Every finding on record at Thomas Rest Haven

Based on observation, staff interviews, clinical record review and nursing standard of practice, the facility failed to ensure that staff used safe transfer techniques and fall preventions for 1 of 3 residents reviewed. Resident #1 had frequent falls and a history of self-transferring, the staff failed to use a gait belt while transferring, and failed to ensure the intervention of slip proof strips on the floor was implemented. The facility reported a census of 33 residents. The facility corrected the deficiency practice per past non-compliance on 1/7/26 through the following actions:*Nursing staff re-education on fall prevention, proper transfer techniques, mandatory use of gait belts and accountability for care plan compliance. *Audits of transfers and ambulation to ensure gait belt use when required. *Supervisory observations by nursing leadership. *Any non-compliance will result in immediate re-education and progressive discipline if indicated. *Ongoing review of fall incidents through QAPI to identify trends and implement further interventions if needed. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit). The resident required partial assistance with transfers and sit to stand, was always incontinent of urine, and was on supplemental oxygen therapy. Her diagnoses included: hypertension (high blood pressure), diabetes mellitus, chronic obstructive pulmonary disease and morbid obesity.The Care Plan for Resident #1, revised on 5/14/25, showed that she had self-care deficits and impaired balance during transitions, required assistance and or walking. The Care Plan documented she was at risk for falls related to impaired balance, and poor safety awareness. It directed staff that she had a fall on 11/2/25 and non-skid strips put in place to the floor in the bathroom on 11/4/25. On 5/23/25 therapy evaluated and resident now a transfer of 2 staff with front wheeled walker (FWW). It directed that on 8/14/25 employee education on falls and staff to toilet resident approximately every 2 hours using toilet in shower room or resident room. Fall intervention on 12/7/25 for a Hoyer (full-body mechanical lift) for all transfers, and staff education to use gait belt when transferring.Morse Fall Scale (risk assessment to help prevent falls) assessment dated [DATE] at 12:00 PM overestimates or forgets limits. Scoring high risk 45 or higher she scored 70.The following was documented in the Nursing Progress Notes:a. On 10/2/25 at 3:46 PM, Resident #1 continues to self-transferb. On 10/2525 at 9:57 PM, the resident was in the bathroom with staff and being transferred to the toilet. Staff could not hold the resident up and slowly put her to the ground. c. On 10/29/25 at 2:48 PM, Resident #1 was found to be self-transferring, reminded to get assistance. d. On 10/30/25 at 9:00 AM, Physical Therapy and Occupational Therapy (PT/OT) orders for strengthening and mobility e. On 11/2/25 at 11:49 AM, resident had a witnessed fall during transfer to the toilet, the resident lost her footing and went down. Non skid strips being put in the bathroom. f. On 12/7/25 at 3:52 PM, the resident was being ambulated by staff to the bathroom in her room, resident stated it felt like her legs were giving out and she was lowered to the floor. g. On 12/7/25 at 7:08 PM, Resident #1 had left distal fracture to the tibia, a splint was placed and she was non weight bearing. She was also found to have a urinary tract infection and was being transferred back to the facility.A Post Fall Evaluation dated 12/7/25 at 3:54 PM, showed that Resident #1 was ambulated by staff to the bathroom in her room and resident stated it felt like her leg was giving out. She leaned on the bathroom door then was lowered to the floor, stated left leg ankle pain with swelling to left ankle noted. The resident was sent to the emergency room.The emergency room Xray report dated 12/7/25, showed that Resident #1 had a fracture of the distal end of fibula and fracture of distal end of right tibia (bones in the lower leg.) A posterior splint was applied and the resident was sent back to the nursing home.A Major Injury Determination Form date of injury 12/7/25, showed the injury to be at the left distal fracture to tibia. The physician response concluded that after reviewing the circumstances, injury and prognosis of the patient, the injury sustained was a major injury. The document was signed on 12/10/25 at 11:54 AM.On 1/14/26 at 10:50 AM, Staff A Licensed Practical Nurse (LPN) said that she was the nurse on duty when Resident #1 had the fall on 12/7/25. When she came into the room, the resident was on the floor in the doorway of the bathroom, she was not wearing a gait belt, and her walker was in the bathroom. Staff A said that the resident was a one-assist, but she thought that most of the time, the aides would use two to transfer her.On 1/14/26 at 11:00 AM, the Administrator said they did not have a policy on gait belt use, but they go by the standards of care.In an observation on 1/14/26 at 12:20 PM, Staff C, Certified Nurse Aide (CNA) and Staff B transferred Resident #1 with the Hoyer mechanical list. Staff C and Staff B said that they had transferred the resident before her fall in December, and at that time, they used two people with a gait belt (GB), because the resident was large and they felt that it was safer with two.The floor in the bathroom of the resident's room did not have gripper strips applied.On 1/14/26 at 12:39 PM, Staff D, CNA said that she was working on 12/7/25 when Resident #1 had a fall in the bathroom. She said that when she came into the room, the resident was on the floor, and she did not have a gait belt applied. Staff D said that at times the resident would be weak and she would ask another staff member to assist her with the transfers. On 1/14/26 at 3:30 PM Staff E, Certified Nurse Aide (CAN) said that she was assisting Resident #1 into the bathroom on 12/7/25 and as she was entering the bathroom, the resident was holding onto a support bar but her legs gave out. She stated she didn't know if her feet gave out. Staff E said that she was behind the resident and when she started to go down, she tried to hold the resident by putting her arms around her, under her arm-pits. She was unable to keep her up, then lowered her to the floor. Staff E said that she hadn't transferred Resident #1 before and was told that the resident did pretty well with just one person assisting. Staff E was not familiar with the resident's care plan or how to access it for reference. Staff E acknowledged that she hadn't applied a gait belt on the resident before transferring her. She said that she had been educated on the use of gait belts and she knew she should have used one with Resident #1.On 1/15/26 at 11:00 AM, the Director of Nursing (DON) and Administrator said that Resident #1 changed rooms on 12/3/25 and when she did, they failed to implement the fall precaution of anti-slip strips in her new room. They were establishing a new process to ensure this step did not get missed again. The DON said that she had a one-on-one meeting with Staff E and provided a special meeting with all care staff regarding gait belt use.According to the Nursing Standard of Practice (provided by the Administrator), if a resident required care other than that established in the minimum standards, that care would be described in the resident's care plan. It would be the responsibility of each staff member to be knowledgeable of each resident care plan and to meet each resident individual needs. All residents requiring assistance with stand/pivot transfers and or ambulation would have a gait belt on for safety.

Based on observation, staff interview, and policy review the facility failed to use universal infection control measures (hand hygiene), and Enhanced Barrier Precautions (EBP) during catheter cares/wound cares for 5 of 5 residents reviewed for infection control (Residents #1, #3, #10, and #26). The facility reported a census of 31 residents.Findings include: 1. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of progressive neurological conditions, Alzheimer's disease, Non-Alzheimer's dementia, and obstructive uropathy. The MDS further revealed Resident #10 utilizes an indwelling catheter. Review of Resident #10's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders, revealed an order to change catheter every 30 days and as needed dated 6/24/24. Observation 9/16/25 at 12:31 PM Staff L Certified Nursing Assistant (CNA), and Staff M CNA completed hand hygiene, donned gloves and gowns. Staff L then raised Resident #10's bed while wearing gloves and proceeded to complete catheter cares. Staff L then cleansed Resident #10's thighs, penis, and down the catheter tubing. Staff L then doffed gloves and donned new gloves without hand hygiene. Staff L then drained Resident #10's catheter drainage bag. Staff L and Staff M doffed gloves and gowns and completed hand hygiene. Staff L then revealed that she should have changed her gloves after raising the bed. On 09/16/2025 at 11:45 AM during lunch observed Hospice Registered Nurse (RN) Staff N and Hospice Certified Nurse Assistant (CNA) Staff O enter the dining room and walked directly to the assisted feeding table. Staff N sat down next to Resident #10 and started pulling her hair back to put it into a ponytail. She did not wash her hands and she did not apply hand sanitizer on her hands and she started feeding Resident #10. She then stopped, opened her backpack, took some sort of barrier out, laid the barrier on the floor. She then sat her back pack on top of the barrier that she laid on the floor. She then pulled out her laptop from the back pack, opened the laptop and typed onto the keypad, and then resumed feeding Resident #10. She did not utilize any hand sanitizer on her hands at that time. Staff O proceeded to sit down next to Resident #9, she started feeding him without using any hand sanitizer on her hands or washing her hands prior to her feeding Resident #9. On 09/16/2025 at 1:53 PM interviewed the Administrator on her expectations of hand hygiene for outside contracted staff. She said she would expect them to wash their hands or at least use hand sanitizer prior to feeding the resident. She would expect them not to fiddle ( touch or mess around with) around with their hair while in the dining room, and to use hand sanitizer after doing so. She stated, that's just the nursing standard of care. The facility policy Titled Hand Washing Policy stated its purpose was to prevent the spread of infection and protect the health of residents, staff and visitors by ensuring proper hand hygiene practices. The policy stated all employees, contractors, volunteers, and visitors must perform hand hygiene according to the following standards before direct contact with a resident. Before preparing, serving or eating food. The facility policy Titled Infection Prevention and Control Manual: Enhanced Barrier Precautions stated gowns and gloves (PPE) will be worn while providing high contact care activities. The facility policy Titled Infection Prevention and Control Manual: Catheter Care was to prevent infection and irritation by washing hands, wearing gloves and obtaining clean equipment for catheter care procedures. 2. Review of Resident #26's MDS dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 14 indicating intact cognition. The MDS further revealed diagnoses of cancer, hypertension, and progressive neurological conditions. Observation on 9/15/25 at 11:16 AM Resident #26 observed to have a dressing on the left hand. When asked Resident #26 revealed he is not sure what happened there. Review of Resident #26's EHR page titled, Progress notes, revealed an entry dated 9/3/25 at 1:50 PM. The entry revealed that Resident #26 had returned from the dermatologist who had completed Microscopically Oriented Histographic Surgery (MOHS) to the top of Resident #26's left hand. Review of Resident #26's EHR page titled, Clinical Physician Orders, revealed an order for a dressing change to the left hand dated 9/5/25. The order revealed to remove the old dressing and cleanse with mild soap, water and Q-tip. Remove drainage/scabbing with dry Q-tip. Apply firm pressure. Apply Vaseline with a clean Q-tip to the wound and cover with a non-stick gauze and secure with paper tape. Observation 9/17/25 at 9:54 AM Staff G Licensed Practical Nurse (LPN) set up sterile area on bed side table of Resident #26. Staff G then donned a gown. Staff G completed hand hygiene and donned gloves. Staff G then removed Resident #26's old dressing on the left hand. Staff G then doffed her gloves and donned new gloves without hand hygiene. Staff G then cleansed the area to the left hand per the physician order. Staff G again doffed her gloves and donned new gloves without hand hygiene. Dressing change then completed per the physician order. Staff G then doffed her gloves and gown and completed hand hygiene at that time. Interview 9/17/25 at 10:05 AM with Staff G revealed she should have sanitized between glove changes during the dressing change. 3. The MDS for Resident #1 dated 7/17/25 revealed a BIMS score of 15/15 indicating normal cognition. The document provided diagnoses of diabetes mellitus, pressure ulcer of right buttock Stage 3 and pressure ulcer of left buttock Stage 3. The document revealed 2 Stage 3 pressure ulcers. Resident #1's Care Plan dated 7/1/25 revealed a focus area of actual impaired skin integrity related to fragile and thin skin, incontinence, friction and shearing potential and Stage 3 pressure injuries initiated on 12/2/22 and revised 6/1/23. Interventions included positioning needs, resident's non-compliance with treatment and interventions, resident sleeping in recliner by choice, following orders and weekly documentation. The Care Plan failed to identify the need for EBP. The hard chart provided a medical diagnosis of squamous cell carcinoma of the right external ear and external auricular canal. The Clinical Physician Orders revealed the following orders: Zinc Oxide External Paste 20% apply to right/left buttock topically two times a day for care and after every bowel movement, start date 8/29/24. Clean drainage from the external ear canal using Vashe moistened gauze and finger swab just around the outside of the external ear canal as needed, start date 8/18/25. Apply Vashe to gauze and place on wound for 3-5 minutes; remove old drainage from wound and peri wound; apply skin prep around wound; apply Aquacel Ag to wound and secure with Mepilex Border dressing start date 8/18/25. Observed on 9/15/25 at 11:26 AM Resident #1 with a bandage covering the right (R) ear. The resident's room did not contain a U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign. Observed on 9/16/25 at 10:14 AM Staff G, Licensed Practical Nurse (LPN)/Infection Preventionist (IP) complete wound dressing to Resident #1's R ear. The staff stated the resident had ear cancer and had been going to the wound care clinic. Staff G brought in the dressing supplies, and placed a barrier on the resident's night stand. The staff sanitized wound scissors, completed hand hygiene and donned gloves. The staff removed the bandage from the ear. Vashe applied to the gauze and placed it on the ear. After 4 minutes the gauze was removed. Staff removed gloves, completed hand sanitizing and donned new gloves. The staff utilized finger swabs for drainage removal, as well as gauze and Vashe. The staff removed gloves, went to the bathroom to obtain more gloves, completed hand sanitizer and donned gloves. The Aquacel Ag was cut to size, Skin Prep applied to skin around the ear, the Aquacel Ag placed, and the Mepilex Border dressing placed on top. Gloves removed and hand sanitizer completed. The staff failed to utilize EBP by not using a gown. Observed on 9/17/25 at 6:30 AM Resident #1 sleeping in the recliner with a U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign on the bathroom door. Observed on 9/17/25 at 10:20 AM Staff G complete wound care to Resident #1's buttocks. The staff washed hands and donned gloves. Resident #1 walked with a walker to the bathroom. Staff G cleansed the area to the buttocks and patted dry. Zinc Oxide 20% placed to the open areas on the buttocks. The staff failed to wear a gown for EBP during the treatment. 4. Review of Resident #3's MDS dated [DATE] revealed a BIMS score of 8/15 indicating moderate cognitive deficit. The document provided diagnoses of benign prostatic hyperplasia, renal insufficiency, and obstructive uropathy. The resident had an indwelling catheter and urinary continence was not rated. Resident #3's Care Plan dated 6/26/25 revealed a focus area of self care deficits revised 6/16/25 contained interventions of toileting 1 assist with emptying catheter, suprapubic catheter and wears a leg bag for urinary drainage initiated on 6/6/24 and revised on 6/20/24. An additional focus area of suprapubic catheter and at increased risk for infections was initiated on 10/2/23. The interventions included assisting with emptying the leg drain bag every shift and as needed (PRN) initiated 5/8/24 and revised 1/3/25 and observing on routine rounds for proper positioning and urine flow initiated 10/2/23. The Care Plan failed to identify the need for EBP. On 9/15/25 at 12:29 PM observed Resident #3 seated in his wheelchair (w/c) with a full catheter leg bag. The room did not have a U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign. Staff L, Certified Nursing Assistant (CNA), came into the resident's room and acknowledged the leg bag required emptying. Staff L went into the bathroom, came back with gloves donned, a gradient cylinder, a container to hold the cylinder, and a barrier to place the container on. The staff proceeded to empty the catheter, stating I hope this doesn't overflow. Observed the urine output to fill the 1100 ml cylinder. The staff failed to wear a gown for EBP during the care. On 9/17/25 at 6:30 AM observed U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign on the bathroom door. On 9/17/25 at 7:20 AM observed Staff G complete cares with Resident #3. The staff completed hand hygiene and donned a gown and gloves. During the continuous observation of application of absorbent pads to lower extremities, hygiene, catheter and peri care and dressing the staff exhibited inconsistent hand hygiene during glove changes. On 9/17/25 at 11:22 AM the Interim Director of Nursing (DON) stated staff should be utilizing EBP during catheter care. The staff disclosed she was unsure whether EBP should be utilized during all dressing changes or if a wound was chronic over 6 weeks. On 9/17/25 at 12:00 PM Staff G stated EBP should be utilized during catheter care and it was recently brought to the facility's attention that EBP should be utilized with all wound care. The U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign on Resident #1 and Resident #3's door revealed providers and staff must wear gloves and gown during high contact resident care activities including dressing, bathing, transferring, hygiene, changing briefs or assisting with toileting, and wound care.

Based on clinical record review, family interview, staff interview and policy review, the facility failed to provide timely and accurate assessment and interventions for 1 of 2 residents reviewed (Resident #31.) Resident #31 had many falls and the staff failed to complete skin assessments with measurements and failed to document and monitor injuries. The facility reported a census of 31 residents. Findings include:According to the Minimum Data Set (MDS) date 8/11/25, Resident #31 had a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive deficits). The resident was independent with eating, transferring and walking 50 feet. Resident #31 had wandering behaviors that occurred 1 to 3 days a week. He had diagnoses that included cancer, anemia, deep venous thrombosis, benign prostatic hyperplasia and dementia. The Care Plan updated on 8/18/25, showed that Resident #31 was at risk for impaired skin integrity related to fragile and thin skin, friction and sheering potential. Staff were to complete weekly treatment documentation to include measurement of each area of skin breakdown, including; width, length, depth type of tissue and exudate and any other notable changes or observations. Resident #31 was admitted to the facility for respite care with the intention of returning to community upon discharge. On 8/7/25, the resident was accepted to a facility with a locked unit.The following was found in the Nursing Progress Notes:a. On 7/29/25 at 10:40 AM, Resident #31 was admitted to the facility for respite care. He had a history of falls, was disoriented, ambulatory and continent of bowel and bladder.b. On 8/2/25 at 3:59 PM the resident was on the floor in front of television. Vitals were taken and a full skin assessment completed (The chart lacked a skin assessment and lacked documentation of notification to family and/or physician).c. On 8/3/25 at 3:15 PM, the resident was found on the floor in his room. He had an abrasion on right lower leg and one on left lower leg. (The chart lacked a skin assessment or note related to measurements or descriptions of injuries).d. On 8/7/25 at 2:40 AM, the resident was found on the floor on his side by the door, the nurse did a full assessment and noted a skin tear to the left wrist and left elbow and on the left back ribs. (The chart lacked a skin assessment with measurements and lacked documentation that the physician had been notified).e. On 8/8/25 at 1:40 PM, dining room, resident was lying on left side on the floor, abrasion with bump noted on left side of forehead, injury type abrasion top of scalp. (The chart lacked a skin assessment with wound measurements and descriptions).f. On 8/9/25 at 2:02 AM, the resident was found to have bruising across the top of his left hand and swelling. (The chart lacked documentation of description and measurements).On 9/15/25 at 2:45 PM, a Family Member (FM) for Resident #31 said that he had so many falls she couldn't remember if they had been contacted for each one. FM said that she saw the residents swollen hand after 8/8/25 on more than one occasion, and the family was concerned about it. It was bruised, and huge. She said that another family member had asked staff if they would do a, X-ray and the response they got from a nurse was that it was not broken. FM said that they didn't know that they could have taken him to the clinic themselves, and they wished they would have done that. When he was transferred to a different facility, they took him right in for an X-Ray and found he had a couple of fractured bones. On 9/15/25 at 12:30 PM, Staff C, Licensed Practical Nurse (LPN) said that on the morning of 8/9, he assessed the resident's swollen hand after the night nurse pointed it out to him. He had the resident move his fingers and grip and he didn't seem to have any pain or any trouble moving it so they just monitored it from there. Staff C said that the resident's wife was visiting that day and she did not voice any concerns to him about wanting to get an X-Ray or further assessment. Staff C said that he was the nurse on duty when the resident fell on 8/8 and he did not have any pain, swelling, bruising at the time. He said that the overnight nurse would have started a skin assessment related to the bruising and swelling. On 9/16/25 at 11:21 AM, Staff B, CNA said that she saw the residents swollen hand and helped the wife get his ring off. Staff B reported the swelling to the nurse, Staff C, and his response was that it was okay and not broken. Staff B said that the wife had voiced concerns about getting further assessment. On 9/15/25 at 1:33 PM, a staff member from the receiving facility reported that when the resident was delivered to the facility on 8/12/25, a staff member met the family and the wife immediately asked them what they were going do about his hand. The nurse saw that it was bruised and swollen so they took him for an X-Ray and found fractures. According to the Imaging Report dated 8/12/25, an exam of left wrist showed fractures of the fourth and fifth metacarpals. On 9/16/25 at 7:52 AM, the Administrator said that she came into the facility at 4 AM on 8/9/25 when the nurse said that the morning it was discovered the swollen hand. She looked at it with the nurse and told him to call the doctor and to document. She said that she found out later he hadn't contacted the doctor. In the process of investigating the residents falls she discovered that skin assessments were not getting completed. The Administrator maintained that the wife had not expressed concerns about the swelling, nor did she ask for an X-Ray. According to a document used to educate nursing staff, titled: Nursing Standards of Practice, page 11, When documenting a change in donation or resident issue in the progress notes, it must be followed up with an appropriate solution or plan and order follow up assessment if needed. Notify the physician as needed with changes for further direction. Assess and notify the physician of concerns and follow orders as directed. Page 14 indicated that staff should set up follow up per-shift assessments with any incident on hot chart form to support evaluating for changes and documenting regarding effectiveness of interventions and resident status.

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 2 of 3 residents (Residents #3, and #32) reviewed. The facility reported a census of 31 residents. Findings include: 1. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS further revealed a reentry back to the facility on 4/18/25 from a short-term general hospital stay. Interview on 9/15/25 at 11:06 AM with Resident #32 revealed that she was in the hospital in April of this year. Review of a facility provided document titled, Notice of Transfer Form to Long Term Care Ombudsman for the month of April 2025 revealed Resident #32 was not included on the form. Interview on 9/16/25 at 11:58 AM with the Social Services Manager revealed that the residents should be on the report and she was unsure why they weren't. The Social Services Manager then revealed that residents who have transferred out of the facility would be expected to be on the report. Interview on 9/16/25 at 12:26 PM with the Administrator/DON revealed that her expectation would be for Ombudsman notification to be completed correctly each month, and when residents are transferred or discharged they should be on the list. The Administrator further revealed that they do not have a policy for the Ombudsman notification, but the facility does follow the regulations. 2. Review of Resident #3's MDS dated [DATE] revealed Resident #3 had reentered into the facility from a short-term general hospital stay 6/16/25. The MDS further revealed a BIMS score of 4/15 indicating severe cognitive impairment. Review of Resident #3's EHR Progress Notes revealed that Resident #3 was in the hospital from [DATE] through 6/16/25. Further review of the EHR page titled Clinical Census, confirmed that Resident #3 was in the hospital on these dates. Review of a facility provided document titled, Notice of Transfer Form to Long Term Care Ombudsman dated June 2025 revealed that Resident #3 was not on the form.

Based on personnel file review, staff interviews, and policy review, the facility failed to ensure that current background checks had been completed for 1 of 4 staff reviewed. The facility reported a census of 31 residents. Findings include:A review of the file for Staff A, Certified Nurse Aide (CNA) revealed that the last Single Contact License and Background Check completed for her was dated 12/3/2020.On 9/16/25 at 2:30 PM, Staff J, Administrative Assistant, said that Staff A was first hired on 12/16/20 and terminated on 11/15/23. She was rehired on 3/1/24 but the file lacked a background check for the rehire. Staff J acknowledged that it hadn't been done and she started the process to run one for the staff member.On 9/18/25 at 3:30 PM the Administrator acknowledged that a second background check should have been completed for Staff A before rehire.According to the facility policy titled: Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July of 2019, The facility would conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to resident, prior to hire.

Based on clinical record review, staff interviews and policy review the facility failed to ensure that staff contacted the physician when a resident had a change in status for 1 of 2 residents reviewed. Resident #31 had many falls during his stay and the chart lacked documentation of physician notification. The resident was found to have a bruised, swollen hand and staff failed to contact the doctor for direction or orders. The facility reported a census of 31 residents. Findings include:According to the Minimum Data Set (MDS) date 8/11/25, Resident #31 had a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive deficits). The resident was independent with eating, transferring and walking 50 feet. Resident #31 had wandering behaviors that occurred 1 to 3 days a week. He had diagnoses that included cancer, anemia, deep venous thrombosis, benign prostatic hyperplasia and dementia. The Care Plan updated on 8/18/25, showed that Resident #31 was at risk for impaired skin integrity related to fragile and thin skin, friction and sheering potential. Staff were to complete weekly treatment documentation to include measurement of each area of skin breakdown. Resident #31 was admitted to the facility for respite care with the intention of returning to community upon discharge. On 8/7/25, the resident was accepted to a facility with a locked unit.The following documentation was included in the Nursing Progress Notes:a. On 8/2/25 at 3:59 PM, the resident was on the floor in front of the television. Nurse did vitals within normal limits (WNL). Did full skin assessment and neuro assessment. Chart lacked skin assessment and notification to family and/or physician. b. On 8/7/25 at 2:40 AM, resident on the floor on his side by the door. Nurse did full assessment and noted skin tear to left wrist and left elbow and on the back ribs. The chart lacked notifications to the doctor or to the family c. On 8/9/25 at 2:02 AM resident had bruising across the top of his left hand and swelling.d. On 8/9/25 at 4:33 AM left iliac crest 7 centimeter (cm) x 4 cm purple bruise on left rear flank, the medical doctor was not notified regarding wound condition.e. On 8/9/25 at 9:56 AM, an abrasion to top of scalp, top of left hand bruised and swollen. The chart lacked documentation of doctor notification of swollen hand.On 9/15/25 at 2:36 PM, Staff H, Licensed Practical Nurse (LPN) said that he worked the overnight shift and many of the falls for Resident #31 were after 10:00 PM. He said that if it was an emergency, the day shift would do the notifications the next day.On 9/16/25 at 7:52 AM, the Administrator said that she came in at 4:00 AM the morning of 8/9/25, she and the overnight nurse looked at the swollen hand together and she had directed the nurse to call the doctor and to document. She said that she found out later that the doctor had not been contacted. She acknowledged that the doctor and family should have been contacted with falls and injuries. According to a document used to educate nursing staff, titled: Nursing Standards of Practice dated 2024, page 11, When documenting a change in condition or resident issue in the progress notes, it must be followed up with an appropriate solution or plan and order follow up assessment if needed. Notify the physician as needed with changes for further direction. Assess and notify the physician of concerns and follow orders as directed. Page 14 indicated that staff should set up follow up per-shift assessments with any incident on hot chart form to support evaluating for changes and documenting regarding effectiveness of interventions and resident status.

Based on clinical record review, staff interviews and policy review, the facility failed to acquire a physician's signature on an Advance Directive in 1 of 3 residents (Resident #29) reviewed. The facility reported a census of 31 residents.Findings Includes: Resident #29's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Resident #29's MDS documented active diagnoses: seizure disorder or epilepsy, traumatic brain injury (brain dysfunction caused by an outside force), malnutrition, anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, post traumatic stress disorder, asthma, chronic obstructive pulmonary disease or chronic lung disease, respiratory failure, type 2 diabetes, atherosclerosis of aorta (build up of fat,cholesterol and other substances in and on the artery walls), rheumatoid arthritis, bilateral primary osteoarthritis of the hip, muscle weakness.The Care Plan with a targeted completion date of [DATE] indicated Resident #29 and or his Representative requested their code status to reflect Do Not Resuscitate (DNR).During the record review, revealed that there was not a physician's signature on the document titled Care Directive Determination that the resident or residents representatives signed at admissions. The policy was a document that all parties involved signed to determine if the resident was found without a pulse or respirations would they like Cardiopulmonary Resuscitation (CPR) started. There was an X next to the option indicating that Resident #29 does not want CPR initiated. Resident #29 wife signed the Care Directive Determination Form on [DATE]. A faxed dated [DATE] was sent to Nurse Practitioner. The fax was sent from the Social Services Director (SSD), with a message to please review and sign Thank You!.In an interview on [DATE] at 10:20 a.m., Staff K stated, when the nurse completes the advanced directive paperwork we would get the signatures of the resident or the power of attorney and then we would fax it to the physician for their signature and they would then fax it back to us. But the social worker usually does it with all the paper work. We usually just do the medical stuff, like the assessments, medications and stuff like that.In an interview on [DATE] at 10:31 a.m., the SSD replied that the nurses are responsible for obtaining the advanced directive signatures and faxing them out to the doctors for their signatures as well, not her.In an interview on [DATE] at 1:09 p.m., the Director of Nursing acknowledged it her expectations of the nurses to make sure the signatures' are on the advance directive's, and that if a fax goes out that they should be checking for the fax to be returned back with in 24-48 hours.Review of the provided facility policy undated and titled Care Directive Determination: Our facility will ensure that all resident rights regarding the use of CPR and other life sustaining measures are carried out. At the bottom of the policy that each resident or resident representative and physician was a place for each individual to sign and date, acknowledging their understanding of the policy.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 3 of 4 residents reviewed (Residents #2, #3, and #10) requiring the use of oxygen. The facility reported a census of 31 residents. Findings include: 1. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of progressive neurological conditions, Alzheimer's disease, Non-Alzheimer's dementia, and anxiety disorder. The MDS further revealed the use of continuous oxygen therapy. Observation 9/15/25 at 11:24 AM revealed the oxygen tubing set ups in Resident #10's room were dated 8/31 on both nasal cannulas. Review of Resident #10's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders, revealed an order to change and date oxygen tubing, nasal cannula, and bag weekly and as necessary with a start date of 3/5/23. Interview on 9/16/25 at 10:11 AM with Staff G Licensed Practical Nurse (LPN) revealed that oxygen tubing should be changed weekly on Sunday night shifts, and dated with initials when changed. Interview on 9/16/25 at 10:17 AM with the Administrator/Director of Nursing (DON) revealed that oxygen tubing should be changed weekly and initialed. A follow up interview 9/16/25 at 11:27 AM with the Administrator/DON revealed that the facility does not have a policy on oxygen tubing change, but the facility does follow nursing standards of care. 2. The MDS for Resident #2 dated 8/14/25 identified a BIMS score of 14/15 indicating normal cognition. The MDS documented a diagnosis of respiratory failure. The document indicated the resident required oxygen. Resident #2's Care Plan dated 8/14/25 contained a focus area of altered respiratory status/difficulty breathing related to acute respiratory failure with hypoxia. The date initiated was 8/2/22 with a revision on 9/9/22. Interventions included change and date oxygen tubing and nasal cannula weekly and as needed (PRN) per orders every Sunday night with a date initiated of 3/5/23; clean and soak nebulizer mask with half vinegar and half water for 10 min per orders nightly and replace nebulizer mask weekly every Sunday night per orders with an initiation date of 11/27/23. The Clinical Physician Orders revealed an order to change and date oxygen tubing and nasal cannula weekly and PRN every night shift every Sunday with a start date of 3/5/23. An additional order was noted to replace the nebulizer mask every Sunday night every night shift with a start date of 11/26/23. The Medication Administration Record (MAR) - Treatment Administration Record (TAR) 9/25 revealed documentation indicating the change and date of oxygen tubing order had been completed on 9/7 and 9/14/25. Observation on 9/15/25 at 10:36 AM revealed Resident #2's oxygen tubing and cannula with a date of 8/31. The concentrator was set at 3 L with the cannula in the resident's nose. Observation on 9/16/25 at 8:19 AM revealed Resident #2's concentrator turned on with the nasal cannula and tubing wrapped and placed in an attached pouch. The tubing had a date of 8/31. 3. The MDS for Resident #3 dated 8/28/25 identified a BIMS score of 81/5 indicating moderate cognitive deficit. The MDS documented diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), acute on chronic systolic and diastolic heart failure and dyspnea unspecified. A Health Condition identified shortness of breath. Resident #3's Care Plan dated 6/26/25 identified a focus area of diagnosis of congestive heart failure (CHF) and A-Fib and at risk for shortness of breath, chest pains, increased edema, and elevated blood pressure initiated 10/2/23 and revised 10/4/23. Interventions included administration of medications, observations and monitoring for side effects. An additional focus area identified altered respiratory status/difficulty breathing related to COPD and CHF initiated 5/23/24. Interventions included monitoring for signs/symptoms of respiratory distress, level of consciousness, and abnormal breathing patterns. The Clinical Physician Orders revealed an order to clean the nebulizer mask nightly and change out mask and tubing weekly on Sunday overnights. Be sure to label and date the mask and tubing, every night with a start date of 5/23/24. The 9/25 MAR - TAR disclosed documentation indicating the nebulizer mask order had been completed daily. Observed on 9/15/25 at 11:27 AM Resident #3's nebulizer mask and tubing did not have a label with a date. Observed on 9/16/25 at 8:22 AM Resident #3's nebulizer mask and tubing did not have a label with a date. Observed on 9/17/25 at 6:30 AM Staff L, Certified Nursing Assistant (CNA), removed the nebulizer mask from Resident 3's room and returned with a mask. Observed on 9/17/25 at 7:47 AM oxygen tubing for nebulizer dated 9/16/25. The facility did not have a policy related to oxygen tubing.

Based on clinical record review, observations, staff interview, and policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 31 residents. Findings include:Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8/15 indicating moderate cognitive deficit. The document provided diagnoses of benign prostatic hyperplasia, renal insufficiency, and obstructive uropathy. The resident had an indwelling catheter and urinary continence was not rated. Resident #3's Care Plan dated 6/26/25 revealed a focus area of self-care deficits revised 6/16/25 contained interventions of toileting 1 assist with emptying catheter, suprapubic catheter and wears a leg bag for urinary drainage initiated on 6/6/24 and revised on 6/20/24. An additional focus area of suprapubic catheter and at increased risk for infections was initiated on 10/2/23. The interventions included assisting with emptying the leg drain bag every shift and as needed (PRN) initiated 5/8/24 and revised 1/3/25 and observing on routine rounds for proper positioning and urine flow initiated 10/2/23.Review of Clinical Physician Orders dated 1/1/25 to 9/17/25 for use of antibiotics revealed the following:Cefpodoxime Proxetil Oral Tab 200 milligram (mg) 2 times/day for urinary tract infection (UTI) for 7 days. Start 1/10/25, end 1/17/25.Ceftriaxone Sodium Injection Solution Reconstituted 1 gram (g), inject 1 g 1 time for UTI for 1 day mix with 1 milliliter (ml) lidocaine start 3/12/25.Ceftriaxone Sodium Injection Solution Reconstituted 1 g, inject 1 g 1 time for UTI. Start 3/14/25.Levofloxacin Oral tablet 750 mg every 48 hours for UTI until 3/22/25, 750 mg every other day for 7 days. Start 3/15/25, end 3/22/25.Amoxicillin-Pot Clavulanate Oral Tablet 875-125 mg 1 tab two times a day (BID) for UTI for 10 days. Start 4/25/25, end 5/5/25.Ceftriaxone sodium injection solution reconstituted 1 g inject 1 g intramuscularly at bedtime related to history of UTI for 1 administration. Start 5/23/25.Cephalexin Oral tablet give 500 mg three times a day (TID) for UTI for 5 days. Start 5/24/25, end 5/27/25.Ceftriaxone sodium injection solution reconstituted 1 g inject 1 g intramuscularly at bedtime related to history of UTI for 2 administrations. Start 5/27/25.Ceftriaxone sodium injection solution reconstituted 1 g inject 1 g intramuscularly at bedtime related to history of UTI for 7 administrations. Start 6/16/25.Cephalexin Oral tablet 500 mg 1 tab BID for elevated white blood cells (WBC) and left shift for 5 days. Start 7/30/25, end 8/4/25.Doxycycline Hyciate Oral 100 mg 1 tab BID for chronic kidney disease, history of UTI. Start 8/21/25, end 8/28/25.The clinical record Point of Contact (POC) Response History for bowel and bladder, catheter care and suprapubic for the past 29 days revealed 9 days where cares were only provided twice in a single day:8/21/25 4:57 AM, 1:59 PM8/22/25 4:52 AM, 9:38 PM8/24/25 11:45 AM, 7:48 PM8/25/25 11:55 AM, 8:44 PM8/31/25 5:21 AM, 9:33 PM 9/9/25 5:26 AM, 7:53 PM9/13/25 5:59 AM, 9:18 PM9/14/25 5:13 AM, 9:52 PM9/16/25 5:26 AM, 7:56 PMObserved on 9/15/25 at 12:29 PM Resident #3 in a wheelchair (w/c) moving around the hallway independently returning to his room. The resident's catheter leg bag was attached to the left lower extremity (LLE) and observed to be very full and expanded. The resident's call light was on and Staff L, Certified Nursing Assistant (CNA), entered the room, observed the resident's leg bag, said it needed to be emptied and hoped it didn't burst. Staff L went into the bathroom, came back with gloves donned, a gradient cylinder, a container to hold the cylinder, and a barrier to place the container on. The staff proceeded to empty the catheter, stating I hope this doesn't overflow. Observed the urine output to fill the 1100 ml cylinder. Observed the urine to be slightly cloudy, have a strong smell and the staff requested vinegar spray to the resident's room. Observed on 9/16/25 at 1:19 PM Resident #3's catheter leg bag 1/2 full while the resident was in the main hallway by the nurses station self propelling his w/c. Observed on 9/16/25 at 2:00 PM Resident #3 in the hallway, the catheter leg bag was over 1/2 full, interacting with multiple CNA's during shift exchange. Observed on 9/16/25 at 3:09 PM Resident #3's leg bag to be full with the resident self propelling in w/c up and down the hall independently passing various nursing staff.On 9/16/25 at 1:27 PM Staff M, CNA, stated catheter cares were completed each shift and as needed.On 9/16/25 at 3:05 PM Staff P, CNA, stated catheter cares should be completed almost every 2 hours. The staff stated this was learned as part of CNA training and part of the facility expectations. On 9/16/25 at 11:22 AM the Interim Director of Nursing (DON), as of 9/16/25, stated catheter bags and care should be emptied each shift or PRN as per the facility's policy. The staff stated she would have a concern if a catheter bag was emptied only twice daily. The staff stated she couldn't remember if the resident would not be receptive to catheter care, but did acknowledge if he was aversive to catheter care then it should be on the Care Plan. On 9/17/25 at 12:00 PM Staff G, Licensed Practical Nurse (LPN)/Infection Preventionist (IP), stated catheters should be emptied once per shift as a minimum. The staff stated catheter drainage bags should be checked during any cares, transfers and if a resident was independent the resident should be checked/monitored throughout the day. The LPN/IP stated the CNA's may empty a catheter multiple times during a shift but only document once per shift. When asked if there was no documentation during a shift, the staff stated if there was no documentation then the task was not completed. The staff stated that she did have a concern with a catheter only being emptied twice daily as it could be a contributing cause to urinary tract infections. On 9/17/25 at 12:30 PM the Administrator stated catheter bags should be emptied minimum of every shift and PRN. The Administrator concurred a lack of emptying a catheter bag and a very full catheter bag could be a contributing factor to UTI's. The facility's Catheter Care Policy did not provide guidance for the frequency of emptying a catheter bag. The Mount [NAME] Hospital Reference Guide provided that a leg bag should be emptied at least two or three times a day, or when it is a third to half full.

Based on observation, clinical record review, staff interview, and policy review the facility failed to provide adequate nursing supervision to prevent an accident and injury by leaving a resident that needed assistance with transfers, was a high risk for falls, and care planned to not leave unattended in the bathroom, unattended on the toilet and the resident fell and received an abrasion to the elbow and abrasion to the hip/buttock for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) for Resident #1, dated 1/23/25, documented a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment for decision-making. The MDS included diagnoses of Non-Alzheimer's Dementia, Parkinson's disease (progressive neurological condition), anxiety disorder, and depression. The MDS documented the resident required substantial/maximal assistance with toilet transfers, used a walker and wheelchair (w/c) for mobility, and used a bed and chair alarm daily. The MDS indicated the resident was always incontinent of bladder, frequently incontinent of bowel, and was dependent on staff for toilet hygiene. The Care Plan for Resident #1, revised on 4/30/24, included a focus area of resident at risk for falls related to impaired balance, poor safety awareness, functional impairment, and/or the use of medications that may increase fall risk and a history of falls. A Care Plan intervention of do not leave resident in bathroom unattended was initiated on 5/8/24. Observation on 3/31/25 at 11:28 AM, Resident #1 was in a recliner in the living room area with an alarm pad in the recliner. A Certified Nursing Assistant (CNA) placed a gait belt on the resident and attempted to assist the resident to stand, the resident was not standing well, so another CNA assisted to transfer the resident from the recliner to the w/c, with the pad alarm moved to the W/C. Incident Report for Resident #1 for un-witnessed fall dated 1/18/25 at 4:50 PM, documented: Incident location in South Shower. Found resident on the floor, partially on top of the w/c scale in the south bath, bowel movement (BM) and blood visible. Resident awake, alert and breathing. Trauma assessment, treated wounds, staff who left the resident was sent home until investigation completed. Resident not taken to hospital. Injuries observed at time of incident: abrasion right buttock, abrasion and bruise right rear thigh, skin tear of right elbow and back of right hand. Predisposing factors: confused, gait imbalance, impaired memory, using walker, ambulating without assistance, and resident was left on the toilet in the south bath unattended by Training Nurse Assistant (TNA), nursing was unaware resident was in the bathroom, and unaware he was unattended. Resident #1's Progress Note titled Post Fall Evaluation, dated 1/18/25 at 5:47 PM, documented: 1/18/25 at 4:50 PM fall was not witnessed, attempting to get out of the bathroom unassisted, was left on the toilet unattended in the south bath by the TNA with the door closed, no other staff were aware resident was in there, injuries of multiple skin tears, abrasions and bruises, and skin tear on right and left elbow. Resident #1's Health Status Note dated 1/19/25 at 4:52 AM, documented: follow-up from fall on 1/18 25, resident complaining of pain to right arm and right flank/back area, has an abrasion to the right elbow/forearm, bandage changed due to bleeding through. Review of Resident #1's two Non-pressure Skin Assessments dated 1/20/25: a. Follow-up assessment for a skin area first observed on 1/17/25 for a skin tear of the right elbow (with multiple tears from previous fall on 1/17/25) that was 10 centimeters(cm.) length X 3.2 cm. width X 0.1 cm. in depth and described as wound bed is bright red, with moderate amount of bright red blood and physician notified on 1/17/25. b. Follow-up assessment for a skin area first observed on 1/20/25 for a bruise of the right buttock that was 10 cm. length X 10 cm. width and described as bruise is light purple, has an abrasion 1.5 cm. X 4 cm. X 0.1 cm. and physician notified on 1/17/25. Interview on 4/7/25 at 5:00 PM, Staff A, Registered Nurse (RN) stated she works 2 days a week and completes the skin assessments. Staff A stated skin assessment forms were not completed on 1/18/25, the day of Resident #1's fall, so she completed the skin assessments on 1/20/25 for the injuries from Resident #1's fall on 1/18/25. Staff A reviewed the skin assessments dated 1/20/25 and confirmed the skin assessments she completed on 1/20/25 she had incorrectly dated as 1/17/25 and should have been dated as 1/18/25 for the date first observed and related to the fall on 1/18/25. Staff A stated at the time of the assessment, the skin tear on the right elbow was large, as the tear started above the right elbow, continued down, around and to below the elbow and had areas where the top layer of skin was missing and open and then patches that did have the top layer of skin in place. Staff A stated she completed the weekly assessment of the right elbow skin tear today and has healed to 0.2 cm. length X 0.5 cm. width X 0.1 cm. depth. Review of Fall Scales completed 11/13/24 - 1/18/25 for Resident #1, documented a total score of 45 and higher represented a high risk for falling: 11/13/24 with score of 80, 1/4/25 and 1/18/25 both with score of 110. Interview on 3/31/25 at 11:29 AM, Staff B, Certified Nursing Assistant (CNA) stated Resident #1 is an assistance of 1 staff for transfers. Staff B stated she knows the residents as she has worked at the facility awhile but staff can look up the residents' level of care in the CNA binder, also had pocket care plans when the facility had agency staff but she does not use personally. Staff B stated if a resident's status changes the changes are put in the communication book. Staff B stated Resident #1 is not to be left alone on the toilet as the resident has an alarm and any resident with an alarm she would not leave alone on the toilet. Interview on 3/31/25 at 11:33 AM, Staff C, CNA stated Resident #1 is a staff assistance of 1 with transfers but sometimes she uses 2 staff due to the alarm pad getting transferred also. Staff C stated the resident has a history of falling. Staff C stated the facility has a communication book for resident care changes and also has pocket care plans. Staff C stated any resident with an alarm she would not leave on the toilet alone, that Resident #1 is not to be left alone in the bathroom and he has an alarm. Interview on 3/31/25 at 11:50 AM, the Administrator/Director of Nursing (ADM/DON) stated the Kardex is the most updated information for staff to look for the residents' care needs and the facility is no longer using pocket care plans. The ADM/DON stated on 1/22/25 she put a note in the communication book for the staff, due to Resident #1 being left alone on the toilet and falling on 1/18/25. Review of Resident List Report dated 1/22/25, revealed a list of the current residents with a note stating: People highlighted do not leave in the bathroom or on the bedside commode alone. Make sure you are following the Kardex in the computer. We do not use pocket care plans any more. Resident #1 was highlighted, with a total of 9 resident names highlighted. Note was signed by the ADM/DON. Interview on 4/1/25 at 9:30 AM, Staff D, TNA started working at the facility 11/5/24 and received orientation with another CNA for 1 month. Staff D stated on 1/18/25 around 4:15 PM, Resident #1 was in the living room and trying to get up on his own to go to the bathroom. Staff D stated he took the resident to the south shower bathroom. Staff D stated he couldn't find a big enough brief for the resident so he went to the resident's room to get a brief and left the resident on the toilet. Staff D stated about 4:30 PM, while he was getting the brief from the resident's room, Staff G, Licensed Practical Nurse (LPN) radioed and told him to go to dinner. Staff D stated he was intimidated by Staff G, as she liked to pick on him and just was not thinking and Staff D went to dinner as he was told and forgot to tell someone that the resident was in the shower room on the toilet. Staff D stated it was his mistake. Staff D stated he came back after his meal break and Staff G asked Staff D if he had left Resident #1 alone in the bathroom. Staff D told Staff G that he did leave the resident alone in the bathroom. Staff D stated Staff G told him to leave for the rest of the day. Staff D stated he received a 3-day suspension and the ADM/DON educated him on not leaving residents alone, to look at the sheet in the communication book for residents' transfer assistance needed, and to call for help if needed. Staff D stated he was aware Resident #1 should not be left alone on the toilet as he had been verbally told by other CNAs during his training. Interview on 4/1/25 at 10:08 AM, Staff E, CNA stated areas to find the residents' care status are the resident's care plan or Kardex and communication book. Staff E stated she would not leave any resident alone on the toilet that needs assistance. Staff E stated the residents that are in the living room are the residents they keep an eye on due to risk for falls, and she would not leave Resident #1 on the toilet alone as he is one of the residents in the living room that they keep a close eye on. Interview on 4/7/25 at 12:45 PM, Staff F, Certified Medication Aide (CMA) stated on 1/18/25 after 4 PM, she was doing the afternoon medication pass and did not see Resident #1 in the living room, so she figured staff had the resident in the bathroom or dining room. Staff F stated she then went looking for Resident #1 and found him in the south bath. Staff F stated the resident was on the floor by the scale, with his pants down to his knees and his legs out in front of him, with a huge skin tear on his right arm, and his arm bleeding a lot. Staff F stated she assumed the resident had been on the toilet and tried to get out of the bathroom. Staff F stated she called for the nurse on the walkie-talkie and Staff G came in and checked the resident, got stuff for the resident's arm, and staff got the resident cleaned up. Staff F stated at the time she did not know who had left the resident in the bathroom as are not supposed to leave the resident alone on the toilet. Staff F stated she was later told Staff D had left Resident #1 alone on the toilet. Interview on 4/7/25 at 1:00 PM, Staff G stated she was working on 1/18/25 and it was after 4:00 PM. Staff G stated Resident #1 was typically in the recliner in the living room, as he was a high fall risk and had a chair alarm. Staff G stated the CNAs started breaks at 4:00 PM and staggered their breaks every 15 minutes, so there are 2 CNAs on the floor. Staff G stated she and Staff F noticed Resident #1 was not in his recliner and started to question where the resident was. Staff G stated Staff F found the resident in the south bath. Staff G stated the resident had a skin tear on his right arm at the elbow and there was blood and BM on the floor, with the resident lying partially on the weight scale and partially on the floor. Staff G stated she completed an assessment on the resident and the resident was alert, conscious, and cussing he wanted to get up. Staff G stated staff got the resident cleaned up and out to the living room. Staff G stated she asked Staff D if he put the resident in the south bath and Staff D said yes. Staff G stated Staff D told her he took the resident to the south bath right before another staff went to break, which would have been approximately 4:15 PM. Staff G stated Staff D reported to her that he went to answer another call light. Staff G stated Staff D went to break at 4:30 PM and was on break when the resident was found in the south bath. Staff G stated she notified the ADM/DON and told Staff D to go home per the ADM/DON's instruction. Staff G stated the resident also had an abrasion on his right hip area and the next day had bruising on his right hip/buttock. Facility policy Falls Assessment Protocol revised 1/4/17, revealed residents identified as high risk for fall will have fall interventions implemented and interventions for reducing the residents' risks for falls will be resident specific and based on assessment findings. Facility policy Minimum Standards of Personal Cares dated 2024, revealed: Minimum standards will be used for all aspects of personal care for residents. If a resident requires care other than that established in the minimum standards, that care will be described in the resident's care plan. It is each staff member's responsibility to be knowledgeable of each resident's care plan and to meet each resident's individual need by following these minimum standards and the resident care plan. Interview on 4/1/25 at 3:45 PM, the ADM/DON stated she felt Staff D knew not to leave Resident #1 alone on the toilet, felt he was busy, made a mistake, and listened to the charge nurse when she told him to go to break. The ADM stated Staff D received a 3-day suspension and education due to the incident. The ADM/DON stated her expectation to not leave any resident that needs assistance alone on the toilet.

Based on observation, interview, and record review the facility failed to ensure that residents were treated with dignity and respect for 2 of 13 residents reviewed. Resident's #238 and #1 reported that a staff member instructed them to urinate in their adult briefs if/when they couldn't assist them to the restroom in a timely manner. The facility reported a census of 37 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #238 had a Brief Interview for Mental Status (BIMS) score of 7 (moderate cognitive deficit). He had diagnoses that included heart failure, hypertension, diabetes, cerebrovascular accident, and traumatic brain injury. Resident #238 was admitted to the facility on [DATE]. The Care Plan for Resident #238, dated 10/8/24, showed that he had self-care deficits and required assistance with activities of daily living. He was unable to ambulate, used a wheelchair and required assistance of 2 staff with the sit to stand mechanical lift for transfers. The resident had bladder incontinence and staff were to clean him after each incontinence episode. On 10/14/24 at 11:00 AM, Resident #238 stated that the facility was under staffed and it often took over 20 minutes to get someone to help him to the toilet. He said that staff would tell him to go ahead and urinate in his brief and they would come and clean him up later. It was on the overnight shift that he was told this, and he didn't get cleaned up until the next morning. The resident said that initially, the staff had set a commode in the middle of the room for him to use, and then they stood back and kept asking if he was done. He said that he was unable to go when someone was watching or in the room, so he asked them to change that arrangement. They tried a couple of different things, such as using a urinal. At one point, the staff member that stood and held the urinal told him to hurry up, I ain't got all night Resident #238 indicated that this had been a stressful and degrading experience for him. A care conference note dated 10/15/24 at 10:45 AM, showed that Resident #238 expressed that it was taking the staff a long time to help him to the toilet. On 10/16/24 at 7:27 AM, Staff C, Certified Med Aide (CMA) said that she overheard staff members saying that a resident had been told to just pee in his brief, but she did not know a specific staff member but that is was an overnight staff. 2) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a BIMS score of 15 (intact cognitive ability). The resident was totally dependent for dressing, and required partial assistance with toileting, sit to stand and transfers. He was frequently incontinent of urine, and always continent of bowel. The Care Plan updated on 9/11/24, showed that Resident #1 had self-care deficits and required assistance with Activities of Daily Living (ADL's). He had impaired balance and Parkinson's Disease. They required assists of one for toileting and had constipation related to decreased mobility. On 10/17/24 at 7:18 AM, Resident #1 was in his room in the recliner. When asked if anyone had ever told him to urinate in his brief, the resident said that's happened to me. When the resident became hesitant and it seemed that the conversation was making him nervous. He said that he didn't remember any details. On 10/16/24 at 3:18 PM, Staff A, Licensed Practical Nurse (LPN) said that she knew that Staff B, Certified Nurse Aide (CNA) told Resident #1 that he was on his call light too often and that he should pee in his brief. The resident then told Staff A that he wanted to get a urinary catheter so he wasn't bothering the night staff so much. Staff A said that she had a conversation with Staff B about this and Staff B responded that he was always on his call light. They have since he started using a urinal at night with him so they didn't have to transfer him. On 10/17/24 at 11:58 AM, Staff B, CNA said that Resident #238 had trouble urinating when someone was in the room. They tried the commode, and when he couldn't go she told him that if he has to go in his brief, it's okay and they could just clean him up later. She said that they had him on the commode one night and he couldn't so they put him back to bed and then he pooped his pants. Someone cleaned him up later. She said that they tried using a urinal, but he couldn't go when someone was there holding the urinal. They put a brief on him at night to help hold the urinal in place so he could hold onto it himself. She denied having told him just to go in his brief but said that if the staff weren't able to get to him in time and he has an accident, it's okay, and they would just clean him up later. Staff B said that Resident #1 always talked wanting to get a catheter and she denied telling him that he should urinate in brief. When asked if the staff were taught how to maintain a resident's dignity regarding incontinence cares, she said that she just tells the residents it's not a big deal when they have to clean them up. On 10/17/24 at 10:17 AM, the Administrator denied having any knowledge of staff telling residents to urinate in their brief and she said that this was intolerable. She acknowledged that Resident #1 had requested a catheter and she told him that there must be a medical need. She said they provide regular education with staff on dignity issues and incontinence issues were addressed. According to the Resident [NAME] of Rights, residents had a right to be treated with respect and dignity, including; the right to reside and receive services in the facility with reasonable accommodation of resident needs and presences except when to do so would endanger the health or safety of the resident or other residents. An undated grievances policy indicated that the facility would encouraged residents to resolve concerns with management and administer without fear of reprisal or intimidation.

Based on observation, interview, and record review the facility failed to provide adequate nursing supervision to prevent falls for 1 of 4 residents reviewed (Resident #24). Resident #24 had a fall that caused injury after he got up from the chair without assistance. The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #24 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit). The resident had verbal and physical behavioral symptoms directed toward others 1-3 days a week. The resident used a wheel chair and a walker for mobility. He was totally dependent on staff for hygiene and dressing and required partial assistance with chair to bed transfers and toilet transfers. The Care Plan for Resident #24, dated 4/6/24, showed that he was at risk for falls due to impaired balance during transitions. He often slept in the recliner and staff were to monitor and assist him in getting out of the chair. The resident had increased anxiety when he was in his room, and this increased the risk of falls. A pressure alarm was used to the bed, recliner, and wheelchair to alert staff to when the resident was getting up. He was unable to utilize his call light, or to ask for assistance due to his cognitive impairment. Staff were to place a floor mat in front of the resident's bed when he was in bed. A Nursing Note dated 4/26/2024 at 6:50 PM, showed that Resident #24 had an unwitnessed fall in the dining room when he got up from the dining room chair and tried to walk back to the living room area. He was sent to the emergency room due to severe left hip pain. The personal alarm was not on the chair at the time. A hospital report dated 4/27/24 at 9:56 AM, showed the active admitting problem diagnosis included; fall as cause of accidental injury in residential institution as place of occurrence, and a closed fracture of neck of left femur. The plan of care included surgery for the following day to include 3 screws across the fracture to stabilize. According to a Nursing Note dated 4/30/24 at 3:11 PM, Resident #24 was readmitted to the facility after left hip repair. He was partial weight bearing for transfers only and staff provided a personal alarm. On 10/16/24 at 11:30 AM, Staff F, Certified Nurse Aide (CNA) said that she was present when Resident #24 fell in the dining room. She didn't see him fall, but remembered that he had tried several times prior to get up and they redirected him to stay seated. Two other CNAs had been in the dining room at the time, one was transferring another resident and one CNA had been assisting a resident with her meal. Staff F said that Resident #24 was easily agitated and they tried to keep him in the recliner out by the TV to keep an eye on him. She said that he'd had some medication changes that had helped keep him calmer. Staff F said that the resident would normally stay in his wheel chair during meals rather than the dining room chair. She didn't remember for sure if he was in his wheel chair on the evening of 4/29/24. She couldn't say for sure if there had been an alarm on his chair, but the resident would stand up very quickly and she didn't know if an alarm would have made a difference because it happened so fast. On 10/16/24 at 11:21 AM, Staff E, CNA, said that she was in the dining room on the evening when Resident #24 got up from his chair and fell . She did not see him get up on his own because she was assisting another resident with a meal. Staff E said that the resident often attempted to get up on his own. She did not know if he had the alarm on or remember hearing the alarm. On 10/15/24 at 1:49 PM, Staff D, Dietary Aide (DA) remembered that he was working the evening that Resident #24 fell in the dining room. He didn't see it happened but heard the commotion. He came out of the kitchen and saw a couple of CNA's with the resident after the fall. The resident was agitated and trying to get up off the floor. Staff D said that Resident #24 was constantly trying to get up from the chair on his own. He didn't know if he had an alarm on, and didn't remember hearing an alarm. In an observation on 10/16/24 at 8:30 AM, Staff G, Certified Medication Aide (CMA) went to the room of Resident #24 to get him up for the morning. The resident was very sleepy, and said no many times while the CNA applied his support hose and sat him on the side of the bed. The motion sensor alarm was turned on and placed under the fitted sheet. Staff G used a gait belt to assist him to stand and he used a walker to ambulate into the bathroom. Staff G assisted the resident to sit on the toilet and he became more agitated and continued to say no. While Staff G turned her back to gather clothing from his closet, the resident stood up from the toilet with the use of his walker. Staff G turned back around to see him standing and quickly got him to sit back down on the toilet. At 8:45 AM, Staff G called for assistance and Staff I, CMA came in the room within a couple of minutes. Staff I stated that she had been present for one of the falls that Resident #24 had. She said the resident fell when he got up from the recliner and tried to walk to the kitchen. She said that he had taken the batteries out of the sensor alarm in the chair. Staff I stayed in the room briefly, then Staff G told her she felt that she could finish up okay without her help, and at 8:52 AM, Staff I left the room. While Resident #24 was sitting on the toilet, Staff G washed his legs and then slipped on a pair of sweat pants just to his ankles. The resident became increasingly agitated and continued to say no and moaned. Staff G stepped out of the bathroom and pulled the wheelchair closer to the bathroom door but failed to lock the wheels. At 9:00 AM, Staff G had the resident stand and hold onto the walker as she wiped his bottom and started to apply a clean brief. While she tried to secure the brief, Resident #24 started walking out of the bathroom with the brief partially attached and his pants still around his ankles. Staff G encouraged him to stop so she could pull up his pants but he kept walking out of the bathroom. She was finally able to secured the brief and pull up his pants just before he got to the wheelchair. She had him turn around with his bottom toward the seat of the wheel chair and he plopped down into the seat. Because the wheels were not locked, the wheel chair moved back slightly. Staff G immediately acknowledged that she should have engaged the brakes. On 10/16/24 at 11:10 AM, the Administrator said that they recently implemented team meetings to brainstorm root causes and possible interventions to decrease falls at the facility. On 10/17/24 at 10:24 AM, the Administrator said that Resident #24 had been a challenge with his impulsiveness and fall risk. She said they had tried many different interventions and she would expect staff to follow through with the Care Plan interventions such as use of motion alarms. She said staff were instructed to get help if/when the resident became agitated. She said that the resident had gotten much better since he had some medication changes. According to policy titled: Falls Assessment, last revised on 5/24/24, residents that were identified as high risk for falls would have fall interventions implemented. The interventions for reducing the residents' risk for fall would be resident specific and based on assessment findings.

Based on observation, interview, and record review the facility failed to ensure that staff were aware of the date that a stock supplement had been opened before administering it to a resident for 1 of 4 residents reviewed (Resident #17). The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15. He was independent with sit to lying, sit to stand, and toilet transfers. His diagnoses included hypertension, diabetes, Alzheimer's, anxiety, depression. The Care Plan last updated on 10/10/24 showed that Resident #17 had self-care deficits and required assistance with Activities of Daily Living (ADL). In an observation of the medication administration for Resident #17, on 10/15/24 at 7:18 AM, Staff H, Licensed Practical Nurse (LPN) prepared Vitamin B-12 500 micrograms (mcg). When asked about a documented open date on the bottle, Staff H acknowledged that there was not an open date, put a pill in with the rest of the medications and administered them to the resident. She then set the bottle aside and said that she would ask the Administrator what she should do with the bottle. Staff H later said that after talking to the Administrator she realized that she should not have administered the vitamin supplement to the resident. In the future, if there was a bottle unmarked, she would destroy the pills, get a new bottle, and document with the open date. On 10/17/24 at 10:26 AM, The Administrator said that she has a nurse go through the medication cart on a regular basis to look for open bottles with no opened date. She said that staff were taught to put the open date on as soon as they open the bottle. She looked through the facility policies and said that she did not find a medication policy that addressed open date documentation.

Based on clinical record review, staff interview, facility policy review, and the Resident Assessment Instrument (RAI) Manual, and policy review, the facility failed to complete and transmit a resident Minimum Data Set assessment upon a resident's discharge within the required time-frame for one of fourteen residents reviewed (Resident #10). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 07/24/24 revealed the Assistant Director of Nursing (ADON) signed the assessment as completed on 08/01/24. The MDS assessment dated [DATE], revealed Resident #10 admitted to the facility on [DATE], and discharged from the facility on 07/24/24. The MDS assessment revealed the DON signed the assessment as completed on 08/01/24. It further documented Staff J, MDS Consultant, signed and submitted the discharge, return not anticipated MDS on 10/17/2024. The Electronic Health Record (EHR) revealed the discharge return not anticipated MDS assessment dated [DATE] was completed on 08/01/24 but was not submitted to CMS. In an interview on 10/17/2024 at 09:16 AM with the Director of Nursing, she acknowledged that they had experienced issues with MDS, with the former MDS coordinator not really fitting in the position. She acknowledged the facility had not submitted the MDS for resident #10 within the required timeframe. The RAI Manual Version 3.0 revealed the discharge return not anticipated MDS assessment must be completed when the resident discharged from the facility and the resident not expected to return to the facility within 30 days. The discharge return not anticipated MDS must be completed within 14 days after the discharge date , and submitted within 14 days after the MDS completion date.

Based on staff interviews the facility failed to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in the facilities building water systems such as by having a documented water management program. The facility also failed to have an assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread and measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. The facility reported a census of 33 residents. Findings include: The facility could not produce documentation of measures taken to track, assess, and prevent Legionella in the facility. On 7/25/23 at 8:55 AM the Maintenance Manager reported that the facility did not have a map of the water pipes. He added that the facility did not have stagnant water to his knowledge. On 7/25/23 at 2:43 PM the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) explained that they never did anything regarding Legionella in the facility. They expected the facility to have a policy and procedure to track, assess, and prevent Legionella in the facility.

Based on staff interviews the facility failed to employ a staff member with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a qualified professional serve as the dietary manager. The facility reported a census of 33 residents. Findings include: On 7/25/23 at 11:32 AM the Dietary Manager reported that she did not have the education and training required for a qualified professional to serve as the Dietary Manager at the facility. She added that she is taking the classes to become certified. On 7/25/23 at 11:45 AM the Director of Nursing (DON) revealed she expected the facility to have a Certified Dietary Manager in charge of the kitchen.

Based on personnel file review, facility policy review, and staff interview the facility failed to provide the recertification dependent adult abuse training within 3 years for 1 of 5 employee reviewed (Staff E, Certified Nurse Aide CNA). The facility reported a census of 33 residents. Findings include: Staff E's Dependent Adult Abuse Mandatory Report Training Certificate dated 5/14/20 listed that she completed the course for the total of two program hours of continuing education. The Certificate indicated that Staff E met the two hour core mandatory reporter training and required a one-hour refresher course within the next three years. On 7/26/23 the Administrative Assistant (AA) reported that Staff E did not have a refresher course certificate. They had her complete the training that afternoon. On 7/27/23 at 8:30 AM the AA said that she was working on a better spreadsheet to monitor and alert when trainings were due. The Abuse Prohibition policy dated July 2019 directed that each employee would take a one-hour recertification training within three years of the initial training and every three years thereafter.

Based on observation, interview, and record review the facility failed to follow physician orders for 2 of 13 residents reviewed (Resident #14 and #31). Following a procedure to remove ingrown toe nails, the podiatrist gave new orders for care of Resident #14's feet. During an interview and observation three days after the appointment revealed that the facility failed to complete the orders for Resident #14. The facility failed to apply Resident #31's ordered edema wear (special socks used to treat swelling) as ordered by the physician. Findings include: 1. Resident #14's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #14 required extensive assistance from two persons for toilet use and bed mobility. In addition, she needed extensive assistance from one person for hygiene and dressing needs. The Care Plan Focus revised 6/23/22 reflected that Resident #14 had a potential for impaired skin integrity related to fragile, thin skin, incontinence, friction, and shearing potential. Resident #14 had diagnoses of hypertension (high blood pressure), congestive heart failure (impaired heart function), and incontinence. The Goal indicated that Resident #14 would not have impaired skin through the review date. The Interventions revised 5/1/23 directed to provide treatments as ordered. On 7/25/23 at 10:10 AM while lying in bed on her back, Resident #14 said that she had chronic pain. She had a couple of ingrown toenails. She went to the podiatrist (foot doctor) a couple of days before to get them worked on. Following the procedure, the podiatrist ordered the staff to be soak her feet but that did not happened. Resident #14's July 2023 Medication Administration Record (MAR) / Treatment Administration Record (TAR) reviewed on 7/25/23 lacked treatment orders for her feet/toes. On 7/25/23 at 9:15 AM Staff B, Certified Medication Aide (CMA), explained that she did not know that Resident #14 had an order to soak her feet. The skin nurse would do the treatments on occasion. On 7/25/23 at 9:22 AM Staff C, Registered Nurse (RN), reported that she worked as needed and did the skin assessments twice a week. She was not familiar with the order for Resident #14 to have her feet soaked. She looked in the electronic chart and could not find the order on the TAR or MAR. She acknowledged that the order did get entered on the 7/22/23 but it did not transfer to the MAR/TAR, so it appeared that the treatment did not get completed. On 7/25/23 at 9:54 AM Staff C removed the bandages from both of Resident #14's great toes (big toes). She reported that the bandages appeared as the same ones that the podiatrist's office applied. Resident #14 told Staff C that no one soaked her feet or completed her ordered treatments. The Order Audit Report reviewed on 7/26/23 listed an order dated 7/21/23 to soak both feet for 20 minutes in two quarts or warm water and one cup of Epsom salt. Apply triple antibiotic ointment (TAO) to both great toes and cover with a Band-aid two times a day for wound care. The revision history indicated that on 7/25/23 the original order included the original value of other orders (no documentation required). On 7/25/23 the staff updated the order to other orders - TAR. The Alert Note dated 7/26/23 at 11:11 AM indicated that Resident #14 returned on Friday July 21 from the podiatrist after having the ingrown section of bilateral great toes removed with new orders. The orders instructed to soak her feet twice a day with Epsom salt and apply TAO to her bilateral toes and cover with a Band-Aid. When the order was entered it did not automatically put on the TAR, resulting in Resident #14 missing three days of treatments. The nurse notified her family and physician. The undated Orders - New Order Process policy directed when receiving a new order via fax, physician visit, or physician rounds input the order into the electronic health record. Then update the MAR/TAR as warranted (needed). 2. Resident #31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating moderately impaired cognition. Resident #31 required limited assistance from one person for bed mobility, transfers, walking, and personal hygiene. The Care Plan Focus revised 7/19/23 reflected that Resident #31 had a diagnosis of hypertension and had an increase risk for chest pains, difficulty breathing, irregular heartbeat, fatigue (tiredness), confusion, and severe headaches. The Intervention dated 7/19/23 instructed to monitor and document any edema (swelling). The Care Plan Focus revised 7/19/23 indicated that Resident #31 had a potential for impaired skin integrity related to fragile, thin skin, and incontinence. The Intervention revised on 7/19/23 directed to provide treatments as ordered. The Order Details dated 6/30/23 included an order for Resident #31 to wear edema wear to her bilateral lower extremities in the morning and remove at bedtime. On 7/24/23 at 2:59 PM while sitting in her recliner, Resident #31 reported that she had pain in her back and was trying to get comfortable. She wore slip-on shoes with no stockings and her feet appeared swollen. She explained that she did not wear edema wear for the last couple of days. She thought she should have them on but she needed help to put them on. The edema wear laid on her dresser by the bed. She explained that she got them out and planned to ask the staff to put them on for her. On 7/27/23 at 7:28 AM the Assistant Director of Nursing (ADON) said that they didn't have any specific policy on assessment and intervention. She said that they would expect nursing to follow standards of practice for assessing residents and providing appropriate intervention. She acknowledged that Resident #31 should have been wearing the stockings to help prevent edema.

Based on observations, clinical record reviews, and staff interviews, the facility failed to adequately supervise residents at risk for falls for 2 of 3 residents reviewed (Resident #190 and #32). Resident #190 had a history of trying to get up by himself and not waiting for the staff to help him. Resident #190 required staff assistance of one with transfers. On 9/19/21, as a different resident walked by Resident #190's room, they noticed him on the floor. The other resident called for staff assistance. Once staff arrived they discovered Resident #190 lying on his left side complaining of pain to his left hip. Despite observing Resident #190 on his left side and complaining of pain to his left hip, three staff members assisted him off the floor and into his bed. After Resident #190 got into bed, the nurse noticed his hip appeared fractured. The nurse transferred Resident #190 to the hospital, where he received a diagnosis of a displaced mildly comminuted intertrochanteric fracture of his left femur (broken left hip). On the day of the fall, the staff witness reports documented that the last time the staff observed Resident #190 was while he ate at supper. One staff member reported they thought Resident #190 was independent with toileting. In interviews with the staff, a few staff members reported the resident showed increased confusion the week before his fall. Some of the staff reported that Resident #190 should be the first one helped after supper to prevent him from self-transferring. Resident #32 admitted to the facility on [DATE] following a fall at home resulting in a pelvic fracture. Resident #32's Baseline Care Plan indicated he had behavior concerns of getting up alone and safety concerns of a history of falls with a broken pelvis. Resident #32 required an assistance of one staff member with ambulation (walking). On 4/23/22, a Therapist discovered Resident #32 lying on his right side at 7:30 AM. At the time of assessment, Resident #32 complained of his right hip and groin hurting. Despite staff observing Resident #32 laying on his right side and complaining of hip pain, the nurse and Certified Nurse Aide (C.N.A.) assisted him into his wheelchair. Resident #32 transferred to the hospital and had an X-Ray that revealed a right femoral neck fracture (right broken hip) with some displacement of the fracture fragments. The facility reported a census of 42 residents. Findings include: 1. Resident #190's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS revealed that Resident #190 required limited physical assistance of one staff member for bed mobility and transfers. Resident #190 required physical assistance of one staff member for ambulation, dressing, toilet use, and personal hygiene. The MDS identified the resident's balance during transitions and walking, was not steady and he was only able to stabilize with staff assistance. The MDS indicated Resident #190 used a walker and wheelchair for mobility. The MDS documented diagnoses of [CONDITION(S)] and non-Alzheimer's dementia. The MDS identified Resident #190 had a history of falls without injury. The Care Plan revised 9/10/21 identified Resident #190, as a risk for falls related to his impaired balance, poor safety awareness, neuromuscular, functional impairment, and/or his use of medication that could increase the risk of falls. The Care Plan interventions included: a. Date Initiated 9/21/21: Reminder signs posted in the resident's room to use a pendent and/or call light then wait for assistance. b. Revision date 8/12/21: Call pendent used to ask for assistance whenever or wherever Resident #190 was located throughout the facility c. Revision date 8/12/21: Encourage the resident to ask for assistance from the staff d. Revision date 8/12/21: Encourage the resident to participate in activities that promote exercise, physical activity for strengthening, and improved mobility e. Revision date 8/12/21: Ensure the resident wore appropriate footwear when ambulating or using his wheelchair f. Initiated 1/23/29: Follow facility fall protocol g. Revised 8/12/21: Keep the resident's personal items; wheelchair, walker and call light within his reach h. Initiated 1/23/20: Monitor, document, report for 72-hours to the physician any signs or symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, or agitation. The Care Plan revised 9/10/21, identified Resident #190 had self-care deficit as evidenced by Resident #190 required assistance with his activities of daily living (ADL's), impaired balance during transitions, incontinence, and the need for assistance with walking. The Care Plan interventions included: a. Revision date 6/3/21: Ambulation: assist of 1 staff with use of forward wheeled walker (FWW) b. Revision date 8/12/21: Mobility: assist of 1. Staff to push Resident #190's wheelchair for long distances. Resident #190 could propel himself at times c. Revision date 6/3/21: Toilet use: assist of 1. Provide incontinence cares with each incontinent episode as the resident allowed d. Revision date 8/19/21: Transfer: assist of 1 with an FWW Resident #190's Care Plan revised 9/10/21 identified the resident had impaired cognitive function and/or impaired thought processes as evidenced by short-term memory deficit, long-term memory deficit, impaired decision making, and/or impaired ability to understand others. The Care Plan interventions included: a. Revision date 8/12/21: Communication: Face the resident when speaking, make eye contact, and reduce any distractions. The resident could understand consistent, simple, and direct sentences. Provide the resident with necessary cues, stop, and return if he becomes agitated. b. Revision date 8/12/21: Use task segmentation to support short-term memory deficits and break down tasks to one step at a time. The Progress Notes for Resident #190 revealed: On 9/9/21 at 10:24 AM, the Health Status Note (HSN) documented that the staff observed the resident wheeling himself in his wheelchair in the wrong direction, going towards his room. The staff noticed a change in the resident's cognition and the resident reported his memory felt worse. The resident required increased assistance from the staff. On 9/16/21 at 5:02 PM, the HSN recorded that the resident transferred himself to the bathroom independently and sustained a skin tear. On 9/20/21 at 12:32 AM, the Incident Note documented that at approximately 7:00 PM another resident found Resident #190 on the floor. Resident #190 laid at the foot of the bed with his back to the wall, with his legs crossed, and he complained of left hip pain. Resident #190 said he attempted to go to bed and he observed a piece of paper on the floor. Resident #190 continued reporting that when he attempted to pick up the paper, his right foot slid, and he fell on his left hip. Resident #190 reported increased pain to his left hip. Three staff manually lifted Resident #190 and placed him in bed. Upon inspection, the left hip appeared fractured. Resident #190 was transported to the local emergency room (ER), at 8:30 PM the ER reported to the facility that Resident #190 went to surgery. The Fall Scale dated 9/1/21, identified Resident #190 at a high risk for falls with a score of 90. The score calculated from Resident #190's history of falls, more than one diagnosis, use of a walker, impaired gait (walk), and mental status. The Fall Investigation - Quality Improvement Document dated 9/19/21 at 7:00 PM recorded that Resident #190 attempted to self-transfer from his bed to his chair and his foot slipped. As Resident #190 fell , he landed on his left hip. The document questioned the following interventions a. Did the resident have an alarm - No alarm b. Was the resident's call light on - No c. Was the resident's call light within reach - yes d. Was the Care Plan followed - yes e. Was an assistive device being used - no f. Were there any environmental hazards present - Resident #190 had a box at the foot of his bed and he was trying to walk to his bed without assistance. The hospital Imaging Report dated 9/19/21 indicated Resident #190 had a displaced and mildly comminuted intertrochanteric fractured left femur (bony areas on the femur where the thighbone attaches to the hip broke into multiple pieces). Written Statements The Written Statement dated 9/19/21 completed by Staff O, RN, documented that Resident #190 became more confused the week before and attempted to transfer by himself to bed. The documentation indicated that the floor wasn't wet, the resident had on clothes, and shoes. Staff O documented that the resident needed an alarm. The Written Statement dated 9/19/21 completed by Staff P, CMA (certified medication aide), documented Resident #190 was really confused lately. Staff P documented that the resident was confused lately, he did not and had not used his call light that was attached to his chair. Staff P documented that Resident #190 stood behind his wheelchair independently at 2:30 PM on 9/19/21. Staff P informed Resident #190 to use their call light. The Written Statement dated 9/19/21 completed by Staff Q, CNA, documented Resident #190 seemed more confused. Staff Q documented that the last time she saw the resident was at supper. Staff Q reported the last time Resident #190 used the toilet was before supper. The Written Statement dated 9/19/21 completed by Staff R, CNA, documented that Resident #190 seemed more confused throughout the day. Staff R documented last seeing Resident #190 at supper and he went to the toilet before supper. Staff interviews On 4/4/22 at 9:36 AM, Staff J confirmed Resident #190 transferred himself to the bathroom on 9/16/21. Staff J denied knowing of any interventions put into place at that time to prevent falls. Staff J reported that at one time Resident #190 had an alarm. Staff J said she didn't know if the fall occurred during that time frame. Staff J stated eventually the facility did implement alarms for Resident #190. On 4/4/22 at 9:57 AM, Staff K reported that she was unsure if Resident #190 was independent at the time of his fall on 9/19/21. Staff K stated Resident #190 required assistance with staff for care, but she believed he ambulated himself to the bathroom. Staff K explained that the nursing staff checked on the resident regularly and the resident used his call light. Staff K said that Resident #190 would turn on his call light in the morning when he was ready to get up. Staff K reported if there were any changes with Resident #190, it would be communicated in the CNA binder at the nurse's station. Staff K stated they did not know if any additional interventions were implemented related to the resident's increased confusion. Staff K stated Resident #190 was intelligent and would outwit the staff. Staff K reported that she felt all the staff checked on the resident frequently to see if he needed assistance. Staff K remarked that they didn't work at the time of the fall on 9/19/21. On 4/4/22 at 11:15 AM, the MDS Coordinator explained that communication with the CNA's and nurses occurred between shifts if a resident had a change in condition. The MDS Coordinator added that an intervention was implemented for Resident #190. They put a sign on Resident #190's wall and a sign on his walker. The MDS Coordinator denied knowing of additional interventions put in place to prevent falls. The MDS Coordinator stated after supper, Resident #190 would propel himself to his room. If the staff saw the resident, they were to encourage him to stay in the main lobby. The MDS Coordinator reported that the resident required assistance with toilet use, transfers, and personal hygiene at time of the fall. On 4/4/22 at 11:35 AM, Staff J commented that she reviewed Resident #190's Care Plan from 9/16-9/19/21. During that time frame no additional interventions were added related to the resident getting up without assistance and/or related to his increased confusion. Staff J remarked that August 2021 was the last time Resident #190's fall interventions were revised. On 4/4/22 at 12:59 PM Staff L stated Resident #190 preferred to stay up late. Staff L stated Resident #190's routine after supper was to go to the recliner. Staff L said Resident #190 was one of the last residents to go to bed, at around 10:00 PM. Staff L reported that Resident #190 had a history of getting up without assistance. The facility put signs in his room to use his call light and to ask for help. One sign was placed on his walker and another on the wall beside his bed. Staff L explained they didn't recall when the signs were placed. Staff L remarked that the current DON and Administrator investigated Resident #190's fall on 9/19/21. Staff L stated the resident had been hallucinating and had an alarm placed, but didn't know when it was placed. Staff L added that the resident had incontinent issues and saw a mental health provider with numerous medication changes all at once due to his cognitive issues. Staff L commented notifying a change in resident's condition to the CNA's by report and/or the communication binder. On 4/4/22 at 2:51 PM Staff B, CNA, stated Resident #190 had increased difficulty with transfers and required increased assistance from staff. Staff B didn't remember if Resident #190 ever got up without waiting for assistance. On 4/4/22 at 3:15 PM, Staff S, CNA, reported that at times Resident #190 transferred himself without using his call light or without waiting for assistance from the staff. Staff S said that Resident #190 got a personal alarm after he fell and broke his hip. Staff S added that right after supper Resident #190 was transferred right away to the recliner in his room. Staff S wasn't sure what happened the night of his fall, as she didn't work that night. If the facility was short staffed, they would leave Resident #190 in the living room. If Resident #190 was left in the living room he would take himself to his room and attempt to self-transfer. Staff S said that the resident would stay in the recliner and then turn the light on when he was ready for bed. Staff S commented that the resident became more confused before his fall on 9/19/21, she didn't know if additional interventions were put into place. Staff S remarked that before his fall on 9/19/21, Resident #190 couldn't alert staff of the need to use the bathroom, because he wasn't aware of the need to go. On 4/4/22 at 4:19 PM Staff M reported that Resident #190 was very forgetful and didn't use the call light or wait for assistance from the staff. Staff M stated that Resident #190 had alarms in place, a note by his bed, and a note on his walker to remind him to ask for help. On 4/5/22 at 7:37 AM Staff T, CNA, reported that Resident #190 had alarms in place before his fall on 9/19/21, but they weren't enforced. Staff T explained that the resident didn't always have the alarms in place, and they weren't used consistently. Staff T added that after supper Resident #190 was the first one done and he would take himself in his wheelchair half-way to his room. Staff T added that the staff would assist Resident #190 to his room, help him to the bathroom, and assist him into the recliner. Staff T commented that the resident used a call pendant or the staff would stop in his room between 6:45 PM and 7:00 PM to see what time Resident #190 wanted to go to bed. Staff T explained that Resident #190 went to bed later, as he was one of the last ones. Staff T said that Resident #190 would not tell the staff when he needed to use the bathroom, as he didn't know. Staff T stated she would check on Resident #190 every 2 hours and offer him the bathroom, but he was incontinent. Staff T said Resident #190 always attempted to self-transfer and didn't wait for assistance from the staff. On 4/5/22 at 7:44 AM, Staff U, CNA, recalled Resident #190's fall and hip fracture, but said she wasn't working at the time. Staff U stated the resident became more unsteady and had a long history of not waiting for staff's help. Staff U reported that if Resident #190 had a wheelchair or walker in reach he would attempt to self-transfer. Staff U reported that it wasn't uncommon for Resident #190 to get up with his walker and go. Staff U stated that once staff took Resident #190 to his room, they knew he needed assistance with the bathroom. After he used the bathroom, the staff assisted Resident #190 to the recliner so he wouldn't transfer himself. Staff U remarked that she knew the resident would transfer himself if he went to his room without staff. On 4/5/22 at 7:56 AM Staff V, CNA, said Resident #190 self-transferred all the time. Staff V reported that she found the resident taking himself to the bathroom at night. Staff V explained that at times the resident used the call light, but he usually got up by himself and went to the bathroom. On 4/5/22 at 9:33 AM, the DON reported that the Resident #190 started to use an alarm after his fall on 9/19/21. The DON stated that she discussed with the staff the need to take the resident back to his room and transfer him right away after meals to his recliner. The DON denied documentation of that, but reported that she did have a discussion to take Resident #190 to his room after meals and transfer him to his recliner. The DON stated Resident #190 propelled himself independently in his wheelchair to his room after meals. The DON denied knowing what Resident #190 did after supper on the night of his fall. The DON stated Resident #190 was incontinent of urine, but didn't know if he had a toileting program, the staff did go in more frequently to assist and encourage Resident #190 to use the toilet. The DON added that the resident would deny the need of assistance from the staff. After his fracture, he required total assistance from the staff. The DON discussed the resident's changes and reminded the CNA's to assist the resident, but denied documentation of the education. The DON reported that the CNA's didn't always read the communication book and a lot of the communication occurred by word of mouth. On 4/5/22 at 10:28 AM Staff W, CNA, stated that the resident had a history of not waiting for staff to assist him with transfers. Staff W added that the resident got up a ton without staff assistance. Staff W reported that the resident did not use his call light and would just get up without help. Staff W declared that Resident #190 was incontinent of urine. Staff W explained that when Resident #190 became incontinent he knew and attempted to take himself to the bathroom. Staff W reported that she usually helped him after meals. Staff W explained that she would assist the resident to his room and transfer him to the recliner after helping him in the bathroom if needed, but didn't think she worked the night of his fall. Staff W remarked that Resident #190 was a fall risk, so she checked him a couple of times. Staff W stated that the resident preferred to go to bed later, and liked to stay up in his recliner. 2. Resident #32's MDS assessment dated [DATE], identified a BIMS score of 12, indicating moderately impaired cognition. The MDS revealed the resident required limited physical assistance of one to two staff for bed mobility, transfers, ambulation, toilet use, and personal hygiene. The MDS coded the resident's balance during transitions and walking as not steady and only able to stabilize with staff assistance. The MDS documented diagnoses of hypertension, [CONDITION(S)] (dizziness), and ataxia (impaired balance). The MDS identified that the resident had a fall in the last month prior to his admission to the facility and one fall with a major injury since admission to the facility. Resident interview On 3/29/22 at 12:45 PM, during the initial tour, observed Resident #32, well-groomed, in his recliner. Resident #32 explained that he attempted to go home the week before on his birthday, just a few weeks ago. Resident #32 explained that it didn't work out because he fell and broke his ribs. After that he came back to the facility. Resident #32 stated that he required assistance from the staff to get up with his walker. An observation showed a urinal in a bucket beside the recliner. Resident #32 explained that he previously fell and got a fracture while at the nursing home, however, he wasn't able to recall the specifics due the length of time that passed. The Baseline Care Plan with an admitted [DATE], identified Resident #32: a. Cognition - alert/cognitively intact b. History of falls - history of a fall resulting in a broken pelvis c. Behavior concern - Resident #32 does get up alone d. Assist of one with bed mobility, transfer, walking, toilet use, and locomotion e. History of falls with injury Progress Notes review On 4/21/21 at 3:41 PM, the Admission Summary identified Resident #32 admitted to the facility from the local hospital. At the time of admission Resident #32 noted to be alert and oriented x 3 (person, place, and time), in good spirits, and accepting of his placement for skilled services. The resident identified with a history of falls and a bed alarm while in the hospital during the night. The resident had [CONDITION(S)] at times and required assistance of 1 with a forward wheeled walker. Resident #32 received orientation to the facility, room, call light, and meal time. On 4/22/21 at 3:06 PM, the Skilled Evaluation identified that Resident #32 obeyed commands and alert and oriented x 3. Resident #32 displayed a pleasant mood without behaviors. On 4/23/21 at 1:20 PM, the Health Status Note (HSN) documented that the aide heard Resident #32, then found him on the floor in the bathroom. Resident #32 denied hitting his head but did complain of pain to his right hip. The head-to-toe assessment revealed no shortening or rotation of his right leg. The staff assisted Resident #32 to his wheelchair with an assistance of three. Resident #32 did not apply pressure to his right leg. The staff notified the son and sent Resident #32 to the local emergency room . On 4/24/21 at 4:12 PM, the HSN revealed that the resident had surgery for a right hip repair. Clinical record review The Fall Investigation - Quality Improvement Document dated 4/23/21, no time, completed by Staff Y, Licensed Practical Nurse (LPN) identified Resident #32 fell in the bathroom. Resident #32 reported that he just fell . The following interventions were reviewed and answered by Staff Y a. Did Resident #32 have a personal alarm, chair alarm, or bed alarm? If Resident #32 used any type of alarm, was it on and functioning? - not applicable b. Was Resident #32's call light on - no c. Was Resident #32's call light in reach of resident - no d. Was Resident #32's Care Plan followed - yes e. Was an assistive device in use - yes f. Was there any environmental hazards present - no The undated Facility Investigation identified a Therapist found Resident #32 on the floor in the bathroom on 4/23/21 at 7:30 AM. The Therapist observed the call light on and notified the nursing personnel immediately of Resident #32's fall. The Rehab Communications dated 4/23/21 indicaed Resident #32 requires staff assistance of one staff with transfers and gait with FWW to patient's tolerance or two to three times daily. The Occupational Therapy Plan of Care dated 4/21/22 documented precautions of a fall risk. Resident #32 required supervision or touching assistance, helper provides verbal cues and/or touching/steadying for mobility toilet transfer. Assistance may be provided throughout the activity or intemittently. The emergency room 's X-Ray report dated 4/23/21 at 11:36 AM revealed Resident #32 had a right femoral neck (a hip fracture involving the thigh bone just below the ball-and-socket hip joint) fracture. Staff Interviews On 4/4/22 at 9:23 AM Staff J, Registered Nurse (RN), confirmed the Baseline Care Plan contained only an admitted [DATE] with undated interventions. Staff J reported the facility implemented a checklist for Baseline Care Plans completed in the resident's electronic health record (EHR). The facility started to use a Baseline Care Plan on the computer, which made it consistent for all staff and dated. Staff J stated that when the Baseline Care Plan was completed on paper, it was a hot mess. Staff J reported the facility nurses were instructed on how to implement fall interventions in the resident's EHR. Staff J remarked that the nurses however, documented the intervention in the resident's progress notes and the MDS nurse added the intervention to the resident's Care Plan in the EHR. Staff J said that when the nurse admits a resident to the facility, they complete the Admit Screener and initiate a Baseline Care Plan, then the Certified Nurse's Aides (CNA) were able to access the Care Plan interventions through the Kardex in the EHR. Staff J explained that with new admissions to the facility, a document titled Admission Care Plan was placed in the CNA's communication book to make the CNA's aware of the new resident needs. Staff J reported being unaware of the fall interventions in place for Resident #32 at the time of his admission on 4/21/21. Staff J reported being unaware of the length of time Resident #32's call light was on before therapy found him on the floor on 4/23/21. Staff J remarked they were unaware if Resident #32 preferred to get up early. Staff J commented that Resident #32 wasn't much of a breakfast person, however, it was possible he was at the time of the fall. On 4/4/22 at 11:10 AM, the MDS Coordinator confirmed that she couldn't determine the dates of interventions on Resident #32's Baseline Care Plan. The MDS Coordinator stated with each new resident's admission a document that provided the information for care was placed in the CNA's binder at the nurse's station. The MDS Coordinator denied knowing how long Resident #32's call light was on before therapy found him on the floor on 4/23/21. The MDS coordinator remarked that due to Resident #32's admission on 4/21/21, the facility staff didn't know the resident's routine, and if he preferred to get up early. The MDS Coordinator added that when Resident #32 returned to the facility on [DATE], the Baseline Care Plan received updated interventions for the admitted [DATE]. The MDS Coordinator confirmed that the facility should have dated the new interventions. On 4/4/22 at 11:30 AM, Staff J stated the CNA received the undated document titled Admission Care plan, at the time of Resident #32's admission on 4/21/21. On 4/4/22 at 12:54 PM, Staff L, RN (the former Director of Nursing, DON), stated at the time of Resident #32's admission to the facility on [DATE], he was alert and oriented x 3. Staff L stated Resident #32 turned on his call light, but didn't wait for staff to assist him to the bathroom. Staff L remarked that Resident #32 told the MDS Coordinator that he thought he could make it to the bathroom by himself and that he should have waited for assistance. Staff L explained that the call light record checked at the time of the fall, showed the call light wasn't on even five minutes. Staff L denied knowing when the report had been printed out. Staff L stated that the CNA's headed to Resident #32's room first thing due to the call light being on. Resident #32 was one of the first residents to get up in the mornings per his preference. Staff L stated Resident #32 used his call light; but he just didn't wait for staff assistance. Staff L denied knowing that Resident #32 got up without assistance before the fall. Staff L denied knowing if Resident #32 was incontinent at the time of the fall. On 4/4/22 at 4:19 PM, Staff M, CNA, said that when Resident #32 first admitted to the facility on [DATE], he was confused and required staff assistance from one person. Staff M stated that the nursing staff reminded the resident to use his call light. Staff M stated she believed Resident #32 had an alarm in place due to a band on his wrist from the hospital, indicating a fall risk. Staff M stated Resident #32 used a urinal beside his recliner and he was continent of urine. On 4/5/22 at 9:27 AM, the DON didn't know how long Resident #32's call light was on at the time of the fall on 4/23/21. The DON denied knowing when therapy completed the screening evaluation for Resident #32. The DON reported that the nurse who completed the Admission Assessment, completed the Admission Care Plan sheet provided to the CNAs. The staff attempted to do a small huddle to review the new admission, however, it didn't always happen. The DON added she implemented starting the Baseline Care Plan in the resident's EHR, connecting it to the CNA's tasks for the new resident.

Based on clinical record review, observations, facility policy review, and staff interviews the facility failed to ensure drugs used in the facility were stored in accordance with the currently accepted professional principles. The facility failed to keep the medication cart locked while not in the direct line of site by the licensed nurse. The facility reported a census of 42 residents. Findings include: During an observation on 3/29/22 at 12:11 PM, observed the North Medication Cart unlocked without nursing staff in the direct line of site. Staff A, Licensed Practical Nurse (LPN), left the medication cart and proceeded into the dining room. At 12:12 PM, Staff A returned to the medication cart. During an observation on 3/31/22 at 7:39 AM, observed the North Medication Cart located at the top of the 300 hall by room [ROOM NUMBER] unlocked. At time of observation, no nursing staff were present at the medication cart. Staff A found in room [ROOM NUMBER] without a direct line of site to the medication cart. The Housekeeper came in and out of room [ROOM NUMBER]. Resident #17 with a BIMS (Brief Interview for Mental Status) score of 6, indicating severe cognitive impairment; ambulated independently past the cart to the end of the hallway. At 7:42 AM the Director of Nursing approached and confirmed that the medication cart was unlocked without nursing staff present. The facility document titled Resident Daily Living Vital Info dated 3/29/22, identified 6 current residents with a wanderguard in place and a high risk for elopement. On 4/5/22 at 9:11 AM, the Director of Nursing stated she expected the medication carts to be locked when the nurse wasn't present and the computer screen to be locked. The DON reported that the facility did not have a policy in place related to the medication cart being locked when unattended.

Based on observations, record review and staff interviews, the facility failed to adequately supervise a resident at high risk for elopement. The resident exited the facility without staff knowledge, which resulted in an immediate jeopardy to the health and safety for 1 of 4 at risk residents reviewed (Resident #8). The facility reported a census of 39 residents. Findings included: A Minimum Data Set (MDS), dated [DATE], revealed Resident #8 admitted to the facility on [DATE]. The MDS identified Resident #8 as independent with transfers and ambulation. The resident did not use an assistive device (walker or cane) to ambulate. Resident #8 had [DIAGNOSES REDACTED]. The resident scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) test indicating moderate cognitive impairment. The MDS identified the resident with disorganized thinking and in-attention behaviors on a continuous daily basis. The MDS identified the behavior of pacing daily and wandering that placed the resident at significant risk of getting to a potentially dangerous place (outside). The wandering also intruded on the privacy of others. The MDS identified the wandering behavior as worse since the previous assessment. A balance during transitions and walking test revealed the resident as not steady but able to stabilize without staff assistance in all areas of testing other than moving on/off the toilet. The resident had 2 or more falls without injury since the prior assessment. The MDS also revealed Resident #8 wore a wander-guard/elopement device on a daily basis. Resident #8's care plan with problem start date of 3/6/19 identified the resident at risk for falls due to poor technique while ambulating and dementia. The approach section of the care plan revealed the resident wandered as a part of his dementia. The care plan directed staff to keep the resident in a safe environment and the resident wore a wanderguard. The care plan also directed staff to intervene if the resident walks too fast. The care plan also revealed the resident may need a different level of care due to his dementia and instructed staff to explore alternative care options with family. Discuss benefits/option to placement settings, arrange for discharge planning conference when assessment by the care plan team recommended a different level of care and complete an elopement assessment quarterly and as needed. Care plan also stated to continue with wander-guard. There were no revisions in the care plan based on the MDS identifying the resident's wandering behavior as worse. An elopement risk assessment, dated 12/5/10 identified the resident with a score of 6 (high risk). Observation showed on 3/9/20 at 11:30 AM the resident walk across the living room area very quickly to the front door in an attempt to follow a visitor out. The surveyor then attempted to leave the facility for lunch. Staff at the desk next to the door stopped the resident at the front door and asked the surveyor to wait for a minute so they could get the resident back to the living room area. The resident stood at the desk area holding on to the desk and a CNA (certified nurse aide) walked the resident to a chair into the living room area. Resident progress notes: 11/1/19 at 4:33 p.m., revealed the resident continued to roam throughout facility during the shift and made several unsuccessful attempts to exit out of doors. 11/9/19 at 4:57 p.m., revealed the resident roamed the hallways per normal for the resident. The resident exit seeking and unsuccessful at exiting the building. 12/10/19 at 5:39 p.m., revealed the resident wandered throughout the facility until mealtime. The resident did not exit seek but continued to go into other resident's rooms, nurses office, and tried to get into the nursing med carts. 12/12/19 at 5:01 p.m., revealed the resident wandered the halls and peeked into other resident rooms. The resident attempted to exit via the front door without success. 12/19/19 at 10:00 p.m., revealed the resident wandered through the halls as usual. Staff could easily redirect the resident. 12/21/19 at 9:57 p.m., revealed the resident wandered and attempted to exit without success. 12/22/19 at 5:48 p.m., revealed the resident wandered and attempted to exit seek without success. An accident/Incident report dated 12/22/19 at 6:45 p.m. completed by Staff Q revealed Staff I (off duty registered nurse) observed the resident in the facility parking lot by the dumpsters while in her car leaving the facility. Staff I pulled back in and got out of her car and brought the resident back into the building. Wanderguard alarm sounding. Review of Resident #8's medical record showed nothing documented regarding the elopement. Resident progress notes did not contain an entry regarding the incident and the record failed to identify staff assessed the resident for injuries or that staff notified the resident's physician or family member. On 3/11/2020 at 9:54 a.m., Staff I Registered Nurse (RN) reported she completed her 6 a.m. to 6 p.m. shift on 12/22/19 and punched out at 6:45 p.m. to go home. She left through the north door and walked across the parking lot to her car. Staff I stated she sat in her car for just a few minutes to make a quick phone call and then started to back her vehicle out of her parking space. Staff I stated as she backed out of the parking space, she happened to look up and see Resident #8 standing in the parking lot near the dumpsters. Staff I stated she immediately pulled her car back into her parking space, got out of her car and walked over to the resident. Staff I took his hand and walked him back into the building. She stated the alarm sounded at the north exit door and she silenced the alarm once inside. Staff I stated she heard the wander guard alarm sounding on the north door prior to reentering the facility with the resident. Staff I also stated no on-duty staff responded to the alarm that sounded on the north door. Staff I stated she went to the north door herself to silence the wander guard alarm and identified the north door area as the only place staff can silence the alarm. Staff I stated she completed a written statement regarding the incident and placed it under the DON's door on 12/23/19. She never heard anything more about the incident or written statement. Staff I stated she did not document the incident in the record because she was off-duty when it occurred. Staff I commented it was a good thing she happened to be in the parking lot at the time. She stated the resident moves fast and would have been long gone had she not been there. Staff I estimated the resident outside 5 to 7 minutes at the most. On 3/30/2020 at 9:38 a.m. Staff I stated the resident wore a long sleeved shirt, jeans and shoes and socks when she observed him outside. The resident didn't say anything about feeling cold. Staff I stated a normal person would have felt cold if they were outside wearing only what the resident wore. On 3/11/20 at 1:00 p.m., the Director of Nursing (DON) revealed that she did not receive Staff I's statement about what occurred on 12/22/20. The DON stated she became DON on 12/12/20 but still shared the office with the previous DON. The previous DON possibly received Staff I's statement. The DON stated she received a call at home from Staff I and then she phoned the Administrator and the previous DON to report staff observed Resident #8 in the parking lot behind the building around 6:45 p.m. in the evening. The DON provided copies of staff statements she received on 3/11/20 (during the survey) regarding Resident # 8 leaving the building unattended on 12/22/19. On 3/11/20 1:24 PM Staff M CNA (certified nurse aide) stated she was in the dining room when she heard the wander guard door alarm go off. She walked to the south door to check it but no alarm sounded at that door. She announced on the walkie that the south door (front door) to the facility was clear and walked to the nurse station area to try to assist the other staff with figuring out how to silence the alarm since they stood looking at the panel. Shortly after this, Staff I returned into the building with the resident and said the resident was outside. Staff I told us how we needed to check and make sure where the residents were. Staff M's CNA statement revealed she worked the evening of 12/22/20 when Resident #8 left the building. Staff M identified self as in the dining room assisting a resident when she heard an alarm sound. Staff M stated she went to the living room door (South door) and then went to the north door and announced on the walkie-talkie to all staff that the doors were clear. Staff M then went back to the alarms panel and Staff I informed her Resident #8 got out of the facility unattended. Staff R's Licensed Practical Nurse (LPN) statement dated 3/11/20, revealed she worked on 12/22/20 and clocked out and left the facility at 6:15 p.m. Staff R was not present when Resident #8 had left the building unattended. On 3/11/20 at 2:08 p.m., Staff Q LPN (agency nurse) stated she worked the evening of 12/22/19 when the resident left the facility. Staff Q stated she responded to the alarm by walking to the alarm panel at the nurse's station. She looked at the panel and did not see any door alarm lights on. Staff Q stated she and Staff N Certified Medication Aide (CMA) stood at the alarm panel at the nurse's station looking for door lights on the panel. A few minutes later, Staff I RN walked into the facility through the north doorway with Resident #8 walking with her. Staff Q stated she did not know what the alarm sound meant and, prior to working at the facility, she did not receive any training at the facility on what different types of alarms they used at the facility. Staff Q stated Staff I RN went to the north door at the service entrance and silenced the wander guard alarm. Staff Q stated she called the DON (current DON) at home and updated her on the incident regarding Resident # 8 getting out of the building and observed in the parking lot by Staff I. Staff Q stated that the CNAs working at the facility that evening did not respond to the alarm and did not check the doors either. On 3/11/20 at 6:23 p.m., Staff L CNA revealed she arrived to work at the facility on 12/22/20 at 6:00 p.m. Staff L stated when she heard the alarms sounding, she went from door to door to try to determine what door alarm activated. Staff L stated when she walked towards the center area by the nurse's station, she saw 2 staff coming back into the building from the north door with Resident #8 walking with them. Staff L stated she did not know if the alarm that activated was a regular door alarm or if it was a wander-guard alarm. Staff L stated she did not receive training to know the difference between the different door alarm sounds at the facility. On 3/12/20 at 10:32 a.m., Staff N CMA (certified medication aide) revealed she worked at the facility on 12/22/19 at 6:45 p.m. when Resident #8 eloped. Staff N stated she just started her shift at 6:30 p.m. and received report and proceeded to conduct narcotic count, when an alarm went off. Staff N stated the alarm was a very loud constant buzzing noise and when she looked at the alarm panel at the nurse's station with Staff Q, they could not determine what door was alarming since the panel did not contain any lights lit up. Staff N stated she just completed her training at the facility and identified the night of the elopement as the first night she worked on her own. She stated she did not receive training to know the difference between the different door alarms the facility had. She stated that while she stood at the panel with Staff Q, Staff I came into the building through the north doorway with Resident #8 walking with her. Staff I stated she assumed Resident #8 followed Staff I out the north door and that Staff I then brought the resident back into the building. On 3/12/20 at 10:52 a.m., the State of Iowa Climatologist identified the weather conditions in Coon Rapids on 12/22/20 at approximately 6:45 p.m. He identified the temperature as 43 degrees with a wind chill of 35 degrees. The winds were from the SSW at 17 miles per hour. There were low clouds and zero precipitation and visibility was 10 miles. On 3/12/20 at 6:07 p.m. Staff K CNA stated she worked the evening of 12/22/19 when the resident eloped. Staff K stated she heard an alarm sound as she assisted a resident in bathroom. Staff K stated she could not leave that resident, so she could not respond to the alarm right away. Staff K stated after she finished assisting the resident out of the bathroom, she responded to the nurse's station where the alarm sound came from. When Staff K arrived at the nurse's station, she stated all of the staff on duty stood around talking about Resident #8 getting out of the building and Staff I bringing him back into the building. Observation of elopement area : Starting at the alarm panel where Staff Q stood looking at the alarm panel, immediately to the right of the panel was a short hallway approximately 20 feet long containing 2 doorways on the right side. The short hallway contained a doorway (2nd door on the right), which was just a regular door without any type of an alarm on it. After getting through that door, there was a short hallway approximately 15 feet in length. At the end of that hallway, was the north exit that led outside, from which the resident eloped. This doorway contained the wander-guard alarm key pad. (The keypad to the right) and the regular door alarm is located on the left with keypad for the regular door alarm. Once out the north door is the parking lot area that contains a partially covered, awning like area where the food deliveries, ambulance etc. do pick-ups and deliveries for goods and services and for residents at the facility. Several staff referred to this area as the service entrance area. This area is all concrete and level. Continuing to walk north towards the garage/shed area (approximately 150 feet), is where there are 3 large dumpsters and where the off duty staff member observed the resident on the night of 12/22/20. The entire parking lot is a paved concrete area. Behind the garage area is the street where the staff member was parked when she saw the resident standing by the dumpsters. To the immediate left of the awning area is a driveway that connects the parking lot and then 100 feet to the side street. The facility generator is also located to the left side next to the driveway area. The posted speed limit is 25 mph. The facility is surrounded on 3 sides by streets and sits on 1 city block. The other ½ of the building is the attached clinic and the assisted living. An undated facility policy titled Elopement Policy revealed the facility strived to prevent elopement of resident's from the facility. The policy defined elopement as when a resident exits the facility undetected and assessed as unsafe to leave the facility unattended. Steps included: a. The facility would assess all residents for elopement risk upon admission and quarterly thereafter to determine if they are at risk for elopement. b. The facility would place a wander-guard bracelet (a signaling device that a resident has left the building) on residents determined at risk for elopement. c. Charge nurses are responsible to see that the wander-guard is placed on the resident initially and will document each shift that the bracelet is in place. d. The maintenance department checks and documents daily that all facility door alarms, wander-guard door alarms, and bracelet function of residents function correctly. They will report any malfunctions of these systems to the Administrator and the Director of Nursing (DON). e. Signs are posted at each exit to remind families/visitors to not let any residents exit the building without the assistance of a staff member. f. The facility will notify all families on admission and at least yearly to not assist any resident to leave the facility. g. When a door alarm sounds, staff members will immediately check the exit indicated by the indicator lights at the nurse's station. h. Staff will redirect any resident attempting to leave the building if possible and to return to the facility. i. If it is determined that a resident is missing, staff shall follow the missing resident procedure. j. Any resident who elopes will have their care plan re-evaluated by the DON or care plan team members. k. The Quality Improvement Committee will evaluate all elopement investigations and reports for the circumstances surrounding the elopement and for possible changes needed in facility systems and procedures. During an interview with the Administrator on 3/18/20 at 9:50 a.m., he reported he discussed the elopement with the former DON and she informed him Resident #8 exited the facility and Staff I accompanied the resident throughout the entire incident. Abatement: The facility abated the immediate jeopardy on 3/17/2020 following completion of an agency employee orientation checklist and training video and education of all staff regarding the alarms in use at the facility and procedure for responding to alarms. Surveyors verified corrections were in place prior to exit.

Based on clinical record review and staff interview the facility failed to provide adequate supervision to prevent accidents for 1 of 10 current residents reviewed (Resident #4). The facility reported a census of 47. Findings include: A Care Area Assessment (CAA) dated 11/12/14 for ADL function status documented Resident #4 had dementia and needed assist with ADL's due to weakness and safety. Resident #4 was up ad lib in his/her room except the bathroom and transferred or ambulated with assist of 1 out of the room with the front wheeled walker. A CAA for falls documented Resident #4 had a history of [REDACTED]. Resident #4 was up ad lib throughout the facility with the front wheeled walker except for bathroom privileges. They had multiple approaches in place on the care plan. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS documented Resident #4 required extensive assistance with activities of daily living (ADL's) including dressing and toilet use and limited assistance with transfer and ambulation. Resident #4's [DIAGNOSES REDACTED]. Resident #4 had 2 falls since the last assessment period with injury (other than major). The Care Plan with a start date of 11/02/12 and a goal target date of 09/07/15 identified Resident #4 with a history of multiple falls at home with no injury. Resident #4's family wanted him/her to be independent without alarms and happy versus with alarms and depressed. They understood he/she could fall with injury. The approaches included: a. Infrared alarm set to sound when in bed dated 01/16/15. b. To pull bedding back around 2 p.m. daily dated 11/10/14. c. Personal alarm by bathroom door to alert staff when going to the bathroom. d. Liked to go to bed shortly after supper dated 06/27/13. e. Signs posted in room and on walker in Polish to remind to use the walker. f. Toilet with a.m. and bedtime cares, between meals and at Resident #4's request. g. Transfer/ambulate with assist of 1 with the front wheeled walker or hand held assist to the bathroom. Up ad lib in room and facility otherwise with front wheeled walker. A Risk Assessment for Falls dated 06/07/15 scored Resident #4 at 23 indicating extremely high risk of falls. The assessment scored Resident #4 at a 4 for gait and balance, indicating unsteadiness, and poor balance standing or walking. Event Reports showed Resident #4 with a history of falls on the following dates, all in his/her room: 10/09/14 at 3:45 p.m., 10/20/14 at 4:00 p.m., 12/17/15 at 6:20 p.m., 01/02/15 at 1:30 p.m., 01/13/15 at 11:10 p.m., 03/17/15 at 3:20 p.m., 03/24/15 at 2:45 a.m., 04/11/15 at 4:45 p.m., and 06/08/15 at 7:15 a.m. The Event Report dated 03/24/15 at 2:45 a.m. documented the sound of a walker wheel heard by staff. Staff walked to Resident #4's room and found him/her laying face down, right arm stuck on the walker, with the walker still standing. Staff assisted Resident #4 out of the walker, and he/she had trouble following requests by staff. Resident #4 had a bruise to the left leg below the hip 4 by 2 cm, and a red area on the left knee 9 by 8 cm. The report failed to address if the infrared alarm was on and functioning at the time of the fall. During an interview on 10/14/15 at 5:55 p.m. Staff E Licensed Practical Nurse (LPN) stated he could not remember details of the fall (3/24/15). Staff E stated if the infrared alarm were on, it would trigger the call light on. He said the call light would beep at the nurse station and staff would respond to it. Staff E stated if they had responded to the call light he would document it on the fall report. Staff E stated if the call light came on it would be from the infrared alarm because Resident #4 did not use the call light. During an interview on 10/14/15 at 11:24 a.m. the Assistant Director of Nursing (ADON) confirmed the event report did not document if the alarm was on and functioning the night of the 03/24/15 fall (as directed on the care plan). A Physical Therapy (PT) Plan of Care with a start of care date of 03/27/15 identified Resident #4 referred due to a recent decline in functional mobility due to illness. Resident #4's prior level of function included supervision with gait on level surfaces, and modified independence (assistive device or extra time needed) with transfers. Resident #4's level at the start of care (03/27/15) included moderate assistance (26-75% assist) with gait on level surfaces and moderate assist of 2 for transfers. The long term goal included Resident #4 would transfer in his/her room excluding the bathroom with the front wheeled walker and modified independence to return to prior level of function. A PT Therapist Progress and Discharge Summary with a start of care 03/27/15 and end of care 04/24/15 documented the goal for Resident #4 to transfer in his/her room excluding the bathroom with the front wheeled walker and modified independence (assistive device or extra time) to return to prior level of function remained unmet, and Resident #4 did not make significant progress toward goals. Complicating factors including cognition prevented Resident #4 from achieving established goals. A Rehabilitative Screen dated 06/03/15 documented Resident #4 assist of 1-2 with transfer and ambulation with the front wheeled walker. The Care Plan continued to reflect Transfer/ambulate with assist of 1 with the front wheeled walker or hand held assist to the bathroom, up ad lib in room and facility otherwise with front wheeled walker. The Resident Progress Notes documented the following: a. On 07/06/15 at 4:42 a.m. Resident #4's a.m. dose of APAP (Tylenol) given at that time for a low grade temp. Resident #4 had an occasional, nonproductive cough, b. On 07/11/15 at 11:33 a.m. Resident #4 with cough in the a.m. Resident #4's temp 98.4 degrees, and lung sounds diminished bilaterally. Oxygen saturations 94% on room air. Resident #4 received PRN (as needed) nebulizer treatment and cough syrup and helped. Extra fluids given, appetite poor. c. On 07/12/15 at 11:04 a.m. Resident #4 with an occasional productive cough, clear sputum, Temp 98.2 and lung sounds diminished bilaterally with oxygen saturations at 95 % on room air. PRN nebulizer treatments and cough med effective. d. On 07/16/15 at 9:03 a.m. Resident #4 had an occasional productive cough of clear sputum. Temp 97.8, and lung sounds clear bilaterally. PRN nebulizer and cough medicine given. e. On 07/17/15 at 4:36 a.m. Resident #4 had an occasional productive cough noted during the shift. PRN cough med given and effective. The Restorative Nursing notes dated 07/14/15 documented Resident #4 getting much weaker. He/she had a deep cough and did not have much of an appetite. Resident #4 did exercises, but tired out easily. Resident #4 had not been walking too far. An Event Report dated 07/17/15 at 8:04 p.m. documented Resident #4 had a fall in his/her room. The report indicated staff found Resident #4 on the floor at 8:00 p.m Staff notified the physician at 8:30 p.m., and the family at 8:40 p.m. Resident #4 left the facility by ambulance at 8:50 p.m. On 07/18/15 at 1:05 a.m. staff received a call from the emergency room nurse reporting Resident #4 admitted for a left high humerus fracture, urinary tract infection and possible pneumonia. A History and Physical dated 07/18/15 documented Resident #4 fell in his/her room, hurt his/her shoulder, transferred to the emergency room , and found to have a fracture. Physical exam showed the left upper extremity in a sling, if pain at all to shoulder listed severe pain. There were deformities and swelling to the left shoulder. The assessment and plan included a left shoulder fracture. They would leave Resident #4 in the sling and start range of motion after several weeks and make sure good analgesia. Resident #4 had questionable pneumonia. An Imaging Report dated 07/17/15 revealed Resident #4 had a moderately displaced, impacted, comminuted fracture of the surgical neck of the proximal left humerus. The report also indicated Resident #4 had a left lung base small pleural effusion (excess fluid in the space surrounding the lung) and adjacent atalectasis (collapse of part of the lung). A PT Plan of Care dated 07/27/15 documented Resident #4 referred following a fall in his/her room and sustaining a left humerus fracture. Resident #4 wore a sling on the left, and it would remain immobilized for several weeks. The plan documented Resident #4 had physical therapy earlier in the year, however unable to make progress secondary to dementia. Resident #4 reported severe pain of the left upper extremity. During an interview on 10/14/15 at 11:24 a.m. the Assistant Director of Nursing confirmed the facility had no investigation regarding Resident #4's falls (other than the information on the event reports). She also confirmed Resident #4 had a cough (prior to the fracture) and they administered cough syrup and assessed. They did not notify the physician. The clinical record lacked documentation of family notification of Resident #4 experiencing cough and weakness, or any evaluation of his/her functional mobility needs related to the change in condition. During an interview on 10/14/15 at 9:24 a.m. Staff A Certified Nursing Assistant stated prior to Resident #4's fall with the fracture he/she did not feel well and was weak. Resident #4 was not doing much (at that time). He/she would wave at staff when they walked by his/her room, for assistance. Staff A stated Resident #4 had a cough and weakness and she reported to the charge nurse, but unsure which one. Staff stated Resident #4 did not use the call light. During an interview on 10/12/15 at 4:45 p.m. Staff D Registered Nurse (RN) stated Resident #4 got up him/herself the night he/she fractured his/her shoulder. Staff D did not find Resident #4, but he/she said he/she was on the way to the bathroom, and fell beside the bed. Staff D thought staff had toileted Resident #4 after supper and then he/she sat in the chair. Staff D stated being fairly new, but thought Resident #4 was used to getting up in his/her room. Staff D stated not being aware of anything going on (with Resident #4). During an interview on 10/12/15 at 5:04 p.m. Staff C CNA stated after supper she took Resident #4 to his/her room, to the bathroom, and then he/she sat in his/her chair, it was too early to go to bed. She could not say the exact time, maybe around 7 p.m. She was not aware of anything going on with Resident #4. During an interview on 10/14/15 at 11:35 a.m. Staff B CNA stated the night Resident #4 fell and hurt his/her shoulder she heard someone yelling for mama, and went to find where it came from. Staff B found Resident #4 on the floor by his/her bed. Resident #4 told Staff B he/she tried to get up. Staff B thought Resident #4 tried to get ready for bed, and the bed (covers) had not been pulled back, and he/she fell beside the bed. Resident #4's walker sat by the window, not in Resident #4's reach where he/she fell beside the bed, but thought it would be within reach from the chair. Staff B stated Resident #4 was wobbly without the walker. She said some days Resident #4 walked well and sometimes he/she did not, and he/she did better with the walker. Staff B stated Resident #4 got tired by the end of the evening and needed more help. Resident #4 liked to go to bed early.

Based on clinical record review and interviews, the facility failed to follow the physician's order [REDACTED].#3 ' s [MEDICATION NAME] ([MEDICATION NAME]- anticoagulant) medication on 2/13/14. Record review identified Resident # 3 sustained continued bowel movements with visual blood present at times between 2/13/14 to 2/17/14, and the clinical record lacked accurate assessment and timely intervention when these incidents occurred. Resident #3 received 5 units of blood during his/her hospitalization on [DATE] and the physician documented the cause of the bleeding had been related to the [MEDICATION NAME] therapy. Concerns were identified for one (1) of nine (9) residents reviewed. Additionally, based on clinical record review and staff interview, the facility failed to adequately plan for and/or attempt alternate interventions prior to the administration of an antianxiety medication for 2 of 9 active residents reviewed (Resident #3 and #8). The facility reported a census of 38 residents. Findings included: A Minimum Data Set (MDS) assessment with a reference date of 1/15/14 identified the resident's mental status as fully intact. The same assessment revealed the resident required assistance from staff with toilet use and personal hygiene, identified the resident as always continent of bowel and required [MEDICAL TREATMENT] services. The MDS identified the resident's birthday of 8/13/39 ([AGE] years of age at the time). a. A facility 2013 Edition Delmar Nurses Drug Handbook included the following information in regards to [MEDICATION NAME]: [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding. Risk factors for bleeding include high intensity of anticoagulation (INR of more than 4), [AGE] years of age or older, hypertension, cardiovascular disease and renal function impairment. Geriatric clients over the age of 60 are at increased risk for bleeding. The handbook revealed the most common side effects of [MEDICATION NAME] therapy as hemorrhage (bleeding) and included symptoms of headache, difficulty in breathing, dizziness, hypertension (low blood pressure) and abdominal or back pain. According to a Physician order [REDACTED].#3's [DIAGNOSES REDACTED]. The same Physician order [REDACTED]. Review of a laboratory report form dated 2/3/14, Resident #3's International Normal Ratio, INR (- a blood test standardizes the results of a [MEDICATION NAME] time test) revealed a high test result of 3.7. According to the laboratory form, a normal INR ranged between 2.0 and 3.0. According to a Physician telephone order dated 2/4/14, a Physician held the resident's [MEDICATION NAME] on 2/4/14 (due to the INR results of 3.7). The same order instructed staff to start [MEDICATION NAME] 6 mg every day beginning 2/5/14. A Physician telephone order dated 2/13/14, included an order for [REDACTED]. Note: Even though the Resident's Physician ordered the [MEDICATION NAME] to be placed on hold, review of a Medication Flowsheet dated 2/1/14 - 2/28/14 revealed staff continued to administer the resident's [MEDICATION NAME] every day between the dates of 2/13 - 2/16/14. The resident required hospitalization on [DATE] as explained below. Review of nursing progress notes and vital sign report forms between 2/13/14 and 2/17/14 revealed the following: 2/13/14 (Thursday) at 5:44 a.m. : staff documented being called to the resident's room at 4:00 A.M. due to the resident having a medium loose bloody stool in his/her bed. Staff documented the resident as being assisted to a bathroom, had a very large watery brown/red stool and the resident complained of his/her stomach feeling as though on fire. Staff documented at 4:20 a.m., the resident again needed to use the bathroom stool and had a second watery brown/red stool. Staff documented the resident declined being seen in the emergency room and requested to see his/her Physician the next day. Further record review revealed staff failed to document any vital signs such as temperature, pulse, respirations, blood pressure or abdominal/back pain. 2/13/14 at 11:05 a.m. : staff documented the resident's son/daughter notified and the family member requested the resident be seen by his/her family Physician. Staff documented the resident as not being able to be seen in the Physician's clinic until 3:45 P.M. on 2/13/14. 2/13/14 at 11:17 a.m. : staff documented speaking to the resident's Physician and the Physician felt the resident's rectal bleeding may be from hemorrhoids. Staff documented the resident as not needing to be seen on 2/13/14 by his/her Physician but rather the Physician ordered stool specimens for [MEDICAL CONDITION], ova and parasites as well as referral to a surgeon for a colonoscopy. Staff documented "...will hold [MEDICATION NAME] over weekend..." 2/13/14 at 2:00 p.m. : staff documented the resident's son/daughter updated with the physician's wishes. 2/13/14 at 9:29 p.m. : staff documented the resident's appointment with a surgeon (scheduled for 2/10/14). 2/14/14 (Friday) at 10:00 p.m. : staff documented the resident had several loose stools in the afternoon, at times being incontinent. Staff documented the resident had a moderate emesis at approximately 8:30 p.m. and described the resident as afebrile (without elevated body temperature). Staff failed to document any further assessment of the resident such as respirations, pulse, abdominal/back pain and failed to describe the resident's loose stools either with our without blood or abnormal color. 2/15/14 at 12:28 p.m. : staff documented the resident stated he/she had several loose stools throughout the night and documented the resident had one loose stool since he/she arose for the day on 2/15/14. Staff documented the resident's temperature as 97.9 degrees at 1:22 p.m., but failed to complete any further assessment such as respirations, pulse, abdominal/back pain or color of the resident's loose stool. 2/15/14 at 9:37 p.m. : staff documented the resident with a loose stool after supper with a moderate amount of bright red blood in the stool and denied abdominal pain. Staff failed to complete any assessment of the resident's vital signs and failed to document the resident's physician being updated of the ongoing blood in his/her stool. 2/16/14 (Saturday) at 2:31 p.m. : staff documented the resident had a soft stool with no blood present upon arising, a small loose stool with no blood present after lunch and the resident complained of lack of appetite. Staff documented the resident's temperature as 98.9 degrees at 2:41 p.m. 2/16/14 at 10:01 p.m. : staff documented the resident had one small loose stool with slight blood present after supper and no further assessment documented. 2/17/14 (Sunday) at 7:36 a.m. : staff documented the resident as transferred to a hospital via ambulance related to [MEDICAL CONDITION] activity and unresponsiveness. The document lacked any further assessment of the resident's condition prior to the resident's transfer. 2/17/14 at 12:47 p.m. : staff documented the resident as admitted to the hospital under acute care for a blood transfusion. Review of a hospital record report dated 2/17/14, a physician documented the resident presented to the emergency room (ER) after a "...spell..." at the facility and became unresponsive while being propelled in a wheelchair. The physician documented the resident as being "out" for approximately 5 minutes and appeared gray in color. The document revealed the resident's hemoglobin level as low at 6.9 (normal 12.0 - 16.0) and the resident's INR as high at 7.3. The Physician documented the resident with a probable [MEDICAL CONDITIONS] episode, lower gastrointestinal (GI) bleeding with [MEDICAL CONDITIONS] [MEDICAL TREATMENT] and excessive anticoagulation. The Physician documented the resident admitted to the hospital for observation. Review of a Physician report form dated 2/18/14, revealed a Physician documented the resident received 2 units of blood on the day of admission to the hospital. The resident ' s [MEDICATION NAME] will be held and INR will be repeated. Review of a Physician report form dated 2/21/14 revealed a Physician documented the resident received an initial 2 units of blood, received an additional 3 units of blood on 2/19 for a total of 5 units of blood. The Physician documented surgery as being consulted during the resident's hospitalization and documented the cause of the bleeding secondary to [MEDICATION NAME] therapy. The resident would remain off the [MEDICATION NAME] and will remain on aspirin on a regular basis. During interview on 9/4/14 at 7:30 A.M., Staff A, Registered Nurse, stated if a Resident presented with blood in the stool, she needed to check and document vital signs and any pain present, document how much blood in the stool and if the blood was fresh or dark. Staff A stated if the resident continued to have blood in his/her stool after a Physician had initially been notified of the blood in the stool , she needed to call a Physician again to report the continued bleeding. During interview on 9/4/14 at 9:40 A.M., Staff O, Licensed Practical Nurse stated if a Resident presented with blood in the stool, she needed to check and document the color and consistency and the stool and check and document vital signs. Staff O stated if a Resident continued to have loose stools after an initial bloody stool, she needed to check and document the color of the stool (re: blood present). During interview on 9/4/14 at 8:25 A.M., the facility Director of Nursing (DON) confirmed staff failed to place the Resident's [MEDICATION NAME] on hold on 2/13/14 and the Resident continued to receive the [MEDICATION NAME] between 2/13 - 2/16/14 until he/she required hospitalization . The DON stated she expected nursing staff to document vital signs, pain. color of loose stools, etc. if a resident presented with blood in the stool. The DON confirmed the resident's record lacked documented assessment of the resident's condition on 2/17/14 prior to transfer to a hospital. During telephone interview with Resident #3's physician's nurse on 9/4/14 at 10:10 A.M., the nurse reported the resident's physician stated she expected nursing staff to hold the resident's [MEDICATION NAME] beginning 2/13/14 as ordered through the weekend of 2/17/14. b. The MDS assessment dated [DATE] documented Resident #3's [DIAGNOSES REDACTED]. The resident continued to have fully intact memory and cognitive abilities. The assessment documented Resident #3 experienced feeling tired or with little energy on half or more days during the assessment period. The resident experienced trouble sleeping and appetite concerns during 2 - 6 days of the assessment period. The resident also experienced shortness of breath with exertion. A Physician order [REDACTED].#3 began taking the [MEDICATION NAME] on 1/15/14. Resident #3's Care Plan dated 3/5/13 lacked documentation in regards to the resident's anxiety and the use of PRN [MEDICATION NAME]. The Care Plan contained no direction for staff to attempt alternative interventions prior to the use of the PRN [MEDICATION NAME]. Review of a June, 2014 PRN Medications Flowsheet and PRN Medication Record revealed Resident #3 received PRN [MEDICATION NAME] 0.5 mg for anxiety, sleep or restlessness on the following dates: June 3, 15, 17, 19, 22, 23, 27 and 29. Review of a Behavior/Intervention Flow Chart form and Nursing Progress Notes dated June, 2014 revealed with 5 PRN administration times, did staff offer alternative interventions prior to the use of PRN [MEDICATION NAME]. Record review revealed staff administered PRN [MEDICATION NAME] 3 times without alternative interventions attempted prior to use. The medication records/progress notes revealed staff documented the resident received PRN [MEDICATION NAME] for anxiety and to promote sleep. Review of a July PRN Medications Flowsheet and PRN Medication Record revealed Resident #3 received PRN [MEDICATION NAME] 0.5 mg for anxiety, nerves or sleep on the following dates: July 1, 6, 7, 10, 11, 12, 14, 16, 18, 21 (twice), 25, 26 and 30. Review of a Behavior/Intervention Flow Chart form and Nursing Progress Notes dated July, 2014 revealed only with 4 PRN administration times, did staff offer alternative interventions prior to the use of PRN [MEDICATION NAME]. Record review revealed staff administered PRN [MEDICATION NAME] 9 times without alternative interventions attempted prior to use. The medication records/progress notes revealed staff documented the resident received PRN [MEDICATION NAME] for nerves and anxiety. Review of an August PRN Medications Flowsheet and PRN Medication Record revealed Resident #3 received PRN [MEDICATION NAME] 0.5 mg for anxiety, nerves, restlessness or sleep on the following dates: August 6, 7, 9 (twice), 11, 12, 13, 14, 17, 18 ,19, 21, 26, 28 and 31. Review of a Behavior/Intervention Flow Chart form and Nursing Progress Notes dated August, 2014 revealed only with 2 PRN administration times did staff offer alternative interventions prior to the use of PRN [MEDICATION NAME]. Record review revealed staff administered PRN [MEDICATION NAME] 13 times without alternative interventions attempted prior to use. The medication records/progress notes revealed staff documented the resident received PRN [MEDICATION NAME] for nerves, anxiety and to promote rest. During interview on 9/4/14 at 7:30 A.M., Staff A, Registered Nurse stated at the time a resident requested a PRN [MEDICAL CONDITION] medication, she first attempted alternative interventions prior to the administration such as talking, offering the use of the toilet or an activity or to assess the resident for pain. During interview on 9/4/14 at 9:40 A.M., Staff O, Licensed Practical Nurse, stated at the time a resident requested a PRN [MEDICAL CONDITION] medication, she first attempted alternative interventions prior to the administration such as visiting, giving the resident a warm blanket or offering the use of the toilet. During interview on 9/4/14 at 8:05 A.M., Resident #3 stated staff don't offer other intervention before giving [MEDICATION NAME]. The resident asked for back rubs at times and one staff person always accommodated the request. Resident #3 stated at the times he/she feels anxious, if nursing staff offered a back rub prior to the use of PRN [MEDICATION NAME] he/she would try a back rub prior to [MEDICATION NAME] use. During interview on 9/4/14 at 8:25 A.M., the facility Director of Nursing (DON) stated she expected staff to attempt non-pharmacological interventions prior to the use of PRN [MEDICATION NAME]. The DON stated the resident's care plan needed to include ideas or approaches to be attempted prior to the use of PRN [MEDICATION NAME]. According a facility 2013 Edition Delmar Nurses Drug Handbook, a special concern included use with caution of a person with impaired renal function in the geriatric client. The handbook included nursing implications/assessment to note reasons for therapy, onset of symptoms, behavioral manifestations and/or clinical presentation. 2. The MDS assessment dated [DATE] documented Resident #8 had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS score of 1 indicating severe cognitive and memory impairment. The resident displayed behavioral physical symptoms not directed at others on 1 - 3 days during the assessment period. Review of a care plan revealed a problem dated 10/18/12 with a dementia, that the resident takes antianxiety and antidepressant medications. The resident gets forgetful and may decide to leave without telling anyone; she/he gets restless after their spouse or family visits and believes that he/she needs to go banking, farming or fix something. The care plan instructed the staff to redirect the resident, walk with the resident, talk calmly, leave him/her alone and try later and/or try a different staff person. Review of the Medication Flowsheet for 8/1/14-8/31/14 documented a physician order [REDACTED]. Review of the PRN Medication Record form revealed staff administered [MEDICATION NAME] 0.5 mg orally for anxiety or restlessness on: 8/2/14 at 10:25 PM; 8/3/14 at 12:45 AM; 8/3/14 at 3:00 AM; 8/3/14 at 8:30 AM; 8/3/14 at 3:00 PM; 8/6/14 at 6:00 PM; 8/11/14 at 9:00 AM; 8/12/14 at 2:45 AM; 8/17/14 at 7:45 AM; 8/28/14 at 2:00 AM; 8/29/14 at 3:30 AM; 8/31/14 at 7:20 AM; 9/3/14 at 12:40 AM. Review of the Behavior/Intervention Flow Chart documented for August 2014 revealed lack of non-pharmacological interventions prior to administration of antianxiety medications. Review of progress notes dated 8/20/14 - 9/3/14 revealed no specific behaviors and interventions in every instance correlating to the administration of PRN [MEDICATION NAME] during this period.