Every finding on record at The New Homestead Care Center

Based on observations, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 3 of 4 residents reviewed (Residents #10, #3, and #30). The facility failed to perform hand hygiene and change gloves when completing resident cares, failed to ensure use of enhanced barrier precautions (EBP) when required, and failed to maintain a catheter bag off the floor. The facility reported a census of 47 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #10, dated 5/7/26, included diagnoses of stroke and right sided hemiplegia (paralysis of 1 side of the body). The MDS identified the resident was dependent on staff for toileting hygiene and always incontinent of bladder and frequently incontinent of bowel. A Brief Interview for Mental Status (BIMS) Score of 15, indicating no cognitive impairment for decision-making. Observation on 6/22/2026 at 11:42 AM, with Resident #10 lying in bed, Staff A, Certified Nurse Aide (CNA) applied gloves, removed the brief, cleansed the groin and scrotum, and turned the resident to his side and cleansed the buttocks. Staff A proceeded with the same gloved hands and applied a new brief, touched the resident's bedding, tied up the trash bag, and then removed her gloves. Staff A failed to perform hand hygiene, applied new gloves, and then applied the resident's braces to feet/legs, shorts and shoes. 2. Resident #3's MDS assessment dated [DATE] revealed the resident had a BIMS score of 14/15 indicating normal cognition. The document coded the resident required substantial/maximal assistance for toileting hygiene and had an indwelling catheter. The Care Plan revised 4/23/26 identified EBP related to a suprapubic catheter as a problem area (4/23/26) with staff interventions to complete hand hygiene prior to and after cares and follow the precautions instituted during high contact activities. A problem area of supra pubic catheter (revised 4/23/26) contained staff interventions for changing catheter as ordered, and report signs and symptoms of a urinary tract infection (UTI). Observed on 6/22/26 at 11:39 AM Resident #3's catheter bag hanging from a bookcase without a dignity bag. The bag was at the height of his bladder. Observed an EBP sign on the resident's door, personal protective equipment (PPE) outside the door, and covered trash cans. Observed on 6/23/26 at 8:00 AM Resident #3's catheter bag hanging from the bookcase without a dignity bag. Continuous observation on 6/24/26 at 11:00 AM of Staff B, CNA, completing catheter care for Resident #3 revealed the following: A. Staff B donned a gown, entered the resident's room, and donned gloves without completing hand hygiene. B. Staff B gathered the canister to empty the catheter bag, an alcohol wipe, and returned to the resident's chair side. C. The staff held the canister with the left hand, removed the drain spout with the right, and emptied the catheter into the canister. The staff placed the canister on the floor, wiped the drainage tube with an alcohol wipe, threw the trash away, emptied the canister into the toilet and placed it on the toilet seat. D. Staff B changed his gloves without hand hygiene. E. Staff B proceeded to use a clean canister to obtain water from the sink to fill the dirty canister, rinsed out the dirty canister and emptied it into the toilet; each time the staff obtained clean water, the dirty canister was placed on the toilet seat until completed and the canisters were placed in separate bags for storage. F. The staff changed his gloves without hand hygiene. G. Staff B flushed the toilet and changed gloves without hand hygiene. H. The staff returned to the resident to complete catheter insertion site care. The staff removed a soaked split sponge with the right hand. I. Staff B obtained disposable wipes from the package with the left hand and cleaned the area with the right hand. J. The staff obtained the split sponge package from the resident's bedside table, opened it, and placed it around the catheter tube insertion using both hands. K. Staff obtained the trash, left the room, removed the gown, and disposed of supplies. The staff failed to complete hand hygiene upon entry into the resident's room, hand hygiene during glove changes, and placed the collection canister on the floor and on the toilet. 3. Resident #30's MDS assessment dated [DATE] revealed the resident had a BIMS score of 11/15 indicating moderate cognitive impairment. The document coded the resident required total assistance for toileting hygiene and had an indwelling catheter. The Care Plan, revised 4/8/26, identified a problem area related to the resident's suprapubic catheter (initiated 4/8/26) provided staff interventions of changing the catheter bag as ordered and providing catheter care as per facility policy. A problem area for EBP (revised 4/8/26) contained staff interventions to follow precautions for high contact activities, and ensure appropriate hand hygiene prior to and after cares. Observed on 6/22/26 at 12:02 PM Resident #30's uncovered catheter bag hanging from a trash can touching the floor. Observed an EBP sign on the resident's door, personal protective equipment (PPE) outside the door, and covered trash cans. Observed on 6/23/26 at 8:35 AM Resident #30's catheter bag without a dignity bag, hanging from the trash can, and touching the floor. Continuous observation on 6/24/26 at 7:50 AM of Staff B and Staff C, CNA, completing activities of daily living (ADL) care for Resident #30 revealed the following: A. Staff B and Staff C donned gowns, entered the resident's room, completed hand hygiene and donned gloves. B. Staff B assisted the resident with rolling in bed, while Staff C completed peri care . C. Staff C completed care maintaining a clean hand, and dirty hand for peri care. D. Staff B completed glove change without hand hygiene. E. Staff B and Staff C placed the brief on the resident and Staff B completed care around the catheter insertion site. F. Staff B changed gloves without hand hygiene. G. Staff and Staff C worked together to don the resident's pants, roll the resident, place a full body lift sling, and transfer the resident from her bed to the recliner. Staff C had placed the catheter on the resident's lap during the transfer. H. Staff C hooked the resident's catheter drainage bag on the trashcan with the bottom of the bag touching the floor. I. Staff C changed gloves with hygiene. J. Staff B changed the resident's top, while Staff C made the resident's bed and gathered items for removal. K. Staff B and Staff C changed their gloves without hand hygiene, gathered the dirty items and left the room. The staff removed their gowns and completed hand hygiene following disposal of items from the room. Staff B and Staff C failed to complete hand hygiene tasks throughout ADL cares, and placed the catheter bag on the trashcan touching the floor. Continuous observation on 6/24/26 at 10:45 AM of Staff D, Registered Nurse (RN), with Resident #3 revealed the following: A. Staff D placed facial tissues around the resident's finger as the staff stated the resident had picked a scab from the finger and it was bleeding. B. The staff disposed of the tissues, entered the bathroom, washed her hands and donned gloves to assess the resident's supra pubic catheter insertion. C. Staff D cleaned the area using disposable wipes and placed a split sponge around the insertion site. D. Staff D disposed of the split gauze packaging, gloves and exited the room. Staff D failed to don a gown before providing care to the resident, change gloves prior to applying a clean split gauze, and complete hand hygiene with glove change and exiting the room. On 6/24/26 at 2:13 PM the Director of Nursing (DON) stated she expected staff to complete hand hygiene upon entry and exit from a resident's room, before donning gloves, and when changing gloves and moving from dirty to clean tasks. The DON stated hand sanitizer was acceptable with glove changes unless the hands were visibly soiled then the staff should wash their hands. The DON expected that if a resident had EBP that gloves and gown were to be used for high contact care including transfers and ADLS. The staff stated suprapubic care was considered an ADL care task. The DON stated a catheter bag should have a cover over it and should hang below the level of the bladder. The DON stated the catheter bag should neither hang from a trash can nor touch the floor. On 6/24/26 at 2:40 PM the Administrator stated staff should complete hand hygiene when entering a resident's room and the use of gloves did not replace hand washing. The Administrator stated EBP should be followed when indicated. The facility's Personal Protective Equipment (PPE) Policy, dated 2025, revealed gloves were a form of PPE, hand hygiene should be completed before donning gloves and after removal, and gloves were not a substitute for hand hygiene. The facility's Hand Hygiene Policy, dated 2025, revealed all staff will perform hand hygiene procedures to prevent the spread of infection. The document disclosed hand hygiene, either washing with soap and water or use of alcohol based hand rub, be completed between resident contacts, and before applying and after removing PPE including gloves. The facility's Enhanced Barrier Precautions Policy, dated 2025, disclosed it is an infection control intervention to reduce the transmission of multidrug-resistant organisms that employs gown and gloves use during high contact resident care activities. The document identified high contact resident care activities including hygiene and device care. The U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP signs on Residents' doors revealed providers and staff must wear gloves and gown during high contact resident care activities including dressing, bathing, transferring, hygiene, changing briefs or assisting with toileting, device care and wound care.

Based on clinical record review, observations, staff interviews, and policy review the facility failed to provide professional standards of care by not providing treatments per physician orders for 2 of 2 (Residents #30, #3). The facility reported a census of 47 residents. Findings include: 1. Resident #30's (Minimum Data Set) MDS assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment. The document coded the resident required total assistance for toileting hygiene and had an indwelling catheter. The Care Plan, revised 4/8/26, identified a problem area related to the resident's suprapubic catheter (initiated 4/8/26) provided staff interventions of changing the catheter bag as ordered and providing catheter care as per facility policy. The clinical record's Physician Orders identified an order to clean the suprapubic site with soap and water, pat dry, daily, then apply split gauze to the suprapubic site, every day shift for prevention purposes with a start date of 5/1/26. On 6/24/26 at 7:15 AM Staff D, Registered Nurse (RN), stated she placed the resident's split gauze in the resident's room as it will get placed when the resident's peri care/catheter care was completed. On 6/24/26 at 10:45 AM when questioned about Resident #3's suprapubic catheter treatment, Staff D stated she normally placed the split gauze at the suprapubic site, but let them (referring to the Certified Nursing Assistants (CNAs)) do it today as they were completing peri care/catheter care. With the request of whether the resident had a split gauze present, Staff D assessed Resident #3's suprapubic insertion site and stated the staff did not place the split gauze and didn't know why they didn't. 2. Resident #3's MDS assessment dated [DATE] revealed the resident had a BIMS score of 14/15 indicating normal cognition. The document coded the resident required substantial/maximal assistance for toileting hygiene and had an indwelling catheter. The Care Plan, revised 4/23/26, identified the problem area related to the suprapubic catheter (revised 4/23/26) contained staff interventions for changing catheter as ordered, and to report signs and symptoms of a urinary tract infection (UTI). The clinical record's Physician Orders revealed an order for split gauze to the suprapubic catheter every day and every evening shift. 1.) cleanse with soap and water around the site, 2.) place split gauze, 3.) secure with a start date of 3/12/2026. On 6/24/26 at 7:15 AM Staff D stated she placed the resident's split gauze in the resident's room as it will get placed when the resident's peri care/catheter care was completed. On 6/24/26 at 10:45 AM Staff D stated she normally placed the gauze pad but since the CNAs were completing peri/catheter cares she let them do it. On 6/24/26 at 11:00 AM Staff B, CNA, completed catheter care for Resident #3. During the observation Staff B removed a saturated split gauze from the insertion area with the resident voicing discomfort. The staff questioned if the resident had pain and the resident confirmed discomfort. When questioned further about the pain, the resident indicated it was no worse than normal. Upon completion of cleansing the site with disposable wipes, Staff B opened the split gauze package and placed the split gauze at the insertion site. On 6/24/26 at 11:15 AM when asked about the placement of the split sponge, Staff B responded that he had never done that and wasn't really sure about what he was doing. The staff stated the nurse normally placed the split gauze at the insertion site, but the nurse had instructed him to do so when finished with the catheter care. On 6/24/26 at 2:13 PM the Director of Nursing (DON) stated a physician's order regarding the care of the insertion site should be completed by the nurse not a CNA. The staff stated if the resident had complained of discomfort with the removal of the saturated gauze, a nurse's assessment should be completed to ensure there has not been a change in the status of the insertion site. The DON expected a physician's order should be completed by a nurse.On 6/24/26 at 2:40 PM the Administrator expected the nurses to complete physician orders. The facility's Medication Orders, dated 2026, revealed that medications should be administered only upon the signed order of a person lawfully authorized to do so. The policy did not address a nurse directing a CNA to administer a treatment.The facility's Job Description: CNA, Revised 5/15/21, disclosed the CNAs apply skills in routine basic nursing, personal care and restorative services.

Based on clinical record review, resident, family, and staff interview, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 3 residents (Resident #1, #2 and #4) reviewed for call lights. The facility reported a census of 47 residents.Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of neurogenic bladder, hyperlipidemia, and multiple sclerosis. Interview 10/21/25 at 8:15 AM with Resident #1's family member revealed that while at the facility on 10/20/25 Resident #1 had their call light on for almost an hour and no staff came to assist Resident #1. Interview 10/21/25 at 9:50 AM with Resident #1 revealed that call lights take over fifteen minutes frequently, and that on 10/20/25 she had a call light on for almost an hour. Resident #1 then revealed that she wears a watch and has a clock on the wall and can read both. 2. Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnoses of cancer, coronary artery disease, heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and liver disease. Interview 10/21/25 at 9:15 AM with Resident #2 revealed that call lights take forever and are always over fifteen minutes to be answered by staff. Resident #2 further revealed that he watches the clock on the wall. 3. Review of Resident #4's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnoses of coronary artery disease, hyperlipidemia, encephalopathy, and peripheral venous insufficiency. Interview 10/21/25 at 9:38 AM with Resident #4 revealed that call lights take over fifteen minutes a lot. Resident #4 then revealed that he watches the clock on the wall. Interview 10/21/25 at 9:27 AM with Staff A Certified Nursing Assistant (CNA) revealed that staff do try to answer the call lights in a timely manner, but the screen for call lights is located in the hallway and at the nurses station. Staff A then revealed there are no call lights above the resident's doors. Interview 10/21/25 with the Administrator revealed that call lights are still a little long, but the facility has been working on them. The Administrator then provided the call light logs for the previous 4 days. Interview 10/21/25 at 12:29 PM with Staff B CNA revealed that call lights can take a little longer sometimes, but does try to answer call lights in a quick time. Staff B then revealed that she cannot guarantee that call lights are always answered in fifteen minutes, but does aim for that. Interview 10/21/25 with Staff C CNA revealed that call lights can take a little bit, but the staff does try to answer them in fifteen minutes or less. Follow up interview 10/22/25 at 11:10 AM with the Administrator revealed her expectation would be for call lights to be answered in fifteen minutes or less. Review of a facility provided document titled, Device Activity Report dated 10/18/25 to 10/21/25 revealed several call light times ranging from 16 minutes to 48 minutes in length. This document further revealed that Resident #1's call light on 10/20/25 was on 47 minutes and 6 seconds before being reset. Review of a facility provide policy titled, Call Light Response dated 10/31/24 revealed:a. Staff members are required to respond to resident call lights within 15 minutes of activation.

Based on observation, interview, and policy review, the facility failed to properly label stored food and failed to maintain sanitary practices by failing to prevent cross-contamination during meal service. The facility reported a census of 50 residents. Findings include: On 4/21/25 at 10:03 AM, a kitchen observation revealed the following: The Victory refrigerator contained an open, unlabeled bottle of reddish-brown liquid. The Frigidaire deep freezer contained the following items: a) an unlabeled bag of round, green, pea-sized contents; b) an unlabeled bag of green, thick-stalked, flower-head contents; c) an unlabeled bag of multicolored sliced contents; d) an unlabeled bag of dark purple contents. The [NAME] walk-in refrigerator contained the following items: a) two (2) unlabeled, undated, uncovered pans of green gelatin-like substance; b) an unlabeled, undated, clear plastic bucket of sliced, solid green items; c) an unlabeled, clear bag of brown, disk shaped meat-like items; d) a pan labeled beef stroganoff with a torn aluminum foil cover that exposed the contents; e) an unlabeled bag of pink, disk-shaped meat-like product; f) two (2) unlabeled stacks of square, white sliced items. The [NAME] walk-in freezer contained the following items: a) an unlabeled, clear bag of orange, round, flat, waffle-cut, items; b) an unlabeled, clear bag of battered, crescent-shaped contents; c) an unlabeled, clear bag of flat, yellow items. On 4/23/25 at 7:31 AM, Staff J, Chef, used pot holders to remove a pan of pureed eggs from the steam table. One pot holder came in direct contact with the cream of wheat in another steam pan. At 7:45 AM, the Certified Dietary Manager (CDM) transported the clean dish cart from one resident unit to another one with a torn cover. At 7:50 AM, during meal service, Staff J grabbed a plate and his right thumb came in contact with the food area surface. An omelet was placed on the plate on the spot where his thumb touched. At 9:38 AM, Staff J was observed preparing mechanically altered lunch menu items. He removed the blender container, scooped the mechanically altered pork into the measuring pitcher, grabbed a steam pan, and placed it on the counter. He then grabbed a steam pan liner, opened the liner, and stuck his ungloved hand inside the liner and lined the steam pan. He placed the mechanically altered pork in the liner. At 12:17 PM, during lunch service observation, Staff J removed the steam pan lids and put them face down on the lower shelf rubber mat. The mat had unidentified debris on it. After the meals were served on that unit, he placed the lids back on the steam pans and transported the steam table to another unit and continued meal service. At 12:28 PM, during lunch service, Staff J attached a plate guard to a resident's plate with ungloved hands. While plating a scoop of scalloped potatoes, a portion fell on to the side of a plate guard. Staff J scraped the portion off of the plate guard and placed the portion back in the scalloped potatoes pan and continued to serve residents. An undated policy titled Food Storage indicated all opened packages or containers must be sealed/covered and accurately labeled. It also indicated food is stored, prepared, and transported by methods designed to prevent contamination. On 4/23/25 at 3:50 PM, the Administrator stated staff should have followed the facility policy regarding food storage, labeling, and service.

Based on observations, resident interviews, staff interviews, and policy review the facility failed to provide food at an appetizing temperature to 2 of 5 residents ( Residents #1, and #40) reviewed. The facility reported a census of 50 residents. Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview on 4/21/25 at 1:30 PM with Resident #1 revealed food temps are terrible, and the food quality has diminished. 2. Review of Resident #40's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 4/21/25 at 12:13 PM with Resident #40 revealed food is often cool when delivered on room trays. 47079 3. On 4/23/25 at 7:49 AM, Staff A, Certified Nurse Aide (CAN) placed a resident's breakfast room tray on the unit kitchen serving counter. At 7:58 AM, a different resident's breakfast room tray was observed on the nurses' station counter. At 7:59 AM, Staff A grabbed the tray from the kitchen serving counter and confirmed she was taking it to the resident's room. Upon request, she got a thermometer from the unit kitchen to recheck the omelet temperature, but it did not work. She also stated they don't check the food temperatures on the unit. She added food temperatures are checked in the main kitchen before being brought up to the unit and again after meal service is completed. At 8:08 AM, the Certified Dietary Manager (CDM) returned at 8:08 AM with a functioning thermometer. At 8:10 AM, Staff A checked the omelet temperature which resulted 99.4 Fahrenheit (F). The CDM instructed Staff A to reheat the omelet. At 8:14 AM, the Director of Nursing (DON) instructed Staff A to replace the entire plate of food. At 8:19 AM, Staff A grabbed the resident's tray of new food and confirmed she was taking it to the resident's room to eat. Upon request, she rechecked the glass of milk on the resident's tray which resulted 53.3 F. She stated she didn't know what temperature milk should be. At 8:23 AM, Staff A confirmed she took the tray that was placed on the nurses' station counter at 7:58 AM to the resident's room to eat. An undated policy titled Food Temperatures indicated hot foods must be served at a minimum temperature of 135 F. It also indicated the temperature of potentially hazardous cold foods will be no greater than 41 F when served to the resident. On 4/23/25 at 3:50 PM, the Administrator stated staff should follow facility policy regarding food temperatures during meal service.

Based on clinical record review, facility document review, resident interviews, observation and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 5 of 5 residents reviewed (Resident #1, #2, #40, #22 and #42). The facility reported a census of 50 residents. Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview on 4/21/25 at 1:27 PM with Resident #1 revealed call lights take over 15 minutes constantly. 2. Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Interview on 4/21/25 at 11:26 AM Resident #2 revealed call lights can often take longer than 15 minutes, and it is usually longer on the weekends. 3. Review of Resident #40's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 4/21/25 at 12:12 PM Resident #40 revealed call lights take longer than 15 minutes often. Review of a facility provided document titled, Device Activity Report with the dates of 4/19/25 12:00 AM through 4/20/25 11:59 PM revealed several call lights being answered in a range of times from 17 minutes 9 seconds to 76 minutes 44 seconds. Review of facility provided documents titled, Resident Council Minutes with a date of 3/25/25 revealed residents think that the call lights have improved, but still have to wait. Review of Resident Council Minutes from 2/28/25 revealed it takes staff 45 minutes to an hour to answer call lights. Resident Council Minutes from 1/31/25 revealed call lights won't be responded to for almost 45 minutes and sometimes longer. 41785 4. The MDS for Resident #22, dated 3/20/25, showed that he was independent with hygiene, toileting, dressing, and transfers. He was occasionally incontinent of urine and always continent of bowel. His diagnoses included: peripheral vascular disease, renal insufficiency, diabetes mellitus and urinary tract infections. The resident scored 14 out of 15 points on the BIMS indicating intact cognition. A Change in Condition MDS dated [DATE], showed that the resident required substantial assistance with toileting hygiene, dressing and transfers. The Care Plan initiated on 3/14/25, showed that Resident #22 was at risk for falls, and staff were to provide toileting assistance before and after meals and as needed. He required assistance of 2 staff for ambulation. On 4/21/25 at 10:00 AM, Resident #22 said that the call light response could take as long as 90 minutes. He said that he would get sore waiting to get transferred off of the toilet. The resident said that there have been times when the call light did not work at all. He thought it was because it needed a new battery. 5. The MDS dated [DATE] for Resident #42, showed that she was admitted to the facility on [DATE] and had a BIMS score of 14 (intact cognitive ability.) She required substantial assistance with toileting hygiene, dressing, sit to stand and toilet transfers. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. Her diagnoses included: Parkinson's Disease, repeated falls and edema. The Care Plan initiated 3/14/25, showed that Resident #42 was at risk for skin breakdown related to urinary incontinence, and limited mobility. Staff were directed to assist to toilet, provide incontinence care, and report signs of skin breakdown. On 4/21/25 at 11:27 AM Resident #42 was sitting in her room near the door. She said that she needed help to get to the bathroom, and at times, it could take more than 25 minutes for staff to respond to the call light. She said that she hadn't had incontinence episodes due to the long wait, but it had been darn close. Resident #42 said that there was a time when one of the call lights wasn't working at all. On 4/22/25 at 6:18 AM, Staff C, Certified Nurse Aide (CAN) said that the call lights would quit working without warning. She said that she would take them apart and fix them herself and would change the battery if she could get into the maintenance room. On 4/23/25 at 10:47 AM, Staff L, CAN said that she had seen that the call lights were not working at times. She said that when this happened, they would discover residents yelling to get assistance if the light wasn't working. Staff L said that they could hear when there was a light on, but they had to go to a screen to see which rooms had lights on and it wasn't very convenient. On 4/22/25 at 9:17 AM, Staff D, Maintenance, said that he could log into the call light system to check if there were any that needed new batteries. He said the call light report was checked on a weekly basis. Staff D said that the staff would sometimes change the batteries and may not get the unit put back together correctly so he asked them not to take them apart. On 4/22/25 at 2:31 PM, the Administrator said that the call light system originally had Android phones hooked up to the system. Staff would carry the phones with them to check which call lights were on. They had trouble keeping track of the phones and they didn't hold a charge very long. She decided to put up a couple of tablets in the hallways and at nurses' station. Staff were expected to check the screens often to see what residents were waiting for assistance.

Based on clinical record review, observation, staff interviews and facility document review, the facility failed to implement timely interventions to prevent pressure ulcers for 1 of 2 residents reviewed. In an observation on 4/22/25 at 8:35 AM, Resident #16 was found to have a small open sore on her buttocks. On 4/23/25 at 7:00 AM nursing staff had not yet followed up with a skin assessment or intervention. The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) She was totally dependent on staff for toileting, dressing, chair to bed transfer and bed mobility. Her diagnoses included cancer, renal insufficiency, diabetes mellitus, dementia, rheumatoid arthritis and osteoarthritis. The resident did not have any skin concerns at the time of the MDS assessment. The Care Plan for Resident #16, updated on 3/26/25, showed that she had impaired cognition, impaired mobility and bladder/bowel incontinence. She was at risk for skin breakdown and staff were to report signs of skin breakdown; sore, tender, red or broken areas. A Nursing Note dated 3/21/25 at 8:51 PM showed that a weekly skin assessment was completed at that time, and there were no new skin issues for Resident #16. On 4/22/25 at 8:34 AM, Staff A, Certified Nurse Aide (CNA,) and Staff B, CNA, prepared to change a soiled brief and provide incontinence cares for Resident #16. The CNA's said they didn't think the resident had any reddened or sore areas. As they wiped the groin on the left side, the resident grimaced and said ouch The resident had a rash in the groin, and it was red. The CNA's rolled the resident onto her left side to reveal a small open spot on the right buttock. They weren't sure if this was a new breakdown and applied a clean brief without ointment or moisture protection ointment. A review of the nursing notes on 4/23/25 revealed that the chart lacked documentation of the reddened groin or open sore on the right buttocks. On 4/23/25 at 7:51 AM, Staff A said that she told the nurse the day before about the rash and the open sore and she responded that she would look at it. On 4/23/25 at 1:42 PM, Staff M, Licensed Practical Nurse, (LPN) said that she did a skin assessment on Resident #16. She agreed that the spot on her bottom looked like it may have been a blister that popped. She got a treatment order for the red area and the open sore. A Wound/Skin Healing Record dated 4/23/25 showed that Resident #16 had a pressure injury on the right buttock that measured 0.4 centimeters (cm) x 0.3 cm. On 4/24/25 at 10:00 AM, the Director of Nursing (DON) said that the CNA's were expected to tell the nurse on duty right away if/when they see a new skin issue. They had ointments that can be used by the CNA's for incontinence protection. A review of the annual assigned education for CNA's did not include recognizing and reporting skin issues.

Based on record review, policy review, and staff interview the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 1 of 3 residents (Resident #26) reviewed. The facility reported a census of 50 residents. Findings include: Review of Resident #26's Electronic Healthcare Record (EHR) revealed that Resident #26 was in the hospital from [DATE] through 12/20/24. Further review of the EHR page titled Clinical Census, confirmed that Resident #26 was in the hospital on these dates. Review of a facility provided document titled, Notice of Transfer Form to Long-Term Care Ombudsman with transfer dates of 12/13/24 through 12/30/24 revealed Resident #26 was not listed on the document. Interview on 4/22/25 at 11:30 AM with the Administrator revealed that Resident #26 was not on the Ombudsman notification for the month of December 2024. The Administrator then revealed that her expectation would be for appropriate notification to the Ombudsman when residents are sent to the hospital. Follow up interview on 4/23/25 at 11:57 AM with the Administrator revealed the facility does not have a policy for notifying the ombudsman for hospitalizations, but the Administrator does expect the facility to follow the regulations.

Based on clinical record review, family interview, staff interview and policy review the facility failed to offer residents a bath or shower on a regular basis for 1 of 3 residents reviewed (Resident #103.) The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #103 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident was totally dependent on staff for hygiene and showers. Resident #103 had a fracture related to a fall in the 6 months prior to admission. His diagnoses included; heart failure, type 2 diabetes, chronic kidney disease, and unspecified fracture of the shaft of left tibia. The Care Plan for Resident #103, initiated on 2/26/25, showed that he was admitted to the facility for rehabilitation services for a fractured leg, with the hope to return home. His ability to complete Activities of Daily Living (ADL) had deteriorated related to a fall. The resident was to have a whirlpool/shower two times a week and as needed. The Clinical Census tab showed that Resident #103 was admitted to the facility on [DATE] and discharged on [DATE]. On 4/21/25 at 12:17 PM, a family member for Resident #103 said that they visited the resident many times during his stay and they didn't know if he had been offered any baths or showers. The document titled: ADL - Bathing Report showed that during his time at the facility he had just two bath/showers on 2/21/25 and on 2/25/25. On 4/24/25 at 10:30 AM, the Director of Nursing (DON) acknowledged that according to the documentation, Resident #103 did not get baths as often as he should have. She said that the standard was to offer at least twice a week. According to a facility policy titled: Bathing, effective 1/3/24, hygiene activities were necessary to maintain skin integrity and promote dignity. Each resident would be offered 2 baths per week.

Based on clinical document review, staff interview, and policy review the facility failed to notify a resident 48 hours in advance when the end of a Medicare Part A stay or when all of Part B therapies were ending to 2 of 3 residents (Resident #204, and #205) reviewed. The facility reported a census of 50 residents. Findings include: 1. Review of Resident #204's Advanced Beneficiary Notice (ABN) revealed Resident #204's last covered day of Part A services was dated 12/23/24. This document further revealed that Resident #204 and the family were notified by telephone of the notice for Part A services being ended by the previous Administrator, but this notice could not be located. 2. Review of Resident #205's ABN revealed the residents last covered day of Part A services was dated 12/30/24. This document further revealed that Resident #205 and the family were notified by telephone of the notice for Part A services being ended by the previous Administrator, but this notice could not be located. Interview on 4/22/25 at 10:28 AM with the Administrator revealed that she was not the Administrator at the time when the two residents of the ABN requests were sent to family members. The Administrator revealed that there was documentation on the form that the family members were notified via phone, but could not find the notices. The Administrator then revealed her expectation would be for ABN's to be completed correctly. Follow up interview 4/23/25 at 11:54 AM with the Administrator revealed her expectation would be for logs to be kept and for the facility to follow the regulations as they do not have a policy related to obtaining ABN notification.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that staff used adequate hand hygiene techniques to prevent the spread of pathogens for 2 of 3 residents (Resident #16, and #30). The facility reported a census of 50 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit). She was totally dependent on staff for toileting, dressing, chair to bed transfer and bed mobility. Her diagnoses included cancer, renal insufficiency, diabetes mellitus, dementia, rheumatoid arthritis and osteoarthritis. The Care Plan for Resident #16, updated on 3/26/25, showed that she had impaired cognition, impaired mobility and bladder/bowel incontinence. The resident was at risk for skin breakdown and staff were to report sore, tender, red or broken areas. On 4/22/25 at 8:34 AM, Staff A, Certified Nurse Aide (CAN) and Staff B, CAN, provided a brief change and incontinence cares to Resident #16. The CAN's left the room with trash and soiled clothing in bags and both failed to wash their hands before leaving the room and going onto the next resident room. 2. The MDS dated [DATE] for Resident #30, showed that she had a BIMS of 14 (intact cognitive ability). The resident was totally dependent on staff for toileting hygiene, showers, dressing, chair to bed transfers. She had an indwelling catheter and was always incontinent of bowel. Her diagnoses included neurogenic bladder, obstructive uropathy and Alzheimer's dementia. The Care Plan updated on 4/2/25, showed that staff were to provide catheter cares twice a day and as needed. The resident was at risk for skin breakdown related to limited mobility and suprapubic catheter. Staff were to use Enhanced Barrier Precautions related to an indwelling catheter and to practice good hand hygiene. On 4/23/25 at 11:22 AM Staff I, Registered Nurse (RN) donned a gown and disposable gloves. With a damp wash cloth, she cleaned around the catheter site and down the catheter tubing several times. Then with the same gloved hands, Staff I pulled the blanket over the resident and adjusted the remote on the bed to elevate the bed. On 4/23/25 at 11:45 AM, the Assistant Director of Nursing (ADON) said that staff were taught to change gloves and use hand hygiene after cares. A facility policy titled: Hand Hygiene Guidelines, last dated 2/18/22, showed that all staff would use the hand hygiene techniques before each resident encounter, after coming in contact with residents' intact skin, lifting moving. Change gloves when moving from a contaminated body site to a clean body site on the same resident.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to have a system in place to ensure residents who received warfarin (blood thinner) along with an antibiotic also received more frequent therapeutic monitoring for 1 of 1 resident (#41) reviewed. The facility reported a census of 50. Findings include: On 4/21/25 at 12:23 PM, Resident #41 stated he regularly took a blood thinner. The Minimum Data Set (MDS) dated [DATE] for Resident #41 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of paroxysmal atrial fibrillation (PAF - intermittent irregular heart beat), end-stage renal disease, Diabetes Mellitus, hyperlipidemia, and above the right knee amputation. It indicated the resident received an anticoagulant (blood thinner) and an antibiotic within the previous seven (7) day lookback period. The Electronic Health Record (EHR) included physician medication orders for a) warfarin sodium oral tablet 6 milligrams (mg); give 1 tablet by mouth in the evening every Tuesday, Thursday, Saturday, Sunday related to PAF dated 3/19/25, and b) warfarin sodium oral tablet 4 mg; give 1 tablet by mouth in the evening every Monday, Wednesday, Friday related to PAF dated 3/19/25. It also included an order dated 3/19/25 for a PT/INR (prothrombin time/international normalized ratio) lab (a lab that indicates how long it takes blood to clot); one time only related to PAF for collection on 3/26/25. On 3/24/25, the EHR included a physician medication order dated 3/23/25 for Amoxicillin-potassium clavulanate (antibiotic) tablet 875-125 mg; give 1 tablet by mouth every 12 hours every 10 days for URI (upper respiratory infection) for 10 days and corrected on 3/24/25 to give 1 tablet by mouth every 12 hours for URI for 9 days. The March and April 2025 Medication Administration Record (MAR) indicated the resident received the warfarin beginning 3/19/25 as ordered and received the antibiotic beginning 3/23/25. The Progress Note dated 3/26/25 at 1:52 PM revealed the resident's INR lab result was 1.5, which indicated the resident's blood took 1.5 times longer to clot than without a blood thinner (normal INR range is 0.8 - 1.2 for people not taking blood thinners). It also revealed no new orders and did not identify a resident-specific therapeutic INR range. On 3/28/25, the EHR included a physician order for PT/INR lab; one time only related to PAF for 1 day to be collected on 4/23/25. On 4/22/25 at 11:09 AM, an EHR and chart review revealed no therapeutic INR range was documented and no subsequent labs were ordered before 4/23/25. On 4/22/25 at 3:02 PM, Staff H, Registered Nurse (RN) stated the INR goal was 2-3 but reported those details and documentation were managed by the Director of Nursing (DON). She stated ordered labs are collected every Wednesday morning. She confirmed Resident #41 received the ordered antibiotic and blood thinner. On 4/22/25 at 3:08 PM, the DON stated the physician verbalized the INR was acceptable but never identified a resident-specific therapeutic INR range. She added the facility checks the INR monthly on routine Wednesday lab day and the physician notifies the staff by noon on what to do based on the morning labs results. On 4/22/25 at 3:24 PM, the DON stated Resident #41 received his oral antibiotic beginning 3/23/25 and added the facility probably should have told the physician about the antibiotic. On 4/23/25 at 3:50 PM, the DON stated staff should have called the physician for orders regarding warfarin and labs. On 4/23/25 at 4:01 PM, the DON indicated the facility did not have a policy regarding INR monitoring during antibiotic therapy. An article dated 7/30/23 retrieved from The National Institute of Health (NIH) (https://pmc.ncbi.nlm.nih.gov/articles/PMC10455514/) indicated numerous studies consistently supports an elevated risk of serious bleeding in patients concurrently receiving antibiotics and warfarin therapy. The article further explained that warfarin inhibits clotting factors that are dependent on vitamin-K and antibiotics can interfere with vitamin-K producing bacteria; thereby, increasing clotting time.

Based on clinical record review, staff interviews and facility policy review, the facility failed to offer Range of Motion (ROM) exercises for 1 of 2 residents reviewed (Resident #16). The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) She was totally dependent on staff for toileting, dressing, chair to bed transfer and bed mobility. Her diagnoses included cancer, renal insufficiency, diabetes mellitus, dementia, rheumatoid arthritis and osteoarthritis. The Care Plan for Resident #16, updated on 3/26/25, showed that she had impaired cognition, impaired mobility and bladder/bowel incontinence. The resident required ROM exercises and staff were to refer to the restorative records for current restorative plan of care. The Restorative assessment dated [DATE] at 12:09 PM, showed that the Program Plan included Bilateral Lower Extremities/Bilateral Upper Extremities (BLE/BUE) exercises 3-5 times a week as tolerated. In a four-week timeframe, from 3/26 - 4/22/25 staff had 12 opportunities to offer the ROM activities. According to the Point of Care (POC) Response History report, from 3/26/25 - 4/22/25, the exercises were offered just 8 times. On 4/23/25 at 8:05 AM, Staff E, Certified Nurse Aide (CAN) said that the facility had two staff members scheduled to provide the restorative program. She said that the CAN's that worked on the floor were not expected to do restorative exercises with the residents. On 4/23/25 at 7:52 AM, Staff K, Certified Medication Aide (CMA) said that she would do restorative, sometimes she would come in on a days off but she had been on leave for 4 months. On 4/24/25 at 9:16 AM, the Assistant Director of Nursing (ADON) said that she had just recently took over the responsibilities of managing the restorative program. She acknowledged that it wasn't always getting done as it should and the expectation was to offer it 3-5 times a week. According to the facility policy titled; Restorative Program, effective 6/28/17, the Range of Motion (ROM) activities would be provided 3-5 times a week.

Based on clinical record review, facility document review, personnel file review, resident interview, family interview, staff interviews, and facility policy review, the facility failed to protect 1 of 3 residents (Resident #1) reviewed from abuse. The facility reported a census of 46 residents. Findings include: Clinical Record Review of Resident #1 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. The MDS reflected diagnosis of stroke, hemiplegia or hemiparesis following cerebrovascular affecting the left side, urge incontinence, pain in left hip, pain in unspecified knee, anxiety disorder and depression. The MDS further documented Resident #1 required total dependence on staff for performing most activities of daily living. The Care Plan documented Resident #1 had behaviors related to depression, anxiety, vascular dementia, personal history of other mental and behavioral disorders and directed staff to implement intervention of maintaining a calm environment and approach to the resident. It further directed staff to communicate with the resident using the resident's preferred name, staff to identify themselves at each interaction, face the resident when speaking and to make eye contact, observe the resident for signs and symptoms of depression, and to encourage residents to verbalize feelings, concerns and fears. The Care Plan also documented Resident #1 needed 24-hour care related to left side paralysis from major stroke and inability to care for herself and required wheelchair mode of transportation to and from activities including toileting assistance. A facility reported incident dated 11/05/24 documented the following: on 10/31/24 Staff A, CNA was recorded on the camera in Resident #1 's room while providing cares and during the cares. The video shows the nurse aide rushing and not demonstrating compassion towards the resident that is sitting in her recliner. The Nurse Aide brings the stand lift to the front of the resident to prepare for the transfer. She very quickly removes the call light which gets looped in resident hair. She abruptly removes the head pillow from behind the resident's head and tosses it onto the bed that is across the room. She then proceeds to move the lift closer to the resident to place the resident's feet onto the platform of the lift. She takes her own foot to push down on the resident's lower leg/upper ankle area to position the foot for placement onto the lift platform. She proceeds to put the harness strap under the arms and hook it up to the lift as she should. The entire time she is not talking to the resident and appears to be in a rush to get the transfer completed. The resident asks to use the restroom, and the Nurse Aide responds in the video that it has only been 40 minutes since she used the restroom, and she can go to her wheelchair. The personnel file for Staff A included a certificate dated 8/19/23 certifying she completed the course for Dependent Adult Abuse. The Disciplinary Report Form for Staff A dated 11/1/24 documented video surveillance revealed the staff was not speaking to the resident during cares, staff positioned the resident's foot on the platform of the mechanical lift using force from her own foot, throwing residents belongings, and refused to take the resident to the bathroom when the resident requested to go. The form documented the staff suspended pending investigation. The Change in Hours Form documented Staff A was terminated from the facility on 11/5/24. In an interview on 2/19/25 at 12:25 pm Staff B, CNA, revealed she was in the vicinity of the interaction between Resident #1 and Staff A, CNA, but did not visually observe the whole interaction, only when Staff A, CNA was punched in the head and the stomach by Resident #1. She just knew she had to take Resident #1 out of the room after Staff A, CNA left the room. In an interview on 2/19/25 at 2:04 pm Staff C, Licensed Practical Nurse (LPN) stated she received a report from Staff A, CNA about Resident #1 hitting her. Staff C, LPN stated she did document the incident in the Progress Notes and reported it to the Director of Nursing (DON) and assessed the resident for injuries. Staff C, LPN further stated she did not ask Resident #1 questions to assess for safety and well-being of the resident after the interaction with Staff A, CNA. In an interview with the Power of Attorney (POA) for Resident #1 on 2/19/25 at 2:14 pm she revealed receiving a call from the facility on 10/31/24 notifying her of the incident about her mother hitting a staff member. She reviewed the camera footage immediately prior to the incident and stated she was horrified about what happened to her mother. Resident #1 POA stated she filed the report with the State Agency and reported the following: To my horror, the video showed the staff member being extremely rude, condescending, and rough with my mother. The staff used her own foot to push my mother's down while putting her in an ez stand. The entire two minute video shows her being rough and pushing my mother around, denying her a shawl when she is cold and jerking her body aggressively and inappropriately. This staff member knows my mother has pain throughout her body and is paralyzed on her left side, yet the staff member is particularly rough to her left side. The video captures audio of the staff member stating that my mom had just gone to the bathroom [ROOM NUMBER] minutes prior and would go straight to the wheelchair My mother had been having a very hard time sleeping the days prior and expressed her fear. POA further stated she did not want Staff A, CNA to treat her mother this way or any other resident for that matter. In an interview with Resident #1 on 2/19/25 at 3:00 pm, she stated her left side was useless and numb, her arms were overworked and rotator cuffs were gone. It was painful for her to raise both of her arms to get into the mechanical stand for transfers. She verbalized ouch everyday to Staff A, Certified Nurse Assistant (CNA) but she didn't believe her. On 10/31/24 Resident #1 stated she needed assistance with transferring and Staff A, CNA was rough with her and hurt her left foot that was paralyzed and it caused her more pain and also denied taking her to the bathroom. Resident #1 stated she hit Staff A, CNA because she had to fight for herself, she couldn't take it anymore. She had a hard time sleeping for weeks at that point because she felt like something bad was going to happen to her. Resident #1 further stated Staff A, CNA was getting rougher and rougher everyday and did something everyday to hurt my arm or leg and threatened to give her a cold shower and it made me panic. Resident #1 revealed Staff A, CNA brushed out her hair when it was tangled up and she was very rough and she told her you have long hair, you should know how it feels but Staff A, CNA told her you better cut it off if you can't take it. She also revealed Staff A, CNA was losing patience with everything and made it clear she was tired of working here, didn't like repetitive work and had a very sour attitude towards her. During an interview on 2/20/25 at 3:00 pm, Staff A, CNA, stated she went in on 10/31/24 around 9:30 am to get Resident #1 up for a vaccine clinic, she hooked her up to EZ stand (mechanical lift) to put her in the wheelchair and while she was bent down to put the residents' left foot on the pedal, Resident #1 hit her in the head, then as she was standing up, she got hit in the stomach. She then left the room. Staff A, CNA stated she didn't see it coming from the resident, she never got hit, this was the first time. She made a report to the charge nurse, and later around 1:45 pm, the charge nurse told her she had to go home. She hasn't returned to work since then. The Progress Notes for Resident #1 revealed the following: On 10/31/24 at 10:20 AM CNA reported to this nurse that when getting resident up from her recliner to the wheelchair, CNA bent down to put pedal on wheelchair, resident punched CNA upside the head. Two CNA's present during cares for resident. When CNA stood up, resident then punched CNA in the stomach. This nurse educated resident on appropriate behavior, not appropriate to hit staff. Resident then smiled then stated, I'm going to shoot her next. She's gonna put a knife in my head. Again, this nurse educated resident on verbal aggression towards staff. On 10/31/24 at 2:30 PM full skin assessment performed head to toe with no bruising, no abrasions, no open areas, and no bumps noted. On 11/2/24 at 3:36 PM 48 hour follow up with no further behaviors noted. Resident has been pleasant towards staff and other residents. Review of the clinical record for Resident #1 revealed a police report was filed and the following outcome noted: no criminality but recommended more compassion during Activities of Daily Living (ADL's). During an interview with the Administrator on 2/20/25 at 12:30 pm he stated the residents should not be mistreated and his expectations were for residents to be treated with dignity and respect. The undated facility provided policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy undated, documented Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. If further outlined the following: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 6. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes abuse that is facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. This would include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the resident's face, labeling resident's pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position. 7. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 9. Mistreatment means inappropriate treatment or exploitation of a resident. 10. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or mental illness.

Based on clinical record review, observations, resident interviews and staff interviews, the facility failed to answer the residents' call light in less than 15 minutes for 3 resident call lights seen during observation. Additionally, two residents (Resident #1 and Resident #50) reported extended call light response time during resident interviews. The facility reported a census of 48 residents. Findings include: 1. The Social Services Assessment of Resident #50 dated 6/6/24 documented the resident to have a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition intact. On 6/10/24 at 11:19 am, Resident #50 stated that she experiences long wait times for her call light to be answered, often greater than 15 minutes. 2. The Minimum Data Set (MDS) assessment of Resident #1, dated 3/14/24 revealed a BIMS score of 14, indicating cognition intact. On 6/10/24 at 11:25 am, Resident #1 stated she felt the facility to be short staffed and stated call lights are answered after at least 15 minutes and longer. 3. During observation beginning 6/12/24 at 11:55 am, it was noted that the staff tablet sitting at the nurses station area near room [ROOM NUMBER] could audibly be heard of call lights ringing. When the tablet was observed, it showed the call light for room [ROOM NUMBER], Bed B, had been turned on at 11:23:20 am. During the continued observation, room [ROOM NUMBER], Bed A, was turned on at was turned on at 11:54:54 am and room [ROOM NUMBER], Bed A, was turned on at 12:04:53 pm. On 6/12/24 at 12:11 pm Staff D, Certified Nurse Aide (CNA) stated the staff is notified of call lights being on by hearing them ring from the tablet at the desk. She walked to the nearest tablet, at the station by the 320 rooms and noticed the tablet was turned off. She stated she was unaware of why it was turned off. She powered the tablet back on and stated she had to wait to log back into the system. On 6/12/24 at 12:12 pm, the tablet was logged back into. When Staff D was asked if she was aware that room [ROOM NUMBER], Bed B had been ringing for over 40 minutes, she stated she did not know that but had been in the room a few minutes earlier. On 6/12/24 at 12:14 pm, Staff E, CNA cleared the call light for room [ROOM NUMBER], Bed B. (Approximately 51 minutes) Observation continued for the tablet for the hall near the 320 rooms. The Director of Nursing came to check the monitor at 12:23 pm and then left the area. She returned at 12:26 pm to check the monitor again. No other staff was observed checking the monitor. room [ROOM NUMBER], Bed A, which had been triggered at 11:54:54 was answered at 12:26 pm, a total of 31 minutes. room [ROOM NUMBER], Bed A, which had been triggered at 12:04:53 pm was answered at 12:27 pm, a total of 22 minutes. Observation was continued with the first tablet, near room [ROOM NUMBER] on 6/12/24 from 1:10 pm to 1:29 pm. The call lights could be heard ringing but despite numerous staff being in the area, no staff was observed checking the tablet to see what call lights were ringing. On 6/13/24 at 9:20 am, the Administrator stated via email the facility does not have a policy regarding call lights. She stated the facility is to follow the regulatory expectation.

Based on observation, policy review, and staff interview the facility failed to implement appropriate infection prevention and control practices during medication administration by staff not completing hand hygiene between residents and touching pills with a bare hand. The facility reported a census of 48 residents. Findings include: During a continuous observation on 6/11/24 from 8:25 AM - 8:48 AM, during the medication pass for 3 different residents, Staff C, Licensed Practical Nurse prepared and administered medication consecutively to 3 different residents without completing hand hygiene before or after administering the medications. Staff C poured 2 pills into the lid of a medication bottle and used her bare fingers to place 1 pill back into the bottle and proceeded to pull another pill out of a medication bottle with her bare finger. Facility policy, Medication Administration revised 4/1/23 documented to wash hands with soap and water prior to beginning medication pass and alcohol waterless sanitizer is acceptable between residents. Interview on 6/13/24 at 9:52 AM, the Director of Nursing stated her expectation is for staff to complete hand hygiene before and after administering medications, between residents and to not touch medications with bare hands, use gloves or pour the pill back into bottle without touching the pills.

Based on clinical record review, staff interviews, facility policy review, and guidance from the RAI manual, the facility failed to ensure the Minimum Data Set (MDS) assessment of each resident accurately reflected the resident's status at the time of the assessment for 2 of 15 residents reviewed (Resident #3 and Resident #10) . The facility reported a census of 48 residents. Findings include: 1. The Weight Summary for Resident #3 documented the resident had been in the facility in 2019 and on 2/8/19 had a documented weight of 355.0 pounds. The next time a weight was documented was 3/1/24, revealing a weight of 285.0 pounds, a difference of 70 pounds over the approximately 5 years between the recorded weights. The MDS of Resident #3, dated 2/8/24 documented an entry date of the most recent admission as 2/2/24. The MDS recorded the resident's current weight as 355.0 pounds. The Clinical Summary in the resident's hospital records, located in his electronic health record revealed the resident had been weighed at the hospital on 2/2/24 at 5:26 am and documented the resident's weight of 284 pounds, 14.4 oz. On 6/11/24 at 1:32 pm, the MDS Coordinator stated the 355 pounds documented on the MDS of Resident #3 was incorrect. She stated she did not see an admission weight documented anywhere but that the 2019 weight should not have been documented on the MDS. 2. The MDS of Resident #10, dated 5/16/24, reflected the resident was administered an anticoagulant medication during the lookback period of the MDS, 5/10/24-5/16/24. The Medication Administration Record (MAR) of Resident #10 for May of 2024 revealed the resident was administered Aspirin and Plavix. Both medications are classified as anti platelet. The MAR failed to reveal the resident was administered any anticoagulant medication. (Anticoagulants slow down blood clotting, while antiplatelet medications prevent platelets from clumping and prevent clots from forming). The MDS of Resident #10 additionally reflected the resident received 0 minutes of Restorative Nursing Walking between 5/10/24 and 5/16/24. The Follow Up Question Report documented Walk to Dine was completed three times a day, every day between 5/10/24 and 5/16/24 for Resident #10. On 6/11/24 at 1:30 pm, the MDS Coordinator stated she began her job in the facility in March of 2024. She stated she was instructed when she was hired not to document any restorative nursing on any MDS. She stated the facility does not have a Restorative Nurse, and the Certified Nurse Aides are completing the programs such as walk to dine. On 6/11/24 at 1:37 pm, the MDS Coordinator stated coding Resident #10 being on an anticoagulant medication was an error and she would submit an MDS modification. On 6/11/24 at 2:49 pm, the Director of Nursing stated the facility's management company instructed the facility staff to remove minutes from the Restorative Program charting. She stated the facility no longer records restorative minutes anywhere. The facility document Comprehensive Assessment and Reassessment, effective 5/10/17, documented the assessment must include at least the following: - Nutritional Status - Medications; prescription and over-the-counter - Special treatments and procedures (which includes therapies and restorative nursing) The facility document failed to address the accuracy of the MDS. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023 directed: Section K: Nutritional Status - Base weight on the most recent measure in the last 30 days - If the last recorded weight was taken more than 30 days prior to the ARD (the date of the assessment), or a previous weight is not available, weigh the resident again. - If a resident cannot be weighed, use the standard no-information code (-) and document rationale on the resident's medical record. Section N: Medications - Check if the resident is taking any medication by pharmalogical classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. -N0415E1. Anticoagulant, check if an anticoagulant medication was taken by the resident at any time during the 7-day look back period. Section O: Special Treatments, Procedures and Programs. - O0500F, Walking. Code activities provided to improve or maintain the resident's self-performance in walking, with or without assistive devices. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. -

Based on clinical record review, and staff interview, the facility failed to complete the residents restorative program 3-5 times a week for 1 of 2 residents reviewed for restorative program (Resident #15). The facility reported a census of 48 residents. Findings include: The Care Plan for Resident #15, revised 3/22/24 identified the resident's restorative program. The Care Plan informed the staff to review restorative records for the current restorative plan of care. The Restorative plan of care revealed the residents restorative program to be completed 3-5 times a week. Review of records revealed in March of 2024 the resident completed the program 5 times. In April of 2024 the resident completed the program 7 times. In May 2024 the resident completed the program 3 times. In June 2024 the resident completed the program 3 times. In an interview on 6/13/24 at 10:02 AM, the Director of Nursing (DON) stated she expects the restorative aides to complete the exercises with the resident per the Care Plan and to document in Point of Care (PCC) when completed.

Based on clinical record review, observation, staff interviews and facility policy, the facility failed to administer tube feeding per physician orders for 1 of 1 resident reviewed for tube feeding (Res #51). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #51 dated 6/4/24 documented a primary diagnosis of muscular dystrophy. The MDS documented the presence of a feeding tube. The MDS recorded the resident received 51% or more of total calories through tube feeding and 501 cc/day (cubic centimeters per day) or more fluid intake per tube feeding. The Care Plan of Resident #51 documented a focus area of nutrition dated 6/6/24, which revealed the resident to be NPO (nothing by mouth) and to have a need for alternate feeding method. It directed staff to provide tube feeding as ordered. The Medication Administration Record (MAR) of Resident #51, for June of 2024 revealed an order for Osmolite 1.2 Cal, give 552 mls (milliliters) via G-Tube (a gastronomy tube, a tube inserted through the abdomen that brings nutrition directly to the stomach) three times a day. On 6/12/24 at 8:36 am, Staff F, LPN stated she would be doing the resident's morning ordered tube feeding. Staff G, Registered Nurse, a nurse consultant for the facility stated she would be observing. Staff F, LPN stated she had been off work for three weeks and had not met or cared for Resident #51, who had admitted to the facility on [DATE]. Staff F first prepared Resident #51's morning medications. She checked his vital signs, and gathered the medications and three boxes of Osmolite 1.2 calories, each containing 237 mls of feeding. On 6/12/24 at 8:49 am, both staff members, after performing hand hygiene and donning personal protective equipment, repositioned Resident #51 to be at the top of the bed. After the resident was at the top of the bed and having raised the head of the bed to a safe position, Staff F removed her gloves, went to the restroom to wash her hands and don clean gloves. On 6/12/24 at 8:55 am, Staff F opened a new 60 ml syringe, and attached the resident's feeding tube to his Mic-Key feeding tube button. She auscultated the feeding tube with air to verify proper placement. She then flushed the feeding tube with 60 mls of water. After administering the resident's medication, and flushing with an additional 60 mls of water, she prepared for the tube feeding. She poured two boxes of Osmolite 1.2 feeding, totaling 474 mls, into a graduate cylinder that had been set up for the tube feeding. After opening the third box of Osmolite, she held the cylinder at eye level and measured the feeding, stating she had a total of 522 mls of feeding. She administered the feeding per gravity at a safe rate and after completing the feeding, gave an additional 60 mls of water per physician order. Staff F was asked to verify how much water and how much feeding she administered to Resident #51. She stated she administered 60 mls of water before medication administration, 60 mls of water after medication administration, 522 mls of feeding, and an additional 60 mls of water after the feeding. She then completed hand hygiene and cleaned her area and supplies. On 6/12/24 at 9:20 am, Staff G, RN, Nurse Consultant verified Staff F administered 522 mls of feeding and verified the resident's order read to administer 552 mls of feeding. The facility document Enteral Feeding Via Nasogastric or Gastronomy tube, revision date 11/5/22 directed This facility shall provide and implement a plan of care for delivery of nutrients via percutaneous enteral gastric (PEG) tube when nutrients cannot be obtained through the alimentary route. Under Assessment, the facility document read Physician's orders for feeding shall include type, amount, frequency and strength of nutritional formula and amount of water used for flushing. Under Preparation, the facility document read: - Ensure enteral feeding is the correct formula, amount and check frequency ordered - Confirm that the correct order is being given to the correct resident.

Based on clinical record review, observation, staff interview, and policy review the facility failed to follow infection prevention standards during incontinence cares for 1 of 4 residents review for incontinence cares (Resident #16). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #16 dated 5/23/24 reflected the resident to have short term and long term memory problems. The MDS revealed the resident totally dependent on toileting and personal hygiene. The MDS reflected the resident always incontinent with urine and bowel. The Care Plan for Resident #16, last reviewed 5/24/24, identified the resident to be incontinent of bladder and bowel. The Care Plan directed staff to provide incontinence care after each incontinent episode. On 6/12/24 at 8:24 AM, Staff A, Certified Nurse Aide (CNA) was providing incontinence care to Resident #16. Resident #16 was laying in bed. Staff A performed hand hygiene and donned gloves. She provided privacy and stated task. Staff A removed the blankets, and opened the incontinent brief which was wet with urine. Staff A then took a clean wet soapy washcloth and performed peri care, front to back on the resident, folding the washcloth to a clean area with each wipe. Staff A then took a clean, dry washcloth and repeated the steps to dry the resident, failing to use a washcloth to rinse the soap off of the resident. Staff B, CNA, then assisted Staff A to turn the resident to her right side. Staff A then proceeded to use the same soiled washcloth to wash the resident's buttocks, front to back on the resident, folding the washcloth to clean area with each wipe. Staff A then took soiled dry washcloth and repeated the steps to dry the resident, failing to use a washcloth to rinse the soap off of the resident. Staff B removed soiled incontinent brief and placed clean incontinent brief. Staff B, then assisted Staff A to turn the resident to her back. Staff A placed soiled linen on floor with no barrier. Staff A, then assisted Staff B to turn the resident to her left side, to position incontinent brief. Staff A and Staff B, closed incontinent brief with fasteners. Staff A, undonned gloves, completed hand hygiene. On 6/13/24 at 12:50 PM the Director of Nursing (DON) stated the staff did not use enough washcloths, did not perform handwashing, did not change gloves, and should not have placed washcloths on the floor. The facility policy Incontinence care, revision date 3/28/24 documented: Residents that are incontinent of bladder and bowel will maintain clean perineal skin for incontinent residents, to examine the skin, and to prevent skin irritation.

Based on record review, staff and family interviews the facility failed to ensure resident rights were met due to a resident was not allowed to have family visit during the end of life for 1 of 2 (Resident #1) residents reviewed. The facility reported a census of 46 residents. Findings include: The quarterly Minimum (MDS) data set [DATE] for Resident #1 revealed the resident scored ,[DATE] for her Brief Interview of Mental Status, which indicated she was cognitively intact. The resident required extensive assist of 1 person for bed mobility, transfers, dressing and toileting and independent with eating with set up help only. The MDS revealed she weighed 133 pounds and did not have a significant weight loss or gain. The MDS identified the resident at risk for pressure related breakdown and identified the resident without pressure sores. The Face Sheet for the resident revealed [DIAGNOSES REDACTED]. The Care Plan focus screen for Covid-19 dated [DATE] included an intervention for staff to follow the guidelines from national, state and local authorities for visitation restrictions. The Progress Note dated [DATE] at 4:39 PM revealed a psychosocial assessment completed after the resident's daughter called concerned the resident had given up. The note revealed the resident stated she was very interested in talking with family. The Progress Note dated [DATE] at 3:04 PM revealed the daughter was concerned the resident was no longer interested in anything that she used to be. The facility notified Hospice and the physician and received new orders for an antidepressant. The Care Plan updated on [DATE] revealed the resident now received hospice care. The Hospice Comprehensive Assessment Note dated [DATE] revealed the daughter reported to the chaplain that she was upset she could not see her mom face to face. The Restricted Visitation for Covid-19 Policy updated [DATE] documented that entry only permitted to immediate family and friends whom need to visit for [MEDICATION NAME] care situations, such as end of life. The Progress Note dated [DATE] at 9:25 PM revealed the resident had started to mottle on her bilateral lower extremities and her hands and her respirations were now shallow. On [DATE] at 4:46 PM the resident's daughter stated her mother died at the facility without family allowed in to see her. She stated she had talked to the Administrator at one point voicing her concern that she was going to have to watch her mom die through her window and the Administrator told her they had to keep Covid-19 out of the facility at all costs and the facility would call her when the time was near. She stated she called hospice on the night of [DATE] because her mom was mottling and had shallow respirations. The nurse told her it was too soon and to call back the next morning. She stated she called the facility 5:00 AM the next morning and let it ring but no one picked up the call. On [DATE] at 9:13 a.m. the daughter reported calling the facility after the 5 a.m. call around 8:45 a.m. and Staff C told her the resident was transitioning. Staff C reported the resident was mottling with shallow breathing and her arms and feet were cold. The daughter asked to come see her mother and she was informed it was not time yet. At 9:30 AM the nurse called and informed her that her mom was dead. The daughter went to the nursing home and was told she could come inside and stay as long as she wanted to after the resident expired. The daughter denied that Hospice informed her she could not visit on [DATE]. The daughter stated Hospice just relayed what the facility said-that it was not time yet. Progress Notes dated [DATE] at 1:42 PM revealed the resident passed away at 9:30 AM and the facility informed the daughter at 9:40 AM. On [DATE] at 3:05 PM the Director of Nursing (DON) stated residents are allowed to have visitors at end of life. One visitor per day for one hour is allowed. She stated that she considered end of life as any significant change and she considered mottling a significant change and would allow for a family visit. She also stated the facility recently allowed some other hospice residents at the facility to have visitors for psychosocial health as well and they considered each resident case by case. On [DATE] at 2:10 PM the physician identified the resident with underlying health conditions which included [MEDICAL CONDITION] and condition likely caused her death but he felt the resident had given up in the end and not being able to visit her family could have hastened the process. On [DATE] at 8:55 AM the Administrator stated the resident's daughter had a difficult time with accepting her mother's nursing home placement. When the COVID visiting restrictions were put in place the facility made sure to place the resident on the ground floor with a patio window so the family could come and go as they pleased. The Administrator stated that once the resident went to hospice level of care she told the family they could visit with any significant change or with any signs that the resident was actively dying. She stated the resident had been like this for a while so that is why the facility wasn't allowing the family in when she first went to hospice. The daughter saw her in the hospital ([DATE]) when she fell recently and she stated the daughter had a window visit with her the day before she passed. The Administrator stated she was not aware of any staff or hospice nurse telling the daughter she couldn't visit the day before she passed away and considered mottling and shallow respirations as a significant change. The COVID-19 screening log for [DATE] lacked any signature for the resident's daughter ,[DATE]-[DATE]. During an interview with Staff C on [DATE] at 10:45 AM she stated she remembered the daughter calling around 7:45 AM on [DATE]. She stated she was in the middle of medication pass and did not recall the daughter specifically asking if she can come in but did ask for an update on her mom's condition. She stated the resident was resting peacefully and denied any pain. She stated the resident never seemed upset that the family wasn't visiting. The nurse stated the family was upset because the resident would never answer the phone and didn't always want to talk to them. She stated the resident was more reserved and wanted left alone to rest in her recliner. The nurse stated the resident was allowed to have visitors to have at end of life. If the family inquires, she is to let the DON Administrator know so they can make arrangements to screen them to allow them in. On [DATE] at 10:30 AM a call was made to the hospice agency providing cares. The Patient Care Manager stated she remembered the daughter calling after her mother passed away expressing concern about not being allowed in the night before to see her mom. During an interview on [DATE] at 11:15 AM Staff D stated she was the primary hospice nurse responsible for taking care of the resident. She stated the hospice nurses are allowed in once every fourteen days and if she feels the resident needs to be seen more often she has to get permission from the Administrator. She stated they are allowed in at end of life only when death of the resident is imminent. The Patient Care Manager was on the call as well and she stated the daughter told her that she was told that her mom was not imminent yet and the facility would not allow her in. During an interview on [DATE] at 11:25 AM Staff E stated that she was the on call nurse the night of ,[DATE]-[DATE]. She stated she received calls from the facility updating her that the resident was transitioning. The hospice nurse offered to make a visit and the facility stated it was not time. Staff E does not recall the daughter asking if she could come into the facility. On [DATE] at 8:47 a.m. Staff E stated she offered a visit but was told by the facility it was not necessary due to COVID. Staff E stated did not tell the daughter she couldn't visit. Staff E informed the daughter to try calling the facility in the morning around 7 a.m. During an interview on [DATE] at 11:30 AM the DON stated she never saw the resident in any distress over visitor restrictions and that the resident felt very content at the facility. The DON stated staff would have to encourage the resident to answer her phone from family because she would ignore the calls. During an interview on [DATE] at 11:40 AM with Staff F she stated that she found the resident passed away the morning of [DATE]. She stated she had taken care of the resident earlier in the week and the resident never seemed to be in distress or upset about her family not visiting. On [DATE] at 12:12 p.m. via email, the Administrator stated facility policy does allow for end of life visits.

Based on clinical record review, observations, interviews and facility record review, the facility failed to prevent three resident's from exiting the facility without staff knowledge, which resulted in an immediate jeopardy to residents health and safety. Residents #51,#4 and #31 all exited from the facility without staff knowledge. The facility's alarm system malfunctioned and there was no alert to staff pagers indicating a door was open or a resident with a wanderguard was at the exit door. Resident #51 was found outside on the grassy hill and no alarm/alert went to staff pagers notifying staff of the resident exiting. Resident #4 wore a wanderguard (bracelet device that would alert staff if the resident attempted to exit the facility) and there was no alert to staff pagers of the resident exiting and the resident was found outside climbing the hill towards a highway. Resident #31 was found outside and the wanderguard did not alert staff of the resident exiting the facility. The facility also failed to assess resident's risk for wandering and potential elopement risk so safety interventions could be added to the resident's plan of care. The facility had two enclosed courtyards with a gait that was paddle locked and staff were unaware how to unlock it if there was a fire, which could affect all residents if a fire occurred in an area where residents needed to be evacuated through the courtyard. Although not part of the immediate jeopardy, the facility failed to provide safe transfers by locking the bed/wheelchairs and having assistive devices within reach for Resident #44, #50 and #8. The facility reported a census of 53 residents. 1. According to the admission Minimum Data Set (MDS), dated [DATE], Resident #51 admitted to the facility on [DATE]. Resident #51 had the following [DIAGNOSES REDACTED]. According to the MDS the resident scored a fifteen out of fifteen on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS indicated the resident required limited assistance of one staff for bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, and toilet use. The MDS indicated the resident experienced inattention behaviors that fluctuates and wandering behaviors that occurred 1 to 3 days. The Care Area Assessment (CAA) worksheet with an assessment reference date of 7/19/18 indicated the resident wandered one time with contributing factors of mild dementia and new admission status. The facility staff would not address Resident #51's behavioral symptoms on the careplan. The admission baseline care plan dated 7/16/18 lacked documentation of resident's wandering behaviors. The care plan dated 7/19/18 did not address the resident's wandering. The care plan dated 7/19/18 addressed the resident's [DIAGNOSES REDACTED]. The care plan instructed staff to keep the resident's routine consistent and provide consistent care givers as much as possible in order to decrease confusion. The nurse's note, dated 7/15/18 at 8:41 a.m., documented the resident as alert and oriented with some noted confusion. The resident was noncompliant with waiting for help and he liked walking around the unit whenever he wanted. The nurse's note, dated 7/16/18 at 10:56 p.m., revealed the resident was alert and oriented with some noted confusion. The resident was noncompliant with calling for assistance with cares and ambulation. The nurse's notes on 7/19/18 at 9:28 a.m., revealed the resident had short and long term memory problems. The nurse's notes on 8/2/18 at 9:41 a.m., revealed the resident with increased confusion, disoriented to place and time and hard to redirect. A faxed communication order on 8/2/18 documented the resident with increased confusion with coughing and wheezing noted early this morning. Lung sounds were clear. The resident knows name, disoriented to place and time. The physician responded for staff to observe the resident for now. A faxed communication order on 8/3/18 indicated the resident was much more confused lately. The facility staff requested an order from the physician for a urinalysis with culture and sensitivity if indicated. The nurse's notes on 8/6/18 at 10:35 p.m., identified the pager went off for courtyard #2 and Resident #51 was found standing in the bushes/flowers in the courtyard with his walker. The resident verbalized wanting to go home. The facility staff assisted him back to his room with his walker. The resident had several superficial scratches to his right posterior leg. The care plan dated 8/9/18, documented the resident wandered (moves with no rational purpose, seemingly oblivious to needs or safety). An antibiotic was initiated for urinary tract infection and the care plan directed staff to redirect the resident from exit doors as needed. The nurse's notes on 8/10/18 at 1:20 p.m., revealed the resident with continued confusion and at times seemed to know his name and location but had vision trouble and seemed forgetful. The nurse's notes on 8/13/18 at 9:51 a.m., revealed the resident was confused at times and had not asked for help this morning and staff assisted him back to his room from the table. The nurse's notes on 8/31/18 at 4:26 p.m., revealed the facility received a phone call from the primary physician. The physician reported receiving a call from the resident's wife who was concerned about the resident's increased restlessness and anxiety this morning. The nurse's notes on 9/7/18 at 2:18 a.m., revealed increased confusion and wandering without walker. The nurse's notes on 9/16/18 at 12:01 p.m., revealed staff heard the resident talking with someone in his room and when asked about it the resident stated well my sister was sitting in the chair there, she must have left. The resident was easily reoriented to situation. A faxed communication order dated 9/16/18 revealed the resident with increased confusion and hallucinations. The nurse's notes on 9/30/18 at 6:15 p.m., revealed the resident out of the building and up the grassy hill. The resident was brought back in by staff with no injuries. The resident had his walker with him and was using it. When staff told Resident #51 that it was chilly and wet outside, the resident stated not if you keep moving. The facility initiated fifteen minute checks around the clock and closed the double doors on the unit. The resident had no further attempts to go outside. A faxed communication order dated 9/30/18, revealed Resident #51 was able to get out of the facility and walk up the steep grassy hill with walker. The resident was found and brought back inside. Previous to the resident eloping from the facility the resident was looking for a ride. Fifteen minute checks started and the unit doors were closed. A faxed communication order dated 10/1/18, indicated the facility placed a wander guard. A device in which sounds an alarm if the resident was near an exit door. The nurse's notes on 10/1/18 at 1:56 p.m., revealed the placement of a wander guard due to Resident #51 wandering. The care plan updated on 10/1/18, revealed the resident experienced wandering (moves with no rational purpose, seemingly oblivious to needs or safety). The care plan directed staff to monitor for signs and symptoms of UTI when increased attempts at going out the doors were noted, redirect resident from exit doors as needed, remove the resident from other resident's rooms and unsafe situations, and the need for a wander guard. In an interview on 10/30/18 at 9:01 a.m., the administrator verified no assessments were done for residents with an elopement risk or exit seeking behaviors. In an interview on 10/30/18 at 12:06 p.m., the State Climatologist verified the closest airport to Guthrie Center was Audubon. At 6:30 p.m. on 9/30/18 the state climatologist indicated it was 48 degrees, 93% humidity, winds N NE at 7 miles per hour (mph), with visibility 4 miles with low cloud coverage with no precipitation. The State Climatologist archived the radar and it indicated on 9/30/18 at 5:30-6:00 p.m. showers went through Guthrie Center. In an interview on 10/31/18 at 9:37 a.m., Staff R, CNA/CMA stated she was in another resident's room in Unit 4 when she went to shut the blinds and saw a resident going up the hill outside the facility with no staff present. Staff R reported it to Staff H, RA/CNA/CMA. Staff R stated it was chilly outside and the ground was wet due to a recent rain shower. Staff R stated the resident had shorts on and a polo t-shirt and he had his walker. Staff R, stated the resident was exhausted and seemed short of breath. Staff R, stated the facility used wander guards and if she noticed a resident with increase wandering or exit seeking she would report it to the charge nurse and the nurses applied the wander guard on the residents. In an interview on 10/31/18 at 8:50 a.m., Staff H, RA/CNA/CMA stated she was passing pills in Unit 3 and it was shift change when Staff R reported to her that Resident #51 was heading up the hill. Staff R and Staff H ran up the hill towards the resident. Staff H reported the resident had his walker and was on the Southwest hill on the grass close to the top of the hill. When staff arrived the resident was confused and wanted to go home. Staff H verified he was a little short of breath and they continued walking with the resident to the pavement. Staff B, drove her car up to the independent living apartments where the resident was brought back to the facility. Staff H walked surveyor up the hill where the resident was found. She stated the resident had exited the front door and when her and Staff R got to the front door the resident was half way up the hill with his walker. The resident was dressed in gym shorts and a t-shirt with tennis shoes on. When Staff H and R got to the resident he was 3/4 up the hill approximately 75-100 yards from front entrance. An interview on 10/31/18 at 10:41 a.m., revealed Staff A, RN working on Unit 2 where Resident #51 resided. She stated she was giving report that evening and an CNA told her that the resident wanted to go down town. Staff A reported the resident had moments of confusion and UTI's occasionally. Staff A stated the resident had dementia and experienced confusion daily. Staff A verified there was no formal assessment for residents who were exit seeking or an elopement risk. She reported she worked here for approximately two months and had a very informal training. She stated there was no education provided for residents who would benefit from a wanderguard and the only education was on the functionality and checking to ensure the wander guard functioned. Staff A verified there was no assessment for wandering residents. Staff A stated if a resident was confused or exit seeking she would consider them a wander risk and recommend a wanderguard to the DON. In an interview on 10/30/18 at 11:03 a.m., with the Interim DON she stated nursing staff were to report a change in condition to the DON and administrator and then they discussed the need for a wanderguard. She verified there was no criteria for wanderguard placement it was a nursing judgement. The Interim DON verified there was no assessment for elopement risk/wandering/exit seeking residents. She stated changes in resident conditions should be reported daily. In an interview on 10/31/18 at 7:46 a.m., Staff S, RN stated she was unaware of criteria or an assessment for residents at risk for wandering. Staff S stated if a resident wandered towards other house holds/units she would question the need for a wanderguard. If she felt a resident needed a wanderguard she would place it on the resident at that time and report it to the on coming shift. Staff S stated this resident was disoriented all the time. In an interview on 11/5/18 at 12:29 a.m., Staff I, nurse consultant verified the admission CAA dated 7/19/18 revealed the resident at risk for wandering and would have expected that be on the resident's baseline and initial care plan. In an interview on 11/6/18 at 2:13 p.m., Staff B, RN stated she was doing narcotic count with Staff H when Staff R yelled that a resident was outside. Staff R and Staff H went out the front door and Staff B followed. Staff B realized it was Resident #51 and instructed staff to continue to walk with the resident up to the top of the hill. Staff B stated it was rainy out and the grass was wet. After Staff B instructed the staff to walk the resident to the top of the hill she went to get her car and drove the resident back to the front door. The resident was confused and looking for his wife. In an interview on 11/6/18 at 1:49 p.m., the MDS coordinator stated when she does a new admission she reviews the nursing notes and point of care notes from the CNAs to determine the appropriateness of the MDS coding. The MDS coordinator reviews nursing notes daily for new orders or any behaviors noted. She stated for Resident #51 a CNA charted he had wandered one day, so she had coded him for wandering one to three days. She stated Resident #51 had increased confusion but thought it was related to the UTI. The MDS coordinator stated when the resident was found in the court yard on 8/6/18 the team discussed the need for a wanderguard but they decided against it. She stated there was no documentation to confirm the discussion. She stated the facility had an elopement assessment two years ago and felt it was helpful to determine if a resident was at risk for elopement. 2. The quarterly MDS assessment dated [DATE] for Resident #4 indicated she had a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. The MDS indicated Resident #4 did not exhibit wandering behaviors. The MDS documented the resident was independent for transfers, walking on and off the unit and used a walker. The MDS listed the following [DIAGNOSES REDACTED]. Review of Resident #4's care plan revealed the following focus with an initiated date of 7/25/18, which indicated the resident experienced wandering (moves with no rational purpose, seemingly oblivious to needs or safety). The following interventions were initiated on 7/25/18: -Approach the resident from the front and walk in step first before redirecting. -Avoid overstimulation. (Noise, crowding, other physically aggressive residents). -Convey an attitude of acceptance toward the resident. -If resident looks for family/significant other, reassure others know where to find her. -Label resident's belongings and environment to promote recognition. -Maintain a calm environment. -Redirect resident from exit doors as needed. -Remove resident from other resident's rooms and unsafe situations. -Wandergaurd -When the resident begins to wander, provide comfort measures for basic needs such as pain, hunger, toileting, temperature (too hot/cold), etc. The following intervention was added to the care plan on 9/17/18, which directed staff to conduct every 15 minute checks of the resident's whereabouts. The care plan indicated this intervention was resolved on 10/5/18. On 10/6/18, an intervention was added which directed the facility staff to assist Resident #4 with calling family member for reassurance about placement in facility, which was usually an effective intervention. Record review of nurse's notes revealed the following notes: On 7/24/18 at 2:01 PM, a wanderguard was placed on her left ankle. On 7/24/2018 at 4:28 PM, Resident #4 was confused today ambulating into other rooms and saying she was leaving. Resident #4 was redirected and taken back to her room. The staff will continue to monitor. On 7/31/2018 at 05:35 AM, Resident #4 was awake much of this shift, wandering and redirection ineffective. Resident #4 argued with staff and was up and down in bed, frequently getting up within a few minutes. The resident was currently sitting in dining room at this time. On 7/30/2018 at 9:20 PM, The resident wandered and wanted to go home and find her son. She wants to a catch a ride with someone and staff have provided redirection. She enjoyed being out in the courtyard area with supervision. Staff have provided magazines and books to keep her involved and busy. On 8/15/2018 at 1:51 PM, Resident #4 wandered in the hallways asking if she could have a ride home and the location of the front door. Resident was easily redirected by staff and with no agitation noted with redirection. After lunch the resident went into her room and settled down in her chair. On 8/19/2018 at 10:32 PM, Resident #4 was restless after supper, wanting to leave, and concerned her family does not know her location. Staff reassured her that her family knew where she lived. Staff informed her storms were predicted for tonight and it will rain soon. The resident stated she wanted to go up the hill, if I get wet I get wet! Staff again explained that it was going to rain, that she was to stay here this evening and that her family had requested this so she was safe. Resident accepted this redirection. On 9/8/2018 at 5:16 PM, at around 3:00 PM the resident was downstairs in the ALF (assisted living facility). The ALF staff reported a visitor informed them that a resident was at the top of the hill walking. The ALF Staff hurried, intercepted and escorted the resident back in the main ALF doors and then called the nursing facility. The resident was transported by staff to the nursing facility's main door as her wanderguard bracelet was intact and not allowing elevator to work. A nursing assessment revealed no injury or ill effects beyond the ongoing chronic right ankle discomfort and resident denied any, as well as apologizing. The staff began 15 minute visual checks at 3:30 PM after resident was settled in her chair in her room. There was a large party going on in the activity room at the time with numerous visitors going in and out of the main door. On 10/24/2018 at 10:47 AM, Resident#4 was confused and wandered occasionally off of her house. She had a wanderguard and was easily redirected. She shows no signs of hallucinations or delusions, had no episodes of crying over the past week and had no verbal or physical aggression. During a staff interview on 10/31/18 at 10:05 AM, Staff P CNA (Certified Nursing Assistant) stated she heard Resident #4 was downstairs in the Assisted Living Facility (ALF). She went downstairs to assist with getting resident back upstairs. Staff P stated she was told by ALF staff that Resident #4 had walked to the highway and was heading towards Panora on Highway 44. She stated she does not remember pager alarming of Resident #4 approaching the front door. Staff P stated when someone enters the code to the Main Entrance to leave or come into the facility it cleared the alarms on the pagers. During a staff interview on 10/31/18 at 11:17 AM Staff Q Universal Worker for Assisted Living (AL) stated a family member told her they noticed a woman with a walker, almost to the stop sign on the gravel road going towards Panora. Staff Q stated she immediately ran out the door and went to see. Staff Q stated Resident #4 stated she wanted to go home. Staff Q stated it took her and the resident an half hour to walk back to the facility because the resident was exhausted. Staff Q stated she did not visualize any injuries other than Resident #4 complaining of ankle pain. Staff Q stated she did notice grass in the wheels of the resident's walker. During a staff interview on 10/31/18 at 1:00 PM Staff F CNA (Certified Nursing Assistant) stated she was called down to the Assisted Living Facility (ALF) because Resident #4 was found by a visitor outside. Staff F stated the resident was found on the gravel road right out of the parking lot from the ALF. When asked if the doors alarmed the day she walked out, she stated there were a lot of visitors going in and out of the building that day. So when someone puts in the code to exit/come in it opens the door and clears the code that notifies staff of a wanderguard being at the Main Entrance. Staff F stated the pagers will say loitering with a resident's name, when a resident with a wanderguard approaches the Main Entrance. During a staff interview on 10/31/18 at 2:22 PM Staff O RN (Registered Nurse) stated there have been glitches in the pagers when the front door was alarmed. Staff O stated that when the Main Entrance door was opened they get a page that states open door. When a resident with a wanderguard approaches the Main Entrance door, the pager will read loitering then the resident's name. With the glitches sometimes these pages did not come on the pagers. During an observation on 10/31/18 at 11:49 AM revealed the route Resident #4 took to leave the building was approximately 0.30 miles. Resident walked out the Main Entrance of the facility, went to the right and walked North around the building on the sidewalk. After the sidewalk ends, there was a grass lawn that leads to where the dumpsters were located. There was an entryway that faces East the leads to a gravel road where she had headed North on, that leads to Highway 44 that runs West and East. The road was very gravely with a drop off on both sides of the road. The speed limit on Highway 44, where the resident was found was 45 MPH (Miles Per Hour). 3. The quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS score of 14, indicating no cognitive impairment. The MDS documented Resident #31 as exhibiting wandering behavior 4 to 6 days but less than daily. The MDS indicated Resident #31 required extensive assistance of two staff for transfers and was independent with set up help for locomotion on and off the unit. The MDS indicated Resident #31 used a wheelchair. The MDS listed the following [DIAGNOSES REDACTED]. Review of Resident #31's care plan with an initiated date of 6/6/18 and revision date of 6/12/18 revealed the resident experienced wandering related to dementia with behaviors, mood disorder, depression, persecuted false beliefs, and delusions. The following interventions were initiated on 6/12/18: -Avoid overstimulation. (Noise, crowding, other physically aggressive residents). -Convey an attitude of acceptance toward the resident. -Develop a pathway for resident to follow. Keep pathway free from obstacles. -If resident looked for family/significant other, reassure that others know where to find her. -Label resident's belongings and environment to promote recognition. -Maintain a calm environment and approach to the resident. -Monitor for s/s of UTI when increased attempts at going out the door(s) were noted. -Redirect resident from exit doors as needed -Remove resident from other resident's rooms and unsafe situations. -Wandergaurd. -When the resident begins to wander, provide comfort measures for basic needs such as pain, hunger, toileting, temperature (too hot/cold). The following intervention of 15 minute checks was added to the care plan on 9/17/18 and resolved on 10/5/18. On 9/25/18, the care plan was updated to with the interventions to call son or daughter-in-law when restless and to redirect with household tasks such as folding wash rags/towels. The nurse's notes revealed the following: On 4/28/2018 at 10:20 PM, the resident wandered the halls in the wheelchair asking how to get to up the hill. On 5/7/2018 at 6:40 PM, the resident wheeled herself up to the front door and was punching key pad stating she needed to get out to go home. She was easily redirected back to household. Her nurse and aide was informed. On 9/11/2018 at 9:39 PM, the resident was at the front door when a peer's daughter was leaving. The resident went out the door the same time as the visitor. The visitor maintained visual contact of the resident until staff were alerted and escorted her back into the building. This occurred in between the ongoing 15 minute visual checks. Resident then again made her way back to the front door very shortly after and was returned to her household by staff. During a staff interview on 10/31/18 at 2:20 PM Staff O stated Resident #31 had a wanderguard on her wheelchair. She stated resident was found outside in the parking lot by a peer's family member. She stated that family member stayed with the resident until staff came outside. Staff O stated she did not see the resident leave but was within sight of the peer's family member. Staff O could not remember who the family member was that was with Resident #31. During an observation on 10/30/18 at 3:50 PM, the surveyor attempted to exit the Main Entrance door. No alarms activated and the door did not open. The door release was pushed and held for 15 seconds and the door did not open. The door was again tested for 45 seconds but did not release and no staff came to the Main Entrance. The door signage read the door would open after 15 seconds. At that time Staff C Maintenance Manager came to the front entrance with a Wanderguard. When asked why the door would not open after holding the release for 15 seconds, he stated when Phillips (a software system company) came to the facility on [DATE] they trumped the 15 second egress release on the door. He stated they were supposed to be coming back out to fix and add a Wanderguard key pad. The Administrator joined in and stated when the fire alarm was activated the front door will unlock, otherwise you need a code to unlock the door. At this time a Wanderguard was brought close to the door, with no alarms sounding, and the door remained locked. The Administrator stated when a resident with a Wanderguard, was in close proximity to the front door staff with get a page indicating someone with a Wanderguard was at the main entrance. Staff will then come up front and clear the alarm with a code. The Administrator stated the code used to be the same code used to enter and exit the building. So if a resident with a Wanderguard tried to get out and someone entered a code to leave/come in, the pagers would clear of any resident that had a Wanderguard who was at the main entrance. In an interview on 10/30/18 at 10:15 a.m., the Administrator stated on 9/8/18, when Resident #4 eloped from the facility a technician from Stanley Health Care came to the facility on [DATE] to troubleshoot the door alarm and function. At that time, the technician noticed a Phillips Lifeline which was separate system/ hardware the facility didn't know about. The Administrator called Phillips Lifeline and they remoted into the facility and changed the door function to be unlocked during the day hours approximately from 7 AM to 7 PM. but when a resident with a Wanderguard came within field then the door would go into lock down with no one in and no one out. Staff would need to come and put the code in the key pad to unlock it. The door was essentially unlocked but would alarm if propped open for an extended period of time. The Administrator verified on the 9/30/18, the facility had no alarm in place. On 10/1/18, the Maintenance Director called Phillips Lifeline and explained the need for an alarm and to set the alarms back to what was present on 9/21/18. A technician from Phillips Lifeline came back to the facility on [DATE] and installed a new key pad with two key codes. One key code was for people coming in and out of door who must enter the code and another key code was for residents with Wanderguard bracelets. The residents with Wanderguard bracelets would alarm and send message to staff pagers and staff must come to door to physically enter a code to stop the alert. At that time they changed the setting so as soon as the door shut it locked and there was no delay. 4. Observation on 10/31/18 at 2:30 PM revealed fire exit doors on all four households led to an enclosed courtyard with one paddle lock in place at the top of the gated doors. During an interview on 10/31/18 at 3:30 PM, when asked who had keys to the padlocks for the courtyard gaits, the Administrator stated the charge nurse and Activity Director had keys to the padlocks. While looking for a nurse to unlock the padlocks, Staff U Housekeeper stated she had a key and would assist us. After about four minutes locating the right key, Staff I unlocked the padlock. In additional interviews with multiple staff, there was no clear system as to who had keys to the paddle locks and who completed safety checks to the paddle locks. Staff were unsure what to do if there was a fire and how the paddle locks would be unlocked if residents were evacuated to the courtyard. The facility abated the immediate jeopardy on 11/2/18. On 11/1/18, the alarm company fixed the alarm system and the state fire marshal verified the alarm system was functioning properly. All staff were issued universal keys to the courtyard paddle locks and received training. The facility added monthly checks for the paddle locks to ensure appropriate function. The facility also educated staff on use of walkie talkies when checking the alarm doors to indicate the door was cleared before resetting pagers. 5. The quarterly MDS dated [DATE] for Resident #8 indicated he had a BIMS score of 13 indicating no cognitive impairment. The MDS indicated he required extensive assistance of 2 staff for bed mobility and toilet use. The MDS indicated Resident #8 had an indwelling catheter and was frequently incontinent of bowel. Review of Resident #8's care plan with a revision date of 11/29/17 revealed he required an indwelling urinary catheter due to his [DIAGNOSES REDACTED]. Keep catheter system a closed system as much as possible. The care plan directed staff to provide catheter care twice a day and as needed, to use a catheter strap and ensure there was enough slack left in the catheter between the meatus and the strap. During an observation on 10/31/18 at 12:30 PM Staff L and Staff M assisted Resident #8 with catheter cares. During cares staff members left Resident #8's bed unlocked and the bed moved while assisting the resident to his side. During an staff interview on 11/6/18 at 1:30 PM the ADON stated staff should keep resident beds and wheelchairs locked during transfers and assisting to new positions. The Administrator stated it was just good practice to lock the beds and wheelchairs while working with residents. 6. The Quarterly MDS dated [DATE], identified [DIAGNOSES REDACTED]. According to the MDS the resident scored a fourteen out of fifteen on the BIMS indicating intact cognition. The MDS indicated the resident required extensive assistance of one staff for bed mobility, personal hygiene, and toileting, The resident was totally dependent of two staff for transfers. According to the MDS the resident frequently incontinent of bowel and bladder. The care plan dated 7/23/18, revealed the resident at risk for falling related to [MEDICAL CONDITION], dementia, impaired cognition, muscle weakness, assist with mobility, incontinence, and depression. The care plan indicated the resident was non ambulatory, transferred with a full body lift with assist of 2, and primary form of locomotion was the wheelchair. Observation on 10/31/18 at 11:22 a.m., revealed Staff J CNA, and Staff K CNA provided incontinence care and raised the resident up out of bed with a full body lift while placing the wheel chair under the resident. Staff failed to lock the brakes on the wheel chair and the resident was lowered down into the chair. 7. The significant change MDS (Minimum Data Set) assessment dated [DATE] for Resident #44 had a BIMS score of 2 indicating severe cognitive impairment. Review of the care plan revealed he required extensive assistance of 1 staff for transfers, walk in room, and locomotion off the unit. Review of Resident #44's care plan with a revision date o (TRUNCATED)

Based on record review and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent an accident for one (1) of six (6) residents at risk for falls. Resident #1 fell on [DATE] and sustained a [MEDICAL CONDITION] and brain hemorrhage when she self-transferred. Staff interviews revealed prior to the fall, staff observed the resident self-transferring frequently and Resident #1 did not reliably use the call light. Record review revealed the resident self-transferred often and lacked the cognitive skills to make decisions about her safety. The facility failed to revise the resident's plan of care based on her needs or increase supervision/monitoring. The facility census was fifty-nine (59) residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] noted heart failure, high blood pressure, [MEDICAL CONDITION], anxiety disorder, depression, [MEDICAL CONDITION] (abnormal heart rhythm), [MEDICAL CONDITION] (slow heart rate), [MEDICATION NAME] degeneration, left eye [MEDICAL CONDITION], low vision right eye, arthritis and muscle weakness as [DIAGNOSES REDACTED]. The MDS also noted Resident #1 required a walker and extensive assistance of one for most ADLs (activities of daily living). The MDS documented Resident #1 had inattention and a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. The Care Plan revision dated 5/11/17 noted that Resident #1 required 24 hour care related to Alzheimer's and [MEDICAL CONDITION] and had a BIMS score of 4 indicating severe cognitive impairment and inattention. The Care Plan noted staff should cue, reorient and supervise and assist as needed. A 5/18/17 revision documented Resident #1's risk for falling related to unsteadiness, progression of [DIAGNOSES REDACTED]. The resident used a walker and for long distance staff were to follow her with a wheelchair. A Confidential Incident Report dated 3/9/17 at 11:25 a.m. noted staff observed Resident #1 swayed and her knees buckled as they assisted the resident to walk with a walker. Staff helped stabilize the resident to avoid a fall. An Progress Note/MDS note dated 5/5/17 at 3:19 p.m. revealed Resident #1 should have assistance of one with a gait belt due to safety issues. The nurse documented they intercept, remind and encourage the resident, but she either forgets or will not comply. An Progress Note/MDS note dated 5/7/17 at 3:20 p.m. identified Resident #1 toileted independently without using the call light, despite needing assistance of one staff. A Confidential Incident Report dated 5/17/17 at 8:50 a.m. identified staff assisted Resident #1 to the floor as a result of weakened lower extremities. A Progress Note/Health Status Note date 5/17/17 at 11:14 a.m. identified Resident #1 had been lowered to the floor because her lower extremities weakened while ambulating to the bathroom. According to the documentation, orthostatic [MEDICAL CONDITION] (significant drop in blood pressure during position change) also factored into the incident. A Progress Note/Restorative Program Note dated 5/19/17 at 2:16 p.m. revealed Resident #1 needed frequent reminder to call and wait for assistance due to non-compliance with ambulation. A Progress Note/Behavior Note dated 6/12/17 at 10:16 a.m. indicated Resident #1 continually attempted to self-transfer and said I don't care; I'm not going to fall. I can walk by myself. A Progress Note/Restorative Program Note dated 6/28/17 at 8:49 a.m. identified although Resident #1 should be walking and transferring with assist of one staff, she will not comply with calling and waiting for help at times. A Progress Note/Health Status Note dated 7/11/17 at 2:33 p.m. revealed staff provided assistance when they realized Resident #1 self-transferred to the bathroom. The nurse also documented they provided assistance to Resident #1 when she witnessed her up walking in the halls. According to the nurse, education had been provided despite the resident having short and long term memory deficit. A Progress Note/Health Status Note dated 7/21/17 at 12:45 p.m. noted Resident #1 used a walker 3 times to walk independently to the bathroom. A Progress Note/Health Status Note dated 7/28/17 at 11:40 a.m. noted a visitor notified staff Resident #1 had fallen. The nurse documented she found Resident #1 lying on the hallway floor right outside of her room. The nurse also documented Resident #1 had initially been non responsive, but slowly began to respond while being assessed. According to the nurse, Resident #1 had a history of [REDACTED].#1's head and she flinched and complained of pain to the left hip/pelvic area. A Progress Note/Health Status Note dated 7/28/17 at 3:05 p.m. revealed Resident #1 had been hospitalized for [REDACTED]. The Radiology Report dated 7/28/17 for the left hip identified an X-ray revealed a left femoral (thigh) neck fracture. The Radiology Report dated 7/28/17 of a computed tomography scan (CT) revealed Resident # 1 had a small area of increased density that appeared new from the previous exam. The report documented these may represent small areas of cortical hemorrhage (bleeding in the brain). The hospital History and Physical Note dated 7/28/17 revealed Resident #1 arrived at the emergency room with complaints of left hip pain and some swelling on the left side of her head. Subsequent work up revealed a left [MEDICAL CONDITION] and small areas of increased density consistent with small areas of cortical hemorrhage. A post op (operative) note dated 8/1/17 noted a preop and postop [DIAGNOSES REDACTED]. The documentation noted Resident #1 fell and injured her hip at the nursing home 5 days ago. According to the document, they delayed surgery until today secondary to the resident being on a blood thinner at the time of the fall, which resulted in an intracranial bleed. The hemorrhage started small but became moderately more extensive over the next 48 hours. The most recent CT showed a slight improvement, which deemed the resident medically stable for surgery, which the resident underwent [REDACTED]. A PT (Physical Therapy) Note dated 8/3/17 noted Resident #1 had very little participation with therapy. A Speech Therapy Note dated 8/3/17 revealed Resident #1 presented with severe expressive and receptive communication deficits secondary to a recent fall. A PT Note dated 8/4/17 noted very little participation with therapy and poor rehabilitation potential at this date. The Progress Note/Admission Summary dated 8/7/17 revealed Resident #1 returned to the facility under Hospice Care. A Health Status Note dated 8/8/17 noted the resident as being unaware of surroundings. A Progress Note/Health Status Note dated 8/8/17 revealed a Therapy Change Form had been received with a verbal report that Resident #1 would not respond or participate with evaluation for safe transfers. The resident should be checked and changed for toileting through the night due to mental status/alertness. A Progress Note/Health Status Note dated 8/9/17 documented Therapy Communication as stand, pivot transfer to the right with assistance of 2 should be used for Resident #1. A Progress Note/Health Status Note dated 8/9/17 revealed while attempting to transfer Resident #1, her arms were flaccid, she did not bear weight or follow any directions. The nurse also noted they transferred the resident back to bed for safety because she would not bend her legs or her waist; which caused her to only sit on the edge of the seat. A Progress Note/Health Status Note dated 8/11/17 revealed while lying in bed the resident would not open her eyes or respond to communication or tactile touch. The nurse also noted the resident's color as pale and demeanor as lethargic. A Progress Note/Health Status Note dated 8/13/17 identified Resident #1's oxygen level as low with labored and moist respirations. The nurse charted the resident had 15 second periods of apnea (not breathing) approximately every 25 seconds. A Progress Note/Psychosocial Note dated 8/14/17 describe a significant change assessment for Resident #1 who could not answer interview questions, therefore having a severe cognitive impairment. A Progress Note/Health Status Note dated 8/14/17 described Resident #1 had been non responsive. The nurse reported the resident would open her eyes with a blank stare. A Progress Note/Health Status note dated 8/17/17 rendered Resident #1 had no pulse or respirations at 6:30 p.m. An interview on 1/23/18 at 8:30 a.m. with Staff D, CNA revealed that she knew Resident #1 had dizzy spells. Staff D said she always gives residents a minute to adjust before they stand. When asked how frequently she checked on Resident #1, Staff D said she constantly looked into every residents' room whenever she walked by. A subsequent interview on 1/29/18 at 1:05 p.m. with Staff D revealed when Resident #1 needed more help, she tried to assist her. When asked, Staff D said she did not know whether to consider Resident #1 as a huge fall risk. According to Staff D, the facility said to help the resident with dressing and toileting. Staff D said the facility told her Resident #1 had dizzy spells, but they did not tell her how often the resident should be monitored or give any specific instructions related to her dizziness. Staff D said she saw Resident #1 self-transferring at times and reminded her to use her call light from time to time. Staff D said she told the charge nurse, but she could not remember who she told. An interview on 1/29/18 at 11:15 a.m. Staff A, CNA revealed she remembered Resident #1 being at risk for falls because she would get up and wander on her own. Staff A said the resident would not use her call light, she would just get up (unassisted) and go find a staff member. The CNA said she typically checked on Resident #1 every 2 hours to see if she needed to use the rest room, but sometimes she had already taken herself to the bathroom. Staff A said she reported to her coworkers at shift change the Resident #1 had been self-transferring. Staff A said she did not know if the information ever reached the DON (Director of Nursing), but she never personally told the DON. An interview on 1/29/18 at 12:05 p.m. with Staff B, CNA revealed she considered Resident #1 at risk for falling because she got up on her own all the time. Staff B stated Resident #1 got dizzy quite often and had trouble with her blood pressure. Staff B said she remembered seeing Resident #1 getting up alone as she walked by her room, and seeing her standing in the door of her room alone from a distance. Staff B said she seemed to remember Resident #1 fell on e time prior to the time she fell and fractured her hip. Staff B said she never received instructions to monitor Resident #1 or to check on her more often. The CNA said she just knew she should intervene if she saw the resident getting up alone. Staff B said she told multiple people at shift change and charge nurses when she saw the resident self-transferring. According to Staff B, Resident #1 self-transferred almost every day, therefore she told many different people on many different days. An interview on 1/29/18 at 1:13 p.m. with Staff C, CNA revealed she recalled how Resident #1 self-transferred frequently and did not use her call light. The CNA said she did not know if the facility considered Resident #1 as a fall risk, but she remembered the resident had dizzy spells. Staff C said the facility said to check on Resident #1 more often than other residents because she liked to self-transfer. Staff C said she told the charge nurse whenever she caught her self-transferring. An interview on 1/29/18 at 1:30 p.m. with the ADON (assistant DON) revealed she saw Resident #1 lying on the floor in the hallway just outside her door when she arrived. The ADON said a visitor informed them of the incident. The ADON said Resident #1 could not move one of her lower extremities. The ADON said although the resident moaned in pain, she had not talked with them for a few minutes, which was out of the ordinary. The ADON said Resident #1 ended up being hospitalized for [REDACTED].#1 had been assessed as a fall risk because of her history of self-transferring. According to the ADON, staff had been informed to be more aware of her because of her fall risk status. The ADON recalled a previous incident when Resident #1 got dizzy and fell against the wall as staff lowered her to the floor. The ADON said she had something wrong with her heart. The ADON said Resident #1 self-transferred on occasion, at least once a day. The ADON stated because of being so forgetful, Resident #1 would say oh, yeah whenever they reminded her to use the call light and wait for help. The ADON said she worked as the restorative nurse and scheduler at the time of Resident #1's injury. She said the only time anyone reported to her was if the CNAs reported to their charge nurse(s). An interview on 1/29/18 at 2:20 p.m. with the prior DON revealed she worked as the DON from October 2016 until August 2017. The prior DON said she considered Resident #1 at risk for falls. The prior DON said Resident #1 had vision problems, and a heart condition that caused her blood pressure to drop, and she frequently self-transferred. The prior DON reported staff informed her they saw Resident #1 up and about in her room. She did not know if the resident used the call light. The prior DON said Care Plan's should have reflected the resident's needs. An interview on 1/29/18 at 3:00 p.m. with Staff E, LPN, revealed she worked as the day time charge nurse for about the last 7 years. Staff E said she remembered Resident #1 being non-compliant with call lights and or waiting for assistance. According to the LPN, Resident #1 just did not have the recall (ability) to remember to use the call light or wait for (staff) help. Staff E also remembered the resident frequently being disoriented to her surroundings. The LPN said Resident #1 complained of dizziness. Staff E said she recalled they implemented checking the resident's blood pressure as a fall intervention. Staff E said she remembered seeing Resident #1 self-transferring and other staff members reported the resident weekly non-compliance. Staff E said Resident #1 fell and required hospitalization for a broken hip. According to Staff E, Resident #1 had been readmitted under Hospice care because her family felt she failed to progress and was at her end. Staff E also said the resident's cognitive status changed significantly after her return (from the hospital). An interview on 1/30/18 at 9:30 a.m. with the current DON revealed they do not use numeric time values on Care Plans to specify the frequency in which a resident should be checked. According to the DON, if they did not follow the specified times, they would be out of compliance. The DON said she assumed the role as the brand new MDS/Care Plan person last April. The DON said they follow (care plan) templates, and it would not be customized unless a new intervention needed to be added. She said they were switching the format of the Care Plans about the time she started. She said all the Care Plans needed to be changed. The DON said many of the Care Plans were not current when she took over. When asked, the DON said she should have made them current, but she did the best she could under the circumstances. She said she also faced the lack of communication as a barrier that interfered with effectively developing Care Plans. The DON said staff did not always keep her informed about how frequently Resident #1 had been attempting to self-transfer. The DON said falls needed to reflect each resident's specific needs related to their circumstances. The DON expressed frustration because of being kept in the dark. When asked how to improve communication, the DON said that's a good question. An interview on 1/31/18 at 10:45 a.m. with Resident #1's physician revealed the fall contributed to Resident #1's demise, but it did not cause her death. The physician said the death certificate reflected Alzheimer's as the cause of her death.

Based on record review, resident and staff interviews, the facility failed to plan for two (2) of four (4) residents to receive adequate supervision during transfers (Resident #1 and Resident #3); and failed to provide assistance to and from the bathroom for Resident #1. Resident #1's care plan directed staff provide assistance with transfers for his/her safety. Record review and staff interviews revealed Resident #1 noncompliant with transfers and staff interviews revealed inconsistency in how much assistances staff provided to Resident #1 during transfers to the bathroom. On 4/29/13, Resident #1 fell and sustained fractures to his/her hip and shoulder when he/she transferred to the bathroom. Resident #3's care plan failed to direct staff to follow hip precautions and failed to inform staff if any assistance needed for transfers. The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool with a reference date of 4/28/13 identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15. A BIMS score of 9 revealed the resident with moderate cognitive impairments. The MDS revealed the resident required one person physical assistance for bed mobility, transfers and using the rest room. The test for balance during transition and walking determined Resident #1 not steady, only able to stabilize his/her balance with staff assistance when moving from a seated to standing position, when moving on and off the toilet and during surface to surface transfers. The balance test revealed the resident had not been observed for walking and or turning around during this time. The same assessment revealed pertinent [DIAGNOSES REDACTED]. The assessment revealed the resident had one fall since admission. Review of the Resident's Care Plans dated 8/8/12 revealed the resident at risk for falling. The same care plan on the focus sheet dated 8/22/12 through 4/29/13 revealed the resident to be reminded to wait for assistance with transfers, ambulation and will have assistance of 1-2 for transfers and ambulation using front wheel walker. The same care plan revealed at risk for gait disturbance related to anti-anxiety medications. The same care plan with entry on 3/21/13 revealed the resident will have 1-2 staff assistance for transfers to maintain his/her safety. Review of the Physical Therapy Evaluation & Plan of Treatment dated 4/24/13 revealed that under Functional Assessment documented transfers, minimal assist required for Resident #1. The same document revealed the resident at risk for falls, gait impairment, mobility impairment and oxygen dependent. Record review of the Occupational Therapy (OT) Evaluation & Plan of Treatment dated 4/25/13 revealed the resident demonstrated decreased strength, balance and activity tolerance, care giver assist for toileting, mobility and at risk of falling. The document further revealed the resident demonstrated loss of balance x 2 for clothing management due to balance and dizziness and required limited assistance for self-toileting. The OT treatment encounter dated 4/2/6/13 documented the resident had been able to stand 1 (min) minute X (times) two (2) with the task and had to sit down due to fatigue. The OT worked with wheelchair mobility in his/her room with his/her O2 tubing. The OT noted the resident required minimal assist to get turned around due to short O2 tubing. Once the resident had been in his/her room the therapist put his/her O2 concentrator from his/her portable tank. The therapist noted the resident demonstrated CGA (contact guard assistance) had been used for bed mobility, self-toileting and transfers. The reported noted the resident had been dizzy. Review of the Incident Report dated 4/29/13 at 1:15 a.m. revealed Resident #1 found sitting on the bathroom floor next to the toilet. The resident's pants down and right leg underneath the left leg. The resident's oxygen tubing had been lying on floor in front of him/her. The resident's wheelchair at the entryway in the bathroom doorway. The resident complained of right shoulder and hip pain. Swelling and decreased mobility noted to the right leg and right leg appears paler and colder than the left. The resident complaining of increased pain with movement, no redness or obvious injury to shoulder. The facility transferred to the county hospital for evaluation. The intervention added to the care plan after the fall was a bed alarm. Review of the Hospital Consult dated 4/29/13 revealed right comminuted intertrochanteric hip fracture and right comminuted humeral head and neck fracture of shoulder following a fall early morning of 4/29/13. Review of the Falls Risk Post-Fall assessment dated [DATE] at 0115 revealed the resident found on the floor. The post fall assessment identified at 10:45 p.m., the resident had been resting in bed. At 1:10 a.m., the aide informed the nurse resident was on the bathroom floor. The report included a history of falls on 10/25/12, 9/24/12, 9/1/12, 8/20/12, 8/18/12. The same report revealed the resident was not able to toilet themselves and required assistance of one staff for toileting. The form identified the following interventions currently being used: slip proof footwear, call light in reach and assistance with transfers. The facility summary of the incident signed 5/7/13 revealed the resident's assessment completed on 4/24/13 showed the resident had the ability to balance stabilized without physical assistance and mobility with devices. (See MDS completed 4/28/13.) During an interview on 7/2/13 at 3:40 AM, Staff H, CNA/CMA (certified nurse aide/certified medication aide) stated she had worked at the facility for about 4 months. She stated she remembered Resident #1 and had taken care of him/her. She stated he/she had been pretty independent and non-compliant, would take self to the bathroom when not supposed to. She stated he/she needed assistance on one staff and they were to remind the resident to ask for assistance before getting up. She stated the resident would tell her, he/she didn't remember to. She stated the resident did know how to use the call light because when he/she needed more oxygen, he/she would use the call light for that. She stated the resident would propel self to the toilet and take 3 steps from he/her wheelchair to toilet self, from the door, it would be 10-15 steps to the toilet. She stated he/she was always around the halls, cheering everyone up. She stated she had witnessed he/her get up on own and take portable oxygen tank (O2) to the bathroom on own. She stated at times the resident would be confused and he/she would repeat things. During interview on 7/2/13 at 4:20 PM, Staff I, CNA stated she had worked there for almost a year and half. She stated she would assist Resident #1 to the bathroom with the gait belt on, she would hold onto the gait belt and the resident would ambulate into the restroom, toilet self and ambulate back. She stated she would find the resident up several times, going from his/her recliner to the bed. She would remind the resident to ask for help and the resident would just say, forgot. She stated when the resident would be in his/her recliner, they would transfer him/her using the gait belt, leave the oxygen (O2) in the recliner or on the wheelchair. She further stated she would find the resident up several times in the room but only once in the hall. She stated the resident knew how to use the call light because once he/she had gone to bed, he/she would use the call light to request help. A written statement by Staff N dated 5/1/1 documented the following: Many times when she would walk into Resident #1's room for breathing treatment she noted the resident standing at the closet getting clothes or already in the bathroom standing at the sink washing up and brushing teeth for the day ...Staff N noted the wheelchair would be in locked position and she would re-educate the resident on the importance of using the call light and waiting for assistance. During interview on 7/8/13 at 1:30 PM, Staff N, LPN stated that during the night the resident always had an alarm on but during the daytime, the resident would be up in the bathroom by him/her(self). She stated Resident #1 had been one of the first resident's she would start her day with because she had a breathing treatment to do in that room. She further stated she had not been certain if the resident had ever been made independent but was always up in his/her room. During interview on 7/2/13 at 4:05 PM, Staff C, CNA, stated she would keep an eye on Resident #1, they needed to know where he/she was, the resident liked to scoop the loop around the household. She stated the resident would use the call light for things like the TV remote, blinds, cell phone and to find his/her socks. Staff C reported the resident knew how to use the call light. She stated the resident would leave the oxygen tubing on beside them when in their recliner or wheelchair. She stated she would leave the resident on the toilet and supervise from the room while the bathroom door was open by a crack left in the door. She stated she felt the resident had been safe because the wheelchair would be locked in front on him/her when sitting on the toilet. She stated the resident did most of the mobility to the restroom, lock his/her brakes then transfer self to the toilet and does just fine, just needed supervision. During interview on 7/2/13 at 4:40 PM, Staff D, CNA stated she had worked at the facility for over [AGE] years. She stated she had known the resident for years. She stated when he/she lived in house 1, he/she had been independent and preparing to return home. He then moved to house 2 and thought independent there as well. She stated she did not care for the resident when he/she moved. She always worked house 1. She stated he/she would take off the oxygen during her visits. The resident moved to house 2 because he/she could see the golfers outside their windows since had a big interest in golf. She stated when she needs to know how to care for a resident, they just need to refer to the communication board. During interview on 7/8/13 at 2:15 PM, Staff F, CNA stated Resident #1 had been very independent when he/she lived in house 1 then when moved to house 2. Staff F reported he/she continued to be independent in his/her room. She stated the resident would use the call light when needing anything so she knew he/she could use it to get help. During interview on 7/8/13 at 3:30 PM, Staff P, RN stated she had been in Resident #1's room about 30-40 minutes prior to his/her fall. After the fall and she entered the room, the resident found on the floor, oxygen tubing at his/her side, and not tangled around anything. She stated after their assessment and receiving orders, the resident had been sent to the emergency room . The resident had been alert and talking the whole time. She stated even though she had just been working in the facility for 3-4 shifts, she knew the resident required assistance of one for transfers and ambulation. She stated she just referred to the communication board located inside the resident's closet door. She stated the resident had always used the call light for assistance the prior nights she had worked. During interview on 7/8/13 at 3:10 PM, the MDS Coordinator stated Resident #1 had been hospitalized twice in April 2013 and his/her condition overall weaker. They received an order for [REDACTED]. She stated he/she fell as a result of the weakness. She stated it's their standard that when a resident returns from the hospital, that they are all considered a one assist until the therapy department can complete their evaluation and communicate it to the nursing staff. She further stated the staff should know if they read the care plans and the communication book. During interview on 5/22/13 at 4:30 PM, the Administrator stated they conduct a daily meeting on business days and review any new falls at each of these meetings. They review what happened and what might work to intervene. She stated all disciplines are there and can make suggestions that might work. They then will update the care plan if they identify new interventions or remove any, otherwise nothing more occurs. She then stated the nurses can add interventions but don't always because they review all falls, with the department head staff at their daily meeting, regularly. 2. The MDS dated [DATE] for Resident #3 revealed a BIMS of 15 which represents cognitively intact. The MDS also revealed the resident required limited assistance of one staff for transfers, bed mobility and using the restroom. The same MDS revealed the resident had no history of falling. Record review of the Physician Transfer Order Report, dated and signed by physician on May 14, 2013, revealed the following pertinent diagnoses; obtundation, venous insufficiency, status [REDACTED].\dislocation precautions for left hip. Precautions include; flexion restriction, no flexion greater than 90 degrees. No hip internal rotation. No hip adduction beyond neutral, no crossing of legs. Otherwise can move hip as tolerated as long as following precautions. The same orders revealed weight bearing status to be touch bearing to equal 0%. Record review of the Resident's Care Plan dated 3/14/13 with most recent entry on 4/22/13 failed to include hip precautions. Review of the initial care plan dated 5/15/13 following hospitalization failed to direct staff to follow hip precautions and failed to inform staff if any assistance needed for transfers. During observation on 5/21/13 at 2:55 PM, Resident #3 had his/her left knee in front of right knee and left foot resting on surface of bed. The hip adduction noted greater than neutral since legs are crossed and foot on the bed. A pillow positioned to the back of the resident providing no support for the hip. During observation on 5/22/13 at 3:27 PM, Staff E, CNA (certified nursing assistant) placed the wheelchair at the resident ' s strong side (right), Staff D, also a CNA placed a gait belt on the resident and both the staff assisted the resident up off of the bed and into his/her wheelchair. Staff E, lifted from under the resident's arm instead of the standard of using the gait belt to lift from. During interview following cares on 5/22/13 at 3:27 PM, Staff E stated she lifted under the resident's arm when she was supposed to use the gait belt for the lift. The DON observing, nodded her head forward, implying she agreed and stated to both CNA's that's right. Record review of Policy and Procedure for Assisted Transfers dated 4/1/08 revealed Stand Pivot transfer with [DIAGNOSES REDACTED] (weakness on one side) resident and staff directed to position the wheelchair close to the bed at a slight angle so that the resident will be moving toward the unaffected side in order to utilize strength of the unaffected side, To instruct the resident to reach for the opposite arm rest and pivot on the unaffected leg while maintaining hold onto the belt and moving with the resident. To avoid excessive hip flexion and adduction to prevent dislocation of prosthesis and to transfer the resident per the resident care plan. During interview on 5/21/13 at 2:55 PM, Resident #3 stated he/she had just had a new hip put in. The resident stated he/she was not aware of any precautions to follow. During interview on 5/22/13 at 2:00 PM, the DON stated she spoke to the ADON and they both spoke to the CNA's about how to transfer appropriately with a resident weak or non-weight bearing on one side, the strong side closest to the place transferring to. She also stated and revealed a posting she placed in the resident's room as a reminder to staff. Review of a posting in Resident #3's room documented the following: Please transfer the resident towards the right side for all transfers, remember to place a pillow between knees when in bed and remind the resident not to bend over 90 degrees and not cross his/her legs. During interview on 5/24/13 at 10:20 AM, Staff B, LPN stated the nurses are responsible for updating the care plans when there are any changes in a resident. She stated they are expected to document on the resident's care plan the communication book and inform Staff C when there are changes. During interview on 5/24/13 at 11:35 AM, the MDS Coordinator stated when she is doing an evaluation, she will review the old care plan, carry what's current and transfer it to the new care plan. She stated the nurses are responsible for keeping the care plan's current for any changes that had occurred. She later stated she would get the hip precautions added to the care plan.

Based on observation, record review and family and staff interviews, the facility failed to provide adequate supervision to ensure against hazards and failed to plan for and direct the nursing care services so the residents ' needs are met for 2 of 5 residents reviewed (Resident #1 and Resident #3). The facility reported a census of 64 residents. Resident #1 fell on [DATE]. A staff member left the resident seated on the toilet and went on break time. The resident rose from the toilet and fell . The resident experienced no apparent injury. Resident #1 fell again on 6/30/2011. The resident had a fractured right hip fracture as a result of the fall. Based on interviews with staff members, it was determined the alarm box was attached to a removable cover on the chair with a safety pin so when the resident rose from the chair, the alarm did not activate to alert staff the resident needed attention. The plan of care did not direct staff how to anchor the alarm. Observation revealed clips were used to anchor alarm boxes, however, the clips did not secure the box and failed to sound to alert staff the resident would be rising from the chair. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 4/23/11 assessed Resident #1 with long and short term memory impairment and moderately impaired decision making skills. The resident had the following indicators of delirium: inattention disorganized thinking and psychomotor retardation. The resident required extensive staff assistance with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. A "balance during transitions and walking" assessment identified the resident as unsteady and only able to stabilize with human assistance when moving from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet and surface to surface transfers. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The resident had [DIAGNOSES REDACTED]. The MDS did not identify falls since the prior assessment. A fall risk assessment dated [DATE] identified the resident with a score of 25. A score of 10 or above represented the resident at a high risk for falls. A care plan, dated 4/28/11, identified the resident with a problem of risk for falls related to previous falls and Parkinson's disease diagnosis. The care plan contained an intervention dated 3/11/11 which identified the resident used an alarm, pinned to his/her clothing. The care plan did not identify how staff should anchor the alarm box to the recliner chair. The Nurses Notes dated 6/21/11 at 1:41 p.m. indicated the resident fell in the bathroom. The resident stated had hit back of the head. The resident self transferred from the toilet and fell against the bathroom cupboard hitting head on the cupboard. The incident occurred at 10:30 a.m. and staff did not observe the injury. During an interview on 7/18/11 at 10:50 a.m., the resident's roommate Resident # 4 stated he/she heard the resident holler after the 6/21/11 fall and stated Resident #1 told him/her had slipped off the toilet. Resident #4 stated he/she has come in the room before and seen the resident start to stand up and Resident #4 would get the nurse. Resident #4 stated the resident would "always get up and the alarm wouldn't sound". Resident #4 stated was not present in the room when the resident fell on [DATE]. On 7/20/11 at 1:30 p.m., Staff D (Certified Nursing Assistant or CNA) stated he placed the resident on the toilet and intended to tell another nurse aide that he placed the resident on the toilet. When he intended to tell the nurse aide, he was told to go to break and then it slipped his mind to tell anyone the resident still sat on the toilet. When asked about a body alarm, Staff D stated he did not place one on the resident and he was aware the resident used an alarm. He just forgot. Following this incident, the facility terminated Staff D's employment at the facility. The Nurses Notes dated 6/30/11 at 1:25 p.m. recorded the resident fell at 11:15 a.m. Staff observed the resident sitting on the floor of the resident's room. The resident would not bear weight and complained of pain in the right hip. At 12:20 p.m., the ambulance transported the resident to the hospital emergency room for an evaluation. The Nurses Notes, dated 7/1/11 at 3:48 a.m. identified the resident would have surgery in the morning to repair the right hip fracture and the resident also had a urinary tract infection. Information from the facility submitted to the Department of Inspections and Appeals and subsequent phone call to the Assistant Director of Nursing, identified the alarm did not sound when the fall occurred. The alarm pulled away from the chair and went with resident to the floor still clipped to the resident. The physician completed a major injury determination form and on 7/1/11 at 3:39 p.m. identified the injury as NOT a major injury. The Nurses Notes identified the resident returned to the facility on [DATE]. Observation on 7/18/11 at 12:30 a.m. revealed the resident seated in the recliner with the alarm box attached by Velcro to a strap on the recliner chair and a clip (no pin) to the collar of the resident's shirt. At that time, the resident remembered he/she fell when he/she "got up to do something". The resident stated he/she didn't know what happened, "I just went down". The resident complained of back pain at the time of the interview. At 12:35 p.m. of the same date, Staff G, CNA and Staff C, CNA transferred the resident from the recliner to the wheelchair via the EZ stand (mechanical standing lift device). The surveyor requested staff to keep the alarm attached so to observe whether it sounded when the resident transferred. The alarm clip pulled away from the resident's clothing and the alarm did not sound; it attached with the clip only. Staff placed the resident on the toilet. Following the use of the toilet, staff placed the resident in the wheelchair. Staff clipped the alarm clip to the resident's shirt. Staff tugged on it and it came off 3 times. On one of the tugging attempts, Staff G told the charge nurse the resident should use a different clip due to it not holding securely to the shirt and coming off when tugged. The charge nurse directed staff to place more clothing in the clip. Staff then did as directed and the resident transported to lunch in the wheelchair On 1:25 p.m. of the same date, Staff G and Staff C laid the resident down and the alarm sounded as it remained clipped to the shirt, with the extra material in the clip. On all observations on 7/18/11 the alarm was attached to the resident's shirt via clip only and no pin as the care plan directed. On the same date at 3:25 p.m. observation revealed the resident in bed with alarm clipped (no pin) to the top of the resident's right shoulder and box attached to the top of the bedrail. Observation revealed on 7/20/11 at 10:15 a.m., the resident in the recliner with the alarm attached with both clip and pin. Staff interviews revealed: On 7/20/11 at 11:11 a.m., Staff F (Licensed Practical Nurse or LPN) stated she saw the resident in the recliner at 10:45 a.m. on the day of the 6/30/11 incident. Staff F administered medication to the resident at that time. Staff F stated she observed the alarm clipped to the resident and did not know for sure how staff attached the alarm box to the recliner. Staff F stated staff used a safety pin to attach the alarm to the resident prior to the 6/30/11 fall. On 6/30/11 she thought staff clipped the alarm only and did not use a pin. Staff F stated she was not concerned with safety due to the lack of pin in use because the clip alone held before. Staff F identified the alarm box attached to the head cover of the recliner on 6/30/11. The head cover is not secured to the recliner and it pulled off the chair resulting in the alarm not sounding. Staff F stated when she reprimanded Staff C for attaching the alarm box to a removable head cover Staff C informed the family did not want safety pins in the chair. Staff F stated the only one that knew this information was Staff C and Staff C did not pass the information on so staff could think of alternative placement. On 7/20/11 at 10:50 a.m., Staff C, CNA stated she worked the day of the incident (6/30/11). Staff C stated she and Staff I heard a loud bang. The resident used an alarm but the family said they did not want it pinned to the recliner so staff pinned it to a doily at the back of the chair. When the resident stood, the alarm box came off the chair and went with the resident to the floor not sounding. Staff C stated the family request for no pins "has been going on for awhile". Staff C stated she did not think it was safe to anchor the alarm box that way but "you have to go by what the family wants". Staff C denied issues with clips coming off causing alarms not to sound. On 7/18/11 at 2:30 p.m. Staff I, CNA stated she got the resident up on 6/30/11. She heard a "boom" and found the resident on the floor. Staff I stated the alarm box went with the resident to the floor and did not sound. On 7/20/11 at 2:20 p.m. Staff I identified the family did not want pins in the resident's chair when (s)he resided on another wing (House 2) The Nurses Notes identified the resident moved to current room 425 on 6/10/11 and previously resided on House 2. On 7/20/11 at 1:25 p.m. Staff A (Director of Nursing) stated she did not know the family didn't want pins in the chair until staff told her after the incident. On 7/20/11 at 3:15 p.m., the resident's spouse stated (s) he never instructed staff not to pin the alarm box to the recliner. The spouse stated staff didn't ask; (s) he accepted the use of the pin and staff has to do what they need to do to keep the resident safe. At that time, the surveyor and spouse discussed the clip on the resident's shirt. The spouse stated the facility also has to pin the clip because the resident's clothing is not heavy enough for the clip. On 7/20/11 at 11:41 a.m. Staff E, LPN identified concerns with clips coming off clothing. Staff A stated the clip needs "a good amount of clothing" in it to hold and some clips hold better than others. 2. An MDS with assessment reference date of 5/11/11, assessed Resident #3 with impaired long and short term memory and severely impaired decision making skills. The resident required total assistance of two staff with bed mobility, transfers and toileting. The resident was nonambulatory and used a wheelchair. The resident had [DIAGNOSES REDACTED]. A variance/incident report dated 7/10/11 at 10:20 a.m. recorded the resident sat in the wheelchair at the dining table for a morning snack. A nurse aide took a plate to the kitchen window and the resident stood up and fell out of the wheelchair onto the floor. The resident did not sustain injury. A fall risk post fall assessment dated [DATE] indicated the alarm did not sound because of clip not tight enough. Staff changed the clip to a "stronger" clip. Observation on 7/18/11 at 1:28 p.m. revealed staff transferred the resident from the wheelchair to the recliner. Prior to the transfer, staff unclipped and then re-clipped the alarm and it stayed secure for the transfer. The alarm sounded. On 2/23/11 at 4:20 p.m., a fall risk post fall assessment did not identify if the alarm sounded when the resident fell . The resident did not sustain an injury. A care plan, dated 2/22/11, directed staff to use a personal alarm at all times. The care plan contained an addendum dated 7/10/11 that stated clip on personal alarm "changed to be sure strong enough to sound". On 7/20/11 at 5:30 p.m., Staff A (Director of Nursing) identified the facility purchased new alarms and the new clips are the ones the facility are having problems with.