Every finding on record at The Village of Ackley

Based on record review and staff interviews the facility failed to accurately code 1 of 1 Minimum Data Set (MDS) assessments for residents with a Pre-admission Screening and Resident Review (PASRR) Level II outcome (a formal determination that confirms if an individual with suspected serious mental illness or intellectual disability requires Medicaid-certified nursing facility care and defines their need for specialized services) (Resident #2). The facility reported a census of 27 residents.Findings Include:Resident #2's MDS assessment dated 12/11//25 identified she didn't have a state level II PASRR serious mental illness and/or intellectual disability or related condition. The MDS documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS included diagnoses of depression, schizophrenia and cognitive communication deficit.Resident #2's PASRR notice of nursing facility approval dated 6/16/25 reflected she experienced a significant change in status and met criteria for Level II with approved specialized services.In an interview on 2/19/26 at 1:52 PM the Administrator revealed when they completed the MDS back in March 2025 they had concerns with the MDS' accuracy by the MDS Coordinator at the time. The Administrator added she no longer worked at the facility, and they haven't had a problem since.On 3/11/26 at 12:00 PM, Staff A, Registered Nurse Assessment Coordinator, reported she is responsible for completing the MDS Assessment. Staff A reported she followed the Resident Assessment Instrument (RAI) manual when completing the MDS. Staff A verbalized the facility normally communicated with her if there is a change from a Level I PASRR to a Level II. Staff A acknowledged the MDS dated [DATE] lacked documentation of the Level II. Staff A confirmed Resident #2's Level II was approved on 6/16/25. Staff A acknowledged the MDS dated [DATE] wasn't accurately coded.On 3/11/26, the Director of Nursing (DON) verbalized Resident #2 met criteria for a Level II. The DON lacked evidence of communication to Staff A for the change in status. The DON expected the staff to code the MDS assessment accurately.

Based on observation, staff interviews, and policy review the facility failed to clean the kitchen convection oven, griddle on the stove, sink, cabinet under sink, and electric griddle. The facility reported a census of 27 residents. Findings include: During an initial kitchen walkthrough on 3/9/26 at 11:44 AM observed the cabinet under the sink next to the ice machine, had a brown-like sticky discoloration alongside the surface of the cabinet doors, the height of the cabinet, and along the top of the cabinet doors. The sink next to the ice machine had mineral deposit build-up all over the faucet, handles, and down the back of the sink. The Bakerspride oven had a brown-like sticky discoloration on the doors. Also observed thick black discoloration on the Vulcan stove top, Vulcan stove top griddle, and Presto flat electrical pan. On 3/10/26 at 10:44 AM observations of the sink, cabinet, Vulcan stove, Vulcan stove top griddle, Bakerspride oven, and Presto electric griddle remained the same as the observation from the previous day.On 3/11/26 at 11:53 AM observations of the sink, cabinet, Vulcan stove, Vulcan stove top griddle, Bakerspride oven, and Presto electric griddle remained the same.On 3/11/26 at 11:53 AM observed a thick black discoloration on the griddle, stove top, and flat electrical pan. Staff B, Dietary Aide (DA), indicated they didn't use the griddle on the stove. They used the flat electric pan and try to clean it weekly, but it is getting bad. Staff B reported he cleaned the Presto electric flat griddle on Fridays. On 3/11/26 at 1:01 PM the Dietary and Housekeeping Manager reported she tried to get everything clean. They used scratch pads to clean the Vulcan stove on Sundays. She indicated the Presto, electric flat griddle was getting bad and didn't know how to scrub it. On 3/12/26 at 11:31 AM the Administrator informed he expected to have a clean kitchen with properly trained staff. He removed two griddles and had two new griddles ordered.Review of the facility's Performance Improvement Plan for Kitchen Cleanliness initiated 2/18/26 revealed a weekly check list that is to be checked daily to assure tasks are done with weekly audits for floors, walls, and equipment. Review of the Dietician Monthly Report dated 2/26/26 revealed they did a kitchen sanitation and meal service audit and reviewed the results with the Dietary Manager.Review of the Weekly Cleaning list for Week of 3/8/26-3/12/26 lacked documentation to indicate the stove top burners got cleaned. The cleaning list did not include the sink next to the ice machine, the cabinets, the oven, or the griddles. Review of the facility's Cleaning Duties Policy reviewed December 2023, instructed the following procedure:1. The Director of Dining Services or lead hospitality coordinator in consultation with the Registered Dietitian Nutritionist /Licensed Dietitian will determine all cleaning and sanitation tasks needed.2. Daily, weekly, and monthly cleaning check-off lists will be available and posted.3. Employees will be trained on when and how each assignment is to be done. This will include cleaning compounds to be used4. Cleaning duties will be assigned to specific positions.5. A cleaning list/schedule will be posted for all cleaning duties and employees completing assigned tasks will date and initial duties completed.6. Employees will be held accountable for cleaning assignments and may face disciplinary action if duties are not completed.

Based on electronic health record (EHR) review, facility records, policy review, resident and staff interviews the facility failed to ensure residents are free from neglect following a fall for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 32.Findings Include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS documented Resident #2 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts, holds, and supports trunk or limbs, but provides the efforts) from sit to stand (The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). The MDS documented Resident #2 had been dependent (Helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed-to-chair transfer (The ability to transfer to and from a bed to a chair or wheelchair). The MDS documented diagnoses of Parkinson's disease, anxiety disorder and depression. The Care Plan Report initiated on 6/18/25 identified Resident #2 had been at risk for falls. The Care Plan Report directed staff to:Ensure appropriate footwear is worn of non-skid socks or shoes when ambulation or mobilizing in wheelchair.Wheelchair loweredNon-skid strips on floor in front of chair and bedBe sure call light/pendent is within reach and encourage use for assistance as needed.The personnel file documented Staff D had a Single Contact License & Background cleared on 7/3/25 with no record of Dependent Adult Abuse. The personnel file documented a hire date of 7/14/25.The Certified Nursing Assistant (CNA) Orientation included the following training:Fall prevention and protocols. Review falls policy and procedures including who should be contacted and review all interventions used to prevent falls.Elder abuse. Trainee able to identify all types of elder abuse and knows reporting protocols including timeframes and who to notify. Includes identification of suspected or actual resident to resident abuse and/or employee abuse.Staff D signed the CNA Orientation on 8/5/25, indicated all checkpoints had been completed. Review of the facility payroll punches revealed Staff D had a start time of 5:59 AM and end time of 3:20 PM on 8/16/25. A Progress Note dated 8/16/25 at 3:20 PM documented the following:the nurse called to resident's room by another resident who reports hearing yelling coming from phoenix hallway. the nurse enters residents' room and observes resident lying prone on floor between bathroom and recliner. Resident noted to have neck turned to left, right side of face lying flat on floor. Resident noted to be attempting to prop self-up on left arm. Left hand palm down on floor, right arm bent at elbow and underneath resident. Both lower extremities (BLE) laid straight out towards bed. Resident's walker within easy reach. Appropriate footwear to bilateral (both) feet. Room free of clutter. Call light is within easy reach, not activated at time of fall. Recliner noted to be in upright and lifted position, foot of chair down. Resident yelling out for help continuously when the nurse enters room, telling nurse, I'm scared, I'm scared. Reassurance is provided while help arrives to room. Resident reports pain to bilat knees and right arm, yells get me up, this floor is hard!. No internal/external rotation noted to BLE. No shortening noted to BLE. No open areas noted to area of head/face nurse is able to assess. Left arm is positioned at resident's left side, resident is assisted to roll to back with assistance from 3 staff. Bilateral Upper Extremities (BUE) with range of motion (ROM) per normal ability. Resident denies pain to RUE once she is no longer lying on it, continues to report pain to bilateral knees. Hip pain is denied. Assistance from 3 staff, a gait belt and front wheeled walker (FWW) utilized to assist resident from floor to wheelchair. Resident able to bear weight per normal ability. Gait is not assessed. Small, superficial abrasions noted to bilateral elbows, bilateral knees. Neuros initiated. Resident accompanies the nurse to nurse's station. Family, primary care provider (PCP) and the Director of Nursing (DON) to be notified.In an interview on 10/15/25 at 9:54 AM, former Staff D, Certified Nurse Aide (CNA), reported she assisted Resident #2 to transfer from the bed to a lift recliner using a gait belt and walker on 8/16/25. Staff D verbalized she removed the gait belt from Resident #2 and turned to remove the personal protective gown she had on when she heard a noise. Staff D turned towards Resident #2 and viewed her laying on the floor on her right side. Staff D verbalized the walker was laying on the floor beside Resident #2. Staff D reported Resident #2 had been conscious. Staff D verbalized she panicked, exited the resident room and left the facility without assisting Resident #2 or reporting the fall to the nurse. Staff D acknowledged she had received training on reporting incidents and what she did by not reporting the fall was wrong. Staff D reported she left the facility around 3:30 PM on 8/16/25.In an interview on 10/20/25 at 10:32 AM Resident #2 recalled she fell recently. Resident #2 stated she didn't lay on the floor very long and that she had been yelling for help. Resident #2 verbalized she was scared and the floor was cold. Resident #2 had been unable to recall if a staff member had been in the room at the time of her fall.In an interview on 10/20/25 at 1:10 PM, Staff B, Registered Nurse (RN) Nurse Mentor, reported Resident #4 alerted her Resident #2 needed help on 8/16/25 around 3:30 PM. Staff B assessed Resident #2 and called for other staff to assist Resident #2 up of the floor. Staff B verbalized she notified the DON of Resident #2's fall around 4:00 PM.In an interview on 10/20/25 at 1:52 PM, the DON reported she received a call from Staff B on 8/16/25 around 4:00 PM. The DON verbalized she had been informed of Resident #2's fall and that Staff D had left prior to the end of her shift. The DON verbalized she had called Staff D on 8/16/25 around 4:25 PM. The DON verbalized Staff D reported she had transferred Resident #2 to her lift recliner, removed the gait belt and turned to remove the gown when she heard Resident #2 fall. The DON reported Staff D stated she panicked and freaked out, exited Resident #2's room and left the facility. The DON verbalized it hadn't been until later that evening she had been informed Staff D had not reported Resident #2's fall prior to leaving the facility. The DON reported she notified the Administrator and [NAME] Director of Quality Care and Clinical Services on 8/16/25 at approximately 8:15 PM.The Incident/Accident Prevention facility policy effective April 2024 documented residents are to receive adequate supervision and assistance devices to prevent accidents. The Incident/Accident Prevention facility policy directed staff to do the following:Upon admission, nurse completes a fall risk assessment and will be updated quarterly with MDS/CP review thereafter. Interventions should be considered upon admission.Fall incidents will be reviewed 3-5 x's/week with DON and Administrator. Interventions will be evaluated for appropriateness. Residents to be visually monitored per Care Plan. When restless, assess need for repositioning, assist to bathroom, assisted ambulation, diversionary activity, 1:1 attention, snacks, drinks, or any verbal expressed needs from resident.Fall interventions will be included on the care plan and available to caregivers.Fall interventions will be reviewed and modified after each fall.The policy lacked direction for staff in reporting falls.

Based on electronic health record (EHR) review, facility records, policy review, resident and staff interviews the facility failed to report an allegation of abuse within the required time frame to the Iowa Department of Inspection, Appeals, and Licensing (DIAL) for 1 of 1 resident (Resident #2) reviewed. The facility reported a census of 32.Findings Include:Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS documented Resident #2 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts, holds, and supports trunk or limbs, but provides the efforts) from sit to stand (The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.) The MDS documented Resident #2 had been dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed-to-chair transfer (The ability to transfer to and from a bed to a chair or wheelchair). The MDS documented diagnoses of Parkinson's disease, anxiety disorder and depression. The Care Plan Report initiated on 6/18/25 identified Resident #2 had been at risk for falls. The Care Plan Report directed staff to:Ensure appropriate footwear is worn of non-skid socks or shoes when ambulation or mobilizing in wheelchair.Wheelchair loweredNon-skid strips on floor in front of chair and bedBe sure call light/pendent is within reach and encourage use for assistance as needed.A review of the facility reported Incidents to DIAL lacked reports of Resident #2 allegation of neglect after knowledge of Staff D, Certified Nursing Assistant had been in Resident #2's room when she fell on 8/16/25 and did not assist or notify the nurse of the fall prior to Staff D leaving the facility.In an interview on 10/15/25 at 9:54 AM, former Staff D, Certified Nursing Assistant (CNA) reported she assisted Resident #2 transfer from the bed to a lift recliner using a gait belt and walker on 8/16/25. Staff D verbalized she removed the gait belt from Resident #2 and turned to remove the personal protective gown she had on when she heard a noise. Staff D turned towards Resident #2 and viewed the resident laying on the floor on her right side. Staff D verbalized the walker was laying on the floor beside Resident #2. Staff D reported Resident #2 had been conscious. Staff D verbalized she panicked, exited the resident room and left the facility without assisting Resident #2 or reporting the fall to the nurse. Staff D acknowledged she had received training on reporting incidents and what she did by not reporting the fall was wrong. Staff D reported she left the facility around 3:30 PM on 8/16/25.In an interview on 10/16/25, the Administrator acknowledged he hadn't reported the incident of Staff D neglecting care for Resident #2 to DIAL due to: Resident #2 had no lapse in careStaff responded to Resident #2's call for help within a minute per video footage.Staff D had been terminated.In an interview on 10/20/25 at 10:32 AM Resident #2 recalled she fell recently. Resident #2 stated she didn't lay on the floor very long and that she had been yelling for help. Resident #2 verbalized she was scared, and the floor was cold. Resident #2 had been unable to recall if a staff member had been in the room at the time of her fall. In an interview on 10/20/25 at 1:10 PM, Staff B, Registered Nurse (RN) Nurse Mentor, reported Resident #4 alerted her Resident #2 needed help on 8/16/25 around 3:30 PM. Staff B assessed Resident #2 and called for other staff to assist Resident #2 up of the floor. Staff B verbalized she notified the DON of Resident #2's fall around 4:00 PM.In an interview on 10/20/25 at 1:52 PM, Director of Nursing (DON) reported she had received a call from Staff B on 8/16/25 around 4:00 PM. The DON verbalized she had been informed of Resident #2's fall and that Staff D had left prior to the end of her shift. The DON verbalized she had called Staff D on 8/16/25 around 4:25 PM. The DON verbalized Staff D reported she had transferred Resident #2 to her lift recliner, removed the gait belt and turned to remove the gown when she heard Resident #2 fall. The DON reported Staff D stated she panicked and freaked out, exited Resident #2's room and left the facility. The DON verbalized it hadn't been until later that evening she had been informed Staff D had not reported Resident #2's fall prior to leaving the facility. The DON reported she notified the Administrator and [NAME] Director of Quality Care and Clinical Services on 8/16/25 at approximately 8:15 PM.In an interview on 10/21/25 at 11:53 AM, the DON verbalized Staff D's lack of assisting and reporting met the facility policy definition for neglect. The DON acknowledged it should have been reported to DIAL.A review of the Abuse Prevention, Identification, Investigation and Reporting Policy revised March 2025 defined Dependent adult abuse under Iowa law, pursuant to Iowa Code Ch. 235E as any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances:A physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement, unreasonable punishment, or assault of a dependent adult which involves a breach of skill, care, and learning ordinarily exercised by a caretaker in similar circumstances. Assault of a dependent adult means the commission of any act which is generally intended to cause pain or injury to a dependent adult, or which is generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act which is intended to place another in fear of immediate physical contact which will be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.The commission of a sexual offense under Iowa Code chapter 709 or Iowa Code section 726.2 with or against a dependent adult.Exploitation of a dependent adult. Exploitation means a caretaker knowingly obtains, uses, endeavors to obtain to use or who misappropriates a dependent adult's funds, assets, medications, or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit, or possession of the funds, assets, medication or property for the benefit of someone other than the dependent adultNeglect of a dependent adult. Neglect of a dependent adult means deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult's life or physical or mental health.

Based on clinical record review and staff interview the facility failed to inform the Long Term Care (LTC) Ombudsman office of a resident transfer from the facility for 1 of 1 resident's reviewed (Resident #9) for hospitalization . The facility reported a census of 28 residents. Findings include: The Nursing Note dated 5/27/24 at 11:28 PM, reflected the hospital admitted Resident #9. The Nursing Note dated 5/30/24 at 11:44 AM, identified Resident #9 returned to the facility. The facility lacked documentation showing the required notification to the LTC Ombudsman of Resident #9's admission to the hospital. During an interview on 2/26/25 at 9:20 AM, the Administrator acknowledged he had the responsibility for sending the notifications to the LTC Ombudsman beginning in June 2024. The Administrator acknowledged the notifications didn't include Resident #9 and would need check with the LTC Ombudsman to see if a former employee sent a notification for Resident #9. During an interview on 2/27/25 at 11:21 AM, the Administrator acknowledged the facility failed to submit the required notifications to the LTC Ombudsman for all residents transferred and discharged during the months of April 2024 and May 2024. The facility failed to provide a policy for required notification to the LTC Ombudsman for resident transfers and discharges.

Based on clinical record review, staff interviews and policy review, the facility failed to treat residents with dignity and respect in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 residents reviewed (Resident #14). The facility reported a census of 28 residents. Findings include: Resident #14's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE] following a short term hospitalization . The MDS identified the Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The MDS included diagnoses of stroke (occurs when blood flow to the brain is interrupted, causing brain tissue damage), non Alzheimer's dementia (a group of cognitive disorders that cause memory loss, confusion and other cognitive impairments similar to Alzheimer's disease but caused by different underlying mechanisms), depression and psychotic disorder (a mental health condition characterized by a loss of contact with reality). Staff C, Quality Life Services MDS Coordinator, signed the MDS indicating completion on 12/16/24. The Nurses Note dated 1/15/24 at 6:34 PM documented by the Director of Nursing (DON) indicated she received a call from Staff A, certified nursing assistant (CNA), stating Staff B, CNA, told Resident #14 to shut the fuck up, you're annoying while transferring Resident #14. The staff removed Staff B from the floor. An assessment completed on Resident #14 revealed no injuries and they didn't recollect the situation. During an interview 2/26/25 at 11:26 AM Staff B recalled she assisted Staff A on 1/15/25 to provide care and transfer Resident #14 into her wheelchair. Staff B indicated Resident #14 screamed and hollered. Staff B acknowledged she reminded Resident #14 that she was in a safe place and they were getting her up for supper. Staff B admitted her emotions got the best of her and told Resident #14 to shut up and the F word may have slipped out. On 2/26/25 at 12:05 PM, Staff A reported she assisted Staff B on 1/15/25 provide care and get Resident #14 up for supper. Staff A acknowledged Resident #14 screamed help me and asked for her mom. Staff A reported Staff B told Resident #14 your mom is fucking dead. Resident #14 continued to yell and scream. They transferred Resident #14 to her wheelchair and Staff A transported her to the dining room. Staff A reported she called the DON to report what happened. On 2/26/25 at 4:30 PM, the DON acknowledged she received a call from Staff A on 1/15/25 and came into the facility. The DON and Assistant Director of Nursing (ADON) met with Staff B. Staff B admitted she told Resident #14 to shut up. They escorted Staff B out of the facility and terminated her employment for inappropriate behavior. The facility failed to provide the date Staff B received training on Resident's Rights. The Resident Rights policy dated April 2019 instructed the following: a. Residents Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. i. The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility will protect and promote the rights of the resident. b. Respect and Dignity. The resident has a right to be treated with respect and dignity.

Based on clinical record review, staff interview and policy review, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis (Resident #19). The facility reported a census of 28 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] included a diagnosis of post-traumatic stress disorder (PTSD). The MDS reflected Resident #19 received an antipsychotic on a routine basis during the lookback period. The Care Plan revised 11/15/24 indicated Resident #19 received an antipsychotic medication related to PTSD nightmares (military service). The Care Plan goal indicated Resident #19 wouldn't experience any adverse effects of the medication. Resident #19's Medical Diagnoses reviewed 2/25/25 included a diagnosis of PTSD effective 11/10/23. Resident #19's PASRR completed 1/20/23 listed a completed negative Level 1 screening. The PASRR lacked documentation of a known or suspected mental health diagnosis. The clinical record lacked a Level II PASRR evaluation submission following the new mental health diagnosis of PTSD effective 11/10/23. The PASRR Screens/Level 1 & Level II Evals policy, revised November 2024 instructed changes in status are required when a resident receives a new mental health diagnosis. During an interview 2/25/25 at 11:45 AM, the Administrator acknowledged no one completed a Level II PASRR evaluation as he expected regarding Resident #19's new mental health diagnosis of PTSD.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal Staffing Data Report (July 1, 2024 - September 30, 2024) review, facility staffing reports review, and staff interviews the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 28 residents. Findings include: The PBJ Staffing Data Report with a run date of 2/19/25 triggered for excessively low weekend staffing (submitted weekend staffing data is excessively low) and for failing to have licensed nursing coverage 24 hours/day (4 or more days within the quarter with less than 24 hours/day licensed nursing coverage). The report reflected 26 days with a failure to notify for 24 hours/day nursing coverage during July 2024 and August 2024. A review of the schedules for the months of July 2024 and August 2024, revealed nursing shifts covered by facility employees and outside staffing agencies. During an interview on 2/25/25 at 3:18 PM, the Director of Nursing (DON) explained the facility used outside staffing agencies to provide coverage of open nursing hours not covered by facility employees. During an interview on 2/25/25 at 3:37 PM, the Administrator reported the facility switched time clocks from Matrix to Dayforce during the quarter of July 2024 to September 2024. On 2/27/25 at 8:11 AM, the Administrator acknowledged the PBJ reporting didn't reflect the actual staffing compared with the daily nursing schedules. During an interview on 2/27/25 at 8:24 AM, the Administrator acknowledged he submitted the PBJ Staffing Data following the quarter of July 2024 to September 2024. The Administrator revealed the timeclock changed from Matrix during July 2024 and was up and running in August 2024. The Administrator explained they verified outside staffing agency hours through email correspondence with the outside staffing agencies. The Administrator confirmed he didn't validate the PBJ data following his submission to verify data accurately reflected the facility records. Through an interview on 2/27/25 at 8:35 AM, the DON verbalized they determine the staffing requirements by the daily census (the number of residents in the facility) and the resident acuity (the severity of a resident's condition and the level of care they need). The DON acknowledged the facility used 5 different staffing agencies to cover open shifts not picked up by facility employees. The facility failed to provide a policy for accurate submission of PBJ Staffing Data. The Staffing Data Submission Payroll Based Journal website found at (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) updated April 18, 2019, provided information on how data is collected and who to contact for questions. Users are strongly encouraged to take additional steps after uploading their data to ensure a successful submission. Therefore, the following verbiage appears upon uploading data to reflect the recommended next steps: a. Check the My Submissions page. This feature will show the status of the zip file. b. Check CASPER for a system generated PBJ Final File Validation Report (FFVR) within 24 hours. If no FFVR appears, run a PBJ Submitter Final File Validation Report to check your file for errors. c. Run the PBJ 1702D (by Employer, the individual daily staffing report) or 1703D (by Job Type, or the job title report) reports to verify the quarterly PBJ data reflects your records. d. For additional assistance contact the Quality Improvement and Enhancement System (QIES) Help desk at iqies@cms.hhs.gov.

Based on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 4 residents reviewed (Resident #1) for falls. Resident #1 had four falls in the month of June. Resident #1 experienced a right ankle injury and a skin tear/bruise to right elbow when a fall resulted from the facility not providing the appropriate level of assistance per therapy recommendations. The facility reported a census of 32 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #1 was independent with bed mobility. Resident #1 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS indicated Resident #1 was ambulatory walking 10 feet and required a wheelchair for locomotion. The MDS documented Resident #1 had frequent incontinence of bowel and bladder. Resident #1's MDS included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation (irregular heartbeat), and fibromyalgia (disorder that causes musculoskeletal pain/tenderness. The Facility Event Reports and observation notes documented June 2024 reflected Resident #1 fell on the following dates: a. 6/8/24 b. 6/17/24 c. 6/21/24 d. 6/27/24 Resident #1's Fall Risk assessment dated [DATE] identified a score of 17, indicating Resident #1 had a risk for falls related to impaired mobility, required used of an assisted device, required staff assistance, had a history of falls, the use of high risk medications, unsteady gait/balance, and diagnosis of Parkinson's, atrial fibrillation (irregular heart rate), dementia, hallucinations (hearing or seeing things not there), restless leg syndrome, insomnia, hypertension (high blood pressure), fibromyalgia (undetermined cause of pain), disorders of bone density/structures, retentions of urine and weakness. The clinical record lacked a fall risk evaluation after 1/14/24 until 6/27/24. The fall risk score on 6/27/24 identified a score of 19, indicating Resident #1 had a risk for falls. According to the evaluation a score of 10 or higher represented a high risk for falls. A Physician Order dated 5/21/24 directed for Physical Therapy, Occupational Therapy, and Speech Therapy complete an evaluation and treatment for Resident #1 due to Parkinson's and falls. A Physical Therapy Note dated 6/6/24 documented Resident #1 required maximum assistance of one with a sitting to standing. Resident #1 had a retro lean and needed assistance to stay on her feet and keep hands on the walker. Resident #1 needed assistance with cross over steps and stutter steps to manage her walker. When in the bathroom, Resident #1 required dependent guided sitting motion to sit. Once sitting, Resident #1 had 6 episodes of spasms resulting in becoming stiff and twitching. Resident #1 required maximum assistance of one staff member to sit to stand post toilet use and a second staff member to complete cares. Resident #1 needed moderate assistance of two staff members to ambulate to recliner, one to manage Resident #1, one to manage the walker, and leg movement. The Physical Therapist called the nursing staff to Resident #1's room to attempt to observe spasms/tone episodes. The Physical Therapy Assistant (PTA) and Certified Nurse Aide (CNA) reported incident as the worst they seen. The PTA recommended two staff members assist Resident #1 and not left alone in bathroom due to fear Resident #1 would have an episode and thrust herself off the toilet as the PTA had to stop her from doing that twice. A Facility Therapy Communication Form dated 6/6/24 recommended 2 staff assist Resident #1 and not leave Resident #1 alone in the bathroom during toilet use. A Progress Note dated 6/6/24 at 1:57 PM documented per therapy, reflected Resident #1 needed assistance of 2 staff and if she used the toilet, don't leave her unattended in her bathroom. Resident #1 had tremors that could cause her to fall off the toilet. A Progress Note dated 6/7/24 at 10:52 AM documented they received therapy communication to use 2 assist and don't leave alone in the bathroom. Care plan updated. The Facility Event Report dated 6/8/24 at 1:20 PM identified a witnessed fall in Resident #1's room. The report documented the CNA and Resident #1's husband walked her to the restroom when her legs spasmed, buckled, and they had to lower her to the ground. Resident #1 didn't hit her head and the staff assisted her into the recliner. The nurse noted a small skin tear to her right elbow. The nurse called Resident #1's Primary Care Provider (PCP) and received a new order to send Resident #1 to the emergency room (ER) for evaluation and treatment. The report lacked any further fall interventions except for the ER transfer. A Progress Note dated 6/8/24 at 6:45 PM reflected Resident #1 returned via ambulance at 5:50 PM with her husband. She had new orders start cephalexin (antibiotic) 500 mg (milligrams) four times a day for a urinary tract infection (UTI). A written statement dated 6/8/24 completed and signed by Staff A indicated she answered Resident #1's call light at 1:15 PM. When she arrived, she saw Resident #1's husband present and requested Resident #1 go back to the recliner. Staff A documented she positioned Resident #1 close to her recliner so she could do a pivot transfer and put a gait belt on her. Staff A documented when she transferred Resident #1 she didn't cooperate very well and she had to lower Resident #1 down on the floor as safely as she could. Staff A noted in her statement, Resident #1's Care Plan indicated Resident #1 required assistance of one staff member with a walker or wheelchair. A Progress Note dated 6/9/24 at 2:00 AM documented the CNA called nurse into Resident #1's room. The CNA seen Resident #1 left ankle black and blue, swollen with increased warmth. The nurse gave Resident #1 Tylenol (pain medication) for her pain. A Progress Note dated 6/9/24 at 9:53 AM documented mild swelling and slight bruising observed on Resident #1's right outer ankle. Resident #1 denied pain with palpation and range of motion. The nurse sent a fax to the PCP to advise on swelling and bruising. A Facility Nursing Memo Form dated 6/9/24 at 9:30 AM documented Resident #1's husband and a staff member lowered her to the floor when she fell on [DATE]. The fax documented the fall assessment revealed only an injury as a skin tear to the right elbow with some mild bruising. The overnight nurse observed swelling and mild bruising to Resident #1's outer right ankle. Resident #1's had range of motion within normal limits and no pain reported with palpation or movement. Resident #1 denied pain when asked. Resident #1 remained assist of two with transfers. The PCP responded to the fax on 6/10/24. The PCP documented urine culture positive, awaiting final results for UTI treatment, discontinue melatonin (sleep aid), and to monitor. The Clinical record lacked documentation regarding an x-ray or diagnosis for the right ankle injury. The Facility Pocket Care Plan dated 6/11/24 directed one staff member with a walker or wheelchair help with transfers and ambulation. The pocket care plan lacked the therapy recommendations from 6/6/24. The Facility Event Report dated 6/17/24 at 8:00 AM identified an unwitnessed fall in Resident #1's room. Someone observed Resident #1 lying on the floor next to her bed in a low position. Resident #1 had her feet under her bed with her head facing the door laying on her left side. Resident #1 reported she had pain but couldn't advise the location. The assessment revealed visible, old, healing bruises, yellow/green in color to ankle from a previous fall with no new skin areas noted. The note documented the staff would notify Resident #1's husband of her fall when he arrived at the facility. A Progress Note dated 6/18/24 documented Resident #1 continued to decline to transfer. Resident #1 downgraded to use full - body mechanical lift for transfer as needed per nursing judgment. A Progress Note dated 6/18/24 at 10:45 PM documented a certified nurse aide (CNA) notified the nurse during report around 10:45 PM that Resident #1 had discoloration to the posterior (back) aspect of the right chin. Upon inspection, the area measured 3 x 5 not measurable in cm (centimeters), the area looked red and purple. Resident #1 denied pain. A Progress Note dated 6/19/24 at 10:58 PM documented the nurse spoke to the family regarding the Resident #1's recent fall. The Facility Event Report dated 6/21/24 at 4:00 PM identified Resident #1 had an unwitnessed fall. The report lacked documentation regarding the event detail, subjective data obtained from the resident, environment details, pain observation, body observation, mental status, possible contributing factors and immediate intervention taken. The Progress Note dated 6/21/24 at 4:00 PM documented the CNA notified the nurse that Resident #1 fell . The nurse discovered Resident #1 laying on the floor beside her bed on her left side facing her nightstand. Resident #1 reported she tried to get from there to go to the bookcase. Neurological checks within normal limits. Resident #1 had two new open injuries, a small skin tear to her left anterior (front) forearm and to her right toe. The progress note lacked a fall intervention. The Observation Detail List report dated 6/27/24 at 1:45 PM identified Resident #1 slid out of her wheelchair due to restless legs and she didn't receive any injuries. The Progress Note dated 6/27/24 at 1:59 PM documented someone called the nurse Resident #1's room due to her being on the floor. Resident #1's husband was present with the fall and reported she had one of her restless leg episodes and slid out of her wheelchair. Resident #1 denied pain or discomfort. Resident #1 required assistance of three staff members with a gait belt to assist the recliner. The new intervention directed to apply a Dycem (nonslip mat) in the wheelchair. The Care Plan revised 5/29/24 lacked documented fall interventions from 6/21/24 and 6/27/24. On 7/9/24 at 11:45 AM, Staff A, CNA, described Resident #1 as very hard to take care of due to her flopping around. She stated she didn't know if she had seizures or anxiety. She stated they tried to calm Resident #1 down so they could transfer her. She stated when she first started working at the facility in June, Resident #1 required assistance of 1 with a gait belt and a walker. Staff A reported she had to lower Resident #1 to the floor during a transfer. Staff A stated she did everything according to the care plan. She reported the husband in the room at the time of the fall. Staff A reported she called for a nurse after lowering Resident #1 to the floor. Staff A reported after Resident #1's first fall in June, they changed her to an assist of 2 with transfers. On 7/9/24 at 4:00 PM, Staff B, Registered Nurse (RN), reported on 6/19/24 Resident #1's daughter spoke to her regarding concerns about a bruise on her mom's chin. Staff B stated she looked into the concerns and told the daughter the clinical record documentation. Staff B stated Resident #1's daughter reported no one notified the family of her fall on 6/17 that resulted in the bruise on the Resident #1's chin. Staff B stated she apologized to the daughter and spoke to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) about the family's concern. She stated she passed it on in report to notify the family or leave a message. On 7/10/24 at 9:30 AM, Staff C, Regional Nurse Consultant (RNC), reported she expected the pocket Care Plan to reflect the therapy recommendation. She stated she expected the Nurse Managers to update the Care Plan and expected the CNAs to follow the pocket Care Plan. On 7/10/24 at 9:30 AM, the DON reported she would expect the staff to notify the family within 48 hours of a condition change or identification of the change. The DON acknowledged the family learned of the fall from 6/17/24 on 6/19/24 when they questioned how Resident #1 received a bruise on her chin. On 7/10/24 at 12:31 PM, Staff C confirmed Resident #1's husband wouldn't count as a second person for a transfer. Staff C reported the facility discussed falls in the morning meeting daily. She stated the team looked to see if interventions are in place. The nurse managers had the responsibility for adding the interventions to the Care Plan. Staff C reported the interventions reflected the root cause analysis and discussed verbally. Staff C reported the fall on 6/27/24, the nurse filled out an observation report instead of the event report which is what the facility uses for an incident report. Staff C confirmed Care Plan didn't include the fall intervention of a Dycem. On 7/11/24 at 2:07, Staff C reported she couldn't locate any additional fall risk assessments for Resident #1 since January 2024. The Incident/Accident Prevention policy dated April 2024 described the purpose of the policy to ensure that the resident's environment remained as free of accidents as possible, the resident received adequate supervision, and assistance devices to prevent accidents. The procedure consisted of the following: 1. Upon admission, the nurse completed a fall risk assessment and updates it quarterly with the MDS/Care Plan review thereafter. The facility should consider Interventions upon admission. 2. The DON and Administrator would review fall incidents 3 - 5 times per week and evaluate the Interventions appropriateness. 3. The staff will monitor the residents visually per the Care Plan. 4. When restless, assess the resident's need to reposition, assistance to the bathroom, assist with ambulation, provide a diversionary activity, 1:1 attention, snacks, drinks, or any verbal expressed needs from the residents. 5. The Care Plan will include fall interventions, available to caregivers. 6. The facility will review and modify fall interventions after each fall.

Based on staff interviews, clinical record review, hospital record review, family interviews, and policy review the facility failed to conduct appropriate assessments, interventions and timely Physician notification for 1 of 4 resident reviewed (Resident #1). Resident #1 experienced difficulty swallowing, poor oral intake, and mouth pain that resulted in weight loss and a hospitalization from [DATE] to [DATE] for acute kidney injury, dehydration (inadequate fluid intakes) and pharyngitis/MRSA (Methicillin - resistant Staphylococcus Aureus - staph infection resistant to several antibiotic to the throat). Resident #1 started having difficulty swallowing on [DATE], went to the ER (emergency room ) on [DATE] and returned to the facility. Resident #1 continued to have difficulty with swallowing with decreased oral intakes after returning from ER. The facility didn't notify Resident #1's primary care provider (PCP) of her continued decline until [DATE] when the gave an order for Speech therapy. The facility reported a census of 32 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #1 required set up or clean up assistance with eating and oral hygiene. Resident #1 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS indicated Resident #1 was ambulatory walking 10 feet and required a wheelchair for locomotion. The MDS coded Resident #1 didn't have a 5% weight loss in the last month or 10 % weight loss in the last 6 months. Resident #1's MDS included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation (irregular heartbeat), and fibromyalgia (disorder that causes musculoskeletal pain/tenderness). Resident #1's Iowa Physician Orders for Scope Treatment (IPOST) dated [DATE], signed by Resident #1 and her PCP reflected she requested CPR (cardiopulmonary resuscitation) and full treatment, including the use of intubation, advanced airway intervention, mechanical ventilation, and cardioversion (machine-initiated restart of the heart) as indicated. In addition, she wished to transfer to the hospital if indicated, including critical care. Review of Physician Order dated [DATE] documented Resident #1 received a regular diet, regular texture with thin liquids, and crush medications unless contraindicated. Review of General Nursing POC (Point of Care) - Tasks dated [DATE] directed the staff to document breakfast, lunch and dinner intakes daily along with offering then documenting a bedtime snack. The Hydration Special Instructions directed the staff to document liquids in cc (cubic centimeter) consumed with meals. Resident #1's Nutritional status Care Plan revised/reviewed [DATE] documented her long-term goal as to maintain her current weight within 5 pounds (#). The Care Plan directed the following nutritional approaches/interventions all dated [DATE]: 1. Acknowledge to Resident #1 that her needs are unique. Convey a willingness to provide acceptable foods. 2. Assist with meal set up and feeding if needed. Monitor for choking or swallowing problems. 3. Monitor bowel sounds as needed (PRN) and document bowel movements. Report nausea to the nurse. 4. Monitor food and fluid intakes with meals and offer snacks. 5. Provide adaptive equipment as needed. 6. Provide diet as ordered and foods of preference. 7. Provide the resident with as much control as possible in routines, food preferences, etc. 8. Record weight and reported changes if greater than 5# to Physician. A Physician Order dated [DATE] directed for Physical Therapy, Occupational Therapy, and Speech Therapy complete an evaluation and treatment for Resident #1 due to Parkinson's and falls. A Progress Note dated [DATE] at 1:46 AM documented Resident #1 returned from her appointment with new orders for PT, OT, ST for Parkinson's disease and falls. A Progress Noted dated [DATE] at 1:39 PM documented the Physical Therapy Assistant (PTA) at the facility. The staff informed her in person regarding Resident #1's new orders for PT, OT and ST therapy. The Clinical Record lacked documentation Resident #1 received a Speech Therapy evaluation and treatment per the Physician order. A Progress Note dated [DATE] at 4:00 AM documented Resident #1 didn't want to drink water. Resident #1's lips and mouth appeared very dry. When the staff attempted to apply mouth/lip moisturizer, Resident #1 became upset. A Progress Note dated [DATE] at 9:40 PM documented the Certified Nurse Aide (CNA) notified the nurse that Resident #1 had discoloration to bilateral lower extremities. The nurse assessed Resident #1 and discovered discoloration of yellow/brown in color. Resident #1 denied complaints of pain or discomfort. Resident #1's husband updated and the nurse notified the PCP by fax. A Progress Note dated [DATE] at 7:26 AM documented Resident #1 in bed resting, mumbling incoherently, unable to hold a conversation, and unable to answer questions. The note documented the night staff reported that during the night shift, Resident #1 couldn't swallow fluids and the fluids ran out the side of her mouth. The dayshift reported the previous day during the day, Resident #1 didn't void. The note included vital signs of blood pressure ,d+[DATE], pulse 74 beats per minute, respirations 18 breaths per minute, temperature 97.3 degrees Fahrenheit (F), and pulse ox (oxygen in blood) 98% on room air. New order received to obtain a urinalysis with culture and sensitivity (UA with cs), and they could obtain the urine via straight catheter if needed. The staff notified Resident #1's husband. A Progress Note dated [DATE] at 9:00 AM reflected Resident #1 awake to take morning medications. She took them with applesauce and then coughed on the drink of water after. Resident #1 acted very confused with slurred speech, minimal urine output, inability to transfer, or even sit up unassisted. A Progress Note dated [DATE] at 9:01 AM indicated Resident #1's primary care provider (PCP) called. The nurse notified them regarding Resident #1's change in condition and new order received to send to emergency room (ER) for evaluation and treatment. Daughter informed about the new order and her condition. A Progress Note dated [DATE] at 10:51 AM documented Resident #1 left facility via ambulance for the ER with papers given to the Emergency Medical Technicians (EMTs). A Progress Note dated [DATE] at 1:30 PM identified the facility received a phone call from ER. Resident #1's labs and scans came back normal. The caller described Resident #1 as in and out of it while at the ER. The hospital would return Resident #1 to the facility via ambulance with no definitive diagnosis. A Progress Note dated [DATE] at 10:55 AM indicated Resident #1 had garbled speech and had difficulty making others understand. Resident #1 had difficulty swallowing medications and water that morning. She received her medications crushed and taken to the dining room for breakfast to monitor due to her difficulty swallowing. A Progress Note dated [DATE] at 1:47 PM reflected Resident #1's husband came to the facility at lunch time and sat with Resident #1 in her room for lunch. Resident #1 took her medications whole and swallowed quite a few times before getting them down but didn't need them crushed. Her speech remained garble but had some improvement. Resident #1's husband knew of her swallowing issues that morning. A Progress Note dated [DATE] at 9:38 PM documented Resident #1 required maximum assistance of two with activities of daily living (ADLs). Resident #1 had difficulty swallowing her bedtime medications but eventually got the medications down. Resident #1 had a dry oral cavity and cracked lips. She received oral cares and encouragement to drink. According to the note, it took several attempts for Resident #1 to figure out how to drink. Resident #1 blew air into the straw before she eventually started sucking water through the straw. A Progress Note dated [DATE] at 2:39 AM documented Resident #1 received crushed Tylenol in applesauce for complaints of mouth pain. Resident #1 had cracked lips with blood, staff cleaned her lips with a washcloth. Resident #1 couldn't drink water by herself and needed staff assistance. Resident #1 unable to suck properly from the straw. A Progress Note dated [DATE] at 11:09 AM documented Resident #1 wouldn't open her eyes but did communicate with the nurse. Resident #1's mouth and lips remained dry. Resident #1 received 2 smaller medications and sips of water. Resident #1 struggled to get the medications down and gargled on the water. The nurse crushed the rest of her medications in applesauce and then she could get the medications down. A Progress Note dated [DATE] at 8:04 PM documented Resident #1 had poor intake at supper, only eating strawberries and bananas. Resident #1 acted confused and had difficulty following instructions. A Progress Note dated [DATE] at 1:47 PM documented Resident #1 as sitting up in a wheelchair with her husband visiting. Resident #1 acted incoherent with terminal restlessness. A Progress Note dated [DATE] at 9:55 PM identified Resident #1's husband told the nurse Resident #1 didn't eat much of her dinner. The note indicated someone would offer her snack, if Resident #1 seemed to be hungry throughout the night. A facility form titled Nursing Memo Form dated [DATE] at 3:20 AM documented the facility notified Resident #1's Physician of her difficulty swallowing thin liquids, dry/chapped lips, and she didn't have a BM since [DATE]. She received a suppository on [DATE] with no results. A Progress Note dated [DATE] at 3:30 AM reflected Resident #1 received a small amount of thin liquids and immediately started coughing. Resident #1 didn't have bowel movement. A Progress Note dated [DATE] at 11:01 AM indicated the facility received a fax regarding Resident #1's current condition. The fax included new orders to send her medication list, speech therapy (ST) to evaluate and treat. In addition, apply Vaseline to upper and lower lips. A Progress Note dated [DATE] at 11:17 PM indicated the facility faxed Resident #1's Medication Administration Record (MAR) to Resident #1's PCP. The staff notified therapy and her husband of her new orders for ST. A Progress Note dated [DATE] at 6:56 PM documented Resident #1 had a 9.1% weight loss in 30 days, 11.8% weight loss in 90 days and 10.4 % weight loss in 180 days. Weights as follows: a. ,d+[DATE] was 128.8 pounds (#) b. ,d+[DATE] was 134# c. ,d+[DATE] was 132.8# d. ,d+[DATE] was 130.8# e. ,d+[DATE] was 133.2# f. ,d+[DATE] was 127# g. ,d+[DATE] was 119.6# The progress note documented current weight 115.4# and a body mass index (BMI) 22.5. The note described Resident #1 as independent at meals and with a stable weight until [DATE] - [DATE]. PO (by mouth) intakes have noted to have decreased since fall on [DATE]; general decline potentially occurring. Resident #1 had an order for speech therapy and was coughing on small sips of thin liquid. Estimated needs include 1300 - 1560 kcals, 42 - 52 grams of protein, and 1500+ ml (milliliters) fluids per day. The dietician recommended a house supplement 4 ounces twice a day between meals. The clinical record lacked documented Resident #1's PCP or family wasn'tified regarding the weight loss. The clinical record reflected no one notified Resident #1 s Physician of her poor meal intakes, poor fluid intakes, and recent weight loss. Resident #1 started having difficulty swallowing on [DATE], went to the ER (emergency room ) on [DATE] and returned to the facility. Resident #1 continued to have difficulty with swallowing with decreased oral intakes after returning from ER. The facility didn't notify Resident #1's Physician of the continued decline until [DATE], the day she received a new order for Speech therapy. The facility failed to document interventions to help with self-feeding and improve oral intakes such as weighted silverware, divide plates, or handled cups with lids. The Care Plan lacked additional interventions related to self-feeding. A Progress Note dated on [DATE] at 6:46 PM documented a new order for Resident #1 to receive Miralax 17 grams daily for constipation. A Progress Note dated [DATE] at 9:28 PM documented the staff encouraged Resident #1 to drink water throughout the shift. Resident #1 had difficulty swallowing medications with each medication pass, as she pocketed medications and held water under her tongue. Resident #1 didn't eat much dinner that evening. Family at bedside and encouraged fluids. The facility report titled Intake: Breakfast, Lunch, and Dinner from [DATE] to [DATE] listed meal intakes documented only on the following dates: [DATE] = Dinner - 76 - 100% [DATE] = Dinner 76 - 100% [DATE] = Dinner 26 - 50% [DATE] = Breakfast 76 - 100% [DATE] = Dinner 26 - 50% [DATE] = Dinner 26 - 50% [DATE] = Dinner 26 - 50% [DATE] = Dinner 26 - 50% [DATE] = Dinner 51 - 75% [DATE] = Dinner 26 - 50% [DATE] = Dinner 51 - 75% [DATE] = Dinner 26 - 50% [DATE] = Dinner - none [DATE] = Dinner - 26 - 50% [DATE] = Breakfast 26 - 50% The facility report titled Intakes: Fluids from [DATE] to [DATE] documented fluid intakes only on the following dates: [DATE] - 60 ml [DATE] - 450 ml [DATE] - 500 ml [DATE] - 150 ml [DATE] - 400 ml [DATE] - 300 ml [DATE] - 1400 ml [DATE] - 240 ml [DATE] - 50 ml [DATE] - 200 ml [DATE] - 500 ml [DATE] - 950 ml [DATE] - 500 ml [DATE] - 550 ml [DATE] - 50 ml [DATE] - 50 ml [DATE] - 1000 ml [DATE] - 450 ml [DATE] - 100 ml [DATE] - 590 ml [DATE] - 240 ml [DATE] - 400 ml [DATE] - 50 ml [DATE] - 100ml [DATE] - 50 ml [DATE] - 50 ml [DATE] - 50 ml A Progress Note dated [DATE] at 12:00 PM documented the facility received a phone call from Resident #1's PCP. The PCP reported the family had concerns from the weekend regarding Resident #1 not acting like herself and having a sore throat. The nurse informed the PCP that Resident #1 had a general decline recently and the staff discussed hospice care with her husband. The PCP provided a new order to transfer Resident #1 to the ER for evaluation and treatment. A Progress Note dated [DATE] at 12:30 PM, the facility sent Resident #1 to the ER by the facility van for evaluation and treatment per family request. A Progress Note dated [DATE] at 9:36 AM documented the hospital admitted Resident #1 for acute renal failure and dehydration. The Hospital Discharge Summary dated [DATE] documented they admitted Resident #1 on [DATE] for acute kidney injury (AKI). The hospital determined the AKI to be prerenal due to decreased oral intakes. Resident #1 received IV fluids with good urinary output and the AKI resolved. Speech therapy followed Resident #1 during the hospital stay for dysphagia (difficulty swallowing). The staff advanced Resident #1's diet to a pureed diet with regular thin liquids. She tolerated the diet change well. Resident #1 received treatment for MRSA pharyngitis (antibiotic resistant bacteria in the throat) with clindamycin (antibiotic) based on the culture and sensitivity report. The hospital contacted Resident #1's neurologist, who recommended to continue with the current medication regimen and follow-up in September. On [DATE] at 11:33 AM, Staff D, Licensed Practical Nurse (LPN), reported Resident #1 had Parkinson's and restless legs. She described her as very restless and shaky. Staff D stated Resident #1's eating was going downhill. She stated Resident #1's intake and swallowing got worse, she felt Resident #1 was declining. Staff D reported management tried to talk to the family about her decline but felt the family were in denial. Staff D stated Resident #1 had very dry lips and complained about one area on the corner of her lip. Staff D reported Resident #1 had a physician's order for Vaseline for her lips. Staff D reported the 3rd shift nurse had sent out a fax about Resident #1's difficulty swallowing and her dry lips. Staff D reported Resident #1 took her pills whole in applesauce and struggled a little bit to take them. Staff D reported Resident #1 came out to eat in the dining room at lunch and stayed in her room for breakfast. She reported she didn't know what she did at supper time. She stated Resident #1 fell asleep a lot during breakfast and that Staff D went in her room to give her encouragement to wake her up. Staff D stated she told the aides if Resident #1 needed assistance with eating. Staff D reported she didn't think Resident #1 had adaptive equipment for her shakes and jerks. On [DATE] at 11:45 AM, Staff A, CNA, reported Resident #1 liked to sleep in during breakfast so she received a room tray. Staff A stated she would elevate Resident #1's head of the bed and check on her to make sure she ate. Staff A reported she provided Resident #1 oral care after she ate. She reported Resident #1 would sometimes do her oral care herself and other times need assistance. Staff A stated Resident #1 voiced complaints of a sore mouth so the staff switched to using swabs instead of a toothbrush. Staff A stated Resident #1's lips had a couple of sores and she would pat the sores with a warm washcloth. Staff A stated she told the nurse about the sores sometime in June. Staff A stated they applied lip balm to Resident #1's lips. Staff A reported Resident #1 came out to the dining room for lunch and ate with a group of ladies. Staff A reported Resident #1 didn't eat or drink as much closer to the time she went to the hospital. Staff A stated she put food on the spoon and tried to give it to her. Staff A reported meal intakes they are supposed to record each meal but they missed it sometimes. She stated they had a lot of charting to do. On [DATE] at 12:07 PM, Staff E, CNA, reported Resident #1 didn't want to get woke up for breakfast. She stated Resident #1 ate in her room, usually cereal and milk. Staff E reported Resident #1 would complain that her mouth was dry. She stated she couldn't suck from a straw because of her dry mouth so they would use a regular cup. Staff E reported Resident #1 had a sore in the corner of her mouth, she put Vaseline on it. She stated she told a nurse about the sore. Staff E reported at the beginning of June she started to see a decline in Resident #1. She stated Resident #1 got stiff and shook really bad. Staff E reported when Resident #1 started to decline, the staff helped cut up her food and put the food on her fork. She stated Resident #1 didn't like the staff feeding her and wanted to do it herself. Staff E reported Resident #1 sat at a regular table and then they moved her to an assisted table when she didn't eat well. Staff E stated Resident #1 would eat in her room at times when her husband visited and helped her. Staff E reported she didn't know of any adaptive equipment. Staff E remarked it was hard to document intakes. She stated it is so busy during the day but they tried their best to get it done. She stated they expected them to document meal intakes. On [DATE] at 12:56 PM, Staff F, CNA reported Resident #1 had a gradual decline and that she had mentioned to the nurses she felt she would be a hospice candidate but she was a full code. Staff F stated Resident #1 had tremors and shakes that got really bad. Staff F described Resident #1 as never a big eater. Staff F stated Resident #1 got out of bed between 9 - 9:30 AM. She stated Resident #1 would lie in bed and eat dry cheerios. She described Resident #1 prior to her hospitalization , as very jumpy and dropped silverware/cups. Staff F stated they moved Resident #1 to an assisted table a week or two before she went to the hospital. Staff F stated she tried to give Resident #1 a bite of food and she would turn her head. Staff F reported Resident #1 had sores in the corner of her mouth and they received orders for Vaseline. She stated the regular Chapstick didn't work. She described Resident #1's lips as very sore. She would pull her head away when they tried to apply the squeeze tube gel. She stated she told a nurse about the sores to her lips. On [DATE] at 1:44 PM, Staff G, CNA, reported Resident #1 didn't eat a whole lot. He stated Resident #1 was never a breakfast person. Staff G reported Resident #1 sat at an assistive table for a few weeks before she went to the hospital. Staff G reported Resident #1 had a poor appetite and intake. Staff G stated Resident #1 didn't respond to the food. Staff G reported Resident #1's had a better fluid intake than food intake. He stated Resident #1 had Parkinson's really bad, due to this the staff had a difficult time providing her due to being really shaky. He stated he offered oral care when Resident #1 got up in the morning and at lunch after she ate. Staff G stated Resident #1 would close her mouth at times and they couldn't get a swab in there. He stated he had difficulties putting on the Chapstick, too. Staff G stated Resident #1's lips looked sore but she didn't complain of any mouth or throat pain. He reported Resident #1 had a water pitcher in her room. He described her as shaky and would spill, so he went and give her drinks. She took one swallow and quit. He reported he didn't know of any adaptive equipment. On [DATE] at 4:00 PM, Staff B, Registered Nurse (RN) reported learning in report on the weekend of [DATE] that Resident #1 had difficulty swallowing her medication. She stated she noted Resident #1 had a as needed (PRN) order to crush medications. Staff B stated she liked to try putting the pills in applesauce first. She stated Resident #1 could take the pills in applesauce but the bigger pills she pocketed. She stated Resident #1 needed a lot of encouragement to swallow and it would take 5 - 10 minutes to give her medications. Staff B reported she liked to offer a full glass of water at each medication pass but Resident #1 wasn't wanting to drink. Staff B reported Resident #1 would only take sips of water. Staff B stated Resident #1's daughter sat at her bedside on [DATE] and told her mom that she needed to drink water, but Resident #1 didn't want to. Staff B stated on the last day of her rotation, Resident #1's husband told her he thought Resident #1 might have a sore throat. Staff B stated she was pretty positive it was Sunday night ([DATE]). Staff B stated she told the husband she would assess Resident #1. Staff B reported she looked into Resident #1's mouth with a light. Staff B stated she didn't see any redness or irritation. When she asked Resident #1, if her throat hurt she said no. Staff B stated she didn't see any signs or symptoms of pain when Resident #1 swallowed. Staff B reported she didn't document her throat assessment in the clinical record but passed on the husband's concern in the report but couldn't recall which nurse she passed it on to. On [DATE] at 6:41 AM, Staff H, RN, reported she worked the weekend before Resident #1 went to the hospital. Staff H reported the staff usually checked the residents for incontinence twice a shift. They checked on Resident #1 more frequently due to her high risk for falls. Staff H stated she applied a mouth moisturizer to Resident #1's lips and mouth as they were so dry. She described Resident #1's tongue as dry and red. She stated she didn't see any rashes. Staff H stated she gave Resident #1 mouth swabs and tried to get her to suck on the swab due to the dryness. Staff G stated she tried thickened liquids to see if it would help. She stated she messaged the Physician about Resident #1's bowels not moving and also about her swallowing problems. Staff H reported when she tried to put Chapstick on Resident #1's lips, she said it hurt. She described Resident #1's lips as very dry and scabbed. She felt that caused her to hurt. Staff H stated the facility talked about her decline and exploring hospice. She stated at the time she didn't know Resident #1 wished to be a full code. She stated she thought the facility was heading for the direction of hospice care. She stated the first step she thought would be to change Resident #1 s code status. Staff H stated she did think about sending Resident #1 out to the hospital for an evaluation but she being pretty new, she didn't know the procedures. She stated Resident #1 had dark urine output. Staff H stated during report they said Resident #1 had more difficulty feeding herself and they moved her to an assisted table. She stated she didn't know when they moved her to the assisted table, but it wasn't too many days before she went to the hospital. She stated working overnight a lot of people are sleeping and you don't get to interact as much as days/evening shifts. She stated she assisted the CNA with Resident #1's cares. Staff H stated she tried her best to get Resident #1 to drink, offering small amounts of water frequently. On [DATE] at 9:15 AM, Staff I, RN, reported she worked on [DATE] and she learned in report that Resident #1 had a hard time taking her medications and needed her medications crushed. She stated when they put Resident #1 to bed that night she had a hard time understanding her but the one thing she did understand is that Resident #1's mouth hurt. She described her mouth around her lips as really dry, with some dried blood. She stated she cleaned Resident #1's mouth up and applied Chapstick cream. She reported Resident #1 had trouble swallowing so she filled up a straw with water and put a drop in her mouth. She stated Resident #1 didn't voice any throat pain. She stated the pain came from the cause of the dried blood around her mouth. She stated there was nothing in Resident #1's mouth. She stated she didn't look at her throat as she didn't have a flashlight. Staff I reported a couple days later, they moved Resident #1 to the feeding table. She stated she didn't know if speech was involved or not. She stated she did ask about hospice and they said the family won't do that. On [DATE] at 9:30 AM, the DON knew about Resident #1's weight loss. The DON stated the Nurse Manager received the information on Friday, [DATE] and she re-sent the information via email to the Nurse Manager on Monday, [DATE] to address. The DON reported with swallowing difficulties she would expect the nurses to assess the situation, notify the provider right away and follow what they advise. She stated she expected someone to notify the provider prior to [DATE] regarding Resident #1's swallowing difficulties. On [DATE] at 9:30 AM, Staff C, RNC (Regional Nurse Consultant) reported she expected the staff to chart intakes for meals and fluids, if they were on a monitoring program. She stated she expected the staff to document whatever the resident had on their task list. Staff C verified Resident #1 should have intake documentation completed for each meal and hydration on days, evenings and overnights. On [DATE] At 12:30 PM, Staff C acknowledged Resident #1 didn't receive speech therapy and the facility didn't follow through on the Physician Order from [DATE]. On [DATE] at 8:41 AM, Resident #1's husband described his wife as not doing very well at that time. He stated his wife had a stay in the hospital and then moved to another nursing home. Resident #1's husband reported he thought his wife had a sore throat for a couple of weeks. He stated he knew his wife told the staff about her sore throat. He reported being there when she told the staff. When asked what the staff did regarding her throat hurting, he stated not much. He reported the staff would give her water but she could hardly talk, she had very dry and sore lips. He stated it was hard to say what the staff did behind the scenes. He stated he didn't see the staff examine or inspect her mouth or throat when he was present. He stated he knew of his wife's swallowing difficulties and her poor intakes. He stated his daughter had to call his wife's doctor to set it up for his wife to go to the hospital. On [DATE] at 9:14 AM, Resident #1's daughter reported she learned for the first time on [DATE] of her mom's sore throat. She stated she visited her mom and asked to look in her mouth. She described her tongue as bright red and the back of her throat appeared red with spots. She stated she knew the week before her mom didn't eat well and they switched her to an assisted table that Thursday, so she decided to look into her mouth to see if that caused her to not eat. She stated she called her mom's provider the next day, [DATE] to see they could do. She stated the Provider said they should probably see her mom in the ER. She stated she didn't think she talked to anyone at the nursing home on the evening of the 30th as she didn't see anyone around. She stated prior to the 30th she didn't recall her dad mentioning anything about her mom having a sore throat. She stated her dad had more concern about her not eating. She stated in theER on Monday her dad did mention her mom had told him she had a sore throat. She reported she didn't know when her mom told her dad about the sore throat. She stated she called him Sunday night to tell him about what she saw in her throat. She didn't recall if he had mentioned anything about a sore throat then or not. She stated she didn't think about looking into her mom's mouth until Sunday. She reported she couldn't tell how long her throat had been like that. She stated she honestly didn't know, it could be the day before or weeks before. She stated her mom had a lot of ups and downs, she usually associated it with a UTI (urinary tract infection) or her Parkinson's. She stated her mom received the all clear of a UTI on [DATE] in the ER, so she knew it wasn't that. She reported at the hospital on [DATE] her mom had lunch and fed herself, eating and drinking on her own okay. She stated in the ER the doctor talked about Lewy body dementia and how the symptoms could come and go. She described her mom's Parkinson's as finicky and they struggled figuring out the right dosage of medication. She stated her mom's primary care provider (PCP) didn't see her since the last certification, when she was doing well. She stated when she called the PCP on [DATE], the provider didn't know about her mom's condition change related to the poor intakes, difficulty swallowing, and/or her sore throat. A facility policy titled Hydration Program effective date [DATE] documented the purpose of the policy was to provide adequate fluid for residents, encourage fluid intake and prevent dehydration. The policy documented these procedural steps: 1. Each resident must have fresh water at the bedside. 2. The staff need to change water pitcher and glass once each 24 hours. 3. Offer each resident a fresh drink when they pass the water. 4. Offer fluids at least mid-morning, mid-afternoon, before retiring at night, and early in the morning. 5. Encourage residents to drink all of their fluids at mealtime. 6. Encourage residents to drink 4 - 8 ounces with each medication pass. 7. Residents with poor fluid intake should have alternative approaches offered, such as popsicles, gelatin, or sugar-free drinks. 8. The staff should monitor the intake of fluids for all residents with feeding tubes or those with fluid restrictions. 9. Monitor for increased signs of thirst; e.g. dry mouth, wetting lips, taking beverage from others. 10. Monitor medication side effects that cause hydration. 11. Monitor for increased confusion, fatigue (tiredness), hot or cold sensations, muscle cramping, headache, dry mouth, crusty dry eyes, dry mucous membranes, and excessive diaphoresis (sweating). 12. Monitor for dark concentrated urine. 13. Monitor for constipation. 14. Monitor abnormal vital signs, orthostatic hypotension (low blood pressure), tachycardia (fast heart rate greater than 100 beats per minute), fever. The policy directed the following regarding documentation: 1. Record intake and output for all residents with catheters, restricted fluids, tube feedings, or forced fluids, then total every 24 hours. 2. Record any unusual pattern of fluid intake in nurse's notes and/or monthly summary[TRUNCATED]

Based on clinical record review, staff interviews, and policy review the facility failed to notify the physician and family for a significant change in condition for 2 of 4 residents reviewed (Residents #1 and #4). The facility reported a census of 32 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS listed Resident #1 as independent with bed mobility. Resident #1 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS described Resident #1 as ambulatory walking 10 feet and required a wheelchair for locomotion. The MDS documented Resident #1 had frequent incontinence of bowel and bladder. Resident #1's MDS included diagnoses of hypertension (high blood pressure), non - Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation (irregular heartbeat), and fibromyalgia (disorder that causes musculoskeletal pain/tenderness). The Facility Event Report dated 6/17/24 at 8:00 AM identified an unwitnessed fall in Resident #1's room. Someone observed Resident #1 lying on the floor next to her bed in a low position. Resident #1 had her feet under her bed with her head facing the door laying on her left side. Resident #1 reported she had pain but couldn't advise the location. The assessment revealed visible, old, healing bruises, yellow/green in color to ankle from a previous fall with no new skin areas noted. The note documented the staff would notify Resident #1's husband of her fall when he arrived at the facility. A Progress Note dated 6/18/24 at 10:45 PM documented a certified nurse aide (CNA) notified the nurse during report around 10:45 PM that Resident #1 had discoloration to the posterior (back) aspect of the right chin. Upon inspection, the area measured 3 x 5 not measurable in cm (centimeters), the area looked red and purple. Resident #1 denied pain. A Progress Note dated 6/19/24 at 10:58 PM documented the nurse spoke to the family regarding the Resident #1's recent fall. A Progress Note dated 6/21/24 at 9:00 AM reflected Resident #1 awake to take morning medications. She took them with applesauce and then coughed on the drink of water after. Resident #1 acted very confused with slurred speech, minimal urine output, inability to transfer, or even sit up unassisted. A Progress Note dated 6/21/24 at 9:01 AM indicated Resident #1's primary care provider (PCP) called. The nurse notified them regarding Resident #1's change in condition and new order received to send to emergency room (ER) for evaluation and treatment. Daughter informed about the new order and her condition. A Progress Note dated 6/21/24 at 10:51 AM documented Resident #1 left facility via ambulance for the ER with papers given to the Emergency Medical Technicians (EMTs). A Progress Note dated 6/21/24 at 1:30 PM identified the facility received a phone call from ER. Resident #1's labs and scans came back normal. The caller described Resident #1 as in and out of it while at the ER. The hospital would return Resident #1 to the facility via ambulance with no definitive diagnosis. A Progress Note dated 6/22/24 at 10:55 AM indicated Resident #1 had garbled speech and had difficultly making others understand. Resident #1 had difficulty swallowing medications and water that morning. She received her medications crushed and taken to the dining room for breakfast to monitor due to her difficulty swallowing. A Progress Note dated 6/22/24 at 1:47 PM reflected Resident #1's husband came to the facility at lunch time and sat with Resident #1 in her room for lunch. Resident #1 took her medications whole and swallowed quite a few times before getting them down but didn't need them crushed. Her speech remained garble but had some improvement. Resident #1's husband knew of her swallowing issues that morning. A Progress Note dated 6/22/24 at 9:38 PM documented Resident #1 required maximum assistance of two with activities of daily living (ADLs). Resident #1 had difficulty swallowing her bedtime medications but eventually got the medications down. Resident #1 had a dry oral cavity and cracked lips. She received oral cares and encouragement to drink. According to the note, it took several attempts for Resident #1 to figure out how to drink. Resident #1 blew air into the straw before she eventually started sucking water through the straw. A Progress Note dated 6/23/24 at 2:39 AM documented Resident #1 received crushed Tylenol in applesauce for complaints of mouth pain. Resident #1 had cracked lips with blood, staff cleaned her lips with a washcloth. Resident #1 couldn't drink water by herself and needed staff assistance. Resident #1 unable to suck properly from the straw. A Progress Note dated 6/23/24 at 11:09 AM documented Resident #1 wouldn't open her eyes but did communicate with the nurse. Resident #1's mouth and lips remained dry. Resident #1 received 2 smaller medications and sips of water. Resident #1 struggled to get the medications down and gargled on the water. The nurse crushed the rest of her medications in applesauce and then she could get the medications down. A Progress Note dated 6/23/24 at 8:04 PM documented Resident #1 had poor intake at supper, only eating strawberries and bananas. Resident #1 acted confused and had difficulty following instructions. A Progress Note dated 6/25/24 at 9:55 PM identified Resident #1's husband told the nurse Resident #1 didn't eat much of her dinner. The note indicated someone would offer her snack, if Resident #1 seemed to be hungry throughout the night. A facility form titled Nursing Memo Form dated 6/28/24 at 3:20 AM documented the facility notified Resident #1's Physician of her difficulty swallowing thin liquids, dry/chapped lips, and she didn't have a BM since 6/20/24. She received a suppository on 6/27/24 with no results. A Progress Note dated 6/28/24 at 3:30 AM reflected Resident #1 received a small amount of thin liquids and immediately started coughing. Resident #1 didn't have bowel movement. A Progress Note dated 6/28/24 at 11:01 AM indicated the facility received a fax regarding Resident #1's current condition. The fax included new orders to send her medication list, speech therapy (ST) to evaluate and treat. In addition, apply Vaseline to upper and lower lips. A Progress Note dated 6/28/24 at 11:17 PM indicated the facility faxed Resident #1's Medication Administration Record (MAR) to Resident #1's PCP. The staff notified therapy and her husband of her new orders for ST. A Progress Note dated 6/28/24 at 6:56 PM documented Resident #1 had a 9.1% weight loss in 30 days, 11.8% weight loss in 90 days and 10.4 % weight loss in 180 days. Weights as follows: a. 12/26 was 128.8 pounds (#) b. 1/30 was 134# c. 2/27 was 132.8# d. 3/26 was 130.8# e. 4/10 was 133.2# f. 5/28 was 127# g. 6/12 was 119.6# The progress note documented current weight 115.4# and a body mass index (BMI) 22.5. The note described Resident #1 as independent at meals and with a stable weight until 5/28/24 - 6/12/24. PO (by mouth) intakes have noted to have decreased since fall on 6/8/24; general decline potentially occurring. Resident #1 had an order for speech therapy and was coughing on small sips of thin liquid. Estimated needs include 1300 - 1560 kcals, 42 - 52 grams of protein, and 1500+ ml (milliliters) fluids per day. The dietician recommended a house supplement 4 ounces twice a day between meals. The clinical record lacked documented Resident #1's PCP or family wasn'tified regarding the weight loss. The clinical record reflected no one notified Resident #1 s Physician of her poor meal intakes, poor fluid intakes, and recent weight loss. Resident #1 started having difficulty swallowing on 6/20/24, went to the ER (emergency room ) on 6/21/24 and returned to the facility. Resident #1 continued to have difficulty with swallowing with decreased oral intakes after returning from ER. The facility didn't notify Resident #1's Physician of the continued decline until 6/28/24, the day she received a new order for Speech therapy. A Progress Note dated 6/30/24 at 9:28 PM documented the staff encouraged Resident #1 to drink water throughout the shift. Resident #1 had difficulty swallowing medications with each medication pass, as she pocketed medications and held water under her tongue. Resident #1 didn't eat much dinner that evening. Family at bedside and encouraged fluids. The facility report titled Intake: Breakfast, Lunch, and Dinner from 6/1/24 to 7/1/24 listed meal intakes documented only on the following dates: 6/4/24 = Dinner - 76 - 100% 6/7/24 = Dinner 76 - 100% 6/8/24 = Dinner 26 - 50% 6/9/24 = Breakfast 76 - 100% 6/9/24 = Dinner 26 - 50% 6/12/24 = Dinner 26 - 50% 6/15/24 = Dinner 26 - 50% 6/16/24 = Dinner 26 - 50% 6/19/24 = Dinner 51 - 75% 6/21/24 = Dinner 26 - 50% 6/24/24 = Dinner 51 - 75% 6/25/24 = Dinner 26 - 50% 6/26/24 = Dinner - none 6/28/24 = Dinner - 26 - 50% 6/30/24 = Breakfast 26 - 50% The facility report titled Intakes: Fluids from 6/1/24 to 7/1/24 documented fluid intakes only on the following dates: 6/1/24 - 60 ml 6/2/24 - 450 ml 6/3/24 - 500 ml 6/4/24 - 150 ml 6/5/24 - 400 ml 6/6/24 - 300 ml 6/7/24 - 1400 ml 6/8/24 - 240 ml 6/9/24 - 50 ml 6/10/24 - 200 ml 6/11/24 - 500 ml 6/13/24 - 950 ml 6/14/24 - 500 ml 6/15/24 - 550 ml 6/16/24 - 50 ml 6/17/24 - 50 ml 6/19/24 - 1000 ml 6/21/24 - 450 ml 6/22/24 - 100 ml 6/24/24 - 590 ml 6/25/24 - 240 ml 6/26/24 - 400 ml 6/27/24 - 50 ml 6/28/24 - 100ml 6/29/24 - 50 ml 6/30/24 - 50 ml 7/1/24 - 50 ml On 7/9/24 at 4:00 PM, Staff B, Registered Nurse (RN), reported on 6/19/24 Resident #1's daughter spoke to her regarding concerns about a bruise on her mom's chin. Staff B stated she looked into the concerns and told the daughter the clinical record documentation. Staff B stated Resident #1's daughter reported no one notified the family of her fall on 6/17 that resulted in the bruise on the Resident #1's chin. Staff B stated she apologized to the daughter and spoke to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) about the family's concern. She stated she passed it on in report to notify the family or leave a message. On 7/10/24 at 9:30 AM, the DON reported she would expect the staff to notify the family within 48 hours of a condition change or identification of the change. The DON acknowledged the family learned of the fall from 6/17/24 on 6/19/24 when they questioned how Resident #1 received a bruise on her chin. On 7/10/24 at 9:30 AM, the DON knew about Resident #1's weight loss. The DON stated the Nurse Manager received the information on Friday, 6/28/24 and she re-sent the information via email to the Nurse Manager on Monday, 7/1/24 to address. The DON reported with swallowing difficulties she would expect the nurses to assess the situation, notify the provider right away and follow what they advise. She stated she expected someone to notify the provider prior to 6/28/24 regarding Resident #1's swallowing difficulties. 2. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #4 required supervision/touching assistance with bed mobility. Resident #4 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS indicated Resident #4 was ambulatory walking 50 feet and required a wheelchair for locomotion. Resident #4's MDS included diagnoses of pneumonia, diabetes mellitus, COPD (chronic obstructive pulmonary disease), dementia, and intellectual disabilities. A Progress Note dated 7/2/24 at 1:04 PM documented Resident #4 had an unwitnessed fall in her room. The note reflected when found Resident #4 sat on her bottom in front of her table. The assessment found her skin free of injury. A Progress Note date 7/2/24 at 9:56 PM documented Resident #4 had a bruise to her right flank. Resident #4 stated, I knew I was going to get a bruise from my fall. The clinical record lacked documentation that the facility notified Resident #4's Physician or family/resident representative of her bruise to the right flank identified after the fall. On 7/11/24 at 2:52 PM, Staff C, Regional Nurse Consultant (RNC), confirmed she couldn't locate the physician or family notification for Resident #4's bruise to her right flank. Staff C reported they expected the facility notify the family and physician of a bruise that occurred related to a fall. A facility policy titled Resident Representative and PCP Notification dated 11/16/23 directed to notify the Resident representative in person or by phone as soon as possible of the following: a. Changes in physician's orders occurring between approximately 8 AM - 10 PM. b. Serious injury or significant change of condition unless otherwise specified. c. ED visits or hospitalization d. Incident that occur after 10 PM, notify on the following day i. Fall without injury ii. Routine changes in PCP orders e. The facility will notify the PCP in person or by phone as soon as possible (ASAP) of the following: i. Serious injury or significant change of condition ii. Falls resulting in head injury of resident on anticoagulants iii. ED visits or hospitalization iv. Critical labs/x - rays v. Death f. Requests for immediate changes in treatment. i. An accident - causing injury and has the potential for needing physician intervention. ii. A deterioration in health, mental or psycho - social status in either life-threatening conditions or clinical complications. g. The facility may notify the PCP by fax for the following: i. Falls without injury ii. Requests for routine changes in physician's orders h. The facility will call about Issues falling outside of these parameters to the PCP and resident representative. i. The facility should review the resident's wishes with the resident/representative and physician prior to decision being made for hospital transfers.

Based on observations, staff, and family interviews the facility failed to provide a safe, clean, comfortable environment for 1 of 4 residents reviewed (Resident #1) for a homelike environment. The facility reported a census of 32 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #1 was independent with bed mobility. Resident #1 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS indicated Resident #1 was ambulatory walking 10 feet and required a wheelchair for locomotion. The MDS documented Resident #1 had frequent incontinence of bowel and bladder. Resident #1's MDS included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation (irregular heartbeat), and fibromyalgia (disorder that causes musculoskeletal pain/tenderness). The Resident Census tab reflected Resident #1's admitted [DATE] to room [ROOM NUMBER] - 1. Resident #1 discharged from the facility on 7/1/24. On 7/11/24 at 9:14 AM, Resident #1's daughter reported when they picked up her mom's belongings on July 4th, it was the first time she saw a cleaning cart the entire time her mom lived at the facility, she described her mom's room as dirty. She reported when she visited her mom, her son like to take off his shoes and by the time they left her son's feet were black. On 7/11/24 at 11:10 AM observation of room [ROOM NUMBER] - 1 revealed the room not cleaned after Resident #1 discharged from the facility on 7/1/24. Observed personal hygiene items, washcloths, towels, bedpans and a full-body mechanical lift in the bathroom. On the wall and light fixture on the left side of the room behind the bedside table, observed dried splattered substance that ran down the wall. The base of the toilet in the bathroom appeared dirty with dust particles and a dried brown substance. The corner wall behind the toilet had a spider web with a small spider in it. The floor in the bathroom and main living area was dirty with dust and debris particles. The base boards in the bathroom looked scratched up and dirty. The window seal and window shelf had a large amount of dust. Observed between the glass window and window screen spider webs with two large spiders. On 7/11/24 at 11:20 AM, Staff J, Housekeeping Supervisor, acknowledged the room wasn't clean. She reported she waited to make sure the family picked up all the belongings. She acknowledged the dry substance on the light fixture/wall, spiders, and dust build up. Observed a large amount of dust particles on Staff J's hand after she ran her hand along what window ledge/shelf. She acknowledged having challenges with housekeeping staff in June. She reported a week and half ago she started to have a housekeeper daily 7 days a week. She stated prior to that it was whoever was available to do it. She stated she did some of the housekeeping herself. She reported her normal housekeeper needed off for a period of time due to an injury. Staff J brought a housekeeper in the room and showed her the areas that needed cleaned and asked her to suck out the spiders from the windows and back of the toilet. On 7/11/24 at 12:20 PM, Staff J agreed the room [ROOM NUMBER] - 1 condition and cleanliness wasn't acceptable. She reported when she runs her hand along the window edge she shouldn't get dust on her hand. Staff J stated Room Cleaning Policy needed changes. The facility provided a To - Do List for daily cleaning to clean resident's rooms directed the following: - Resident bathrooms and trash daily - Room dust, sweep and mop 1 to 2 times a week The Environmental Service policy dated April 2024 instructed the facility to ensure cleanliness in all areas of the nursing center. In addition, the policy directed to thoroughly clean the resident rooms with the following procedure: - Empty wastebaskets, replace liner - Wipe down all bathroom fixtures with correct cleaning solution including sink, counter areas, resident provided fixtures, furniture, handrails, or equipment - Clean stool with correct cleaning solution - put cleaning solution in stool, brush to clean, flush - wipe off rim, seat, and entire outer shell of stool - Clean mirror - Wipe and clean light fixtures - Wash window as needed - Clean fill soap dispenser - Clean and fill towel dispenser - Wipe down wall walls of bathroom as needed - Wipe down shelves, end table, nightstand, bed, ect. Including legs - Wet mop restroom - Wet mop living area/vacuum

Based on clinical record review and staff interviews, the facility failed to provide Speech Therapy (ST) as ordered by the Physician order for 1 of 1 resident reviewed (Resident #1) for therapy services. The facility reported a census of 32 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #1 was independent with bed mobility. Resident #1 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS indicated Resident #1 was ambulatory walking 10 feet and required a wheelchair for locomotion. The MDS documented Resident #1 had frequent incontinence of bowel and bladder. Resident #1's MDS included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation (irregular heartbeat), and fibromyalgia (disorder that causes musculoskeletal pain/tenderness). A Physician order dated 5/21/24 directed the facility to provide Physical (PT), Occupational (OT), and ST evaluation and treatment. A Progress Note dated 5/21/24 at 1:46 AM documented Resident #1 returned from her appointment with new orders for PT, OT, ST for Parkinson's disease and falls. A Progress Noted dated 5/22/24 at 1:39 PM documented the Physical Therapy Assistant (PTA) at the facility. The staff informed her in person regarding Resident #1's new orders for PT, OT and ST therapy. The Clinical Record lacked documentation that Resident #1 received a ST evaluation and treatment as ordered by the Physician. On 7/10/24 At 12:30 PM, Staff C, Regional Nurse Consultant (RNC) confirmed Resident #1 did receive ST and the facility didn't follow-up through on the Physician's Order from 5/21/24. The Physician/Extenders Orders policy effective date April 2024 documented the charge nurse must record the physician orders in the electronic medical record or other appropriate places as designated by the nursing policy. In addition, if the facility didn't follow through on orders, they need to notify the Primary Care Physician and Power of Attorney within approximately 24 hours and document it in the electronic health record.

Based on clinical record review, staff interviews, and policy review the facility failed to accurately document a fall and the required assessment related to a fall in the medical record for 1 of 4 residents reviewed (Resident #4). The facility failed to complete thorough incident reports for 3 out 4 residents (Residents #4, #1, and #2). The facility reported a census of 32 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #4 required supervision/touching assistance with bed mobility. Resident #4 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS indicated Resident #4 was ambulatory walking 50 feet and required a wheelchair for locomotion. Resident #4's MDS included diagnoses of pneumonia, diabetes mellitus, COPD (chronic obstructive pulmonary disease), dementia, and intellectual disabilities. A Facility Event Report (facility incident report) dated 6/6/24 at 12:45 PM reflected Resident #4 had an unwitnessed fall in her room. The description stated Resident #4 put on her call light and then tried to get up to use the restroom. She tripped on either the call light or the oxygen tubing. She denied hitting her head and reported she landed on her bottom. The review of the event report revealed an incomplete form. The following sections on the event form were blank and not filled out: event details, subjective data, environment, pain observations, body observations, neurological check, mental status, and interventions. Review of the Progress Notes dated 6/6/24 and 6/7/24 lacked documentation that Resident #4 fell . The progress notes lacked documentation of a fall assessment, neurological assessment including vital signs, post fall evaluation and a fall risk evaluation. 2. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #1 was independent with bed mobility. Resident #1 required partial/moderate assistance of one staff member with transfers and toilet use. The MDS indicated Resident #1 was ambulatory walking 10 feet and required a wheelchair for locomotion. The MDS documented Resident #1 had frequent incontinence of bowel and bladder. Resident #1's MDS included diagnoses of hypertension (high blood pressure), non - Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation (irregular heartbeat), and fibromyalgia (disorder that causes musculoskeletal pain/tenderness). The Progress Note dated 6/21/24 at 4:00 PM documented the CNA notified the nurse Resident #1 fell . The nurse discovered Resident #1 laying on the floor beside her bed on her left side facing her nightstand. Resident #1 reported she tried to get from there to the bookcase. Neurological checks within normal limits. Resident #1 had two new open injuries, a small skin tear to left anterior forearm, and to her right toe. The Facility Event Report dated 6/21/24 at 4:00 PM identified Resident #1 had an unwitnessed fall. The event report lacked documentation regarding the event detail, subjective data obtained from the resident, environment details, pain observation, body observation, mental status, possible contributing factors, and the immediate intervention taken. 3. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #2 as independent with bed mobility, transfers, and walking 150 feet. Resident #2' s MDS included diagnoses of syncope (fainting) and collapse (fall), muscle weakness, pain in the right hip and lack of coordination (balance). A Progress Note dated 4/15/24 at 7:52 AM documented Resident #2's husband notified staff that his wife fell on the floor. The staff observed Resident #2 sitting behind the door of her room on her bottom with her legs extended out in front of her. Resident #2 held herself up with both of her hands open on the floor with her elbows locked. Resident #2 explained as she looked in her closet, she slipped and landed on her bottom. Resident #2 had pain/discomfort in her right leg along with shortening and external rotation. The staff called the Primary Care Provider (PCP), who gave an order to send Resident #2 to the emergency room . An Event Report dated 4/15/24 at 7:52 AM documented Resident #2's husband notified the staff that his wife fell on the floor. Review of the event report revealed an incomplete form. The following sections on the event form were blank and not filled out: event details, subjective data, environment, pain observations, body observations, neurological check, mental status, possible contributing factors, notification guidelines, and interventions. On 7/11/24 at 8:15 AM, Staff C, Regional Nurse Consultant (RNC), reported she expected the staff to fill out the event form (incident report) entirely. She also stated she expected the staff to document a fall in the progress notes. On 7/11/24 at 1:45 PM, Staff C acknowledged the facility had a concern with the completion of incident reports. She reported the facility planned to start a Process Improvement Plan (PIP) team to review the process and provide staff education. The Electronic Medical Record policy effective April 2024 instructed the facility to maintain medical records on each resident within accepted professional standards of practice. The policy further documented that the electronic medical record will contain sufficient information to identify the resident, a record of the resident assessments and incident/risk management records completed by nursing staff upon unusual occurrences taking place in the facility.

Based on clinical record review, policy review and staff interview, the facility failed to have a system in place to ensure residents who use Coumadin (blood thinner) received their therapeutic monitoring as ordered by the physician for 3 of 3 residents reviewed (Residents #5, #13, #16). The facility failed to get Resident #5 and Resident #13's lab draws completed for at least 6 days. Resident #13 had an elevated lab level that required the facility to hold his medication for 2 doses. When Resident #5 missed her lab draw, the facility failed to get her lab draw completed resulting in her missing 8 days of her coumadin. The facility failed to follow the Physician's order for Resident #16 and drew their lab early resulting in a low therapeutic level for their convenience. When interviewed the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) reported someone else had the responsibility for ensuring the labs got completed. The DON showed the survey team her desk and said the orders might be on there, with her hand on a 4-inch pile of papers with orders. The facility didn't know they had a problem until the surveyor questioned an order. The facility failed to ensure orders got implemented. The survey team notified the facility of the immediate jeopardy (IJ) on 4/3/24 at 4:45 PM, that began on 3/27/24. The facility removed the immediacy on 4/4/24. a. On 4/2/24 the facility reviewed all 3 residents and ensure each resident received the correct Coumadin dose and completed a lab requisition slip for each resident for their next lab draw. b. The facility developed a new lab order process that involved the use of a lab log and lab requisition order. c. On 4/3/24 the facility educated the nurses regarding the new processes for lab orders, prothrombin time (PT)/ international normalized ratio(INR) orders tracking and residents on anticoagulants that receive an order for an antibiotic. The facility lowered the scope and severity from a level J to a D after ensuring the facility implemented their removal plan. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) of 7, indicating severely impaired cognition. The MDS indicated Resident #13 received an anticoagulant (Coumadin) within the previous 7 days or since admission. Resident #13's Resident Profile reviewed on 4/9/24 at 10:54 AM included diagnoses of an acute embolism (blood vessel blockage), thrombosis (limited blood flow) of unspecified deep veins of the lower left extremity, and long term (current) use of anticoagulants. The Care Plan Problem revised 2/26/24 identified Resident #13 had long term use of anticoagulant therapy related to an acute embolism and thrombosis of unspecified deep vein of distal lower extremity and another pulmonary embolism. The Care Plan documented a goal of no active bleeding. Resident #13's Active Orders reviewed on 4/3/24 included the following blood thinner orders effective 2/14/24: a. Warfarin 2.5 milligrams (MG) once a day on Monday, Wednesday, Friday 4:00 PM 7:00 PM. b. Warfarin 5 MG once a day on Tuesday, Thursday, Saturday 4:00 PM 7:00 PM. The Progress Notes dated 4/2/24 at 5:01 PM written by the Director of Nursing (DON) indicated they discovered Resident #13 missed their INR following the discovery of another resident with a missed INR. Each person who received Coumadin had their medical chart reviewed, revealing Resident #13 had an order for an INR lab draw scheduled for 3/28/24. The nurse failed to enter the lab draw into the Medication Administration Record (MAR), therefore causing no completion of the lab. The DON added Resident #13 continued to take the current dose of Coumadin during that time. The facility received an order to draw a stat (immediate) PT/INR lab. Review of untitled hospital form with current Coumadin dosage and next INR lab draws for Resident #13 listed his INR goal as 2.3, with a diagnosis of history of deep vein thrombosis (DVT). On 2/28/24 documentation revealed an INR level of 2.63 with the next INR draw for 1 month and to continue the current dose. The form lacked documentation of an INR drawn on 3/28/24. On 4/2/24 documentation revealed an INR of 3.52 and with an order to hold 2 doses of Coumadin and then change the order to 5 MG for 4 days and 2.5 MG for 3 days. On 4/3/24 at 12:05PM, the DON reported the Assistant Director of Nursing (ADON) conducted a monthly audit to monitor INR and Coumadin orders. The DON added she didn't have a process in place to ensure INR labs are completed as ordered. The DON then proceeded to place her hand on top of a stack of papers on her desk measuring approximately 4 inches, reporting it as orders. She reported being behind and that the orders for the INRs could be in the stack of papers. The DON again confirmed they didn't have a process in place to monitor INRs except a monthly audit that is completed by the ADON. On 4/3/24 at 12:17 PM, the ADON explained she completed an audit once a month regarding INRs and confirmed the facility didn't have a process in place to ensure the completion of INRs. According to undated information from the Coumadin manufacturer Bristol [NAME] Squibb Pharma Company, patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of warfarin (Coumadin). The cause of the increased sensitivity is unknown. The most serious risks associated with anticoagulant therapy with Coumadin are hemorrhage in any tissue or organ. Coumadin is a narrow therapeutic range drug and may be affected by factors such as other drugs. Periodic determination of PT/INR is essential. The Anticoagulant Therapy policy dated March 2024, instructed the resident response to warfarin therapy will be evaluated on the basis of International Normalized Ratio (INR). The physician will direct how often the lab values are drawn and monitored. The most current copy of the resident's PT/INR will be kept in the resident's chart. During an interview 4/9/24 at 8:30 AM, the Director of Quality and Clinical Services remarked they expected the staff to follow INR orders as ordered. 47079 2. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS included diagnoses of diabetes mellitus, anemia (low iron blood level), venous insufficiency (a vein condition that allows blood to flow backward and pool in the legs), a cardiac pacemaker, prosthetic heart valve, and long term current use of anticoagulants (blood thinners). Resident #5 received an anticoagulant within the 7 day lookback period. The Care Plan Problem revised 1/13/24 indicated Resident #5 received anticoagulant therapy. The Intervention directed the staff to adjust the medication dosage per facility protocol, monitor labs, flowsheets as ordered. Resident #5's Order History reviewed on 4/9/24 at 10:18 AM included the following warfarin (anticoagulant) orders a. Started 3/6/24: 2.5 MG once a day on Sunday. The order discontinued on 3/13/24. - Laboratory order for a Prothrombin Time/International normalized ratio (PT/INR - blood test used to determine how long it takes blood to clot) dated 3/13/24. b. Started 3/13/24: 5 MG once a day on Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday. Resident #5's Medication Administration Record (MAR) dated 3/6/24 - 4/4/24 reflected she received warfarin continuously from 3/6/24 to 3/26/24. Resident #5's MAR dated 3/15/24 - 4/11/24 included an order regarding Coumadin Use interactions. The order contained special instructions that a recheck of the PT/INR may be warranted within 7-14 days of a medication change. Monitor for signs or symptoms of bleeding. Notify the Physician of any change in condition. A Progress Note dated 3/13/24 at 2:04 PM identified Resident #5's INR lab result as 1.67. On 4/2/24 at 3:49 PM, the Director of Nursing (DON) reported Resident #5 didn't receive their warfarin since 3/26/24. She stated an agency nurse received an order on 3/13/24 to collect a new INR on 3/26/24 but didn't enter the lab order in Resident #5's electronic health record (EHR). She confirmed they didn't collect the lab because it didn't appear on the DON's lab list and the pharmacy didn't send future warfarin due to the facility not sending a follow up order. The Coagulation Report (Lab Result) dated 4/2/24 at 7:14 PM listed the INR as 1.02. The Phone Message/Call *Final Report* dated 4/3/24 indicated the provider learned Resident #5 accidentally had her warfarin held for the previous week. The provider gave an order to resume warfarin at the current dose and recheck the INR in 1 week. 3. Resident #16's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of diabetes mellitus, atrial fibrillation (improper heart function that allows blood to pool inside the chambers), cerebral vascular accident (stroke), long term use of anticoagulants (blood thinners), a cardiac pacemaker (machine used to help pump blood in the heart effectively), and endocarditis (inflammation of the inner lining of the heart chambers and valves usually caused by a bacterial infection). It also indicated Resident #16 received an anticoagulant and an antibiotic within the 7 day lookback period. The Care Plan Problem dated 11/5/19 indicated Resident #16 received anticoagulant therapy. The Interventions directed the staff to be aware of possible drug interactions, such as antibiotics. The Order History report reviewed on 4/9/24 at 8:34 AM included the following orders: a. Dated 2/29/24: Warfarin 3 MG give 1.5 MG (0.5 tablet) once an evening. b. Vancomycin (antibiotic) 1 gram (200 milliliters ML). Give 1250 MG per 250 ML. - Dated 2/29/24: Once a day. Discontinued 3/9/24. - Dated 3/11/24: Once a day every other day. Discontinued 3/21/24. - Dated 3/21/24: Once a day on Saturday, Monday and Wednesday. Discontinued 3/29/24. - Dated 3/29/24: Give 1250 MG on 3/31/24 and 4/2/24 after Vancomycin draw. Discontinued 4/3/24. - Dated 4/5/24: Give 1250 MG on Friday. - Dated 4/8/24: Per 4/3/24 order, last dose scheduled. c. Dated 3/4/24: PT/INR. No documentation of subsequent PT/INR lab orders. The untitled hospital form with Coumadin dosages and next lab draw reflected Resident #16's INR goal as 2-3. The INR on 3/4/24 had a result of 4.3, with the next INR due in 2 weeks. The form lacked documentation of completed labs after 3/4/24. The Phone Message/Call *Final Report* dated 4/4/24 at 8:11 AM listed Resident #16's INR lab result as 3.11. The provider said to continue her warfarin at the current dose and recheck in one week. The Anticoagulant Therapy effective May 2024 directed the staff to minimize the adverse effects of anticoagulant therapy through laboratory monitoring ordered by the resident's physician and follow up. Warfarin and Antibiotics: Drug Interactions and Clinical Considerations published online 7/30/23 to the National Library of Medicine indicated due to its narrow therapeutic index, warfarin necessitates frequent monitoring and dose adjustments to maintain the delicate balance between adequate anticoagulation and the risk of bleeding or thrombotic (blood clot) complications. Monitoring is typically conducted by assessing a PT/INR, with diligent surveillance of any elevations in PT/INR levels to prevent adverse outcomes. However, one common complication associated with warfarin therapy is the heightened risk of major bleeding, particularly when co-administered with medications capable of influencing its metabolism. In particular, antibiotics have the potential to interfere with warfarin's anticoagulant effect through various mechanisms. Antibiotics can induce or inhibit the activity of cytochrome P450-2C9, an enzyme crucial for warfarin metabolism. Additionally, some antibiotics can disrupt the population of vitamin K-producing bacteria in the intestines, further modulating warfarin's pharmacological response. As a result, these drug interactions can either enhance or diminish warfarin's efficacy, with potential clinical consequences. The importance of managing these interactions becomes evident when considering the narrow therapeutic index of warfarin. Increased warfarin levels can have detrimental effects, while subtherapeutic levels may lead to inadequate anticoagulation. And while some antibiotic classes carry a higher risk of bleeding events than others, a comprehensive understanding of the potential interactions between different antibiotics, including penicillin derivatives, fluoroquinolones, cephalosporins, sulfa drugs, anti-mycobacterial agents, macrolides, and metronidazole and warfarin, is necessary.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 34. Findings include: During a continuous dining observation on 4/3/24 beginning at 12:05 PM, Staff E, Dietary Aide (DA), took the temperature of two (2) foods. The temperatures measured outside the acceptable holding temperature. The pureed tater tot casserole had a temperature of 133.1 Fahrenheit (F) and the chef salads temperature measured 52.1 F. At 12:08 PM, Staff E said she didn't normally check the temperature of a salad, she just served them. She reported she didn't even know how to check their temperature. At 12:12 PM, Staff A, Dining Services Manager (DSM), instructed Staff E to put the salads in ice the next time she brought salads to the dining area to they stayed cold. The facility served the residents the salads after checking their temperature. At 12:32 PM, Staff C prepared a resident plate containing the mechanical soft turkey. When asked to verify the temperature, Staff C measured the mechanical soft turkey temperature as 129 F. The staff reheated the turkey to 190 F before they served it to a resident. The staff served the pureed turkey to a resident without rechecking the temperature or being reheated. The Food Preparation and Service policy revised October 2018 directed food held at temperatures between 41 F and 135 F promoted the rapid growth of pathogenic organisms that cause foodborne illness. The policy instructed to maintain the temperature above 135 F. At 12:43 PM, Staff E checked the holding temperature of the pureed serving and noted it measured 133.1 F. Staff E continued to serve the pureed serving. The Food Temperature/Food Safety policy dated 3/4/24 instructed the cooks to measure temperatures before food is served to ensure the temperatures of the food maintained below 41 F and above 135 F. If foods are not at the proper temperature, the food will be reheated to 165 F for 15 seconds or cooled to the proper temperature. It also indicated cold foods will be placed in a pan with the item over a deeper pan of ice to assure cold foods are kept at 41 F or below. On 4/9/24 at 11:15 AM, the Chief Clinical Officer reported the staff should follow the food temperature policy.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by (a) improperly storing food, (b) failing to maintain correct dishwasher operation, and (c) failing to prevent cross contamination during food service. The facility reported a census of 34 residents. Findings include: On [DATE] at 4:30 PM, Staff D, Dietary Server, picked up a stack of plates and placed both thumbs on the food surface side, then they placed them in the serving plate dispenser. On [DATE] at 11:35 AM, a kitchen observation identified (a) an unlabeled, bag of red substance with an expiration date of [DATE], (b) an unlabeled, undated bag of meat chunks, and (c) an undated, opened bag of pasta. On [DATE] at 11:45 AM, Staff A, Dining Services Manager (DSM), described the dishwasher as a low temp, chemical appliance. She cycled the dishwasher and rubbed a chlorine test strip against the inside of the dishwasher cover. The test strip did not change color, indicating a lack of sanitizer. She repeated the process four (4) times and yielded the same results. She changed the empty sanitizer supply jug and repeated the dishwasher sanitizer test which again indicated a lack of sanitizer. On [DATE] at 12:00 PM, Staff E, Dietary Server, placed three (3) sheets of wax paper on the steam table serving counter. She leaned forward over the steam table serving counter and her abdomen directly contacted the top of the center piece of wax paper. - At 12:15 PM, Staff E raised a steam table pan lid with her ungloved hand. She put the lid back down on the pan, put on gloves, and used tongs to remove the steam table pan lid. She placed the tongs on a separate sheet of wax paper. She sorted the dietary tickets with her gloved hand then grabbed a plate with the thumb of the same hand directly on the food surface side of the plate where food was placed. - At 12:28 PM, Staff E used the same tongs to remove a steam table pan lid and placed the tongs beside the gray serving scoop on the middle wax paper where her abdomen touched. - At 12:30 PM, a staff member handed the DSM a pair of gloves over the glass divider and one fell behind the sink faucet. The DSM grabbed the glove from behind the faucet and gave the pair of gloves to Staff F, Dining assistant who used the gloves while buttering bread. - At 12:33 PM, Staff E used the tongs to remove and replace a steam table pan lid and laid the tongs on the first sheet of wax paper and came in direct contact with the exterior side of a serving scoop. - At 12:40 PM, Staff E grabbed a slice of buttered bread from Staff F with the gloved hand used to touch non food surfaces. - At 12:47 PM, Staff E grabbed a stack of the dessert plates and her right thumb touched the food surface side of the plate within the buffered rim area. On [DATE] at 12:52 PM, Staff E reported they used the dishwasher to wash the breakfast dishes after finishing the breakfast service. On [DATE] at 1:05 PM, the DSM cycled the dishwasher and rubbed a chlorine test strip against the inside of the dishwasher cover. The test strip again didn't change color, indicating a lack of sanitizer. She repeated the process three (3) times and yielded the same results. She requested maintenance to troubleshoot the dishwasher. The maintenance staff stated the actuating device was probably worn out and needed replaced. After multiple attempts, the DSM performed a sanitizing strip test that reflected present sanitizer. The Storage policy dated [DATE] instructed foods held in refrigerators or other storage areas shall be appropriately covered, labeled and dated. The Sanitation policy dated [DATE] directed if the dish machine required a chemical sanitizer, proper levels of the chemical will be checked at each meal's dish run. The Food Production and Service policy dated [DATE] indicated all food is prepared following proper sanitary practices including adequate temperatures, good hygiene, infection control, and protection from contamination. It also indicated bare hands should never touch ready to eat foods directly bread, sandwiches, fresh fruit etc. Disposable gloves are required or foods will be served with clean tongs, scoops, forks, spoodles, spatulas, or other suitable utensils to avoid bare contact of foods. On [DATE] at 11:15 AM, the Chief Clinical Officer stated (a) all food should have a label and a date when opened, while expired food should be discarded, (b) staff should follow sanitizing regulations, (c) dishes should be handled by the edges, and (d) utensils used to handle non food items should not be placed with food serving utensils; tongs should not be put with ladles.

Based on observation, staff interviews, document reviews, and policy review, the facility failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to evaluate where hazardous conditions may occur in the water systems and implement measures to prevent waterborne pathogens. In addition, the facility failed to provide hand hygiene supplies for each resident and/or visitor. The facility reported a census of 34 residents. Findings include: An observation on 4/2/24 at 7:50 AM revealed empty soap dispensers in Resident #23's bathroom and in the visitors' main hall men's bathroom. An observation on 4/2/24 at 2:57 PM revealed an empty hand sanitizer dispenser located on a pillar between the Assistant Director of Nursing's office and the food serving area. Follow up observations on 4/3/24 at 7:02 AM and 4/4/24 at 7:37 AM revealed the aforementioned dispensers remained empty. On 4/4/24 at 8:14 AM, Staff K, Environmental Services (EVS), stated she tried to check each room for hand hygiene supplies but some resident rooms don't have a soap dispenser or had an old dispenser that needed replaced. She stated the facility had been transitioning dispensers and she helped maintenance replace some dispensers but couldn't help due to being busy. She didn't know of any room that didn't have soap. On 4/4/24 at 8:43 AM, Staff C, Maintenance Supervisor, reported trying to get dial auto dispensers because the supplier for the old dispensers discontinued the soap refill cartridges. He asked if each room needed a soap dispenser. The Infection Prevention and Control Program policy, revised December 2023, states an Infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. On 4/4/24 at 10:55 AM, Staff C, Maintenance Supervisor stated a third party company tested the water but he couldn't access the prior water testing results. In addition, he couldn't locate the water management control policy. During an interview on 4/4/24 at 11:30 AM with the Administrator, the third party representative, Staff C, and Staff J, Maintenance Assistant; the third party representative stated he didn't test the facility's water supply for anything other than chlorine levels which included free chlorine. He added he didn't test the facility's water on a routine, monthly basis. Staff C and Staff J stated they didn't perform the resident water temperature checks and they didn't have system measures to identify or prevent the growth of Legionella and other opportunistic waterborne pathogens. The facility didn't have a water flow diagram available for review. The Handwashing policy dated 2/29/24 indicated hand hygiene continues to be the primary means of preventing the transmission of infection and directed staff to perform hand hygiene with soap and water before and after direct resident contact. An undated policy titled Water Management Control Policy indicated the Water Management Program Team would (a) identify building water systems using a flow diagram, (b) identify areas of potential concern, (c) identify areas of potential exposure to residents via water droplets or aspiration, (d) apply control measures as a corrective action, (e) determine whether control measures produce effective limits, (f) continue to monitor results, and (g) document results. On 4/9/24 at 11:15 AM, the Chief Clinical Officer stated hand hygiene should occur between glove changes and should include soap and water or sanitizer.

Based on observation, staff interviews, and policy review, the facility failed to follow the approved diet menu and failed to measure accurate servings for residents who received pureed diets. The facility reported a census of 34 residents. Findings include: The facility's menu for lunch for 4/3/24 identified the following items to be served as part of the planned pureed textured diet. a) Roast Turkey b) Stuffing c) Chicken Gravy d) [NAME] Vegetables e) Bread/Margarine f) Coffee Cream dessert On 4/3/24 at 11:30 AM, a kitchen observation revealed the Dietitian approved Week 4 menu items didn't get prepared for lunch. The staff served the following menu items for lunch on 4/3/24. a) Tater Tot casserole b) [NAME] vegetables c) Salad, chef and regular On 4/3/24 at 11:30 AM, watched Staff A, Dining Services Manager (DSM), prepare the pureed diets. She used a spatula and placed two (2) unmeasured amounts of tater tot casserole into a blender. She added an unmeasured amount of low fat milk to the blender and mixed the contents. She checked the consistency and added an unmeasured amount of milk two (2) more times. She blended the contents then poured it into two (2) small bowls. She stated each bowl contained 1 serving of pureed for each resident. She told the kitchen server to use the black, #4 serving scoop for the beans (vegetables). On 4/3/24 at 11:35 AM, witnessed the kitchen didn't have a pureed conversion chart to determine pureed diet serving size. A policy titled Pureed Diet dated January 2021 directed staff to use the following pureed diet procedure. a) Measure out desired number of servings into container for pureeing. b) Puree food. c) Add any necessary liquid/fats/stabilizers etc. to obtain mashed potato/pudding consistency. d) Measure the volume of food after it has been pureed. e) Divide the total volume of the pureed food by the original number of portions. This is the NEW PORTION size. On 4/9/24 at 11:15 AM, the Chief Clinical Officer stated pureed preparation should use the volume method that involves measuring.

Based on clinical record review, policy review and staff interviews, the facility failed to ensure code status between the facility and hospice were congruent for 1 of 2 residents reviewed for advanced directives (Resident #10). The facility reported a census of 34 residents. Findings include: Resident #10's Clinical Census listed an admitted [DATE]. Per the Census, Resident #10 discharged to the hospital on [DATE] and returned on [DATE]. The Cardiopulmonary Resuscitation (CPR)/NO CPR Directives, dated [DATE] and signed by the physician revealed Resident #10 desired CPR. The Contracted Hospice form dated [DATE], signed by Resident #10's Power of Attorney (POA) directed to provide no resuscitation for Resident #10. The form lacked a physician's signature. Resident #10's Progress Note dated [DATE] at 11:06 AM documented by Staff B, Registered Nurse (RN), the facility noted a full code status with no signed copy of the Do Not Resuscitate(DNR) form located. The nurse spoke with the family who reported Resident #10 didn't want to be resuscitated. Staff B called Resident #10's Hospice provider for clarification. Resident #10's Progress Note dated [DATE] at 11:06 AM documented by Staff M, Licensed Practical Nurse (LPN), they received a DNR status from her Hospice provider. The Care Plan Active Problem revised [DATE] reviewed [DATE] at 2:58 PM reflected Resident #10 wished to receive CPR. Resident #10's Physician Orders reviewed on [DATE] at 11:09 AM listed an order for full code order dated [DATE] and an open-ended end date. Resident #10's Face Sheet reviewed [DATE] at 11:16 AM revealed a diagnosis of an encounter for palliative care dated [DATE]. On [DATE] at 4:26 PM, the Assistant Director of Nursing (ADON) said she believed Resident #10 returned from the hospital on a Friday. She would typically make the changes but thought she didn't work that day. The ADON explained the Director of Nursing (DON) could have made changes and so could have the nurses but couldn't confirm all the nurses knew how to do it. On [DATE] at 5:05 PM, the ADON reported she spoke to the Hospice nurse and they were waiting for the provider to sign the DNR order. On [DATE] at 9:02 AM, the ADON explained if a resident went on hospice they technically change to a DNR and would get the Iowa Physician Orders for Scope of Treatment (IPOST). The ADON added Resident #10 came from the hospital with Hospice orders and the facility typically would get an IPOST with DNR at that time. The ADON confirmed the facility didn't receive an IPOST when Resident #10 returned from the hospital. On [DATE] at 9:35 AM, the ADON said when Resident #10 admitted to the facility she had a full code order. The ADON further stated when Resident #10 went to the hospital and then returned to the facility she had a DNR code status according to the Hospice form. The ADON stated Resident #10 admitted to the hospital on [DATE] and returned to the facility on hospice on [DATE], a Friday. The ADON stated she assumed someone else could have changed it or taken care of the Hospice order. The Nursing Facility CPR/DNR policy dated [DATE] instructed when a resident is a no code or DNR in the facility, Cardio Pulmonary Resuscitation or CPR will not be initiated in the event that a resident experienced a lifeless condition. When a resident is coded or CPR in the facility, Cardio Pulmonary Resuscitation or CPR will be initiated by the staff when a lifeless condition is observed and someone will call 911. In the event that a resident and/or responsible party member (as appropriate) decide to change to the CPR/DNR designation, they may do so at any time by speaking to a nursing staff member. That nursing staff member will be responsible for ensuring the appropriate facility CPR/No CPR directives form is completed and physician's signature is obtained (if required) with the physician orders updated. On [DATE] at 8:30 AM, the Regional Director of Quality and Clinical Services reported the facility expected the code status between Hospice and the facility match. In addition, the nurses receive an updated IPOST.

Based on observation, record review, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision and assistive devices to ensure the environment was as free of hazards as possible for a resident at risk for elopement (when a resident leaves the building without staff knowledge or consent) for 5 of 5 residents reviewed. Resident #1 was identified with unspecified dementia, cognitive impairment, poor safety awareness, and recently had her wander guard (personal alarm sensor bracelet) removed. Investigation revealed facility staff failed to intervene on 5/2/23 when Resident #1 was observed wandering during the night fully clothed and had put her coat on. Resident #1 exited the facility unnoticed by facility staff and was found by a community member in their yard. She had walked a city block on sidewalks that dropped off 6 inches to a parking lot, crossed two residential streets, and walked through a grass lawn. The resident was last seen at the facility at 4:00 a.m. and was returned to the facility at approximately 5:00 a.m., the facility had been unaware that the resident had eloped until contacted by the community member. It was determined that the main entrance to the unit had a magnetic alarm and locking system that was observed to take up to 1 minute and 54 seconds to close, lock, and re-activate the alarm system. Staff were observed to enter and exit the door and failed to assure that the alarm system was reactivated before leaving the area. The facility identified an additional 4 residents that were at risk of elopement and did not have a wander guard sensor at the time of the elopement. These circumstances posed Immediate Jeopardy to resident health and safety. The facility reported a census of 34 residents The facility was notified of the Immediate Jeopardy beginning on 5/2/23 on 5/10/23 at 2:15 p.m. The IJ was removed on 5/10/23 when the facility completed education with all staff that they must remain at main entrance double door to the unit until the door shuts, the alarm is reactivated, and the green light turns on. Door codes were changed and will be changed routinely and as needed. Four residents were moved from the upper unit to the lower unit due to increased risk of wandering and elopement. Residents that remain on the upper level that have wandering behaviors now have a wander guard device on. The scope and severity was lowered from a K to an E at the time of the survey after ensuring the plan of correction was put in place and implemented. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/6/23 that documented Resident #1 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment. A score of 5 identified severely impaired cognition. The MDS failed to identify Resident #1's wandering status, and identified was independent for transfer and walking in room and normally used a walker. The resident's diagnoses included non-Alzheimer's dementia, hypertension, and anxiety disorder. Observation on 5/9/23 revealed Resident #1 independently ambulated quickly with her walker in the hallway. Ankle wander-guard sensor bracelet noted present on ankle and checked by nurse at this time. Resident #1 stated that she needed to be good because she has that thing on her ankle. An Elopement Evaluation form completed on 4/13/23 identified the resident ambulatory and inaccurately identified resident as having no elopement risk factors, which included: cognitively impaired, poor decision-making skills, and or pertinent diagnosis (example, dementia, Alzheimer's, anxiety disorder). The evaluation also failed to identify that the resident has exhibited any additional risk criteria which included: history of wandering, making statement that they are leaving, or displayed behaviors that might indicate an attempt to leave (body language, etc.). Resident identified as at minimal risk for elopement based on this evaluation. Additional information included: no exit seeking behaviors, does not talk about leaving facility or desire to go home, wander guard discontinued. Review of Resident #1's Care Plan included the following history: A problem had been initiated on 2/3/23 and resolved on 4/13/23 which identified the resident at risk for elopement related to impaired cognition and a history of voicing desire to leave and included the following approaches: anticipate and assess for any unmet needs, may leave the unit with staff escort/supervision, provide safety reminders, wander guard placed on ankle; nursing to check placement and function every shift. The Care Plan documented the problem was discontinued and no interventions were in place at the time of the incident to prevent elopement. Following the elopement, the Care Plan was revised on 5/2/23 to include a problem focused on resident wandering and risk for elopement related to impaired cognition and recent elopement event. Goal identified that resident would wander safely within specified boundaries. Approaches included: avoid over-stimulation, equip with device that alarms when wanders, check for proper functioning of device every shift, remove resident from other resident's rooms and unsafe situations, and when resident wanders provide comfort measures for basic needs. The Care Plan further identified a focus area of impaired thought processes related to cognitive deficit as evidenced by confusion, forgetfulness, makes poor decisions, and wandering. A facility form titled, Safety Event-Elopement completed by Staff A, Registered Nurse, (R.N.) documented the elopement event occurred on 5/2/23 at 5:25 a.m. and included the following: Resident #1 left the building and was found at the corner of 3rd and [NAME] by a former kitchen employee. The resident sustained no injuries. Prior to the elopement the resident had been walking on the unit with coat on and had previous unsuccessful attempts. Resident was restless and confused. The resident noted to have dementia and anxiety disorder, wander guard had been recently discontinued. Resident willingly walked back to the unit, escorted to room, and wander guard placed. An Elopement Evaluation form completed on 5/2/23 at 11:34 a.m., by the Director of Nursing (DON) identified the resident ambulatory and accurately identified the resident with elopement risk factors, which included: cognitively impaired, poor decision-making skills, and or pertinent diagnosis (example, dementia, Alzheimer's, anxiety disorder). The evaluation identified that the resident had exhibited additional elopement risk criteria which was identified as making it off the unit. Resident identified as at risk for elopement based on this evaluation and an elopement care plan initiated. In an interview on 5/9/23 at 1:14 p.m. Staff A, R.N. confirmed she was the nurse on the night of 5/1/23-5/2/23 and had been on the upper unit with Resident #1 until approximately 3:30-4:00 a.m. Staff A had observed the resident wandering about the unit that evening fully dressed, and when she left the unit Resident #1 was seated near the fish tank visiting with another resident by the nurse's station. Staff A stated that she had not noticed that Resident #1 had a coat on when she saw her. Staff A responded that had she noticed that she had a coat on she would have thought that was something she should look into, and would have asked her why she had the coat on. Staff A confirmed that she was aware her wander guard had been discontinued, and had wondered why, but stated it was not her decision. Staff A described Resident #1 was typically confused and wandered about the unit on her shift. Staff A denied that Resident #1 had talked about leaving that night. Staff A responded that a former kitchen employee who lived down the street had called her about 5:00 a.m. and made aware had found Resident #1. Confirmed that facility staff had no idea the resident was outside. Staff A recalled she had returned the resident to the unit via the North main double doors to the unit. She pushed the red button on the wall outside the unit which disabled the door alarm and then always waits upon entering to hear the magnet lock engage because with air pressure that door cannot latch, but further denied that she was aware of any time the door had not worked properly. Stated that she thinks she saw the green indicator lights on the door after entered and magnet engaged, but couldn't be sure. Stated they had tested the door after the elopement and found that is was working properly, and further denied that she had done anything with the override button. Confirmed this exit is the only exit off the unit that doesn't require steps to get to an exit from the facility. Confirmed that Staff B, Certified Nursing Assistant (CNA) was the only staff person that remained on the unit after she left. Staff A denied that she had used this exit to leave the unit that night, and had used the West hallway door which is locked and unlocks only after a code entered. Staff A described Resident #1 was pleasantly confused when returned to the unit, assessed with no injuries, and was warm to touch. In an interview on 5/8/23 at 4:34 p.m. Staff B, CNA stated on the night of the elopement Resident #1 had been up and dressed and had been walking in a circle throughout the unit, but had not noticed her going to the doors. Staff B stated that the resident wasn't normally up on the night shift, but sometimes she doesn't sleep well and would be up. Staff B stated that she was aware that the resident had a wander-guard and had not been aware that had been removed until after the incident. Confirmed that Staff A, RN had left the unit about 4:00 a.m., and had exited by the West hallway doors as usually does. Staff B responded that she had last seen Resident #1 at approximately 3:30 a.m. walking in the halls, and confirmed that she did have her clothes and her coat on. Staff B responded that it was unusual for her to have her coat on, but denied that she had done anything in response. Staff B added that she thought Resident #1 had a wander guard on and that if she had tried to exit the unit the wander guard alarm would have sounded. Reported she started her rounds at approximately 4:00 a.m., and would have been the only staff person on the unit. Denied that she had heard the door alarm sound. Staff B could not recall if the alarm indicator lights were green when she checked the alarm, and denied that she had touched the override button. In an interview on 5/9/23 at 1:55 p.m. the community member, who found Resident #1 confirmed that on 5/2/23 she was in bed asleep and heard the doorbell to her garage walk in door repeatedly ring which was odd because no one used that door. Stated she went out her front door and met Resident #1 walking in the grass of her front lawn with her walker, and estimated the time as 4:40 a.m. Stated that she recognized the resident from having worked at the facility and knew that she shouldn't be outside, on her own at night. She responded that Resident #1 seemed confused and recalled that the resident had stated she was trying to get a book to her daughter. Confirmed that she had walked the resident back to the 3rd avenue entrance where she called the nurse. Informed, after referring to her cell phone call log, that it was 5:00 a.m. when she called the nurse, and further stated that they had no idea that the resident had left the facility. The community member stated that she was surprised that the resident hadn't fallen because the sidewalks are so uneven, it was dark, and there are no street lights on that side of the street. She confirmed that the resident would have had to cross [NAME] street to get to her house. Described [NAME] street as a very busy street because it is the main street into town and only a couple of blocks from the school. While standing in the lawn with the community member the surveyor observed that trucks and delivery vehicles were noted to be frequently traveling the street. From the facility the resident would have ambulated down an incline to the sidewalk. It was further noted that there was a drop from the sidewalk to the parking areas adjacent to the sidewalk, and hazards such as storm sewers at the crosswalks. The resident would have had to cross [NAME] and 3rd Avenue to reach the community members house. During interview and observation on 5/9/23 at 12:35 p.m. the Maintenance Supervisor confirmed that he had been called the night of the elopement and responded in about 25 minutes. The Maintenance Supervisor demonstrated that when a code was entered from inside the unit and the door pad was pressed, the door alarm was deactivated, as indicated by the green lights turning off, and the door automatically opened and then was closed by an automatic closure device until a magnetic lock engaged and a sound was heard. The Maintenance Supervisor timed the demonstration and reported that it took 1 minute and 54 seconds from the time the door started to open and the green lights turned off, until the door closed, the lock engaged and the green lights came on again. The Maintenance Supervisor reported that there was not anyway to adjust the closure device which can take from 1-3 minutes for the door to open and close and then up to another minute for the lock to engage and reactivate the alarm. Confirmed that during the time that the door is opening and closing and the green lights are not on the door can be physically opened and closed without the alarm going off. Reported that staff are supposed to stay until the door was completely closed, they hear the magnet click close, and the green lights turn on. The Maintenance Supervisor confirmed that was not possible to see the green lights from the outside of the unit when exiting the unit, and would require staff to wait for the click. Further stated he doubted that staff waited that long. Stated he understood Resident #1 had a wander guard sensor alarm that had been removed. Explained that the wander guard was a separate alarm sensor located at door and would have alarmed when she had exited the door. During observation and an interview on 5/9/23 at 3:39 p.m. with the Director of Nursing (DON) two CNA's entered the unit after they pushed the red button that disarmed the door alarm. The staff were observed to walk through the door, enter the unit, the door shut behind them and it took 54 seconds from the time they walked through the door until the light was observed to turn green as timed by the DON. During that time the staff were observed to walk to the far end of the unit and turn the corner and were out of sight of the door before the light turned green again. The DON confirmed that while the green light was off the door could be opened for any amount of time and residents could exit without the alarm sounding unless they were wearing a wander guard alarm sensor. The DON stated that there was a problem, staff were not waiting until the alarm was re-engaged which gave an opportunity for anyone without a wander guard to leave the long-term care unit and then leave the facility as the doors to the outside are not alarmed in other areas of the building as Resident #1 had done. The DON further stated that at the same time that they had evaluated Resident #1 for continued need for the wander guard they had also removed the wander guard from two other residents. The DON additionally stated that when the wander guard was removed for Resident #1 just the intervention that directed the wander guard sensor should have been removed and the problem should have remained to direct staff on interventions and what to be alert for with the wander guard removed. The DON stated that there were 4 residents that were at risk of wandering/elopement that currently were not protected by the wander guard system and they were unable to place new sensors as the facility had installed a new wander guard system downstairs and they had not replaced as all residents were scheduled to move downstairs within the next two weeks. The DON confirmed would expect staff to stand at the door until the green light appeared and the door was alarmed. Additionally, confirmed that some residents on the unit with a high BIMS might have the code to the door alarm as it had not been changed in a while. The facility was unable to provide a policy or criteria used to determine wander guard placement or removal. Review of facility policy titled Wandering and Risk for Elopement Policy and Procedure included the following: It is the policy of the facility to provide a safe environment for all residents. Will maintain a process to manage residents that wander and to provide safety to resident who are at risk for elopement from the facility. Any resident that is at risk for wandering and/or elopement will have a wander guard placed on their wrist or ankle. In an interview on 5/10/23 at 10:45 a.m., the State of Iowa Climatologist reported the temperature in [NAME], Iowa on 5/2/23 at 4:00 a.m. was 40 degrees Fahrenheit, with a wind chill of 31 degrees Fahrenheit, no precipitation, with clear skies.

Based on clinical record review, picture and video review, staff interview and the Admission Agreement Extended Care form, the facility failed to maintain the dignity and respect of 2 of 4 residents while caring for those residents who resided in the Memory Care Unit (Residents #1 and #2). The facility identified a census of 46 residents. Finding include: The Director of Nursing and Administrator documented on 5/9/16 the facility staff met with Staff A to discuss pictures and video/s of two residents that she had posted on Snap Chat. Staff A reported she had posted pictures and videos of residents to Snap Chat and named Resident #1 as one of residents. Staff A could not recall when she had posted the pictures/videos. Staff A stated she thought it was funny and that's why she posted the pictures. Staff A was informed she violated the resident's privacy, dignity and what she did was demeaning. Staff A wanted to know who had turned in the video to the facility and seem unremorseful of her actions. Snapchat is a video messaging application whereas using the user can take photos, record videos, add text and drawings. The sent photographs and videos are known as Snaps. Snapchat community guidelines directed their users to keep it legal and directed users to not take Snaps of people without their knowledge or consent. The community guidelines address invasion of privacy and urged their users to not take Snaps of people not to violate their privacy in spaces. The community guidelines did not address humiliation. A copy of the undated photographs posted on Snapchat showed 2 pictures of Resident #2 as follows: a. Picture #1 showed Resident #2 sitting down with a sad emoji face covering his/her face with documentation under the photo a caption read stayed up all nighhhht. And can't sit still. b. Picture #2 - showed Resident #2's face clearly visible with a laughing emoji with tears posted across his/her body. A copy of the undated video posted on Snapchat showed Resident #1 walking independently wearing his/her undergarments on the outside of his/her sweat pants. Interviews: During an interview 6/3/16 at 11:04 a.m., Staff A, Certified Nursing Assistant (CNA) confirmed he/she took the Snap Chat (a social media site) video/pictures and sent them to friends. The staff member indicated he/she took the video of Resident #1 because he/she thought it funny. The staff member also confirmed to taking the pictures of Resident #2 because the resident had just fallen asleep after having been up all night wandering. During an interview 6/3/16 at 8:57 a.m., Staff B, Assisted Living Aide, indicated he/she received a text from a friend in the community who received the above stated video/pictures who described them to him/her and questioned their appropriateness/acceptability. Staff B told the friend the videos/pictures were not appropriate and questioned who sent them to him/her. The friend confirmed Staff A sent him/her the video/pictures. Staff B went to the friend ' s house took a video of the snap chat video/pictures with his/her personal cell phone and immediately sent the information to Staff C, Social Services. Resident Record Review documented: 1. According to a Minimum Data Set (MDS) assessment form dated 5/5/16, Resident #2 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 3 with fluctuating inattention and disorganized thinking. The resident required extensive assistance of staff with bed mobility, transfers, ambulation, dressing and personal hygiene. Review of an Interim Plan of Care form (not dated), the Resident expressed the following behaviors: a. Alert. b. Irritable. c. Confused. d. Uncooperative. e. Forgetful. 2. According to a Minimum Data Set (MDS) assessment form dated 4/16/16, Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had the ability to make self-understood, usually understood others, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15. The MDS identified Resident #1 displayed fluctuating inattention, disorganized thinking and required limited assistance with dressing and extensive assistance with personal hygiene. Review of a Care Plan dated 5/6/16, revealed a problem that indicated the resident resided in the Memory Care Unit related to a [DIAGNOSES REDACTED]. The approaches included the following: a. The resident had been becoming paranoid and delusional. b. The resident required supervision with dressing and hygiene but ambulated independently. Review of the facilities Admission Agreement Extended Care form dated June 2013, the Rights and Responsibilities of Resident/Responsible party included the following: a. Your dignity as a human being would have been preserved. b. You would receive kind and considerate treatment and care at all times. A reasonable person would feel their privacy had been violated if his/her care provider posted videos/photograph of this manner on any social media site.

Based on observation, clinical record review, staff, physician and family interviews and review of facility policy/procedures, the facility failed to assess and provide interventions for residents after a fall and an onset of adverse symptoms which represented a change in physical condition (Resident #1, #4). The sample consisted of 4 residents and the facility reported a census of 49 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 11/12/14. The MDS reflected the resident rarely/never understood other people and had short and long-term memory impairments. The MDS revealed Resident #1 had active [DIAGNOSES REDACTED]. The Care Plan, dated 11/14/14, identified the resident at risk for falls related to dementia and current independence without assistive devices. Computerized Event (incident) Reports included: An Event Record dated 2/10/15 at 3:15 p.m. recorded at 6:03 p.m. identified the staff found the resident lying on his/her back in the hallway. The record identified the fall to be unwitnessed. The resident exhibited pain and rubbed his/her left knee. The record reflected the resident ' s pain was estimated at 2 to 3 on a scale of 1-10 based on facial expression and rubbing of the knee. The nurse documented he notified the physician and family. The record noted on 2/10/15 at 8:46 p.m. the nurse updated the primary physician with vital signs, rubbing the knee behavior and mild swelling of the left knee. The physician stated she wished the resident be observed, and if discomfort persisted or range of motion became compromised, that an x-ray of the affected area be obtained by a portable x-ray service. An undated update evaluation note identified the facility sent the resident out of the facility with a [MEDICAL CONDITION]. The 24 Hour Nursing Communication report dated 2/10/15 identified the resident fell at 3:15 p.m. and may have x-ray of left knee if condition deteriorates. A Resident Progress Note dated 2/10/15 at 8:46 p.m. and documented by an agency registered nurse (Staff B), noted the resident had been found lying on his/her back in the hallway (see also event from earlier this evening). Staff B observed the resident after the event to be rubbing left knee. Staff B administered PRN (as needed) APAP (Tylenol) with the 4:00 p.m. medications and the primary physician was updated on the vitals, the rubbing of the knee behavior, and mild swelling of the left knee was also observed and reported. The physician stated she wished the resident to be observed, and if discomfort persisted or range of motion became compromised, then an x-ray of the affected area was to be obtained by portable x-ray service. Staff B transcribed the telephone order and the order would be passed on by inter-shift report. Review of the February MAR (Medication Administration Record) reflected Staff B gave the resident his/her routine Tylenol on 2/10/15. Review of the MAR indicated [REDACTED]. When interviewed on 3/4/15 at 12:50 p.m. Staff B (agency registered nurse) stated he last worked in this facility in the locked/dementia unit months ago. Staff B then verified on 2/10/15 a nursing assistant, Staff A found the resident on the floor. Staff B stated he went to the locked unit and found the resident lying on the floor. Staff A stated he thought the resident was in pain. Staff B denied asking the nursing assistant why he thought the resident was in pain and denied asking Staff A where he thought the resident had pain. The nurse asked the resident if he/she had pain at which time the resident verified he/she had pain. The resident stated the word " pain " . Staff B asked the resident if he/she could move his/her legs and arms. The nurse denied assessing range of motion to the resident's legs or arms. The nurse and the nursing assistant then assisted the resident up off the floor. The resident required the physical assistance of 2 people to walk. Staff B stated he assisted the resident to a chair at the table in the dining room. He gave the resident his/her routine Tylenol and an as needed dose of Tylenol around 6:00 p.m. The nurse stated he observed the resident rocking in the chair and rubbing his/her left knee at which time he believed the resident had discomfort in the knee. The nurse denied any other interactions with the resident that evening. Staff B stated he talked to the resident's primary physician who identified him/herself on the telephone. The physician gave a new order; If necessary and/or if condition deteriorated they could send the resident to the emergency room . Staff B stated he transcribed the physician's orders [REDACTED]. The nurse, Staff B stated the nursing assistant, Staff A informed him, they had more difficulty in assisting the resident to bed. Staff B denied assessing the resident after being informed of a decline in condition after the resident sustained [REDACTED]. Staff B denied performing neurological checks on the resident. Staff B also stated when he talked to the resident's primary physician, the physician stated he/she wanted a portable x-ray if the resident's condition deteriorated. Staff B stated the resident was walked independently. Staff B stated he did not assess the resident again that night due to the resident was already in bed. Staff B stated he did not check the resident's skin for signs or symptoms of injury. Staff B stated he did check the resident's knee at the time of the fall. Staff B stated the resident's knee was mushy, like fluid. Staff B stated he did not notify the resident's family of the resident's fall. Staff B then stated he wrote the physician's orders [REDACTED]. Staff B denied knowing the facility and the physician did not utilize portable x-ray services. Staff B stated he wrote the physician's orders [REDACTED]. Staff B stated in his nurse ' s training, he was taught to perform and document neuro (neurological) checks at the time and after an unwitnessed fall. Staff B stated he was also taught to perform and document orthostatic blood pressures (lying, standing and sitting) after a resident sustained [REDACTED]. Staff B stated it would have been better if he had performed an assessment of the resident after being informed of his/her decline the night of his/her fall. The facility policy/procedure titled FALLS (no date) identified a purpose of the policy was to ensure if a resident falls, a thorough assessment is completed and appropriately documented with interventions identified to prevent future falls. The policy identified the charge nurse, Director of Nursing and the Administrator would be the responsibility person. The procedures included and directed staff to do the following: a. The nurse is to complete a thorough head to toe assessment of the injury. The nurse should complete range of motion (ROM) to determine possible injury. If any head involvement, complete neuro checks as per policy. If an unwitnessed fall and the resident has cognitive problems, complete neuro checks as per policy. Do not move the resident until complete. b. Complete ortho-static (orthostatic) blood pressures (blood pressure lying, standing and sitting) at the time of the fall along with full set of vitals (respirations, pulse). c. Notify the physician and family. d. Perform neurological exam if head injury, resident is unable to identify if hit head and cognitively impaired or if the fall was unwitnessed and the resident is cognitively impaired. e. Assess for injury-Description of assessment completed, description of injuries; bruise, skin tear, size and location and be exact. f. Notify the physician and family with date and time. On 3/4/15 at 2:24 p.m. a certified nursing assistant, Staff A was interviewed and stated on 2/10/15, he was working alone in the locked dementia unit. Staff A stated he was seated in the locked unit lobby when he heard the resident say " oh " . He then found the resident on the floor in the hallway. Staff A stated he knew right away the resident was in pain. The resident's normal speech was babbling and did not make any sense. Staff A stated the nurse, Staff B, came to the unit. When Staff B moved the resident, the resident verbalized pain and his/her face grimaced with pain. Staff A stated it was obvious the resident was in pain with movement. Staff A informed the nurse he did not see the resident fall. Staff B informed the nursing assistant the resident had a tendency to lower him/herself to the floor. They assisted the resident onto his/her side. Staff A stated it was painful for the resident to sit up. Staff A informed the nurse the resident was in pain. The nurse then instructed the nursing assistant to check the resident's vital signs and neuros, (neurological assessment) (nursing assistants are not trained to assess). They placed a gait belt on the resident and lifted the resident up into a wheelchair. The resident expressed pain. Staff A asked the nurse how fast the resident could have the pain medication. After they assisted the resident up off the floor into the chair, they did not transfer the resident again until bedtime. Staff A stated right away the resident would try to get up out of the chair and would cry out. The nurse then informed the nursing assistant, since the resident was trying to get up; he/she would be fine (although range of motion had not been assessed). The nurse stated there was nothing wrong with the resident. Staff A stated at bedtime the resident could not bear weight and was in pain. Staff A informed the nurse that it was difficult to assist the resident into bed and was painful for the resident. The resident required assistance of two people to transfer into bed. When interviewed on 3/5/15 at 2:33 p.m. an LPN, Staff G stated she was assigned to the locked unit on the day shift on 2/11/15 and again on 2/12/15. On 2/11/15 she was informed at 6:00 a.m. the resident had fallen and they were monitoring the resident's knee. The resident required more assistance for transfers and walking. Staff G stated she assessed the resident while the resident sat in a chair. She did not perform range of motion to the resident's hips. Staff G stated she gave the resident his/her normal medications and did not give the resident any additional/as needed pain medication. Staff G stated on 2/12/15, the resident stayed in bed. Staff G stated she did not assess the resident that day and did not send any paper work with the resident when the resident left the facility for x-rays. Staff G stated she did not give the resident any of his/her morning medications on 2/12/15. Staff G denied giving the resident his/her morning scheduled Tylenol on 2/12/15. When interviewed on 3/5/15 at 1:00 p.m. the Administrator, a registered nurse, stated on 2/11/15 she was in the unit 3 to 4 times. She observed staff walking the resident with the assistance of two persons. The resident walked with a limp and bent over at the hips. Review of the resident's computerized clinical record revealed a lack of further assessment until 2/11/15 at 5:02 a.m. The progress note at 5:02 a.m. identified the resident slept all night, upon palpation of the knee resident showed no signs of pain or discomfort. Resident showed little facial grimacing and moaning when the nurse palpated the left hip. Review of the Progress Note dated 2/11/15 at 8:33 a.m. by the Administrator identified the resident moving slow compared to his/her norm. The resident voiced complaints of pain. The resident expressed pain in knees when touched. The note reflected the physician would be coming today and the resident received Tylenol for pain. The next Progress Note dated 2/11/15 at 9:45 p.m. identified the physician observed the resident. The physician had the resident stand to see if the resident had pain from the fall. The resident was not able to stand without help so an x-ray was scheduled for 2/12/15 at 10:00 a.m. The Progress Note dated 2/12/15 at 5:50 a.m. reflected at 4:45 a.m. the facility staff heard the resident yell for the bathroom. Staff found the resident standing by the bathroom door holding onto the counter. The resident had a slight limp favoring the right side. The next Progress note, dated 2/12/15 at 10:32 a.m. reflected the resident's physician telephoned and reported the resident had a [MEDICAL CONDITION]. The Progress Note dated 2/12/15 at 1:16 p.m.(late entry for 2/11/15 at 1:06 p.m.) by Staff H, a licensed practical nurse, identified the quarterly nursing assessment revealed the resident did not respond to questions appropriately. The resident was pleasant, calm and cooperative with the assessment. Resident denied any pain or discomfort at that time. Staff reported at times the resident would say " ow " or " ouch " . The resident ' s gait seemed strong and steady without assistive devices per self. The resident ' s balance was without concerns at this time. A Nurse Practitioner Progress Note dated 2/25/15 documented the resident as post left compound [MEDICAL CONDITION]. The resident was sent to Ames where the physician put pins into the hip for repair. The resident is currently crossing his/her legs due to his/her dementia. The resident had a left femoral neck fracture that was impacted and walking on it and complained of pain at that time. A Hospital History and Physical dated 2/12/15 documented Resident #1 non-ambulatory for a couple of days following a fall, found to have an impacted left femoral neck fracture. The resident had very advanced Alzheimer's dementia and was chronically unable to verbalize or answer questions. There initially did not seem to be any acute injury. The patient was not complaining of pain. However, in the past he/she actually did not feel much pain with his/her other injuries. Over the past couple of days, it had been noted the resident was simply not walking any longer. A Hospital Operative Note dated 2/12/15 reflected the resident was a [AGE] year old who had been wheelchair bound for two days. The x-rays revealed an impacted femoral neck fracture. The patient had an impacted femoral neck fracture that came together nicely with percutaneous screws. Review of the physician's clinical records, maintained in the local physician's clinic, identified a lack of documentation of notification of the resident's fall on 2/10/16. Review of the resident's file in the clinic revealed the staff documented communication with the nursing home staff, new orders given and physical encounters. These notations lacked documentation for 2/10/15. When interviewed on 3/4/15 at 12:10 p.m. the resident's primary physician stated she was first notified of this resident's fall on 2/11/15 when she made routine rounds at the nursing home. The physician stated if anyone in her clinic received a call from the nursing home it would be documented in the record and she was in the office on 2/10/15 and was on call the evening/night of 2/10/15. The physician stated she did not utilize or order portable x-rays and she did not order a portable x-ray on 2/10/15. The physician stated she would have recalled if the nurse had called her on 2/10/15. The physician stated when she observed the resident on routine rounds on 2/11/15, she ordered an x-ray, however the facility staff informed the physician it would be easier to wait until the next day and obtain the x-ray in the physician's office rather than send the resident to the emergency room /hospital for x-rays. When interviewed on 3/4/15 at 4:00 p.m. a licensed practical nurse (LPN), Staff F stated she made rounds with the resident's primary physician on 2/11/15 at 4:00 p.m. Staff F stated she was not assigned to the unit that night. She stated the physician wanted her to go on rounds due to the nurse assigned to the unit was an agency nurse. When they entered the locked dementia unit, the physician immediately asked why the resident was in a wheelchair. The nursing assistant stated the resident had fallen the night before. The physician stated she was not aware of this resident's fall. They place a gait belt on the resident. The staffing agency nursing assistant informed them the resident was in pain and had not been walking. Staff F and the physician assisted the resident to a standing position. The resident stated " ow " and moaned. The physician touched the resident on his/her hip at which time the resident moaned. The resident did not bear weight and was visibly in pain. The physician stated she wanted the resident sent to the hospital for an x-ray. Staff F asked the physician if they could wait and send the resident to the physician's office the next day for an x-ray. The physician verbalized concern that the facility failed to notify her of the resident's fall on 2/10/15. Staff F stated she informed the resident's charge nurse, Staff B, of the need to call the resident's power of attorney/family member of the physician's orders [REDACTED]. Staff F stated the next day she, Staff F, realized Staff B failed to call/inform the resident's family of the physician's rounds and new order. Staff B had not followed the facility policy/procedures and did not assess the resident when a change of condition occurred or after a fall. Staff B did not notify the physician nor the resident ' s family but documented the physician and family was notified and the physician gave orders regarding a portable x-ray. Staff B stated he administered an as needed [MEDICATION NAME] for pain following the fall; however, the medication record identified as needed (PRN) [MEDICATION NAME] (Tylenol) had not been given. Based on staff and physician interviews and review of medication records [REDACTED]. When interviewed on 3/5/15 at 9:40 a.m. the resident's family member (Durable Power of Attorney)stated she was not informed of the resident ' s fall on 2/10/15, until the facility called her on 2/12/15, to state the resident had a [MEDICAL CONDITION] and was being transferred to hospital. The family member stated she would have expected to be informed at the time the resident fell , of the resident's pain, decline in condition, of the physician's visit, new orders on 2/11/15 and of the resident's transfer to the clinic on 2/12/15 for an x-ray. The family member stated the resident had a history of [REDACTED]. 2. Resident #4 had an MDS assessment with a reference date of 1/21/15 which reflected the resident rarely/never understood other people. The MDS revealed the resident required extensive assistance with bed mobility, transfers and walking. The MDS identified the resident had active [DIAGNOSES REDACTED]. A Resident Progress Note dated 2/26/15 at 12:45 p.m. reflected the resident stood up and then sat down on the floor next to the recliner. A Resident Progress Note dated 2/26/15 at 4:00 p.m. identified the resident grabbed the door handle and then sat self on the floor. The note identified this as intentional and controlled, the resident did not fall. Staff assisted the resident off the floor and to the bathroom. Observation on 3/3/15 at 7:00 a.m. revealed the resident alone in the locked unit lobby. The resident called out that he/she needed to go to the bathroom. The resident stood up and then fell to the floor. A nursing assistant, Staff K summoned a nurse to the unit. A nurse, Staff G, arrived on the unit. The resident informed the nurse, he/she was waiting for her to pick him/her up. Observation revealed bleeding from the resident's right elbow. Continued/close observation revealed Staff G applied a gait belt to the resident and Staff G and Staff K lifted the resident from the floor. Observation revealed the nurse failed to assess the resident for pain and/or injury prior to lifting the resident from the floor. Staff G then went to exit the unit. When interviewed on 3/3/15 at 7:05 a.m. Staff G verified she transferred the resident, after the fall prior to assessing the resident for injury. Observation on 3/3/15 at 7:10 a.m. Staff I, registered nurse, came to the unit and asked Staff K if the nurse Staff G assessed the resident. Staff K denied any assessment. Staff I then assessed the resident.

Based on observation, record review, staff and resident interviews and review of the facility repositioning policy, the facility failed to implement planned interventions to prevent the development of pressure ulcers for residents at risk for Pressure sores (Resident #12, #11, #2, and #4). The sample consisted of 12 residents and 4 of the 12 residents were identified as high risk for pressure ulcers. The facility reported a census of 60 residents. Findings include: 1. The following describes pressure ulcers: Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin toes only it may appear with persistent blue or purple hues. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white necrotic substance). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 4/30/14, which identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident depended upon staff for bed mobility, transfers, dressing, toilet use (frequently incontinent) and personal hygiene. The resident required extensive assistance with eating. The MDS identified the resident at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers. The resident had one unstageable pressure ulcer covered by eschar (hard covering). The ulcer measured 0.4 cm by 0.3 cm. The MDS reflected the resident had pressure reducing devices for the chair and bed but did not have a turning or repositioning program. The Care Plan dated 5/7/14 identified the resident had a problem with a decline in health and spending more time resting and a problem with fragile skin. The Care Plan reflected the resident had a current skin breakdown problem and a pressure area to the right heel on 3/12/14. The approaches dated 5/5/14 directed staff to apply heel protectors on the resident ' s feet when in bed, utilize the pressure reducing mattress and use a wheelchair cushion overlay (on seat of chair) at all times. Resident Progress Notes dated 7/22/14 at 1:10 p.m. identified a weekly skin assessment had noted a pressure ulcer to the right heel. The ulcer measured 0.3 cm by 0.3 cm (centimeter) and covered with tan eschar. The surrounding tissue was pink warm and dry. A Wound/Skin Record identified the resident had a right heel pressure ulcer with an onset of 3/11/14. The assessment of 7/29/14 revealed the wound as unstageable. The wound measured 1.1 cm by 2.9 cm. which showed an increase from 7/23/14. The document revealed on 7/23/14 the wound measured 0.3 cm by 0.3 cm. Observation on 8/5/14 at 11:15 a.m. revealed the resident lying on his/her bed. The resident's shoes laid on the bedspread next to the resident. The resident wore socks. The resident laid on his/her back with heels directly on the bed. A nurse, Staff M verified the lack of any pressure relief for the resident's heels. Staff M removed the resident's right sock and removed a dressing from the resident's right heel. Observation revealed black eschar over the right heel. The nurse stated the staff should have placed a heel protector on the resident's heels when they assisted the resident to bed. The nurse estimated the black eschar on the right heel measured 1.5 cm by 1 cm. The nurse summoned the C.N.A., Staff N assigned to this unit to the resident's room. Staff N denied knowing the resident had heel protectors, denied knowing she was to place heel protectors on this resident while in bed, and denied knowing where to find this resident's heel protectors. Staff N stated she was an agency C.N.A. and she was not familiar with this resident. Staff N denied having any instruction or care plans to know which residents required what care. Review of the TAR (treatment administration record) for August 2014 revealed a treatment dated 3/12/14 for staff to apply heel protector (large boot) every shift while in bed. 2. Resident #12 had a MDS assessment with a reference date of 7/2/14 which revealed the resident required extensive assistance for bed mobility and eating, and totally dependent upon staff for transfer assistance, dressing, toilet use, personal hygiene and bathing. The MDS reflected the resident was always incontinent of urine and frequently incontinent of bowel. The [DIAGNOSES REDACTED]. The MDS identified the resident at risk for the development of pressure sores. The MDS identified the resident did not have pressure sores but did experience moisture associated skin damage. The Care Plan dated 7/8/14 identified the resident's risk for skin breakdown as related to increased incontinence and lack of control of bowel/bladder following his/her stroke. The Care Plan directed the staff to check and change the resident's incontinent product before and after each meal and/or activity. The approaches reflected a pressure reducing mattress was to be on the bed at all times and a pressure reducing cushion in the wheelchair (on seat). The Care Plan directed staff that the resident should wear heel protectors while in bed. Observation on 8/4/14 at 1:20 p.m. revealed Staff C (certified nursing assistant) pulling Resident #12 backwards in a geriatric chair to the lobby area in the skilled unit. Observation revealed food soiling on this resident's skin around the mouth from the noon meal. On 8/4/14 at 1:30 p.m. Staff C stated she last provided any personal care for this resident at 11:30 a.m. when they assisted him/her up for the noon meal. She stated she was placing the resident in the lobby area to be taken to the ice cream social in another area of the nursing home. Staff C stated the resident was to be repositioned and checked for incontinence at least every 2 hours. Staff C stated the ice cream social was scheduled to begin at 1:30 p.m. and the second shift staff would care for the resident after the ice cream social. Staff C stated she understood the resident had been up for 2 hours without repositioning or perineal cleansing. Staff C then pushed the resident from the skilled unit to the nursing unit for the ice cream social. Observation on 8/4/14 at 3:08 p.m. revealed Staff R and Staff Q (certified nursing assistants) assisted Resident #12 from the lobby in the skilled unit to his/her bedroom. Staff R from a staffing agency and Staff Q stated they had been assigned to another unit and after completing their shift they came down to the skilled until to help other staff. At this time the resident stated his/her bottom hurt from sitting so long. Staff R and Staff Q transferred the resident from the chair to the bed. The staff changed the resident's disposable brief. Observation revealed the resident's buttocks red in color with deep creases. The resident asked to be positioned on his/her side due to pain in his/her buttock. The resident had been seated 3 ? hours before repositioned. Review of the facility's Repositioning Policy dated 1/10/01 identified residents who were unable to reposition themselves would be repositioned every two (2) hours, or more frequently as determined by the nursing team. 3. Resident #11 had an MDS with a reference date of 7/16/14 which revealed the resident required extensive assistance with transfers and walking in his/her room, and required total dependency upon staff for bed mobility, dressing, toilet use, personal hygiene and bathing. The MDS identified [DIAGNOSES REDACTED]. The resident had a Stage 1 or greater pressure ulcer and was at risk for the development of pressure ulcers. The MDS reflected the resident had a pressure reducing device on the bed and chair but not have a turning and repositioning program. The Care Plan dated 7/30/14 identified the resident at risk for skin breakdown related to increased incontinence and decrease mobility, lack of control of bowel/bladder and a pressure ulcer on the left heel. The approaches instructed the staff to offer and assist with toileting before and after each meal and/or activity. The approach reflected the resident would have a pressure reducing mattress to the bed at all times and a cushion in the wheelchair. The resident would wear heel protectors while in bed. The Care plan reflected the blister to the left heel was resolved at this time and it would be alright for the resident to wear shoes again but to continue to use heel protectors when in bed. Observation on 8/4/14 at 1:22 p.m. revealed Staff C pushed Resident #11 in a wheelchair to the skilled unit sitting area. The resident sat with his/her head down with eyes closed. Observation revealed loose food particles on the resident's clothing. When interviewed on 8/4/14 at 1:30 p.m. Staff C stated they last provided any personal care for this resident at 11:00 a.m. when they assisted him/her up for the noon meal. She stated the resident had not been repositioned or checked for incontinence since 11:00 a.m. She stated she was placing this resident in the lobby area to be taken to the ice cream social in another area of the nursing home. She stated this resident was to be repositioned and checked for incontinence at least every two hours. She stated the ice cream social was scheduled to begin at 1:30 p.m. She stated the second shift staff could care for this resident after the resident returned from the ice cream social Staff C stated she understood the resident had been up for two and a half hours without repositioning or perineal cleansing. A Resident Progress Notes dated 7/1/14 at 1:45 p.m. weekly skin assessment revealed blistered area to left lateral heel remained dry. Area measured 3 cm by 3.6 cm with dried brown intact skin covering wound bed. A Resident Progress Notes dated 7/1/14 at 9:34 p.m. the nurse applied [MEDICATION NAME] cream to both heels. Area to left heel where blister was present remained dry. A Resident Progress Notes dated 7/9/14 at 9:55 a.m. noted the weekly skin assessment revealed left lateral heel remained dry with a darkened hard scabbed like area that measured 3.6 cm by 3.8 cm and less than 0.1 cm deep. Review of the Resident Progress Notes dated 7/14/14 at 11:26 a.m. noted area on left heel reopened, area measured 1.5 cm (centimeters) by 0.5 cm. Review of the Resident Progress Notes dated 7/22/14 at 10:00 a.m. noted the weekly skin assessment revealed an area to the heel area as closed. 4. Resident #2 had an annual MDS assessment with a reference date of 6/11/14 which revealed [DIAGNOSES REDACTED]. The same MDS identified the resident scored 6 out of 15 on cognitive testing which indicated severe cognitive impairment. The resident depended upon staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The resident did not walk. The MDS identified the resident at risk for pressure sores and had 1 unhealed pressure sore at a stage III. The area measured 1.7 by 0.5 centimeters and 0.1 cm in depth. The MDS had a pressure reducing device for the bed and chair and had a turning/repositioning program. The resident had 1 stage II pressure ulcer present upon admission. The Care Plan dated 6/18/14 identified the resident at risk for skin breakdown related to contractures, bowel and bladder incontinence, and decreased mobility. The Care Plan reflected the resident had a chronic pressure ulcer to the coccyx area. The approaches instructed the staff to reposition the resident every hour and to limit the resident's time up in his/her wheelchair to 1 hour as the resident allowed. The resident had a donut cushion in place in the wheelchair and staff must monitor for further skin breakdown with placement of the donut cushion (Donut cushions will cause pressure). A Wound/Skin Record dated 7/21/14 indicated a stage II pressure ulcer to this resident's midline coccyx which measured 2.1 cm (centimeters) by 0.6 cm and less than 0.1 cm deep. The wound had scant serous drainage. Observation on 8/4/14 at 11:53 a.m. revealed the resident lying on his/her bed. The ADON (Assistant Director of Nursing) and Staff J (certified medical assistant) transferred the resident from the bed to the wheelchair. Observation on 8/4/14 at 2:45 p.m. revealed the resident remained in his/her wheelchair. Staff C and Staff J transferred the resident from his/her wheelchair to his/her bed. After lying the resident on the bed, the staff prepared to provide personal cleansing. Staff C removed the resident's brief from under the resident by pulling the disposable brief out from under the resident. Observation revealed the skin pulled with the brief which resulted in a shearing force. The staff did not limit the time the resident sat in the wheelchair to 1 hour and did not provide repositioning every hour as directed in the plan of care. Observation on 7/29/14 at 1:02 p.m. revealed the resident in the dining room after the noon meal. The Director of Nursing asked the resident if he/she was going to BINGO. The resident informed the Director of Nursing he/she needed to go to the bathroom. The staff did not encourage the resident to limit the amount of time up in the chair and did not try to encourage the resident to lie down after the noon meal, prior to attending BINGO.

Based on observation, record review and resident and staff interviews, the facility failed to prevent and provide planned interventions for the prevention of pressure ulcer development for 1 of 11 residents reviewed (Resident #12). The facility reported a census of 54 residents. Findings include: 1. Resident #12 had a Minimum Data Set (MDS) assessment with a reference date of 10/1/14. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident depended upon 2 staff persons for bed mobility and transfers. The resident did not ambulate. The MDS reflected the resident depended upon 1 staff person for personal hygiene, toilet use, dressing and eating. The MDS identified the resident at high risk for the development of pressure ulcers and did not currently have an ulcerat high risk for developing pressure ulcers. The Care Plan dated as last reviewed on 7/8/14 identified the resident with the problem of being at risk for skin breakdown. The approaches directed staff to place a heel protectors on the resident's heels when in bed. Observations of the resident revealed the following: On 10/7/14 at 8:55 a.m. the resident slept in bed and observation revealed only the left foot had the heel protector on. The right heel rested directly on the mattress with toes pointed upward which placed pressure onto the right heel. On 10/8/14 at 7:07 a.m. the resident laid in the geriatric chair. The resident wore only cotton socks to both feet. The resident's feet rested directly on the foot rest. The resident voiced of both heels getting sore and tender. On 10/8/14 at 7:13 a.m., Staff H, LPN entered the room when the resident began to complain of both heels being sore. Staff H asked the resident if he/she wanted the heel protectors on, the resident stated yes and Staff H placed the heel protectors to both heels. On 10/8/14 at 5:16 p.m. the resident laid back in the geriatric chair in his/her room without heel protectors covering the heels. Observation revealed the heel protectors on the chair in the corner of the room. The foot rest of the geriatric chair had been raised with one leg flexed and sole of foot on foot rest (increased pressure to the heel). On 10/9/14 at 10:54 a.m., Staff J, CNA was interviewed and stated the resident should have heel protectors on (feet) when in bed and unsure if the boots needed to be on when the resident laid in the chair. Staff J stated she would have to ask the nurse. Staff J stated she had seen other staff place the heel protectors on the resident's feet when the resident laid in the geri chair. On 10/9/14 at 10:57 a.m. Staff F, RN was interviewed and stated the resident should have the heel protectors on while in bed and that she had seen the resident in the geri (geriatric) chair wearing the heel protectors.

Based on observation, record review, interviews with family, staff, physician and the wound care nurse and review of policy documents, the facility failed to provide adequate supervision to ensure against hazards from self, others and elements in the environment and the health service supervisor failed to supervise the implementation of the written health care plan (Resident #1, #5, #6). The facility identified a census of 55 residents. A Care Plan identified Resident #1 should have a physically limited secured environment and lived in the memory unit. The door to the medication room, which led off the secured unit, was left open. The facility failed to provide adequate supervision and the resident eloped through the open medication room door and found approximately 2 hours later, face down in the snow. The facility failed to supervise Resident #5 and Resident #6 and follow the Care Plan of Resident #6. The Care Plan directed staff to have visual contact with Resident #6 in order to provide safety to other residents. Resident #5 was found in Resident #6 ' s bed and partial unclothed. Resident #6 stood by the bed and dressing self. Findings include: 1. According to a Minimum Data Set (MDS) assessment form dated 12/18/13, Resident #1 had [DIAGNOSES REDACTED]. The assessment reflected the resident sometimes had the ability to make self- understood and understands others, with moderately impaired cognitive skills, short and long term memory deficits, with a fluctuating level of consciousness, the inability to speak and independent with transfers and ambulation. A Care Plan with a problem start date of 12/25/13, documented the resident had elopement precautions related to impaired cognition, pacing, going to exit doors and pushing on doors. The approaches directed staff to perform the following: a. Check alarmed locked doors per facility policy. b. Limit to physically secure environment. c. Observe for indicators of elopement potential such as verbal, loitering near exits, jacket, anxiety and restlessness. d. Provide appropriate level of supervision/surveillance to monitor. Example: check every 10-30 minutes if restless or anxious e. See and follow missing resident policy. f. Supervise when off the locked unit. A Risk Assessment for Elopement and Wandering form dated 12/23/13, identified the resident as an elopement risk but resided on a locked unit. A Risk Assessment for Elopement and Wandering form dated 6/14/13 identified the resident as an elopement risk but resided on a locked unit and would set off door alarms. An Elopement Form dated 8/1/13, reflected at 11:30 a.m. the staff found the resident outside of the memory care unit patio gate and ambulating on the sidewalk. The interventions directed staff to perform the following: a. A lock company checked the lock on the patio gate. b. The lock as placed on daily checks. c. Staff education on the lock. d. Outside door locked until gate had been fixed. A Social Service Reassessment form dated 12/24/13 reflected the resident wandered at times. According to a Resident Progress Notes forms, the following entries had been documented: On 2/3/14 at 3:41 a.m. the resident roamed a lot every night. On 12/23/13 at 4:16 a.m. the resident up roaming and banging on the doors and the medication cart however not a new behavior. On 12/22/13 at 4:35 a.m. the resident as up half of the night and the other half the resident roamed and took mini naps but this had been the resident's normal routine. A Fall Risk Assessment and Interventions form dated 12/23/13 identified the resident with a score of 21. A score of 7 or above identified a resident at a higher risk for falls. A Resident Progress Notes form dated 2/4/14 at 4:30 a.m., documented the following information by Staff A, Licensed Practical Nurse (LPN) This nurse had been notified staff had been unable to find the resident in the New Horizon area (memory care unit/locked unit). This nurse checked all rooms, bathrooms and closets in New Horizons. The medication room door had been open with a cart placed in front of the door. The nurse began checking rooms in the Phoenix area (ICF hallway that runs parallel to Horizon and assessable through the medication room) while Staff F, medication aide (MA) stayed with residents in the New Horizons. Staff C, MA began going in the hallway to the north. Placed a phone call to Galaxy Way (2nd floor ICF area) and informed Staff B, LPN that staff could not find the resident. Staff B came down to New Horizons. This nurse checked bathrooms by Gemini (skilled unit) and grabbed her coat and jacket. This nurse went outside on 3rd Avenue (south side of the building) and walked east and met Staff C, CNA at the corner. Staff C went back into the building due to not wearing a coat. The nurse went back west down 3rd Avenue to the end of the block and walked around to the garden area, back by the Lofts (assisted living), through the alley way behind Genesis and then around to the front of the building. Found the resident on Circle C drive (just outside the front door) face down on an ice patch wearing a night gown and slipper socks moaning and with cold skin to the touch. The staff member removed her coat and jacket and placed them over the resident's upper half and jacket over the resident's legs. The staff member used her cell phone and called inside of the building to get help. Staff B came along with Staff J, dietary aide. The staff members carried the resident inside of the building. Multiple blankets had been placed over the resident. Vital signs included a temperature of 78.3 degrees (normal 98.6 Fahrenheit) Fahrenheit (F), pulse of 75 (normal 60-100), oxygen saturation at 88 % (normal 96-100 percent) at room air and no blood pressure. The resident's right eye had been black and swollen and he/she had abrasions to his/her bilateral knees. The temperature outside had been 9 degrees F with snow and ice on the ground. Utilizing the cell phone of Staff A, a telephone call had been placed to the Assistant Director of Nursing (ADON) and the physician with a new order received to send the resident to the hospital via the ambulance. The ambulance and son had also been called. During an interview 2/5/14 at approximately 10 a.m., the State Climatologist reported the temperature on 2/4/14 at 4:55 a.m. as 15 degrees F, winds north at 10 miles per hour, a wind chill of 2 degrees F, cloudy skies and with occasional snow since 3:35 a.m. According to an email from a Volunteer Ambulance Service dated 2/12/14, telephone calls and pages occurred on 2/4/14 as follows: a. At 5:45 a.m. - The Hardin County Sheriff Dispatch service. b. At 5:49 a.m. - The Ackley Ambulance had been paged. c. At 5:49 a.m. - IAM responding sent out. (a system that sent out the same information to a cell phone and/or email to the responders) d. At 5:53 a.m. - A crew member called in and planned to meet the ambulance on the scene. e. At 5:55 a.m. - A crew member on scene and canceled the Eldora Emergency Medical Service. f. At 5:59 a.m. - Ackley ambulance en route. g. At 6 a.m. - Ackley ambulance arrived. According to a Patient Care Report form dated 2/4/14 at 6:15 a.m., the ambulance service had been unable to obtain the resident's neuro (neurological) checks and status of the resident ' s pupils or eyes because the resident's eyes had been tightly shut and swollen and he/she had an altered mental status. The narrative section documented the following: Paged to Presbyterian Village for a resident that fell outside, exposed possibly for 2 plus hours according to the staff. Upon arrival the patient had been in the main entry wrapped in blankets. The staff reported vitals as a temperature of 78.3 degrees F, pulse of 75, and oxygen saturation rate of 88 % at room air and with a temperature increase to 81.3 degrees F after blankets. Attempted a c-collar (device to protect neck) but the patient had been resistive, turning his/her head and pushing the device away with his/her hands. The staff placed the resident on a back board and loaded the resident, applied hot packs to the axillary and popliteal regions in the Village entry. Attempted temperature in the ambulance but the thermometer only read "Lo". Vitals as recorded. An Iowa Pre-hospital Care Report Supplement form dated 2/4/14, documented the following information: Removed wet nightgown and wet socks, covered the resident with blankets. A physical exam revealed bruising to the right eye with swelling, abrasion marks around the bruised eye. Both arms bent at the elbows and strongly contracted, nursing staff stated that had not been normal for the patient. A red mark noted on the left forearm approximately 3 inches long. Bilateral knees have large abrasions and bright red. The patient made grunting noises, expiring air forcefully thru pursed lips causing the lips to flap. Nursing staff at Presbyterian Village stated that as normal behavior. Called the emergency room with an estimated time of arrival as 3 minutes. Gave report, arrived in ER met by a physician and nurses and the care had been turned over. An appendix to this entry included: unable to obtain oxygen saturation rates due to the hands having been to cold. An Emergency Department Record form dated 2/4/14 with an admitted d of 6:26 a.m., documented the following information: a. At 6:45 a.m. - A temperature of 83.6 degrees F. b. At 7:30 a.m. - A temperature of 84.5 degrees F, blood pressure of 102/68, pulse 55 (beats per minute), oxygen saturation level of 87 % with 6 liters of oxygen running and respirations at 19 (per minute). An emergency room (ER) Triage/Assessment form dated 2/4/14 at 6:59 a.m., documented the following information: a. Chief complaint as hypothermia. b. Skin - pink and cold c. Nail bed color - pale/white d. Sinus bradycardia (less than 60) with regular heart rhythm. e. Respiratory findings - grunting and snoring. f. Lung sounds diminished throughout. g. Temperature of 86.8 degrees F rectally. h. An apical pulse of 52 (beats per minute), blood pressure 112/56 and respirations at 26 (per minute). An emergency room Progress Note form dated 2/4/14 at 9:23 a.m., the resident's core temperature as 30.9 degrees Celsius (C). An emergency room Progress Note form dated 2/4/14 at 9:55 a.m. revealed the resident's core temperature as 33.1 degrees Celsius is 91.58 Fahrenheit. An ER Disposition form dated 2/4/14 at 11 a.m. reflected the resident's condition at the time of discharge from ER as critical with a core temperature of 35.1 C/95.2 F. An ED Physician Notes form dated 2/4/14 identified the resident with severe hypothermia secondary to exposure, shock secondary to hypothermia, frostbite to bilateral knees and a questionable head injury. A Progress Notes form dated 2/5/14, reflected the most recent vital signs in the computer as a temperature of 100.8 F, pulse of 115, respirations 20, pulse oximetry level of 95% with 2 liters of oxygen and a blood pressure of 195/83. The nurse rechecked it with the physician at that time and it registered at 182/88. The resident ' s pulses ranged from 76 to 91 since last seen the previous night. Respirations stayed about 20 and the resident ' s pain had been 0 to 10 utilizing the face's scale. The resident's skin condition included the following: Right hand - a blister on the palmar surface that measured 4.5 centimeters (cm) x (by) 3 cm. Left hand - a blister on the palmar surface which measured 8 x 5.5 cm. Right eye - purple/red skin color changes measured at 8 x 3 cm. Bridge of nose - a scabbed area that measured 1 x 0.5 cm. Middle of the forehead - erythmic purplish color changes that measured 3.5 x 3.5 cm. Above the right eye - erythmic purplish color changes that measured 1.2 x 1.5 cm. Right knee - a scabbed area of damaged skin measured as 6.5 x 7 cm with an area of [DIAGNOSES REDACTED] and purple skin color changes that measured 22 x 15.5 cm. Lateral to that area on the right knee an area of [DIAGNOSES REDACTED] purple skin color that measured 2.7 x 2 cm. Right ear lobe - mildly red. Left knee - a scabbed area measured at 6 x 7 cm and an area of [DIAGNOSES REDACTED]/purple skin color changes measured as 10.5 x 9 cm. The assessment section of the form revealed the resident had hypothermia, cardiac arrhythmia which had been resolved, frostbite as detailed above and dementia. According to a Progress Notes form dated 2/7/14, a Wound Care Nurse assessed and documented the following areas as described: Burn 1: A frostbite burn noted, full thickness (probable due to eschar), location (left knee, shape (irregular) size and depth 10.2 x 7.5 cm, characteristics (dry eschar with unroofed blisters superior/lateral edge), margin (deep pink with purple rimmed edge), discharge (small serous). Burn 2: A frostbite burn noted, full thickness (probable full thickness due to eschar), location (right knee, shape (irregular), size and depth 11 x 9.4 cm, characteristics (irregular shaped dry eschar center with deep pink peri wound skin, part of which were unroofed blisters), margin (irregular), discharge (small serious. Burn 3: A frostbite burn noted, full thickness, location (right medial knee), shape (round), size and depth 1.5 x 1.5 cm, characteristics (filled with serious fluid), margin (defined), discharge (none). Burn 4: A frostbite burn noted partial thickness (unknown), location (right forearm), shape (oblong), size and depth 1.9 x 2 cm, characteristics (eschar), discharge (none). Burn 5: A frostbite blister burn(s) noted, location (unroofed blister of the left palm), shape (oval), size and depth 5.2 x 5.5 cm., characteristics (deep pink, clean), margin (distinct), discharge (scant serious. Burn 6: A frostbite injury burn(s) noted, partial thickness, location (right palm), shape (oval), size and depth 4.5 x 5 cm), characteristics (serous fluid filled blister), margin (distinct), discharge (none). Bilateral eyes had been swollen and deep purple in color. During an interview 2/7/14 at approximately 2 p.m., a wound care nurse reviewed with the surveyor the information documented above. The nurse indicated she had been unable to identify the length of time of exposure by the wounds due to several unknown elements like position; time elapsed since actual exposure and etc. The nurse indicated she had not been able to debride the wounds on the resident knees due to the amount of time that had elapsed since the exposure and her visit. To debride frostbite burns the procedure needed to take place the same day. During an interview on 2/5/14 at approximately 12 p.m., a physician shared the following information: Due to the exposure, the resident now had heart damage. The hospital had to administer excessive amounts of warm fluids to increase the resident's body temperature which put the resident into congestive heart failure (CHF).The resident's kidneys had not shut down. The physician had been unable to identify the length of time the resident had been exposed based on the condition of the resident ' s frostbite burns. On 2/13/14 at 11:07 a.m., Staff C, CNA confirmed she had been working in the Memory Care until on the morning of 2/4/14 with Staff F, CNA and the resident had been wandering per normal routine. The staff member confirmed the medication room doors as open between the Memory Care Unit and Phoenix (unit) with a laundry cart positioned up against the doorway on the Memory Care Unit side as there had been a resident on the Phoenix side vomiting and she had been afraid the resident may choke. The staff member confirmed the facility staff sometimes left the medication room doors open at night and placed the medication cart in front of the doorway but that night the cart had not been available so she utilized the laundry cart. At around 3:30 a.m. the staff member observed the resident enter his/her room however she had not looked at a clock rather she assumed the time as she had just completed rounds. At 4 p.m. (looking at her watch) she took another resident to the bathroom which took about 5-10 minutes. When she came out she looked for the resident to take him/her to the bathroom however the resident had not been found on the unit. The staff member then searched the Phoenix unit, could not find the resident so at approximately 4:30 a.m. she ran to the Gemini unit to inform Staff A, Licensed Practical Nurse (LPN). At that point, Staff A and Staff C split up and went around a portion of the outside of the building each going different ways. The staff member returned to New Horizons and asked Staff F if she heard anything with a reply of no. That had been when she asked Staff D, Financial Manager (in the Wellness Center) to help. Staff D planned to drive around the area while Staff C went up to the 2nd floor and looked everywhere on that unit. She then went back down to New Horizons and out the diagonal lounge door, around the garden and back into Gemini and into the Phoenix area. The staff member denied going to the main entrance of the building at any time during her search. The staff members had no means to communicate so she never knew the resident had been found outside while she kept searching for him/her. At one point she came back into the Gemini unit and observed Resident #2 crawling out of bed while screaming so she went to make sure the resident had been alright and lifted him/her back into bed as there had been no other staff members present on the unit. After she assisted the resident she returned to the Phoenix unit at which time staff informed her the resident had been found and the ambulance as on the way. The staff member returned to Gemini to check on Resident #2 but he/she remained in bed. At that point the staff member returned to New Horizons and stayed there until shift change. The staff member confirmed the facilities standard of practice as leaving the medication room doors open if they were short staffed. The staff member also confirmed she heard the door alarm sound on 2/4/14 at 2:30 a.m. but there had not been a panel on the New Horizon unit so the nurse usually called them to inform the staff of the status but she did not think anything about it because Resident #1, staff and delivery drivers set off the alarms a lot. During an interview 2/13/14 at 11:07 a.m., Staff C explained Resident #2 as "almost" falling out of bed further described as a potential to fall head first out of bed if the resident would have pushed on his/her feet positioned in the bed. The staff member repositioned the resident in bed, covered him/her, and denied taking him/her to the bathroom and with the inability to understand the resident due to his /her dysphasia. The staff member indicated she had not informed Staff A of the incident until later, but not that day. During an interview 2/4/14 at 9:50 a.m., Staff F confirmed Staff C informed her she could not find Resident #1 and asked her to search the Phoenix and New Horizon units. Staff F did so and went back and stayed in the New Horizons Unit. The staff member confirmed the medication room doors as open with the laundry cart positioned in front of the door on the New Horizons side. The staff member confirmed Resident #1 as known to wander, there were other residents in the unit known to wander, that she had not known if the doors in the facility had been checked or locked at night but she never locked them when she worked and she had not known if alarms were disarmed at night or not. During an interview 2/5/14 at 1:50 p.m., Staff A confirmed on 2/4/14 at 2:30 a.m., the main door alarm sounded but she had been in a resident's room so she did not get to the alarm box before it had been cleared but she knew the alarm had been for the main entrance because Staff M called her to inform her of the status. Both staff members knew Staff B, LPN had gone to break so she told Staff M the door alarm had been Staff B going outside for break and failed to investigate the alarms and never spoke to Staff B about the incident. At 4:30 a.m. the staff member called the New Horizons unit and asked for assistance to reposition a male resident in Gemini. Staff C answered the telephone and said she planned on looking for Resident #1 because she had not seen him/her for a bit but would come right over. Staff A waited for assistance but no one arrived so she went to New Horizons and had been informed the resident as not found. She searched the rooms, asked when the resident had last been observed with a reply of, not long ago he/she had been walking in the dining room. While Staff A looked through the rooms Staff C took off to a place unknown. At this point the staff member noted both medication room doors as open with a laundry cart across the doorway in the Memory Care unit side and that this had been a standard of practice so the staff members could hear call lights on both the New Horizons and Phoenix units. The staff member then called Staff B and informed her Resident #1 as not found. Staff A began searching the Phoenix area as Staff C came down the hallway and said she could not find the resident and planned to go outside and search. Staff A gave her pager for the Gemini call lights to Staff F, retrieved her coat and jacket and went outside the Gemini entrance on 3rd street to search for the resident. She headed east to Butler Street and met Staff C on the corner who informed her she could not find the resident in front of the building. Staff A directed Staff C to go back inside because she had not been wearing a coat. At that point Staff A went West, around the back of the building, through the garden area to the diagonal entry, around the assisted living unit, down the alley looking in windows, checking inside and out then came around the front of the building walked up the Circle C drive and found the resident face down just South of the main entrance where the sidewalk met the driveway at around 5:30 a.m. The resident had been wearing a night gown and slipper socks with his/her legs exposed from just above the knees to the ankles and not moving but moaning. There had been snow and ice on the cement so the staff member took off her coat and jacket and placed the coat on the resident's upper body and her jacket on the resident's lower body. The staff member then used her cell phone and called into the building. Staff B came outside and as they prepared to lift the resident to take him/her inside Staff J arrived and the 3 staff members carried the resident into the building while slipping on the ice. They laid the resident on his/her back inside the first sliding glass doors in a heated area. The staff member left to get blankets while Staff B and Staff J stayed with the resident. On her way back she handed the blankets off to an unknown person and went to retrieve more supplies. When she returned to the resident she checked his/her vitals. The staff member thought the resident's temperature had been 78.3 degrees F, pulse in the 90's, an oxygen saturation rate of 88% but she had been unable to obtain a blood pressure. The staff member then called the Assistant Director of Nursing (ADON) and the physician on call. She received an order to transport the resident to the hospital via an ambulance. Between calling the physician and waiting for a return call, she rechecked the resident's blood pressure and still had been unable to obtain a reading. After she received an order to transport the resident she went to the unit to get paperwork and called the resident's son with a plan to meet him/her at the hospital. When she returned to the resident, she rechecked the resident's temperature and it had been up in the 80's. At that point the resident had been making a noise with his/her lips but this had been normal for the resident. While the staff awaited the arrival of the ambulance, she noted the resident's bilateral knees had rug burns and he/she had a bruised and swollen right eye. When the ambulance arrived they loaded the resident up and she sent the paperwork with the crew. The staff member confirmed the resident as exit seeking and that she had been aware the resident had eloped another time. The staff member stated when the resident had been found it had not started snowing yet and the temperature had been 9 degrees F outside (she looked on her phone) not windy but very cold. During an interview on 2/12/14 at 9:47 a.m., Staff A stated she knew nothing about an elopement checklist form before this elopement. The staff member confirmed the Director of Nursing (DON) had given a directive not to keep the medication room doors open prior to the event but she had not been aware of any audits to assure the staff had been following through according to that directive. The staff member also confirmed when she arrived to work the night shift on 2/11/14 the 2nd shift staff had left the medication room opened and unattended with treatment supplies, sharps and etc. present in the medication room however no residents where known to wander on the Phoenix unit. During an interview on 2/5/14 at 3:35 p.m., Staff B, Licensed Practical Nurse, stated on 2/4/13 at 2:30 a.m. she left the building for a break from the Gemini entrance onto 3rd street and had been outside less than 15 minutes but denied hearing an alarm sound at any time. At 5 a.m. she received a call from Staff A who asked her to come down stairs to assist in looking for Resident #1. The staff member went directly down to New Horizons and stayed in the unit and searched each room. When she arrived in the unit the staff member confirmed both medication rooms doors as open between New Horizons and Phoenix with a laundry cart positioned along the door entrance in New Horizons. The staff member confirmed this had been a standard of practice for the 3rd shift at the time. The staff member stated she later received a telephone call from Staff M, CMA working in Galaxy indicating staff found the resident. Once the girls were back in the New Horizons unit the staff member went to assist Staff A on Circle Drive and found the resident on the ground, face down in the driveway with his/her head towards the building and feet towards the street on a patch of ice covered in blankets or coats. Staff A had been sitting beside the resident while the resident made moaning sounds like he/she had been in pain and had been obviously cold. The staff members propped open the door to the main entrance of the facility while Staff J joined them. Staff A and Staff B held the resident's arms while Staff J held the resident's feet while they took the resident into the main entrance of the facility. They positioned the resident on his/her back and placed more blankets over him/her. A staff member checked the resident's temperature which registered in the high 70 ' s; the pulse and/or oxygen level registered in the 80's but there had been no blood pressure. Staff B sat with the resident, propped his/her head up on the blankets, held his/her hand and tried to warm up the resident while the staff waited for the ambulance. The staff member could not recall the temperature outside and or the time of morning. The staff member stated the resident had not been shaking but his/her left eye had been swollen shut, had a goose egg on the forehead, his/her knees had been scraped up and she questioned if the resident's left arm had frostbite because the area had been discolored further described as real red with a pale middle. During an interview 2/5/14 at 5:15 p.m., Staff J, Dining Services, stated she came to the facility on [DATE] at 4:30 a.m. as a delivery driver always arrived at that time on Tuesdays. She entered the facility via the lower diagonal door and the delivery driver had already arrived at the facility but had the code for the service door so had started delivering supplies. She went to the panel and bi-passed the service entrance code so the alarm would not have sounded. Both she and the service driver had been in and out at that point as she had been in the back room unloading the supplies while he loaded and delivered them from the truck. The delivery driver left the facility at 5 a.m. and she re-locked the door. The staff member confirmed this procedure as a standard of practice for the facility. At 5:15 a.m. Staff E, Laundry informed her the resident had been missing at which time she went upstairs to the mansion door and observed the girls attempt to lift the resident up but the area had been way to icy. She went to assist the staff and the resident into the main entrance of the facility by the circle driveway. She sat with the resident until the ambulance arrived and then went on with her work. A verbal statement provided by the delivery driver to Staff L, Services Director, documented the following information: He arrived at the facility for a delivery at 4:30 a.m. on 2/4/14. He had been at the facility unloading food at the service entrance on the East of the building for about a half hour. He stated he only observed 3 people the entire time he had been at the facility. One of them had been Staff J who let him into the building. The other 2 people were a man and a woman who looked like they were on their way to work. When asked how long the service door had been left unlocked and unattended he said maybe 2 minutes at one time, at most. He quoted it took him about 1 to 2 minutes to load and 1 to 2 minutes to unload the supplies. A written statement provided by Staff D dated 2/4/14 reflected Staff D and her husband arrived at the Village around 4:35 a.m. The lights were out in the Wellness Center, so they didn ' t try the doors there and went in through the service entrance door. A delivery driver was delivering supplies so they walked in right behind him as he was going through the door. The doors going in from the hallway to the Wellness Center were not locked so they went in. Staff E came in probably sometime before 5:00 a.m. Staff D stated she usually unlocks the sliding doors to the entrance to the Wellness Center but when she looked, they were already unlocked so she did nothing. Staff D guessed it had been approximately 5:10 a.m. when Staff C came into the Wellness Center and asked if they had seen a "wanderer". Staff D and her husband stated had had seen anything so she (Staff C) looked around a bit and left. After Staff C left, Staff D had her husband check the restrooms in that area to make sure there had been no one in there. At approximately 5:20 a.m., Staff D saw Staff C outside the Wellness Center entrance looking around. Staff D guessed she went out the service door entrance from the direction she came from. Staff D told her husband that it appeared they (other staff) were still looking for someone so she planned on going to see if they needed help. Staff D met Staff E in the hallway, outside the Wellness Center and they both went to New Horizons. Staff E started looking in rooms. Staff D saw Staff C there and she stated she had seen the resident earlier but had no idea where the resident was now. Staff D went down to talk to Staff B to get the details about what had been done so far in the search. At that time, the doors were open both ways through the medication room with a cart nearby. Staff D documented she thought the cart was in the doorway of the medication room initially when she saw it. Staff D asked how long they had been looking for the resident. Staff D thought she remembered them saying since 4:30 a.m. Staff C stated she wondered if they should call the police. Staff D stated if it had been awhile since they started looking then they should call the police. Staff D knew at that point she had been in the medication room but didn't have to move the cart to get in there, so it had been out of the doorway by that point. Staff F had been present and mentioned that she had been in Gemini (area of facility). Staff D could not remember who said it or at exactly what point they said it, but sometime while she had been down in New Horizons, they said that the main door alarm went off around 2:30 a.m. but they thought it was Staff B going out on her break. Staff D told them that she and her husband would get in our truck and start driving around the