 AM documented the resident would be transferred to a larger hospital due to re-breaking her left hip. The hospital radiology report dated 10/30/23 documented a newly displaced overriding oblique fracture of the distal left femur. The census tab in the Electronic Health Record (EHR) documented the resident returned from the hospital on 11/3/23. The EHR documented the resident admitted to Hospice on 11/16/23 and the resident passed away on 11/28/23. The Major Injury Form signed by the physician on 11/02/23 determined the injury sustained by the resident was a major injury. During an interview on 1/31/24 at 3:05 PM, Staff A, RN explained the resident was supposed to have a gait belt on for all transfers. He further explained Staff B, CNA reported the fall to himself and the 3 rd shift nurse coming on. When he went to the resident's room to assess the resident they found her on the toilet. He explained Staff B, CNA reported she was walking the resident when she turned her attention away for a second and the resident fell . Staff B, CNA picked the resident up off the floor and put the resident on the toilet prior to notifying the nurse. Staff B, CNA was not using a gait belt. Review of Staff B, CNA's personnel file documented she received gait belt training on 7/12/23. During an interview on 1/31/24 at 4:20 PM, Staff C, Licensed Practical Nurse (LPN) explained he would expect the CNAs to follow protocol of notifying the nurse after a resident falls. He further explained if, after the assessment, it was safe to get the resident up they will do so. If the resident was ambulating at the time of the fall, he would assess if staff was utilizing a gait belt and any other necessary equipment. During an interview on 2/01/24 at 10:00 AM, Staff D, RN explained she would expect the CNA to alert the nurse if a resident falls before doing anything. She further explained she would expect a gait belt to be used for ambulation and staff to stay with the resident at all times. During an interview on 2/01/24 at 11:24 AM the Director of Nursing (DON) explained she would expect staff to use a gait belt for a resident requiring 1 assist. She further explained she would expect the caregivers hands to be on the gait belt at all times. The undated facility policy titled Use of Gait/Transfer Belt identified that gait belts are used to prevent unnecessary injuries to staff and residents. The policy directed staff to hold the gait belt with both hands during ambulation. The facility policy titled Falls, last reviewed on 4/23, directed staff to leave the resident as is until assessed by a nurse. 42133 2. Resident #1's MDS assessment dated [DATE] documented a BIMS score of 0 indicating severe cognitive loss. The MDS documented Resident #1 with physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 4-6 days per week; verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) 4-6 days per week; rejection of care that is necessary to achieve the resident's goals for health well-being 4-6 days per week; and wandering 4-6 days per week. The MDS listed diagnoses of Alzheimer's Disease with late on-set and Non-Alzheimer's Disease. The MDS documented Resident #1 was independent in sit to stand transfers and required supervision to touch assistance with chair to bed/to chair transfers. Resident #1 also required supervision to touch assistance when walking 10 feet, 50 feet, and 150 feet. The Care Plan revised 8/15/23 documented Resident #1 with limited physical mobility and directed in the following: a. When the Resident becomes agitated, intervene before agitation escalates. Guide way from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Provide 30-minute checks x 72 hours. Revision 1/15/24. c. Monitor the Resident's location every 1 hour. Document the location and attempt diversional interventions in behavior log as needed. Revised 8/12/23. The Care Plan also noted Resident #1 with impaired thought processes related to Alzheimer's Disease and directed the staff to cue, orient, and supervise as needed. Upon entrance into the CCDI unit on 1/31/24 at 11:00 AM seven residents sat in recliners in the front CCDI lounge with two additional residents seated in wheelchairs in the lounge. No staff were visible in the lounge or in the hallways. At 11:11 AM Staff E, Certified Medication Aide (CMA) came out of the CCDI medication room behind a closed door to the CCDI front lounge to administer medications to a resident sitting in the CCDI lounge. Staff E, CMA returned to the medication room and shut the door. No staff visible in the J hallway or CCDI front lounge at this time. At 11:18 AM Staff F and Staff G, CNA's came to the dining room and started to assist residents from the lounge to the CCDI dining room. At 11:35 AM Staff E, CMA communicated she was leaving the unit and would return in a few minutes. Staff E, CMA left the unit and no staff were present in the front CCDI lounge area with three residents still sitting in the recliners and one resident sitting in a wheelchair. At 11:40 AM Staff E, CMA returned to the CCDI unit. On 1/31/24 at 1:21 PM Res. #1 walked up to a housekeeping cart parked outside of the CCDI dining room and tried to open the three ring binder that sat on the cart. The housekeeper told him everything was good. Resident #1 proceeded up the hallway to the CCDI lounge. Resident #1 checked the garbage and Staff F informed him the garbage was fine. Resident #1 stated, okay, then I will go across the street. Resident #1 then walked to the CCDI shower room door off the front lounge and shook the door handle and pushed on the door. The door did not open. He then went to the kitchen hallway door off of the CCDI lounge and shook the door handle and tried to open the door. The door did not open. On 1/31/24 at 1:23 PM with entrance into the CCDI Unit five residents sat in recliners and three residents sat in wheelchairs in the front lounge. No staff present in the front lounge. At 1:24 PM Staff E, CMA walked back onto the unit. Resident #1 observed wandering in the front lounge and pulling at his pants at this time. Staff E, CMA verbalized he probably needed to go to the bathroom. Staff F, CNA assisted Resident #1 to the restroom. On 1/13/24 at 2:04 PM Staff E, CMA described Resident #1 as excitable and they try interventions for the resident, but those don't always seem to work. On 1/31/24 at 2:18 AM Staff G, CNA reported Resident #1 was very active and had a history of being one to one supervision in the past. During an observation on 1/31/24 at 2:31 PM Staff E, CMA observed standing in the CCDI medication room at the Medication Cart. Staff D, Registered Nurse (RN) observed half way down the J hallway talking to two oncoming CNA staff. Resident #1 opened a punch number lock on a closet door and entered into the locked room with the door closing behind him, creating a situation where the resident whereabouts would be unknown. No staff were visible in the front CCDI lounge at this time. The Surveyor immediately alerted Staff E, CMA that Resident #1 had accessed the locked area. Staff E,CMA seemed confused and stated, what? Surveyor reported Resident #1 had opened the closet door and was inside the locked room. Staff E,CMA punched in the lock number and opened the door. Resident #1 sat leaning against a small bedside table with approximate seven inch by seven-inch area of wetness to the front of his pants. Staff E, CMA redirected the Resident out of the locked room to be toileted. During an interview on 1/31/24 at 2:32 PM Staff D, RN reported the door is supposed to be locked. Resident #1 should not have been able to open the door. On 1/31/23 at 3:15 PM Staff I, CNA reported Resident #1 is very busy, they just communicate and keep a watch on him the best they can. It is tough now as they have 17 residents and they usually only have 14 in the unit. She had been informed a few months ago that they do not provide one to one supervision at the facility. A review of the Point of Care Location/Safety Check Record for January 2024 showed Resident #1 documented with a safety check completed at 2:00 PM. Observation on 2/01/24 at 8:12 AM revealed the CCDI closet door locked at this time. Observation of the CCDI activity closet on 2/01/24 at 8:13 AM revealed Resident #1 had traveled approximately four feet into the room behind a locked door. Five feet from where Resident #1 sat leaning on the bedside stand, an oversize wheelchair scale (6.5 feet long by 4.5 feet wide) contained an approximate 1/4 - 1/2 inch raised threshold from the floor with an approximate six-inch rise to the scale which provided a potential for fall with injury. Across from the scale a four-tier wire shelf with 4-7 plastic tubs per shelf, full of items, stood unsecured that had the potential to be pulled down. Six feet from where Resident #1 had been found, a wooden shelf had two bottles of nail polish remover each half full containing a warning label instructing harmful of ingested. In case of accidental ingestion, give fluids liberally and consult with the local Poison Control Center. Both nail polish removal bottles contained a warning to keep out of reach of children. The shelf also contained a 1 ounce (oz.) bottle of lotion with a keep out of reach of children label, noting external use only. A plastic tub carrier on the same wooden shelf contained over 25 different colors of opened nail polish. The wooden shelf also contained two full 4 oz. bottles of multi-purpose glue with a warning of choking hazard due to small parts. Another carrier contained over 15 bottles of washable paint which contained a warning label choking hazard due to small parts. Another plastic tub contained 11 Dab O Ink pens accessible with a warning label to not ingest and keep out of reach of children. The room also contained a small four-tier black wire shelf with plastic tubs, binders, multiple charging cords and four music memory devices on an unsecured wire rack that could be pulled over. A review of the Progress Notes revealed Resident #1 had a witnessed fall on 1/21/24 and a Morse Fall Risk scale completed with a score of 65 indicating a high fall risk. During an interview on 2/01/24 at 10:30 AM the Administrator reported the facility did not have a policy regarding supervision. She stated she expected the staff to have eyes on the resident when the resident was awake to ensure his safety and the safety of other residents which is what the staff provided. On 2/01/24 at 11:20 AM the Corporate Nurse reported he did not know if the CCDI closet door had been locked or unlocked when Resident #1 accessed the closet. He reported he had looked at the door after the incident on 1/31/24 and found there was a flip lock mechanism on the inside of the door. He could not say how Resident #1 exactly got into the closet, but the Activity Director and other staff were not aware of the flip mechanism on the inside of the door that could prevent the closet door from locking. The Corporate Nurse acknowledged the hazards of the weight scale, wire shelves, and chemicals in the closet. He verbalized he expected residents should not be able to access facility locked areas. During an interview on 2/01/24 at the administrator reported the residents of the CCDI should be supervised for their safety.

Based on observations, clinical record review, staff interview, family interview, physician interview, the director of the emergency room interview, and facility policy review, the facility failed to assure that staff provided appropriate assessments and interventions for one (1) resident who presented with a high blood sugar (Resident #1). This failure resulted in the resident having a significant change of condition, a trip to the emergency room (ED) for treatment, and an attempted stabilization of condition. The ambulance crew then attempted to transfer the resident to a larger hospital when he suffered a cardiac arrest (heart beat stopped) in the ambulance and passed away, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of June 29, 2023. The Facility Staff removed the Immediate Jeopardy on June 20, 2023 through the following actions: a. Assurance that all necessary future facility staff and agency had been educated on the updated Blood Glucose Policy, the new policy document (Finger Stick Blood Glucose Policy, 6/11/23) would have been included within the human resources new hire orientation packets for the appropriate staff (certified medication aides (CMA) and (&) licensed nurses). b. Assurance that all necessary future facility staff and agency staff were educated on the updated Resident Change of Condition, Assessment & Intervention Policy, the new policy document (Resident Change of Condition, Assessment & Intervention, 6/29/23) would have been included within the human resources new hire orientation packets for the appropriate staff (CMA's & licensed nurses). The scope lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 57 residents. Findings Include: A State of Iowa, Iowa Department of Public Health Certificate of Death for Resident #1 indicated the cause of death as systemic sepsis, etiology unknown with cardiovascular collapse. Other significant conditions included type II diabetes mellitus with hyperosmolar/hyperglycemic state, coronary artery disease, chronic diastolic heart failure, dementia, history of right hemispheric CVA (cerebral vascular accident), peripheral vascular disease with bilateral below the knee amputation, chronic kidney disease, and smoking. A Minimum Data Set (MDS) assessment form dated 3.15.23 indicated Resident #1 had diagnoses that included a non traumatic brain dysfunction, diabetes mellitus (DM), anemia, coronary artery disease (CAD), heart failure (HF), hypertension (HTN), cerebrovascular accident (CVA) and non-Alzheimer's dementia. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (severely impaired cognitive skills), exhibited verbal behavior symptoms one (1) to three (3) days during the look back period (14 days), as non ambulatory, dependent on staff with transfers, locomotion and bathing, required extensive assistance of staff with bed mobility, dressing, eating, personal hygiene and toilet use and as always incontinent of his bowel and bladder. Review of the Resident's Care Plan included the following Focus areas and Interventions as dated: a. The Resident could have been physically aggressive related to (r/t) dementia with behaviors. (revised 1.4.23) b. The resident had a potential for care resistance r/t dementia. (revised 3.7.23) c. The resident had DM. (revised 1.4.23) 1. If an infection presented itself, consult with a physician regarding any changes in diabetic medications. (initiated 1.4.23) 2. Monitor/document and report as needed (PRN) any signs and symptoms of hyperglycemia, increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace), acetone breath (smelled fruity) and slurred speech. (initiated 1.4.23) d. The resident had DM without medication usage. (revised 1.4.23) A Medication Administration Record (MAR) form dated 6.1.23 thru 6.30.23 revealed on 6.8.23 the resident presented with a blood sugar of 495 (a dangerously high level). Record review of the facilities Progress Notes revealed the following entries as dated: a. 6.7.23 at 9:10 p.m. - Resident with a nonproductive cough. Resident also presented with crackles throughout his lung fields. Head of bed (HOB) elevated 45 degrees. Resident afebrile. No further assessment completed. (i.e., vital signs, skin color, shortness of breath and no physician notification. b. 6.8.23 at 4:12 a.m. - Resident rested in bed with HOB elevated. No cough or audible wheeze noted. Temperature (T) 97.9 degrees Fahrenheit (F) and oxygen saturation (O2 sat) at 94% at room air. No further assessment completed and no mention of an elevated blood sugar with the corresponding assessment expected as directed above in the care plan. c. 6.8.23 at 9:21 a.m. - A new order received for Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligrams (mg)/3 milliliters (ml) 0.083% 1 vial orally via a nebulizer every morning (am) and at bedtime (HS) for wheezing and cough and 1 vial every 4 hours PRN for cough and wheezing. No assessment completed throughout the day. A facility report sheet dated 6.8.23 indicated the resident had not felt well on the day and afternoon shift and failed to eat supper. d. 6.9.23 at 1:20 a.m. - HOB elevated, respirations (R) easy with no audible wheeze noted. Soft non-productive cough noted at times. Pain at a 0. No further assessment completed. e. 6.9.23 at 3:41 p.m. - It had been noted the Nurse Practitioner (NP) had been in the facility and had reviewed the recent weight change form. At that time the staff identified a weight gain. The staff called a family member and left a message. At that time staff identified no further concerns. g. 6.9.23 at 9:01 p.m. - When the resident's urine output had been measured staff noted the urine as dark brown in color when they drained 350 milliliters (ml) from his catheter bag. Staff planned to continue to monitor for improvements/worsening of symptoms. No further assessment completed. i. 6.10.23 at 5:50 a.m. - Resident positioned in bed with HOB elevated. Resident with a urine output of 100 ml of dark colored urine. Not cough noted. Staff questioned Resident if his chest felt better following a nebulizer treatment and the resident stated yes. The resident sounded more alert than usual. j. 6.10.23 at 8:22 a.m. - Resident positioned in bed with HOB elevated. Lungs clear to auscultation. No signs and symptoms of distress noted. No cough or complaints of pain. No further assessment completed. k. 6.10.23 at 3:50 p.m. - The nurse checked routine vitals on the resident and noticed his vitals registered as follows: pulse 100, R 36, O2 saturation, when registered at 68%, and T 97.7 degrees F. Resident also continued to have very dark and concentrated urine. The resident's demeanor also appeared altered as he normally had been very vocal and agitated during cares and on that day he had not been. Call placed to NP and family and decision made for transfer to the hospital. A Clinic Note from a NP dated 6.8.23 (no time identified) indicated the resident had been seen for concerns regarding a cough and wheezing. Staff reported his cough and wheezing as significant and caused some discomfort. Staff reported no change in appetite and no increased fatigue. The NP ordered Albuterol Nebs twice a day (BID) and every 4 hours PRN. The NP documented the visit diagnosis as an acute cough. During an interview 6.29.23 at 7:50 a.m. the NP described the communication at the facility along with cares had been really poor. The NP confirmed she had not been told about the resident's high blood sugar on 6.8.23. During an interview 6.29.23 at 10:40 a.m. the NP reported concern for the residents individual safety at the facility because of the facilities failure to staff enough nurses. The NP confirmed she would have expected staff to report the residents high B/S to her for intervention. An Oral Intake form revealed the resident ate the following as dated: a. 6.6.23 at 8:44 a.m. - 51-75% of the meal. 1:07 p.m. - 0-25% 7:41 p.m. - Refused b. 6.7.23 at 8:28 a.m. - 26-50% 12:18 p.m. and 6 p.m. - 0-25% c. 6.8.23 at 9:03 a.m., 12:18 p.m. and 6 p.m. - 0-25% d. 6.9.23 at 9:59 a.m., 12:25 p.m. and 6 p.m. - 0-25% e. 6.10.23 at 8 a.m. - 0-25% A facility Charge Sheet dated 6.9.23 into 6.10.23 on the night shift included documentation that directed staff to have monitored the resident's respiratory and catheter status. A facility Charge Sheet dated 6.10.23 for the 6 a.m. until 2:15 p.m. described the resident as congested, with a cough and O2 sat of 96%, pulse 100 and respirations 22. A facility Charge Sheet dated 6.10.23 on the afternoon/evening shift included the following documentation that pertained to the resident: blood sugar on 6.8.23 had been 495 with one to one staff assistance required. His blood sugar on 6.5.23 registered at 207. Staff documented an O2 sat of 69% and hard to have been obtained, pulse of 100 and respirations 35. Sent to ED at 3:35 p.m. An ambulance report form dated 6.10.23 at 7:26 p.m. indicated the primary diagnosis as diabetic hyperglycemia. Facility staff reported to the ambulance crew upon arrival the patient normally had been very vocal and mildly combative but for the past two (2) days had been very quiet and refused to eat or drink. Staff verbalized concern with the concentration of his urine. Staff had not completed a blood sugar check. An emergency room (ED) Provider Notes form dated 6.10.23 at 4:09 p.m., the resident present with a hyperosmolar hyperglycemic state (life threatening) with the chief complaint described as an altered mental status. The resident's blood glucose level registered at 681. One of the interventions for the ED staff had been administration of insulin. The Final Impression listed the following diagnosis: a. Hyperosmolar hyperglycemic state b. Anemia c. History of a CVA d. Dementia, unspecified dementia severity, unspecified dementia type e. Hyperkalemia f. Pneumonia of the right lung due to an infectious organism. g. Urinary tract infection with hematuria. During an interview 6.29.23 at 11:51 a.m. an ED Director confirmed staff should have notified a provider and received orders for insulin especially since the resident had not been on any diabetic medications. Additionally, staff should have monitored blood sugars and sent the resident to the ED on 6.8.23. The ED Director felt it had been difficult to say if the high blood sugars caused the resident to go into cardiac arrest because he had many co-morbidities plus he was septic when he arrived at the hospital on 6.10.23. During an interview at the same time an ED Physician indicated staff should have called the provider, rechecked the resident's blood sugar, assessed if there had been any reason for the high blood sugar i.e., had he eaten or been sick. If his blood sugars continued high he should have been brought into the hospital. The Physician confirmed the resident's high blood sugar could have been prevented and the provider absolutely notified. During an interview 6.28.23 at 6:16 p.m. Staff F, CMA/CNA confirmed she had been the CMA who took the resident's blood sugar and instantly reported it to Staff B, LPN. Staff F indicated she worked with the girls on the floor that day but she knew Staff B went to see the resident. Staff F stated she honestly had not known what happened because when the next shift arrived Staff B had not been present for report. The staff member described the resident's demeanor at the time of the high blood sugar as normal because he cussed and swore at the girls. The staff member described the facilities protocol when a resident's blood sugar presented high, over 300 it should have had been to report to the charge nurse and she would have expected Staff B to have reported back to her interventions but she never followed through accordingly that day and she should have notified the NP right away. When questioned what should have occurred the staff member stated number 1 the blood sugar should have been rechecked and Physician notified. The staff member knew Staff B notified the NP about the resident's respirations but not the blood sugars. During an interview 7.5.23 at 1:38 p.m. Staff B, LPN confirmed they worked 6.8.23 from 6 until 2:30 p.m. and she had been the only nurse in the building with 3 CMA's. The staff member confirmed she had been aware the resident's blood sugar registered high and stated she reported it to the NP along with his congestion and a sore on his right butt cheek. Staff E, CNA/CMA and Staff F, CNA/CMA had also been present. Staff B indicated that all four people were present in the same area when she reported the blood sugar to the NP. Confirmed she reported to PM nurse, Staff H, LPN/Agency the high blood sugar and that the resident failed to eat breakfast or lunch. Stated she assessed the resident but failed to document the assessment because she had been too busy running to other stations looking for resident medications due to the fact of medication change over that night so residents had missing medications. The staff member indicated she had skilled residents to have been assessed, insulin and blood sugars, and that it had been a lot of work for 1 nurse. Staff B described the resident as fine on her shift and acted normally combative and refused cares. Staff B offered that maybe the NP failed to hear her because of her voice and the fact she had not been normal since the 5th of last month d/t double pneumonia, laryngitis, sinus infection, and an ear infection so maybe the NP had not heard her because she had no voice. During an interview 6.28.23 at 4:49 p.m. Staff E, CNA/CMA confirmed she worked the with the resident on the day shift Thursday and Friday as a CNA and she thought Staff F, CNA/CMA that checked his blood sugar. The staff member described the resident's demeanor as usual. The staff member indicated the resident had been put on nebulizer treatments the day before or something she knew something respiratory had been going on but there was nothing that drew her attention there was something going on with the resident. Staff B indicated when she worked as a CMA and if a resident's blood sugar had been high she would have reported the incident to the charge nurse. The staff member knew Staff F told Staff B about the high blood sugar somewhere along the line and she had been 90% sure NP stood right there but the situation had not seemed like a serious matter at the time. During an interview 6.29.23 at 1:35 p.m. Staff E confirmed the resident's blood sugar as taken before he ate because she fed him and he only took a couple bites and she heard the nurse say the blood sugar registered high but nothing more. During an interview 6.28.23 at 5:01 p.m. Staff G, CNA confirmed she worked Thursday June 8th from 2 p.m. until 10 p.m The staff member stated she knew the resident real well and that night he had been real nice so he was off and he failed to eat much. The staff member further described the resident's normal behavior as hyper and aggressive and that day he was not himself. The staff member indicated she reported the situation to an unknown nurse. During an interview 6.29.23 at 4:17 p.m. Staff H LPN/Agency staff confirmed they worked with the resident on 6.8.23 during the 2 p.m. until 10 p.m. shift but she never received report r/t his high blood sugar rather that he was congested and started on nebulizer treatments. The staff member indicated when she sat and fed him that night she heard his congestion plus he only ate bites of food. Staff H confirmed if a resident presented with a blood sugar of 495 she would have called the NP and wait for guidance due to the fact the resident had no insulin order. The staff member would have also rechecked his blood sugar with a different and clean finger because he had stool on his hands a lot of the time. The staff member confirmed the elevated blood sugar would have been a red flag for her. During an interview 6.29.23 at 6:27 a.m. Staff I, CNA confirmed she worked Thursday night at 10 p.m. and during report they told her the resident had not eaten supper. The staff member stated because he failed to eat supper she tried to wake him up around 12 a.m. on rounds but his breath sounds appeared deep. The staff member reported to Staff J, RN that night the resident failed to wake up with the attempted arousal. During an interview 6.29.23 at 7:23 a.m. Staff J, RN confirmed she worked 10 p.m. until 6 a.m. June 3rd through the 11th. and received report but no one reported to her the resident's high blood sugar on 6.8.23 but in that time period they were concerned with his urine and his breathing. The staff member confirmed all staff should have continued an assessment of his blood sugar status. The staff member confirmed if a resident presented with a blood sugar of 495 she would have called the MD or NP and that staff should have reported the incident off to her. During an interview 6.29.23 at 1:22 p.m. Staff K CNA confirmed she worked 6.9.23 2 p.m. until 10 p.m. The staff member indicated when she worked with the resident that shift she described him as not himself further described as subdued. His urine appeared very dark which she further defined as brown with no sediment and decreased output. The staff member reported the resident had not eaten supper on Wednesday night 6.7.23 and 6.9.23 and when he refused to eat she reported the condition to the charge nurse. During an interview 6.28.23 at 12:42 p.m. Staff A, CNA/CMA stated she knew the resident had a high blood sugar on Thursday because staff checked his blood sugars on Monday and Thursdays. The staff member stated if he had a high blood sugar on Thursday it should have been addressed and reported to the physician. During an interview 6.28.23 at 4:31 p.m. Staff D, LPN described the resident's normal demeanor as aggressive. The staff member stated she had no knowledge the resident had been diabetic. During an interview 7.6.23 at 10:40 a.m. a family member indicated he knew the facility failed to follow procedure because someone from the ED called him and said the resident should have been there two days prior.

58.28(135C) Safety. The licensee of a nursing facility shall be responsible for the provision and maintenance of a safe environment for residents and personnel. (3) Resident safety. e. Each resident shall receive adequate supervision to protect against hazards from self, others, or elements in the environment. (I, II, III) DESCRIPTION Based on clinical record review, observations, and staff interviews, the facility failed to provide supervision and/or assistance needed by residents to prevent accident (injury) for 3 of 17 residents reviewed (Residents #7, #46, and #113). The facility reported a census of 60 residents. Findings include: 1. Resident #113's Quarterly MDS (Minimum Data Set) assessment dated [DATE], current at the time of the fall with major injury, documented a BIMS (Brief Interview for Mental Status) score of 00, indicating severe extensive cognitive impairment. Resident #113 required extensive assistance of one person for ambulation, dressing, and personal hygiene. Resident #113 required a walker or wheelchair for mobility. The MDS section Health Conditions indicated Resident #113 had two falls without injury since the prior assessment. The Facility Self-Reported Incident dated 9/6/21 documental that Staff H, Certified Nurse Aide (CNA), assisted Resident #113 to the dining room for breakfast. As they walked Resident #113's walker caught on a threshold (divider between flooring) of the carpet and the resident fell . As a result of the fall, Resident #113 fractured their right hip and shoulder. The Care Plan Focus area dated 1/9/21 indicated Resident #113 had an activities of daily living (ADLs) self-care performance deficit related to dementia. The intervention dated 7/21/21 regarding transferring: directed the staff that per PT (Physical Therapy): Resident #113 was an assist of one with a walker (FWW) (front wheeled walker). The facility provided handwritten untitled statement dated 9/6/21 completed by Staff H regarding Resident #113's fall with fractures resulting in a major injury. Staff H documented that she walked Resident #113 to breakfast about 8:00 AM. Staff H explained that when she reached to pull out a chair to place the pressure alarm in the seat of the chair, Resident #113 continued walking forward. As Resident #113 walked forward, her walker caught on the threshold strip between the hallway and dining room. Staff H continued handwritten statement documented that she thought Resident #113's got their foot caught behind the wheel of the walker causing her to fall forward onto her right side. Resident #113 got a cut above their right eyebrow from their eyeglasses. Resident #113 moaned and said she was hurting. After the nurse took Resident #113 vital signs, she tried to sit up but was unable due to her intense pain. Staff H stayed with Resident #113 until the paramedics arrived around 8:40 AM. The Major Injury Determination Form dated 9/6/21 documented the description of injury as possible fractures to the right upper and lower extremities. The circumstances of the incident that caused injury were documented as a fall when ambulating to the dining room. The resident's previous functional ability was an assist of one. The Medical Doctor (MD) documented the patient's prognosis as Resident #113 had a closed fracture to the right hip and right humeral head that required surgical repair and an inpatient admission. The MD marked that after reviewing the circumstances, injury, and the prognosis of the patient, the MD believed the injury sustained was a major injury pursuant to the 481 Iowa Administrative Code 50.7(1)(a)(3). The typed statement dated 9/10/21 by the facility's Maintenance Manager documented that he checked the threshold strip going into the Dining area of the Dementia Unit and found it to be securely fastened to the floor. The Maintenance Manager documented that he saw nothing wrong with it (threshold strip). During an observation on 3/2/22 at 12:59 PM it revealed the threshold strip between the hallway and dining area of the Dementia Unit to be secured well to the floor surface and did not appear to be a trip hazard. The facility provided typed document dated 9/13/21 signed by DON (Director of Nursing) indicated she had a conversation with Staff H regarding the use of the gait belt with Resident #113 before she fell . During that interview Staff H admitted that at the time of Resident #113's fall that resulted in fractures and major injury, she didn't have a gait belt on Resident #113. The documentation reported that Staff H explained that she was unable to come in to the facility to write an addendum to her statement because she moved out of state. During an interview on 3/2/22 at 12:59 PM Staff I, CNA, stated they were working the day that Resident #113 fell fracturing her hip and shoulder on 9/6/21. Staff I denied witnessing the resident fall, as a result she couldn't say what happened or if Staff H had a gait belt on Resident #113 or not. During a follow-up interview on 3/3/21 at 11:20 AM, Staff I reported that gait belts were very easily accessible and pulled one out of her pocket. Staff I explained that most CNAs carried one and there was one in most residents rooms, as well as in the shower rooms. Staff I said that all staff were aware of what residents needed a gait belt for safety which included Resident #113. Staff I remarked that they never before saw Staff H ambulating (walking) any resident without using a gait belt. During an interview on 3/3/21 at 7:25 AM Staff G, Registered Nurse (RN), verified that they were working 9/6/21 when Resident #113 had their fall/fracture and they assessed Resident #113. Staff G reported that she made all the notifications to the provider, family, and called the ambulance. Staff G stated that she asked Staff H about the incident and circumstances. Staff H replied that they did have a gait belt on Resident #113 when she assisted them from the unit lounge area down to the dining room when the resident fell . Staff G explained that she worked with Staff H many times and they always used a gait belt when she ambulated residents. Staff G reported that some days later the facility DON told her she spoke with Staff H on the phone to about the incident. The DON explained that Staff H admitted that they actually didn't have a gait belt on Resident #113 when she fell . During a follow-up interview on 3/3/22 at 10:20 AM, Staff G stated that gait belts were very easily accessible for staff and that most residents had gait belt on their walker. Staff G reported the staff generally carried a gait belt on them, there were gait belts in the shower rooms, in the clean utility room, and in a locked staff supply room. Staff G explained that all staff were trained to use gait belts and which residents required the use of a gait belt. Staff G commented that she never observed any staff ambulating a resident without a gait belt that needed one for safety. During an interview on 3/3/22 at 9:40 AM Staff J, CNA, reported that they work on the Dementia Unit often. Staff J explained that gait belts were easily accessible for the staff. Staff J remarked that they always kept a gait belt around their waist and said that most CNA's did too. Staff J added that if the staff didn't have one, staff could usually find one in most of the resident rooms, the shower room, and the linen cart. Staff J stated that they knew Resident #113 required the use of a gait belt because they were unsteady. Staff J believed that all CNA's knew they needed to use a gait belt with Resident #113. Staff J declared that they never saw any staff on the Dementia Unit ambulate Resident #113 without using a gait belt. During an interview on 3/3/22 at 9:50 AM Staff K, Licensed Practical Nurse (LPN), declared that they did not work at the facility at the time Resident #113 had their fall with fracture on 9/6/21. Staff K stated that gait belts were very accessible at the facility. Staff K explained that there were multiple places that staff could find one such as in every resident room, on some resident's walkers, and in the bags on the back of resident wheel chairs. Staff K remarked that the staff were trained to use gait belts and which residents required the use of gait belts when assisting with ambulation and transfers. Staff K stated they didn't see staff ambulate or transfer residents that require gait belts for safety without using a gait belt. During an interview on 3/3/22 at 10:43 AM Staff L, Agency CNA, stated gait belts were easy to access at the facility and most resident rooms have gait belts in them. Staff L reported that they always kept a gait belt with them and they use a gait belt with every resident that isn't transferred with total mechanical lifts or mechanical stand-up type lifts. During a telephone interview on 3/3/22 at 12:30 PM with Staffing Agency A, Human Resources of the Staffing Agency, indicated Staff H worked at the Staffing Agency at the time of Resident #113's fall with fracture. Staffing Agency A verified that Staff H did work for them and did work at the facility on 9/6/21. Staffing Agency A explained that when they were made aware of the Resident #113's incident (fall with fracture) they put Staff H on Administrative Leave. Staffing Agency A reported their facility required them to respond and provide a written statement regarding the incident. When Staff H failed to comply with their facility's requirements, the Staffing Agency took that as a voluntary termination and they terminated Staff H for noncompliance. Staffing Agency A explained that Staff H no longer work for their Staffing Agency. The undated Use of Gait/Transfer Belt policy documented it was the responsibility for all nursing and rehab staff. The Purpose section explained that the use of a gait belt was to safely transfer and ambulate a resident. The other purpose was to prevent unnecessary injuries to staff and residents. The Guidelines section indicated to keep a gait belt (transfer belt) available at all times, as they never know when it would be needed. The Procedure section recorded that during ambulation, the staff member was to walk to at the resident's side and slightly behind, while holding the belt with both hands. 2. The Minimum Data Set (MDS) for Resident #46 dated 1/5/22 documented a Brief Interview for Mental Status (BIMS) of 00, indicating severe cognitive impairment. The MDS documented diagnoses included cancer, hypertension (high blood pressure), and gastro-[CONDITION(S)] reflux disease. The Nurses Note dated 2/12/22 at 2:47 AM documented no reports of discomfort from having her hand hit by another resident (Resident #7) on 2/10/22. Resident #46 did not appear to be fearful. The Nurses Note dated 2/13/22 at 5:15 AM documented resident did not report any discomfort or feelings of fearfulness from resident to resident contact on 2/10/22. The Progress Notes lacked documentation related to a resident to resident incident on 2/10/22 or 2/11/22. The Care Plan's lacked documentation regarding the incident or an intervention to prevent further incidents. The last revision to the Care Plan was done on 12/27/21. 3. The MDS for Resident #7 dated 2/2/22 documented a BIMS of 12, indicating moderately impaired cognition. The MDS documented diagnoses included heart failure, hypertension and Diabetes Mellitus. The Care Plan Focused area revised 9/2/21 indicated Resident #7 had a potential mood problem related to his frustration of his health state. The intervention dated 9/2/21 directed behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.). The Care Plan Focused area initiated on 2/16/22 recorded that Resident #7 had a potential to be verbally aggressive related to ineffective coping skills. The intervention initiated on 2/16/22 directed to analyze the key times, places, circumstances, triggers, and what de-escalates behavior then document. The Nurses Note dated 2/10/22 at 7:30 PM documented an environmental aide informed Staff F that Resident #7 hit Resident #46. Resident #46 was attempting to show Resident #7 the newspaper, when Resident #7 hit Resident #46's hand. When the staff attempted to educate Resident #7 to not be rude or hit other residents, Resident #7 told them staff to shut up and called them stupid. Staff F attempted to redirect and calm Resident #7 but he continued to say rude comments about the other staff. Staff F told Resident #7 to stay in his room and avoid Resident #46. Resident #7 refused to stay in his room but reported that he would behave. Staff F called Staff E to notify her about the situation. The progress notes lacked documentation on 2/11/22 regarding the situation. The Incident Note dated 2/12/22 at 2:45 AM indicated that Resident #7 had no contact with Resident #46 for that shift. The progress notes lacked further documentation related to the incident following the 2/12/22 Incident Note. The facility provided document labeled Writer's Statement dated 2/10/22, signed by Staff E, Social Services. Staff E documented that Staff E visited with Resident #7 regarding the incident with Resident #46. Staff E documented providing instruction to Resident #7 to ask for an aide or a nurse to move Resident #7 away from him if she needed to be moved away from him. During an interview on 3/1/22 at 2:34 PM, Staff E stated there was no additional documentation or incident report to provide as it did not exist. During an interview on 3/2/22 at 2:43 PM Staff B, LPN, reported that when a resident to resident altercation occurred the residents should be separated, assessed for injury, and have 72-hour follow-up monitoring assessments set up. The Abuse Prevention and Identification policy revised on 2/22 documented the section Responsibility. The residents must not be subjected to abuse by anyone, including but not limited to other residents. The policy defined resident to resident as a physical contact that occurred, which included but was not limited to where residents were hit, slapped, pinched, or kicked that resulted in physical harm, pain, or mental anguish. The facility would presume that instances of abuse caused physical harm, pain, or mental anguish in a resident with cognitive and/or physical impairments which could result in a resident being unable to communicate physical harm, pain, or mental anguish, in the absence of evidence to the contrary. An example would be a resident slapping another resident who was physically or cognitively impaired, even though the resident who was slapped showed no reaction such as yelling out or grimacing, it is to be presume the resident experienced pain. The Abuse Investigation Including Sexual Assault and Resident to Resident policy revised 12/19 documented that the facility would implement measures to prevent further potential abuse of residents while the investigation was in process. The section labeled Resident to Resident: Investigation Procedure indicated the following A. Separate all residents involved and ensure a safe environment for both residents. B. Nurse to check vital signs, do a head-to-toe assessment, a pain assessment, a full skin inspection on all residents involved to assess for physical injury, and assess the resident's emotional status. C. Complete incident report form on both residents involved D. Review the Care Plan and place appropriate interventions to minimize reoccurrence of another altercation. E. Document the altercation even in all the resident's charts that were involved in the altercation along with the updated care plan intervention to minimize further altercations. The Post Resident to Resident Altercation section explained to continue observation on all residents involved in the altercation at a minimum weekly to determine if the care plan interventions continue to be effective with minimizing altercations.

Based on clinical record review, manufacturers information for whirlpool tub/chair, the facility education information and staff interviews, the facility failed to plan for and direct nursing care and services to ensure Resident #1 received adequate supervision from hazards. Resident #1 fell from a whirlpool chair during a bath and sustained multiple fractures when the staff had removed the safety bar to properly cleanse the resident. Multiple staff reported they had removed the safety bar and or safety belt during a resident's bath. In addition, after the incident the staff left Resident #1 unattended with the bath water up to the resident's chin. The facility reported a census of 86 residents. Findings include: A Physician order [REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE], documented the resident had functional limitations on one side of his/her upper and lower extremities with the inability to walk and as dependent on staff for activities of daily living that included bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, bathing and personal hygiene. A Care Plan dated 4/28/11, included a problem of potential for self care deficit. The approaches included the following: a. 12/31/09 allow and encourage the resident to participate in activities of daily living (ADL) of her upper body. b. 12/31/09 total assist with ADL to the residents lower body. c. 12/31/09 total assist with peri cares and Foley catheter cares two times a day and as needed. d. 12/31/11 encourage the resident to participate in ADL as able. e. 12/31/11 praise accomplishments. f. 12/31/11 Hoyer sling may be left under the resident per request in the recliner or wheelchair due to immobility and leg pain. g. 3/8/11 may leave unattended when in whirlpool per resident "to soak". The resident ' s care plan documented he/she physically impaired due to right side weakness. A major injury determination form dated 5/3/11 documented Resident #1 had been in the whirlpool, seated in a reclined position in the whirlpool chair when the staff released the chest bar to wash under the resident ' s breast and abdominal folds. At this time the resident slid out of the chair, legs first then his/her upper body propelled forward. An Incident Report form dated 5/3/11 at 5:30 a.m., documented the resident had slid out of the lift into the whirlpool tub, complained of right knee pain and had his/her head up against the front of the tub. The certified nursing assistant had told the nurse they had lifted the resident up just enough to wash under the resident ' s breasts and stomach and the resident just slipped forward and onto their knees in the whirlpool tub and hit their head. The nursing assistant drained the water from the tub and 5 staff members assisted the resident from the tub with the use of a Hoyer lift device. The resident's vital signs had been 183/99, pulse of 122, respirations 20 and a temperature of 98.9 degrees Fahrenheit. The resident had complained of bilateral knee pain with the transfer and went for an evaluation at the emergency room for evaluation. A CAT scan dated 5/3/11of Resident #1 ' s identified a supracondylar fracture of the distal left femur. The CAT documented the fracture is impacted. The CAT scan documented there is a fracture of the proximal tibia metaphysic. The impression concluded a supracondylar fracture of the distal left femur; and fracture or anterior tibia plateau without plateau depression. The impression also revealed marked osteopenia in his/her left ankle with no definite fracture seen. The hospital report dated 5/3/11 identified the resident injured both his/her legs in a fall earlier today. The summary identified a right proximal tibia metaphysic fracture, non displaced; a left distal femoral condylar fracture (commuted, minimally displaced; and commuted left tibia plateau fracture, non displaced. The resident would be placed in an immobilizer. During interview on 5/18/11 at 12:20 p.m., Staff B, CNA stated she felt so bad about the incident. Staff B stated the resident was in the hydraulic shower chair with their legs over the right side of the chair, the clip safety belt was attached and positioned across the resident's breasts and the positioning bar was down in front of the resident for safety. Staff B said because of the resident's size they would lean backward in the chair so Staff B lifted the resident ' s legs over the whirlpool tub and then lowered the resident down into the water, put on the whirlpool jets and cleansed the resident. Staff B lifted the resident up out of the whirlpool in the hydraulic shower chair and kept the resident elevated above the tub, removed the clip belt and pushed the safety bar up so they could cleanse the resident's breasts, under the resident ' s abdominal folds and perineal area. As Staff B cleansed the resident's buttocks, the resident rapidly slid out of the chair and landed down in the tub with their legs under their body. Staff B stated she frequently removed the safety devices on the shower chair to cleanse the resident and that everybody did. Staff B stated she was never trained on how to use the whirlpool tub. Staff B stated it was just take a resident in look at the tub and push buttons. During interview on 5/19/11 at 11:45 p.m., Staff A, Certified Nurse Aide, CNA, stated Staff B had asked them to help transfer the resident to the whirlpool chair for a bath. They put the sling under the resident and hooked the resident up to a Hoyer lift device. The staff members put the resident in the shower chair, put the safety bar down but did not connect the safety clip belt, covered the resident with a sheet and took the resident to the shower room. They raised the resident in the shower chair and put the resident in the whirlpool tub. Staff A then left the shower room. Staff A was assisting another resident when they heard Staff B yelling for help. Staff A entered the shower room and saw Staff B was standing by the tub holding the resident who was bent forward, kind of sideways, leaning into the corner of the tub with the water just below the resident's shoulders. There were also 3 other nurses present. The staff members got a gait belt around the resident so they had something to hold onto while someone got the Hoyer lift device and brought it into the shower room. The staff members put the Hoyer sling under the resident the best they could and hooked the resident up to the Hoyer lift device. The resident was raised as high as the device would go. They thought the battery was dead so Staff B ran to get another battery. Staff A said they were having a hard time getting the resident over the side of the tub so they and Staff B went to get an empty bed to put the resident in once transferred out of the tub. Staff A stated it was the facilities standard of practice to utilize the safety devices. During re-interview on 9/14/11 at 9:20 a.m., Staff A stated the safety belt had not been on the whirlpool chair or she was told it was broken when she assisted in the transfer of the resident. Staff A felt it was everyone's responsibility to assure the belt was connected. Staff A confirmed she was able to cleanse an obese resident in the whirlpool chair appropriately without lifting the safety bar and not remove the safety bar on the whirlpool chair when bathing a resident until they had been drying or dressing the resident. Staff A confirmed witnessing other staff not use the safety belt on the whirlpool chair in the past. During interview on 5/13/11 at 10:45 a.m., Staff C, Licensed Practical Nurse, LPN stated when she entered the shower room the resident was in the whirlpool tub with their face pressed against the front of the tub and their chin was touching the water. The tub drain was not pulled and the call light was not on in the shower room. The resident was left alone and in immediate danger. Staff C stated Staff B told her they had lifted up the safety bar to wash the resident ' s abdominal folds and the resident had slid out of the shower chair. Staff C stated the facility standard of practice was to use the safety clip belt and the safety bar when transferring a resident in the hydraulic shower chair unless the resident is being transferred in and out of the chair. Staff C confirmed she was trained that if the safety belt was on and/or around a resident and the safety bar had been secured it had been considered safe for the resident. Staff C confirmed she had given obese residents a whirlpool bath and felt she had been able to properly cleanse those residents without removing any form of the safety devices. During interview on 5/19/11 at 1:35 p.m., Staff D, Registered Nurse, RN, stated she assessed the resident for injuries and how to get the resident out of the whirlpool safely. Staff D noticed the whirlpool chair was in the high position. During interview on 5/19/11 at 2:00 p.m., Staff E, RN, stated she was halfway down the hall when they heard Staff B yelling " help! help". Immediately she turned around and ran back to the nurse's station to find Staff B outside the shower room, across from the nurse ' s station near the piano, knowing Staff B had left the resident in the whirlpool tub, she immediately entered the shower room. Staff E saw the whirlpool lift chair up in the air with no one in it. Staff E looked into the whirlpool tub and saw the resident in the bottom part of the tub with their legs under him/her. Staff E stated it was facility policy to properly secure all safety equipment when using a lift device and to have 2 people present with a lift transfer device which includes the hydraulic shower chair. During interview on 9/13/11, Staff G, CNA confirmed they were trained to ensure the bar was down in front of the resident and the safety belt was connected. Staff G stated she had put the safety bar in the up position but left the safety belt in place so she could get to the residents abdominal folds better but she never removed both of the safety devices at the same time. During interview on 9/13/11 at 4:10 p.m., Staff H, CNA stated she had taken off the safety belt for cleansing a resident but as soon as she was done, she would put it back on. During interview on 9/13/11 at 3:45 p.m., Staff I, CNA stated she had not been formally trained on using the whirlpool when it was initially installed however, an informal shift to shift orientation took place at the time. Staff I confirmed when bathing an obese resident she would do any additional cleansing required in the residents bed rather than in the whirlpool chair and would not remove the safety belt or safety bar. During interview on 9/13/11 at 3:30 p.m., Staff J, CNA stated she never removed the safety devices while bathing a resident because safety devices had been there for a reason. Staff J stated she never witnessed peers not utilizing the safety devices (seatbelt and safety bar) when using the whirlpool chair. During interview on 9/13/11 at 2:30 p.m., Staff K, CNA confirmed she was shown how to give the whirlpool bath. Staff K stated when she used the whirlpool she always used the safety devices. Staff K stated when bathing a larger resident in the whirlpool it was possible to do so without removing the safety devices. During interview on 5/19/11 at 3:00 p.m., Staff F, Director of Nursing, stated their expectations for nursing staff was to prevent accidents and provide supervision. Staff F stated staff expectations was to use all of precautions for maximum resident protection. Review of a facilities staff education form dated 3/1/11, documented staff needed to remember that resident safety and supervision was a primary responsibility for all. Review of the Century Operating and Product Care Instructions booklet dated 3/2003, documented the following under safety instructions: a. The resident should sit firmly, securely and in the direction to face the panel to avoid injuries. b. Safety straps are in good condition and properly fastened. The facility failed to ensure all staff were properly trained regarding use of safety devices when utilizing the whirlpool tub. Multiple staff reported they had put the safety bar in the up position and or removed the safety belt when cleaning a resident. No documentation was provided to the Department that the facility and or DON had directed staff to not remove the safety belt and or safety bar in order to properly cleanse the resident.