Every finding on record at The Vistas at Bettendorf

Based on employee file review, staff interviews, and facility policy review the facility failed to ensure staff completed the required Dependent Adult Abuse training within 6 months of hire and that staff completed renewal training within 3 years of previous training for 3 of 9 staff reviewed ( Staff C and Staff D, Certified Nurses Aide and Staff E, Cook). The facility reported a census of 70 residents. Findings include:1. Review of Staff C, Certified Nurses Aide (CNA)'s employee file documented a hired date of 3/27/25. A Dependent Adult Abuse (DAA) certificate to indicate the training completed within 6 months of hire not found in the file. 2. Review of Staff D, CNA's employee file revealed documentation DAA training completed on 5/16/23. The file did not have documentation the renewal training had been completed within the required 3 years. 3. Review of Staff E, [NAME] employee file revealed documentation DAA training completed on 10/22/22. The file did not have documentation the renewal training had been completed within the required 3 years. During an interview on 6/3/26 at 10:00 AM, the Human Resources (HR) Director stated Staff C, CNA had not completed the DAA training. She added Staff D, CNA had not completed the three year reviewal of DAA training, and Staff E, [NAME] never completed the right renewal DAA training. During an interview on 6/03/26 10:17 AM, Administrator stated DAA should be completed within 6 months of hire and renewed every 3 years. Review of the undated facility policy titled Abuse Prevention Program revealed the program has mandated training on abuse prevention, identification and reporting. That the training is for new hires and existing staff members as required by Centers for Medicare and Medicaid Services (CMS).

Based on observation, facility policy review and staff interviews, the facility failed to label, date and store food in accordance with professional standards in an effort to prevent cross contamination and food borne illness. The facility reported a census of 70 residents.Findings include:During an observation on On 6/2/26 at 11:17 AM, the resident refrigerator in the Rehab hallway noted to have sticky substances on the door and on the interior shelves. The refrigerator contained the following unlabeled an undated resident food items: a. Grapes in a sandwich sized bag with no name or date indicated. b. A opened tea drink with no name or open date indicated, and an expiration date of 4/26/26.c. 3 - individual sour cream packets with an expiration date of 11/20/25.d. 8 - individual undated coffee creamers.e. 1 - patterned face mask located in the bottom drawer with no name indicated.f. Mustard container with an expiration date of 5/13/25g. A drink in a to go container with lid and straw with no name or date indicated.The freezer contained 1 blue and black bio mask with the indicated use for migraines. A visible hair noted in the velcro strap of the mask. On the top of the refrigerator sat two containers of a protein supplement with an expiration date of 4/27/26. The protein supplement containers had a cream-colored liquid noted at the base of each container. During on observation on 6/2/26 at 11:17 AM, a refrigerator on the second floor noted to have food particles on inside of the unit. The following food items found in the refrigerator: a. 7- individual Italian dressing packets with an expiration date of 04/04/26.b. 1- yogurt container with an expiration date of 5/23/26.c. An open container of chocolate milk with no name or opened date indicated.d. An apple juice container with an expiration date of 04/16/25.e. 2 -sandwiches wrapped in plastic film with no name indicated, and dated 5/27/26.f. Mexican food in a to go container with no name or date indicated. g. Grapes stored in a sandwich sized bag with no name or date indicated.During an interview on 6/02/26 11:27 AM, Staff B. Licensed Practical Nurse (LPN) stated third shift are to clean the refrigerator and check for expired and unmarked items.During an interview on 6/3/26 11:00 AM, the Administrator stated she expected that the refrigerators are cleaned, all food dated, labeled and expired food thrown out.Review of the facility policy titled Food Safety Requirements dated 12/29/25 revealed, a Guideline section, which directed, in part: All foods stored in the refrigerator or freezer shall be covered, labeled and dated.

Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure a resident only received medications prescribed to them for 3 of 3 residents reviewed (Resident #19, Resident #1, and Resident #3) for medication errors. The facility reported a census of 70 residents.Findings include:1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS documented he had diagnoses of hypertension, renal insufficiency, and diabetes.Review of the Medication Error Incident Report for Resident #19 documented on 02/03/26 morning medication administration, he received another resident's medication. The medication given were: aspirin 81 mg (milligrams), Caltrate (calcium and vitamin D supplement) 600mg+D3 20MCG (micrograms), carvedilol (beta- blocker works by slowing the heart rate and relaxing blood vessels)12.5 mg, ferrous sulfate (iron supplement) 325 mg, furosemide (diuretic, often called a water pill) 40 mg , hydrochlorothiazide (diuretic) 25mg and a Multivitamin tablet.Review of the February 2026 Medication Administration Record (MAR) revealed Resident #19 had not been prescribed to take: Caltrate, carvedilol, furosemide, hydrochlorothiazide or a multivitamin on 02/03/26.During an interview on 6/4/26 at 9:30 AM, the Director of Nursing (DON) explained on 2/3/26 the nurse became distracted when pulled away from the cart. When the nurse returned to the cart she failed to identify the resident prior to giving the medication. The DON reported she expected staff to do the 6 rights of medication administration and staff are to always identify the resident by asking the resident to confirm.2. Resident #1's MDS assessment date 5/20/26 identified a BIMS score of 9 of out 15, indicating moderate cognitive impairment. The MDS documented he had diagnoses of congestive heart failure, dementia, and renal insufficiency.Review of the Medication Error Incident Report for Resident #1 documented on 5/4/26 morning medication administration, he [Resident #1] received another resident's medication. The medications given were: amlodipine besylate (antihypertensive) 5mg - 2 tabs, carbamazepine ER (extended release anticonvulsant) 2 capsules, lacosamide (anticonvulsant) 200mg, Macrobid (antibiotic) 100 mg, potassium chloride ER (extended release) 20mg, and vitamin C 500mg.Review of the May 2026 MAR revealed Resident #1 had not been prescribed to take: carbamazepine, lacosamide, Macrobid, potassium chloride or Vitamin C on 05/04/26.During an interview on 6/3/26 at 2:53 PM Staff G, Certified Medication Aide (CMA) reported that on the day of the medication error she had put Resident #1's medications in a med cup and got called away to help another staff with a transfer. Staff G explained she put the med cup in the cart to go help. When she came back, she then started getting Resident #20's medications ready and got called away so put that cup in the cart. When she got back to the cart, she gave Resident #1 his medication from one of the med cups in the cart. Staff G stated realized she gave Resident #20's medications to Resident #1. She stated she reported it right away to the nurse and notified the family and physician right away too. 3. Resident #3 MDS assessment dated [DATE] identified a BIMS score of 3 of out 15, indicating severe cognitive impairment. The MDS documented diagnoses of hypertension, seizure disorder and cerebrovascular accident (stroke), transient ischemic attack, or stroke.Review of the Medication Error Incident Report for Resident #3 documented on 05/22/26 morning medication administration, he received another resident's medication. The medication given were: amiodarone HCL(medication used to treat a heart arrhythmia) 200 mg, apixaban (anticoagulant, or blood thinner) 5 mg, carvedilol 12.5 mg, clopidogrel bisulfate (antiplatelet) 75 mg, doxazosin mesylate (antihypertensive) 4 mg, empagliflozin (medication used to expel excess blood sugar) 10 mg, Gabapentin (anticonvulsant) 100 mg, pantoprazole sodium (used to treat acid reflux) delayed release, paroxetine HCL (antidepressant) 40 mg, senna plus (stool softener) 8.6-50 mg, spironolactone (diuretic) 50 mg, and torsemide (diuretic) 20 mg.Review of the May 2026 MAR revealed Resident #3 not prescribed amiodarone, apixaban, carvedilol, clopidogrel, doxazosin, empagliflozin, pantoprazole, paroxetine, senna, spironolactone or torsemide on 05/22/26. During an interview on 6/4/26 at 8:18 AM Staff H, CMA reported she was getting Resident #2's medications ready while talking to Resident #3, and then got side track and gave Resident #3 the medications for Resident #2. Staff H stated got a nurse right away and the nurse assessed him and called the doctor and family right away too.Review of the undated facility policy titled Medication Errors revealed, in part: Medication Errors include H. Wrong Person. A document titled Medication Administration listed the 6 Rights of Med Admin(stration), which included: the right patient, the right med, right time, right route, right dose and right documentation. The document listed Common Medication Errors which included, Wrong.Client.

Based on observation, clinical record review, facility policy review, family and staff interview, the facility failed to complete wound treatments as ordered by the physician for 1 of 3 residents (Resident #1 ) reviewed for physician orders. The facility reported a census of 75 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #1 with a BIMS (Brief Interview for Mental Status) score of 9 out of 15, which indicated a moderate cognitive impairment. The MDS list of diagnoses included unspecified dementia, coronary artery disease and diabetes mellitus.During an interview on 10/22/25 at 10:32 AM, Resident #1 family representative discussed concerns regarding the wound care her family member is receiving for a diabetic foot ulcer. They stated during a visit on 9/27/25, they observed the dressing on the resident's foot was dated 9/25/25. They stated on 9/28/25 the dressing continued to be dated 9/25/25. The family member stated they asked about when the dressing should be changed and was informed by a Staff G, LPN (Licensed Practical Nurse) the dressing should have been changed on 9/27/25. The family member stated the nurse did change the dressing and stated the dressing should be changed every day or every other day, they were not sure. Review of the September 2025 Treatment Administration Records (TAR) revealed the following orders for wound care:a. Left medial heel - Cleanse wound, apply calcium alginate, and cover with border gauze. Every evening shift for wound care. Start Date: 9/16/25. D/C (discontinue) Date: 9/22/25. Review of the September 2025 revealed no documentation of the above treatment completed on 9/16/25, 9/18/25, and 9/22/25. b. Left medial heel - Cleanse wound, apply lodosorb (a gel that is applied to wounds for absorption of drainage and cleaning out the wound) to wound bed, calcium alginate, 4 x4 , roll gauze and secure with tape. Every day shift for wound care. Start Date: 9/23/25. D/C Date: 10/6/25. Review of the September 2025 revealed no documentation of the above treatment completed on 9/23/25 and 9/27/25. A 2 documented on 9/24/25, 9/26/25, and 9/30/25. Per the TAR Chart Codes, a 2 is used to indicate Drug Refusal. Review of the October 2025 TAR revealed the following orders, in part:a. Left medial heel - Cleanse wound, apply lodosorb to wound bed, calcium alginate, 4 x4 , roll gauze and secure with tape. Every day shift for wound care. Start Date: 10/7/25. D/C Date: 10/13/25. Review of the October TAR revealed no documentation of the above treatment completed on 10/7/25, 10/9/25, 10/10/25, and 10/11/25.b. Left medial heel - Cleanse wound, apply lodosorb to wound bed, calcium alginate, 4 x4 , roll gauze and secure with tape. Every day shift for wound care. Start Date: 10/14/25. D/C Date: 10/20/25.The October TAR indicated the above treatment completed daily as ordered. c. Left medial heel - Cleanse wound, apply lodosorb to wound bed, calcium alginate, 4 x4 , roll gauze and secure with tape. Every day shift for wound care. Start Date: 10/21/25.The October 2025 TAR indicated the above treatment completed on 10/21/22. During an observation on 10/22/25 at 1:06 PM, Resident #1 observed to have an intact dressing on his left foot dated 10/20/25. During an interview on 10/22/25 at 2:40 PM, Staff B, RN (Registered Nurse) reported the date on the dressing today was not dated 10/21/25, he was unsure of the date. He had asked the ADON to change the dressing that day.During an interview on 10/22/25 at 7:43 AM, Staff C, RN reported she worked 10/21/25 and admitted she did not change Resident #1's dressings that day. She was the only nurse for 28 residents during her shift. During an interview on 10/23/25 at 12:15 PM, Staff G, RN stated if medications or treatments were not signed out, it may not have been done or the nurse forgot to sign it out. If the resident refused the treatment or medication, the nurse would need to document this on the TAR and document this a 24-hour nurse's communication log so the nurse on the next shift could complete. During an interview on 10/23/25 at 12:02 PM, the Assistant Director of Nursing reported the following: The only explanation for treatments or medications that were not signed out would be if the resident refused and she would expect the nurse to document why with different numerical codes on the TAR. Review of the facility policy titled Physician Orders, Approval Signature of Administer dated 10/13/25, directed: a. The individual administering the medication must initial the resident's MAR on the appropriate line after administering medications.b. Topical medications used in treatments must be recorded on the resident's treatment record.c. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall note in the EMAR with the appropriate code and make a progress note as to why med was not given.

Based on clinical record review, facility policy review, family and staff interview, the facility failed to notify the family representative of the development of a diabetic foot ulcer for 1 of 3 residents (Resident #1) reviewed for notifications. The facility reported a census of 75 residents.Finding include:The Minimum Data Set (MDS) dated [DATE] identified Resident #1 with a BIMS (Brief Interview for Mental Status) score of 9 out of 15, which indicated a moderate cognitive impairment. The MDS list of diagnoses included unspecified dementia, coronary artery disease and diabetes mellitus. The MDS indicated at the time of assessed Resident #1 did not have any wound or skin problems. Review of the electronic health record (EHR) revealed a [Name redacted} Wound Physician's Initial Wound Evaluation & Management Summary, dated 9/15/25, revealed a Diabetic Wound of the Left, Medial Heel Full Thickness. The summary indicated, in part: Etiology (type) Diabetic; Duration: less than 1 days.Estimated Time to Heal: 2-4 months.Wound Size (L x W x D): 3.0 x 6.0 x 0.1 cm (centimeter). During an interview on 10/22/25 at 10:32 AM, Resident #1 family representative sated the facility did not tell them of the development of the resident's diabetic foot ulcer. They stated they were not aware of the wound, and learned of it when the Wound Care provider came to the resident's room to provide care during their visit. During an interview on 10/23/25 at 10:24 AM, the MDS Coordinator reported the nurse who found the wound first is responsible for notifying the family that same day. During an interview on 10/23/25 at 12:02 PM, the ADON (Assistant Director of Nursing) stated she expected nursing staff to notify the family of any change of condition, new wounds, new medication orders, any new orders, any behavioral changes. She would also expect them to document the notification in the progress notes the same day.A review of the Facility Policy titled: Change in a Resident's Condition or Status, dated as last revised December 2016 and had the following documentation:1. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source;b. There is a significant change in the resident's physical, mental, or psychosocial status;c. There is a need to change the resident's room assignment;d. A decision has been made to discharge the resident from the facility; and/ore. It is necessary to transfer the resident to a hospital/treatment center.2. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on record review, staff interview and facility policy review, the facility failed to ensure two residents took their medications and left the medications at the bedside (Residents #9 and #54) and failed to ensure Resident #42 swallowed his medications before Resident #20 took them. The facility reported a census of 70 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] identified Resident #20 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Non-Traumatic Brain Dysfunction, Non-Alzheimer’s Dementia and Peripheral Vascular Disease. The MDS also identified Resident #20 as independent with most activities of daily living. A review of an incident report completed by the ADON (Assistant Director of Nursing) dated 5/21/25 revealed the following: CNA reported to nurse that Resident #20 took another resident’s medication. The other resident brought down his medications with him to first floor so he could take it with dinner. This other resident went to this resident’s room and set his meds down and this resident took his meds. (the incident report did not identify the name of the other resident later identified as Resident #42) Medications included: Tegratol 400 mg (milligrams) and Keppra 750 mg. The Medical Director was notified, instructed staff that she would be very tired and shouldn’t walk around and to call pharmacy for medication interactions. Resident #20 verbalized feeling very tired and was educated not to walk around her room that night. Resident #20’s Care Plan failed to address the problem of the above incident where she took Resident #42’s medications. A review of Resident #20’s progress notes for entire month of May 2025 had no documentation of the above incident. 2. The MDS dated [DATE] identified Resident #42 as severely cognitively impaired with a BIMS of 04 and had the following diagnoses: Cerebrovascular Accident (stroke), Seizure Disorder and repeated falls. The MDS also identified Resident #42 as independent with most activities of daily living. A review of an incident report completed by the ADON (Assistant Director of Nursing) dated 5/21/25 revealed the following: CNA reported to nurse that Resident #20 took another resident’s medication. The other resident brought down his medications with him to first floor so he could take it with dinner. This other resident went to this resident’s room and set his meds down and this resident took his meds. (the incident report did not identify the name of the other resident later identified as Resident #42) Medications included: Tegratol 400 mg (milligrams) and Keppra 750 mg. The Medical Director was notified, instructed staff that she would be very tired and shouldn’t walk around and to call pharmacy for medication interactions. Resident #20 verbalized feeling very tired and was educated not to walk around her room that night. On 6/28/24, the Care Plan identified Resident #42 with the problem of a Seizure Disorder and instructed staff to give him his seizure medication as ordered by doctor and to monitor/document side effects and effectiveness. The care plan failed to address the incident where he took his medications in for another resident and the need to have the nurse ensure she/he observed the resident actually swallowing the medications. A review of Resident #42’s progress notes for entire month of May 2025 had no documentation of the above incident. In an interview on 8/14/25 at 8:16 AM, the ADON (Assistant Director of Nursing) reported the following: a. When asked about the incident on 5/21/25 at 5:00 PM where one resident took another resident’s medications, she reported Staff B, LPN gave Resident #42 his medications which he took with him to Resident #20’s room. b. Resident #20 picked up Resident #42’s medications and took them. c. Resident #20 has a BIMS of 15, but is very forgetful and has short term memory. d. Resident #42 acted like he took his medications in front of Staff B, however he actually did not swallow the pills. He likes to take his medications with his meals. e. Staff B should have taken his medications to him at the dining room table. The DON (Director of Nursing) and ADON provided nursing staff with education. f. She was not sure if this should have been addressed on the residents’ Care Plans. In an interview on 8/14/25 at 8:57 AM, Staff C, RN reported the following a. When asked about the incident on 5/21/25 at 5:00 PM where one resident took another resident’s medications, she reported Resident #20 reported she took Resident #42’s medications. She was taking care of Resident #20 and did not know what medications Resident #42 had in the medication cup. b. She could not explain why Resident #42 had his medications with him when he went into Resident #20’s room and she ended up taking his medications. In an interview on 8/14/25 at 9:15 AM, the Director of Nursing reported the following: a. When asked about the incident on 5/21/25 at 5:00 PM where one resident took another resident’s medications, she reported she received a phone call from the ADON who reported Resident #20 took Resident #42’s medications. b. Staff B, LPN thought she gave Resident #42 his medications upstairs before he went to visit Resident #20 downstairs. When he got to her room, he put the cup of his medications on her table and she picked them up and took them. She could not recall the names of the medications. c. Resident #42 usually likes taking his medications with his meals. d. She expected the nurse to actually watch him swallow his pills to prevent this error. e. Actions she took after this error occurred was she educated Staff B and the rest of the nursing staff on the importance of watching the resident actually swallow their medications. In an interview on 8/14/25 at 9:39 AM, Staff B, LPN reported the following: a. When asked about the incident on 5/21/25 at 5:00 PM where one resident took another resident’s medications, she reported she was up on 2nd floor and went to give Resident #42 his pills. She could not remember what they were. She handed them to him in the medication cup, he picked them up and put the cup by his mouth as if he actually took meds. She did not check his mouth to see if he actually swallowed them. In the past when she handed him his pills, he would say he wanted to take the pills down to the dining room with him. She would tell him no, she would give them later. That day, she did not ask if he wanted to take his pills then or with his meals. She actually thought he took them. b. She was not familiar with his routine and there was nothing on the MARs or care plan that would let her know he preferred to take the medications with his meals. He specifically said the doctors told him he needed to take his medications with food. She though it would be helpful if there were instructions on the MARs for incidents like this. c. When asked what could have been done to prevent the incident, she reported she could have stood there for another 30 seconds to make sure he swallowed his medications. Not ten minutes later, another resident wanted her to leave his medications there for him to take later with supper. d. When asked what was done to prevent this kind of error again, she reported all nurses were educated by notes left in their mailboxes. A review of the facility policy titled: Medication Administration with the last revision date of 6/21/21 had documentation of the following procedure: a. Identify the resident by picture and check the eMAR (Electronic Medication Administration Record). Each medication is to be verified for the right dose, right medication, right time as well as well as right route, by comparing the label on the medication container to the eMAR. b. Read the label three times before dispensing the medication into the med cup or pill pouch. c. Administer the medication. d. Observe the act of swallowing. e. Record the medication given on the eMAR after the medication is swallowed. 2. Resident #54’s MDS assessment dated [DATE] showed a BIMS score of 9/15 indicating a moderate cognitive loss. The MDS listed diagnoses of Non-Alzheimer’s Dementia, Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that makes it hard to breath), bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, activity levels and cycling between high and low depression which can impact the ability to function in daily life, affecting thinking and behaviors) and mild cognitive impairment of uncertain/ unknown etiology. Resident #54's Medication Review Report (MRR) signed by the Provider on 7/08/25 listed an order for an Albuterol Sulfate Inhalation Aerosol Solution 108 (90 base) micrograms per actuation (MCG/ACT) give two inhales orally every six hours as needed for shortness of breath/COPD. The MRR lacked documentation Resident #54 could keep the medication at the bedside. During an observation on 8/13/2025 at 8:33 AM Resident #54 observed sitting in his chair with an Albuterol Sulfate Inhaler sitting within reach on his bedside table approximately 2 foot away. Resident #54 reported that he had COPD and when he takes the inhaler it helps him breath. Observation on 8/13/25 at 8:40 AM revealed the hallway outside of Resident #54 room with no medication cart or nurse in the hallway. Interview completed on 8/13/25 at 1:15 AM Staff H, RN stated medications cannot be left at the bedside unless the care plan specifies the resident can have their medications at the bedside. Usually that includes medications like inhalers and eye drops. Sometimes a resident will ask the nurse to leave medications at the bedside, but those are just over the counter medications. If a resident asks and the medication is an over the counter medication, he will leave the medication with the resident, otherwise certain residents get really upset. Resident #54 cannot have medications left at the bedside, but he does have an inhaler he keeps at the bedside. Staff H assumed Resident #54 has an order for the inhaler to be at the bedside. Resident #54 likes his independence so he has not pulled the inhaler out of the room. Resident #54 is a resident that is in between. He is alert, but is not totally 100% alert. He has good and bad times. Interview on 8/13/25 at 12:00 PM Staff I, RN explained the nurses are not to leave medications at the bedside. Interview on 8/13/25 at 1:35 Staff J, LPN voiced the nurses absolutely do not leave medications at the resident's bedside. Interview completed on 08/13/2025 at 2:00 PM Staff K, LPN stated resident medications are not to be left at the bedside. If a resident does not take their medication, the nurses are to take the medication with them. They lock the medication in the medication cart and re-approach the resident to take later. An 8/13/25 review of Resident #58 Electronic Health Record (EHR) Care Plan, Progress Notes, Assessments and Electronic Medication Administration Record (EMAR) August 2025 lacked documentation of a self-medication administration assessment for safety. On 8/14/25 at 7:21 AM Staff T, Housekeeping voiced he finds pills on the resident floors in their rooms all the time. During an interview on 8/14/25 at 9:44 PM the DON reported there are no residents that self-administer their medications at this time. They provided an education back in June 2025 specifically about not leaving medications in resident rooms. In order for a resident to have medications in their room, a self-medication administration assessment would be completed by herself, the Assistant Director of Nursing (ADON) or the charge nurse followed by an observation of the resident for medication safety. The resident or legal representative would have to sign a medication administration safety form. The DON reported there is no medication safety assessment for Resident #54 because he cannot self-administer his medications and the nurses should not have left any medication in the resident’s room. During an interview on 8/14/25 at 11:09 AM the DON explained they utilize the medication administration competency form for training new nurses. A charge nurse would be responsible for training and observing the new nurse complete medication administration for competency. Each year they do nurse medication competency where she or the ADON watch each nurse complete three resident medication passes. 3.) The Minimum Data Set (MDS) dated [DATE] identified Resident #9 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Cerebral vascular accident (CVA) , depression and hemiplegia The MDS also identified Resident #9 as partial to moderate assist with most activities of daily living. On 08/12/2025 at 3:14 PM Resident #9 medications on overbed table next bed, 6 pills in a medication cup. She just woke up when entered the room and no staff present in the room. On 08/14/2025 at 11:04 AM Resident #9 Staff U, RN stated I did work Tuesday on the day shift. I did administer Resident #9 medications. I do not leave her medication in her room because sometimes she will not take her medications. She shouldn't have had them in her room she has been know to store them. Resident #9 takes them in front of me. She should not have medications sitting in her room. I have no idea why they would have been in her room. There were not any medications in the room when I was in the room. Staff U stated medications should not be left in a residents room. 08/14/2025 at 11:15 AM Assistant Director of Nursing (ADON) states medications should not be left at the bed side. Resident #9 would not be appropriate to take medications by herself independently or self administer. We did inservice in June at the nurses meeting about medication administrations. We did bring up to the nurses that medications should not be left at the bedside. Our policy is they should watch them take the medications and swallow the medications.

Based on observation, clinical record review, document review and staff interview the facility failed to clean resident fingernails as part of grooming for 1 of 6 resident sampled (Resident #58). The facility identified a census of 70 residents.Finding include:The 6/11/25 Minimum Data Set (MDS) Assessment documented Resident #58 with severely impaired decision making and unable to recall the current season, location of own room, staff names and faces or that they are in a nursing home. Resident #58 exhibited inattention, disorganized thinking and altered level of consciousness continually present, without fluctuation. The MDS lacked documentation Resident #58 exhibited any physical or verbal behaviors. The MDS noted Resident #58 with impairment on both lower extremities (hip, knee, ankle, foot); utilized a wheelchair and was dependent upon staff for shower/bathing, toileting hygiene and personal hygiene. The MDS documented Resident #58 as always incontinent of bowel and bladder. The MDS listed diagnoses of Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety, depression, end stage renal disease. The Activities of Daily Living (ADL) Self-Care Performance Deficit Care Plan revised 7/17/25 directed the staff under Bathing/Showering to check nail length and trim/clean on bath days and as necessary and to provide extensive assistance of two staff for bath/shower every Sunday morning as necessary. Observation on 8/12/25 at 3:45 PM Resident #58 lay in bed with her right middle finger, ring finger and pinky finger in her mouth licking her fingers. Resident #58 had a dried brown-black substance under her right middle, ring and pinky fingers. During an observation on 8/13/25 at 10:30 AM Staff D and E, Certified Nursing Assistants (CNAs) completed peri-cares for Resident #58 while lying in bed. Staff E asked Staff D to hand her a disposable wet wipe. Staff E lifted Resident #58 right hand and wiped her fingers and attempted to wipe under two fingernails, then placed her hand back down. Observation after cares revealed Resident #58 right forefinger, middle, ring, and pinky fingers with a brown-black substance under her fingernails. Interview on 8/13/25 10:40 AM Staff D explained morning cares include washing the resident's face, under arms, performing peri-cares, applying lotion to the arms/legs and setting the resident up or providing oral care for the resident. Staff D voiced second shift and activities complete nail care. Observation on 8/13/25 at 10:46 AM revealed Resident #58 lying in bed supine. The room smelled of bowel movement. Resident #58 had her right hand inside the front of her brief digging. Resident #58 brought her right hand out of her brief. Her right hand had dark brown/black substance under her forefinger, middle, ring, and pinky fingers. Interview completed on 8/13/25 at 10:45 AM Staff F, CNA verbalized morning cares consist of washing the residents face, brushing their teeth and completing peri-cares. Staff F said the aides usually try to set up to do fingernail care around 10 AM several days per week. She stated if the resident wants their nails done, they will do them then. When asked about residents that could not make that decision, she said they do their nail care if they have time. Staff F thought is was the same on both floors. Interview on 8/13/25 at 11:44 Staff G, CNA explained there is a lady that comes up on the floor that complete fingernail care. She is an environmental aide. She is not sure how often she comes to the floor, but she is on the floor often and she does the nail care. On 8/13/25 at 11:45 AM Staff H, Registered Nurse (RN) stated activities does nail painting and the restorative aides do nail care as an extra from time to time. He had never observed there is any routine nail care that the aides provide. An 8/14/25 review of Resident #58 Shower Sheets showed no nail care documented as completed for the following showers:a. 6/03/25b. 6/13/25c. 6/24/35d. 6/27/25e. 7/04/25f. 7/11/25g. 7/15/25h. 7/18/25Interview on 8/14/25 at 9:48 AM the Assistant Director of Nursing (ADON) reported she expects the CNAs to completed fingernail care with showers/baths and as needed. During an interview on 8/14/25 at 9:51 AM the Director of Nursing (DON) reported activities does a trim and nail polish activity, but it is the responsibility of the CNAs to trim and clean the fingernails with the showers/baths twice a week and as needed. The Undated Nail Care Policy provided by the facility documented a purpose to promote cleanliness, prevent the spread of infection and to prevent injury to the resident or others due to jagged, sharp edges. The Policy lacked direction to the staff on when nail care was to be provided.

Based on clinical record review, policy review and staff interview, the facility failed to monitor a change in condition which resulted in a hospitalization for 1 of 1 residents sampled (Resident #37). The facility reported a census of 70 residents.Findings include:Resident #37's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. Resident #37 had functional limitation in range of motion on one side of the upper and lower body, utilized a wheelchair and was dependent upon staff for toileting hygiene, bathing, lower body dressing and personal hygiene. The MDS noted Resident #37 was always incontinent of bowel and bladder. The MDS listed diagnoses of stroke, heart failure, end stage renal disease, diabetes mellitus, hemiplegia (paralysis on one side of the body)/hemiparesis (weakness on one side of the body), and morbid obesity. The Bladder Incontinence Care Plan, revised 3/11/25, directed to monitor/document for signs and symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. A 7/13/25 8:47 PM Health Status Progress Note documented Resident #37 with a temperature of 97 degrees Fahrenheit (F) and complaints of burning with urination. A facsimile (fax) sent to the Provider to update on the resident's condition and awaiting a return fax.A Fax dated 7/14/25 to the Provider documented Resident #37 had complained of burning with urination, was incontinent, used a bed pan and briefs. The Fax noted Resident #37 was afebrile and vital signs were within normal limits and asked for a physician order for a urinalysis and culture. The bottom of the Fax contained hand written documentation faxed 7/14 at 1:30 PM. The Fax included a Physician Order/Response of yes. There was no fax date/time posted on the document. A review of the Progress Notes and Vital Sign Records revealed no vital signs documented for 7/14/25. A 7/16/25 10:30 PM Nurse Progress Note detailed a clean catch urine sample had been collected and placed in the fridge for the laboratory to pick up in the AM. The urine was cloudy and dark yellow with a strong odor. A 7/17/25 5:30 AM Nurses Progress Note documented Resident #37 with an altered mental status, unable to answer most questions, imaking guttural sounds. Vital signs blood pressure 168/44, pulse 58 beats per minute, respirations 22 breaths per minute, temperature 102 degrees F, pulse oximeter 90-92 percent on room air. The Provider was notified and gave a verbal order to send to the emergency department (ED) for evaluation and treatment. A 7/17/25 1:57 PM Nurses Progress Note documented Resident #37 had been admitted to the hospital with urosepsis (a severe, life threatening condition where a UTI spread to the blood stream, causing a systemic inflammatory response known as sepsis. The progression can lead to organ damage and septic shock if not treated promptly). A 7/17/25 6:20 AM ED Form documented Resident #37 arrived by ambulance with a Chief Complaint of gargled speech, burning sensation with peeing and the facility sent a urinalysis (UA) with no results. Vitals and Sepsis Screening documented a temperature of 103 degrees F, blood pressure 123/90, pulse rate 82, respirations 26, pulse oximeter of 88% (low) and altered mental status. Visit reason: sepsis alert. A 7/17/25 ED Physician Note, Final Report documented Resident #37 with a past medical history of diastolic heart failure, hypertension, diabetes, hyperlipidemia, prior admission for urosepsis presented in the ED with fever and altered mental status. The Resident was found to have sepsis with a white count of 23 and a fever of 103.7. The Resident was given 1 liter of fluid due to diastolic heart failure, Zosyn after review of prior sensitivities, likely urinary source with positive nitrates, many bacteria, many white cells, moderate leukocyte esterase. The chest x-ray showed moderate pulmonary edema and resident admitted with internal medicine for further management. An 8/13/25 review of Resident #37 Electronic Health Record (EHR) revealed a 4/23/25 Emergency Department Final Report noting Resident #37 had been admitted to the hospital 4/22/25 with a diagnosis of acute hypoxic respiratory distress, fever, sepsis and acute UTI prior to the 7/17/25 ED visit. Further review of Resident #37 EHR (Progress Notes, Temperature Record, Blood Pressure Record, Pulse Record, Respiration Record, Pulse Oximeter (oxygen) Record, Assessment Tab) lacked documentation of any documented physical assessment/monitoring, or vital signs from 7/14/25 until the morning of 7/17/25 when Resident #37 was transferred out to the ED. Interview on 8/13/25 at 10:16 AM Staff H, Registered Nurse (RN) reported when a resident complains of UTI symptoms, the nurses writes up a communication form and fax it to the Provider. They also have access to an on-call physician if they need something immediately. The nurses have a form they use to communicate to each other on what has been done. Staff H verbalized he is not aware of any protocols for assessing/monitoring the resident's condition while waiting for orders from the Provider. During an interview on 8/13/25 at 12:00 PM Staff I, RN reported when a resident exhibits signs of a UTI, especially burning, she calls the Provider versus faxing and has the staff push fluids. She is not sure if there is a specific facility protocol or if any actual direction had ever been given on monitoring a resident's condition, but as a nurse she would take vital signs and document every shift, especially if there is a history of sepsis or past hospitalization. On 8/13/25 at 12:16 PM the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated the nurses can fax or call the physician when there is a change in condition. She provided a faxed UA order from 7/14/25. Staff S, RN sent out the fax and Staff N, LPN noted the order when it was returned. The ADON noted the Provider usually has a time stamp on the physician order, but the fax did not have a time stamp on the order. The ADON thought the Provider had been in the facility on 7/15/25 and had probably addressed the order that day and had seen Resident #37. The ADON looked for the Provider 7/15/25 progress note, but she could not find any documentation the resident had been seen. The ADON voiced Resident #37 is incontinent of urine which may have caused a delay in getting the urine sample. If the nurses cannot get a clean catch UA within twenty-four hours, the facility has an order for a straight catheterization to be done. The ADON verbalized while a UA is pending, if a resident is symptomatic, there should be a urinary assessment and monitoring completed in the nursing progress notes. They follow the McGeer criteria and the nurses would document to that. The nurses can ask the physician to start an antibiotic while the UA is pending. She wasn't sure if they had a specific policy/protocol for documenting an assessment and would have to check. Interview on 8/13/2025 at 5:42 PM Staff N, reported Resident #37 complained to her on 7/13/25 that she had burning down there. She took her temperature which was normal and she sent a fax off to the Provider. She didn't work again after that time. When she returned to work, she was told she had been hospitalized for a UTI. During an interview on 8/13/25 at 6:04 PM the Provider/Medical Director voiced he had not seen Resident #37 on 7/15/25. He expects the nurses to be monitoring vital signs, at least a temperature and blood pressure to ensure the blood pressure is not falling which would indicate sepsis. The nurses should also monitor for worsening flank pain, burning, decrease urine output, etc. They are trying to work within antibiotic stewardship and hold off on ordering antibiotics unless the resident is really symptomatic. It is a big fault of the facility, they need to improve their documentation. The Medical Director verbalized there is a big problem with the length of time it takes the laboratory to return the specimen results. Interview completed on 8/14/25 at 7:43 AM the MDS Coordinator reported there is only one lab service that comes in and does in-house laboratory draws and pick-ups. The laboratory staff pick up the specimens in the morning and transports the specimens to St. Louis, Missouri where the specimen is process. Then the culture is sent to Cincinnati, Ohio to have the culture and sensitivity completed. Then they finally get the laboratory report faxed to the facility. The MDS Coordinator didn't know where the laboratory faxes are received at the facility. The MDS Coordinator voiced she feels the facility should have some sort of urinary assessment based on the Mc Geer criteria for at least 48 hours to monitor the resident's condition when they are symptomatic for a UTI, but to her knowledge, there is no protocol or assessment processes in place to monitor for urinary symptoms until the urinalysis results return. The laboratory takes a long time to get the reports back. An 8/14/25 review of Resident #37 Urinalysis collected on 7/13/25 (per the Progress Notes) documented a specimen collection date of 7/17/25 at 4:11 PM and a Reported date of 7/25/25 at 11:38 AM. The MDS Coordinator explained the Specimen Collection date is the date and time the specimen is processed by the laboratory service and the Reported date/time is when the results are sent back to the facility. The UA had a lapse of 9-10 days from the time of collection to the return of final results. Interview on 8/14/25 at 9:48 AM the Director of Nursing (DON) reported the facility had no system in place to direct the assessment/monitoring of a resident's change in condition regarding UTI's. The Change of Condition Policy, undated, provided by the facility documented a procedure to assess change of condition and take appropriate actions; document observations, actions taken and response, record at consistent time intervals; report at change of shifts, using the eight-hour report and communication book as a reporting guide. Documentation provides data to ensure continuity of care, written evidence of reason resident received care, a method to review and evaluate care, a legal record and records used to legally prove or disprove failure by the licensed nursing staff, in determining the extent of an injury, the series of events, the actions take by the staff. The Change of Condition Documentation Guidelines under Burning and/or Discomfort in Urination directed to take a full set of vital signs, perform a head to toe physical assessment, assess color, consistency, and odor of urine, signs and symptoms, intake and output each shift for 24 hours after symptoms have subsided and results of laboratory work if applicable. The Policy directed the licensed staff nurse will make the initial assessment of the change of condition, report the findings to the DON/ADON and document the findings in the electronic medical record progress notes and flag the chart. The charge nurse and the DON/ADON will monitor residents with a condition change until the condition is resolved or stabilized. Documentation must reflect ongoing assessment/progress or lack of progress. Any licensed nurse on any shift may place a resident on the 24-hour report. The resident's name on the 24-hour report will identify which residents require follow-up documentation during each shift. Only the DON or ADON may remove a resident from follow-up documentation, after they believe the resident is stable.

Based on clinical record review, document review and staff interview the facility failed to document completion of fifteen-minute checks to ensure appropriate supervision which resulted in a fall on 5/27/25 for 1 of 4 resident sampled for supervision (Resident #82). The facility identified a census of 70 residents. Findings include:Resident #82's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating a moderate cognitive loss. The resident was dependent upon staff for toileting hygiene, upper/lower body dressing, and partial/moderate assistance (helper does less than half the effort. The helper lifts, holds, supports trunk or limbs, but provides less than half the effort) with bed positioning (sit to lying position and lying to sitting on side of the bed). The MDS listed diagnoses of Alzheimer's Disease, Cerebrovascular Accident (stroke), other fracture, anxiety, depression, and a stress fracture of the hip, unspecified. The Activities of Daily Living (ADL) Care Plan revised 5/07/25 directed the following care:a. Resident #82 to be non-weight bearing to the right upper and lower extremity.b. Staff to assist with bed mobility and encourage to reposition every two hours. The High Risk for Falls Care Plan initiated 5/01/25 documented the following interventions:a. Ensure call light is within reach and encourage to use it. Initiated 5/01/25.b. Ensure resident is wearing non-skid socks. Initiated 5/10/25.c. Follow facility fall protocol. Initiated 5/01/25. d. Dusk to dawn night light placed by resident's sink in room. Initiated 5/23/25e. Low bed with floor mat. Hospice to provide wedges for bed boundaries. Initiated 5/28/25. The Care Plan lacked documentation of the initiation of 15-minute supervision checks on 5/04/25. A review of the May and June 2025 15-Minute Check Sheets from 5/04/25 to 6/07/25 revealed the following missing documentation indicating no checks had been completed:a. 5/06/25 6:00 AM to 1:45 PMb. 5/06/25 2:15 PM to 5:45 PM.c. 5/07/25 8:00 PM to 5:45 AMd. 5/08/25 6:00 AM to 9:45 PMe. 5/19/25 11:30 AM to 1:45 PMf. 5/20/25 6:00 AM to 1:45 PMg. 5/26/25 11:45 PM to 5:45 AMh. 5/27/25 2:15 PM to 8:45 AMA Progress Note dated 5/27/25 at 10:03 PM documented the nurse was alerted by staff that Resident #82 was on the floor observed sitting in an upright position resting against the bed. Resident #82's 5/27/25 10:36 PM Unwitnessed Fall Report prepared by Staff O, LPN documented the staff alerted Resident #82 was on the floor. The Fall Report documented Resident #82 had confusion, incontinence, recent changes in cognition, gait imbalance, impaired memory and a recent change in medication. The Fall Report lacked documentation of the last time a visual check had been completed on the resident. Resident #82 did not sustain an injury from the fall. Interview on 8/13/2025 at 2:14 PM Staff L, Licensed Practical Nurse (LPN) voiced she was not sure why Resident #82 had been placed on 15-minute checks. The resident had been trying to get up unassisted and she was supposed to be non-weight bearing. The resident liked to have her feet on the floor and would be positioned diagonally on the bed lwhen she was trying to get up unassisted. During an interview on 8/13/25 at approximately 2:50 PM Staff M, LPN reported Resident #82 had been placed on 15-minute checks for at least three days when she returned from the hospital but wasn't sure why she had been placed on the checks after that. Staff M explained the 15-minute checks are designated to the Certified Nursing Assistant (CNAs) and they document the 15-minute checks on a paper form. There are no staff specifically assigned to provide the 15-minute checks and no one is responsible to ensure the 15-minute documentation gets completed that she is aware of. They were checking that the resident's legs were in the bed as she would dangle her arm off the bed and put her feet on the floor. Interview completed on 8/13/2025 at 3:28 PM Staff N, LPN reported Resident #82 was on 15-minute checks when she returned from the hospital. The resident would forget that she couldn't get up and move on her own. They just wanted to monitor her more consistently. The CNA's would assist and encourage her to reposition if they found her laying across the bed with her legs on the floor. The CNA's should have documented the 15-minute checks. Staff N verbalized even if the checks were not signed off, she feels the staff probably did the 15-minute checks. Interview on 8/13/2025 at 3:59 PM Staff O reported she had filled out an incident report when Resident #82 fell on 5/27/25. She had been working with Staff P, CNA. Staff O explained she was not responsible for doing the 15-minute checks. It was the CNA's responsibility. Staff O could not recall the last time that Resident #82 had a 15-minute check completed prior to her fall on 5/27/25 at 10:03 PM. She did not document it in the incident report but she could check with the Director of Nursing (DON) to see if she had it documented. Staff O had only been alerted that Resident #82 was on the floor by the night shift. During an interview on 8/13/25 at 4:18 PM the Administrator reported she was not the Administrator when Resident #82 fell on 5/27/25. However, she expects there will be accountability if a resident is on 15-minute checks. Going forward they will be reviewing their 15-minute check process and documentation to ensure accountability. Interview completed on 08/13/2025 at 4:57 PM Staff P, reported Resident #82 was on 15-minute checks as she was always trying to get up out of bed and she couldn't because she had a broken hip and a wrist fracture. The night of 5/27/25 she was assigned to take care of Resident #82 and it would have been her responsibility to document the 15-minute checks. She was on her way out of the facility at the end of her shift, when she glanced into Resident #82 room and noted she was on the floor by her bed. Staff P thought she had last checked Resident #82 between 9:30-9:45 PM as she peeked in on her right before she went into another resident's room. She thought Resident #82 was sleeping in her bed at that time, but it was dark. Staff P commented she was just really busy and the documentation slipped her mind. Interview on 8/13/25 at 7:26 PM Staff Q, CNA reported Resident #82 was on 15-minute checks because she was confused and trying to climb out of bed. It was the CNA's responsibility to do the 15-minute checks, but at night the nurse would cover the checks while the aides completed resident rounds. The CNA's had the responsibility of completing the documentation. To her knowledge, the charge nurses did not review the 15-minute check documentation. The CNA's completed the 15-minute check sheets and put in a folder for Staff C, LPN to scan in to the resident's electronic record.Interview completed on 8/14/25 at 8:20 AM Staff R, Registered Nurse (RN) reported Resident #82 was on 15-minute supervision checks. The family kept coming in and finding Resident #82 laying across her bed with her feet hanging out of the bed. The family came to her on 5/20/25 and questioned the effectiveness of the 15-minute checks and if the checks were being completed. She explained to the family the 15-minute checks were being completed, but the resident was very restless and could move and change positions in the bed pretty fast. Staff R pulled the 5/20/25 15-minute check sheet to show the family the checks were being completed and the form on 5/20/25 was blank. The family was upset when they saw the 15-minute check form. She passed it on to the ADON to let her know the checks were not being documented. The CNA's were supposed to do the 15-minute checks to ensure Resident #82 was safe. During an interview 8/14/25 at 9:54 AM the Director of Nursing (DON) reported the 15-minute checks are completed for different reasons, such as 72 hours post hospitalization and as a short-term intervention after a fall. They put the 15-minute check sheets out on a clip board for the staff to document on. The DON didn't know if they had actually ever gone through the expectations of the checks with the nursing staff or communicated what exactly is to be done as part of the checks. The Assistant Director of Nursing (ADON) commented the CNA's sign their name and document the location of the resident such as room, bed, activities, etc. It is just to lay eyes on the resident to ensure they are safe. The ADON and DON both explained they expect the aides to document the 15-minute checks as the checks are completed, not at the end of the shift. The DON expects the charge nurse to check the 15-minute sheets to ensure the checks are getting done and the documentation is complete. The DON voiced they had a change-over in staff and they had gotten lax on training the new nurses and that falls on the them. The DON stated the facility did not have a policy or procedure guiding the 15-minute supervision checks.A 8/14/25 review of the Fall Assessment Policy and Protocol, revised 2/26/20, lacked any guidance or direction to the staff regarding 15-minute supervision checks.

Based on record review, staff and resident interviews, and policy review the facility failed to follow the rehabilitation directives and provide sufficient services to residents in need of their services for 1 of 4 residents reviewed (Resident #9). The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) report dated 7/31/24 indicated Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive impairment. The MDS further indicated diagnoses including: Multiple Sclerosis, paraplegia (inability to move part of the body), and epilepsy. It documented the resident needed partial/moderate assistance for upper body dressing, complete dependence on staff for lower body dressing, and complete assistance for transfers. The Care Plan initiated 11/29/22 instructed restorative therapy staff to provide bilateral lower extremity range of motion (ROM), bilateral upper extremity ROM, and all extremity stretching 1-5 times per week. A review of the Restorative Nursing Flow Sheets from June to August 2024 revealed restorative staff failed to provide programming for five weeks during that timeframe. In an interview on 8/26/24 at 12:07 PM, Resident #9 noted she should be receiving restorative care but there was only one restorative person for the whole building so it was not happening. In an interview on 8/28/24 at 10:01 AM, Staff A, Certified Nursing Aide (CNA)/Restorative Nursing Aide (RNA) reported she was pulled to work on the floor as a CNA today. Restorative care does not get done when she is pulled. She explained she was the only staff doing restorative care. She exclusively completed programming for Resident #9 as the resident was so contracted and wants only her to do it. She noted maybe once per week she gets to see her residents. In an interview on 8/28/24 at 10:32 AM, the Director of Rehab explained she expected the frequency of restorative care ordered to be followed. It must be completed at least one time per week if it is written that way. In an interview on 8/29/24 at 9:26 AM, the Director of Nursing explained they used to have two people running restorative care but right now they only have one. Unfortunately Staff A has been getting pulled to work the floor quite a bit and has not been meeting her frequencies due to this. She noted she was aware this was a problem. The facility policy titled Restorative Program, dated 10/02/18 instructed restorative care to be performed by the certified rehabilitation aides as ordered by Therapy Director/Occupational Therapist/Physical Therapist/Attending Physician, depending on availability of staffing. The facility must provide adequate resources for the completion of the programs developed for each resident, including but not limited to staffing and education.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide the required documentation needed for transfers to the hospital for 1 of 4 residents reviewed for hospitalization s (Resident #18). The facility reported a census of 69 residents. Findings Include: The MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #18 scored a 11 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed medical diagnosis for Benign Prostate Hyperplasia (BPH), obstructive uropathy, and a Urinary Tract Infection (UTI) in the last 30 days. The MDS revealed resident used an indwelling catheter. The Progress Note dated 7/4/23 at 1:52 PM, revealed the resident had a low grade Temperature of 99.3, as needed (PRN) Tylenol given at 1:45 PM SP 02 (pulse Oximetry) -92% at room air oxygen (O2) at 3 liters (L)) applied per nasal cannula for precaution. Pulse-113 beats per minute (bpm); Respirations-32 breaths per minute, no complaints of shortness of breath. Blood pressure (BP) -117/78. Continued to monitor. The Progress Note dated 7/4/23 at 6:17 PM revealed the resident noted with the following Vital Signs (VS): Pulse 127 bpm, respirations 40 breaths per minute, O2 92% on 3 L, temperature 99.5 post APAP (acetaminophen), BP 160/80. Provider notified and orders received to send resident to emergency department (ED) for evaluation and treatment. Medics called and Power of Attorney (POA) notified and agreeable. The Progress Note lacked documentation of the paperwork sent and who the facility notified at the local hospital for the transfer. The Progress Note dated 7/4/23 at 9:54 PM, revealed the resident admitted to local hospital with sepsis/UTI. The Progress Note dated 7/21/23 at 2:21 AM, revealed the resident flushed in face, skin warm to touch at 1:10 AM. Temperature 100.2 Respirations 22 breaths per minute, pulse: 125 bpm; O2 85% room air. Resident confused. Called provider at 1:30 PM and informed that resident showed signs/symptoms (s/s) of sepsis. Ordered to send resident to emergency room (ER) for evaluation and treatment. Called resident's son at 1:50 AM and informed him that resident transferred to the hospital for assessment. Medic EMT's arrived to facility at 1:50 AM and resident left facility at 2:00 AM to local hospital. The Progress Note lacked documentation of the paperwork sent and who the facility notified at the local hospital for the transfer. The Progress Note dated 7/21/23 at 6:39 AM revealed nurse received a call from local hospital and spoke with RN (Registered Nurse) who stated resident admitted to hospital for UTI/sepsis. The Progress Note dated 8/4/23 at 11:19 AM, revealed the resident showed a change in the early AM and refused breakfast. The resident's vital sign: temperature-98.3; BP-152/86; pulse-117 bpm; respirations 28 breaths per minute; Sp 02-91%-02 at 3 L. Notified the provider's officer for orders to send the resident to ER for evaluation and treatment. POA notified and agreed with order. The Progress Note lacked documentation of the paperwork sent and who the facility notified at the local hospital for the transfer. The Progress Note dated 8/4/23 at 8:35 PM, revealed the nurse received a call from the Registered Nurse (RN) at the local hospital and requested information for the medication the resident received today. The administrations of medications and protein reviewed and the date of the last catheter change provided. The Physician Note dated 9/26/23 at 2:46 PM (late entry), revealed resident seen today as the provider paged over head to report to his room. Resident not feeling well all day and per nursing and not very responsive, but eyes open. Asked the resident what was wrong, he stated, I don't know but something. Provider asked him what hurt and he was unable to say. Nursing reported resident had a fever, heart rate (HR) elevated, and low SP O2. Discussed concern for sepsis with nurse and his son. His son was agreeable for him to go to ER. Plan: Send resident to ER for further evaluation due to concern for sepsis. Place 2 L of O2 on resident now via nasal cannula (NC). The Progress Note dated 9/26/23 at 2:54 PM revealed the Certified Nurse Aide (CNA) called the nurse into the resident's room. Resident displayed a blank stare and didn't verbalize. Skin pale. Temperature- 101.1; pulse- 21 bpm; respirations 22 breaths per minute; pulse Oximetry: 90% on room air; blood pressure: 117/88. Call placed to provider. The Progress Note dated 9/26/23 at 3:11 PM, revealed new orders per provider to send to ER for evaluation and treatment. POA notified. The nurse assessed resident, resident awake but didn't respond to questions asked. Resident placed on 2 L of O2 per NC. The Progress Note dated 9/26/23 at 3:22 PM revealed resident left the facility via Medics at 3:20 PM to the local hospital. The Progress Note lacked documentation of the paperwork sent and who the facility notified at the local hospital for the transfer. The Progress Note dated 9/26/23 at 8:04 PM, revealed resident admitted to local hospital for sepsis. The Progress Note dated 10/24/23 at 5:54 PM, revealed the resident displayed s/s of altered mental status, labored breathing, and elevated temperature along with increased heart rate. The Director of Nursing (DON) notified of resident's condition and plan discussed to send resident to ER for evaluation. POA Son notified of situation and agreed to send to local hospital. Order to send obtained from provider. Medics called. Awaited transport. The Progress Note dated 10/24/23 at 6:16 PM revealed the Medics transported resident out of the facility to the local hospital per POA request. The Progress Note lacked documentation of the paperwork sent and who the facility notified at the local hospital for the transfer. The Progress Note dated 10/24/23 at 11:50 PM, revealed the resident admitted to the local hospital for UTI. The Progress Note dated 11/19/23 at 9:10 AM, revealed resident didn't feel well and had small emesis at 9:00 AM. Nurse assessed resident VS: Temperature-99.5 non-touching forehead; BP-138/86 (left arm) Pulse-114 bpm; Respirations-32 breaths per minute; SP O2-87% room air 02 at 2.5 L applied per nasal cannula. This Nurse recheck residents VS: Pulse-113; Temperature-97.8 Respirations-32 breaths per minute; SP 02-92% at 2 L. The Progress Note dated 11/19/23 at 12:17 PM, revealed the resident continued to be lethargic. Temperature rechecked at 9:45 AM. Temperature 100.2, PRN Tylenol 325 milligrams(mg) given at 9:55 AM, rechecked at 11:30 AM and temperature 100.8 due to Tylenol being ineffective. Respirations- 32 breaths per minute; Pulse 112 bpm and rapid. The provider notified and an order to send resident out to local ER for evaluation and treatment. The Progress Note dated 11/19/23 dated 12:47 PM revealed ambulance and fire department at the facility and the resident left the facility at 12:50 PM to the local hospital. The POA notified of resident's condition. The Progress Note lacked documentation of the paperwork sent and who the facility notified at the local hospital for the transfer. The Progress Note dated 11/19/23 at 4:45 PM revealed the Caseworker from the local hospital called and asked questions regarding mobility and family support. The Progress Noted dated 12/22/23 at 5:38 PM, revealed resident's vitals obtained following a conversation with the resident displaying behaviors of altered mental status. The DON notified of resident's condition and orders received from provider to send to ER for evaluation. The POA notified per phone and agreed to transport. Medics called and en route. The Progress Note dated 12/22/23 at 5:50 PM, revealed the resident out of the facility with medics to the local hospital. The Progress Note dated 12/23/23 at 2:50 PM, revealed the resident admitted to the local hospital for urosepsis. The Progress Note lacked documentation of the paperwork sent and who the facility notified at the local hospital for the transfer. During an interview on 1/4/24 at 11:03 AM, Staff B, Licensed Practical Nurse (LPN) queried on what she completed when a resident transferred to the hospital. Staff B stated she obtained an order from the provider, notified the POA and called the medics and gave them report. She stated she filled out a transfer form, printed a face sheet, POA form, Iowa Physician Orders for Scope of Treatment (IPOST), a list of the medications, when the resident exited the building, and called and gave report to the hospital. Staff B asked where she charted this information and she stated in the Progress Notes. Staff B queried if the documentation sent would be documented and she stated yes and what time the medics arrived and when they left. Staff B asked if the name of the person she spoke to at the hospital would be documented and she stated yes, she documented the name and title of the person notified at the hospital. During an interview on 1/4/24 at 12:09 PM, the DON queried on what they completed when a resident transferred to the hospital and she stated they received an order, notified the family, printed off the face sheet, sent the IPOST, medication list, and notified the hospital. The DON asked where they documented it and she stated in the nurse's notes and she didn't believe they documented what paperwork they sent. She stated they didn't have a transfer form and she didn't think she ever told them to document the name of who they spoke to at the hospital. The DON asked her expectation on what needed documented and she stated the facility didn't lay out exactly what needed documented in the documentation. Review of the Need for Discharge or Transfer Facility Policy dated January 2017 revealed the following information for emergency transfers: a. Nursing should contact an ambulance service and provider hospital, or facility of resident ' s choice, when possible, for transportation and admission arrangements. b. Nursing should complete and send with the resident a Transfer Form which documents: 1. Current diagnosis and reasons for transfer/discharge, 2. Contact information of the practitioner responsible for the care of the resident, 3. Resident representative information including contact information, 4. Current medications, treatments, lab and/or radiological findings, and functional status, 5. Special instructions or precautions for ongoing care, 6. Comprehensive care plan goals, and 7. Any other documentation, as applicable, to ensure a safe and effective transition of care. 8. A copy of any Advance Directive, Durable Power of Attorney, DNR (Do Not Resuscitate) or Withholding or Withdrawing of Life-Sustaining Treatment and IPOST forms should be sent with the resident. c. The original copies of the transfer form and advance directives accompany the resident. Copies are retained in the medical record. d. Nursing should document information regarding the transfer in the medical record.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to consistently notify the Long Term Care Ombudsman of resident transfer to the hospital for three of four residents reviewed for hospitalization (Resident #8, #18, and#54). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #54 dated 11/17/23 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Nurse's Note dated 7/12/23 at 12:30 PM documented, Resident complained of (c/o) of nausea and vomiting also c/o dizziness resident skin clammy stated I feel like I'm going to pass out this Nurse obtained residents vital signs Temp-95-7 Pulse-95 respirations -22, Sp 02 (oxygen saturation)-96% room air- blood pressure (BP)-100/74 [Name Redacted] notified at 10:45 via phone for order to send resident out to emergency room (ER) for evaluation and treatment. The Nurse's Note dated 7/12/23 at 1:06 PM documented, Resident sent out to [Hospital Name Redacted]. Review of the Ombudsman Notification Report for July 2023 did not include Resident #54's transfer to the hospital on 7/12/23. On 1/4/23 at 3:06 PM, the facility Administrator explained via email the facility did not have a policy for Ombudsman Notification. 45775 2. An Electronic Health Record (EHR) review revealed a hospitalization for Resident #8. A Nurse's note dated 11/19/23 at 3:00 PM, revealed the resident experienced shortness of breath and wheezing, with congestion and a non productive cough. The resident assessed as lethargic, and an administration of an as needed (PRN) albuterol inhaler ineffective. On 11/19/23 at 3:35 PM, a Physician's Order received to send the resident to the emergency room (E) for evaluation and treatment. Hospital records revealed the resident admitted on [DATE], and discharged back to the facility on [DATE]. A review of the EHR lacked documentation of Ombudsman notification for the transfer to and from the hospitalization . 47336 3. The MDS assessment dated [DATE] revealed Resident #18 scored a 11 out of 15 on the BIMS exam, which indicated cognition moderately impaired. The MDS revealed medical diagnosis for (benign prostatic hyperplasia BPH, obstructive uropathy, and a Urinary Tract Infection (UTI) in the last 30 days. The MDS revealed resident used an indwelling catheter. The Progress Note dated 7/21/23 at 2:21 AM, revealed received orders to send resident to ER for evaluation and treatment. Called resident's son at 1:50 AM and informed him that resident transferred to the hospital for assessment. Medic EMT's arrived to facility at 1:50 AM and resident left facility at 2:00 AM to local hospital. The Progress Note dated 7/21/23 at 6:39 AM, revealed nurse received a call from local hospital and spoke with Registered Nurse (RN) who stated resident admitted to hospital for UTI/sepsis. The [Facility Name redacted] July 2023 Ombudsman notification form lacked documentation for Resident #18 hospitalization on [DATE]. The Progress Note dated 11/19/23 dated 12:47 PM revealed ambulance and fire department at the facility and the resident left the facility at 12:50 PM to the local hospital. The POA notified of resident's condition. The [Facility Name redacted] November 2023 Ombudsman notification form lacked documentation for Resident #18 hospitalization on [DATE]. During an interview on 1/4/24 at 12:52 PM, Social Services queried on when she notified the Ombudsman and she stated she sent a report at the beginning of each month. Social Services asked who was on the report and she stated the resident who went in and out of the hospital or if they discharged home. Social Services queried if the report included residents who went to the ER and she stated no, not if their stay under 24 hours. Social Services asked if resident hospitalized documented on the Ombudsman monthly report and she stated yes, she put the date they left and the day they returned to the facility. During an interview on 1/4/24 at 1:40 PM, Social Services stated Resident #54 not documented on the Ombudsman July report because she wasn't at the hospital for over 24 hours. Social Services stated she didn't know why Resident #18 didn't get documented on the July and November Ombudsman monthly reports. Social Services stated she missed documenting Resident #8 hospitalization in November.

Based on clinical record review, staff interview, and facility policy review the facility failed to accurately code receipt of an antiplatelet medication on the Minimum Data Set (MDS) assessment for one of five residents reviewed for unnecessary medications (Resident #51). The facility reported a census of 69 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Section N of the Assessment lacked receipt of antiplatelet medication for Resident #51 during the last seven days. The Physician Order dated 2/19/21 documented, Clopidogrel Bisulfate Tablet 75 milligram (mg) with directions to give 1 tablet by mouth one time a day. Review of the Medication Administration Record (MAR) dated December 2023 revealed the resident received the medication daily every day of December 2023. On 1/4/24 at 12:51 PM, the MDS Coordinator acknowledged the medication was supposed to be charted as an antiplatelet. The Facility Policy titled [Facility Name] Resident Assessment Instrument (RAI), revised 11/17, did not specifically address accuracy of the MDS.

Based on observations, clinical record review, staff interviews, and facility policy review, the facility failed to update a Care Plan after hospitalization s for respiratory disease for 1 of 3 residents sampled (Resident #8). The facility reported a census of 69 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 10/23/23, listed diagnosis for Resident #8 included asthma, acute bronchitis, and dementia. The MDS identified the resident ' s Brief Interview for Mental Status (BIMS) score as 6 out of 15, indicating a severe cognitive impairment. During an observation on 1/2/24 at 12:33 PM, the resident noted with a wet sounding intermittent cough while in the dining room for lunch. The resident tested positive for COVID on 12/24/23. A Nurse's Note dated 9/29/23 at 7:39 PM, revealed the resident experienced dyspnea (shortness of breath), tachycardia (high heart rate) and an audible wheeze when breathing in and out. Orders received from the provider to send the resident to the emergency room (ER) for an evaluation and treatment. A Nurse's Note dated 10/3/23 at 1:29 PM, revealed the resident returned to the facility after a hospitalization for chronic obstructive pulmonary disease exacerbation (worsening). A Nurse's note dated 11/19/23 at 3:00 PM, revealed the resident experienced shortness of breath and wheezing, with congestion and a non productive cough. The resident assessed as lethargic, and an administration of an as needed (PRN) inhaler ineffective. Hospital records revealed the resident admitted on [DATE] for reactive airway disease. A review of the clinical record reviewed Physician orders: a. Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligrams/3 milliliter (MG/ML) 0.083%) 1 vial inhale orally every 4 hours as needed for Wheezing, cough, with start date of 4/8/23. b. Oxygen at 2-4 liters per minute (L) per nasal cannula to keep oxygen saturation above 92%, start date of 9/15/22. A review of the Care Plan revealed a lack of a Focus Area related to Respiratory services. During an interview on 1/4/24 at 12:56 PM, the MDS Coordinator stated Resident #8's Care Plan should have been updated after the hospitalization in September 2023 to reflect the respiratory diagnosis related to the admission. A facility policy, dated 11/2017, titled Comprehensive Care Plan Procedure section #4 directed the Care Plan at a minimum to identify: a. Services that will be furnished to attain or maintain the resident ' s highest practicable physical, mental and psychosocial well being.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to provide assistance to an incontinent resident to ensure an opportunity to use the bathroom at least every two hours for 1 of 1 residents (Resident #58) in the sample. The facility reported a census of 69 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 12/29/23, listed diagnosis for Resident #58 included severe dementia, anxiety, and dementia. The MDS assessed the resident required substantial assistance to use the toilet, and experienced frequent urinary and bowel incontinence. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating a severe cognitive impairment. The Care Plan, dated 12/19/23, revealed a focus area for Activities of Daily Living (ADL's) with an intervention for toilet use which included extensive assist of one staff with handheld assistance. During an interview on 1/3/24 at 2:30 PM, Staff C, Certified Nursing Assistant (CNA) stated residents who are incontinent are assisted to use the toilet every 1.5 to 2 hours. On 1/3/24 during a continuous observation from 2:40 PM until 5:15 PM, Resident #58 sat in her wheelchair near the Nurses Station of the Unit. During this time staff observed assisting other residents to and from their room. No staff asked or assisted Resident #8 to her room to use the toilet. At 5:15 PM during the observation, Staff C asked the resident if she is ready for supper, and assisted her to the dining room. During an interview on 1/3/24 at 5:16 PM, Staff C stated she did not know what know what time Resident #8 last used the toilet. She stated it was before her shift started at 2:00 PM. Staff C denied assisting or asking the resident if she needed to use the toilet During an interview on 1/4/24 at 1:40 PM, the Director of Nursing (DON) stated she would expect staff to offer to assist residents who are frequently incontinent if they need to use the toilet at least every two hours. When asked if 2 hours and 45 minutes is too long for a resident to wait. The DON stated it is, especially since the resident was assisted to the dining room to wait for a meal. The facility policy, dated 9/1992, titled Toileting Incontinent Residents Procedure section, #2 directed staff to toilet resident no less often than before and after meals, upon rising from rest or before bed or rest, and every 2-4 hours during sleep.

Based on facility policy review, clinical record review, observations, and staff interviews, the facility failed to ensure the facility's Pneumonia Vaccination Policy reflected current vaccination guidance and failed to ensure Nursing Staff utilized proper hand hygiene during administration of eyedrops for one of one resident reviewed for administration of eyedrops (Resident #11). The facility reported a census of 69 residents. Findings include: 1. Review of the Facility Policy titled [Facility Name Redacted] Pneumonia Vaccine Program dated 2/5/22 revealed, in part, the following per numbers 6 and 7 on the policy: The CDC (Centers for Disease Control and Prevention) and ACIP (Advisory Committee on Immunization Practices) recommend the following schedule for the PCV15 and PPSV23 or PCV20: a. Administer PCV15 followed by PPSV23 a year later; or b. Administer PCV20 If the resident already received a PCV13 and PCV23 series, no additional vaccines are currently recommended. On 1/4/23 review of CDC guidance per the website https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed September 22, 2023 revealed the following information under webpage Pneumococcal Vaccination: Summary of Who and When to Vaccinate: The Section of the Webpage titled, Received PCV13 at Any Age and PPSV23 After Age [AGE] years documented, Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV20 should be administered at least 5 years after the last pneumococcal vaccine. On 1/4/24 at 12:21 PM, the Director of Nursing (DON) acknowledged the policy would be the current policy. 45775 2. The Minimum Data Set (MDS) Assessment Tool, dated 12/1/23, listed diagnosis for Resident #11 included respiratory failure, anxiety, and depression. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Physician Order Summary for Resident #11 included the medical condition of macular degeneration (an eye disease causing blurred vision). A clinical record review revealed a Physician's Order for doralamide-timolol solution 22.3-6.8 milligram/milliliter (mg/ml) 1 drop in each eye two times daily for macular degeneration. During an observation on 1/4/24 at 8:05 AM, Staff D, Licensed Practical Nurse (LPN) prepared medications for Resident #11. At 8:11 AM, Staff D donned gloves and removed the dorzolamide-timolol eye drop bottle from a plastic bag. At 8:12 AM, without completing hand hygiene and donning new gloves, Staff D administered one drop of dorzolamide-timolol in each eye of Resident #11. Staff D administered the drops with her right hand, while she assisted the resident in keeping her eye open with her left hand. After administering the eye drops, Staff D removed and discarded the gloves, and proceeded with administering oral medications to Resident #11 without first completing hand hygiene. During an interview on 1/4/24 at 1:31 PM, Staff D stated she did not complete hand hygiene or change gloves after handling the bag containing the vial of eye drops. Staff D stated she should have taken the vial out, then completed hand hygiene and donned gloves before administering the drops. During an interview on 1/4/24 at 1:36 PM, the DON stated she would expect staff to take any medication in a plastic bag out of the bag while preparing the medications for administration. She stated after taking the medication out of the bag she would expect the staff to complete hand hygiene. The policy, dated 7/2/2020, titled Medication Administration Guidelines, Administration of Eye Drops sections directed staff at #2. Wash hands before, and after, giving eye drops, to avoid cross contamination.

Based on clinical record review, family member and staff interviews, the facility failed to prevent two facility acquired pressure ulcers from developing, nor provide care and services to promote healing for one of two residents reviewed in the sample with pressure ulcers. (Resident #111). The facility identified a census of 59 residents. Findings Include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an 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 tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). 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 is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). May be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. According to the Minimum Data Set (MDS) assessment dated [DATE] identified Resident #111 as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 3, required extensive staff assistance with most activities of daily living and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Nurse's Notes revealed the resident admitted to facility on 2/11/21. A review of the following MDS Assessments revealed the following information: a. On 2/17/21 - On Admission the resident identified with no pressure ulcers. b. On 5/11/21 - The resident without pressure ulcers. c. On 8/3/21 - The resident identified with one Stage II pressure ulcer. A review of the Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 6/8/21 - The resident with an unstageable pressure ulcer to the left heel. b. On 8/3/21 - The resident with a Stage III pressure ulcer to the left hip. A review of the Census Tab in the EMR revealed the resident hospitalized on the following dates: a. On 6/25/21 - Sent to hospital returned 6/28/21. b. On 8/13/21 - discharged to hospital did not return. A review of the Care Plan identified the resident with the following problem: I have the potential for pressure ulcer development. a. On 7/3/21- I have a Stage II pressure ulcer on my left heel. b. On 7/3/21- I have a Stage III pressure ulcer on my left hip Care Plan Interventions: a. Due to my Alzheimer's, I tend to remove the dressings and not keep my heel offloaded. Staff is to attempt to offload, replace dressing as needed and reposition. b. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] c. I am to have Pressure Relief Ankle Foot Orthosis (PRAFO) boots on while in bed. I am non-compliant in leaving them on. d. I require a pressure relieving/reducing device on my bed/chair Review of the Following Wound Nurse Practitioner Notes revealed: a. On 6/8/21 at 2:06 PM - Patient has an unstageable pressure ulcer on her left heel that she sustained one week ago. The wound has been stable in size. There is eschar over the wound making it difficult to determine the stage. Patient continuously pulls off dressings when they are applied by the nurses. NARRATIVE NOTES: Patient will have dressings changed every other day, off load pressure as much as she can tolerate. Wound will be cleansed with normal saline or wound cleanser prior to dressing changes. Apply Vaseline gauze to wound bed, cover with [MEDICATION(S)] border gauze or Soform gauze to secure in place. Patient has Alzheimer's disease and is confused most of the time. She does try to pull off her dressings and does not keep PRAFO boots on while in bed. Nurses are doing an excellent job keeping the wound covered with the appropriate dressings and repositioning. The entry did not include documentation of measurements of wound b. On 6/15/21 at 12:50 PM - Wound stable from last week, starting to show signs of healing. The resident's wound measured Length (L) =2.6 centimeters (cm) x Width (W) = 3.1 cm x Depth (D) = 0.1 cm. Assessment: There are no signs of infection in the wound, and the patient denies any pain from the area. Plan: Continue to apply Vaseline gauze to wound, cover with [MEDICATION(S)] bordered gauze pad, change every other day. Patient does not tolerate PRAFO boots due to dementia and pulling things off. Continue to attempt to offload pressure as the patient will tolerate. c. On 6/22/21 at 2:31 PM - The resident denies any pain in the wound. There are no signs of infection in the wound. The wound measures L = 2.5 cm x W = 3.0 cm x D = 0.1 cm today. Assessment: The wound is stable, improving slowly. Will continue same dressing plan as previously noted. Plan: Continue to apply Xeroform gauze to wound, cover with [MEDICATION(S)] bordered gauze pad - may use Kerlix if patient tolerates this better. Change dressing every other day. May change dressing to Vaseline gauze with bordered gauze pad next week. d. On 6/28/21, the Admit/Readmit Screener documented the left heel pressure ulcer L = 2 cm x W = 3 cm x D = 0. Stage 2 previously had before hospital stay, no new open areas noted, bruising from IV and lab draws. e. On 6/29/21 at 3:22 PM - The resident had an unstageable pressure ulcer on her left heel. The nurses have been changing her dressing daily with an [MEDICATION(S)] bordered gauze pad. Today the wound is larger than previously, it measures L = 3.2 cm x W = 2.3 cm x D = 0.1 cm. The wound is 100% eschar. The wound could not be debrided due to the patient's cognition and inability to stay still. The wound had been cleansed with wound cleanser. Xeroform gauze placed over the wound, covered with [MEDICATION(S)] bordered gauze pad. There are no signs of infection in the wound currently. f. On 7/20/2021 at 11:41 AM - Finding: Stage II pressure ulcer left heel - measures 0.5 cm x 0.2 cm x 0.1 cm, applied Xeroform gauze to wound, covered with [MEDICATION(S)] bordered gauze pad, it is much improved from 2 weeks ago, large amount of eschar removed with good new skin growth underneath. g. On 8/3/2021 at 1:43 PM - Left hip wound Stage III pressure ulcer measured L= 2.8 cm x W = 1.9 cm x D = 0.1 cm and surrounding tissue intact with [CONDITION(S)]. Left heel wound Stage II pressure ulcer measured L= 0.6 cm x W =0.4 cm x D = 0.1 cm with surrounding tissue intact. Treatment/Plan of Care - low air loss mattress, offload area - heel and buttock, nutritional supplements as prescribed, keep legs elevated. Treatment - left heel - cleanse cover with Zguard and [MEDICATION(S)], change every other day or as needed (PRN). Treatment left hip - cleanse, cover with Zguard and [MEDICATION(S)] - change every other day or PRN, PRAFOS and air mattress. The Wound Nurse Practitioner Notes failed to have documentation of pressure ulcer assessments for 21 days from 6/29/21 through 7/20/21. Review of a Nurse's Note dated 7/1/2021 at 2:59 AM, failed to have documentation of an assessment of the pressure ulcer to the left heel identified 6/8/21. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the initial skin assessment dated [DATE] identified resident with pressure sore to left trochanter measuring L = 3 cm x W = 3 cm x D = 0: Stage III. Wound care: Xeroform and [MEDICATION(S)] daily. Diet: Pureed added protein liquid 30 milliliters (ml) twice daily (BID) due to poor intake. Dietitian and Physician notified. In an interview on 6/21/22 at 5:07 PM, the resident's family member reported the resident did not have bedsores when she first arrived to the facility, but she ended up with one to her foot and one to her hip. In an interview on 6/23/22 at 7:48 AM, the Director of Nursing (DON) reported the resident did not have the pressure ulcers when admitted to the facility, that the ulcers to her left heel and left hip had been facility acquired. She also reported the resident did not like to be touched, would kick off the dressings, did not like the boots on, and had not always been compliant with being repositioned. A review of the facility policy titled: Pressure Ulcers/Skin Breakdown-Clinical Protocol dated as last revised 4/1/18 documented the following under the Assessment/Recognition section: The nurse shall describe and document/report the following: a. Full assessment of the pressure sore, including location, stage, length, width and depth, presence of exudates or necrotic tissue. b. Complete a Pain Assessment. c. Document the resident's mobility status. d. Provide current treatments, including support surfaces. e. Document all active diagnoses. f. During resident visits, the Physician will evaluate and document the progress of wound healing, especially those with complicated, extensive, or poorly healing wounds. The policy failed to address the need to document assessments/measurements of the pressure ulcers on a weekly basis.

Based on record review, family member and staff interviews, the facility failed to provide a Continuous Positive Airway Pressure ([CONDITION(S)]) Machine (machine utilized at night for people with breathing problems such as sleep apnea) as ordered upon admission for one of two residents reviewed with respiratory orders. (Resident #111). The facility identified a census of 59 residents Findings Include: The Minimum Data Set (MDS) Assessment, dated 7/23/21 identified the resident as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 3, also required extensive staff assistance with most activities of daily living and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Nurse's Notes revealed the following entries in regard to the resident's [CONDITION(S)]: a. On 2/11/21 4:54 PM, admitted an [AGE] year-old female resident diagnosed with: muscle wasting and atrophy. b. On 2/11/21 8:00 PM, Continuous Positive Airway Pressure ([CONDITION(S)]) Machine on at bedtime (HS) and off in the morning for sleep apnea and remove per schedule. [CONDITION(S)] had not been sent over from other facility, daughter is aware. c. On 2/12/21 4:12 PM, [CONDITION(S)] on at bedtime for sleep apnea and remove per schedule. [CONDITION(S)] not here. d. On 2/15/21 8:18 PM, [CONDITION(S)] (on HS off am) at bedtime for sleep apnea and remove per schedule [CONDITION(S)] - not in facility at this time. e. On 2/18/21 9:02 PM, [CONDITION(S)] (on HS off am) at bedtime for sleep apnea and remove per schedule has not been delivered yet from former facility. f. On 2/20/2021 10:05 PM, [CONDITION(S)] not in yet. g. On 2/21/21 4:13 PM, [CONDITION(S)] not in yet. h. On 2/21/21 8:07 PM, [CONDITION(S)] not delivered yet. i. On 2/23/21 9:19 PM, [CONDITION(S)] not in. j. On 2/25/21 7:06 AM, [CONDITION(S)] on at HS off am at bedtime for sleep apnea and remove per schedule - not available k. On 2/25/21 10:32 PM, [CONDITION(S)] on at HS off am at bedtime for sleep apnea and remove per schedule - not available l. On 2/26/21 7:40 AM ,[CONDITION(S)] on at HS off am at bedtime for sleep apnea and remove per schedule - not arrived m. On 2/27/21 7:43 AM, [CONDITION(S)] on at HS off am at bedtime for sleep apnea and remove per schedule - not arrived n. On 2/27/21 8:44 PM, [CONDITION(S)] on at HS off am at bedtime for sleep apnea and remove per schedule. [CONDITION(S)] needs (to be) delivered. o. On 3/1/21 9:34 PM, [CONDITION(S)] not here. p. On 3/2/21 8:22 PM, [CONDITION(S)] on at HS off am at bedtime for sleep apnea and remove per schedule -not here. q. On 3/3/21 8:17 PM, [CONDITION(S)] on HS off am at bedtime for sleep apnea and remove per schedule - no [CONDITION(S)]. r. On 3/4/21 7:58 AM, no [CONDITION(S)]. s. On 3/4/21 9:57 AM, [CONDITION(S)] on HS off am at bedtime for sleep apnea and remove per schedule - not in building. t. On 3/5/21 8:01 PM, [CONDITION(S)] on HS off am at bedtime for sleep apnea and remove per schedule - not here. u. On 3/6/21 8:00 PM, [CONDITION(S)] on HS off am at bedtime for sleep apnea and remove per schedule. [CONDITION(S)] not in facility at this time. v. On 3/7/21 8:32 PM, [CONDITION(S)] on HS off am at bedtime for sleep apnea and remove per schedule - not in facility. w. On 3/8/21 8:36 PM, this nurse called the Power of Attorney (POA) about the [CONDITION(S)]. POA stated she dropped it off in a big box sometime after resident arrived. POA stated she left it at the door and doesn't know what happen after that. POA stated her name is on the bottom of the [CONDITION(S)]. The box had the room number she was at another facility. x. On 3/9/21 8:55 AM, [CONDITION(S)] on HS off am at bedtime for sleep apnea and remove per schedule resident does not have. y. On 3/9/21 8:21 PM, [CONDITION(S)] unavailable. z. On 3/12/21 1:23 PM, Resident's [CONDITION(S)] has arrived. The notes failed to have documentation that an order had been obtained for the [CONDITION(S)] upon Resident #111's admission, or that attempts had been made to obtain the machine for her. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. Orders had not been obtained for [CONDITION(S)] upon admission 2/11/21 b. On 3/10/21 2:56 PM, [CONDITION(S)] on HS (hour of sleep) off in the morning for sleep apnea and remove per schedule c. On 3/12/21 11:20 AM, [CONDITION(S)] on at HS and off in AM every morning and at bedtime A review of the Care Plan identified the resident with the following problem on 3/12/21: I have an altered respiratory status/difficulty breathing related to sleep apnea and failed to address the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 6/21/22 at 5:07 PM, the resident's family member reported when the resident had first arrived to the facility, she recalled she brought the [CONDITION(S)] to the facility and handed it to a nurse. She also reported the resident did not have the [CONDITION(S)] for at least 3 months. She spoke to the former Administrator and the former Director of Nursing (DON) about it and she received conflicting messages which said they had received the [CONDITION(S)] and others which said they never received it. They asked her to purchase another machine and did not want to reimburse her for it. In an interview on 6/22/22 at 1:56 PM, Staff F, Licensed Practical Nurse (LPN) reported if a resident had been admitted with orders for a [CONDITION(S)] and she did not have it upon admission, the Admitting Nurse should try to contact the family to figure out where the machine is and contact the DON to see if they could get one for the resident. This should be documented in the Nurse's Notes. In an interview on 6/23/22 at 7:48 AM, the DON reported if a resident had been admitted with orders for a [CONDITION(S)] and she did not have it upon admission, she would expect the nurse to contact the family to bring from it home and if they don't have one, contact the Home Medical Supply to have one delivered to the facility. This should be documented in the Progress Notes. When asked about the resident's [CONDITION(S)] machine, she thought the family said they dropped one off at the front door. The daughter reported to the former DON and to this DON that she dropped it off. The former DON thought they should rent one for her, however, the former Administrator would not approve of renting one for the resident because he had heard she no longer used it. Both DONs argued with the former Administrator daily about it.

Based on observation, record review, staff, Pharmacist and resident interviews, the facility failed to administer medications as ordered for 1 of 7 residents reviewed (Resident #6), and failed to provide wound care as ordered and prescribed for 3 of 3 residents reviewed with identified pressure sores (Resident's #4, #5 and #6). The facility reported a census of 64 residents. Findings include: 1. The 7/15/21 Minimum Data Set (MDS) Assessment Tool revealed Resident #4 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A potential for skin impairment initiated 1/5/15 on the Nursing Care Plan directed staff to apply a Prafo boot to the resident's right foot due to a pressure ulcer on the heel. A 7/20/21 Wound Assessment form completed by the Wound Nurse Practitioner (NP) revealed an unstageable pressure sore located on the right heel that measured 3.4 centimeters (cm) by 2.0 cm by 0.1 cm, with moderate serosanguinous drainage (yellow-pink colored fluid), the surrounding tissue fragile, erythematous and macerated. The NP ordered staff to cleanse the wound with wound cleanser, apply Xeroform gauze to wound, cover with [MEDICATION(S)] bordered gauze changed 1 time daily, increase protein in resident's diet, and prevalon boots to bilateral feet to offload area. The orders on the form were noted 7/20/21 by Staff F, Licensed Practical Nurse (LPN). A Progress Note transcribed by the Wound NP on 8/3/21 described the right heel wound as a Stage III pressure ulcer (full-thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed) that measured 3.5 cm by 2.1 cm by 0.1 cm, and continued the same treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July, 2021 Treatment Administration Record (TAR), revealed the treatment ordered by the wound NP on 7/20/21 not initiated until 7/29/21. When reviewed on 8/11/21, the August, 2021 TAR, revealed wound care not provided on 8/3/21, 8/6/21, 8/9/21 and 8/10/21. Staff interviews revealed: On 8/3/21 at 1:55 p.m., Staff G, LPN, stated the facility was very short staffed, at times there was only 1 nurse in the building and why treatments didn't always get done. On 8/16/21 at 6:56 p.m., Staff F, LPN, stated wound care/treatments were not done as ordered due to staffing issues, the facility had started to use agency staff and it seemed like staffing had improved with use of the agency staff. On 8/16/21 at 11:10 a.m., the Director of Nursing (DON) stated there was no policy or procedure for following physician orders, but nurses should always follow physician orders, or seek clarification from physician to revise the order. 2. The 6/11/21 MDS Assessment tool revealed Resident #5 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A pressure ulcer problem initiated on the Nursing Care Plan 1/2/19 directed staff: a. Administer treatments as ordered and monitor for effectiveness, initiated 3/27/20. b. Assess/record/monitor wound healing, initiated 3/27/20. A 7/20/21 Wound Assessment note documented by the Wound NP revealed Resident #5 had a Stage II pressure sore on the right heel that measured 3.1 cm by 3.2 cm by 0.1 cm, with moderate serosanguinous draining, fragile and macerated surrounding tissue, and wound bed erythematous with 25 percent slough tissue, and directed staff to offload heels, provide nutritional supplements as prescribed, and apply moistened [MEDICATION(S)] to wound bed, cover with [MEDICATION(S)] dressing changed daily. The order was noted by Staff F, LPN on 7/20/21. Progress Notes transcribed by the Wound NP revealed: a. On 8/3/21 heel wound measured 2.5 cm by 1.5 cm by 0.1 cm. b. On 8/12/21 the heel wound worsened and now stage III pressure ulcer (full-thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed) measured 2.5 x 1.5 x 0.1 cm. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff documentation on the July, 2021 TAR revealed wound care not provided 7/21/21, 7/24/21, and 7/25/21. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the TAR, July 2021 through August 12, 2021 revealed wound care not provided 7/29/21, 8/3/21, 8/6/21, 8/10/21. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the August, 2021 TAR, reviewed through day shift 8/11/21 revealed staff documented the presence of the boots on all shifts except day shift 8/3/21. Observations of the resident on 8/5/21 at 5:22 p.m., on 8/9/21 at 8:47 a.m. and at 12:31 p.m., on 8/10/21 at 9:28 a.m. and 12:01 p.m., and on 8/11/21 at 10:10 a.m. and on 12:16 p.m. all revealed the resident with gripper socks on and did not wear prevalon boots. Observation on 8/11/21 at 12:16 p.m. revealed the resident's prevalon boots positioned between the exterior wall and wardrobe furniture piece. Staff discontinued the prevalon boot order at 2:00 p.m. on 8/11/21 and rewrote the order as prevalon boots on while in bed for heel offloading, staff to document every shift. Interview on 8/11/21 at 12:28 p.m., when asked about the status of the resident's prevalon boots, Staff G, LPN, stated she would have to check on them. 3. The 7/2/21 MDS Assessment tool revealed Resident #6 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A skin issue problem initiated on the Nursing Care Plan 2/15/21 directed staff to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A 7/20/21 Wound Assessment note documented by the wound NP revealed Resident #6 had a Stage II pressure ulcer on the right heel that measured 3.0 cm by 1.2 cm by 0.1 cm, with erythematous fragile surrounding tissue, wound bed erythematous, no drainage, and directed staff to offload heels, provide nutritional supplements as prescribed, and apply Xeroform gauze to the wound, cover with [MEDICATION(S)] dressing changed daily. Nursing staff noted the form 7/20/21 that it was a repeat order. A Progress Note transcribed 8/12/21 by the wound NP revealed Stage II pressure ulcer of the right heel measured 3.0 cm by 2.0 cm by 0.1 cm, foul smelling purulent drainage, surrounding tissue edematous and slightly erythematous, and directed staff to administer [MEDICATION(S)] (a strong antibiotic) 500 milligrams (mg) oral twice daily for 10 days for a wound infection. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/21/21 - Apply Xeroform gauze to right heel wound, cover with [MEDICATION(S)] dressing daily. The order discontinued 7/2721. Documentation on the July, 2021 TAR revealed the wound care not provided on 7/21/21, 7/23/21, 7/24/21 and 7/25/21. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/29/21 - Apply [MEDICATION(S)] to right heel wound, cover with 4 inch by 4 inch gauze, secure with rolled gauze and tape daily. The July, 2021 TAR revealed the treatment was not administered 7/29/21. The August, 2021 TAR, reviewed 8/11/21 revealed the treatment not administered 8/3/21, 8/6/21, 8/9/21 and 8/10/21. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/20/21 - Administer Oxycodone (a very strong narcotic analgesic) 5 mg oral 4 times daily. The August, 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Narcotic Inventory Control Sheets revealed staff administered the last Oxycodone pill from the resident's inventory on 8/4/21 at 12:20 a.m., and received 60 Oxycodone 5 mg tablets at 10:00 p.m. on 8/5/21. During an interview 8/12/21 at 11:05 a.m., a Pharmacist at the facility's Pharmacy stated they were not notified that the facility had exhausted the resident's Oxycodone supply until 9:45 a.m. on 8/5/21 by Staff F, LPN. The prescription required the physician's authorization, the Pharmacy notified the physician 8/5/21 at 9:58 a.m., and received the physician's authorization to dispense the medication 8/5/21 at 11:10 a.m. The facility utilized the Emergency Medication supply box for the 6:00 p.m. dose on 8/5/21, and Pharmacy delivered the prescription later in the evening. The Pharmacist stated the facility had to either call or fax the Pharmacy of the need for a narcotic refill, preferably 5 days before the supply was exhausted in order for the Pharmacy to obtain any authorizations required and so the resident would not have to go without the medication.

Based on observation, record review, and staff interview the facility failed to store a medication at the appropriate temperature to maintain the stability for usage in 1 of 2 refrigerators reviewed. The facility identified a census of 70 residents. Findings include: 1. During an observation in the Dementia Care Unit on 3/11/20 at 12:59 p.m. with Staff C, Licensed Practical Nurse (LPN) found the refrigerator in the medication room at 30 degrees Fahrenheit (F*). Staff C reported not aware medications required to have certain temperature while in the refrigerator. A vial of the liquid medication [MEDICATION NAME] ( an anti-anxiety medication) concentrate sat in the refrigerator. Review of the vial label instructed to store the medication in the refrigerator at 36 to 46 degrees F*. Staff C commented she would have someone with her to dispose of the medication. Record review of the Daily Temperature Record for the months of November and December 2019, also January, February, and March 2020 showed 23 missing temperature readings. The Daily Temperature Record showed 11 days the refrigerator read at 36 degrees Fahrenheit (F*) while the rest of the days showed temperatures ranging from 22 to 34 degrees. Further review of the Daily Temperature Record noted a hand written note on top of the (log) form stating- Refrigerator 36-46 F*. During an interview on 3/12/20 at 7:44 a.m., the Administrator reported she expected the temperature range of the refrigerators to be followed as directed. The Administrator stated would check the refrigerator out to see if it needed replacing. During an interview on 3/12/20 at 11:10 a.m., the Director of Nursing (DON) noted the temperatures and commented the Pharmacy comes quarterly and should have also caught the temperatures as the Daily Temperature Record is kept on the refrigerator.

Based on clinical record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents for one of three residents reviewed resulting in the resident sustaining an injury to the face and laceration above the left eye in the infraorbital area which was sutured and glued in the emergency room and bilateral nasal bone fractures. (Resident #1) The facility census was 72 residents. Findings include: 1. The Admission Record documented Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and required extensive assistance of one for bed mobility, transfers, toilet use and personal hygiene needs. The Plan of Care directed staff to check the resident first on 4:00 a.m. rounds (initiated 1/15/18), the resident required extensive assistance of one with a gait belt and walker in the room, distant supervision with a walker in hallway (initiated 1/17/18), when doing rounds at night (if awake) take to the bathroom so the resident does not take self (initiated 1/15/18) and 15 minute checks to assure safety (initiated 4/21/17 and updated 4/23/18). The Incident/Accident Report sheet dated 11/6/18 at 4:30 a.m., revealed the resident was observed sitting on the floor in the room with copious amounts of blood streaming on the floor from the residents face. The walker was several feet away. Last seen at 3:00 a.m., when staff assisted the resident to the toilet and back to bed. The sheet revealed staff disciplinary action taken to prevent recurrence. Progress Notes dated 11/6/18 at 6:31 a.m., revealed the resident had swelling to the left eye, cheek, forehand and left eye swollen shut. The Charge Nurse notified the physician who ordered to send to the emergency room for evaluation. The History and Physical dated 11/6/18, revealed the resident had injury to the face, laceration above the left eye in the infraorbital area which was sutured and glued in the emergency room . The resident had swelling of the left eye and eye lid that needed close monitoring. The CT of the Head revealed a left forehead periorbital hematoma and a bilateral nasal bone fractures. The resident had an elevated CPK ([MEDICATION NAME] phosphokinase) possible traumatic rhabdomyolysis (breakdown of muscle tissue). During interview on 12/16/18 at 11:14 a.m., Staff A, Certified nurse aide, CNA reported at 12:45 a.m. she assisted the resident to the bathroom and back with the walker. Staff A reported she started rounds at 4:00 a.m., and did not check the resident. Staff A went back after rounds and found the resident on the floor. Staff A reported the resident had dried blood on their face and the floor had dried blood. Staff A reported the resident's left eye was swollen shut. Staff A reported the resident required 15 minute checks and she did not do their job and should have checked the resident every 15 minutes. During interview on 12/17/18 at 2:23 p.m., Staff B, Charge Nurse reported Staff A reported the resident had a fall. Staff B reported she observed the resident on the floor and the residents left eye was swollen shut and dried blood was on their face and clothing. Staff B noted dried blood on the floor as well. Staff B reported Staff A changed their story of when she last checked on the resident. Staff A finally reported she did not complete the required 15 minute checks. During interview on 12/17/18 at 1:27 p.m., Staff C, CNA reported staff complete the 15 minute checks every 15 minutes and document the check when completed. During interview on 12/17/18 at 1:47 p.m., Staff D, CNA reported staff make visual checks on the residents and document the checks every 15 minutes. During interview on 12/17/18 at 12:17 p.m., Staff E, CNA reported staff pass a clip board around to complete the visual 15 minute checks. Staff E reported staff document the checks at the time they complete them. The facility corrected the violation on 12/7/2018 after educating staff on importance of safety and conducting 15 minute checks.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and failed to develop an individualized Care Plan with interventions to prevent falls for a resident with a known history of falls and getting up without assistance (Resident #1). The sample consisted of 4 residents and the facility identified a census of 64 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 4/15/15 which identified the resident had [DIAGNOSES REDACTED]. and a history of falls. The resident scored 5 of 15 on the Brief Interview for Mental Status (BIMS) test. A score of 5 identified the resident had a severe impairment with cognitive skills. The MDS reflected the resident required extensive assistance from staff with bed mobility, transfers, walking in the room, and toilet usage. The MDS assessment with a reference date of 6/3/15, identified the resident had 2 falls with no injuries and 1 fall with a major injury since the last assessment. The Morse Fall Risk assessment dated [DATE], identified the resident had a score of 55. A score of 55 reflected the resident to be at a high risk for falling. The Care Plan dated 4/21/15 reflected the resident had dementia and Parkinson ' s disease with a recent fall resulting in an elbow and pelvic fracture. The resident could be impatient and staff were to explain the need to wait for staff assistance; cue, reorient and supervise. (The resident had a problem with severe cognitive skills). The Care Plan reflected the resident had limited physical mobility related to weakness. The interventions dated 5/22/15 directed staff to provide assistance of 1 person and a gait belt, body pillow and physical and occupational therapy as needed. The Care Plan dated 5/27/15 identified the resident with limited physical mobility related to weakness and limited mobility with an intervention of a floor alarm when in bed on 5/28/15. The Care Plan did not show the increase activity of the resident. Documentation in Resident #1 ' s Physical Therapy Plan of Care and Progress Notes revealed the following information: On 4/23/15, the resident required balance precautions including fall risk. The skilled physical therapy was needed to improve balance and fall recovery skills in order to decrease risk for falls. The Physical Therapy notes dated 4/27/15, reflected the resident performed bed mobility with modified independent, functional transfers with contact guard assist and ambulation of 80 feet with a hemi walker and contact guard assist. The Therapists Progress and Discharge Summary dated 6/3/15 showed the resident required verbal cues for functional transfers and ambulation with a hemi walker. Complicating factors, including self-limited behaviors and a recent fall, with the resident transferred to acute care, prevents the resident from achieving all established goals. An Incident/Accident Report dated 5/19/15 at 5:50 a.m. reflected the staff observed the resident on the floor with the resident ' s back against the bed. The resident stated she/he wanted to use the commode. Steps taken to prevent reoccurrence noted to continue the plan of care and the high/low bed. An Incident/Accident Report dated 5/20/15 at 9:15 p.m. reflected the staff observed the resident on the floor with the back against the bed with no injuries. The intervention steps directed staff to use a body pillow in the bed. An Incident/Accident Report dated 5/28/15 at 10:15 p.m. reflected the staff found the resident on the floor in the resident ' s room. The nurse performed range of motion to all extremities. The resident reported of trying to get some water. The intervention steps directed staff to add a floor alarm. An Incident/Accident Report dated 6/3/15 at 5:45 p.m. reflected the staff found the resident on the floor by the nursing station on their right side. The resident complained of right shoulder and right hip pain. With an attempt to do range of motion, the resident screamed out in pain. After calls were made, an ambulance transported the resident to the hospital. The Hospital Imaging report dated 6/3/15 identified the resident had a comminuted fracture of the intertrochanteric region of the right proximal femur (hip) and a fracture of the proximal right humerus (upper arm). Observation on 6/15/15 at 10:14 a.m. reflected the resident sitting in a wheelchair with an alarm attached. The resident wore an immobilizer around the right arm and to the waist and an air boot on the right lower leg. The resident voiced her/his whole body hurt. The Progress Notes reflected the following: On 4/9/15 at 4:49 p.m., the resident attempted to stand and wanted to go home. The nurse attempted to several times to reorient without success. The resident remained 1:1 (one resident & 1 staff person). The resident denied pain but took a book and threw it at a staff member. At 12:30 p.m., the nurse administered a narcotic analgesic (Vicodin) for possible pain. Once the resident became relaxed at 1:15, the 1:1 stopped but the resident remained in the lounge for supervision. On 4/14/15 at 4:25 p.m., the resident had not attempted to get out of bed since the first night at the facility, so the facility discontinued the floor alarm. A family member informed the nurse that Resident #1 has a history of sun downing (gets confused in the evening part of the day.) On 4/19/15 at 6:19 p.m. the resident is restless after the evening meal and staff repositioned the resident. On 5/3/15 at 9:15 p.m. the resident will try to self-transfer in the day room without asking for help. The staff re-educated the resident to ask for help and not to transfer without a gait belt and assistance. On 5/8/15 at 9:19 p.m. the resident is insistent to try to transfer self. Staff re-educated the resident to wait for staff, as not to occur another fall and injury. On 5/10/15 at 10:26 a.m. the resident is impulsive and continues with multiple attempts to transfer without assistance. On 5/10/15 at 9:49 p.m. the resident is active with trying to get up by self, not understanding the need for help. On 5/13/15 at 5:38 p.m. the resident self-transferred from the wheelchair to the bed after breakfast this morning. Staff brought the resident to the dayroom for observation. On 5/23/15 at 2:01 p.m. the resident attempted to self-transfer multiple times during the shift. On 5/23/15 at 8:23 p.m. the resident continues with frequent attempts to get up without assistance. On 5/24/15 at 11:36 a.m. the resident continues with multiple attempts to self-transfer out of the chair. On 5/27/15 at 6:01 p.m. the resident attempted to self-transfer from the wheelchair to the recliner. The resident voiced complaints of pain in the left arm. The nurse administered Vicodin. The nurse continued to re-educated the resident to ask for assistance to transfer. On 5/29/15 at 6:03 a.m. the resident is observed sitting on the floor in the room. Staff initiated a bed alarm. The resident stated was getting up to get some water. The floor alarm was added to Care Plan when the resident in bed. On 6/3/15 at 12:00 a.m., staff found the resident lying on their right side of the body, on the floor by the nurse ' s station. The resident complained of right shoulder pain and right hip pain. With an attempt to do range of motion, the resident screamed out in pain. The right leg was shorter than the left leg. Calls were made and the ambulance transported the resident to the hospital at 6:45 p.m. On 6/15/15 at 10:16 a.m. Staff J, Certified Nursing Aide, CNA, was interviewed and stated doing 15 minute checks on named the residents on the floor who were on the list for residents to make sure they are okay. She 15 minute checks and it included Resident #1. On 6/15/15 at 2:25 p.m. Staff D, Certified Nursing Aide-CNA, was interviewed and stated on the day the resident fell , it was her orientation. Staff D stated she and Staff C CNA took another resident to the second floor by elevator. Resident #1 sat in the first recliner in the day room, across from the elevator. The recliner propped up the resident ' s feet. As they were going up in the elevator, another staff person, Staff F, CNA, came down the elevator and found the resident on the floor. Staff D stated she and Staff C came off the elevator and saw the resident lying in the hallway by the nurse ' s station. Staff D could not recall if the alarm sounded or the position of the foot rest. The resident had jelly beans; beans were on the floor. The distance from the recliner to where the resident laid on the floor measured approximately 8 to 10 steps. On 6/15/15 at 3:30 p.m. Staff C, CNA, was interviewed and stated Staff D and herself placed the resident in the recliner after supper, around 5:30 p.m. The resident had the feet (recliner foot rest) in the up position. They took another resident to second floor in the elevator. Another CNA (Staff F) from second floor came down the elevator and found the resident on the floor, in the hallway. We heard the overhead intercom for a nurse to go to the first floor right away. We came down the elevator, in about 5 minutes, and saw the resident on the floor. The recliner did not have an alarm. It was not longer than 15 minutes since they had last seen the resident. The nurse came and they tried to make the resident comfortable on the floor until the medics arrived. On 6/15/15 at 4:40 p.m., Staff E, Unit Assistant, was interviewed and stated seeing the resident in the recliner before she took another resident to second floor. Staff E stated when she came back down the elevator, she saw the resident on the floor. Staff F was in the elevator, also and got off on first floor. She saw the resident on the floor and told Staff F. She reported of being gone about 5 minutes from seeing the resident in the recliner to the floor. On 6/16/15 at 2:20 p.m. Staff F, CNA, was interviewed and stated she saw Staff C and D, CNAs, on the second floor, with Staff C introducing Staff D to the Nurse. Staff F stated she took the elevator to the second floor, to get some kitchen information. Staff E got off the elevator first and reported the resident on the floor. Staff F got on the overhead intercom and paged for a nurse to first floor as soon as possible. The Staff C and D came down the elevator. The resident came in the facility with a fracture to the arm and hip and lately, had started using that side of the body. The resident had always tried to get up from where she/he sat. Staff F remarked of not knowing why the resident did not have an alarm in the recliner, but should have. An interview on 6/16/15 at 2:30 p.m. Staff A, Licensed Practical Nurse, reported the resident did not have an alarm in the recliner, but it could have made a difference. Staff A stated the resident had little patience for waiting and had sun dow[DIAGNOSES REDACTED]. On 6/16/15 at 3:45 p.m. Staff B, Registered Nurse, reported the resident would want to go to bed after the evening meal. Due to getting other residents from the dining room, staff placed Resident #1 into the recliner in the day room, across from the Nursing Station. Staff B stated she was working on the second floor assisting residents in the unit with their evening meal. Staff B stated she heard the overhead intercom page for a nurse to come to the first floor. That night there were cups of jelly beans sitting on the nurse ' s station and she wondered if that is what the resident saw and attempted to get them. The resident cried out in pain. She noted the resident had to take several steps to get over toward the nurse ' s station from the recliner. Staff B stated she had seen the resident stand up from the recliner many times before. An alarm would have brought attention, but she questioned how long would it have taken for someone to respond. Staff H commented of knowing other residents need to go upstairs after the meal, but questioned why someone did not stay down (on first floor) while other staff took resident ' s up (to second floor). Staff B stated she asked Staff C that question as the new aide could have stayed on first floor. Staff C stated the new aide needed to be with her (Staff C). Staff B asked Staff H why there were no staff on the first floor and Staff H did not respond. On 6/16/15 at 4:45 p.m., the Director of Nursing, (DON) reported the facility did not have a policy for 15 minute checks. The DON stated the staff do 15 minute checks on new residents for 3 days and then on residents who are at high risk for falls. The DON stated the 15 minute checks are not on the care plans and are performed when other interventions have failed. An interview on 6/17/15 at 10:50 a.m. the DON reported there were 5 staff persons assigned to first floor, with 2 of them also assigned to second floor. Standard of care is not to do 1 to 1 with residents. She said her interviews and statements from staff show a lapse of 3 minutes from when the resident seen resting comfortably in the recliner to lying on the floor. An interview on 6/17/15 at 2:15 p.m. the Director of Nursing, Registered Nurse, DON, reported every resident is care planned for high risk An interview conducted on 6/17/15 at 2:20 p.m., with Staff H and I, Registered Nurses and Care Plan Coordinators, and the DON, reported the Care Plan for the resident's high risk for falls included the interventions of extensive assist with 1 staff person and gait belt, for rehabilitation services and to explain to the resident to wait for available help. When asked how this helps a resident with a BIMS of 5, there were no comments at first. The DON replied staff would reassure the resident. Staff H remarked everyone gets a chance with Rehabilitation Services. When asked why the Care Plan had not been updated with the resident ' s increase activity, there were no comments.

Based on clinical record review, observation and staff interviews, the facility failed to provide adequate supervision for one of four residents reviewed with falls and injuries (Resident #7). The facility census was 67 residents. Findings Include: Resident #7's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score as the resident was unable to complete the test. The cognitive status for Resident #7 revealed moderate cognitive impairment with long and short term memory problems. Resident #7 had documented inattention, disorganized thinking and psychomotor retardation. Resident #7 ' s MDS identified extensive assistance of one to two staff members was required for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The MDS identified the following Diagnoses: [REDACTED]., and hallucinations. The MDS dated [DATE] for Resident #7 revealed a need for limited assistance of one staff member for dressing, toilet use and bathing. Resident #7 listed as supervision by one staff person for bed mobility, transfers and ambulation on and off the unit with a walker. The care plan with an initiation date of 4/24/14 identified Resident #7 at high risk for decrease in his/her functional level. Interventions dated 4/25/14, 7/24/14 and 8/20/14 directed Nursing Staff to pick up the room floor and keep the area clutter free for Resident #7, required the room door remain open so staff can monitor the resident for 15 minute checks due to forgetting to wait for staff assistance with mobility and transfers. A care plan dated 10/10/14 identified the following intervention, due to many attempts to stand or self- transfer, staff is utilizing a sensor alarm for Resident#7's safety (recent fall) ...sensor alarm at all times while in bed, wheel chair and recliner. Review of Resident #7's Incident/Accident Report forms revealed the resident had a history of [REDACTED]. Review of the Therapy Screen Request dated 8/19/14 revealed Resident #7 listed as a fall risk with balance and ambulation issues. The recommendation included a Physical Therapy evaluation for lower extremity strengthening, balance training and safety education. Transfer with the assist of one staff person and recommended hourly checks. Review of the Certified Nursing Assistant (CNA) Daily Communication Sheet dated 8/20/14 notation was written on Resident #7 that he/she was 1:1 with all Activities of Daily Living (ADL) cares, 15 minute safety checks throughout every shift for now and had a 15 minute check sheet. Review of the hospital medical records and radiology report for Resident #7 dated 10/7/14 at 8:31 p.m. revealed identification of an Acute sub-capital right femoral neck fracture. Surgical intervention completed to stabilize the femur fracture. Review of the nursing progress notes dated 10/7/14 revealed Resident #7 discharged to the hospital following a fall and pain to the right leg. Review of the nursing progress notes dated 10/10/14 revealed Resident #7 was readmitted to the facility following a hospital stay for right hip fracture repair. Incident Report dated 10/12/14 at 5;45 a.m. revealed staff responded to an alarm sounding for Resident #7 with staff members locating Resident #7 on the floor with swelling and bruising noted to right hip, right elbow and right side of the head. Resident #7 was transferred to the hospital for evaluation and treatment. The hospital radiology report dated 10/12/14 at 8:23 a.m. revealed Resident #7 suffered a comminuted intra-articular proximal ulnar fracture. The right hip radiology report revealed no new hip fracture identified but Resident #7 has 3 surgical screws in place across the right femoral neck. Review of the nursing progress notes dated 10/12/14 at 1:54 p.m. revealed Resident #7 returned from the hospital with a [DIAGNOSES REDACTED]. During an interview on 11/10/14 at 9:15 a.m., Staff Q, CNA/Certified Medication Aide (CMA) indicated Staff Q worked on 10/7/14, the night Resident #7 fell . Staff Q was floating between 1st and 2nd floor that day and was upstairs when the resident fell . Staff Q reported last time Resident #7 was observed occurred in the main dining room where the resident was eating supper. Staff Q stated the role of the CNA is to know the Care Plans of the residents you work with. The CNA can look at the Care Plan as needed and expected to do so often if not daily to know the care needs of the residents. The Care Plans are available at each of the Nurse's Stations. Staff Q reported had not worked much with Resident #7 as a CNA more as a CMA. Staff Q stated what had remembered what other CNA's reported the resident was supervision and every 15 minute checks when in the room and stand by assist to transfers and ambulation. Staff Q stated at the point of last seeing the resident in the dining room did not know who took the resident back to the resident's room. Staff Q reported knew the resident known to leave his/her front wheeled walker (FWW) and get up and walk without it. Staff Q also stated knew the resident had falls in the past but none were major prior to the10/7/14 incident. During an interview on 10/12/14 at 11:30 a.m., the Director of Nursing (DON) reported Resident #7 fell on the 2-10 p.m. shift on 10/7/14. The DON indicated the resident was assist of 1 for ambulation and transfers utilizing a FWW, 15 minute checks and 1:1 in room at time of the fall, there were no alarms in place. The only time the resident to be alone in the room was when the resident was in bed. The DON stated after Resident#7 fell on [DATE] he/she was recommended for a therapy evaluation and after the evaluation the Care Plan updated to include the 1:1 assist in the room and halls with 15 minute safety checks. The CNA's were communicated the info on Resident #7 and it is the expectation of the CNA's to know and review the Care Plans for any changes. The DON stated each CAN received a Groups Duties list daily when at work. Those sheets become the "bible" for the CNA's to follow and know assist levels for the residents and any condition changes that occur. Also there is a shift report the Nurse and CNA's from the previous shift review with the oncoming shift on condition changes that occurred with the residents. The DON reported had learned of Resident #7's fall on 10/7/14 at approximately 7:30 p.m., per Staff M, the Registered Nurse (RN) on shift that night. Staff M reported found Resident #7 on the floor in his/her room unattended behind the room door. Resident #7 complained of right leg and shoulder pain. Staff M carried out the proper facility procedure when a resident falls and Resident #7 was sent to the local emergency room for evaluation. According to the DON Resident #7 was admitted with a right hip fracture. Staff M did report after the fall Staff M discussed Resident #7's Care Plan with Staff N, CAN responsible for the care of Resident #7 the evening of the fall on 10/7/14.. During an interview on 11/12/14 at 1:00 p.m., the Administrator reported she learned of Resident #7's fall and fracture on 10/7/14 from the DON early morning on 10/8/14. The Administrator reported when met with Staff N, thought Resident #7 was on 15 minute checks. Staff N informed if Staff N had consulted the Care Plan on Resident #7 would know the resident was not to be left alone. Staff N acknowledged had not reviewed the Care Plan for Resident #7. During an interview on 11/12/14 at 2:25 p.m., Staff M, RN on duty the night Resident #7 fell reported was the Charge Nurse for the 2nd shift on 1st floor where Resident #7 resides. Staff M stated Resident #7 was previously independent with a FWW and prior to the fall experienced functional decline was confused and required more observation and assistance. Staff M reported at the time of Resident #7 ' s fall the resident was 15 minute checks and when up and about walking or in his/her room the door needed to be open and after his/her fall in August 2014 per physical therapy was to be more visual to staff or keep an eye on the resident. Staff M indicated Resident #7 thought his/her room was an apartment and would close the door to the room often. Staff M's recollection was prior to the fall Resident #7 could be left unattended when in the room with 15 minute checks and was known to try toileting self on his/her own. Staff M indicated thought the 1:1 with all ADL cares does not mean a staff had to be with Resident #7 at all times when in the room. That was not how it was communicated to Staff M and reported unaware how the intent was communicated to the other CNA's. There are residents where the Care Plan is very direct or explicit what the 1:1 meant. The Care Plans gave more direction on the 1:1 and staff could not leave the resident alone in the room. Staff M reported on 10/7/14, had been standing at the medication cart at approximately 6:35-6:40 p.m. and could hear a noise and not sure where it was coming from. Staff M called out for who needed help and found Resident #7's door shut and when got closer to the room heard the resident say "help me, somebody help me." Prior to this incident Staff M observed Resident #7 at approximately 6:30 p.m. walking with a FWW followed by a staff member walking behind Resident #7 exiting the main dining room after supper. Staff M reported witnessed Resident #7enter his/her room, and heard the staff ask the resident if going into the room now and did not recall any staff follow the resident into the room. Staff M then went down the ramp into the main dining room to pass medications and once done came back to the 1st floor near the Nurse's Station. Staff M reported that took a maximum of 4 minutes. Within a minute of being at the medication cart Staff M heard a noise and it sounded like a knocking noise that led Staff M to Resident #7's room. Staff M went to check on Resident #7and reported the resident stated he/she had fallen. Resident #7 was observed by Staff M lying on the floor on his/her right side and told Staff M that his/her right arm and leg hurt. Staff D, 1st shift Licensed Practical Nurse came to assist Staff M. Staff with Resident #7. Staff M discussed Resident #7 ' s status with the hospital staff after Resident #7 was transported for evaluation and learned Resident #7 suffered a right femur fracture. Staff M indicated the Care Plan book is at the Nurse's Station and accessible to all Nurses and CNA's as they are responsible to check the Care Plans. During an interview on 11/10/14 at 4:42 p.m., Staff N, CNA reported was a full time 2nd shift CNA and worked all floors as a float. Staff N indicated was working 2nd shift on the first floor and Resident #7 one of the residents worked with that night. Staff N explained that Resident #7's level of care was 15 minute checks when in his/her room and stand by assist in hallways when ambulating and had a FWW. Staff N reported last time Resident #7 observed was about 2-3 minutes prior to Staff M RN found Resident #7 on the floor. Staff N reported a 15 minutes check was performed at approximately 7:00 p.m. and the resident was standing near the sink in the resident's room with the FWW and was brushing his/her teeth. Staff N stated had walked away from Resident #7 as was safe and had the FWW and went to check on other residents. Staff N reported the resident was a 1:1 stand by assist in hallways. Staff N explained the interpretation was Resident #7 did not need someone with them at all times in the room and had the 15 minute checks. Staff N indicated was not aware of the 1:1 assistance for Resident #7 with the Care Plan available to CNA ' s. Staff N reported about 5 days prior the fall on 10/7/14 while working on the Rehab Hall Staff N observed Resident #7 walking down the hallway unassisted with no one with the resident. Staff N assisted the resident back to the day room. Staff N reported aware the resident had a history of [REDACTED]. During an interview on 11/12/14 at 4:00 p.m., Staff D, LPN reported had worked the 1st shift on the day Resident #7 fell . Staff D was staying over to finish paperwork from the day and was after supper sometime. Staff D indicated was at the 1st floor Nurse's Station on the computer charting and saw Staff M come to the station to get a blood pressure cuff and seemed anxious. Staff D explained asked if could help and what was going on. Staff M reported Resident #7 was on the floor Staff M completed an assessment and made the phone calls as I remained with the resident and stayed there to keep the resident calm. Staff D reported noticed Resident #7 lying on the floor near the closet in the resident's room near the doorway to the room. Staff D stated at the time of the fall Resident #7 according to the care plan was allowed stand by assist in the room with 15 minute checks. Resident #7could be left in the room when in bed or when in the recliner, but staff needed to be with the resident in the room if up and moving around. Staff D reported learned of Resident #7's fractured hip when back at work the next day on 10/8/14. Staff D stated Care Plans are available in a book at the Nurses' Station and the Nurses and CNA's are responsible to review these Care Plans frequently for updates. There are shift meetings where staff members discuss any changes that occurred for residents. According to Staff D the shift meetings are performed between all shifts every shift. During an interview on 11/12/14 at 5:21 p.m., Staff O, CNA reviewed the Care Plan for Resident #7 and stated the entry for 8/20/14 had been in place for the resident but didn't know exactly how long, but it was not new. The interpretation Staff O explained of the 1:1 assist in room means to stay with the resident in the room when up and when in the chair or bed to do the 15 minute checks. Staff O reported it is the responsibility of the Nurses and CNA's to review the Care Plans of residents on a regular basis, but the staff do get report when comes on shift every time we work to know if any changes occur. During an interview on 11/13/14 at 8:25 a.m., Staff P, CNA reported was a float, but worked with Resident #7. Staff P explained interpretation of 1:1 assist in room and halls with the 15 minute safety checks for now is to be in the room with the resident when up and not in bed. Prior to the fall in August for Resident #7, the resident could be up ad lib in room at the sink with the door open. After some falls the resident was then 15 minute safety checks and CNA ' s are to be in the room with the resident when up. Changes are made on the Care Plans at Care Conference or when a condition change occurs with a resident. Staff P explained if off work a couple of days, would ask the Nurse or other CNA's about any changes since being off and also check the Care Plans on the residents assigned. As a CNA, the DON has told us numerous times at meetings that it is CNA ' s responsibility to know residents and know the care needs and any changes staff members are responsible to check the Care Plan. Staff P indicated the entry for 8/2014 on Resident #7's Care Plan is not new on the Care Plan as had been there awhile. The Care Plan books are at the Nurses' Stations and can be accessed on the computer as have looked at them on the computer a couple of times. During an interview on 11/13/14 at 9:18 a.m., Staff R, CNA reported usually worked on the 2nd floor in the loop area but do get assigned to 1st floor and the Rehab hall approximately once a week. Staff R indicated when interpreting a Care Plan that has a directive of 1:1 assist in room means to stay in the room with the resident while the resident is up in the room. Staff R stated had residents on 2nd floor with 1:1 assist on his/her Care plan and the CNA does not leave the resident while in the room unless in bed or recliner. Staff R commented that did check the Care plans for the residents to work with at least every other day and find out if any changes in a Care plan by report at shift change or if the Nurse leaves a note for the CNA's that a change has been made. The DON at CNA meetings will remind the CNA's it is our responsibility to check our residents' Care Plans for any changes. There are Care Plan Books/Binders at each Nurse's Station for the CNA's to access. CNA's are held accountable for knowing the Care Plans on assigned residents. There are group lists for each area worked and kept at the Nurse's Station in a binder for the CNA to pull out a copy to reference to for the assist levels on each resident in a particular area. Review of the Comprehensive Care Plans Policy updated 5/7/00 indicated the purpose of the policy to be: a. To develop quantifiable objectives for the highest level of functioning, the resident may be expected to obtain. b. To develop care directives to maintain the optimum health status when dependent on staff for needs. The policy of a comprehensive care plan will be that a care plan be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. The services provided or arranged will meet professional standards of quality and will be provided by qualified persons in accordance with the resident's written plan of care. Review of the Falls Assessment Policy and Protocol updated 3/9/07 indicated the purpose of the policy to be: a. To identify residents who are at risk for falls. b. To identify precipitating events leading up to falls that do occur, to identify patterns to falls. c. To implement interventions to prevent or reduce the incidence of further falls. The Fall Care Plan section of the policy states: a. After the resident has been assessed and potential causes for falls have been identified, specific interventions to manage the fall(s) will be identified on the Care Plan. Interventions may take the form of environmental management, behavioral management, toileting and incontinence management, medication reduction and management, and acute illness identification and treatment. b. Each fall will be evaluated and specific interventions added to the Plan of Care. 3. Staff will be updated on these changes. Observation on 11/10/14 at 10:47 a.m. revealed Resident #7 in the facility television room seated in a wheelchair with foot pedals, shoes on and an alarm in place.

Based on record review and interviews, the facility failed to provide adequate supervision for one of four residents. Resident #1 sustained a right hip fracture when his/her fall intervention had not been in place.Staff interview established the nurse had forgotten to turn the resident ' s alarm on. The facility reported a census of 76 residents. Findings include: According to the Admission Record dated 7/1/14 Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognitive decision making skills. The assessment identified Resident #1 had signs and symptoms of delirium that fluctuated with his/her inattention. (Inattention referred to the resident's difficulty focusing attentions, easily distracted, or difficulty following what was said.) The MDS revealed Resident #1 required assistance of one staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The test for balance identified Resident #1 unsteady and only able to stabilize with staff assistance during the following times: when walking, when moving from seated to standing position, when turning around, moving on and off the toilet and during surface to surface transfers (transfers between bed and chair or wheelchair). The MDS identified Resident #1 with hypertension, [DIAGNOSES REDACTED] and non-Alzheimer's Dementia The Initial Care Plan dated 5/27/14 directed the staff to transfer with assistance of two staff with a gait belt and walker. The Care Plan initiated on 6/5/14 directed the staff to provide assistance of one staff with a gait belt and walker for transfers and ambulation, provide frequent reminders of need for assistance. The care plan noted Resident #1 had poor vision in his/her right eye and could only see shadows/shapes. The care plan informed staff Resident #1 had a tendency to self-transfer and could be restless at times. The care plan directed staff to use a sensor alarm when in bed, wheelchair, and recliner; and to periodically check alarm to make sure resident has not turned it off. A care plan update initiated on 6/18/14 documented staff utilized a body alarm due to being noncompliant with his/her safety needs. The Fall Risk assessment dated [DATE] revealed Resident scored a "19". A score of "10" or above represented a HIGH RISK. The Progress Note dated 6/20/14 at 10:30 p.m. for 7:05 p.m. revealed the nurse heard the resident calling for help from the nurse's station. The nurse found Resident #1 on bathroom floor. Resident #1 voice the need to go to the bathroom. Resident #1 did not use the call light even though it was attached to the toilet. The resident could not straighten his/her right lower extremity and was transferred to the emergency room . The Incident/Accident Report dated 6/20/14 at 7:05 p.m. revealed staff heard Resident #1 calling for help. The staff found Resident #1 on the bathroom floor on his/her right side. Resident #1 complained of right leg, knee and hip pain. Resident #1 transported to the hospital by ambulance at 7:15 p.m. The report revealed Staff A had last observed Resident #1 at 6:50 p.m. The reported noted the resident's level of consciousness after the fall as alert and confused. The Investigation of Injury form dated 6/20/14 at 7:05 p.m. revealed potential concerns noted and immediate corrective action taken. The report noted the resident had short term memory impairments. The form revealed the chair alarm not turned on after toileting. The form revealed the care plan was not followed and staff education provided. The Operative Note dated 6/21/14 revealed Resident #1 had a displaced fracture of the right femoral neck and had surgical repair. The nurse's notes dated 6/24/14 documented the resident had been readmitted to the nursing home following a right hip fracture. Resident #1 had a surgical incision to the right hip area approximately 6 inches in length, with 24 intact staples. Resident #1 would need the assistance of two staff for transfers. An interview on 7/3/14 at 11:47 a.m. Staff A, (registered nurse) reported Resident #1 had been in the hall by the nurse's station and asked to use the restroom. Staff A stated Resident #1 was fidgeting so he/she assisted Resident #1 to the restroom. Staff A forgot to turn the alarm back on when he/she assisted Resident #1 back in the wheelchair. Staff A left Resident #1 in the wheelchair by the nurse's station. Staff A did not know how Resident #1 moved from the nurse's station to his/her room. Staff A reported Resident #1 had been found by his/her recliner in his/her room. Staff A stated the call light (cord) had been tied to the wheelchair and she did not know how this had occurred. An interview on 7/3/14 at 12:03 p.m. Staff B, certified nurse aide (CNA) reported she took Resident #1 to the bathroom before supper. Staff B reported after supper, around 6:15 p.m., she offered to take Resident #1 to the bathroom, but the resident declined. At 6:45 p.m., she offered Resident #1 a snack and the resident had been sitting in the wheelchair by the nurse's station. Staff B reported that was the last time she had seen the resident until Staff A reported Resident #1 had been found on the floor at 7:05 p.m. Staff B had been with Staff C to help another Resident when the nurse asked for help with Resident #1. Staff B reported Resident #1's alarm had been on prior to supper. Staff B reported Resident #1's alarm box had been kept in a mesh bag that zips up, and was used to prevent the resident from turning the alarm off, although she had not seen Resident #1 turn off the alarm. An interview on 7/3/14 at 12:15 p.m. Staff C, CNA reported she did not provide any cares for Resident #1 the evening of the incident. Staff C did observe Resident #1 sitting in the wheelchair by the nurse's station. Staff C reported he/she was in a room assisting another resident with cares when the nurse asked for help because Resident #1 was on the floor.