Every finding on record at Trinity Center at Luther Park

Based on clinical record review, staff and family interviews, and facility policy review, the facility failed to maintain a complete and accurate medical record for 1 of 5 residents whose Electronic Health Records (EHR) were reviewed (Resident #5). Following a fall, the facility failed to document the incident in the EHR of Resident #5. The facility reported a census of 115 residents. Findings include:The Minimum Data Set (MDS) Assessment of Res #5 dated 4/16/26 documented the resident to be severely cognitively impaired. The MDS recorded a prior history of the resident having falls. The Care Plan of Resident #5 identified a Focus category of potential for falls. It directed staff that should a fall occur, to follow post fall policy. A review of the Assessment Section of the Resident's EHR recorded post fall evaluations of falls which occurred on 4/17/26 and 5/8/26, with no further evaluations documented. A review of Progress Notes for Resident #5 revealed no documentation of any falls after 5/8/26.On 8/25/26 at 12:44 pm, a family member of Resident #5 stated the resident experienced a fall from bed on 7/6/26, the day she returned to the facility following a hospitalization. On 8/25/26 at 2:11 pm, the admission Nurse for a contracted hospice company confirmed she was in the facility re-enrolling Resident #5 into hospice following her hospitalization. She also stated the resident fell from her bed during the time frame the nurse was in the facility on 7/6/26 and she informed the unit nurse of the fall. She also stated the facility nurse administered comfort medications of morphine and ativan (pain medication and anxiety medication) to the resident after the fall. According to the 6:00 am to 2:00 pm staff schedule for 7/6/26, Staff A (LPN) and Staff B and Staff C (both CNAs) were assigned to the unit where Resident #5 resided. On 8/25/26 at 2:25 pm Staff A, LPN stated she was not notified of Resident #5 having a fall on the day she was readmitted from the hospital and was unaware of her having any fall. She confirmed she was on duty that day and participated in the admission process of Resident #5. On 8/26/26 at 10:08 am, Staff B, CNA confirmed she was one of two CNAs on duty the day of the fall who assisted Resident #5 back into bed. She stated she had just checked on Res #5 a short time earlier, and then Staff C, CNA informed her of the fall. She stated they went and informed Staff A, LPN who was going to assess the resident, and she and Staff C transferred the resident back into her bed following the fall. On 8/26/26 at 3:04 pm, the Assistant Director of Nursing (ADON) confirmed Resident #5 had a fall on 7/6/26. She stated she was the first staff member to observe the resident just after she fell and she notified a staff CNA to go tell Staff A, LPN about the fall. She stated at the time of the observation, she was rounding with the wound care provider and another staff member was a short distance away who she notified of the fall. She also notified the hospice nurse and a family member of the resident who were in the hallway of the fall and she then continued her rounding with the wound care physician. The ADON was asked if she was able to provide any documentation of the resident's fall as none had been located in the resident's EHR. On 8/26/26 at 3:19 pm, the ADON stated she also was unable to locate any documentation of the fall in the resident record. She added she had called Staff A and left a message for her to call her back. On 8/26/26 at 3:39 pm, Staff A returned the call to the ADON. During a second interview with the State Surveyor, Staff A stated she had previously not remembered Res #5's fall but now did recall it. She stated she was told the resident was on the floor and she did attempt to assess the resident but the family member of the resident refused to allow her to assess the resident due to her being at the end of life. She said she had failed to document the fall because it was a busy shift. She recalled the family member asking why she was taking vital signs on a hospice resident and she explained it was policy to check vital signs after a fall. She recalled the family member was upset and wanted the resident transferred back to the bed and given medications. She stated she administered the resident medications and did a follow up check half an hour later. She felt she had passed the information onto the next shift but stated the fall may not have been listed on the 24 hour report (a daily communication log used for tracking resident updates, changes, etc). Staff E, Registered Nurse (RN) came on duty at 2:00 pm on 7/6/26 on the unit Resident #5 resided on. On 8/26/26 at 10:19 am, Staff E stated she received no report from Staff A, LPN informing her of Res #5's fall on 7/6/26 so therefore did no fall follow up assessments. The Medication Administration Record (MAR) of Resident #5 for July 2026 revealed no documentation of Staff A, LPN administering any medications to the resident on 7/6/26. Morphine and ativan were not recorded as being administered until the 2:00 pm to 10:00 pm shift by an alternate staff member. No documentation of a notification of the fall to a medical provider was located in the Electronic Health Record. On 8/26/26 at 3:47 pm, the ADON stated her expectation is for a risk management report to be completed, and a post fall assessment to be completed after any fall. She stated even if there are refusals by the family of completing an assessment, the fall still needs to be documented in the clinical record. The facility policy titled Fall Prevention/Risk Assessment, review date 10/15/24 documented the following: Point 9: When any resident experiences a fall, the facility will:Assess the resident.Complete a post-fall assessment.Complete an incident report.Notify physician and familyReview the resident's care plan and update as indicatedDocument all assessments and actionsObtain witness statements in the case of injury

Based on observation, clinical record review, resident, staff and family interviews and facility policy review, the facility failed to uphold a resident's right to dignity and respect for 1 of 3 residents (Resident #1) reviewed. Staff did not offer Resident #1 choice in her care, opting to utilize a mechanical lift for all transfers between her bed and wheelchair rather than facilitating toilet transfers. This approach resulted in the resident becoming incontinent of bowel and bladder, despite her ability to remain continent when provided with toileting assistance. The facility reported a census of 115 residents. Findings include: The Minimum Data Set (MDS) of Resident #1 dated 8/7/26 documented diagnoses including aphasia (the inability to produce speech) and stroke. The MDS documented that the resident had modified independence (some difficulty with new situations only) for cognitive skills for daily decision making. The Care Plan of Resident #1 identified a Focus Area of occasional bowel and bladder incontinence, revision date 9/12/25. The Care Plan directed staff to toilet the resident at routine times, dated 9/12/25. The Care Plan identified an additional Focus Area of self care performance deficit related to a prior stroke, revision date 5/28/2019. The Care Plan directed staff that the resident is alert and oriented but has an inability to speak clearly and when communicating with her, to ask her yes/no questions which she can readily answer, dated 7/17/26.The Care Plan additionally directed staff for toileting, to transfer Resident #1 to the toilet with a pivot disc with the assistance of one staff member.For other transfers such as to and from her wheelchair and bed, the Care Plan directed staff to use two staff assistance with the pivot disk and if the resident was unable, then to use a full body mechanical lift for transferring. On 8/24/26 at 4:05 pm, the son of Resident #1 expressed concern regarding his mother's toileting and transfer care following her transfer to the first floor. He reported that while staff consistently used a pivot disc for toileting when she resided on the second floor, first-floor staff currently utilize a full-body mechanical lift and place her in bed, resulting in incontinence. Although he acknowledged that she experienced increased weakness following a recent urinary tract infection, he stated that family members are able to successfully transfer her when they take her out of the facility for visits, and she maintains continence during outings by offering consistent toileting assistance. He noted that while his mother has had a communication barrier since a 2006 stroke, she remains of sound mind and can reliably respond to yes/no questions regarding her needs. He stated that while he appreciates the facility's overall care, he objects to the current practice of denying her opportunities for toileting.During this interview, the resident was asked several yes/no questions. She stated yes when asked if she was happy living in the facility and yes when asked if she was happy with her new room since moving downstairs. She also answered yes when asked if she would prefer to be able to use the toilet. On 8/25/26 at 10:49 am, the Assistant Director of Nursing (ADON) confirmed that staff are expected to continue using a pivot disc for toileting, noting that the resident remains fully aware of her need to use the restroomOn 8/25/26 at 10:53 am, during an observation of Res #1's room and restroom, no transfer disc was seen.On 8/25/26 at 10:55 am, Staff F, Certified Nurse Aide (CNA) stated she took care of Resident #1 prior to her moving to her current room. She noted that while she works on the same unit, she is not routinely assigned to the resident's current hall, though she does assist with two-person transfers using the full body mechanical lift. When questioned about how staff determine the resident transfer status, Staff F provided a copy of the CNA Care Guide, which directed that Resident #1 should be transferred using a pivot disc, or a mechanical lift if the resident is unable to use the disc. She added that she believed a member of the therapy team had recently been looking for the pivot disc in her room. On 8/25/26 at 11:04 am, Staff G, CNA stated the normal routine for Resident #1 is that she gets laid down after meals and staff change her brief after she urinates. She stated the resident used to live on the second floor but since she had moved to the first floor, they only use the mechanical lift for transfers. She stated the resident's care plan states to use the pivot disc if able or or the lift. She stated she did try the pivot disk on the first day the resident moved to the lower floor and it didn't go well so she had never tried it again. She stated staff had only used the mechanical lift since that time. She stated she had not seen the disc since the first day the resident moved to her current room.On 8/25/26 at 12:00 pm, the Director of Therapy stated that a new evaluation was scheduled for Resident #1, noting that her previous care plan had specified the use of a pivot disc. He stated that the first-floor staff should have been aware of the prior therapy communication and should have followed the existing care plan upon the resident's room change. He indicated that the disc was currently in his office and that he would provide updated instructions to staff following the upcoming evaluation. Additionally, he stated that if staff feel unsafe using the pivot disc, his expectation is for them to contact the therapy team for training, and that any new weakness exhibited by the resident should also be reported to the therapy department. The Physical Therapy Discharge summary dated [DATE] documented Patient is able to perform Stand Pivot Transfer with pivot disc and maximum assistance.The Facility Policy titled Resident Rights, revision date 10/8/24 identified the following: Point 1: Right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.Point 7: Right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: participation in planning process, participation in establishing expected goals and outcomes, being informed of changes to plan, receive services and/or items noted in the plan, and to see and to sign the plan after significant changes.Point 10: Right to be treated with respect and dignity.

Based on clinical record review, staff and family interviews, and facility policy review, the facility failed to assess or investigate a resident's fall for 1 of 3 residents reviewed for Nursing Supervision (Res #5). The facility neglected to document the incident, complete necessary post-fall assessments, conduct a root cause analysis of the fall, or notify the physician of the fall. The facility reported a census of 115 residents.Findings include:The Minimum Data Set (MDS) Assessment of Res #5 dated 4/16/26 documented the resident to be severely cognitively impaired. The MDS recorded a prior history of the resident having falls. The Care Plan of Resident #5 identified a Focus category of potential for falls. It directed staff that should a fall occur, to follow post fall policy. A review of the Assessment Section of the Resident's Electronic Health Record (EHR) recorded post fall evaluations of falls which occurred on 4/17/26 and 5/8/26, with no further evaluations documented.A review of Resident #5 Progress Notes revealed no documentation of any falls after 5/8/26. On 8/25/26 at 12:44 pm, a family member of Resident #5 reported the resident had fallen out of bed upon returning to the facility from a hospital stay on 7/6/26. The family member stated that while she was in the hallway with the hospice nurse, the Assistant Director of Nursing (ADON) walked by and informed them that the resident had fallen out of bed. On 8/25/26 at 2:11 pm, the admission Nurse for the contracted hospice company stated that the resident had returned from the hospital and was re-enrolling in hospice on 7/6/26. The nurse recalled she was initially alone in the room while the resident rested comfortably in bed, but left to complete the paperwork in the hallway when the family member arrived. The nurse recalled that the ADON walked towards them and inquired about the hospice readmission, and notified them that the resident was on the floor, and then continued to walk past them. She stated she and the family member returned to the room, and saw the resident on the floor beside her bed with no other staff in the room. She stated she placed a pillow under the resident's head and covered her where her gown was raised. The family member stayed with the resident while she went to notify staff of the fall. She stated she located the Licensed Practical Nurse (LPN) on duty and the LPN instructed two Certified Nurse Aides (CNA) to assist the resident back into bed. She stated the CNA informed her a staff member had been in the room a short time earlier to assist the resident to eat but the resident refused the meal and they then left the room. She recalled a fall mat (a floor cushion placed next to the bed to reduce severity of injury if a person falls) had been in place when she had been in the room earlier but was no longer in place when they went in to see the resident after the fall. She stated one of the CNAs told her they had forgotten to replace the fall mat after attempting to feed the resident. (The resident had no apparent injuries). The hospice Skilled Nursing Visit Note dated 7/6/26 documented that approximately 30 minutes after the hospice nurse left the room, a facility staff member informed her the resident had fallen out of bed. The note further described upon returning to the resident's bedside, the resident was lying on the floor, with no fall mat present, on the tile floor in the fetal position. The note documented that she and the family member placed pillows and a blanket for comfort and went for help. The note also recorded that facility staff administered both Morphine and Ativan (end of life comfort medications for pain and anxiety) as the resident was moaning and calling out nonsensical sounds. Facility staff transferred the resident back to bed. The resident remained very restless and continued to try to crawl out of bed. The family member remained at bedside. The Visit Note documented times of the visit beginning at 12:00 pm and ending at 1:00 pm.A review of the resident's EHR showed no record of a fall on 7/6/26. Nursing progress notes for that date contained no reference to an incident, and no post-fall assessments had been documented. According to the 6:00 am to 2:00 pm staff schedule for 7/6/26, Staff A (LPN) and Staff B and Staff C (both CNAs) were assigned to the unit where Resident #5 resided. The Fall Risk Evaluation form was completed by Staff A, LPN, on 7/6/26 indicating a high risk of falls. On 8/25/26 at 2:25 pm Staff A, LPN stated she was not notified of Resident #5 having a fall on the day she was readmitted from the hospital and was unaware of her having any fall. She confirmed she was on duty that day and participated in the admission process of Resident #5. On 8/25/26 at 3:29 pm, Staff D, Certified Medication Aide (CMA) stated she works from 2:00 pm to 10:00 pm. She stated on 7/6/26, she was not informed of Res #5 having a fall. She had no memory of anyone reporting this to her. The Medication Administration Record (MAR) of Resident #5 for July, 2026 documented Staff D recorded a pain level of 10/10 and provided morphine for pain to Resident #5 at 3:59 pm on 7/6/26.On 8/26/26 at 10:08 am, Staff B, CNA confirmed she was one of two CNAs on duty the day of the fall who assisted Resident #5 back into bed. She stated she had just checked on Res #5 a short time earlier, and then Staff C, CNA informed her of the fall. She stated they went and informed Staff A, LPN who was going to assess the resident. She stated the resident's family member was in the room and did not want the nurse to do any vital signs. She thought this was because the resident was on hospice and not doing well. She stated she and Staff C picked the resident up off the floor and transferred her back into bed. Staff C, CNA was on vacation during the survey and did not return messages for an interview. Staff E, Registered Nurse (RN) came on duty at 2:00 pm on 7/6/26 on the unit Resident #5 resided on. On 8/26/26 at 10:19 am, Staff E stated she received no report from Staff A, LPN informing her of Res #5's fall on 7/6/26 so therefore did no fall follow up assessments. On 8/26/26 at 3:04 pm, the ADON confirmed she had seen Resident #5 lying on the floor on 7/6/26. She stated she was rounding with the wound care provider throughout the building. She stated as she walked down the hallway, she spotted the resident on the floor. She reported there was a CNA in the hallway so she directed the CNA to go inform Staff A of the fall. She recalled as she was exiting the unit, the hospice nurse and the resident's family member were in the hallway and she also informed them and continued to round with the wound care provider.The ADON was asked if she was able to provide any documentation of the resident's fall as none was located in the EHR. She stated she would expect there to be a risk management (incident report) to have been done and a post fall assessment. She stated she did not personally follow up on the fall as Staff A had been notified of the fall as the nurse on duty for that unit. She stated as she and the wound care provider rounded the second floor, she asked the second floor ADON to go downstairs and check with Staff A if she needed any assistance regarding the fall. On 8/26/26 at 3:19 pm, the ADON stated she also was unable to locate any documentation of the fall in the resident record. She added she had called Staff A and left a message for her to call her back.On 8/26/26 at 3:39 pm, Staff A returned the call to the ADON. During a second interview with the State Surveyor, Staff A stated she had previously not remembered Res #5's fall but now did recall it. She stated she was told the resident was on the floor and she did attempt to assess the resident but the family member of the resident refused to allow her to assess the resident due to her being at the end of life. She said she had failed to document the fall because it was a busy shift. She recalled the family member asking why she was taking vital signs on a hospice resident and she explained it was policy to check vital signs after a fall. She recalled the family member was upset and wanted the resident transferred back to the bed and given medications. She stated she administered the resident medications and did a follow up check half an hour later. She felt she had passed the information onto the next shift but stated the fall may not have been listed on the 24 hour report (a daily communication log used for tracking resident updates, changes, etc). The MAR for 7/6/26 failed to reflect any medications given by Staff A. On 8/26/26 at 3:47 pm, the ADON stated her expectation is for a risk management report to be completed, and a post fall assessment to be completed after any fall. She stated even if there are refusals by the family of completing an assessment, the fall still needs to be documented in the clinical record. The facility policy titled Fall Prevention/Risk Assessment, review date 10/15/24 documented the following: Point 9: When any resident experiences a fall, the facility will:Assess the resident.Complete a post-fall assessment.Complete an incident report.Notify physician and familyReview the resident's care plan and update as indicatedDocument all assessments and actionsObtain witness statements in the case of injury

Based on observations, record review, staff and Iowa Department of Public Health (IDPH) interviews, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines. The facility failed to do the following; ensure staff followed proper infection control practices during resident's cares and transmission based precaution procedures to prevent the spread of COVID-19 by failing to follow facility policy and CDC guidelines, to test residents who had been exposed to other residents positive for COVID-19, separate COVID-19 positive residents from roommates, to wear proper personal protective equipment (PPE) and to properly handle contaminated linens for 20 of 20 residents reviewed (Resident #2, #6, #11, #12, #27, #32, #36, #42, #59, #68, #74, #75, #85, #91, #96, #97, #100, #118, #126, #127). The facilities failure to protect their residents from exposure to high risk infections put the residents at a serious likelihood of harm. The facility reported a census of 109 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on December 26, 2025 at 4:59 p.m. The IJ began on November 29, 2025. The facility staff removed the immediacy on December 16, 2025 by implementing the following actions;a. Residents exposed to a resident with covid positive results will be tested immediately, and residents will be tested on a section of the building that had a high rate of positive testing resultsb. All residents who have been positive will be reviewed on 12/16/25 to determine whether they need to be put back to transmission based precautions for 10 days.c. All residents on the second floor will be tested on [DATE]. d Residents in the room with covid positive resident will be moved to a different room as soon as the room is available.e. Education will be completed to All staff on mask wearing and linen handling beginning 12/16/25 and on-going shifts.f. Staff working on the highly positive COVID unit will be tested beginning 12/16/25 and on-going shiftsThe scope was lowered from K to H at the time of the survey. Findings include: On 12/15/25 at 8:45 AM, Staff B, Licensed Practical Nurse (LPN) and Staff C, LPN were observed on a unit with Covid positive residents sitting at the nurses' station without masks. They both placed the mask over their mouths and noses when the state surveyor approached. During an observation on 12/15/2025 10:45 AM, Staff BB, CNA is observed exiting a residents room, wearing gloves, pushing a patient transfer device (EZ stand), parking along the wall in the hallway and entering a resident's room across the hall while wearing the same gloves. On 12/15/2025 at 10:52 AM, observation revealed droplet precaution sign outside of Resident #59's door with Personal Protective Equipment (PPE) supplies bin outside of room. Resident's room door is open, with resident #59 laying in bed. On 12/15/25 at 10:53 AM, Staff D, Certified Nurse Aide (CNA) was observed on the same unit with with her ear loop mask tucked under her chin. On 12/15/25 at 11:00 AM, Staff E, contracted Physical Therapy Assistant (PTA) was observed on the same unit with her ear-loop mask tucked under her chin while she searched for a N95 mask. She stated the facility had been using N95 masks for Covid positive droplet precaution residents. On 12/15/2025 at 3:20 PM, observed droplet precaution sign and PPE supplies bin outside of Resident #74's room, with resident's room door open. Observation on 12/16/2025 at 1:25 PM, revealed Resident #59's room door open, resident is on TBP for positive COVID, Staff GG, CNA, outside of room donning PPE to include a gown and gloves. Stuff GG, CNA currently wearing a standard surgical mask and enters resident's room. Staff GG, CNA provides cares for Resident #59, the room door is open and the curtain is pulled a quarter of the way across the room, while roommate is on the other side of the room. At 1:30 PM another staff member approaches doorway and asks Staff GG, CNA to assist in another room when done caring for Resident #59. 1:35 PM, Staff GG, CNA exits Resident #59's room, gown, gloves and mask are removed. Leaving resident's door open and carrying unbagged linens with bare hands, stops at PPE drawer in the hallway and gets a new standard surgical mask and puts it on. Staff GG, CNA then proceeds to carry unbagged linen to the soiled laundry bin halfway down the hallway and drops items in. Uses hand sanitizer and enters another room to assist as requested earlier. On 12/16/2025 3:10 PM, Staff HH, CNA is observed carrying personal care supplies from hall B to hall C, wearing a mask, pulled down below her nose only covering her mouth. After delivering supplies to storage cart on hall B, Staff HH, CNA is observed at the entrance to hall B pulling her mask down and drinking out of a water bottle, replacing her mask to cover her mouth and sets water bottle back on hand railing and walks away. On 12/16/2025 at 5:20 PM, DON provided a spreadsheet she stated is used for reporting positive COVID-19 cases to CDC's National Healthcare Safety Network (NHSN) (healthcare-associated infection tracking system) and to Iowa Department of Public Health (IDPH). Review of this document indicated residents who had been tested for influenza and/or COVID-19, resident's symptoms and date reported, the date the test was administered with results, and the date resident was removed from isolation/TBP. On 12/16/25 at 8:17 AM, Staff F, RN was observed in the dining room on the same unit wearing her mask below her nose. She raised it above her nose when the state surveyor approached her. On 12/16/25 at 3:28 PM, Staff G, LPN was observed on the unit with mask requirements at the nurses' station with his mask hanging off of his right ear. On 12/17/25 at 11:02 AM, Staff H, contracted Registered Occupational Therapy (OTR) exited a resident's room wearing a PPE gown and gloves and carrying a green pair of pants. She rolled up the pants, placed it in the laundry bin, and returned to the resident's room wearing the same PPE. At 11:09 AM, she exited the resident's room wearing PPE gown and gloves carrying a clear plastic bag of laundry. She threw it in the laundry bin and returned to the resident's room. At 11:12 AM, Staff H stated she received infection prevention education but didn't remember receiving education about exiting EBP with PPE. She stated when she's providing services to a resident on EBP, she changes gloves after touching the resident, exits the resident's room to place any linen into the laundry bin, then returns to the resident's room. She stated the residents' rooms do not have disinfectant wipes, so she takes the gait belt to the office to clean it. Observation on 12/18/2025 at 11:30 AM, Facility Nurse Practitioner, observed standing at nurses station, not wearing a mask. Staff T, Assistant Director of Nursing (ADON), asked Facility Nurse Practitioner to put on a mask and wear while on the unit. Nurse Practitioner donned a mask. 1. Review of Resident #6's Significant Change Minimum Data Set (MDS) dated [DATE] revealed admission to the facility on 7/17/2025 in a private room receiving hospice level of care. A Brief interview for Mental Status (BIMS) of 7 (severe cognitive impairment), diagnoses including atrial fibrillation (A-fib), coronary artery disease, hypertension, stage 3 chronic kidney disease, type 2 diabetes mellitus, hyperlipidemia, history of stroke with left sided weakness, and chronic obstructive pulmonary disease (COPD). Resident #6 is dependent on staff assistance pushing her wheelchair for mobility, dependent with use of mechanical lift for transfers, and needs substantial assistance rolling side to side in bed, sitting to lying, and lying to sitting on side of bed. Review of Resident #6's Care Plan initiated on 7/17/205 included the following focus and interventions:a. High risk for COVID exposure due to communal living. Observe for signs and symptoms of COVID. Obtain rapid COVID test as indicated and report results to facility provider, should Resident #6 have a positive test, isolate per CMS/CDC guidelines.b. Resident #6 has altered respiratory status/difficulty breathing related to COPD, interventions to include, monitor/document changes in orientation, increased restlessness, anxiety and air hunger. Monitor for signs and symptoms of respiratory distress, headaches, lethargy, confusion, and report to facility provider as needed. Use of oxygen at 2 liters per minute (LPM) via nasal cannula as needed to keep oxygen saturation greater than 90%. c. Resident #6 has altered cardiovascular status. Administer cardiac medications as ordered, monitor vital signs and notify provider of significant abnormalities, monitor/document/report any signs or symptoms of chest pain, chest pressure, heartburn, nausea, vomiting, shortness of breath, excessive sweating, and dependent edema (swelling from excessive fluid accumulation). Review of facility provided COVID-19 tracking spreadsheet indicated Resident #6's symptoms started on 12/2/2025, COVID-19 testing on 12/2/25 with positive results and Transmission Based Precautions (TBP) initiated. Review of Resident #6's Nursing Progress notes revealed the following:12/2/2025 at 1:19 PM, Staff Z, LPN, documented, Long Term Care Evaluation: vitals temperature (T) 97.1, pulse (P) 62, respirations (R) 18, blood pressure (BP) 117/68, SpO2 94% on room air. Respiratory: No signs of difficulty breathing, no shortness of breath noted, right and left lungs clear, no oxygen, head of bed is not elevated, no cough. 12/2/2025 at 5:25 PM, Staff Z, LPN, documented, resident #6 tested positive for COVID, voicemail left for family. 12/3/2025 at 6:49 AM, Staff A, RN, documented, at 6:35 AM it was brought to my attention Resident #6 appeared to have passed away. Upon inspection and assessment, she has passed. Assistant Director of Nursing (ADON) notified. Called hospice and told then Resident #6 had passed away, also disclosed that resident had a diagnosis of COVID yesterday before her passing. 2. Review of Resident #11's admission MDS dated [DATE] revealed, resident was admitted to the facility on [DATE] to a private room. A BIMS of 15 (cognitively intact), diagnoses of coronary artery disease, deep vein thrombosis, heart failure, peripheral vascular disease, type 2 diabetes mellitus, and pleural effusion (excess fluid builds up in the space between the lungs and chest wall, restricting lung expansion, causing shortness of breath, chest pain, and cough). Resident #11 requires moderate assistance (helper does less than half the effort, lifts or holds trunk or limbs but provides less than half the effort) with transfers and mobility with the use of a walker or wheelchair. Review of Resident #11's Care Plan, initiated 9/24/2025, included the following focus and interventions: a. Altered cardiopulmonary functioning, potential for shortness of breath, lung congestion, chest pain, decrease in level of consciousness, acute heart failure. Administer cardiac medications as ordered, blood pressure monitoring, use of anticoagulants (blood thinner), observe for signs and symptoms of cardiac decompensation and report to provider. Daily weights for cardiac monitoring as ordered, notify provider of 3 pound weight gain in 1 day or 5 pounds in one week. b. Resident #11 requires the use of diuretics related to congestive heart failure and bilateral lower extremity edema. Administer medications as ordered, notify provider of increase in edema and lung congestion. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #11's symptoms started on 12/3/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #12 was removed from TBP on 12/8/2025 after 5 days of isolation/TBP. Review of Resident #11's Nursing Progress notes revealed the following:11/30/2025 at 7:42 AM, Staff AA, RN, documented, Resident #11 exhibits cold symptoms; congestion and cough. Reports a sore throat, denies any malaise (feeling discomfort or illness), BP 110/65, P 85, SpO2 94% on room air. Rapid COVID test completed with negative results at this time. On call provider made aware with orders for Guaifenesin (medication used to relieve chest congestion and make coughs more productive) 400mg every 4 hours as needed x 10 days. 12/2/2025 9:10 PM, Staff B, LPN, documented, Resident #11 tested positive for COVID. 12/8/2025 at 5:34 PM, Staff S, LPN, documented, Resident #11 removed from droplet isolation precautions due to resolved active COVID signs and symptoms at this time. 3. Review of Resident #12's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] to a semi-private room (shared with one roommate R#75). A BIMS of 14 (cognitively intact), diagnoses of Multiple Sclerosis, contractures, neurogenic bladder, hypertension, and anxiety disorder. Resident #12 is dependent on staff assistance for mobility in her wheelchair and assistance with the use of a mechanical lift for transfers. Review of Resident #12's Care Plan revised on 8/27/2025 failed to indicate Resident's risk for COVID. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #12's symptoms started on 12/3/2025, COVID-19 testing on 12/3/25 with positive results and TBP initiated. Resident #12 was removed from TBP on 12/12/2025 after 9 days of isolation/TBP. Review of Resident #12's Nursing Progress notes revealed the following:12/2/2025 at 12:38 AM, Staff Y, LPN, documented, resident able to express self to staff, body temperature warm to touch, dry and intact. In bed, head elevated per resident's desires, call light in reach. 12/3/2025 at 8:47 PM, Staff Z, LPN, documented, resident noted coughing, rapid COVID test completed, results positive, BP 121/68, P 118, T 98 and O2 95%. On call provider notified and received an order for mucinex 600mg twice daily x 10 days. 12/8/2025 at 2:46 PM, Staff A, RN, documented, vital signs (T)98.5, (P)108, (R)18, (BP)113/61, SpO2 95% on room air. Lung sounds diminished in the bases bilaterally and expiratory rhonchi in the right upper lobe. Loose, non-productive cough. Resident is alert. No other signs and or symptoms (s/sx) of COVID. 4. Review of MDS dated [DATE], revealed Resident #27's admission to the facility on 7/31/2024 to a semi-private room (Roommate with Resident #12), BIMS of 15 (cognitively intact) and diagnoses of non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, depression, and psychotic disorder. Review of Resident #27's Care Plan initiated 7/31/2024 failed to indicate Resident's risk for COVID. Review of Resident #27's nursing progress notes, failed to provide documentation related to Resident #27's exposure to COVID positive roommate, attempt to separate from roommate or provide interventions to reduce risk of transmission, provide COVID testing and monitoring for symptoms. 5. Review of MDS dated [DATE], revealed resident #32 was admitted to the facility 10/21/2025 in a private room, BIMS 13 (cognitively intact) and diagnoses of atrial fibrillation (A-fib), heart failure, hypertension, and unspecified toxic encephalopathy. (brain dysfunction caused by unknown toxins, can cause confusion, memory loss, personality changes, poor concentration or seizures). Resident #32 is independent with the use of a walker. Review of Care Plan, initiated 11/3/2025, revealed the following focus and interventions for Resident #32:a. Altered cardiopulmonary status with potential for shortness of breath, lung congestion, edema, chest pain, decreased level of consciousness, cyanosis related to congestive heart failure, A-fib, and hypertension. Avoid overexertion, requiring frequent rest periods during completion of activities. Notify nursing staff of any shortness of breath, chest pain, or irregular heartbeat. Observe for signs and symptoms of cardiac decompensation and report to provider. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #32's symptoms started on 12/1/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #32 was removed from TBP on 12/8/2025 after 5 days of isolation/TBP. Review of Resident #32's Nursing Progress notes revealed the following:11/17/2025 at 6:37 PM, Staff U, RN, documented, Nurse Practitioner is here and new order received, cough drops mouth/throat lozenge every 2 hours as needed, may have at bed side per resident's request. 12/1/2025 at 2:26 PM, Staff B, LPN, documented, called Resident #32's family and notified about Vaseline under the nose for redness.12/2/2025 at 12:39 PM, late entry created 12/3/1015 at 3:41 PM, Staff B, LPN noted, Resident #32 was tested positive for COVID, family and manager notified. Isolation precautions put in place. 12/2/2025 at 12:44 PM, Staff T, ADON, documented, positive for COVID, isolation in place. 12/3/2025 at 1:04 PM, Staff T, ADON, documented, symptoms started on Sunday (11/30/2025) with a runny nose and increased tiredness. On 12/2/2025 resident #32 was tested with a rapid COVID test and tested positive. 12/8/2025 at 5:12 PM, Staff T, ADON, documented new orders for Tussin (medicine to relieve symptoms of cough and chest congestion cause by the common cold, flue, allergies, or minor bronchial irritations) 15mg every 6 hours as needed. Rapid COVID test completed, results negative. 12/8/2025 at 5:32 PM, Staff S, LPN, documented, resident #32 removed from droplet isolation precautions due to resolved signs of active COVID signs or symptoms at this time. 6. Review of MDS dated 11/12025, revealed Resident #36's admission to the facility on [DATE] to a semi-private room (roommate with Resident #59), BIMS of 0 (resident is not able to complete the assessment) and diagnoses of A-fib, hypertension, kidney disease, type 2 diabetes mellitus, aphasia (language disorder, impairing language, understanding speech, reading and writing), hemiplegia, seizure disorder, and history of stroke. Resident #36 requires maximal assistance for transfers and is independent with a wheelchair for mobility. Review of Resident #36's Care Plan initiated 12/5/2024 failed to indicate Resident's risk for COVID. Review of Resident #36's nursing progress notes, failed to provide documentation related to Resident #36's exposure to COVID positive roommate, attempt to separate from roommate or provide interventions to reduce risk of transmission. Review of Resident #36's Medication Administration Record (MAR) indicated an order dated 12/11/2025 for COVID MONITORING: monitor for new cough, sore throat, new shortness of breath or difficulty breathing, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose. See nurses notes and progress notes findings every shift for 10 days. Vitals were obtained and documented each shift. The ordered nursing progress notes linked to three times daily COVID monitoring provided the following two nursing documentations:12/11/2025 at 4:50 PM, Staff AA, RN, documented, no cough or difficulty breathing noted. 12/13/2025 at 1:07 AM, Staff Z, LPN, noted, Resident #36 resting quietly with no complaints of discomfort, NO breathing difficulty. On 12/16/2025 at 1:18 PM, Resident #36 was observed self propelling in his wheelchair, exiting his room. Outside of resident #36's room, a three drawer bin with PPE, had a folded blanket, shirt on a hanger, and underwear sitting on top. Resident #36, unmasked, retrieved laundry and blanket and returned to the room. During an interview on 12/16/2025, Staff G, LPN stated in this room, Resident #59 is COVID positive, Resident #36 is not. LPN stated Resident #36 had been tested with negative results. When LPN was asked about facility's procedure for separating roommates when one is COVID positive and the other is negative, LPN stated Resident #36's roommate had a full assessment, nursing staff will monitor Resident #36 with basic vitals. LPN stated Resident #36 had been tested again and was negative, the results for these tests would be documented in the nurses progress notes in Resident #36's records. An interview on 12/16/25 at 3:12 PM, Staff F, RN stated, she has encouraged Resident #36 to spend time outside of his room and encouraged to wear a mask. Nurses are monitoring for signs and symptoms of COVID. Staff F, RN stated she was not sure if Resident #36 had been tested for COVID, at this time Staff F, RN called Staff S, the Infection Preventionist for more information. Staff F, RN continues by stating I haven't been on the floor in awhile, to know what we're doing. After communicating with Staff S, Infection Preventionist, Staff F, RN stated right now we are focusing on alert charting and monitoring for COVID symptoms, if symptoms start then the resident is tested for COVID. In an interview on 12/16/25 at 3:24 PM, Staff T, ADON, acknowledged Resident #36 cohorting (an infection control strategy where patients with the same contagious condition are grouped together in a specific area to prevent spread to others) with Resident #59 who is COVID positive and stated questions related to the cohorting would need to be redirected to the facility's Infection Preventionist Staff S, for further clarification. 7. Review of MDS dated [DATE] revealed Resident #42's admission to the facility on 4/7/2025 to a private room, BIMS of 12 (moderate cognitive impairment) and diagnoses of hypertension, kidney disease, type 2 diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, bipolar disorder, asthma, and sarcopenia (age related progressive loss of muscle mass, strength and function). Resident #42 is dependent on staff for transfers and mobility in her wheelchair. Review of Resident #42's Care Plan, initiated 4/7/2025, included the following focus and interventions:a. Altered cardiopulmonary status with potential for shortness of breath, lung congestion, edema, chest pain, decreased level of consciousness, cyanosis, diaphoresis, complaints of nausea and vomiting related to hypertension and asthma with wheezing. Avoid overexertion, requiring frequent rest periods during completion of activities. Observe for signs and symptoms of cardiac decompensation and report to provider. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #42's symptoms started on 12/3/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #42 was removed from TBP on 12/8/2025 after 5 days of isolation/TBP. Review of Resident #42's Nursing Progress notes revealed the following:12/3/2025 at 1:00 PM, Staff T, ADON, documented, on 12/2/2025 Resident #42 had cough and runny nose. Rapid COVID testing completed results positive. Isolation present. 12/8/2025 5:37 PM. Staff S, LPN, documented Resident #42 removed from droplet isolation precautions due to resolved signs of active COVID signs or symptoms at this time. 8. Review of Resident #59's MDS dated [DATE] revealed resident #59 was admitted to the facility on [DATE] to a semi-private room (roommate with Resident #36), BIMS of 14 (cognitively intact) with diagnoses of coronary artery disease, heart failure, cardiomegaly (enlarged heart), hypertension, type 2 diabetes mellitus, anxiety disorder, depression, COPD, chronic respiratory failure, obstructive sleep apnea, disease of spinal cord, and requires oxygen. Resident #59 is dependent for transfers with assistance of a mechanical lift and uses a power wheelchair for mobility. Review of Resident #59's Care Plan revised 12/4/2025 provided the following focus and interventions:a. Resident #59 has an altered cardiovascular status related to hypertension, heart failure, and coronary artery disease. Administer cardiac medications as ordered. Daily weights, if 5 pounds gain in one week, administer additional Lasix that day. Monitor and report any signs or symptoms of coronary artery disease, chest pain or pressure with activity, shortness of breath, excessive sweating, and dependent edema. Oxygen at 2 liters via nasal cannula continuous. b. Resident #59 is at risk for signs and symptoms of COVID-19. Follow facility protocol for COVID-19 screening and precautions. Observe for signs and symptoms of COVID-19, document and promptly report fever, coughing, sneezing, sore throat, and/or respiratory/breathing issues. c. Initiated 12/11/2025, Resident #59 requires isolation precautions, specifically related to the COVID-19 infection. Observe effectiveness of medications; observe for signs and symptoms and inform provider if worsening. Intervention initiated 12/16/2025; Carry on conversations with Resident #59 during care so that he does not feel isolated; Resident #59 is receiving antibiotics for COVID associated respiratory infection, observe for potential side effects and report to the provider; notify provider of any worsening COVID symptoms; isolation per policy. d. Resident #59 has altered respiratory status, difficulty breathing related to heart failure, respiratory failure, and COPD exacerbation. Assess lung sounds as needed and notify provider of abnormal findings. Monitor for signs and symptoms of respiratory distress and report to provider. Continuous oxygen at 2 lpm via nasal cannula. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #59's symptoms started on 12/11/2025. Review of Resident #59's Nursing Progress notes revealed the following:12/11/2025 at 10:02 AM, Staff AA, RN, documented, Resident #59 presents with hoarse voice, reports feeling fatigued. Occasional cough, reporting clear to greenish sputum at times, and slight pain with cough. No respiratory distress or effort with breathing. Rapid COVID completed with positive results. Isolation protocol initiated. 9. Review of MDS dated [DATE], revealed Resident #68 was admitted to the facility on [DATE] to a private room, BIMS of 15 (cognitively intact) and diagnoses of cancer, Afib, heart failure, hypertension, kidney disease, type 2 diabetes mellitus, and respiratory failure with hypoxia (critical condition where lungs fail to get enough oxygen into the blood). Review of Resident #68's Care Plan, initiated 11/26/2025 included the following focus and interventions:a. Resident #68 requires assistance of 1 with a gait belt and walker for ambulation and transfer. b. Altered cardiopulmonary status with potential for shortness of breath, lung congestion, edema, chest pain, decreased level of consciousness, cyanosis, diaphoresis, complaints of nausea and vomiting related to heart failure and acute respiratory failure. Avoid overexertion, requiring frequent rest periods during completion of activities. Instruct resident to notify nursing staff of any complaints of shortness of breath, chest pain, irregular heart rate. Observe for signs and symptoms if resident is unable to report symptoms and notify provider if signs and symptoms exist. c. Oxygen at 2 lpm via nasal cannula as needed. d. Observe for signs and symptoms of cardiac decompensation and report to provider. e. Enhanced Barrier Precautions (EBP) due to chronic wounds, gowns and gloves to be worn with all direct care. Proper hand washing before and after all cares. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #68's symptoms started on 11/29/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #68 was removed from TBP on 12/9/2025 after 7 days of isolation/TBP. Review of Resident #68's Nursing Progress notes revealed the following:11/28/2025 at 10:50 AM, Staff L, RN documented a Skilled Evaluation note stating, no signs of difficulty breathing, no shortness of breath noted. No cough, no signs of respiratory distress or discomfort noted at this time. 11/29/2025 at 8:09 AM, Staff AA, RN documented a Skilled Evaluation note stating, no signs of difficulty breathing, no shortness of breath noted. Right and left lung clear, no oxygen. Cough present with moist/loose non-productive cough noted. Reports cough not new, denies concerns at this time. 11/30/2025 at 8:37 AM, Staff AA, RN documented a Skilled Evaluation note stating, no signs of difficulty breathing. Shortness of breath noted, Resident #68 reported shortness of breath upon exertion. Right and left lung clear. No oxygen, head of bed elevated at 30 degrees. Cough present with moist/loose non productive cough noted. Small amount of thin secretions. Residual cough. 11/30/2025 at 5:33 PM, Staff AA, RN documented an Administration note, Albuterol sulfate inhalation nebulation, 3 ml inhaled orally via nebulizer every 6 hours as needed for shortness of breath, SpO2 94% on room air, no respiratory distress observed or reported. 12/1/2025 at 10:07 AM, Staff BB, Certified Medication Aide (CMA) document an Administration note, Albuterol sulfate inhalation nebulation, 3 ml inhaled orally via nebulizer every 6 hours as needed for shortness of breath, wheezing. Resident #68 requested Albuterol nebulizer for shortness of breath and wheezing. Nurse was notified. 12/1/2025 at 10:40 AM, Staff U, RN documented a Skilled Evaluation note stating, SpO2 90% on room air, no signs of difficulty breathing or shortness of breath noted. Right lung upper lobe wheezes on auscultation, lung sounds present on exhalation. Left lung upper lobe wheezes on auscultation, lung sounds present on exhalation. Moist/Loose non-productive cough present with small amounts of clear moderate consistency secretions. As needed nebulizer treatments administered, Nurse Practitioner here and notified of noted wheeze and cough. 12/1/2025 at 11:05 AM, Staff U, RN documented wheezing and shortness of breath noted this morning, as needed nebulizer treatment administered. Nurse Practitioner is here and saw resident. New order received; Mucinex 600mg by mouth twice daily x 7 days. 2 view chest x-ray today. Continue as needed nebulizer treatments. X-ray scheduled with portable x-ray services. 12/1/2025 at 11:59 AM, Staff U, RN documented Nurse Practitioner is here and saw Resident #68; verbal order received for rapid COVID test. Rapid COVID test administered and positive results noted. Nurse Practitioner and ADON aware, Resident #68 in droplet precaution, will continue to monitor. 10. Review of MDS dated [DATE] revealed Resident #74's admission to the facility on 5/5/2025 in a private room, BIMS of 15 (cognitively intact) and diagnoses of hypertension, polyneuropathy (nerve damage in extremities causing weakness, numbness, tingling and burning pain affecting sensory and motor functions), aortic valve stenosis (serious heart condition, aortic valve narrows causing obstructive blood flow), and weakness, Resident #74 is independent with transfers and mobility with the use of a wheelchair. Review of Resident #74's Care Plan revised 11/10/2025 indicated the following focus and interventions:a. Altered cardiovascular status related to hypertension. Assess for chest pain, enforce the need to call for assistance if pain starts. Monitor, document and report any signs or symptoms of coronary artery disease.b. Initiated 12/14/2025, require care isolation precautions specifically related to the COVID-19 infection. Observe for signs and symptoms and inform provider if worsening. Ensure resident stays in room, away from other people as much as possible (contact and droplet precautions). Monitor vitals and notify provider of abnormalities. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #74's symptoms started on 12/13/2025. Review of Resident #74's Nursing Progress notes revealed the following:12/13/2025 at 9:30 AM, Staff AA, RN, documented, Resident #74 with complaints of loss of taste, also presents with nasal congestion. Denies any cough or s

Based on clinical record review, staff interviews, and policy review the facility failed to appropriately provide consistent and thorough assessments for COVID positive residents and residents exposed to COVID, for the ordered 10 days, also failed to complete a neurological assessment for a resident with an unwitness fall for 17 of 21 residents reviewed. (Resident #11, #12, #18, #27, #32, #36, #42, #59, #68, #74, #75, #85, #91, #96, #97, #100, #118) Facility reported a census of 109 residents. Findings include:1. Review of Resident #11's admission MDS dated [DATE] revealed, resident was admitted to the facility on [DATE] to a private room. A BIMS of 15 (cognitively intact), diagnoses of coronary artery disease, deep vein thrombosis, heart failure, peripheral vascular disease, type 2 diabetes mellitus, and pleural effusion (excess fluid builds up in the space between the lungs and chest wall, restricting lung expansion, causing shortness of breath, chest pain, and cough). Resident #11 requires moderate assistance (helper does less than half the effort, lifts or holds trunk or limbs but provides less than half the effort) with transfers and mobility with the use of a walker or wheelchair. Review of Resident #11's Care Plan, initiated 9/24/2025, included the following focus and interventions: a. Altered cardiopulmonary functioning, potential for shortness of breath, lung congestion, chest pain, decrease in level of consciousness, acute heart failure. Administer cardiac medications as ordered, blood pressure monitoring, use of anticoagulants (blood thinner), observe for signs and symptoms of cardiac decompensation and report to provider. Daily weights for cardiac monitoring as ordered, notify provider of 3 pound weight gain in 1 day or 5 pounds in one week. b. Resident #11 requires the use of diuretics related to congestive heart failure and bilateral lower extremity edema. Administer medications as ordered, notify provider of increase in edema and lung congestion. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #11's symptoms started on 12/3/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #11 was removed from TBP on 12/8/2025 after 5 days of isolation/TBP. Review of Resident #11's December 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/2/2025, Discontinue (D/C) date 12/8/2025 The MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered. Review of Resident #11's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.2. Review of Resident #12's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] to a semi-private room (shared with one roommate). A BIMS of 14 (cognitively intact), diagnoses of Multiple Sclerosis, contractures, neurogenic bladder, hypertension, and anxiety disorder. Resident #12 is dependent on staff assistance for mobility in her wheelchair and assistance with the use of a mechanical lift for transfers. Review of Resident #12's Care Plan revised on 8/27/2025 failed to indicate Resident's risk for COVID.Review of facility provided COVID-19 tracking spreadsheet indicated Resident #12's symptoms started on 12/3/2025, COVID-19 testing on 12/3/25 with positive results and TBP initiated. Resident #12 was removed from TBP on 12/12/2025 after 9 days of isolation/TBP. Review of Resident #12's December 2025 MAR/TAR revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/3/2025, Discontinue (D/C) date 12/12/2025. The MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered. Review of Resident #12's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.3. Review of MDS dated [DATE], revealed Resident #27's admission to the facility on 7/31/2024 to a semi-private room (Roommate with Resident #12), BIMS of 15 (cognitively intact) and diagnoses of non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, depression, and psychotic disorder. Review of Resident #27's Care Plan initiated 7/31/2024 failed to indicate Resident's risk for COVID.Review of Resident #27's December 2025 MAR/TAR, failed to indicate COVID monitoring assessment due to resident's exposure and cohorting with COVID positive roommate. Review of Resident #27's nursing progress notes, failed to provide documentation related to Resident #27's exposure and cohorting with COVID positive roommate.Review of facility provided COVID-19 tracking spreadsheet lacked documentation of Resident #27 being tested for COVID.4. Review of MDS dated [DATE], revealed resident #32 was admitted to the facility 10/21/2025 in a private room, BIMS 13 (cognitively intact) and diagnoses of atrial fibrillation (abnormal heart rhythm) , heart failure, hypertension, and unspecified toxic encephalopathy. (brain dysfunction caused by unknown toxins, can cause confusion, memory loss, personality changes, poor concentration or seizures). Resident #32 is independent with the use of a walker. Review of Care Plan, initiated 11/3/2025, revealed the following focus and interventions for Resident #32:a. Altered cardiopulmonary status with potential for shortness of breath, lung congestion, edema, chest pain, decreased level of consciousness, cyanosis related to congestive heart failure, atrial fibrillation (A-Fib), and hypertension. Avoid overexertion, requiring frequent rest periods during completion of activities. Notify nursing staff of any shortness of breath, chest pain, or irregular heartbeat. Observe for signs and symptoms of cardiac decompensation and report to provider.Review of facility provided COVID-19 tracking spreadsheet indicated Resident #32's symptoms started on 12/1/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #32 was removed from TBP on 12/8/2025 after 5 days of isolation/TBP. Review of Resident #32's December 2025 MAR/TAR revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/2/2025 at 2:00 PM, Discontinue (D/C) date 12/8/2025. MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered.Resident#32's Medication Administration Record documented that the resident received Tussin Cough oral syrup 15milligrams per 5 milliliters by mouth on December 9, 2025 at 7:42 p.m., the medication was classified as a PRN medication (given to resident upon request).Review of Resident #32's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.5. Review of MDS dated 11/12025, revealed Resident #36's admission to the facility on [DATE] to a semi-private room (roommate with Resident #59), BIMS of 0 (resident is not able to complete the assessment) and diagnoses of A-fib, hypertension, kidney disease, type 2 diabetes mellitus, aphasia (language disorder, impairing language, understanding speech, reading and writing), hemiplegia, seizure disorder, and history of stroke. Resident #36 required maximal assistance for transfers and is independent with a wheelchair for mobility. Review of Resident #36's Care Plan initiated 12/5/2024 failed to indicate Resident's risk for COVID.Review of Resident #36's December 20025 MAR/TAR indicated an order dated 12/11/2025 for COVID MONITORING: Monitor for new cough, sore throat, new Shortness of Breath or difficulty breathing, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes findings every shift for 10 days.Review of Resident #36's Nursing Progress notes failed to provide complete monitoring assessments indicating assessed symptoms, new cough, sore throat, new shortness of breath or difficulty breathing, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose every shift (three times daily) for complete 10 days as ordered. 6. Review of MDS dated [DATE] revealed Resident #42's admission to the facility on 4/7/2025 to a private room, BIMS of 12 (moderate cognitive impairment) and diagnoses of hypertension, kidney disease, type 2 diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, bipolar disorder, asthma, and sarcopenia (age related progressive loss of muscle mass, strength and function). Resident #42 is dependent on staff for transfers and mobility in her wheelchair. Review of Resident #42's Care Plan, initiated 4/7/2025, included the following focus and interventions:a. Altered cardiopulmonary status with potential for shortness of breath, lung congestion, edema, chest pain, decreased level of consciousness, cyanosis, diaphoresis, complaints of nausea and vomiting related to hypertension and asthma with wheezing. Avoid overexertion, requiring frequent rest periods during completion of activities. Observe for signs and symptoms of cardiac decompensation and report to provider.Review of facility provided COVID-19 tracking spreadsheet indicated Resident #42's symptoms started on 12/3/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #42 was removed from TBP on 12/8/2025 after 5 days of isolation/TBP.Review of Resident #42's December 20025 MAR/TAR indicated an order dated 12/11/2025 for COVID MONITORING: Monitor for new cough, sore throat, new Shortness of Breath or difficulty breathing, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes findings every shift for 10 days. Start date 12/3/2025, D/C 12/9/2025. The MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered. Review of Resident #42's Nursing Progress Notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.7. Review of Resident #59's MDS dated [DATE] revealed resident #59 was admitted to the facility on [DATE] to a semi-private room (roommate with Resident #36), BIMS of 14 (cognitively intact) with diagnoses of coronary artery disease, heart failure, cardiomegaly (enlarged heart), hypertension, type 2 diabetes mellitus, anxiety disorder, depression, COPD, chronic respiratory failure, obstructive sleep apnea, disease of spinal cord, and requires oxygen. Resident #59 is dependent for transfers with assistance of a mechanical lift and uses a power wheelchair for mobility.Review of Resident #59's Care Plan revised 12/4/2025 provided the following focus and interventions:a. Resident #59 has an altered cardiovascular status related to hypertension, heart failure, and coronary artery disease. Administer cardiac medications as ordered. Daily weights, if 5 pounds gain in one week, administer additional lasix that day. Monitor and report any signs or symptoms of coronary artery disease, chest pain or pressure with activity, shortness of breath, excessive sweating, and dependent edema. Oxygen at 2 liters via nasal cannula continuous. b. Resident #59 is at risk for signs and symptoms of COVID-19. Follow facility protocol for COVID-19 screening and precautions. Observe for signs and symptoms of COVID-19, document and promptly report fever, coughing, sneezing, sore throat, and/or respiratory/breathing issues. c. Initiated 12/11/2025, Resident #59 requires isolation precautions, specifically related to the COVID-19 infection. Observe effectiveness of medications; observe for signs and symptoms and inform provider if worsening. Intervention initiated 12/16/2025; Carry on conversations with Resident #59 during care so that he does not feel isolated; Resident #59 is receiving antibiotics for COVID associated respiratory infection, observe for potential side effects and report to the provider; notify provider of any worsening COVID symptoms; isolation per policy. d. Resident #59 has altered respiratory status, difficulty breathing related to heart failure, respiratory failure, and COPD exacerbation. Assess lung sounds as needed and notify provider of abnormal findings. Monitor for signs and symptoms of respiratory distress and report to provider. Continuous oxygen at 2 liters per minute via nasal cannula. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #59's symptoms started on 12/11/2025.Review of Resident #59's December 2025 MAR/TAR revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/11/2025, end date 12/21/25 Review of Resident #59's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.8. Review of MDS dated [DATE], revealed Resident #68 was admitted to the facility on [DATE] to a private room, BIMS of 15 (cognitively intact) and diagnoses of cancer, A-fib, heart failure, hypertension, kidney disease, type 2 diabetes mellitus, and respiratory failure with hypoxia (critical condition where lungs fail to get enough oxygen into the blood).Review of Resident #68's Care Plan, initiated 11/26/2025 included the following focus and interventions:a. Resident #68 requires assistance of 1 with a gait belt and walker for ambulation and transfer. b. Altered cardiopulmonary status with potential for shortness of breath, lung congestion, edema, chest pain, decreased level of consciousness, cyanosis, diaphoresis, complaints of nausea and vomiting related to heart failure and acute respiratory failure. avoid overexertion, requiring frequent rest periods during completion of activities. Instruct resident to notify nursing staff of any complaints of shortness of breath, chest pain, irregular heart rate. Observe for signs and symptoms if resident is unable to report symptoms and notify provider if signs and symptoms exist. c. Oxygen at 2 liters per minute via nasal cannula as needed. d. Observe for signs and symptoms of cardiac decompensation and report to provider. e. Enhanced Barrier Precautions (EBP) due to chronic wounds, gowns and gloves to be worn with all direct care. Proper hand washing before and after all cares. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #68's symptoms started on 11/29/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #68 was removed from TBP on 12/9/2025 after 7 days of isolation/TBP.Review of Resident #68's December 20025 MAR/TAR indicated an order for COVID MONITORING: Monitor for new cough, sore throat, new Shortness of Breath or difficulty breathing, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes findings every shift for 10 days. Start date 12/2/2025, D/C 12/9/2025. The MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered.Review of Resident #68's Nursing Progress Notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.9. Review of MDS dated [DATE] revealed Resident #74's admission to the facility on 5/5/2025 in a private room, BIMS of 15 (cognitively intact) and diagnoses of hypertension, polyneuropathy (nerve damage in extremities causing weakness, numbness, tingling and burning pain affecting sensory and motor functions), aortic valve stenosis (serious heart condition, aortic valve narrows causing obstructive blood flow), and weakness, Resident #74 is independent with transfers and mobility with the use of a wheelchair. Review of Resident #74's Care Plan revised 11/10/2025 indicated the following focus and interventions:a. Altered cardiovascular status related to hypertension. Assess for chest pain, enforce the need to call for assistance if pain starts. Monitor, document and report any signs or symptoms of coronary artery disease.b. Initiated 12/14/2025, require care isolation precautions specifically related to the COVID-19 infection. Observe for signs and symptoms and inform provider if worsening. Ensure resident stays in room, away from other people as much as possible (contact and droplet precautions). Monitor vitals and notify provider of abnormalities. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #74's symptoms started on 12/13/2025.Review of Resident #74's December 2025 MAR/TAR revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/13/2025 at 2:00 PM, Discontinue (D/C) date 12/23/2025. The residents MAR/TAR lacked documentation of all COVID assessments being completed as ordered.Review of Resident #74's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.10. Review of Resident #75 MDS dated [DATE] revealed admission to the facility on 5/17/2024 to a semi-private room (roommate Resident #12), BIM of 3 (severe cognitive impairment) and diagnoses of hypertension, chronic kidney disease, A-fib, and other specified signs and symptoms involving cognitive functions and awareness (brain fog, memory lapses, difficulty concentrating, altered mental status), stenosis of carotid artery, arterial fibromuscular dysplasia, hypertensive heart disease Resident #75 requires maximal assistance with transfers and mobility with the use of a gait belt and walker. Review of Resident #75's Care Plan revised 9/11/2025 indicated the following focus and interventions: a. High risk for COVID exposure due to communal living. Observe for signs and symptoms of COVID. Obtain rapid COVID test as indicated and report results to provider, should Resident #75 have a positive test, isolate per CMS/CDC guidelines. b. Resident #75 has altered cardiovascular status related to stenosis of carotid artery, arterial fibromuscular dysplasia, hypertensive heart disease. Administer medications as ordered. Monitor, document, and report any changes in lung sounds on auscultation, edema and changes in weight as needed. Review of Resident #75's December 2025 MAR/TAR failed to indicate monitoring for symptoms due to exposure to COVID positive roommate. Review of Resident #75's nursing progress notes and orders, failed to provide documentation related to Resident #75's exposure to COVID positive roommate, attempt to separate from roommate or provide interventions to reduce risk of transmission, and ordered monitoring for COVID symptoms. 11. Review of MDS dated [DATE] revealed Resident #85 was admitted to the facility on [DATE] to semi-private room (roommate with Resident #100), BIMS of 11 (moderate cognitive impairment) and diagnoses of kidney failure, history of rhabdomyolysis (breakdown of damaged muscle tissue), malnutrition, spondylosis lumbosacral region (degenerative changes in lower back), metabolic encephalopathy (condition causing brain dysfunction leading to confusion, seizures, or coma), bed confinement status, and weakness. Resident #85 is dependent on all transfers and mobility with the use of a mechanical lift and wheelchair. Resident #85's Care Plan, initiated 8/8/2024 indicated the following focus and interventions:a. Resident #85 requires enhanced barrier precautions (EBP) due to an extensive pressure area. Infection Preventionist to educate staff on donning (putting on) and doffing (removing) of equipment. Proper handwashing before and after all cares. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #85's symptoms started on 12/2/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #85 was removed from TBP on 12/8/2025 after 6 days of isolation/TBP.Review of Resident #85's December 2025 MAR/TAR revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/2/2025 D/C date 12/8/2025. MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered.Review of Resident #85's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.12. Review of Resident #91's MDS dated [DATE] revealed Resident #91 was admitted to the facility on [DATE] to a semi-private room (roommate Resident #118), BIMS of 0 (resident is not able to complete the assessment) and diagnoses of history of a stroke, hypertension, type 2 diabetes mellitus, arthritis, and aphasia. Resident #91 requires maximal assistance for transfers and mobility with use of a wheelchair. Review of Care Plan revised on 12/16/2025 indicated the following focus and interventions for Resident #91:a. EBP required due to MDRO CRE E. Coli (multi-drug resistant organism, superbug resistant to powerful antibiotics). Gowns and gloves to be worn with all direct care, Infection Preventionist to educate staff on donning and doffing of equipment. Proper handwashing before and after all cares. b. Altered cardiovascular status related to hypertension and history of stroke. Administer medications as ordered. Monitor, document, and report any changes in lung sounds on auscultation, edema and changes in weight as needed. Review of facility provided COVID-19 tracking spreadsheet indicated Resident #91's symptoms started on 12/3/2025, COVID-19 testing on 12/2/25 with positive results and TBP initiated. Resident #91 was removed from TBP on 12/8/2025 after 5 days of isolation/TBP.Review of Resident #91's December 2025 MAR/TAR revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/3/2025, D/C date 12/8/2025. MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered.Review of Resident #91's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.13. Review of MDS dated [DATE] revealed Resident #96 was admitted to the facility on [DATE] to a semi-private room (roommate Resident #97), BIMS of 0 (resident is not able to complete the assessment) and diagnoses of stroke, hypertension, hemiplegia affecting left side, emphysema, and COPD. Resident #96 requires maximal assistance with transfers and mobility. Review of Resident #96's Care Plan revised 12/8/2025 indicated the following focus and interventions:a. Initiated 10/28/2024, Potential risk for community acquired infection while living in a healthcare setting. Antibiotics as ordered, encourage oral fluids and nutrition as tolerated. Follow standards for outbreak testing and mitigation. Sanitize high touch surfaces to decrease the risk of infection. b. Initiated 12/8/2025, Resident #96 requires isolation precautions specifically related to the COVID-19 infection. Encourage resident to cover their mouth and nose when coughing or sneezing, ensure good infection control measures and PPE are used when working with resident. Contact and droplet isolation, encourage keeping door closed. c. Altered cardiovascular status related to hypertension and history of stroke. Assess for chest pain and shortness of breath and monitor vital signs per protocol.d. Diagnosis of COPD, give aerosol or bronchodilators as ordered monitoring for side effects and effectiveness. Monitor for signs and symptoms of acute respiratory insufficiency. Monitor, document, report any signs and symptoms of respiratory infection.Review of facility provided COVID-19 tracking spreadsheet indicated Resident #96's symptoms started on 12/7/2025, Resident #91 was removed from TBP on 12/12/2025 after 5 days of isolation/TBP.Review of Resident #96's December 2025 MAR/TAR revealed an order for Covid positive assessment: Monitor temperature, pulse ox (oxygen saturation), assess lung sounds, shortness of breath or labored breathing, for changes in resident's baseline alertness. Monitor for NEW symptoms since isolation started; cough, sore throat, loss of taste or smell, chills, fatigue, nausea, vomiting, diarrhea, muscle or body aches, headache, congestion, runny nose, every shift for 10 days. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code other/see nurses notes and enter findings of assessment in progress notes. Start date 12/7/2025, D/C date 12/12/2025. MAR/TAR failed to provide vitals and assessments for complete 10 days as ordered.Review of Resident #96's Nursing Progress notes failed to provide complete assessments indicating assessed symptoms, lungs sounds, shortness of breath, and any changes to resident's baseline alertness every shift (three times daily) for complete 10 days as ordered.14. Review of MDS dated [DATE] revealed Resident #97 was admitted to the facility on [DATE] to a semi-private room. (Roommate with Resident #96) Resident #97's BIMS 0 (Resident was not able to complete assessment) and diagnoses of heart failure, type 2 diabetes mellitus, Alzheimer's Disease, and seizure disorder.Review of Resident #97's Care Plan revised 8/27/2025 failed to indicate Resident's risk for COVID.Review of Resident #97's December 2025 MAR/TAR failed to indicate monitoring for symptoms due to exposure to COVID positive roommate.Review of Resident #97's nursing progress notes and orders, failed to provide documentation related to Resident #97's exposure to COVID positive roommate, attempt to separate from roommate or provide interventions to reduce risk of transmission, and ordered monitoring for COVID symptoms. 15. Review of MDS dated [DATE], revealed Resident #100's admission to the facility on 8/1/2024 in a semi-private room. (roommate Resident #85, who tested COVID positive on 12/2/2025), BIMS of 13 (cognitively intact) and diagnoses of hypertension, type 2 diabetes mellitus, asthma, and adult failure to thrive. Review of Resident #100's care plan, revised 12/6/2025 indicated the following focus and interventions:a. Altered cardiopulmonary status with potential for shortness of breath, lung congestion, edema, chest pain, decreased level of consciousness, cyanosis, diaphoresis, complaints of nausea and vomiting related to hypertensive heart disease and asthma. Interventions included avoiding overexertion, requiring frequent rest periods during completion of activities. Observe for signs and symptoms of cardiac decompensation and report to provider.b. Initiated 10/29/2024, Potential risk for community acquired infection while living in a healthcare setting. Follow standards for outbreak testing and mitigation and sanitize high touch surfaces to decrease the risk of infection.c. Revised 12/6/2025, resident requires care isolation precautions specifically related to the COVID-19 infection. Encourage resident to cover their mouth and nose when coughing or sneezing, ensure good infection control measures and PPE are used when working with resident. Contact and droplet isolation, encourage keeping door closed. Review of facility provided COVID-19 tracking spreadsheet indica

Based on observation, staff interview, and policy review, the facility failed to label food stored in the refrigerator, failed to properly thaw meat used for lunch meal service, and failed to discard delivery boxes. The facility reported a census of 109 residents.Findings include: On 12/15/25 at 8:35 AM, the following items were observed during kitchen tour:1) One (1) pack of frozen ham thawing in an aluminum pan full of standing water in the sink.2) Seven (7) packs of thawed ham in an aluminum pan of standing hot water.3) Three (3) flattened delivery boxes lying on a kettle (large machine used for making soups, etc)4) An unlabeled, clear, plastic container with sliced, white, oval items.5) An unlabeled, clear, plastic container with sliced, light green, disk shaped items.6) A unit refrigerator with a multicolored, cloth item with a resident label later identified as a coldpak. At 9:10 AM, Staff A, Registered Nurse (RN) stated she did not know who placed the item in the refrigerator. The Certified Dietary Manager (CDM) informed the unit nurse that resident healthcare items cannot be placed in the resident food storage refrigerator. Staff A stated she didn't know where to put it then. On 12/17/25 at 4:35 PM, Staff KK, Nurse Consultant stated items should be dated and labeled when stored and delivery boxes should be stored appropriately. On 12/17/24 at 4:50 PM, the CDM stated the ham located in the standing hot water pan was present because the cook placed the 7 frozen hams in the oven to speed up the thawing process. A policy titled Food Handling Policy revised 7/24/24 indicated defrosting will be done by placing the frozen item in the refrigerator until thawed or placed in a cold-water bath for defrosting. It also indicated no soiled cloths, boxes, cartons or other items that may contaminate food will be placed on food preparation surfaces. It further indicated leftover food can be stored for up to three (3) days and a label will be affixed to the container with the following information:a) Name of the food itemb) The date food was placed in containerc) Indicate if contents include a common allergen such as peanuts, tree nuts or eggsd) Check recipe card provided by main kitchene) Evening staff will discard leftover food items that have been held for over three (3) days in the refrigerator.

Based on record review, staff interviews, and policy review the facility failed to ensure staff documented the non-pharmacological interventions attempted prior to the administration of anti-anxiety medication for one of five residents reviewed for unnecessary medications (Resident #39). The facility reported a census of 109 residents.Findings include:A significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, dementia and anxiety. The MDS revealed the resident had impaired short-term and long-term memory and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident had inattention and disorganized thinking present, and rejected care 4-6 days during the look-back period. The MDS indicated the resident took an antipsychotic medication. The Care Plan revised 2/25/25 revealed the resident required use of an antipsychotic medication due to behaviors of anxiety and aggression related to senile degeneration of the brain. The behavioral triggers included physical aggression (pushing away) and combativeness toward staff during cares, resistance to cares, pacing and wandering. The care plan directed staff to administer medications as ordered at the lowest therapeutic dosage, and observe for any side effects of the medications. The Treatment Administration Record (TAR) dated 2/2025 and 6/2025 revealed to monitor for antipsychotic medication side effects. The Progress Notes revealed Lorazepam (Ativan) (an antianxiety medication) 0.5 mg (milligrams) given by mouth (PO) as needed (PRN) for anxiety and/or restlessness on the following dates and times: a. On 2/19/25 at 11:10 AM, the resident had on the same shirt for the past two days. Nurse approached resident to change clothing. Resident was restless and anxious. Lorazepam medication administered.b. On 6/30/25 at 9:55 AM, food given. No other non-pharmacological interventions were documented prior to administration of the PRN lorazepam. In an interview 12/22/25 at 11:35 AM, Staff U, Registered Nurse (RN) reported she documented nonpharmacological intervention in the progress notes prior to giving a PRN medication and documented the nonpharmacological interventions that were not effective. In an interview 12/22/25 at 11:45 AM, Staff G, Licensed Practical Nurse (LPN) reported when she signed out an antianxiety medication, she added a note at that time of the interventions that were attempted. He also entered a progress note with the things that were tried but didn't work before he administered an antianxiety medication. Staff G stated he had been told to try three things before he gave a PRN medication, and then document if the nonpharmacological interventions were effective or not. In an interview 12/22/25 at 2:31 PM, Staff A, RN, reported whenever she gave a PRN medication, she clicked on the PRN medication in the electronic health record, and she had to document the reason for the PRN medication. At that time, she typed a note with what things she did before she gave the PRN medication. Staff A stated she could also put in a progress note to document the interventions that staff had done or tried. In an interview 12/22/25 at 2:47 PM, Staff V, LPN, reported she documented the nonpharmacological interventions in the progress notes whenever she gave a PRN antipsychotic or antianxiety medication. In an interview 12/23/25 at 12:34 PM, Staff T, Assistant Director of Nursing (ADON), reported she expected staff to document nonpharmacological interventions before a PRN medication administered. She expected the nonpharmacological interventions documented in the progress note on the EMAR as the staff gave the medication. The listing of 1-2-3 on the MAR should be where the staff documented the interventions that were done prior to the PRN medication administration. An undated Psychotropic Medication Monitoring policy revealed psychotropic medications include antianxiety medications. The facility supported the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. The use of psychopharmacologic medications for dementia-related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual resident needs, preferences and routines is the most appropriate and first-line treatment for dementia-related behaviors. The goal was to determine the underlying cause of residents having difficulty sleeping so the appropriate treatment of environment or medical interventions that could be used prior to psychopharmacologic medication use.

Based on clinical record review, staff interviews, and policy review, the facility failed to notify the resident's representative in writing of a transfer to the hospital and a policy for bed hold including reserve bed payment for 1 of 3 residents reviewed for hospitalization (Resident #3). The facility reported a census of 109 residents.Findings include: The Minimum Data Set (MDS) for Resident #3 dated 11/01/25 indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated severely impaired cognition. It included diagnoses of kidney failure, non-Alzheimer's dementia, Alzheimer's disease, a hip fracture, and traumatic brain injury. It revealed the resident required setup assistance with eating, maximal assistance with toileting, toilet transfers, dressing, and personal hygiene, and was independent with oral hygiene and all other forms of mobility. The Care Plan revised 9/24/24 included impaired cognitive function/impaired thought processes related to unspecified dementia with confusion and directed staff to discuss concerns about confusion, dementia disease progression, nursing home placement with the resident's family members' names listed. The Progress Notes dated 8/03/25 indicated the resident fell and sustained right hip pain and was transferred to the Emergency Department. It included a progress note at 11:24 AM that indicated a family member was notified of the transfer and a bed hold. The Medical Record did not include a signed or dated, written notification of transfer notification or bed hold policy with reserve payment. On 12/18/25 at 9:35 AM, the Social Services Worker (SW) stated the bed hold was documented in progress notes but the form was not completed. On 12/18/25 at 12:06 PM, Staff F, Registered Nurse (RN) stated the bed hold and representative notification of transfer form were not completed. The facility did not have a policy available for bed hold and transfer notification. A Bed Hold Policy effective 12/2025 revealed the facility shall inform residents or their representative prior to transfer to the hospital of the bed hold policy. The bed hold policy will be provided to the resident or representative within twenty-four hours of an emergency transfer to the hospital.

Based on direct observation, clinical record review, staff interview, policy review and Resident Assessment Instrument (RAI) Manual the facility failed to ensure proper Minimum Data Set (MDS) coding by coding residents as having physical restraints when they did not have physical restraints present, and by not coding a residents mental illness when indicated for three of twenty-two residents reviewed for MDS assessments (Resident #4, #9, and #21). The facility reported a census of 109 residents. The Minimum Data Set (MDS) assessment for Resident's #9 and #21, last completed on 09/06/2025 for Resident #9, and 09/20/2025 for Resident #21, indicate both residents had a physical restraint in the form of a bed rail present, as denoted in question P0100. The care plan for Resident #9, last updated 11/28/2025, documented the resident prefers to have side rails on their bed as it makes them feel safer. The care plan for Resident #21, last revised 12/03/2025, documented the resident prefers to have bed rails on their bed to make them feel safer and because it enhances the residents mobility in bed. A Bed rail assessment for Resident #9, completed on 11/28/2025, documented the bed rail was present at resident request and enhanced the residents mobility in bed. A bed rail assessment for Resident #9, completed on 12/11/2025, documented the bed rail was present at resident request and enhanced the residents mobility in bed. A direct observation on 12/18/2025 revealed the bed rails to be present but noted the bed rails to be partial side-rails that did not restrict a residents ability to get in or out of bed. An interview on 12/18/2025 at 01:36 PM with Staff W, Assistant Director of Nursing (MDS), stated she took fully responsibility with the MDS coding issue. She stated she recently attended an Iowa Health Care Association training where she learned they had been coding bed rails as restraints in error. In an interview on 12/18/2025 at 01:45 PM with Staff X, MDS Coordinator, she expressed confusion on whether or not to code the bed rails as a restraint on question P0100. She stated they do not have an MDS policy but follow the State Resident Assessment Instrument (RAI Manual). The 10/2025 Resident Assessment Instrument states the following for question P0100. Physical restraints are any manual method or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's body. The assessments present indicate the bedrails in question do not restrict movement, but enhance mobility. The annual MDS assessment dated [DATE] revealed Resident #4 had diagnoses of bipolar disorder, psychotic disorder, intermittent explosive disorder, anxiety, and depression. The MDS indicated the resident not currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have a serious mental illness or a related condition. The Care Plan revised 5/22/23 revealed the resident had a PASRR Level I completed. The care plan also revealed the resident had diagnoses of anxiety disorder, major depression, dementia with behavioral disturbance. The care plan directed staff to do a PASRR re-evaluation if there was a change in a major mental illness condition. Resident #4's PASRR dated 10/7/25 revealed a Level II outcome. The PASRR included the resident's diagnoses of major depressive disorder, delusional disorder, bipolar disorder, anxiety disorder, and Alzheimer's dementia. In an interview 12/18/25 at 9:35 AM, Staff F, MDS Coordinator, reported she completed the residents MDS assessments at least quarterly. Staff F reported she got information to complete MDS assessments and care plans from the medical records and interviews with the resident. She reviewed the resident's PASRR to see if a Level II PASRR was required, and then she marked the MDS under section A1500 yes if the PASRR directed her to mark the question for a PASRR condition. In an email 12/18/25 at 10:54 AM, Staff W, Assistant Director of Nursing, wrote they do not have a policy for MDS assessments, they followed the RAI Manual. The Long-Term Care Facility RAI User's Manual updated 10/2025 revealed the following: a. Review the Level I PASRR form to determine whether a Level II PASRR was required.b. Review the PASRR report provided by the State if Level II screening was required.c. Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II PASRR Conditions.d. Code A, serious mental illness: if resident has been diagnosed with a serious mental illness.

Based on observation, record review, staff interview, and policy review, the facility failed to use a gait belt while transferring a resident who required assistance with mobility for 1 of 22 residents (#103). The facility reported a census of 109 residents.Findings include: On 12/16/25 at 1:23 PM, Staff I, Certified Nurse Aide (CNA) was observed watching a visitor attempt to transfer Resident #103 without assistance. When the resident began losing balance, Staff I assisted the visitor with transferring the resident from a recliner to his wheelchair without using the gait belt wrapped around her waist. On 12/16/25 at 1:52 PM, J, CNA stated gait belts should be used to transfer residents who are off balance, can't stand by themselves, or for safety issues. She stated staff uses a gait belt for Resident #103 except when his friend comes. His friend gets him out of the chair himself. On 12/16/25 at 2:01 PM, Staff K, Registered Nurse (RN) stated the resident walks by himself but gets up with assistance. She stated a gait belt should be used with residents who require assistance. On 12/16/25 at 2:09 PM, Staff K, RN stated she doesn't know if the resident's friend was provided education regarding the safety importance of using a gait belt for resident transfers and didn't know where the education documentation would be.The Minimum Data Set (MDS) for Resident #103 dated 11/01/25 revealed a Brief Interview for Mental Status (BIMS) score could not be obtained due to the resident being rarely or never understood. It included diagnoses of non-Alzheimer's dementia, traumatic brain injury, age-related mental decline, visual loss, and syncope (temporary loss of unconsciousness from reduced blood flow to the brain), and collapse. It indicated he was dependent with toileting, required setup assistance with eating, moderate assistance with dressing and chair-to-chair transfers, and maximal assistance with all other Activities of Daily Living (ADLs) and forms of mobility. It also indicated the resident had a fall since admission to the facility and used a wheelchair for mobility in the previous 7-day look-back period. The Care Plan revised 5/07/25 indicated the resident required assist x 1 with FWW (front-wheeled walker) at baseline with use of wheelchair on occasions with poor balance/mobility. It also included the resident's potential for falls related to generalize weakness, decreased mobility, poor safety awareness, and non-compliance with transfer status. It did not include the resident's friend resisting staff assistance with resident transfers nor education provided to the resident's friend on the safety importance of gait belt use for resident transfers.A Resident Care Conference Summary document dated 11/12/2025 did not include educating the resident's friend on the safety importance of gait belt use for resident transfers. It also did not include the resident's non-compliance with transfersThe Progress Notes did not include any documented education provided to the resident's friend regarding the safety importance of gait belt use for resident transfers.On 12/17/25 at 8:02 AM, Staff L, RN stated a gait belt is required for residents who require staff assistance for transfers for safety. She stated staff should use a gait belt when transferring Resident #103.On 12/17/25 at 8:48 AM, Staff I, CNA transferred Resident #103 with a gait belt. On 12/17/25 at 12:43 PM, Staff M, CNA stated if a resident requires assistance with transfers, a gait belt should be used. On 12/17/25 at 12:55 PM, Staff N, CNA stated a gait belt should be used when a resident requires transfer assistance from staff. On 12/17/25 at 12:59 PM, Staff O, CAN stated a gait belt should be used for resident transfers if they require staff assistance. On 12/17/25 at 1:31 PM, Staff P, Quality Assurance (QA) stated she did not have any documentation of the resident's friend being educated on the importance of using a gait belt for resident transfers.On 12/17/25 at 1:37 PM, the Director of Nursing (DON) stated she would have to look for documentation of any education provided to the resident's friend regarding the importance of using a gait belt with resident transfers. She also stated she had not heard about the resident's friend transferring him.On 12/17/25 at 4:17 PM, the DON stated CNAs should notify charge nurse or the manager, if available. The charge nurse should report it to the manager. A policy titled Gait Belt, Transfer, Wheel Chair effective 3/07/07 indicated residents who are unable to transfer or ambulate independently shall be assisted by staff instructed in proper procedures. A gait belt shall be used when a resident needs assistance with balance and/or strength.

Based on observation, staff interviews and policy review, the facility failed to ensure staff used proper food handling procedures to prevent possible contamination of food during lunch service with food uncovered. The facility reported a census of 111 residents. Findings include: During an observation 10/30/24 at 12:15 PM, the steam table was transported from unit B1 to unit C1 with the sweet potatoes and peas uncovered and with the bread partially uncovered. This steam table was transported from the dining room in unit B1, down a resident hallway, out into the main area and then into unit C1, down resident hallway in unit C1 and into the dining room in unit C1. Meals were then served to residents in unit C1 from the steam table. During an interview 10/30/24 at 12:50 PM, the Certified Dietary Manager (CDM), stated food should be covered during transportation in the hallways and in main areas, for infection control purposes. The CDM stated an expectation food is covered during transportation. During an interview 10/30/24 at 4:30 PM, the Administrator acknowledged an expectation food is covered on the steam table during transportation from one unit to another unit. Review of facility policy Food Handling, with a revision date of 7/24/24, documented the facility will store, prepare, distribute and serve food in accordance with professional standards for food service safety. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering food is appropriate, either individually or in a mobile food cart.

Based on record review, policy review, and staff interviews the facility failed to complete a discharge summary and discharge plan for 1 resident (#113). The facility reported a census of 111 residents. Findings include: The Electronic Health Record (EHR) revealed Resident #113 was admitted to the facility on [DATE] for skilled services. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #113 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. The EHR included diagnoses of vertebral fractures (fractured back bones). It also documented she was independent with eating, required supervision with oral hygiene, and required maximum assistance with all other Activities of Daily Living (ADLs) except upper body dressing. The EHR lacked discharge plan and discharge summary documentation. On 10/31/24 at 8:33 AM, the administrator stated the discharge plan and discharge summary were not completed due to the circumstances surrounding the resident's discharge from the building. In an email on 10/31/24 at 11:19 AM, the administrator indicated the documentation was not completed. A policy titled Admission, Transfer, Discharge Policy revised 9/04/24 indicated resident-initiated discharge clinical records would contain a discharge care plan. The policy did not include specific directives regarding discharge summaries.

Based on observations, staff interview, clinical record review and policy review the facility failed to provide appropriate catheter and peri-care for 1 of 1 resident (#103) to prevent a urinary tract infection. The facility reported a census of 111 residents. Findings include: On 10/29/24 at 1:45 pm, Resident #103 stated he had a urine bag (indwelling catheter) but could not remember if he had taken an antibiotic. The Minimum Data Set (MDS) assessment for Resident #103 dated 8/06/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of Transient Ischemic Attack (TIA- a brief blockage of blood flow to the brain that causes stroke-like symptoms), Cerebral Infarction (stroke caused by blocked blood flow to the brain), Chronic Obstructive Pulmonary Disease (COPD), and a history of Urinary Tract Infections (UTIs). The MDS indicated Resident #103 was independent with eating, required setup assistance with oral hygiene, and required moderate assistance with toileting hygiene, bathing, sit-to-stand and bed-to-chair transfers. It indicated the resident required intermittent catheterization. The Electronic Health Record (EHR) included a progress note dated 8/23/24 which indicated the resident had an indwelling catheter upon return from an acute care setting (hospital). It also included an order dated 10/14/24 for Cipro Oral Tablet 500 mg and instructed staff to give 1 tablet by mouth two (2) times per day for a UTI for seven (7) days. The Care Plan dated 9/26/24 directed staff to use extended barrier precautions (EBP) per Center for Medicare and Medicaid Services (CMS) guidelines. On 10/30/24 at 10:08 AM, Staff A Certified Nurse Aide (CNA) and Staff B, CNA performed peri-care and indwelling catheter care for Resident #103. Continuous observation revealed Staff A and Staff B donned Personal Protective Equipment (PPE) and entered the resident's room. They performed hand hygiene and donned gloves. Staff A placed a plastic bag on the resident's bed, removed her gloves, and got another bag. Staff B got a pack of Procare wipes and donned new gloves. She removed one (1) wipe from the package and wiped the resident's testicles in an upward toward the resident's penis and wiped the penis tip. She got another wipe from the packaging and wiped the resident's penis tip and catheter tubing away from the resident. At 10:21 am, Staff A and Staff B assisted the resident to a sitting position on the bedside. During repositioning, Staff B grabbed the catheter drainage bag by the drain spigot and adjusted it against the resident's leg. Staff B lowered the drainage bag above the urine cylinder, opened the spigot, and emptied the drainage bag. She closed the drainage bag, grabbed an alcohol wipe from Staff A, and wiped the spigot tip. Staff A took the cylinder and emptied the urine into the toilet. Staff B, removed her gloves, pulled the resident's pants back up, and helped him back to the chair. Staff B did not perform hand hygiene between peri-care and indwelling catheter care. At 10:33 am, the Director of Nursing (DON) informed Staff B she would be retrained on peri-care and catheter care. A facility policy titled Peri Care Policy revised 8/19/24 indicated the purpose of the policy was to prevent infections and directed staff to perform peri care on male residents by washing the perineal area starting with the urethra and working outward. A facility policy titled Handwashing/Hand Hygiene revised 6/15/24 directed all personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It also directed staff to use alcohol-based hand rub or soap and water before and after handling an invasive device.

Based on record review, staff interview, and policy review the facility failed to notify the Long Term Care (LTC) Ombudsman of a resident transfer as required for 1 of 3 residents reviewed who were transferred from the facility (Resident #75). The facility reported a census of 111 residents. Findings include: Resident#75's Clinical Census Report documented that the resident had transferred from the facility on 3/30/24 to a hospital, and reentered the facility on 4/8/24. The clinical record lacked the documentation of notification to the LTC Ombudsman that the Resident #75 had transferred to the hospital. During an interview 10/31/24 at 1:10 PM the Director of Nursing (DON) stated the facility did not report to the Ombudsman when the Resident #75 went to the hospital. The facility policy titled Admission, Transfer, Discharge revised 9/4/24 instructed the staff to notify the State Ombudsman of any/all facility-initiated discharges for assistance with transition and support of the resident and representative.

Based on record review, staff interview, and policy review the facility failed to conduct a thorough investigation of an alleged violation of abuse by a resident, by not interviewing staff regarding the allegation for one (Resident #5) of three residents reviewed. The facility reported a census of 115 residents. Findings included: The Five Day Minimum Data Set (MDS) assessment for Resident #5 dated 1/14/24, included diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, and depression. The MDS indicated the resident had a Brief Interview for Mental Status score of 14, which indicated no cognitive impairment for decision making. Review of resident's progress note dated 3/7/24 at 3:10 PM documented: This nurse brought resident to the bathroom and saw a bruise located on resident's right cheek. Resident became tearful and stated, I got the shit beat out of me. Resident then finished using the bathroom and this nurse brought resident to the Assistant Director of Nursing (ADON) for further investigation. This nurse sat in the office with ADON while investigating. Resident appeared to be confused on where the actual location of bruise was at further in conversation. Resident was only able to describe the attackers skin color being, black, tan, I don't know, I don't like these questions. Resident did believe that the person was a couple of teen girls who room with her. Resident was unable to mention what she was stuck with. Resident feels scared. Resident called her daughter mom. Resident mentioned that confusion is her diagnosis. Resident was unable to give an exact time or date of when this event took place. Resident then was able to mention that this happened on Monday or Tuesday. Review of resident's incident report dated 3/7/24 at 2:25 PM documented: Nursing Description: resident reported to nurse that she had a bruise on her right cheek because someone beat the shit out of her. Resident reported that on Monday or Tuesday afternoon, she was sitting in her room when 1-2 teenage women she roomed with came up behind her and beat her up, hurt her arms, and drug her across the floor because she has nice clothes. Resident Description: I got the shit beat out of me. It wasn't yesterday. It was probably Monday or Tuesday. It was a woman she came up from behind me. I didn't see her. She said I better not tell. I'm scared to go back to my room. She didn't like the way I dress. She said I was showing off because I have nice clothes. It was two girls, but I don't know what they looked like. It was just my arms they got. They drug me across the floor. They had girlish clothes on. They were in their teens. Review of facility's Investigation Summary for Resident #5 3/7/24 documented: Immediate Action Taken: investigation started, physician and family notification, state initial report, and skin assessment, listed the resident health record documents reviewed, and concluded with summary further documented conclusion of unable to substantiate allegation and investigation completed. Investigation summary did not document any staff interviews completed. On 8/14/24 at 3:30 PM, review of facility's incident folder for Resident #5 dated 3/7/24, provided by the Administrator, lacked documentation of any staff interviews regarding incident of resident's allegation of abuse. Interview on 8/14/24 at 4:23 PM, Staff A, Certified Medication Aide stated has been employed at the facility for 2 years and was not interviewed regarding Resident #5's allegation incident on 3/7/24 and was not aware of the incident. Interview on 8/14/24 at 4:25 PM, Staff B, Certified Nurse Aide stated has been employed at the facility for [AGE] years and was not interviewed regarding Resident #5's allegation incident on 3/7/24 and was not aware of the incident. Interview on 8/14/24 at 4:27 PM, Staff C, Licensed Practical Nurse stated she has been employed at the facility for 3 years and was not interviewed regarding Resident #5's allegation on 3/7/24 and was not aware of the incident, but was aware of a different reported incident with Resident #5. Facility policy, Abuse Prevention, Identification, Investigation, and Reporting Policy, reviewed/revised 8/5/24, included investigation protocols of attempt to obtain witness statements from all known witnesses. Interview on 8/14/24 at 6 PM, the Administrator (ADM) confirmed the incident folder for Resident #5 lacked documentation of any staff interviews completed. The ADM further stated expectation to complete staff interviews when doing investigations.

Based on record review, resident and staff interview, and policy review the facility failed to complete an incident report and notify the physician and resident's emergency contact/next of kin for a new bruise for 1 (Resident #1) of 3 residents reviewed. The facility reported a census of 115 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 6/28/24, included diagnoses of Parkinson's (condition that deteriorates the brain) and Non-Alzheimer's. The MDS identified the resident was dependent on staff for toileting, dressing, and personal hygiene and had a Brief Interview for Mental Status score of 12, which indicated mild cognitive impairment for decision making. Interview on 8/14/24 at 10:45 AM, the resident stated she had a bruise on her upper right arm that is getting better; that she had woke up one morning and found the bruise. The resident stated she reported it to staff and was not sure what caused the bruise. Resident's progress notes documented on 6/28/24 at 9:12 PM - New skin issue of bruise on right upper arm, 3.5 centimeters (cm) length and 3.5 cm. width. Review of resident's progress notes for 6/28/24 - 7/1/24, lacked documentation of physician and emergency contact notification of new bruise. Facility policy, Notification of Changes reviewed/revised 2/2024 documented the purpose of this policy is to ensure the facility promptly consults the resident's physician and notifies the resident's representative when there is a change requiring notification. Interview on 8/14/24 at 11:15 AM, the Administrator (ADM) stated she had not been aware of the bruise, confirmed no incident report was completed, and the physician and family were not notified of the bruise at the time it was observed. The ADM stated her expectation with any bruise bigger than a quarter, the staff are to complete an incident report and the physician and family are to be notified at that time

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide basic life support to a resident requiring emergency care. Resident #1 was found unresponsive at meal time on [DATE] around 12:15 p.m., staff initiated chest compressions but failed to access the emergency cart which contained emergency equipment including a suction machine and Ambu bag to provide rescue breathing. Upon arrival of emergency medical services (EMS) after 20 minutes unresponsive, suction produced removal of a large food bolus. EMS intubated and transported to hospital where resident later expired due to asphyxiation. This failure posed an Immediate Jeopardy to the residents health and safety. The facility reported a census of 108 residents and 31 residents who requested cardiopulmonary resuscitation (CPR). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 3:15 p.m the facility staff removed the immediate Jeopardy on [DATE] through the following actions: * Staff re-educated on the CPR policy, where to locate the emergency equipment and provide rescue breathing when providing CPR (Education initiated and ongoing). *All supply areas have signs placed on doors to state emergency storage supply *Director of Nursing of designee will conduct three interview to three licensed nurses to validate CPR process by responding to the four processes identified on the audit sheet weekly for four weeks. The scope lowered from a K to a E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a resident census of 108. Findings include: A Policy and Procedure with revised date [DATE], documented the Emergency Procedure-Cardiopulmonary Resuscitation (CPR) stated: It is the policy of the facility to respond to medical emergencies for residents, staff and visitors. Policy Explanation and Compliance Guidelines: *The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate basic first aid and summon for assistance. *A nurse will assess the situation and determine the severity of the emergency, stay with the resident, designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. *All available staff will respond to the emergency accordingly. *Charge Nurse will designate a staff member to obtain emergency cart and bring to the code site, ensure accurate documentation of the event and delegate any other duties or tasks as needed. *this will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS. *If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. An Admission Minimum Data Set (MDS) assessment tool, dated [DATE], documented Resident #1 with a Brief Interview for Mental Status (BIMS) score of 12, for which indicates moderately impaired with decision making abilities. The MDS revealed the resident required staff assistance for bed mobility and dressing, and independent with set up for eating, and functional limited range of motion in the lower extremities (hip, knee, ankle, foot). The MDS revealed the resident's diagnoses included thyroid disorder, hip fractures, non-Alzheimer dementia, hemiplegia or hemiparesis, seizure disorder, epilepsy and bipolar disorder. An Iowa Physicians Orders for Scope of Treatment (IPOST) signed by family (Durable Power of Attorney for Health Care) on [DATE] at 1:39 p.m., identified the request for CPR for Resident #1. Record review revealed Progress Notes documented: * (late entry) dated [DATE] at 1:43 p.m., documented when the emergency medical technician (EMT) asked for a portable suction, I retrieved it and I hooked it up, but the emergency medical technician were the ones who used it. *on [DATE] at 1:53 p.m., Daughter called out to nurse that resident needs help, that she does not look good. Nurse immediately went into resident's room. Noted resident unresponsive, pale with food in front of her. ? resident choked on food. Did the Heimlich , no food noted in resident's mouth. Instructed the other nurse for us to put resident on the floor to start cardiopulmonary resuscitation (CPR). CPR was started but, still no pulse. I and other nurse took turn doing chest compressions until paramedics arrived and took over. *on [DATE] 4:18 p.m., I was in the room giving the res her scheduled Norco at 12:32 p.m., and res was eating and talking at that time. Then I went down to C hall to give insulin's. I gave my last insulin about 12:50 p.m., and was putting the insulin back in the cart when I heard the resident's daughter say she needed a nurse in her room, that she did not look good. I rushed to her room, upon entering the other nurse was doing the Heimlich maneuver. She said let's get the resident on the floor and me and the med aid lifted the resident to the floor and started doing CPR. We told the medication aid to call 911. When we switched doing chest compressions this nurse went out to call 911. I gave the 911 operator all the necessary info and I headed back to relieve the other nurse. We switched doing chest compressions until the EMT arrived to relieve us. I gave the EMT the info of what happened and stayed close the answer questions. At about 1:15 p.m., the EMT asked for portable suction; I retrieved the suction for them. *At about 1:30 p.m., the EMT said they had a rhythm on the resident and were going to transfer to the hospital. *at 4:31 p.m., On call physician notified of residents transfer to Methodist hospital. Phone call to daughter to follow up on the events that occurred this afternoon. Resident in critical care unit on life support at this time. During an interview [DATE] at 11:00 a.m., Staff B, Registered Nurse (RN) confirmed her involvement with participation in the CPR process with Staff A, Licensed Practical Nurse (LPN) . Staff B explained that when she entered the residents room, Staff A stated that they needed to lay the resident on the floor and begin CPR. Staff B explained that no mouth to mouth was given while she was in the residents room, only chest compressions until the ambulance arrived. Staff B was not able to determine how long chest compressions were being done, only it seemed like a long time. During an interview on [DATE] at 1:20 p.m., Staff C, certified medication aide (CMA) confirmed that he was in the residents room while Staff A and Staff B performed CPR on the resident. Staff C stated that he was in involved with the participation in the process of CPR. Staff C explained that while he was in the residents room only chest compressions were being performed on the resident and no mouth to mouth was performed. During an interview on [DATE] at 1:00 p.m., Staff A confirmed her involvement with participating in the CPR process with Staff B. Staff A confirmed that mouth to mouth was not performed and only chest compressions were performed on Resident #1. Staff A stated that she attempted the Heimlich maneuver on the resident but failed to check to see if anything was in Resident #1's airway. Staff A stated that the expectation of the nursing staff is to follow the policy and procedure for CPR. The Des Moines Fire Department patient record dated [DATE] documented at 1:11 p.m., responded to cardiac arrest patient at [NAME] Park nursing home. EMS given incorrect location from dispatch that was across the street from where patient resided. Police Officer arrived first at incorrect location. Delay resulted from incorrect location and the time it took to find the correct location through dispatch. Upon arrival at correct location, Lead and fire medic: brought [NAME] device, ambu bag, red bag, and monitor to patient room, Additional support brought stretcher and additional equipment when they arrived. Staff led EMS through nursing home (NH) to patient room on second floor. Patient was found unresponsive on floor of nursing home room with ineffective manual CPR being performed by NH staff. Patient had several family members in the room along with a roommate. It was unknown if arrest was witnessed. Patient's daughter stated that the patient had been in that state for at least 15 minutes. Patient's roommate stated that she was the last person to talk to the patient and that that was 30 min. prior td EMS arrival. The patient's daughter stated that she had POA and did not wish for her mother to be coded. When asked for documentation nursing home staff stated that patient did not have an advance directive and that the patient wished to be a full code to which daughter agreed. EMS had already placed patient on monitor with initial rhythm of Asystole (lack of cardiac activity). CPR was initiated, When advanced airway efforts were initiated, considerable amounts of food were found in the patient's airway. Intubation efforts were delayed to suction out the food and then the patient was intubated. No blood, bile or vomit were found in airway, Patient's rhythm during subsequent pulse checks. After administration of Epinephrine, return of spontaneous circulation was achieved with a strong pulse and normal sinus rhythm. CPR discontinued and RESQPOD ( a threshold device that attaches to the airway during CPR to enhance negative pressure and increase perfusion) was removed. Patient was moved onto a backboard and secured fully without issue. Patient lifted and placed on EMS stretcher without issue. Patient brought through nursing home to ambulance by stretcher. Phone report made to the hospital and transport initiated. Patient went back into cardiac arrest approximately 2 minutes prior to hospital arrival. At hospital, patient transferred to resuscitation room bed by backboard without issue. Patient care transferred to resuscitation team. During an interview on [DATE] at 1:45 p.m., the facility DON, confirmed and verified that the nurses are expected to follow the CPR policy and procedure and do mouth-mouth along with chest compressions and to obtain the crash cart. The State of Iowa Certificate of Death dated [DATE], documented the immediate cause of death-asphyxia (suffocation), due to choking on food bolus and description of injury -choked on food.

Based on clinical record review, observation, and staff interview, the facility failed to serve a resident a mechanical soft diet as ordered by the physician. During the noon meal service on [DATE], the ticket incorrectly directed staff to serve a regular diet to a resident who required a mechanical soft diet. During the process of serving the incorrect diet, this surveyor stopped the dietary staff from serving the meal. These circumstances posed an Immediate Jeopardy to the residents health and safety. (Resident #2). During closed record review the facility failed to serve the correct diets for 2 of 4 residents reviewed. (Resident #1 and Resident #3). The facility reported a census of 108 residents and identified 11 residents on a mechanical altered diet. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of on [DATE] on [DATE] at 4:15 p.m. The facility staff removed the Immediate Jeopardy on [DATE] through the following actions: Provided the following education to all staff: *Dietary Orders; *Dietary communication form to be completed with resident name, room number, allergies, and adaptive equipment *Copy of original physician diet order to be attached to dietary communication form and delivered to dietary department (kitchen) *Dietary staff will review diet order and if any changes are needed to meet the approved diet orders for [NAME] Center the nurse will be notified to obtain new order from provider. *Cullinary Coordinatro has been given access to point click care and Martin Brothers guest card as a back up to Certified dietary manager * Review the entire building diet report, compare to actual orders in point click care and resident physical chart for accuracy *Review and update all meal tickets for the current residents The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a resident census of 108. Findings include: 1. The 5 day Skilled Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 with diagnosis for which included anemia, malnutrition, adult failure to thrive, and underweight. The MDS documented the Brief Interview for Mental Status (BIMS) score of 14 for which indicated no impaired decision making abilities, required set up assistance for eating and extensive assistance of one for bed mobility. The MDS revealed a swallowing disorder for which signs/symptoms of possible swallowing disorders as coughing or choking during meals or when swallowing medications, and mechanically altered diet is required for which is require change in texture of foods or liquids (pureed food, thickened liquids). The MDS documented weight of 83 pounds. The Discharge ordered dated [DATE] from Unity Point Health instructed staff to give Dysphasia level 5 diet- minced and moist. The International Dysphagia Diet Standardization Initiative (IDDSI) dated 2019, showed a level 5 diet as regular with minced and moist meat. During an interview on [DATE] at 10:45 a.m., the dietary manager stated that the definition of soft and bite sized food is that texture includes foods that are soft, tender and moist throughout, they can be mashed or broken down with pressure from a fork, spoon or chopsticks. food piece sizes should be no larger than 1.5 cm by 1.5 cm (size of a thumbnail) to minimize choking risks. The Clinical Physician Orders dated [DATE] at 11:32 a.m., instructed staff to serve a Regular diet, Mechanical Soft texture, Thin consistency. The plan of care documented a problem of Resident #2 has a nutritional problem relate to history of inadequate intake of food/fluid and weight loss. Interventions include: *Provide, serve regular diet with mechanical soft texture and thin liquids as ordered. *Set-up/assist as needed. *Encourage good intake at all meals. *Monitor intake of food/fluid and record every meal. The Data Base for Nutritional Assessment/Reassessment and Resident Progress Notes dated and signed by the dietician on [DATE], documented, Resident was hospitalized recently and returned on skilled care with diet changed to regular with mechanical soft texture and thin liquids. Resident is being treated by speech therapy and was noted to cough at meal times 3. Resident is at nutritional risk related to anemia and depression, need for mechanical soft texture with some swallowing difficulty noted. Problem on going with change to mechanical soft texture. The Diet Type Report dated [DATE] at 11:25 a.m., documented Resident #2 to receive a Regular Mechanical Soft diet. The Week at a Glance menu for week 2 documented that following noon meal: *Caprese chicken *Garlic and basil pasta *Green beans *Blueberry pie bar Observation on [DATE] at 11:30 a.m., revealed during the noon meal service at the Redwoods dining room. Staff D (dietary cook) was plating the room tray for Resident #2, Staff D proceeded to place a regular piece of chicken, pasta, and mixed vegetables on the plate. This surveyor observed the dietary ticket that Staff D was using to plate Resident #2 food, the dietary ticket read regular-regular. The diet roster from [DATE] documented regular-mechanical soft diet. This surveyor questioned Staff D on the diet that was served to Resident #2. Staff D explained that they just follow the dietary ticket that is printed for the dietary staff to use. This surveyor questioned the diet that was served. Staff E (culinary chef) went to double check on the computer system the diet that was ordered by the physician. Staff E came back to the dining room and confirmed and verified that Resident #2 diet is regular-mechanical soft and handed Staff D a diet order communication form verifying the diet order. Staff D proceeded to give Resident #2 a regular-mechanical soft diet for which consisted of ground chicken. Staff D and Staff E confirmed and verified that Resident #2 was going to receive a regular piece of chicken, not the mechanical soft diet that was ordered. During an interview on [DATE] at 1:15 p.m., Staff D, confirmed and verified that the dietary ticket read regular-regular and that Staff D follows the diet ticket that is printed. During an interview on [DATE] at 1:22 p.m., Staff E, confirmed and verified that Resident #2 was on a mechanical soft/ground diet per Dr orders and that Staff D was going to serve a regular diet. During an interview on [DATE] at 5:15 p.m., Resident #2 confirmed and verified that they have been receiving a regular diet and would of ate the piece of chicken that would of been served to her. During an interview on [DATE] at 4:00 p.m., the facility director of nursing confirmed and verified that the facility failed to serve Resident #2 the correct diet of regular-mechanical soft, and verified during the noon service that staff were going to serve a regular piece of chicken. During an interview on [DATE] at 1:15 p.m., the facility dietary manger confirmed and verified that the dietary staff need to follow the resident right diet per physicians orders. The Dietary Spreadsheets for Week 2, instructed staff to serve a mechanical diet that consisted of 3 ounces of ground caprese chicken. 2. An Admission MDS assessment dated [DATE], documented Resident #1 with a BIMS score of 12, for which indicates moderately impaired with decision making abilities. The MDS revealed the resident required staff assistance for bed mobility and dressing, and independent with set up for eating, and functional limited range of motion in the lower extremities (hip, knee, ankle, foot). The MDS revealed the resident's diagnoses included thyroid disorder, hip fractures, non-Alzheimer dementia, hemiplegia or hemiparesis, seizure disorder, epilepsy and bipolar disorder. The MDS also documented no nutritional approaches. The plan of care had a problem for potential of nutritional problem related to dementia, depression and chronic pain diagnosis along with new admission. Interventions include: *Provide, serve regular diet with regular texture and thin liquids. *Foods should be soft/moist and bite size. *Monitor intake of food/fluid and record every meal. A Speech Therapy Progress Note dated [DATE] at 1:47 p.m., Patient seen for on going dysphagia intervention. Co-treatment occurred with Occupational Therapy, working on self-feeding. Patient was pleasant and cooperative, more interactive today. Patient was able to feed herself when food/cup placed in her hand with assistance. No anterior loss or spillage noted. Mastication was slightly prolonged but functional with good bolus control. No overt sign/symptoms of aspiration or penetration appreciated. Recommend patient remain on Level 7: easy to chew diet with Level 0: thin liquids but up grade to bite size eat. Assistance with feeding as needed, single drinks from straw, medications whole in puree. The After Visit Summary from Unity Point Health dated [DATE], documented discharge diet orders: *drink consistency-level 0 *thin and food texture- level 7, Easy to Chew, bite sized meat. The Clinical Physicians Orders dated [DATE], documented an order for regular diet, regular texture, thin consistency, soft and bite sized. The Week at a Glance for Week 5 had a menu of: *Bacon Wrapped Pork Loin *Baked Sweet Potato *Pickled Beets *Bread/Margarine *Cookie The Progress Notes dated [DATE] at 1:43 p.m., documented Late Entry: When the emergency medical technician (EMT) asked for a portable suction, I retrieved it and I hooked it up, but the EMTs were the ones who used it. The Progress Notes dated [DATE] at 1:52 p.m., documented, Daughter called out to nurse that resident needs help, that she does not look good. Nurse immediately went into resident's room. Noted resident unresponsive, pale with food in front of her. Question if resident choked on food. Did the Heimlich, no food noted in resident's mouth. Instructed the other nurse for us to put resident on the floor to start CPR. CPR was started but, still no pulse. I and other nurse took turn doing chest compressions until paramedics arrived and took over. The Progress Notes dated [DATE] at 4:18 p.m., documented, Incident Note Note: I was in the room giving the res her scheduled Norco at 12:32 p.m., and resident was eating and talking at that time. Then I went down to C hall to give insulin's. I gave my last insulin about 12:50 p.m., and was putting the insulin back in the cart when I heard the res's daughter say she needed a nurse in her room, that she did not look good. I rushed to her room, upon entering the other nurse was doing the Heimlich maneuver. She said let's get to res on the floor and me and the med aid lifted the res to the floor and started doing CPR. We told the med aid to call 911. When we switched doing chest compressions this nurse went out to call 911. I gave the 911 operator all the necessary information and I headed back to relieve the other nurse. We switched doing chest compressions until the EMT arrived to relieve us. I gave the EMT the info of what happened and stayed close the answer questions. At about 1:15 p.m.,the EMT asked for portable suction; I retrieved the suction for them. About 1:30 p.m., the EMT said they had a rhythm on the resident and were going to transfer to the hospital. The Progress Notes dated [DATE] at 4:31 p.m., documented: On call physician notified of residents transfer to Methodist hospital. Phone call to daughter to follow up on the events that occurred this afternoon. Resident in critical care unit on life support at this time. The Progress Notes dated [DATE] at 4:39 p.m.,documented late Entry: Res's family had asked the nursing staff to stop CPR, but because the resident was a full code we could not stop CPR until the EMTs were here. This was explained to the family. The Progress Notes dated [DATE] at 10:56 a.m., documented Late Entry: This nurse spoke with the daughter, and her husband. They came to pick up all of the resident's belonging because they said they had decided to disconnect the life support and the resident had passed away that morning. This nurse offered a hug and condolences. The Des Moines Fire Department patient record dated [DATE] documented at 1:11 p.m., responded to cardiac arrest patient at [NAME] Park nursing home. EMS given incorrect location from dispatch that was across the street from where patient resided. Police Officer arrived first at incorrect location. Delay resulted from incorrect location and the time it took to find the correct location through dispatch. Upon arrival at correct location, Lead and fire medic: brought [NAME] device, ambu bag, red bag, and monitor to patient room, Additional support brought stretcher and additional equipment when they arrived. Staff led EMS through nursing home to patient room on second floor. Patient was found unresponsive on floor of nursing home room with ineffective manual CPR being performed by NH staff. Patient had several family members in the room along with a roommate. It was unknown if arrest was witnessed. Patient's daughter stated that the patient had been in that state for at least 15 minutes. Patient's roommate stated that she was the last person to talk to the patient and that that was 30 min. prior td EMS arrival. The patient's daughter stated that she had POA and did not wish for her mother to be coded. When asked for documentation nursing home staff stated that patient did not have an advance directive and that the patient wished to be a full code to which daughter agreed. EMS had already placed patient on monitor with initial rhythm of Asystote. CPR was initiated, When advanced airway efforts were initiated, considerable amounts of food were found in the patient's airway. Intubation efforts were delayed to suction out the food and then the patient was intubated. No blood, bile or vomit were found in airway, Patient's rhythm during subsequent pulse checks. After administration of Epinephrine, return of spontaneous circulation was achieved with a strong pulse and normal sinus rhythm. CPR discontinued and RESQPOD ( a threshold device that attaches to the airway during CPR to enhance negative pressure and increase perfusion) was removed. Patient was moved onto a backboard and secured fully without issue. Patient lifted and placed on EMS stretcher without issue. Patient brought through nursing home to ambulance by stretcher. Phone report made to the hospital and transport initiated. Patient went back into cardiac arrest approximately 2 minutes prior to hospital arrival. At hospital, patient transferred to resuscitation room bed by backboard without issue. Patient care transferred to resuscitation team. The History and Physical from Unity Point Health dated [DATE] at 2:01 p.m., documented that patient presents with unresponsive episode-found unresponsive at [NAME] Park, brought in by Des Moines. Found food in mouth. Narrative note-Patient is a [AGE] year old female presenting to the Emergency Department by ambulance for unresponsive. Per EMS, the patient was found unresponsive at [NAME] Park. Upon arrival the patient did not have a pulse, she was then in asystole on the monitor. CPR was given as well as epinephrine and she was also intubated. Pulse returned about 20 minutes after CPR. EMS states that when they intubated the patient there was food in her throat so they suctioned and then there was successful placement of the tube. A Physician Discharge Summary dated [DATE] at 8:35 p.m., documented, Patient is a [AGE] year old woman who is admitted to the Intensive Care Unit (ICU) today after cardiac arrest. Her family was visiting her today at the facility and upon walking into her room, notes that she was slumped over, blue, and agonallly breathing. She did look like she had been eating with food around her and in her lap. Her roommate said she had been speaking to her about 10 minutes prior. They checker her pulse and it was absent. They yelled for help and staff started CPR. EMS was called and arrived in about 20 minutes. They then took over CPR and it was another several minutes before ROSC was achieved. EMS intubated her and discovered some food in her mouth/airway upon doing this. She was previously admitted to the hospital about a month in June after a fall resulting in a hip fracture. During that stay, she did have an aspiration event with resulted in right lower lung collapse. Assessment/Plan- Acute hypoxic respiratory failure, now status post cardiac arrest-likely due to aspiration event. Shock, likely cardiogenic. Discussed with family about a prolonged cardiopulmonary resuscitation effort, her comorbidities, and age, her chances of a meaningful neurogenic recovery are extremely low. She is requiring significant support at this time. They have opted to not pursue any further aggressive measures. We will compassionately extubate and focus on comfort measures after additional family has had time to arrive. A physician note dated [DATE] at 9:39 p.m., documented, called to see patient for unresponsiveness. On exam the patient did not respond to verbal or physical stimuli. No heart of lung sounds were heard and the patient had no response to painful stimuli. Pupils were fixed and dilated. Patient pronounced dated at 5:54 p.m. Next of kin/family at bedside. Autopsy offered and declined. Direct cause of death was cardiopulmonary arrest which occurred as a result of likely aspiration event. A State of Iowa Certificate of Death dated [DATE], with a death date of [DATE] at 7:54 p.m., documented immediate cause of death-asphyxia due to choking on food bolus. During an interview on [DATE] at 1:15 p.m., the dietary manager commented that the prior chef was warned for putting resident diets into the martin brothers system due to the chef not having the qualifications as needed. The dietary manager stated that the chef admitted to putting diet orders into the computer system. The dietary manager heard about the incident with Resident #1 on [DATE], the dietary manager was able to see that the chef put regular-regular diet into the Martin Brothers computer system and failed to add the moist, bite size. The dietary manager was not able to produce the diet ticket for Resident #1, said that normally after the resident get there food at meal times the tickets are thrown away. During an interview on [DATE] at 3:54 p.m., the family stated that they came to see their mom on [DATE] around noon and found mom slumped over in the recliner. The family member hollered for a nurse to come to the room. The family member stated that when they went into the room they noticed some meat on their mom shirt, they were not able to remember if the meat was bite size or not, only that it was a white meat. During an interview on [DATE] at 11:00 a.m., Staff B (registered nurse), explained that Resident #1 was sitting up in the recliner and had her noon meal on a tray table in front of her, Staff B was not able to remember what was on the room meal tray. During an interview on [DATE] at 1:20 p.m., Staff C (certified medication aide), explained that he saw her noon meal on the tray table and saw some white meat but was not able to remember what kind of food was on her room tray. During an interview on [DATE] at 1:00 p.m., Staff A (licensed practical nurse) confirmed and verified that Resident #1 was sitting in a recliner with table tray across her lap with noon meal on it. Staff A could not remember what was on the tray. Resident #1 was unresponsive so Staff A attempted to do the Heimlich maneuver, Staff B came into the room and resident was transferred to the floor and CPR was initiated. During an interview on [DATE] at 1:06 p.m., Staff G (certified nurse aide), stated that she remembers white meat on Resident #1 room tray. Staff G stated that the meat was not moist and no gravy present. Resident #1 eats independently in her room. During an interview on [DATE] at 5:15 p.m., Staff F (speech/language pathologist) explained that a moist, bite size pieces mean usually a 1.5 by 1.5 cm size of meat. Most facilities will go with a mechanical soft or ground meats with a level 7 diet that comes from the hospital. During an interview on [DATE] at 4:15 p.m., the dietary manager explained that when Resident #1 came to the facility it was ordered as a level 7 diet with moist bite size pieces for which should of been a mechanical soft/ground meet diet at the facility. The dietary manager acknowledged that the facility and clinical record lacked any documentation of diet communication forms for Resident #1. 3. A Quarterly MDS assessment dated [DATE], documented Resident #3 with diagnosis for include heart failure, renal insufficiency, renal failure, and diabetes mellitus. The MDS documented a BIMS of 13 for which no impaired decision making abilities, needs extensive assistance of two for bed mobility and is independent after set up for eating. Resident with weight loss that is not physician prescribed weight loss regimen. The plan of care with a revision date of [DATE], documented Resident #3 has a nutritional problem related to Diabetes, GERD, anemia, chronic renal failure and morbid obesity diagnosis along with increased nutritional needs for healing. Interventions include: *Resident is allergic to citrus foods. Staff will ensure that these foods are not served to her. *Provide, serve regular diet with regular texture and thin liquids as ordered. *She is to avoid high potassium and high sodium foods and fluids are limited to 1500 ml daily. *Encourage appropriate choices at meals and snacks. *Encourage protein intake. *Monitor intake of food/fluid and record every meal. The Unity Point Internal Medicine Discharge Summary dated [DATE] at 10:28 a.m., documented diagnosis of Type 2 Diabetes Mellitus with hyperosmolar hyperglycemic state, with discharge diet orders of Diabetic Diet. The Medication Review Report signed and dated by the nurse practitioner on [DATE], documented a diet order of regular diet, regular texture, thin consistency with a start date of [DATE]. A Resident Diet Order Communication form dated [DATE], documented a new admit, diet order-regular foods, regular texture, thin liquids. A physician consultation form with an encounter date [DATE] at 10:30 a.m., documented: I have ordered a low potassium diet at the care center- I understand this is challenging so I asked the patient to avoid high potassium foods. She is having labs completed every other week for close monitoring. Diabetes Mellitus- uncontrolled. A physician telephone orders dated [DATE] documented low potassium diet. A Resident Diet Order Communication form with no date, documented Resident #3 to receive a low potassium diet. A Data Base for Nutritional Assessment/Reassessment signed and dated by the dietician on [DATE], documented a regular diet with regular texture. The Resident Progress Notes dated and signed by the dietician on [DATE], documented Nutritional status triggered. Resident is eating well at most meals and is tolerating a regular diet with regular texture and thin liquids. She is allergic to citrus and staff will ensure that she is not served citrus foods. During an interview on [DATE] at 4:15 p.m., the dietary manger confirmed that the chef texted the manager on [DATE] with a diet order change. The diet order change was for Resident #3. The new diet order that came into the kitchen was a low potassium on the dietary communication for and the diet was entered into the Martin Brothers computer system as a renal diet for which the facility does not offer, so the dietary manager change the diet in the martin brothers computer system to a regular diet, regular texture with thin liquids and low potassium food. The dietary manager confirmed and verified that the chef failed to enter the diet as ordered and failed to follow the standardized diets that the facility has to offer and placed the resident at risk.

Based on clinical record review, facility policy review and staff interviews, the facility failed to report an unusual occurrence to the state agency, Iowa Department of Inspection and Appeals (DIA) in a timely manner. Resident #1 had an incident for which placed the resident in the hospital and later died . The facility reported a census of 108 residents. Findings included: An Admission Minimum Data Set (MDS) assessment tool, dated [DATE], documented Resident #1 with a Brief Interview for Mental Status (BIMS) score of 12, for which indicated moderately impaired with decision making abilities. The MDS documented that the resident required extensive staff assistance for bed mobility and dressing, and independent with set up for eating. The MDS indicated that the resident had functional limited range of motion in the lower extremities (hip, knee, ankle, foot). The MDS documented that the resident had the diagnoses including thyroid disorder, hip fractures, non-Alzheimer dementia, hemiplegia or hemiparesis, seizure disorder and bipolar disorder. Record review revealed Progress Notes documented: * (late entry) dated [DATE] at 1:43 p.m., documented when the emergency medical technician asked for a portable suction, I retrieved it and I hooked it up, but the emergency medical technician were the ones who used it. *on [DATE] at 1:53 p.m., Daughter called out to nurse that resident needs help, that she does not look good. Nurse immediately went into resident's room. Noted resident unresponsive, pale with food in front of her. The resident choked on food. Did the Heimlich , no food noted in resident's mouth. Instructed the other nurse for us to put resident (res) on the floor to start cardiopulmonary resuscitation (CPR). CPR was started but, still no pulse. I and other nurse took turn doing chest compressions until paramedics arrived and took over. *on [DATE] 4:18 p.m., I was in the room giving the res her scheduled Norco at 12:32 p.m., and res was eating and talking at that time. Then I went down to C hall to give insulin's. I gave my last insulin about 12:50 p.m., and was putting the insulin back in the cart when I heard the res's daughter say she needed a nurse in her room, that she did not look good. I rushed to her room, upon entering the other nurse was doing the Heimlich maneuver. She said let's get to res on the floor and me and the med aid lifted the res to the floor and started doing CPR. We told the med aid to call 911. When we switched doing chest compressions this nurse went out to call 911. I gave the 911 operator all the necessary info and I headed back to relieve the other nurse. We switched doing chest compressions until the emergency medical technician (EMT) arrived to relieve us. I gave the EMT the information of what happened and stayed close the answer questions. At about 1:15 p.m., the EMT asked for portable suction; I retrieved the suction for them. *At about 1:30 p.m., the EMT said they had a rhythm on the resident and were going to transfer to the hospital. *at 4:31 p.m., On call physician notified of residents transfer to Methodist hospital. Phone call to daughter to follow up on the events that occurred this afternoon. Resident in critical care unit on life support at this time. Review of Progress Notes dated [DATE] at 10:56 a.m., revealed (late entry), This nurse spoke with the daughter, and her husband. They came to pick up all of the residents belonging because they said they had decided to disconnect the life support and the resident had passed away that morning. This nurse offered a hug and condolences. The Policy and Procedure for Abuse Policy with revised date [DATE], identified the policy: All resident have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the residents medical condition. *Neglect of a dependent adult, means deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adults life or physical or mental health. *All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, no later then two (2) hours after the allegation is made, or no later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation but do not resulted in serious bodily injury. *Serious bodily injury is an injury involving extreme physical pain: involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring surgery, hospitalization , or physical rehabilitation. During an interview on [DATE] at 11:15 a.m., the facility director of nursing stated that looking back at the incident and reviewing the investigation, the facility failed to notify DIA of the episode.

Based on documents review, observations, and interviews, the facility did not ensure to honor preferences regarding schedules of medication administration, meals, and changing of leg wraps for 1 of 4 residents (Resident # 2) in the sample reviewed for dignity. The facility reported a census of 110 residents at the time of the survey. Findings include: The Annual Minimum Data Set (MDS) dated [DATE], documented that Resident#2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident scored a 11 out of 15 for the Brief Interview for Mental Status (BIMS) which indicated the moderate cognitive impairment. The MDS indicated application of non-surgical dressings to feet, and ointments/medications. The MDS also documented that Resident # 2 required limited assistance of one person for bed mobility, dressing, toilet use, and personal hygiene, and required set up assistance for eating. The Order Summary Report with Active Orders as of 8/4/22 included the following; [MEDICATION(S)] tablet 137.5 micrograms by mouth in the morning for hypothyroidism; elevate Bilateral Lower Extremities (BLE) feet as tolerated by the resident during the day, everyday and evening shift, compression wrap to left arm ON IN AM, OFF AT Hour of Sleep (HS) everyday and evening shift, and compression Velcro device to BLE wear compression device, to only be removed for an hour to complete leg hygiene, then reapply every day. The Care plan for the resident indicated Activities of Daily Living (ADL) self-care performance deficit related to (r/t) the need of supervision and minimal assist as needed (prn) for safety. The care plan directed staff to provide assistance with setting up and cutting up food; assist with dressing, and personal and oral hygiene. The care plan also indicated the application of [CONDITION(S)] wraps to BLE. On 8/1/22 at 3:04 PM, Resident#2 reported about staff being late in giving her medications. Resident#2 she had 2 pills that should be taken on a empty stomach, a [CONDITION(S)] pill and another one but I don't get them until after breakfast. Resident#2 she kept telling them. Resident#2 also reported that the facility had been late in serving meals, and that today she did not get her lunch until after 1:20 PM, and breakfast had been close to 9:00 AM. On 8/3/22 at 7:54 AM, Resident#2's room door had been wide open, which revealed the resident sitting quietly in her wheelchair while she held a word puzzle book on top of the bedside table, the television had also been on. At 8:08 AM, Resident#2 could be heard from the hallway sobbing. Resident#2 invited the surveyor into her room while she continued to cry and reported to watch television to stay awake, and she did not get breakfast yet. Resident # 2 then reported that on Monday morning she did not get breakfast until 9:30 AM, I was told they were so slow in the kitchen. Resident#2 also reported that she got herself up from bed this morning and that nobody helped her. Resident#2 further pointed to her unmade bed, and reported that nobody entered to make her bed yet. Resident#2 stated that she had wraps that wear put every 24 hours, and they are supposed to be changed everyday. Resident#2 reported that staff members had not been consistent in changing the wraps on her lower extremities. Resident#2 said, that last Monday it had been 3:00 PM, and nobody had come to change the wraps. The resident told the lady that came in and she said the other girl went home at 2:00 PM, and nobody was going to do it. The resident reported she wore the wraps from 7/31/22 until 8/2/22 before they got changed, and they are to be changed everyday. On 8/3/22 at 8:47 AM, the Activities Director (AD) entered and served Resident#2's breakfast food. Resident#2 asked the AD for medications that she was supposed to get before eating. The AD told the Resident#2 that she (AD) was going to get somebody to give Resident#2 those medications. On 8/3/22 at 8:53 AM, once the AD left the room, Resident#2 started to cry again, as observed and heard from the hallway. Resident#2 did not touch her breakfast food. On 8/3/22 at 8:54 AM, Staff L, Assistant Director of Nursing (ADON) entered Resident#2's room and Resident#2 requested her medicines before she ate her food, and indicated she wanted those medications on an empty stomach. Resident#2 also told Staff L that on Monday she did not eat until past 9:00 AM, and did not get her medications before meal. Staff L report she would make sure to schedule her (Resident#2 s') medications earlier so it could be given before breakfast. On 8/3/22 at 8:57 AM, Staff N Certified Medication Aide (CMA) entered Resident#2's room and told Resident#2 that he was the one to prepare and give her medications. At 9:04 AM, Resident#2's crying had been audible in the hallway, Resident#2 ate her breakfast food and drank her orange juice, without waiting for her medications. At 9:06 AM, Staff N re-entered the room and offered Resident#2's morning medications. At 9:09 AM, Staff N reported that there were no directions for staff to give Resident#2's pills on empty stomach. Staff N reported that that he thought that is only what she prefers. On 8/4/22 at 9:29 AM, Staff O Licensed Practical Nurse (LPN) that Resident#2 is very particular and wants things done in certain ways and times --and when we say somebody will go in and do the wraps, she gets anxious when it takes longer. Staff O verified that the leg wraps should be done daily, and reported that she did the wrap on Tuesday and the resident told her that it was not changed on Monday. Staff O, reported she did not know who worked that day. On 8/4/22 at 9:52 AM, Staff L, ADON acknowledged the importance of following best practice guidelines in administration of medication and treaments, and also the importance of honoring residents' choices and that providing consistency in schedules could relieve Resident #2's anxiety. The facility's schedule for meal times show: Breakfast hours: 7:30 AM to 8:30 AM; Lunch hours: 11:45 AM to 12:30 PM; and Supper Hours: 5:30 AM to 6:15 AM. The manufacturer's information for [MEDICATION(S)] or [MEDICATION(S)] (https://www.[MEDICATION(S)].com) provides, Take [MEDICATION(S)] as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. The facility's policy titled, Resident Rights with revised date 1/21/22 noted that the facility will ensure all direct care and indirect care staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents.

Based on clinical record review, staff and physician interviews, facility policy review and review of online reference sources, the facility failed to intervene following receipt of a critical Potassium laboratory value for 1 of 4 sampled (Resident #1) for assessment and intervention. On [DATE] at 8:15 p.m., Staff A (Licensed Practical Nurse) received a phone call from laboratory informing him of Resident #1's critically high potassium level. Staff A failed to document the call and failed to notify Resident #1's physician of the critical value. Staff A reported the information to Staff B (Registered Nurse) who directed staff on all floors to check for faxed receipt of the lab results. Staff B reported he did not know the lab or its value, so did not report to physician. On [DATE] at 8:50 a.m., the staff found Resident #1 unresponsive and without a pulse and initiated Cardiopulmonary Resuscitation and called for Emergency Medical Services. The Death Certificate listed Resident #1's immediate cause of death as acute kidney failure due to [CONDITION(S)] The facility reported a census of 97 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment did not document any special treatments or procedures while at the facility. The resident had severely impaired memory and cognitive abilities, based on a Brief Interview for Mental Status score of 7. Resident #1 entered the facility on [DATE]. The Advanced Registered Nurse Practitioner (ARNP) Progress Note dated [DATE] documented she was asked to see Resident #1 due to increased weakness and nausea. The resident appeared in pain during the visit, which she took Narco (an opioid pain medication) for, but the Narco made her nauseated. The patient's appetite has been poor and she was weak and pale during the visit. The resident informed the ARNP she felt nauseated in the morning, making it hard for her to eat. The ARNP offered transfer to the hospital, but Resident #1 declined, stating they won't do anything. The ARNP voiced concerns to the resident and Resident #1 agreed to have laboratory (lab) work done. The ARNP's plan included to ask family members about a Hospice consult due to Failure to Thrive in an adult and orders to obtain lab samples. The ARNP ordered measurement of the resident's CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), A1C (to measure her blood glucose history) and a Vitamin D level. The Nurse's Note dated [DATE] at 5:31 a.m. documented Resident #1 slept well and the ordered lab tests were drawn without difficulty. Results of the CMP dated [DATE] showed the test as obtained at 6 a.m. and resulted at 8:14 p.m. The resident's potassium level measured 8.7 mmol/L (minimoles per liter) and a reference range for potassium as 3.5 - 5.1 mmol/L. The comments section documented repeat of the test to verify the result. A lab technician called Staff A (Licensed Practical Nurse) to inform him of the result at 8:13 p.m. and Staff A read back the result to the lab technician. Review of Progress Notes from [DATE] 2:56 p.m. to [DATE] at 9:52 a.m. revealed no documentation regarding the resident's critically high potassium level. According the Mayo Clinic web article dated [DATE], potassium is a chemical that is critical to the function of nerve and muscle cells, including those of the heart. A potassium level higher than 6.0 mmol/L can be dangerous and usually requires immediate treatment. If you have symptoms of high potassium, particularly with kidney disease, high potassium can cause muscle fatigue, weakness, paralysis, abnormal heart rhythms and/or nausea. The Nurse's Note dated [DATE] at 8:50 a.m. documented Staff A went to Resident #1's room to give medications and insulin. The resident was not responsive and had no pulse. Staff initiated CPR (Cardio Pulmonary Resuscitation). At 8:58, the Assistant Director of Nursing (ADON) documented Resident #1 experienced lethargy, nausea and vomiting for the past several days; the resident did not want to eat or drink. The resident wished to stay in bed for breakfast. Labs have been requested from the lab draw done yesterday but have not been received at this time. The floor nurse (Staff A) notified the ADON he found Resident #1 unresponsive, assessed her and found the resident to be without a pulse. The resident was a full code, staff initiated CPR and called 911. Paramedics arrived and transported Resident #1 to the hospital. At 12:30 p.m., the DON documented the resident's physician called the facility and reported Resident #1 passed away. Review of Resident #1's Emergency Department (ED) record revealed she arrived in the ED on [DATE] at 9:40 a.m. with presentation of pulseless electrical activity (PEA, which results in electrical activity in the heart muscle, but no pulse). The note documented the resident as last seen at 8:30 a.m. (normal) and found unresponsive without a blood pressure at 8:55 a.m.; bystander CPR started at the facility. Staff note the resident as in the process of Hospice enrollment but no DNR (Do Not Resuscitate) yet. Medics noted PEA with pacer spikes (on the electrocardiogram), did multiple rounds of Advanced Cardiac Life Support with 3 mg (milligrams) of [MEDICATION(S)]. Resident #1 had received approximately 45 minutes of CPR prior to arrival. ED staff attempted one more round of [MEDICATION(S)] with [MEDICATION(S)] without response and pronounced Resident #1 dead at 9:46 a.m. Resident #1's Certificate of Death documented she expired on [DATE] at 9:46 a.m. The certificate listed her immediate cause of death as acute kidney failure due to [CONDITION(S)] (high blood potassium). During interview at the facility on [DATE] at 10:50 a.m., the DON stated Staff A failed to document the call or the lab results. Staff A passed the information to the next nurse and said he waited for the faxed copy of the lab results to arrive before notifying the physician. During a telephone interview on [DATE] at 11:21 a.m., Staff A stated lab staff called him with Resident #1's lab results on [DATE], but lab staff did not fax (send a facsimile) a copy of the results. Staff A stated he knew Resident #1 had more results coming than a potassium level, so that's why he waited. The morning of [DATE] around 7 a.m., Staff A stated the resident seemed fine and when Staff A went back after breakfast, the resident had passed away. Staff A got the ADON and they started CPR. When asked to recall the critical lab number, Staff A replied 8.0 something. Staff A did not write it down because he waited for the fax before calling the doctor. Staff A stated he knew 8.0 was a very high potassium level, but he did not call because he didn't have all the resident's lab information. Staff A stated he reported to the oncoming nurse (Staff C) that Resident #1 had critical labs, but not which lab or the value. When asked what a critical value meant for a resident, Staff A stated it meant emergency and in looking back, he should have called. Staff A also stated he called another nurse after his shift (Staff B) and asked him to remind Staff C to look for Resident #1's faxed lab results. Staff A thought he left the faciity on [DATE] around 9:15 p.m. During a phone interview on [DATE] at 11:54 a.m., Staff B, (Registered Nurse) stated he remembered the call from Staff A on [DATE]. Staff A told him Resident #1 had a critical potassium level and asked him to remind Staff C look for the fax results; Staff C already knew to do so. Staff B said he learned what to with lab values (like calling the doctor) during orientation and critical values would have been called to the doctor. During a phone interview on [DATE] at 1:40 p.m., Staff C (Registered Nurse) stated he worked evening and night shifts on [DATE]. During evening shift change on [DATE], Staff A informed Staff C he had a call from the lab about a critical lab for Resident #1, but did not say what the value measured and that a fax would come. Staff A told him he'd forgotten the lab test or the value. Staff C did not call the lab as it was closed and asked staff on other halls to watch for the faxed report; no one had them. Staff C stated he called Staff A to check the lab and value, but Staff A did not answer the phone. Staff C thought about calling the doctor but he did not have the lab or its value and did not call; he did not inform the DON. Staff C stated he could not remember receiving facility training about calling physicians for lab values and the facility had on-call doctors available. Staff C stated if he had known the results of the resident's potassium level, he would have called the doctor immediately. During an interview on [DATE] at 2:00 p.m., the Assistant Director of Nurses (ADON) stated the facility uses a dual fax system for lab results and she audited the results daily since the incident with Resident #1. When asked to comment on Staff A's actions, the ADON stated if further lab results had not arrived by fax after an hour of the verbal report of a critical value, Staff A should have called the physician to report. The ADON was not notified of any of this at the time. Staff had been talking with the ARNP about the resident's overall decline and whether Hospice should be initiated. The labs were ordered to check the resident's overall condition. During an interview on [DATE] at 2:20 p.m., Resident #1's Physician stated if a nurse received a report of a resident's critical lab value, they should have picked up the phone and called; they call for everything else. Staff A was a good nurse. However, staff shouldn't wait to report a critical lab value. Resident #1 could not have been treated either in or out of house; she had End Stage Renal Disease (ESRD or kidney failure) and [CONDITION(S)] would have been the only treatment. During an interview on [DATE] at 2:37 p.m., the Administrator and DON revealed lots of things went wrong. The resident's physician told staff that critical lab values should be called to report. The Administrator stated that conversations with staff revealed that some staff needed understanding of the meaning of critical test results and that RNs and LPNs showed some difference in perception/training regarding lab values. The facility's Clinical Protocol on Lab and Diagnostic Test Results, revised [DATE], instructed that a nurse will identify the urgency of communicating with the Attending Physician based in part, on the seriousness of any abnormality. Nursing staff will consider whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). The facility's Nursing Home Medical Director Agreement, dated [DATE], documented that appropriate physician coverage is provided to patients 365 days per year and 24 hours per day, and that patient consultations are provided in a timely manner on a mutually agreed upon schedule. The scenario detailed above resulted in a past-noncompliance Immediate Jeopardy situation for facility residents. On [DATE], the facility initiated measures to correct the Immediate Jeopardy situation. A Self-Identification and Correction Form dated [DATE] and titled Reporting and Documentation of Critical Lab Values identified all nursing staff present in the building were educated immediately as to the Policy Procedure on [DATE]. Nurses coming onto shifts were educated prior to starting their shift and all other nurses would continue to be educated prior to starting their nursing shift. The policy directed that staff would notify the physician/ARNP in a timely manner regarding critical lab values. The policy documented: a. Critical labs that are called to us from lab need to be documented in the progress notes and reported to the physician within one hour of receiving test values. b. Do not wait for faxed lab values before you call. Call within one hour of receiving the value. c. If we do not receive faxed lab values by the end of your scheduled shift, call back the lab and request them again and then document in the progress notes that you have done so. d. If the lab is closed for the night, call the hospital and ask to speak with the lab. Once you talk to lab staff, make sure they are looking for lab results under pathology lab. The Education Sign-In Sheet documented the facility began educating nursing staff on [DATE] and completed the education on [DATE].

Based on clinical record review, observations, facility policy review and staff interviews, the facility failed to provide an environment free of accidents hazards and failed to provide adequate supervision for six residents. The facility failed to adequately assess and implement effective interventions for Resident #21, at risk for elopement, who removed his wander-guard device. The facility failed to respond to a sounding door alarm. Resident #21 eloped from a 2nd floor alarmed door and ambulated down 16 concrete stairs with a walker and exited the facility without staff knowledge. The facility failed to properly transfer Resident #33, #81, #90. Resident #90 sustained a laceration to the lower extremity requiring 14 sutures. Resident #81 hit her head. The staff failed to safely transport Resident #90 her wheelchair. The facility failed to assess the safety of a power chair for Resident #82. Resident #82 lost control of the power wheelchair and had her feet pinned between the power chair and the wall. Resident #82 sustained a rolled skin tear that required a transfer to the emergency department for repair. The facility reported a census of 100 residents. 1. Elopement: The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 had a diagnosis that included diabetes, dementia, vascular dementia, depression, asthma, mood disorder, spinal stenosis, [CONDITION(S)], and falls. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairments. The MDS documented physical behaviors and wandered 1-3 days during the lookback period. Resident #21 had independence with bed mobility, transfers, and walking in and out of the room. Resident #21 required staff assist of one for dressing and toileting. Resident #21 not steady when moving from seated to standing position, required the use of assistive devices at all times for balance. Resident #21 wore wander/elopement alarm daily. Review of Care Plan, updated 2/25/21 revealed resident had major depressive disorder with psychotic symptoms and received an anti-depressant. The Care Plan revealed Resident #21 at risk for wandering due to dementia, noncompliant, and refused to wear a wander-guard. The Care Plan directed staff to complete wander-guard checks each shift, if staff notice wander-guard off, locate it and reapply, and complete elopement assessment per protocol. Progress notes revealed the following: a. On 2/27/2021 at 11:52 a.m., Resident #21 exhibited anxious behaviors and was moving from chair to chair. Resident unable to follow direction at times related to dementia. Resident #21 often unaware of safety needs and does not ask for assistance. Observed Resident #21 standup from his chair, begin walking without his walker, lose balance, and fell to his knees. No injuries were noted and the staff notified the physician and family. The staff implemented an intervention when exhibiting anxious behaviors, offer activities i.e. walking, snack, drinks, etc. to see if this will help calm down and eliminate risk of getting up from chair to chair. The staff documented Resident #21 continued to remain at risk for falls. b. On 2/27/2021 at 11:32 p.m., Resident hard to redirect, going to other residents rooms and not using his walker as instructed. c. On 3/19/2021 at 12:25 a.m., Resident awake and wandering around the hallway. Will continue to monitor. d. On 3/29/2021 at 9:52 p.m., Resident #21 outside to the courtyard between B1 and C1 halls from the B-2 hallway door. Resident #21 eloped without any witnesses. The Nurse shut off the alarm when noticed it was alarming, and proceeded to locate all residents. A Nurse Aide noticed Resident #21 outside in the courtyard and assisted him back to C1 hall. e. On 3/30/2021 at 7:50 a.m., the staff notified the Physician of the incident from last night and received an order to place a wander-guard that was discontinued last month. Review of the Treatment Administration Record (TAR) dated 2/1/21 to 2/28/21 revealed wander-guard initiated on 7/8/20 and discontinued on 2/25/21. The TAR ordered the staff to check the placement and function of the wander-guard every shift. The TAR dated 3/1/21 to 3/31/21 revealed wander-guard placement check every shift for elopement risk initiated 3/29/21. Elopement assessment dated [DATE] revealed Resident #21 scored 1, indicating an elopement risk and a wander-guard needed. A fall risk evaluation dated 1/10/21 revealed Resident #21 at risk for falls. A 24 Hour Report sheet dated 2/25/21 revealed Resident #21's wander-guard discontinued and an elopement assessment completed. An Elopement Wandering Policy revised March 2021 revealed, the facility ensured that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accident, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. A Daily Clinical sheet dated 2/26/21 revealed Resident #21's wander-guard removed due to Resident #21 removing the wander-guard by himself. The sheet documented elopement assessment completed to evaluate behavior of wandering versus elopement and Resident #21 not seeking an exit. Review of Video Surveillance on 3/30/21 from 7:08 p.m. to 7:18 p.m. showed Resident #21 exiting 2nd floor B hall; Staff N approach the exit door, turned off the alarm and pulled the door shut; Resident #21 walked in courtyard past the 1st floor window on C hall; resident brought inside to common area on C hall on 1st floor. During an interview on 3/30/21 at 2:28 p.m., the Director if Nurses reported Resident #21 had no previous attempts of exit seeking behavior until this incident. Resident #21 had dementia and this was the first time he had exited through the exit door. Resident #21's had a usual behavior of walking from his room to the common area (on 2nd floor), walk to/from meals, and walk back to his room. During an interview on 3/30/21 at 2:43 p.m., Staff N (Registered Nurse) reported working at the time of the Resident #21's elopement. Staff N worked at the facility for 3 years and had no knowledge of the elopement policy. Staff N did not hear an alarm sound but noticed the exit door on hall B had a red light instead of green light. Staff N walked to the door and ensured it was shut and then heard the alarm and turned it off. Staff N reported the staff working did not hear the exit door alarm from the common area. He thought someone wearing a wander-guard tripped the alarm. Staff N did not open the door and look to see if anyone exited. Staff N checked to see if the two residents he thought were wearing wander-guards were on the unit. He saw a man with a walker, thought it was Resident #21, and the other man was in bed. Staff N had no knowledge Resident #21's wander-guard was removed the month prior. Staff N did not think it should ever come off due to Resident #21's wandering behaviors. When Staff N learned Resident #21 eloped he notified the manager. When Resident #21 returned to the unit the staff placed a new wander-guard on him. Staff N reported Resident #21 requested to go home when he eloped. Staff N was surprised resident #21 met the criteria to have the wander-guard removed. Staff N had concerns for Resident #21 walking down a flight of concrete stairs carrying his walker due to balance issues. During an interview on 3/31/21 at 9:27 a.m., Staff L (Clinical Administrative Assistant) reported Staff N (Registered Nurse) notified her on 3/29/21 at 7:30 p.m. of the elopement. Staff L reviewed the surveillance camera footage and placed a new wander-guard on resident #21's right wrist. Staff L reported Resident #21 had a wander-guard removed in February as he wouldn't leave on. On Monday 3/29/21, Staff L implemented another style of wander-guard that requires to be cut off and not reusable. Staff L reported in February 2021, Resident #21 did not have exit seeking behaviors when assessed for elopement and that he scored low enough to not require a wander-guard. During an interview on 3/31/21 at 10:45 a.m., Staff U (Maintenance) reported he reported to the facility the evening of 3/29/21 to make ensure the exit doors and alarms functioned properly. He pulled and tested the doors to ensure they were working. He did not find any issues. Staff U reported when the exit door is pushed open an alarm goes off. If the bar on the door is pushed for 15 seconds the door opens. While pushing on door, you hear beeping, light on magnet turns from light green to amber color and then door opens. Goes into alarm, a solid tone goes to radios. Get message the door has been breached and which door breached or needs checked. He gets message on his company phone about door alarms, but only says door breach. On 3/29/21, a resident without a wander bracelet went through the fire exit doorway on Redwood B. System does self-check daily. Email report automatically sent to facility manager/ maintenance supervisor every day at 6:45 a.m. The nurse pull system, call buttons, wander management, and door security are all tied into one system. During an interview on 3/31/21 at 11:00 a.m., Staff Q (Certified Nurse Aide) reported she observed Resident #21 on 3/29/21 between 5:00 p.m. and 6:00 p.m. in the Courtyard with his walker. Staff Q ran outside, placed gait belt on Resident #21 and assisted him inside. Staff Q reported Resident #21 walks independently with a walker, but often forgets to take walker with him. Resident #21 had a steadier gate later in day. During an interview on 3/31/21 at 1:30 p.m., the Director of Nurses (DON) reported Staff U (Maintenance) verifies the wander-guard is functioning correctly by running a daily report. Staff L (Clinical Administrative Assistant) had the training on how to initiate a wander-guard into the system and set up a new bracelet. The DON reported all residents should have an order if they are to wear a wander-guard and have a care plan indicating this as well as resident behaviors. When Resident #21 had his wander-guard discontinued it was documented on the 24 hour report sheet. He had been ripping off his wander-guard and was not demonstrating exit seeking behaviors prior to the incident. DON stated they do have an elopement binder where high risk resident pictures are kept at the nurses' station. DON stated resident #21 needs more supervision and when a bed is available on the 1st floor they would like to move him. DON stated it is everyone's responsibility to check when an alarm sounds. The facility started education with staff on 3/31/21. During an interview on 3/31/21 at 4:50 p.m., Staff O (Certified Nurse Aide) reported he looked out the window on 3/29/21 and saw another Nurse Aide from a different neighborhood running. He looked to see what was going on and observed Resident #21 standing by the courtyard gate. He then realized why the Nurse Aide was running towards the gate. Staff O informed Staff N (Registered Nurse) that Resident #21 eloped. The exit door should not open and Resident #21 should have a wander-guard on his wrist. Staff O reported the nursing staff utilize a walkie. The call buttons ring to the walkie and they have 15 min to respond to the resident's needs. Staff O stated the facility changed the call service at the beginning of the year. Staff have to enter a number to get out of any door, but that didn't happen on Monday night. Resident #21 pushed on the door and walked through it and there was not an alarm or alert on the walkie. Resident #21 had a wander-guard bracelet but didn't have one on at the time of the incident. Staff O stated if Resident #21 would have had wander-guard on and he got near the door, he would've received a message on his walkie to tell him which resident and what door resident at. It would let him know, but on Monday, he didn't get any kind of notification, not even that the door alarm had went off. Staff had training on new alarm system/call system when started to use new system. Had an in-service. Staff O believed something was wrong with the system. Staff L and Staff O tested the door after the incident happened. When they held the door for 2 seconds, they could open the door and get out. There was a system fault, something wasn't right, he stated. The fire emergency door shouldn't just open when you push on it. There is a delay (per sign on door, need to hold x 15 sec before door latch releases). Staff L had tried the door first, pushed on it for 2 seconds, opened the door, then reset the alarm, then Staff O tried it and the same thing happened. Staff O revealed staff is supposed to get alert on computer, but no one could hear the alarm. Maintenance had to come in and check the system and doors after the incident. Staff O said he isn't sure which residents have wander-guards on and knows when he gets an alert on the walkie, to visually go check for a resident. During an interview on 3/31/21 at 5:10 p.m. with Staff P (Certified Nurse Aide) reported Staff Q Nurse Aide) was in break area getting a drink of water when she saw a resident outside in the courtyard. The resident pushed on the door/gate trying to get out but the door was locked. Staff P reported the staff assisted Resident #21 to the Cedar common area, and called the nurse upstairs to see if they were aware of a resident missing. Within a few minutes Staff L (Registered Nurse) entered the Cedar common area wondering what happened and why they didn't hear the alarm. Staff O (Nurse Aide) assisted Resident #21 back upstairs to his unit. Resident #21 had his walker when she observed him outside. Staff P wondered how he got downstairs without anyone noticing. The staff all carry walkies and when an alarm goes off, an alert goes to the walkie and indicates the location of the door and unit. On 3/29/21 she did not get alert or alarm message. Staff P checks residents at night during her shift to check for a bracelet on their ankle or wrist. She knows which residents wear a wander-guard. During observation of door checks by Health Facilities Surveyors on 4/1/21 at 9:00 a.m. the surveyor sounded the door alarm at the far end of Hall A on the second floor and it took 10 seconds to release to open. The door alarm was an intermittent high pitched tone for the 10 seconds prior to release. At the time the door released the alarm tone become a solid high pitched tone. Two additional surveyors were located in the common area where all hallways meet. One surveyor reported she was able to faintly hear the alarm while the third surveyor was not able to hear the high pitched tone. Staff H (Nurse Aide) walked past and stated what is that noise? An activity staff member who was present in the common area stated, O don't hear anything. Staff H carried a walkie that sounded with a notification that an emergency door on opened on Hall A. Staff H proceeded down the hall looking into the rooms as she passed. She disabled the alarm and went through the door to look down the stairs. Two minutes lapsed between the notification on the walkie and the staff response. The surveyor proceeded to test the door in hallway B where there was a 10 second delay before the door released. Two staff responded to this alarm within 45 seconds. During an interview on 4/1/21 at 10:40 a.m., Staff R (Registered Nurse) reported she worked at the facility for two years. The staff complete elopement risk assessments every 3 months, as well as whenever staff noticed any resident behaviors, or a near elopement incident. The elopement risk assessment helped determine whether residents needed a wander guard device. Staff R reported Staff Z (Licensed Practical Nurse) completed an elopement assessment on Resident #21. Staff R reported Resident #21 had a wander risk due to dementia, he ambulated up and down the hallways but had no exit seeking. Resident #21 had a wander-guard for a period of time, but noncompliant with wearing it. During an Interdisciplinary Team (IDT) meeting, they discussed whether the resident an elopement risk versus a wander risk. They determined the resident not an elopement risk. Staff R reported the IDT team met around 2/26/21 and discussed Resident #21, who kept removing the wander-guard bracelet off. Staff R stated she was unsure why they didn't use an alternative type of wander-guard, and did not recall any discussion about getting or using something else. Staff R reported the facility had switched to a new type of wander-guard band due to a new alarm system installed. The resident had a wander-guard on when had the old system. Staff R acknowledged she entered a late entry progress note 3/29/21 at 8:29 p.m., but made the progress note effective 2/25/21. Staff R stated there had been confusion as to whether the floor nurse who worked 2/25/21 documented or progress note when the wander-guard for Resident #21 discontinued. It was brought to her attention by the DON that no note had been entered, so she entered the progress note 3/29/21 evening regarding Resident #21's wander-guard discontinued last month. The resident's wander-guard had been off as of 2/25/21. Staff R reported staff wrote on the 24 hour report sheet whenever changes on a resident or to know if a wander-guard removed. Staff documented the wander-guard checked on the Treatment Administration Record, and each unit had a wander binder with which residents had a wander-guard. During an interview 4/1/21 at 3:25 p.m., Staff X (Certified Nurse Aid) acknowledged she had education on 3/30/21 about alarms after an incident had occurred with one of the residents. Staff X stated if an alarm went off they are to run towards the alarm and stop the resident from exiting. Staff X reported residents who are at risk had bracelets or a wander-guard. The wander-guard got checked by the nurses each shift. During an interview 4/1/21 at 3:28 p.m., Staff K (Licensed Practical Nurse) reported she just heard about the incident and received instructions by management personnel on how to respond to alarms. Staff K reported wander-guards checked by ensuring the resident had the wander-guard on and lit up, which meant the wander-guard worked. Staff K reported when a resident moved close to an exit or tried to enter a code, an alarm sounded on the walkie system and alerted them that a resident loitering at a door/exit and needed to go investigate. Staff K reported if she wasn't able to get to the resident fast enough, other staff could run and get to the resident in time. During an interview 4/1/21 at 3:25 p.m., Staff Y (Certified Nurse Aide) reported when she heard an alarm sound, she went and investigated the source, and looked to ensure residents on the unit were accounted for. Staff Y reported an alarm signal came over the walkie with the location of the alarm. Staff Y acknowledged he had training regarding the new alarm system, what to do whenever she heard an alarm, and the process for checking the alarm. During an interview 4/1/21 at 3:21 p.m., Staff V (Certified Medication Aide) acknowledged she had been educated on 4/1/21 about the door alarms before her shift. Staff V stated whenever an alarm heard, she needed to check the doors, check the stairs, let other staff know, and take a census of all residents in the unit. During an interview 4/1/21 at 3:25 p.m., Staff E (Certified Nurse Aide) stated she had received education on 4/1/21 about the wander-guards and door alarms. If a door alarm sounded, she would check the door and look down the stairs, reset the door alarm, and report to the nurse. Staff E reported if she heard a wander-guard alarm, she needed to check for the resident and the area. During an interview on 4/1/21 at 3:31 p.m., Staff W (Certified Nurse Aide) had been educated on the alarms, call lights, and wander guards. Staff W reported if heard alarm, he checked on the resident, notified the nurse or a coworker. The facility was notified of the Immediate Jeopardy on 4/1/21 at 12:55 p.m. The Immediate Jeopardy was removed on 4/1/21 as the facility provided all staff education on the revised the elopement policy, revised the elopement policy, conducted new elopement assessments on all residents, which included response to door alarms, a plan to complete elopement assessments upon admission, quarterly and with any significant change, a plan to conduct alarm drills three times a week on alternating units and shifts, and audit all staff knowledge of the elopement process with satisfactory answer of an elopement quiz. These corrective actions were verified while onsite on 4/1/21. The scope was lowered from a J to a G due to the additional findings at a harm level. 2. Improper Transfer: An MDS dated [DATE] documented Resident #90 had diagnoses of [CONDITION(S)], coronary artery disease, hypertension, [CONDITION(S)], [CONDITION(S)] disorder, depression, muscle weakness, multiple falls, and idiopathic peripheral autonomic [CONDITION(S)]. The MDS revealed the resident had a cognition score of 7 out of 15, indicating severe cognitive impairments. Resident #90 had a fall prior to admission to the facility. Resident #90's Care Plan dated 12/10/20 revealed impaired though process and unawareness of safety. The resident is care planned as a risk for falls and skin integrity issues due to fragile skin and needing assistance with transfers. The care plan revealed the resident required assistance of one staff member to transfer. A fall risk assessment dated [DATE] revealed Resident #90 at risk for falls. #170 Skin Concern sheet dated 3/2/21 at 9:45 p.m., revealed resident #90 sustained a skin tear to right lower front leg during a staff assisted transfer. Resident #90 assessed for pain, area cleansed with normal saline, patted dry and steri strips applied. A Progress Note dated 3/3/21 9:58 p.m., revealed Resident #90 unstable in her recliner and attempted to get out more than once. Redirecting the resident failed. Staff attempted to transfer the resident and Resident #90 tried to fight back and slipped attempting to sit on the floor. Staff pulled her back from falling to the floor and another staff member assisted the resident into the recliner. The Nurse Aide transferred the resident to the wheelchair a cut noted to left inner thigh with scant bleeding. Manager notified, evening supervisor notified and a skin picture taken. The area to left leg cleaned and covered with gauze. The on-call physician notified and advised to send to the hospital for evaluation. Resident transferred to the hospital at 9:30 p.m. A Progress Note dated 3/4/21 at 12:34 a.m. revealed the resident returned from the hospital with sutures. An Emergency Department sheet dated 3/3/21revealed Resident #90 sustained 6 centimeter (cm) (length) by 3 cm depth laceration to the left knee during a transfer. The laceration required 14 sutures. The Facility Investigation of the incident showed the incident occurred on 3/3/21. The resident sent to the ER for evaluation and sustained a 2-inch laceration on left knee during a transfer. The summary of the investigation revealed a root cause of the laceration due to improper transfer techniques. Witness statements showed Staff A (Registered Nurse) attempted to transfer the resident by placing his arms around the resident's upper body trunk. Staff B (Certified Nurse Aide) attempted to lift the resident the same way by putting her arms around the resident's upper body with her leg in between the resident's legs. After the resident transferred, Staff B noticed a skin tear to the resident's left leg. Resident at the time of the incident a one-person transfer. A written statement dated 3/4/21, Staff A (Registered Nurse) reported he tried to transfer the resident, the resident started to slip. He reported he put her back in the chair and Staff B and assisted the resident to the wheel chair and Staff B noticed her pants were wet and the resident's thigh had a cut on it. Staff A reported he had nothing in his pockets would have caused the cut on the resident's leg. A written statement from Staff B (Certified Nurse Aide) reported she saw Staff A moving the resident from her chair to the wheel chair by lifting Resident #90 by the upper arms. Staff B reported Staff A almost dropped Resident #90 and she reported telling him to put the resident back in the chair. Staff B reported she told Staff A there is a proper way to transfer the resident. Staff B reported she wanted to get a gait belt but felt Staff A did not want to wait and wanted to get the resident in the chair. Staff B reported she told Resident #90 to give her a hug and Staff B stood up the resident and transferred the resident to the wheel chair. She reported Staff A requested to have the resident stand again so he could place a chair alarm. Staff B wrote Resident #90 put her left leg in between Staff B's legs when the resident stood up. Staff B reported the resident never complained about pain but when the resident sat back down, Staff B reported her leg wet. Staff B reported fat tissue and blood on her pant leg. Staff B reported #90 had a gash in her leg and brought it to Staff A and her night supervisor's attention. An employee education dated 3/4/21 revealed ten staff present for the time of the education on transfers for Resident #90. A Gait Belt Transfers and Ambulation policy reviewed 3/4/21 revealed staff are to utilize a gait belt, non-skid socks, slippers or proper fitting shoes. Staff should have push up from chair or bed when standing up. Resident should be on the edge of the chair or the bed with feet uncrossed. Staff should have resident support a weaker side. While lifting support is given around the waist by means of gait belt. Remind the residents to support themselves by placing hands on the arms of a chair. Staff are to move with the resident and to lower themselves with resident and bend their knees. During an interview on 3/30/21 at 1:06 p.m., Staff B (Certified Nurse Aide) reported she witnessed Staff A (Registered Nurses) attempt to transfer the resident by putting his arms around the residents upper body and move Resident #90 from her chair to the wheelchair. Staff B reported Resident #90 almost fell . Staff B reported she educated Staff A to utilize a gait belt for transfers for residents. Staff B reported she wanted to go grab a gait belt but saw Staff A grab the resident's arm as if to lift up Resident #90 again. Staff B reported she stopped him and transferred the resident herself by placing her arms around her and transferring her to the wheelchair. She reported the resident stood with no difficulty. Staff B reported Staff A told her to get Resident #90 up because he needed to place the chair alarm under her. Staff B reported she helped stand up the resident and put her knee between her legs to help her stand. Staff B reported when she sat Resident #90 back down to her wheel chair she noticed her leg wet and saw blood and fat tissue on her pant leg. Staff B noted a skin tear in the resident's thigh. Staff B reported she told the night supervisor what occurred. Staff B reported she was suspended the next day for improper use of transfer for resident safety. During an interview 4/01/21 9:34 a.m., the DON reported she felt the injury to Resident #90's leg was due to staff improperly transferring the resident. The DON reported she spoke with a physician regarding the resident's wound and what occurred and the physician reported the pressure from their knee could cause a skin tear. 3. Hazard: A MDS assessment dated [DATE] revealed the Resident #9 revealed the resident had diagnoses of hypertension, Alzheimer's, anxiety, depression, psychotic disorder, and metabolic [CONDITION(S)]. The MDS revealed the resident's cognition is severely impaired. The resident required assistance of two staff members for transfers and does not ambulate. Resident #9's MDS revealed resident required assistance with a wheelchair for mobilization. A Care Plan revealed the resident required assistance of two for transfers and used a wheelchair for locomotion on the unit and staff are to assist resident with backing up from the table in her wheelchair. Care plan reported Resident #9 has altered mobility and self-propels in wheelchair. Resident #9 has impaired cognition. A fall risk assessment dated [DATE] revealed the resident at risk for falls. During an observation on 3/30/21 at 9:08 a.m., a staff member pushed resident up to her table in her wheelchair. Resident #9 did not have pedals on her wheelchair. Staff member pushed the resident's wheelchair forward towards the table in a distance approximately six feet. During a second observation on 4/1/21 at 8:26 a.m., Staff C (Certified Nurse Aide) pushed the resident into her room from the hallway for cares. The resident at the time did not have pedals on her wheelchair. The staff member pushed the resident in her wheelchair approximately 12 feet. During an interview on 4/6/21 at 2:21 p.m., the DON reported she expected staff to use wheel chair pedals for residents when pushing a resident in a wheelchair. The DON presented a policy for safe transportation to and from resident's room, to an activity, and or safe assistance from staff and or family regarding locomotion on and off the unit dated April 2021. The policy directed staff to utilize wheel chair pedals when pushing a resident in the wheel chair. 4. Improper Transfer: The annual MDS assessment dated [DATE] for Resident #81 revealed BIMS score of 13 that indicated intact cognition for decision-making. The MDS included she required extensive assistance of one staff for transfers and walking in room and used a walker and include diagnoses of arthritis, [CONDITION(S)], and fracture. Further included she had falls with injury since her prior assessment. Resident #81's Care Plan revised on 8/28/19 included self-care deficit with limited physical mobility and required assist of 1 staff with all cares transfers, mobility and positioning, ambulation with her using a walker. If further included a focus are of high risk for falls and required a gait belt for all ambulation. The facilities Fall- Witnessed report dated 2/28/21 at 2:39 p.m., revealed a Nurse Aide reported the resident fell while she was assisting her. The Nurse found the resident on her right side with her head on the floor towards the roommate's bed. The walker with the gait belt on it in front of resident towards her TV. Resident stated she fell back coming from the toilet with assistance. The aide left her to grab something and she lost her balance and fell . Resident verbalized she did hit her head twice and it was hurting. The Gait Belt Transfers and Ambulation policy reviewed 1/20/21 included the following when assisting a resident with ambulation: a. Put the gait belt around the resident securely. b. Assist the resident to a standing position. c. Walk on the resident weaker side. d. Walk with the resident by placing one hand around the back of the waist and the other in the loop of the gait belt. e. Walk the resident according to the Care Plan. During an interview on 4/6/21 at 8:02 a.m., Staff H (Registered Nurse) explained a Nurse Aide reported Resident #81 fell . Staff H found the resident on the floor. The gait belt on the walker. When the aide left the room she asked the Resident what happened and she explained she left me for a minute and I fell . During an interview on 4/6/21 at 8:13 a.m., Staff E (Certified Nurse Aide) confirmed she assisted Resident #81 to the bathroom. When finished after standing, removed her gait belt to pull up her pants and forgot to put it back on. Staff E explained she had one hand on the Residents back and used the other hand to change the pad in the chair when the resident fell . 5. Improper Transfer: The quarterly MDS assessment dated [DATE] for Resident #33 revealed BIMS score of 9 that indicated impaired cog [TRUNCATED]

Based on clinical record review, staff and resident interviews and observations the facility failed to provide adequate supervision for 1 of 3 open sampled residents (Resident #1). The facility reported a census of 118. Findings include: According to the Minimum Data Set ((MDS) dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive ability. Resident #1 required extensive assistance of 1 staff for transfers, walking with assistance of walker, dressing, toilet use and personal hygiene. The resident utilized a wheelchair to move about the facility. Resident #1 had frequent urinary incontinence and occasional bowel incontinence. The staff utilized a bed alarm, chair alarm and a floor mat alarm daily to alert the staff when movement is detected. Review of Resident #1's Care Plan dated 2/16/19, indicated the resident had a risk for falls due to vision problems and poor safety awareness. The Care Plan directed the staff to check resident after 10 p.m. to 6 a.m. shift change and offer toileting, place a fall mat next to bed, floor and pressure alarm in bed and chair, keep walker within reach and staff directed not to leave resident un-attended in the bathroom. The Care Plan dated 1/8/20, directed staff to transfer the resident with the assistance of a mechanical lift and 2 staff. Review of a fall investigation report dated 1/7/20, revealed a nursing assistant assisted Resident #1 to the toilet, the staff stepped outside of the resident's room to grab a brief, the aide returned to the room and found the resident on the floor. The staff sent the resident to a local hospital, the resident sustained [REDACTED]. The facility suspended the responsible staff pending an investigation. The facility camera's revealed the following time line: a. At 15:58 Staff A-C.N.A assists Resident #1 from the common area to her room. b. At 1600:45 Staff A exits the resident's room. c. At 16:03:51 Staff A re-enters the resident's room with a brief in hand. d. At 16:04:19 Staff A calls for Staff B-C.M.[NAME] to the resident's room. e. At 16:04:57 Staff B summons Staff C-LPN to the resident's room. f. At 21:36 a portable x-ray completed. g. At 22:16 results return with a possible fracture and physician gave order to transfer the resident to a local emergency room . h. At 4:49 (1/8/19) the resident returns from the emergency room with a boot to the left foot and a follow up appointment scheduled for 1/19/20. The investigation revealed the root cause of the fall is determined to be the result of leaving the resident unattended on the toilet by staff. The resident is considered a high risk for falls due to having alarms and has had a history of [REDACTED]. Review of a X-ray Report dated 1/7/20, revealed the resident had a x-ray due to a fall. The results revealed a displaced [MEDICATION NAME] fracture through the medial melleolus and displace oblique fracture thru the distal fibula. The surrounding tissue noted to have swelling. During an interview with Staff A-C.N.A on 1/28/20, the aide stated she assisted the resident to the toilet in her room. Staff A completed personal cares and when she looked for a fresh brief in the resident's bathroom closet, finding the board empty. Staff A told the resident to stay sitting on the toilet as she goes to the next room to get a brief for the resident. Staff A entered the next room and retrieved a brief, at this time she noted the other resident in the bed with her feet dangling out of bed, Staff A stopped and assisted the resident. She stated when she returned to Resident #1's bathroom, she found the resident on the floor, yelling for help. Staff A summoned help at this time from other staff members. Staff A stated she and 2 other staff lifted the resident off the floor and sat her in the wheelchair. The resident went to the dining room to eat the evening meal. Staff A stated the resident did not have to bear weight on her foot as the staff lifted her up and into the wheelchair. After the evening meal Staff A asked Staff C-C.N.A for assistance transferring the resident to their bed. At the time of the transfer into bed the resident could not bear weight on left leg and complained of pain to area. Staff A alerted the charge nurse of the complaints. Staff A stated she was suspended after the investigation started for a period of 3 days and received a disciplinary write up for not following the policy regarding leaving a resident who uses alarms unattended on the toilet. Staff A stated she is upset over the fall because she knew she should not have left a resident who uses alarms alone on the toilet. Staff A asked the resident to remain sitting on the toilet while she went next door. During an interview with Staff B-Certified Medication Aide on 1/28/20 at 4:20 p.m., Staff B stated she was passing medications in the common area when Staff A summoned help in Resident #1's room. Staff B entered the room and noted Resident #1 laying on the floor in front of her toilet. Staff B notified Staff D-LPN. Staff B stated the facility policy is to not leave a resident who uses alarms sitting alone on the toilet. Staff B stated Resident #1 uses alarms in their bed and chair. During an interview with Staff C-C.N.A on 1/28/20 at 4:38 p.m., Staff C stated he assisted Staff A to get the resident into bed. Staff C stated the resident did not bear weight on her left leg during that transfer. Staff C stated you are not to leave a resident who uses alarms and is a fall risk alone on the toilet. During an interview with Staff D-LPN on 1/29/20 at 10:30 a.m., Staff D stated Resident #1 was an assist of 1 staff prior to her fall, she utilized alarms in her bed and chair, is a fall risk and has periods of confusion at times. Staff D stated she got called to the resident's room after she had a fall. Upon initial assessment her left ankle area looked normal but the resident complained of pain with the assessment. Upon asking Staff A about the fall, the staff told her she placed the resident on the toilet and left the room to get a brief. Staff A-LPN stated it is not appropriate to leave a resident who is a fall risk and utilizes alarms alone on the toilet for any length of time. Review of an Incident Report dated 1/7/20 at 4:15 p.m., indicated a C.N.A assisted Resident #1 to the bathroom, the aide left the bathroom to obtain a brief, leaving the resident unattended on the toilet. The staff returned and found the resident on the floor in her bathroom. Review of the Progress Notes dated 1/7/20 at 5:22 p.m., revealed a Certified Nurses Aide assisted the resident to the bathroom, left the resident in the bathroom to get the resident a brief. When the aide returned she noted the resident lying on the floor in bathroom. Review of the POS [REDACTED]. The nurse documented the staff left the resident unattended in the bathroom. Review of a Resident Toileting Policy dated 1/4/2020, directed staff when assisting a resident to the toilet who needs physical support/assistance, or who has an alarm due to progressive cognitive decline, you may not leave them unattended in the bathroom. This does not mean you cannot stand outside the bathroom to give them privacy but you may not leave the room. During an interview with Staff E-RN/Director of Nurses on 1/29/20 at 11:20 a.m., Staff [NAME] stated when she became aware of the fall and fracture, she began re-education with all staff regarding safety in the bathroom including having the supply cupboard stocked prior to doing cares and to not leave resident's alone in the bathroom who are identified as a fall risk and utilizes alarms.

Based on clinical record review, staff interview and review of facility policy and procedure the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for for residents, (Resident #6, #5, #3 and #4). The facility census was 118 residents. Findings include: 1. A reentry Minimum Data Set (MDS) assessment tool, dated 9/24/19, documented Resident #6 with impaired short term memory and moderately impaired decision making abilities. The resident required extensive assistance with all aspects of daily living. The MDS documented the resident with [DIAGNOSES REDACTED]. The resident had a fall with no injuries. Resident #6's Plan of Care with a initiated dated 2/10/19 and a revision date 8/14/19, had a focus area for high risk for falls related to confusion, history of falls, incontinence, psychoactive drug use, unaware of safety needs, and attempts to self transfer at times. Interventions include: *Uses pressure pad alarm in chairs and wheelchair. has floor mat alarm by bed. Ensure the devices are in place as needed. A Fall Incident Report dated 9/24/19 at 1:38 a.m., documented Registered Nurse with another resident when Certified Nursing Assistant reported the fall. Upon entering the hall, Resident #6 was laying in front of the wheelchair, head towards wall and feet towards wheelchair. Vital signs taken, went to assess range of motion but pain with movement of left hip. When asked if hurt, resident put hand on left hip and said right here. When lightly touching left leg or foot resident would jerk/jump. No other injuries noted at this time. Phoned Power of Attorney, and physician, orders received to send to emergency room . The Post Fall Evaluation dated 9/24/19 at 1:54 a.m., documented Resident #6 had a fall which resulted in an emergency room visit/hospitalization , with pain in the left leg/foot, with prior history of falls in the facility. The Emergency Department Notes dated 9/24/19 at 2:07 a.m., documented Resident #6 had a witnessed fall while walking, fell on to left side, no injury to the head or neck, complaints of low back and left hip pain with a [DIAGNOSES REDACTED]. The X-ray Report dated 9/24/19 at 4:14 a.m., documented acute proximal left femur fracture due to a fall with left hip pain, findings include: an acute proximal left femur fracture noted involving the trochanters and base of the femoral neck. A Major Injury Determination Form, signed and dated by the physician on 9/27/19 at 1:34 p.m., stated after reviewing the circumstances of the incident causing the injury the previous functional ability of the patient, and the patients prognosis, I believe the injury sustained is a major injury. During an interview on 10/17/19 at 12:25 p.m., Staff H, Certified Nursing Assistant stated there was no pad alarm on the wheelchair, and didn't know one had to be on the wheelchair as care planned. During an interview on 10/17/19 at 11:40 a.m., Staff F, RN confirmed and verified there was no alarm sounding when came out of another resident room to assist with the resident that fell . During an interview on 10/17/19 at 4:30 p.m., Staff G, LPN stated the expectation of the staff is to follow the residents plan of care and to have had the pad alarm while the resident was in the wheelchair. During an interview on 10/21/19 at 1:08 p.m., Staff I, CNA confirmed and verified there was no alarm sounding as staff came out of another resident room. 2. An Annual MDS assessment tool, dated 7/14/19, documented Resident #5 had a Brief Interview for Mental Status score of 12, moderately impaired cognition for decision making skills. The resident required staff assistance for transfers, ambulation, toileting, and personal hygiene and had no falls since the latest admission. The resident's [DIAGNOSES REDACTED]. The MDS documented the resident was on a scheduled pain medication regimen and received an opiod in the last 7 days of the reference period. The Care Area assessment dated [DATE], documented the resident had potential for falls with difficulty maintaining sitting balance, impaired balance during transitions, anti-depressants, anti-anxiety medications, [DIAGNOSES REDACTED]. Resident was at risk for falling due to taking anti-depressant, anti-anxiety and opiod and will proceed with the plan of care. Resident #5's Plan of Care had a focus area, with a initiated date of 2/20/19, stated resident is at risk for falls related to confusion, psychoactive drug use, unaware of safety needs. Interventions include: *Uses a FMA (floor mat alarm) and motion sensor alarm. Ensure the devices are in place. Motion sensor alarm alerts staff in the hallway. The Progress Notes dated 8/17/19 at 12:40 p.m., documented Resident #5 on floor, upon arrival in room, this nurse found resident on the floor next to recliner. Lying horizontally on left side, head against the wall. Alert and conscious, stating I fell , can I get up. Noted moderate amount of blood on floor, from deep cut on the left shin. Applied pressure, asked house keeper to call supervisor, who came right away, called family right away and family gave OK to send to hospital. Order received per phone from the Doctor. 911 called and they arrived shortly thereafter. Left with the resident on the stretcher. Prior to the fall, the Certified Nursing Assistant had assisted resident to the recliner and covered with blanket as normally does, per the Certified Nursing Assistant the FMA was not in use due to the refusal by the resident which does at times. The Progress Notes dated 8/17/19 at 4:30 p.m., documented Resident #5 arrived back to facility in daughters car. This nurse and supervisor assisted with getting resident into wheelchair. Resident appeared tired and weak, family informed by this nurse and supervisor the trauma and movement may be contributing factors. Resident appears in good mood. Laceration is covered with dressing upon arrival. No drainage noted. Per daughters, Resident #5 received 35 staples and the emergency room physician told them to remove the staples in 14 days. Review of the POS [REDACTED]. Resident with prior history of falls in the facility with similarities between current and post falls, attempting to get out of the recliner. 3. A reentry MDS with an assessment date 9/24/19, documented Resident #3 with moderately impaired for decision making abilities, inattention and disorganized thinking, hallucinations, delusion, physical behavioral symptoms directed toward others, and other behaviors directed toward others and wandering 1-3 days during the reference period. The resident required supervision in how resident walks between locations in his/her room, and how resident walks in corridor on unit. The resident's [DIAGNOSES REDACTED]. The Resident #3's Plan of Care with a revision dated 9/10/19, identified resident had a behavior problem due to dementia, wandering, anxiety and delusional disorder, aggressive behaviors to family members and other residents. Interventions include: *Anticipate and meet needs. *Assure resident is safe. *Be mindful of location when resident is up and ambulatory and attempt to keep at arms length from other residents. *Provide 1-1 activities with resident if anxious. *Provide divisional activities like snack and encourage fluids. *Provide 1-1 with staff due to recent behaviors and aggressive altercation with another resident with a date of 9/21/19. *Red Rose program, high risk for resident to resident behavior. *Redirect or distract resident is being over affectionate toward other residents. Staff to redirect resident from getting into other resident rooms. The Physical Incident Report dated 9/21/19 at 10:04 p.m., documented Resident #3 allegedly put their hand on the right side of another resident face. The Progress Notes dated 9/21/19 at 1:06 p.m., noted Resident #3 before lunch and after lunch started to show signs and symptoms of anxiousness, pacing the halls and inability to redirect at times and several episodes of tear-fullness. Nurse and staff have redirected resident with activities of daily living, communication, snacks. Currently resident is watching television in main area with stuffed animal. The Progress Notes dated 9/21/19 at 9:53 p.m., documented alleged resident to resident altercation. Investigation on going, no injuries observed. Resident had multiple tearful episodes this shift along with getting irritated and upset and yelling multiple times. Resting quietly in bed. A Significant Change in Status (MDS) assessment with a reference dated 8/20/19, documented Resident #4 with a Brief Interview for Mental Status score of 4, indicated severe decision impairment. The resident had verbal behavior symptoms directed towards others, and other behaviors directed towards others and wandering 4 to 6 days occurred and change in behaviors had gotten worse. The resident required limited assistance with how walks between locations in his/her room and walks in the corridor. The residents [DIAGNOSES REDACTED]. Resident #4's Plan of Care with a initiated date 7/12/19, identified the resident as potential to be physically aggressive related to history of altercation, dementia, poor impulse control. Interventions include: *Provide emotional support to the resident. *When agitated: intervene before agitation escalates, guide away form source of distress, engage calmly in conversation, if response is aggressive, staff to walk away calmly and approach later. A Physical Incident Report dated 9/21/19 at 10:14 p.m., documented no physical contact was seen by this author. No injuries observed at time of incident. The Progress Notes dated 9/21/19 at 10:22 p.m., documented the resident reported to Certified Nursing Assistant I was hit by that lady when resident asked to point out the lady that did this resident was able to recall and then stated, oh hell I don't know. No redness regarding injury noted to resident face at this time. Son was notified and reassured this matter would be investigated and would get back to him as soon as we knew something. Review of the facility footage on 10/16/19 at 1:01 p.m., for the incident on 9/21/19, revealed the following: *5:27 p.m., no resident or staff in the Birch hallway, then Resident #3 started to ambulate down the hall way towards the double doors into the unit. *5:29:14 p.m., Resident #3 started to ambulate with the merry walker into Resident #4's doorway of the residents room, able to see the right rear of the merry walker as ambulated through the door way. *5:29:35 p.m., Resident #3 sat down in the merry walker in the door way of Resident #4's room. *5:29:55 p.m., Resident #4 started to push Resident #3 out of the door way while Resident #3 was still sitting in the merry walker, Resident #4 had a walker in front of him, both residents started to punch each other back and forth. Resident #4 pushed Resident #3 out into the middle of the hall way and attempted to go around the merry walker, and Resident #3 hit Resident #4, Resident #4 hit Resident #3 back. Resident #4 finally was able to move around Resident #3 and started to ambulate down the hallway to the common area. Resident #3 immediately turned the merry walker around and chased Resident #4 to the common area, Resident #3 caught the other resident and they both turned towards each other and started throwing punches back and forth with both hands to the face, arms and shoulders, Resident #4 started to loose balance and grabbed onto Resident #3's arm for stability, while Resident #3 continued to punch the other resident in the face, neck, arm and shoulders. *5:32:09 p.m., Staff J, Certified Nursing Assistant came into view of the camera and took Resident #4 away from Resident #3 and proceeded to assist out of view of the camera. Resident #3 sat down in the merry walker and began to cry. *5:32:32 p.m., Staff K, Certified Nursing Assistant was seen coming down the hallway to the common area and looked at Resident #3 sitting in the merry walker crying and continued to walk on by. *5:33:56 p.m., Staff L, Llicensed Practical Nurse came into view of the camera and walked by Resident #3 who was still in the merry walker, and continued to walk out of the unit through the double doors. *5:37:49 p.m., Staff L came back through the double doors onto Birch unit and stopped at Resident #3 still in the merry walker, and did a quick look over the residents arms, face and neck, then walked out of view of the camera into the common area. During an interview on 10/15/19 at 4:20 p.m., Staff G and Staff M (Registered Nurse) both stated the facility Director of Nursing spoke to the staff on the Birch unit and explained to them Resident #3 had just been readmitted back to the facility on [DATE] for behaviors and staff needed to keep a close eye on her at all times to make sure there is no altercation between any of the residents on the Birch unit. During an interview on 10/16/19 at 12:36 p.m., Staff K confirmed and verified the facility Director of Nursing brought each of the staff into the office and explained the staff needed to keep a close eye on the resident at all times, which is different from 1-1 supervision. Keeping a close eye on the resident means they are in your vision at all times, 1-1 supervision means that you are with in an arms length away from the resident at all times. During an interview on 10/14/19 at 4:01 p.m., Staff J confirmed and verified the facility Director of Nursing brought each of the staff into the office and explained the staff needed to keep a close eye on the resident at all times, which is different from 1-1 supervision. Keeping a close eye on the resident means they are in your vision at all times, 1-1 supervision means that you are with in an arms length away from the resident at all times. Staff J stated it was their responsibility to make sure Resident #3 was in their line of vision at all times and Staff J got distracted from that due to being called over by the charge nurse whom was passing medications to assist in identifying who the residents were. Staff J confirmed that not until there was a commotion in the Birch hallway the resident was not in the line of vision as requested by the facility Director of Nursing. Staff J stated the last time Resident #3 was in their line of vision was around 4:30 p.m., and could not recall where the resident was after that time. During an interview on 10/16/19 at 12:38 p.m., Staff L confirmed and verified the facility Director of Nursing brought each of the staff into the office and explained the staff needed to keep a close eye on the resident at all times, which is different from 1-1 supervision. Keeping a close eye on the resident means they are in your vision at all times, 1-1 supervision means that you are with in an arms length away from the resident at all times. Staff L stated no assessments were completed on Resident #3 or Resident #4 as no red marks were seen as they did a quick eye over the residents. During an interview on 10/21/19 at 12:40 p.m., the facility Director of Nursing stated all the staff were brought into the office and explained that Resident #3 needs to have an eye on them at all times due to just being readmitted to the facility on [DATE] and that it is different from being a 1-1 supervision. Keeping an eye on a resident is the expectation the resident is always in your line of vision and 1-1 supervision is the expectation that staff are at a arms length away from the resident. The Allegation for Abuse/Resident to Resident checklist dated 8/24/16, instructed staff to: *Ensure Residents are safe/separate the residents and keep them separated the remainder of the shift. *If staff is suspected remove staff from the floor immediately. *Resident to Resident: Complete head to toe assessment and complete progress note on both residents. *Obtain witness statements from all staff on the hallway including house keeping, maintenance, activities and dietary. *Notify Director of Nursing once you have obtained all statements. *Notify DIA hotline. Document the time you called DI[NAME] *Notify physician for both residents. *Notify both residents Family/PO[NAME] *Complete incident report for both aggressor and victim. *Place both residents on alert charting times 72 hours.

Based on clinical record review, observation, family interview, and staff interviews, the facility failed to prevent the development of pressure sores, failed to complete wound assessments, failed to communicate decline in residents condition and deterioration of sacrum wound that developed osteomylitis and failed to complete wound treatments as ordered for 2 of 4 residents reviewed for pressure sores, ( Resident #97 and Resident #9). The facility reported a census of 115 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 97 identified a Brief Interview for Mental Status (BIMS) score of 12 without signs/symptoms of [MEDICAL CONDITION]. A score of 12 indicated moderate cognitive impairment. The MDS documented the resident displayed no behaviors during the 7 day look-back period which included no rejection of cares. The MDS revealed the resident required the extensive physical assistance of 1 person for bed mobility, transfers, dressing, personal hygiene, 2 persons for toilet use, and independent with set up help only with eating. The MDS revealed the resident walked once or twice with the assistance of 1 person in the room and corridor. The MDS documented [DIAGNOSES REDACTED]. The MDS recorded a weight of 329 pounds. The MDS recorded the resident at risk of pressure ulcers/injuries but did not have any unhealed pressure sores. The Discharge Return Anticipated (DRA) MDS assessment dated [DATE] documented the resident went to the hospital on [DATE]. The MDS documented the resident displayed verbal behaviors directed toward others on 1 to 3 days of the 7 day look-back period but did not display rejection of cares. The MDS revealed the presence of unhealed pressure ulcers/injuries but failed to document the number or types. The Significant Change MDS assessment dated [DATE] documented the resident returned from the hospital on [DATE]. The MDS identified a BIMS score of 09 without signs/symptoms of [MEDICAL CONDITION] which indicated moderate cognitive impairment. The MDS documented the resident rejected cares on 1 to 3 days of the 7 day look-back period. The MDS revealed the resident required the extensive physical assistance of 1 person for personal hygiene, 2 persons for bed mobility, dressing, toilet use, and supervision of 1 person for eating. The MDS revealed the resident totally dependent upon 2 persons for transfers and did not walk in room or corridor during the assessment period. The MDS record the presence of 1 Stage II, 2 Stage III, and 1 Unstageable Deep Tissue Injury pressure ulcers. The care plan revealed the following: a. On 1/23/19 a new problem onset identified a potential for altered skin integrity due to history of irritation of skin and resident scratched, picked her skin. A blister present on the coccyx upon admit and excoriation to the perineal area. The resident chooses to lay in recliner most of the day, eating meals in room and watching TV. The interventions included: the nurse to assess skin twice weekly and notify the doctor as needed; treat skin issues as ordered; NIP (nutritional supplement) due to pressure areas; peri-care per staff; gel cushion and dicem (anti-slip mat) in recliner; moisture barrier cream twice a day and as needed as resident allows; and standard pressure reducing mattress. b. On 2/11/19 a new intervention started for an alternating air mattress. c. On 2/11/19, a focus area identified the resident sometimes resistive to care and staff direction related to adjustment to nursing home and dementia. Another focus area identified an ADL (Activities of Daily Living) self-care performance deficit related to [MEDICAL CONDITION]. d. On 2/22/19 staff directed to provide assistance of 1 staff for dressing, 1 staff with gait belt for transfers, the use of the wheelchair to go to meals and back per resident preference, and to complete the restorative nursing program as ordered. e. On 3/25/19 a new focus area identified an Unstageable pressure sore at the sacrum (located at the base of the lumbar vertebrae and connected to the pelvis) related to incontinent of bowel (diarrhea)/bladder, resistive to peri-care/repositioning, and poor nutritional intake. The new interventions directed staff to: apply treatment per order; encourage good nutrition and hydration in order to promote healthier skin; and keep the skin clean and dry. f. On 3/26/19 the care plan documented the resident non-complaint with cares, repositioning, and incontinence cares. g. On 4/1/19 new interventions directed staff to frequently turn and reposition the resident and to provide NIP supplement to promote wound healing. h. On 4/1/19 and revised 5/3/19 an entry directed staff to monitor and document location, size, and treatment reporting abnormalities, failure to heal, signs/symptoms of infection, maceration (softening skin) etc. to the doctor. i. On 4/9/19 staff directed to use the hoyer (mechanical) lift with 2 staff for transfers starting 4/8/19. j. On 4/11/19 the care plan again informed staff the resident non-compliant with repositioning and turns. k. On 4/12/19 new focus areas identified an Unstageable pressure sore at the left gluteal fold, an Unstageable pressure sore at the right gluteal fold, and a Stage II pressure sore at the right buttock (fluid filled blister); all related to incontinent with bowel (diarrhea)/bladder, resistive to peri-care/repositioning, and poor nutritional intake. l. On 5/2/19 staff advised the resident could sit up in the Broda chair (a type of reclining wheelchair) with Roho (pressure relief) cushion for meals up to 1 hour at a time as tolerated. The January, February, and (MONTH) 2019 Treatment Administration Records (TARs) documented an entry for the administration of [MEDICATION NAME] ointment to be applied topically to the coccyx every shift as a preventative treatment to maintain skin integrity. The TARs documented the [MEDICATION NAME] treatment routinely completed 3 times a day at 5:30 a.m., 1:30 p.m., and 9:30 p.m., every day of the month with only 2 exceptions. The staff visualized the resident's buttocks approximately every 8 hours. The (MONTH) 2019 TAR contained an entry to apply metahoney to the pressure sacrum, bilateral gluteal fold, right buttock, and cover with [MEDICATION NAME] daily until healed. The TAR reflected 4/17 and 4/22 left blank indicating the treatment not completed. The progress notes lacked documentation of any refusals to complete the treatment on those days. The Progress Notes revealed the following: a. On 1/11/19 at 9:48 p.m. a care plan charting note revealed the resident alert to self, transferred with assist of 1, mobility via wheelchair with frequently asking staff to propel but self-propelling encouraged, and the resident out in the dining room and able to feed self. b. On 3/22/19 at 9:23 a.m. the resident's blood sugar reading high at 516 and staff updated the primary ARNP (Advance Registered Nurse Practitioner). At 1:43 p.m., the resident noted to continue with some watery loose stools but none since 9:30 a.m. that day. The resident complained she didn't feel good, and orders to obtain specimen for[DIAGNOSES REDACTED] test (type of infection that causes diarrhea). c. On 3/23/19 at 1:27 p.m. the resident refused to get out of bed so given a bed bath and the resident on contact precautions for loose stools and emesis. d. On 3/23/19 at 8:27 p.m., the nurse observed a pre-existing bloody blister to the left side of the resident's buttock getting bigger and tender. Peri care provided, barrier cream applied, and fax sent out to physician about condition as resident refusing to lay in bed on her side to reduce pressure to her bottom. e. On 3/23/19 at 8:46 p.m. the[DIAGNOSES REDACTED] test results reported as negative and a fax request sent to the physician to discontinue the [MEDICATION NAME] order due to diarrhea. f. On 3/24/19 at 3:50 a.m. the resident's temperature 98.2 degrees, had a small amount of loose stool, [MEDICATION NAME] (a protective barrier) applied to buttock to prevent excoriation, and the resident remained on a pressure relief mattress with HOB (head of bed) elevated 30 degrees. At 12:28 p.m. the resident had a small amount of diarrhea, refused to get up, refused cares, bed bath given, and the resident ate in room while in bed. At 6:25 p.m. the resident continued with diarrhea, refused cares including per-care. Resident assisted by 4 staff and a gait belt to transfer to the wheelchair so the resident could get clean and the bed changed. g. On 3/25/19 at 2:00 a.m. dry excoriation observed on the left buttock with [MEDICATION NAME] documented as placed on the resident's buttock. At 12:03 p.m. the resident refused to get out of bed to check weight and at times refusing cares. At 1:46 p.m. the resident had generalized body weakness and found to have pressure sores to her bottom. The resident received cares and took all meds during that shift. A new order received to send the resident to the hospital and the ambulance service contacted. At 3:26 p.m. Staff P, Registered Nurse (RN)/facility wound nurse, documented a detailed Skin/Wound Note. Staff P recorded the resident had 4 areas of Unstageable pressure. The sacrum area measured 5.5 cm (centimeters) by 11.9 cm, the left gluteal fold measured 1.6 cm by 2.2 cm, the right gluteal fold measured 2.7 cm by 8.2 cm, and a Stage II pressure at the right buttock measured 2.7 cm by 8.2 cm. Staff P wrote the resident with impaired skin integrity related to incontinent of bowel due to diarrhea for 2 to 3 days, incontinent of bladder, and noted the[DIAGNOSES REDACTED] test negative. Staff P documented the resident had generalized body weakness due to diarrhea, refused to be out of bed, was non-compliant with cares, refused/resistive during peri-care and repositioning/turns while in bed. Staff P documented the resident had poor nutritional intake related to current illness and [DIAGNOSES REDACTED]. h. On 3/26/19 at 11:06 a.m. a call was made to the hospital and informed the resident admitted for UTI (Urinary Tract Infection) and general body weakness. i. On 3/29/19 at 10:09 p.m. the resident arrived back from the hospital at 5:25 p.m. The resident was alert and oriented times 2 (person/place), assist of 1 with ADL's but uncooperative during care. The resident was started on an antibiotic for UTI. j. On 3/30/19 at 2:39 a.m., the presence of open sores and eschar (dead tissue) to sacral area, area cleansed and [MEDICATION NAME] applied. The resident was on a pressure relief mattress. At 1:05 p.m. the resident noted to be very uncooperative during cares, wound to buttock cleaned, treatment applied. The resident refused to get out of the bed during the shift. At 9:02 p.m. documented the treatment continued to the buttock and the resident refused to get up that evening. k. On 4/1/19 at 1:56 p.m. the resident noted to spend time in room, refused to get up. The resident had been turned and changed as the resident was incontinent of both bowel and urine. At 10:18 p.m. the staff documented the resident needed fed during the shift. l. On 4/4/19 at 3:33 a.m. the resident on a pressure relief mattress. At 12:32 p.m. the resident refused to get up from bed, cares were provided, treatment to wounds completed, and the resident turned to sides to reduce pressure from her buttock. At 9:27 p.m. documented the resident stayed in bed all shift, checked, changed, and turned as needed. m. On 4/5/19 at 12:18 p.m. documented the resident stayed in bed all day and reposition on side at least every 2 hours. n. On 4/7/19 at 6:30 p.m. a post fall evaluation was documented for a witnessed fall. The fall occurred in the resident's room while peri-care being done. The evaluation documented yes to change in mental status, change in behaviors, and change in mobility status. The evaluation documented a Stage I pressure issue on buttock with non-blanchable [DIAGNOSES REDACTED]. At 9:31 p.m. the incident note documented the resident lowered to the floor as she was unable to bear weight when being cleaned up and the bedding being changed. The incident note recorded a scant amount of blood noted from the existing wound on buttock, the wounds cleaned, treatment completed, and weekend supervisor made aware. o. On 4/8/19 at 9:15 p.m. a new order received from the primary ARNP to evaluate the resident to be a hoyer transfer and documented family notified. p. On 4/10/19 at 11:29 p.m. a new order received from the primary ARNP to apply metahoney (treatment designed for wounds that have difficulty healing on their own) to the pressure area on the sacrum and cover with [MEDICATION NAME] (self-adherent, soft silicone foam dressing) daily until healed; documented family notified. q. On 4/15/19 at 1:11 p.m. the resident repositioned but refused getting out of bed throughout the shift. r. On 4/20/19 at 3:05 p.m. the resident's son gave verbal authorization to see the wound doctor that week. s. On 4/22/19 at 11:05 a.m. an Activity Significant Change MDS progress note documented the resident recently laid in bed often. t. On 4/30/19 at 8:20 a.m. the resident's blood sugar level high at 530 and the primary ARNP and family notified. u. On 5/3/19 at 8:47 p.m. a Life Enrichment Note documented the resident now on a 1 to 1 program but at times refusing visits and spending a lot more time in room. v. On 5/8/19 at 10:57 p.m. a new order received from the ARNP Wound Nurse to cleanse the coccyx with Vashe (intended for use in cleansing, irrigating, moistening and [MEDICATION NAME] acute and chronic wounds), a nickel thick layer of Santyl (a [MEDICATION NAME] agent) to the wound bed to slough covered area (have a layer of skin come off), loosely pack with fluff gauze to fill cavity, sprinkle collagen (a protein) powder to red granulation tissue (new growth of connective tissue associated with wound healing), cover with border gauze, and change daily. w. On 5/10/19 at 9:17 a.m. a Communication with Family note, documented by the Social Worker (SW), recorded the resident's son came to discuss the resident's current state after being told by the nurses the resident refused a lot of cares and chose to stay in bed all day. He stated he felt like his mom may be giving up. The SW wrote she educated the son about hospice and palliative care and the son expressed interest in information on palliative care. The SW wrote she would discuss options for the resident with the clinical team and would follow up with the son early the next week. At 12:27 p.m. the son went to Staff U, Licensed Practical Nurse (LPN), to request a UA (urinalysis) test. Staff U wrote the resident had been down, refusing to do things, incontinent of bowel and urine, and changed per staff. At 12:33 p.m. Staff U documented she sent a fax out to the physician requesting a UA per family request. x. On 5/13/19 at 3:45 p.m., the son came to visit the resident and complained of the resident not able to stay awake, engage in conversation, or eat a meal. Staff A, LPN, wrote she tried to explain that aides help with the feeding in the room and the resident refused getting up. The son requested a UA and palliative care evaluation. Staff A documented a fax had been sent to the primary ARNP and staff still waiting for a response. y. On 5/14/19 at 5:53 a.m. orders received for palliative care and UA with dysuria (painful urination); UA obtained without difficulty with cloudy yellow urine output. At 2:36 p.m. a fax was sent to the primary ARNP with the UA results and son notified. The wound doctor saw the resident and treatment done. z. On 5/15/19 at 7:45 a.m. the resident was red and flushed, her temperature was 99.4 degrees. The resident had a High FBS (fasting blood sugar reading), the on-call doctor was notified. At 7:58 a.m. the son updated on the resident's status and the daughter-in-law to be in the facility that day. At 8:40 a.m. a Communication with Family, documented by the SW, noted the daughter-in-law visibly upset and wanted to see the primary ARNP when she arrived to do rounds and wanted to ensure the resident on the list to be seen. The SW explained to the daughter-in-law she does not communicate directly with the ARNP but assured the resident would be seen and she referred the daughter-in-law to the ADON (Assistant Director of Nursing) who would be better equipped to answer nursing related questions. The SW apologized to the daughter-in-law that the family not aware of the resident's health decline. The SW recorded the daughter-in-law and son very upset the resident may be hospice appropriate and the SW immediately notified the DON of the interaction. At 8:57 a.m. Staff U documented the resident was very sleepy during the shift, barely opening her eyes. Staff put the resident's dentures in her mouth and tried to feed her but she spit out the food. The resident refused medications. Staff U documented the physician was aware and would be in to see the resident. The resident had been repositioned in bed. At 9:19 a.m. Staff P documented she tried to talk to the son to give update related to the wound as the ARNP Wound Nurse would like to know if family wanted aggressive treatment to the wound, and if they did, a referral to infectious specialist would be given. The son did not answer the call so she spoke to the daughter-in-law and gave updates of wound care plan. Staff P documented the daughter-in-law got a hold of the son and reported he wanted to be as aggressive as possible with treatment. At 11:20 a.m. Staff U documented the ambulance arrived and the resident transferred by 3 persons and a hoyer. The daughter-in-law wanted to know how long the resident had been refusing meds and Staff U informed her just that morning and the resident was fed in her room with very poor appetite. At 12:09 p.m., Staff U documented the daughter-in-law spoke to the physician regarding the residents decline. A recheck of the blood sugar had been done at 10:00 a.m., BS 597. The physician was notified of vital signs abnormal for the resident. The Physician stated the resident will be sent to the hospital per family request. The facility still waiting on the C&S (Culture & Sensitivity) report from the UA test. Staff called for ambulance transport. The Facility Skin & Wound Evaluations revealed the following: The clinical record lacked documentation of pressure sore Skin & Wound Evaluations for any areas dated prior to 3/25/19. The care plan identified a blister to the coccyx 1/23/19 and the Progress Notes identified a pre-existing bloody blister to the left side of the resident's buttock getting bigger and tender on 3/23/19. Pressure sore Right Buttock a. On 3/25/19 the resident had a new intact serum filled blister that measured 2.7 cm by 8.2 cm. The surrounding tissue had [DIAGNOSES REDACTED] (redness of the skin), was excoriated and fragile. The blister was in-house acquired. b. On 4/1/19 the blister measured 1.6 cm by 1.5 cm with100% granulation and light serosanguinous exudate (bloody, watery fluid drainage), progress improving. The resident had been sent to the hospital with a Stage II pressure at the right buttock (blister) and the resident readmitted with the blister broke open. Staff were directed to cleanse the wound with cleansing spray or soap and water, apply Z-guard paste to cover all open areas and apply [MEDICATION NAME] to the reddened areas on the buttocks and coccyx. Education included; alternating air mattress in place, NIP supplement to promote wound healing, frequent turn and repositions, keep skin dry and clean, and wheelchair cushion in place. c. On 4/9/19, the area to the right buttock was marked a Stage III pressure area. The area measured 1.5 cm by 1.4 cm with100% granulation tissue and light serosanguineous exudate. The surrounding tissue was [MEDICAL CONDITION]. The area was deteriorating. The resident was seen by the primary ARNP on 4/10/19 and the treatment changed to cleanse site with normal saline, apply/pack with metahoney, cover with [MEDICATION NAME] daily until healed. Continue all previous interventions. Education included; the resident non-compliant for turning and repositioning, encourage to turn frequently, appetite poor and diagnosed with [REDACTED]. d. On 4/15/19 the area measured 1.5 cm by 1.6 cm with100% [MEDICATION NAME] tissue (thin tissues that cover all the exposed surfaces of the body) and light sanguineous exudate (bloody drainage). Noted wound healing well. e. On 4/22/19 the area measured 1.1 cm by 1.4 cm and was resolved. Pressure sore Right Thigh (Rear) a.k.a. Right Gluteal Fold a. On 3/25/19 a new Unstageable pressure area measured 1.8 cm by 2.3 cm with 100% eschar (dead tissue). The surrounding tissue had [DIAGNOSES REDACTED] was excoriated and fragile. b. On 4/1/19 the area measured 1.4 cm by 2.4 cm, 80% [MEDICATION NAME] tissue and 20% slough (a layer or mass of dead tissue separated from surrounding living tissue in a wound), light serosanguineous exudate. The resident sent to hospital with Unstageable pressure due to suspected deep tissue injury at the right rear thigh and readmitted with Stage II at the right rear thigh. Staff directed to cleanse the wound with cleansing spray or soap and water, apply Z-guard paste to cover all open areas and apply [MEDICATION NAME] to the reddened areas on the buttocks and coccyx. c. On 4/9/19 the area measured 2.1 cm by 1.7 cm with100% granulation tissue. Had light serosanguineous exudate and the surrounding tissue had [DIAGNOSES REDACTED]. The area was deteriorating. The resident was seen by primary ARNP 4/10/19 and treatment changed to cleanse site with normal saline, apply/pack with metahoney, covered with [MEDICATION NAME] daily until healed. Continue all previous interventions. d. On 4/15/19 the area measured 1.6 cm by 1.0 cm with100% [MEDICATION NAME] tissue. Pressure sore Left Thigh (Rear) a.k.a. Left Gluteal Fold a. On 3/25/19 a new Unstageable pressure area measured 1.6 cm by 2.2 cm with 100% eschar. The surrounding tissue with [DIAGNOSES REDACTED], excoriated and fragile. b. On 4/1/19 area measured 1.8 cm by 1.6 cm with 20% [MEDICATION NAME] tissue and 80% slough. The area had serosanguineous exudate. Resident #97 sent to hospital with Unstageable pressure due to suspected deep tissue injury at the left rear thigh and readmitted with Stage II at the left rear thigh. c. The clinical record lacked an assessment completed on 4/9/19. d. On 4/15/19 area measured 1.4 cm by 1.4 cm with 100% [MEDICATION NAME] tissue. It had light sanguineous exudate. e. On 4/22/19 area measured 0.9 cm by 0.1 cm and was resolved. Pressure sore Sacrum a. On 3/25/19 a new Unstageable pressure area measured 5.5 cm by 11.9 cm, with 100% eschar. The surrounding tissue had [DIAGNOSES REDACTED] and was excoriated and fragile. The pressure area was in house acquired. b. On 4/1/19 the area measured 8.9 cm by 6.4 cm with 90% slough and 10% eschar. It had light serosanguineous exudate with a faint odor. The resident was sent to hospital with Unstageable pressure due to suspected deep tissue injury at the left rear thigh and readmitted with Stage II at the sacrum. Treatment to the area included to cleanse the wound with cleansing spray or soap and water, apply Z-guard paste to cover all open areas, apply [MEDICATION NAME] to the reddened areas on the buttocks and coccyx. c. On 4/9/19 the area measured 6.9 cm by 4.4 cm with 50% granulation tissue and 50% slough. It had light purulent exudate (type of liquid that oozes from a wound that can be a sign of infection), progress deteriorating. The area had a depth of 0.5 cm. The resident was seen by the primary ARNP with treatment changed to cleanse site with normal saline, apply/pack with metahoney, cover with [MEDICATION NAME] daily until healed, and continue all previous interventions. d. On 4/15/19 the area measured 10.0 cm by 6.6 cm with 40% granulation tissue and 60% slough. It had moderate purulent exudate, progress deteriorating. Noted resident seen by the primary ARNP, noted a depth of 0.5 cm, treatment changed the previous week, would continue to apply and re-evaluate treatment effectiveness, and continue all previous interventions. e. The residents clinical record lacked an assessment of the wound for the week of 4/22/19. f. The residents clinical record lacked an assessment of the wound for the week 4/29/19. g. On 5/7/19 the area measured 7.8 cm by 4.3 cm with 30% [MEDICATION NAME] tissue, 40% granulation tissue and 30% slough. It had light serous exudate. The area was deteriorating. The resident was seen by ARNP Wound Nurse on 5/7/19 with wound measurements of 8.5 cm by 3.6 cm by 1.6 cm. The area was 25% slough, 10% partial thickness, 25% [MEDICATION NAME] and 40% red granulation. It had [MEDICATION NAME] islands and the bone was palpable. There was moderate thin serous drainage with slight pain, managed with pain medication. Started treatment of [REDACTED]. Observations revealed the following: a. On 5/13/19 at 11:32 a.m. Resident # 97 laid in bed positioned on her back. b. On 5/14/19 at 9:33 a.m. Resident # 97 positioned on her right side in bed with a pillow on her left side of back to position. At 11:59 a.m. Resident # 97 laid in bed on her back, air pump in place on the bed, and functioning. Attempted conversation with the resident and she did not really respond. c. On 5/14/19 at 1:32 p.m. the ARNP Wound Nurse, Staff P, and Staff A, entered the room to provide cares. Staff A and Staff P assisted the resident to roll onto her right side. The ARNP Wound Nurse unpacked the sacral wound, measured 5.5 cm by 5.3 cm by 2.4 cm straight depth, and stated some necrotic tissue present in the wound that needed removed. The ARNP Wound Nurse stated the wound bed was 30% slough/necrotic tissue, 10% [MEDICATION NAME] tissue, the rest granulation tissue. The ARNP Wound Nurse reported the wound areas were pressure related. Noted a foul odor coming from the unpacked wound. The ARNP Wound Nurse stated they were treating the wound with Santyl (a [MEDICATION NAME] agent) to get to the healthy tissue and that was why there was odor coming from the wound. The ARNP Wound Nurse debrided the necrotic issue then re-measured. The measurements were 5.7 cm by 5.0 cm by 2.2 cm straight depth with 3.7 cm of tunneling at 9 o'clock and 1.7 cm of undermining at 11 o'clock to noon. The ARNP Wound Nurse stated the bone was exposed and informed staff they needed to reach out to family to see how aggressive they wanted with treatment as bone exposure could mean possible osteo[DIAGNOSES REDACTED] (bone infection). The ARNP Wound Nurse said if the family wanted aggressive treatment then infection control gets involved otherwise they would focus on keeping it from getting worse in the facility. Staff A washed hands, donned gloves, then cleansed the wound with normal saline, repacked the wound with Santyl gauze, then collagen powder on the outer skin areas where granulation tissue present, and a new foam dressing applied. Resident # 97 did moan at some points during the dressing change. Staff P stated the resident started with a decline overall, then had some loose stools, and a Stage II to III pressure area developed. Staff P stated the depth of the wound was new for the resident. d. On 5/15/19 at 8:35 a.m., Staff U attempted to rouse the resident to take drinks of water, drinks of Pepsi, and to attempt a bite of food. Resident # 97 was slow to respond or open eyes and moaned in response to being rubbed on the arm. Resident # 97 did take in dentures, but did not take a drink or meds. Staff U gave Resident # 97 a bite of food which the resident spit out. Staff U stated the resident was not going to accept anything at that time so she would just wait for the doctor who was supposed to be coming. Staff U reported she worked for the facility for a year and was familiar with Resident # 97's cares prior to going to the hospital. Staff U stated prior to going to the hospital the resident used to be up talking and walking. Staff U responded the resident came from the hospital with the pressure sores. Staff U reported the resident had 2 pressure areas on the gluteal folds that healed up and the other pressure area remained on the sacrum. Staff U stated when the resident went to the hospital her bottom just red and the wound nurse saw the resident before she went to the hospital. Staff U again clarified she had never seen the pressure areas on the resident's bottom before the hospitalization , the sacral area was just red. e. On 5/15/19 at 11:15 a.m., observed paramedics arrive to the resident's room to assess and transport the resident to the hospital. Resident # 97's daughter-in-law at the resident's bedside with Resident # 97's son on the speaker phone. The family relayed concerns the resident showed signs of dehydration with wrinkled skin and increased temperature above 100 degrees Fahrenheit. The daughter-in-law reported she spoke to the primary ARNP who had just been in the facility to assess the resident and the ARNP told her she had not been made aware the resident's condition that bad. Physician orders, primary ARNP visit, ARNP Wound Nurse visits, revealed the following: The primary ARNP Routine Visit note dated 1/16/19 recorded the resident examined for a routine visit and noted all chronic conditions stable at that time. The primary ARNP Routine Visit note dated 3/13/19 recorded the resident examined for a routine visit and noted no acute concerns per nursing staff or family and all chronic conditions stable at that time. The fax order sheet dated 3/23/19 documented the resident had 1 blood blister to her left bottom/groin that measured 6.0 by 6.0 cm, the skin intact but raw, cream applied, and requested treatment for [REDACTED]. A new order given for Duoderm to open area on the buttocks and change every 3 days. The hospital Discharge Summary dated 3/29/19 documented the resident admitted to the hospital on [DATE] for increased confusion, urinary tract infection, and AKI (Acute Kidney Injury). The discharge orders included treatment to coccyx/buttock of: clean with

Based on record review and staff interviews, the facility failed to provide adequate nursing supervision to protect residents against hazards from themselves, others, or the physical environment for 2 of 8 residents reviewed (Resident #1 & Resident #7). The facility identified a census of 110 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 6/5/16, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident experienced severe cognitive impairment and displayed verbal behavioral disturbances toward others. The MDS also documented Resident #1 required extensive assist of 1 staff for transfers, but could ambulate (walk) independently. A fall assessment dated [DATE] revealed a score of 16. A fall assessment dated [DATE] revealed a score of 14. The assessment form indicated a score of 10 or greater meant the resident was at high risk for falls. An MDS dated [DATE] revealed the resident displayed severe cognitive impairment and verbal aggression. The MDS documented Resident #1 rejected cares and did not ambulate in his/her room or off unit during the assessment period. The MDS also documented the resident as totally dependent on 2 staff for surface to surface transfers. A care plan with a problem/onset date of 6/15/16 identified the resident as at risk for falls related to [DIAGNOSES REDACTED]. The care plan directed staff to provide 1 staff assist with ambulation during the night and provide standby assistance when the resident attempted to sit due to decreased depth perception. A problem/onset dated 6/15/16 revealed the resident experienced a self-care deficit due to a [DIAGNOSES REDACTED]. The care plan directed staff to assist with transfers as needed (prn). A care plan with a problem/onset date of 11/23/16 revealed the resident was at risk for altered thought, communication related [DIAGNOSES REDACTED]. The care pain directed staff to remain aware of the resident's confusion and verbal behaviors with cares and transfers. A problem onset dated 11/23/16 revealed the resident was at risk for falls related to previous injuries, limited safety awareness, confusion related to dementia, and a previous right hip fracture. The care plan directed staff to provide assist of 2 staff for transfer by Hoyer (a mechanical device used to transfer a resident by placing them in a sling, lifting them and physically taking them from one surface to another.) Departmental notes dated 8/13/16 at 1:33 p.m. documented Resident #1 became weak when he/she ambulated for long distances and had depth perception problems when aligning to sit in a chair. The notes revealed the resident required assist of 2 staff for both situations. An incident report dated 8/14/16 at 11:44 p.m. revealed the resident got up independently to go to the bathroom and staff found him/her on the floor. Departmental notes dated 8/14/16 at 10:05 p.m. revealed at 9:33 p.m. the resident got up independently to go to the bathroom and fell . The resident complained of hip, back, and neck pain. The facility notified the resident's family and they gave consent for staff to transfer Resident #1 to a local hospital emergency room for evaluation and treatment Departmental notes dated 8/15/16 at 4:05 a.m. revealed hospital staff notified the facility the resident had been admitted with a right hip fracture. Notes dated 8/18/16 at 9:50 p.m. revealed the resident returned to the facility at 3:00 p.m. Departmental notes dated 9/30/16 at 2:49 p.m. revealed during an occupational therapy assessment, Resident #1 was unable to bear weight. Departmental notes dated 1/12/17 at 12:01 a.m. revealed a late entry dated 1/11/17. During the 2:00 p.m.-10:00 p.m. shift an aide had called a nurse into the shower room to help because Resident #1 was combative with cares. Departmental notes dated 1/13/17 at 2:45 p.m. revealed the occupational therapy staff notified the nurse that a certified nursing assistant (CNA) needed staff assistance because the resident was on the floor. The nurse went to the resident's room and the CNA reported she attempted to place a Hoyer pad (sling) under the resident, but he/she displayed resistive behaviors and slid around the CNA feet first. The CNA then lowered the resident to the floor. The notes revealed during a nursing assessment, the resident's range of motion was within indicated normal limits. Three staff then assisted the resident to bed. Departmental notes dated 1/13/17 at 9:14 p.m. revealed the resident complained of severe pain to the right leg when staff transferred him/her from bed to wheelchair. During assessment, the resident complained of pain to the right upper leg. The nurse documented the right leg looked swollen compared to the other. Staff notified the resident's physician ,who gave an order to transfer the resident to a local hospital emergency room for evaluation and treatment. Departmental notes dated 1/14/17 at 1:05 p.m. revealed hospital staff notified facility staff Resident #1 had been admitted due to right femur fracture. Notes dated 1/17/17 at 9:53 p.m. documented the resident returned from the hospital via ambulance at 3:00 p.m. and remained totally dependent on staff for all care needs. A Follow-up/Conclusion to the resident's the fall on 1/13/17 completed by the director of nursing revealed the resident had a fall on 4/8/16. The report indicated the resident had more weakness during ambulation at times in the last few weeks and staff monitored for possible physical therapy involvement. The resident required more help with ambulation at night because he/she had not been fully awake when getting up to the toilet. Staff documented they had been monitoring the resident became the resident had become weaker with ambulation. During an interview dated 2/8/17 at 8:25 a.m. and at another at 2:15 p.m., Staff H, CNA reported had cared for the resident for the past 4 months; during the last 2 months, the resident had been physically combative during cares and he/she had tried to strike staff when cares were given. Two days before the fall on 1/13/17, the resident had been physically combative. Staff H stated on 1/13/17 at approximately 12:00 p.m., she went to the resident's room to assist him/her to get up for lunch. Once in the room, she activated the call light, completed incontinence care, dressed the resident and placed the Hoyer sling under him/her as she rolled the resident toward her. At the same time, the resident became combative and his/her legs slipped off the bed and hit the floor. Staff H reported the resident was unable to bear weight and she tried to keep the resident from hitting his/her head. She reported 30 minutes went by from the time she activated the call light. Then, therapy staff came into the room to see the resident's roommate and saw her on the floor with the resident. Staff H stated there is not enough staff to assist with transferring residents. During an interview dated 2/8/17 at 8:59 a.m. Staff G, CNA reported on 1/13/17 she went to lunch from 11:00 a.m.-11:30 a.m. When she returned, occupational therapy staff told her she needed to go to the resident's room because staff needed help. When she arrived, she saw Staff H sitting on the floor with the resident. Staff F, RN had completed an assessment and the resident screamed for help. Staff G reported the resident's combative behavior had escalated during the last 3 - 4 months; Resident #1 flailed his/her arms, slapped staff and rejected cares. Staff G stated the resident needed 2 staff to assist with transfers and positioning the Hoyer sling under the resident. Staff G reported it is not safe for 1 staff to provide cares. During an interview dated 2/8/17 at 9:37 a.m. Staff F, RN reported she knew the resident well and he/she yelled constantly and was combative, i.e. pushed, shoved, and attempted to strike staff. Staff F reported at the time of the incident she knew the resident's call light had been on between 15 minutes to 30 minutes, but she couldn't leave the commons area because there were residents in the common area and they could not be left alone. She reported it would have been appropriate to have 2 staff assist with placement of the Hoyer sling and added staff knew they could call for additional assistance if the resident became combative or resisted cares. During an interview dated 2/8/17 at 12:10 p.m., the Director of Nursing (DON) stated the resident had a history of [REDACTED]. The DON reported staff have been directed to seek additional staff when needed. Two staff are needed when preparing the resident for a Hoyer transfer; including placement. 2. According to the MDS dated [DATE], Resident #7 had a [DIAGNOSES REDACTED]. The MDS documented the resident required limited assist of one staff for bed mobility and required oversight, encouragement or cueing with ambulation during the assessment period. A Fall assessment dated [DATE] documented a score of 14. A score of 10 or greater meant the resident was at high risk for falls. A care plan with a problem/onset dated 12/21/16 revealed the resident's potential for injury related to falls due to unsteady gait at times. Interventions directed staff to observe the resident when he/she ambulated around the unit and observe when he/she ambulated around obstacles Departmental notes dated 11/21/16 at 2:26 p.m. revealed the resident limped on the right lower extremity and leaned toward the right side. Notes dated 11/23/16 at 1:55 p.m. documented the resident limped slightly throughout the evening shift. Notes dated 12/2/16 at 2:01 p.m. documented staff saw the resident sitting on the floor. Two staff with a gait belt assisted the resident with ambulating in the hallway. Notes dated 12/7/16 at 9:34 a.m. documented the resident ambulating independently but unsteady. Notes dated 12/9/16 at 1:38 p.m. documented the resident as unable to make his/her needs known as the resident did not speak. Departmental notes dated 12/19/16 at 3:04 p.m. documented the resident as severely impaired cognitively and unable to locate his/her room. Departmental notes dated 1/10/17 at 9:08 a.m. documented a CNA reported she found the resident on the floor lying on top of his/her side rail. The resident sustained [REDACTED]. Departmental notes dated 2/9/17 at 9:57 p.m. documented a nurse sitting at the nurse's station noted the janitor vacuuming the floor in the unit. At 7:50 p.m., she heard the vacuum turn off and heard a thump. The nurse looked up and saw the resident on the floor between the nurse's station and the medication cart lay on his/her right side. A nurse and a certified nursing assistant (CNA) assisted the resident up and to a chair. The nurse assessed the resident and didn't find any bruises or bumps. The nurse noticed the resident's right foot pointed outward so staff took the resident to his/her bed by wheelchair and called the resident's physician, who ordered staff to send him/her to the local hospital emergency room for evaluation. At 11:50 p.m. an entry documented hospital staff notified the facility Resident #7 sustained a left femur fracture and would be admitted for treatment. A radiology Final Report dated 2/9/17 at 10:57 a.m. documented the resident sustained [REDACTED]. A facility investigation dated 2/9/17 documented the resident as alert to self and unable to make needs known due to an inability to verbally communicate. The investigation revealed the resident had abnormal involuntary movements, ambulated with a slouch, and leaned to the right causing falls due to the loss of balance. The resident at times walked throughout the unit during a 16 hour shift at a fast pace, but looked and understood when to step over objects. The investigation documented the resident's speed and leaning to the right side caused one foot to step in front of the other and made the resident trip. Surveillance video of the event showed Staff M, housekeeping vacuumed the commons area as the resident walked up to the vacuum cord, stopped, looked, saw the cord, and started to lift one foot at a time to cross the cord. The video revealed as the resident crossed the cord, his/her toe caught it. The resident then took two more steps, regained his/her balance, took another step, stepped on the interior side of the left foot, and fell . A witness statement from Staff M reported as he vacuumed the commons area near the table close to the nurse's station, he heard the vacuum shut off, turned around and saw the resident on the floor about 12 feet away He yelled to the nurse who came and assessed the resident. Staff M received a one day suspension because staff is to keep the walking path for residents clear. During an interview dated 2/14/17 at 3:05 p.m., Staff M reported he failed to erect a hazard sign when he vacuumed. He reported he tried to watch the residents because the power cord is a tripping hazard. He reported he hadn't told anyone to watch for residents if they come close to the power cord. During an interview dated 2/14/17 at 3:15 p.m. the facility's Housekeeping Supervisor reported staff are not to string electrical cords when they can't keep an eye on the cord at all times.

Based on record review, family and staff interviews the facility failed to ensure 1 of 5 residents received kind and considerate care and failed to maintain a resident's dignity (Resident #1). Record review established Resident #1 lacked the ability to comprehend Staff F's remarks and a reasonable person would find the oral language used by Staff F on 11/26/16 to Resident #1 as disparaging, derogatory; and would likely view Staff F's language as a threat of harm. The facility reported a census of 115 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] listed Resident #1's [DIAGNOSES REDACTED]. The MDS indicated Resident #1 had long and short term memory problems and severely impaired cognition. The assessment revealed the resident required extensive assistance of two staff for dressing, toilet use and personal hygiene; and one staff for eating. The care plan dated 11/16/16 directed staff to keep Resident #1 out of the reach of a specific resident, and for nurses to do a skin check every night at bed time until further notice. The August 2016 revised abuse policy defined resident abuse to include, injuries of unknown source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the location (being located in an area not generally vulnerable to trauma). The Abuse policy identified all residents had the right to be free from verbal abuse; and residents must not be subject to abuse by anyone, including but not limited to facility staff, etc. The policy noted that abuse is defined differently under both State and Federal law and regulation. The policy identified a caretaker as a person who is a staff member of a facility or program who provides care, protection or services to a dependent adult by contract through employment. The policy included the following as result of the willful misconduct/reckless acts of a caretaker taking into account the totality of the circumstances. Assault of a dependent adult meant the commission of any act which is generally intended to cause pain or injury to a dependent adult or which is generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act intended to place another in fear of immediate physical contact which will be painful, injurious insulting or offensive coupled with the apparent ability to execute the act. The policy defined the Federal Certification Guidelines as follows: Verbal abuse defined by the policy as the use of oral language that willfully included disparaging and derogatory terms to residents regardless of the residents' ability to comprehend. The policy listed examples as threats of harm and saying things to frighten a resident. A Resident Incident Report indicated witness as Staff B and Staff D both Certified Nurse Aides (CNAs) who heard Resident #1 screaming, and then overheard Staff F, LPN (licensed practical nurse) asking Resident #1 if he/she wanted his/her medication the easy way or the hard way. Staff According to the report, Staff B reported what she witnessed to Staff E, LPN on 11/26/16 at 8:00 a.m. No injuries were noted from this incident but on assessment some old bruising had been noted. The report indicated staff assessed the resident and identified old bruising. The old bruising identified yellowish/green bruising around the mouth and to both upper extremities, which had been previously reported, but no new injuries. Record Review for Resident #1 identified the old bruising completed by Staff E on 11/26/16: a). A Wound Assessment Report completed by Staff E, (Licensed Practical Nurse)/LPN identified bruising that measured 2 cm (centimeter) x 2.5 cm, green/yellow coloring, located on the right corner of Resident #1's mouth. The bruising had first been identified on 11/26/16. b). A Wound Assessment Report noted that a 3 cm x 2 cm green/yellow bruise on the left corner of Resident #1's mouth had first been identified on 11/26/16. The bruising had first been identified on 11/26/16. c). A Wound Assessment Report noted that a 9 cm x 5 cm green/yellow bruise on Resident #1's right forearm had first been identified on 11/26/16. The bruising had first been identified on 11/26/16. d). A Wound Assessment Report noted that a 4 cm x 3 cm green/yellow bruise on Resident #1' s left wrist had first been identified on 11/26/16. The bruising had first been identified on 11/26/16. A follow up and conclusion to the unexplained bruising on Resident #1 had been signed and dated by the DON (Director of Nrsing) on 11/26/16 at 10:00 a.m. According to the document, Staff F had been sent home as a result of Staff B and Staff D alleging they overheard Resident #1 scream and Staff F saying to Resident #1, You can either take your meds the easy way or the hard way . A Notice of Leave Pending Investigation had been issued to Staff F on 11/26/16 for an allegation of abuse against her. A Resident Incident Report dated 11/26/16 at 10:30 a.m. indicated Resident #1's daughter reported multiple bruises around the mouth area and both upper extremities to Staff E. A Departmental Note dated 11/26/16 at 12:05 p.m. and signed by Staff E indicated that a CNA told her Resident #1 had been heard screaming, and then Staff F had been overheard saying You can either take this the easy way or the hard way, regarding medication administration. A Departmental Note dated 11/26/16 at 1:27 p.m. and signed by Staff E, indicated Resident #1 had a 9 cm x 5 cm bruise to the right forearm, a 4 cm x 3 cm bruise to the left wrist, a 2 cm x 2.5 cm bruise to the right corner of the mouth and a 3 cm x 2 cm bruise to the left corner of the mouth. An Incident Witness Statement dated 11/26/16 and signed by Staff D, indicated she heard Resident #1 screaming and yelling Oh My God as she overheard Staff F say, Do you want this the hard way or the easy way ? Staff D wrote that she and Staff B told Staff E. An interview on 12/21/16 at 3:20 p.m. with Staff D (CNA), revealed that she worked the day shift when the incident occurred. Staff D reported she said it happened about 7:00 or 7:15 a.m. She said she had just left Resident #1's room and entered another resident's room across the hall with Staff B. According to Staff D, they heard Resident #1 yelling Oh My God. Staff D stated she had never heard Resident #1 yell like that. Staff D said if staff were persisted at doing something Resident #1 did not want done, then Resident #1 will yell. Staff D said they heard Staff F yell You can either do this the easy way or the hard way . Staff D stated they immediately went to report what they heard to Staff E (LPN). As they passed Resident #1's room, they noticed Staff F in the hall at the med cart and noticed Resident #1 alone in his/her room. According to Staff D, she continued taking residents to the dining room and then helped feed them. The CNA said that once residents were done with breakfast and seated in the lounge area, she went on break about 10:00 a.m. Staff D said Staff F worked at the med cart from the time they told Staff E until the time she went on break. The CNA said she saw Staff F at the med cart on Redwood Avenue when she returned from break about 15 minutes later. Staff D said Staff F worked on the floor for about an hour before they called her downstairs. According to the CNA, Staff F returned a little while later. She said Staff F had been crying and said someone reported her for abusing Resident #1. Staff D said Staff F had left the floor by the time she returned from helping another resident. Staff D said she had only worked with Staff F a couple of times before and thought Staff F was a good nurse. The CNA said she had never heard Staff F talk that way to residents before. When asked to describe Staff F's tone of voice, Staff D reported Staff F's tone of voice was serious. An interview on 12/21/16 at 9:00 a.m. and subsequent interviews with Staff B revealed that she and Staff D had gotten Resident #1 up and were on their way out of the resident's room as Staff F, entered. Staff B stated she and Staff D heard Staff F say We can either do this the easy way or the hard way. According to the CNA, she believed Staff F meant taking medication since she entered the resident's room to administer medication. The CNA stated they heard Resident #1 screaming loudly. According to the CNA, Staff F had exited Resident #1's room right after they heard the resident scream, and she went into the resident's room to see what had happened. Staff B said Staff D stayed in the room across from Resident #1's room where they had been when they heard the scream. According to the CNA, when she entered the room, the resident seemed angry and irritated as he/she sat in the wheelchair. Staff B said the resident seemed unharmed. The CNA said she asked the resident if he/she was OK, but he/she did not respond. The CNA said she wheeled the resident from his/her room to the sitting area, and immediately reported what she knew to Staff E. According to the CNA, Staff E told her she had heard a scream, but thought another resident had screamed. Staff B said she became suspicious when she overheard Staff F say something so inappropriate. Staff B said she became good friends with Staff F when they 1st started working together. Staff B stated Staff F had been a very helpful nurse when she first started at the facility, but as time passed, she became less helpful. According to Staff B, she thought Staff F had been a little too harsh to residents at times. The CNA said she saw Staff F administering medication with a spoon a day or two before the incident. Staff B said it almost appeared that Staff F shoved the spoon in the resident's mouth. According to the CNA, it happened in the dining room. She could not remember which resident when asked, but knew it had not been Resident #1. The CNA stated she had not reported what she saw because other staff talked about it too, and she thought it was common knowledge. Initially, the CNA refused to name other staff that knew Staff F had been too rough when she shoved the spoon in a resident's mouth. The CNA said it could cause conflict with her coworkers if they knew she named them. Finally, the CNA divulged a coworker's name in confidence, but that person denied knowing anything about it. The CNA said if Staff F returned to work at their facility, she would probably keep her distance and continue to be suspicious of her. Staff B stated she was a mandatory reporter, and would not hesitate to speak up if something did not set right with her. Staff B said there had never been any conflict between her and Staff F. Staff B said about a week before the incident she noticed a bruise about the size of a thumbprint on the right side of Resident 1 ' s chin. The CNA said she reported it to Staff G. She said the resident still had the bruise on the day of the incident, but it had changed in color and appearance by then. Staff B stated she had not noticed any other bruising. An Incident Witness Statement dated 11/26/16 and signed by Staff B, indicated she heard Staff F, say to Resident #1, you can take this the easy way or the hard way , and then heard the resident scream on the 6:00 a.m. to 2:00 p.m. shift on 11/26/16. An interview on 12/21/16 at 1:00 p.m. and subsequent interviews with Staff E (LPN) revealed that Staff B approached her at about 8:00 a.m. as she stood by the med cart on Redwood Boulevard near the common area. Staff E said Staff B asked her if she heard Resident #1 screaming. The LPN said she told Staff B she thought it was another resident that frequently screamed. Staff E stated she had never heard Resident #1 scream and he/she usually sat very quietly in the common area. The LPN said Staff B reported that Resident #1 screamed and she overheard Staff F tell Resident #1 you can either take the meds the easy way or the hard way. After she heard of the allegation, Staff E said she checked and Resident #1 had been seated in the lounge area. The LPN said she wanted to ensure that the resident was not with Staff F. Staff E said she went and talked with Resident #1 who denied having pain or any recollection of anything happening to him/her. The resident seemed confused, but able to interact. When asked, Resident #1 could not recall whether or not he/she had taken their medication. According to Staff E, nothing seemed peculiar or out of the ordinary. Staff E said she visualized Staff F down Redwood Avenue hallway by the med cart. Staff E said she did not think Staff F suspected that anyone had made an allegation against her at that point. Staff E said she called the ADON (assistant director of nursing) downstairs shortly after 9:00 a.m. and reported what she knew. According to Staff E, the ADON told her to tell Staff F to go downstairs to the break room right away and wait for the DON. Staff E said she immediately approached Staff F at the med cart on Redwood Avenue near the common area and told her to go downstairs and wait for the DON. According to the LPN, Staff F asked what happened, and Staff E told her the DON would speak to her. Staff E said she kept Staff F within sight, until she entered the nurses' station where she put her paperwork away and collected her belongings. Staff E reported the DON called her shortly after to ensure that Resident #1 had been assessed and all the necessary paperwork had been completed. Staff E said she first noticed the bruising when she assessed the resident after the alleged incident. Without looking at the documentation, the LPN described the bruising she saw as yellowish/greenish bruising on both sides of Resident #1's mouth. Staff E also saw purplish reddish bruising to both forearms. When asked what she knew about Staff F' s character, Staff E stated that about a month or two before, she borrowed Staff F ' s blood pressure cuff with permission, and put it on the desk after using it. Staff E said about a half an hour later, Staff F saw her from a distance and called for her very loudly. The LPN said Staff F approached her and asked where her blood pressure cuff was. As Staff E went to get it, Staff F followed her and said, don't ever leave it there again because it could get stolen. According to Staff E, Staff F said the prior in front of a CNA and multiple residents. Staff E said she did not appreciate the way Staff F spoke to her. Staff E said Staff F had worked at their facility as an agency nurse for many months, and they worked together quite a bit. The LPN stated that Staff F can be rude and short tempered and does not seem to work with well with others. Staff E stated she had not known of any bad blood between Staff F and Staff B, and had never heard either one of them say something bad about the other. Staff F did not believe that Staff B or Staff D were malicious. An Incident Witness Statement dated 11/26/16 and signed by Staff E, indicated Staff B, and Staff D reported Resident #1 had been yelling and then Staff F had been overheard telling the resident You can either take them the easy way or the hard way . An interview on 12/26/16 at 10:30 a.m. with Resident #1's daughter revealed she and her brother paid a random visit to their parent on 11/26/16. According to her, the resident sat in his/her wheelchair when they first arrived. The family member said she noticed bruising around her parent's mouth, which was more pronounced on the right side. The daughter said at first glance, she thought someone pinched the side of Resident #1's mouth. She described the bruise as purple/yellow and about 2 inches big. She described a smaller purple/yellow bruise on the left corner too, which was not as pronounced. Once she got a closer look, she thought that someone's thumb made the larger bruise on the right side and fingers caused the bruise on the left side, as if someone squeezed her parent's mouth. She said her brother thought the same thing. The family member said she could not actually see an impression left by fingers. She described another bruise that she estimated as about a 3 inch elongated deep purple bruise on the right forearm. Resident #1's daughter said she and her brother thought that it was plausible that the bruise on the arm could have easily been caused during a transfer, but expressed much more concern about the bruising around the mouth. The daughter said those were the only bruises apparent to them because their father/mother had clothes on. She and her brother sat at a table in the dining room when a nurse asked to speak to them. The nurse told them another nurse had been overheard saying we can either do this the easy way or the hard way. The family member said they did not tell the nurse about the bruises, and the nurse did not mention the bruises to them either. Resident #1's daughter said they initially did not do anything about it, but called back at 8:00 a.m. the following Monday to set up a meeting. After not hearing from the facility yet, she called back again about 10:00 a.m. and left a message that emphasized the urgency of the matter. The daughter said the DON finally called back about 11:00 a.m. She said the DON did not seem surprised about the bruising because she thought the DON had a little time to check into it before she called her back. Resident #1's daughter said they met with the facility on 11/30/16. She said they discussed the bruising and how it happened, but stated nobody really knew what happened. She said they told her an agency nurse got sent home. The family told them they did not want that nurse taking care of their parent, which the facility assured them of. She said the facility said a spoon is used for medication administration and Resident #1 could have bitten down on it too hard. The daughter said she told them they could believe what they want, but she believed someone pinched her parent's mouth. The daughter said she could not see any way possible that it happened from biting down too hard on a spoon. The family member said they asked their parent what happened, but he/she is demented, and unreliable. A document titled ' Summary of Bruise of Unknown Origin on Resident #1 on 11/26/16 ' and authored by the DON concluded that after talking to staff, it seemed that Resident #1 very commonly becomes resistive and combative with cares, and when he/she is given medication or food/drink, clamped his/her mouth down. The DON continued by writing that the problem happened so frequently that staff does not think to document it because it is not abnormal for the resident to do it. The documentation continued to note that it appeared with the bruising that the resident could have a utensil/cup/end of a medicine cup placed in his/her mouth and clamped down on it hard causing the bruising to his/her mouth. An interview on 12/27/16 at 9:40 a.m. and subsequent interviews with the DON revealed that when she spoke to Staff F about the allegations against her, she denied the allegations and thought staff had ganged up on her. The DON stated a week or 2 before the incident, other CNAs told her they heard Staff F talking on the phone to a Doctor at shift change. According to the CNAs, Staff F asked them to be quiet while she spoke to the Doctor. The CNAs told the DON they apparently had not gotten as quiet as she wanted them to, because Staff F slammed the phone down and broke it after she finished her conversation with the Doctor. When asked, the DON said Staff F denied that she slammed the phone down, and gave a completely different reason for how the phone got broken. The DON said she spoke with Staff F about conducting herself in an appropriate way. According to the DON, other employees had told her Staff F had a short fuse. Based on what she had heard, she thought Staff F was capable of what she had been accused of saying to Resident #1. The DON stated Resident #1's daughter reported the bruises on her parent's arms and face to Staff E on 11/26/16 at 10:30 a.m. when she came to visit. The DON said that although the bruises had not previously been documented, their investigation concluded that Staff B had reported them to Staff G on 11/21/16, and therefore they were not related to the alleged incident. The DON stated she first knew about Resident #1's bruises when Staff E told her about them when she arrived to investigate the incident on 11/26/16. Per the abuse task interview with the DON on 12/27/16 at 10:00 a.m., the facility investigates everything and reports anything suspicious in nature, like multiple bruises or injuries in abnormal places. An Incident Witness Statement from Staff B, related to unexplained bruising on the right side of Resident #1 ' s mouth had been dated 11/28/16. Staff B stated she noticed the bruise on the right side of Resident #1's lips while she assisted the resident to bed on 11/21/16. According to the CNA, she reported the bruise to Staff G, RN (Registered Nurse). An interview on 12/28/16 at 10:12 a.m. with Staff G, RN revealed that she worked at the facility through a staffing agency for about 5-6 weeks. She stated Staff B told her about the bruising around Resident #1's mouth about a month ago. The RN said she had only worked on Resident #1's hall for the 2nd or 3rd time. The RN said she had administered medication to Resident #1 in the common area, and recalled that she saw an approximately 2 cm circular shaped reddish bruise on the right corner of the resident's mouth. To her recollection, she believed she only saw a bruise on one side of the mouth. The RN said she believed she had noticed it the day before too. According to the RN, Staff F told her about it at shift change. The RN said the resident sat in the common area by the TV, when the RN asked Staff F about the redness and bruising around the resident's mouth. The RN stated Staff F told her They already know about it . Staff G said she assumed an incident report had been initiated. When asked what she would have done differently, the RN said she wished she would have checked to see if an incident report had been initiated. The RN said she did not want to make excuses, but it had only been about her 3rd day on that floor. She said she had worked at Trinity for about a week and a half before that and did not really know the names of the residents. Staff G said when she had charted, she noticed that nobody else had been charting about Resident #1's bruises. She stated she knew the facility expected her to report any injuries that she either saw or had been aware of. According to the RN, the bruise had been there for a while. She said it kept getting bigger and turned from red to purple. Staff G said the DON asked her to give a statement at a later date. An Incident Witness Statement related to unexplained bruising on the right side of Resident #1 ' s mouth had been dated 11/28/16 and signed by Staff G. The document indicated Staff B reported to her on 11/21/16 that Resident #1 had a bruise on the mouth. According to the RN, she checked the bruise, and acknowledged she had already seen it and been informed about it by the previous nurse. Staff G stated she had the impression it had already been documented and the facility had also been informed. At the top of the document, someone wrote CNA claims to have reported this bruise to nurse on 11/21/16 . An interview on 12/21/16 at 12:30 p.m. with Staff H, LPN revealed her impression of Staff F. Although she thought highly of Staff F as a nurse, Staff H said Staff F had an unpredictable attitude. The LPN mentioned Staff F got upset once during report because the laptop had not been on top of the computer when she came in. Staff H said Staff F yelled at the other nurse and stormed out. According to Staff H, Staff F has slammed doors and broke a phone by slamming it down. Staff H said she reported Staff F for not being able to work well with others. An Incident Witness Statement dated 11/26/16 and signed by Staff F, indicated she went to Resident #1's room before 8:00 a.m. to administer medication. According to the LPN, Resident #1 struck out, like the combative behaviors he/she demonstrated every day. The LPN stated she told the resident to take her medication so they would make him/her feel better. Staff F indicated Resident #1 said, What are you trying to do, kill me? According to Staff F, Resident #1 took the medication, and then she took the resident up to the TV room to wait for breakfast. The LPN said the resident had no complaints, and she had not been abusive to Resident #1 in any way. The LPN stated she would never physically or verbally abuse a resident or coworker. An interview on 12/27/16 at 9:56 a.m. and subsequent interviews with Staff F, LPN revealed that she had verbally reprimanded Staff B multiple times for excessive breaks, being unavailable to do her job and talking on her phone in a resident's room in front of the resident. Staff F said the incidents of disciplinary action occurred the same week that Staff B made allegations of abuse against her. Staff F reported Staff B tends had been rude and disrespectful to staff in front of residents and other staff. According to the LPN, if Staff B's behavior continued, she would have given her a written reprimand. Staff F said she knew of a recent incident where Staff B told Staff H off in front of residents. The LPN said she had never talked to the Administrator or the DON about the verbal reprimands that she gave Staff B. She stated she wanted to handle the situation by herself. According to Staff F, Staff B and Staff D were across the hall from Resident #1's room helping another resident. Staff F stated she had just gone in to Resident #1's room alone to administer medication and the door had been left open. The resident had sat in the wheelchair in his/her room. According to the LPN, Resident #1 can be difficult and combative at times, but taking the time to talk with him/her sometimes helps. The LPN said she crushed the medication and mixed them with applesauce to administer them. According to Staff F, Resident #1 kind of pushed her hand away the first time she attempted to spoon feed the medication, but the resident willingly took them on the second attempt. Shortly after she was told by an LPN said she had to speak to the DON downstairs in a conference room. The DON said that Staff B told her she overheard the LPN say You can either take these meds the easy way or the hard way . Staff F said the news devastated her and she started crying. Staff F denied the allegations and said she had never been disciplined at Trinity before. She said they love her there, and she got along with Staff B and Staff D fine. The LPN stated that she did not like drama or issues, and hated to confront Staff B because she can be very dramatic at times. The LPN repeated she thought she got along with staff fine. When asked about conflict with other employees, Staff F mentioned a time when Staff E borrowed her blood pressure cuff. The LPN said Staff E said she would return it. About 20 minutes later, the LPN asked Staff E about the blood pressure cuff, and Staff F showed her where she left it. Staff F told Staff E to never to leave it unattended again because it could get stolen. The LPN said she had to meet with Staff E and the 2nd floor manager at Staff E' s request. Staff F said she had previously been investigated at a different facility. She thought it might have been in 2006, but could not be sure. She stated she put medication in a resident's hand, but then the resident said he/she did not want to take it. The LPN said when she tried to get the medication back; the resident said the LPN squeezed her hand. When asked about the bruising on Resident #1, the LPN said she saw slight discoloration around the resident's chin area on 11/26/16 when she administered the medication. The LPN stated that she had never seen the bruising around the resident's mouth before that day, and denied that she ever told another nurse about the bruising during a previous shift report. When she had been informed that other people previously identified the bruising, Staff F stated her responsibilities include identifying and reporting injuries of unknown origin. The LPN stated she had already said she did not remember, which means she did not remember. Record review established Resident #1 lacked the ability to comprehend Staff F's remarks and a reasonable person would find the oral language used by Staff F on 11/16/16 as disparaging and derogatory. A reasonable person would likely view Staff F's language to Resident #1's on 11/26/16 as a threat of harm.

Based on medical record review, observation, and staff interview, the facility failed to provide interventions to prevent pressure sores from worsening for 2 of 7 residents reviewed with skin breakdown (Residents #6 & #11). The facility reported a census of 114 residents. Findings include: 1. The quarterly (Minimum Data Set) MDS assessment dated [DATE], identified Resident # 6 had [DIAGNOSES REDACTED]. The MDS identified the resident had total dependence on two staff for bed mobility, transfers, bathing, and toilet use. The MDS indicated the resident had bladder and bowel incontinence. The MDS revealed the resident had been at risk for pressure ulcers, but had no pressure ulcers during the assessment period. The annual MDS assessment dated [DATE], identified the resident had total dependence on two staff for bed mobility, transfers, bathing, and toilet use. The MDS indicated the resident had bladder and bowel incontinence. The MDS revealed the resident had a risk for pressure ulcers, and had two stage 2 pressure sores with suspected tissue injury. The care plan dated 11/30/16, identified the resident had potential for skin integrity impairment due to impaired mobility and incontinence. The care plan indicated the resident had a history of [REDACTED]. a. Perform skin assessments per protocol and provide treatments as ordered. b. Reposition the resident when in bed and the chair. c. Place the resident in bed in-between meals, if not attending activity. d. Provide incontinence care per protocol. e. Place a foam cushion in the wheelchair and an air mattress on the bed. The resident information form dated 11/28/16, revealed the resident required assistance for positioning and used a mechanical lift for transfers. The resident information form directed staff to use an alternating air mattress, pad the wheelchair arms, and place a foam cushion in the wheelchair. The form did not address any issues related to skin breakdown or concerns. The progress notes dated 11/16/16, included the resident had two superficial open areas on the left side of the coccyx. The physician treatment plan included: a. Repositioning the resident every 2 hours. b. Encourage alternate activities in order for the resident to have time in bed off his/her bottom. c. [MEDICATION NAME] barrier cream around the open wound and [MEDICATION NAME] to the wound bed until areas healed. The Braden assessment (a tool used for predicting pressure ulcer risk) completed 11/20/16, revealed the resident scored 11, which indicated the resident had a high risk for pressure ulcers. The wound assessment reports revealed the following: 10/27/16 - One Stage 2 pressure ulcer to the sacrum measured 1.0 centimeter (cm) length (l) x 1.2 cm wide (w) 11/6/16 - One Stage 2 pressure ulcer to the coccyx measured 0.5 cm (l) x 0.5 cm (w) 12/6/16 - One Stage 3 pressure ulcer to the right buttock measured 4.8 cm (l) x 3 cm (w), and one Stage 3 pressure ulcer to the left buttock measured 2.0 cm x 1.0 cm. The departmental nurse's notes revealed the following: 10/2/16 - skin assessment completed and no issues noted. Skin clean, dry and intact. 10/27/16 - a second open area found on the coccyx measuring 1.0 cm x 1.2 cm above the first area. [MEDICATION NAME] used as preventative treatment. 10/29/16 - an order obtained to apply Duoderm to coccyx and change duoderm every 3 days and as needed. 11/10/16 -Duoderm discontinued and an order obtained to apply supermax to coccyx 3 times a day. 11/15/16 - Supermax discontinued and an order obtained to apply [MEDICATION NAME] 3 times a day. 11/21/16 - coccyx area intact. Barrier cream applied. 12/6/16 at 2:30 p.m. -a pressure area observed to buttocks. No residue or [MEDICATION NAME] visible when nurse looked at the resident's bottom. A family member reported when he/she had looked at the area 3 days prior, the area had almost healed. The treatment administration record (TAR) for December, 2016, revealed [MEDICATION NAME] ointment ordered 11/15/16, and applied topically 3 times a day as a preventative treatment. On 12/7/16, [MEDICATION NAME] ointment ordered to be applied to pressure areas on buttocks after each incontinence episode. The Medication Administration Record [REDACTED]. During observation on 12/6/16 at 6:30 a.m., Resident #6 found lying supine in bed, with knees flexed toward the left side. At 7:08 a.m., the resident sat in a wheelchair (w/c) in the lounge area. At 7:35 a.m., staff wheeled the resident in a w/c to the dining room and placed the resident in the w/c by the table. At 7:50 a.m., the resident sat in a w/c with eyes closed and head bowed by the dining room table. At 8:20 a.m., the resident sat in a w/c in the dining room. At 8:40 a.m., the resident was served breakfast. At 9:15 a.m., the resident continued to sit in the w/c in the dining room. At 9:22 a.m., staff moved the resident from the dining room to the lounge area to watch t.v. The resident continued to sit in the wheelchair. At 10:25 a.m., Staff E, Certified Nursing Assistant (CNA) wheeled the resident in a w/c to the resident's room. Staff E and Staff F, CNA used a mechanical lift and transferred the resident into bed. Staff E confirmed the resident's brief was wet. Staff E and Staff F removed the resident's pants and brief and provided incontinence care. During cares, observed a large open sore and reddened area to the resident's right and left buttocks, below the coccyx area. Staff E reported the nurse typically provided treatment to the resident's bottom after lunch, after lying the resident down. Staff E stated she was not sure what kind of treatment the nurse provided. At 11:30 a.m., Staff A, CNA, assisted Staff D, Licensed Practical Nurse (LPN), roll the resident to the left side, and removed the resident's pants and brief. Staff D reported the resident had open wounds to bilateral buttocks. Staff D stated It's bad, it's big. Staff D stated the wound had gotten larger since the last time she had observed the area. Staff D reported the resident had only one wound the previous month, but currently had two pressure wounds. Staff D left the room and obtained a measuring device. At 11:34 a.m., Staff D returned to the resident's room. Staff D used a paper ruler and measured the wounds. Staff D reported the following measurements: Right buttocks wound - 4.8 cm x 3.0 cm Left buttocks wound - 2.0 cm x 1.0 cm During an interview on 12/6/16 at 11:20 a.m., Staff D, LPN, reported when a skin concern identified, staff completed a skin assessment and documented on the skin assessment manager in the computer. Staff D checked the TAR and reported another nurse had documented [MEDICATION NAME] applied 12/6/16 at 7:00 a.m. Staff D stated a wound identified to coccyx area on 10/27/16, and the last assessment completed on 11/6/16. In an interview 12/6/16 at 3:30 p.m., Staff D reported skin assessments were completed weekly on each resident. Staff D acknowledged the first time he/she saw resident #6's wounds on the buttocks was on 12/6/16, when the surveyor inquired about treatments done. Staff D reported when a wound found, the nurse documented an assessment, notified the physician for treatment orders, and contacted the wound nurse. In an interview 12/7/16 at 1:35 p.m., Staff B, LPN, reported when a bruise or open area found on the resident's skin, or CNA reported a concern, the nurse assessed the area, faxed information to the resident's physician, and contacted the QA/skin nurse. Staff B stated a skin assessment charted every week on the wound assessment manager. Staff B stated they assigned days when assessments had to be completed. Staff B reported Resident #6 had skin assessments assigned every Sunday on the 2-10 p.m. shift. Staff B reported when she assessed the Resident #6's wound last month, the resident had a small open area on the buttock area, and [MEDICATION NAME] applied. Staff B stated interventions in place to prevent pressure areas included an air mattress on the bed and a cushion in the w/c. Staff B stated staff would ly the resident down when they could, but family wanted the resident up for activities. In an interview 12/8/16 at 9:00 a.m., the Director of Nursing (DON) reported she expected skin assessments completed on bath days, at least once a week. The DON reported when a skin concern identified, the nurse entered information in the wound manager or nurse's notes on the computer, and an incident report filled out. The DON stated their protocol included monitoring a wound or bruise for 72 hours or until the area healed. In an interview 12/6/16 at 3:00 p.m., the facility's QA (Quality Assurrance)/certified wound nurse reported when a skin concern identified, the nurse documented a note in the computer under the skin assessment manager section. The QA/wound nurse reported staff are supposed to let her know when a new skin concern, such as a pressure sore, developed so she could observe the wound and make recommendation for wound care, but sometimes she had not found out about a skin issue or wound until at least a week later. The QA/wound nurse reported she often times found out about a resident's wound when she read the communication report or when reviewed the medical record. The QA/wound nurse acknowledged skin assessments or wound documentation found under the wound tab or under the wound assessment manager in the computer, and sometimes the nurse's notes. The QA/wound nurse confirmed Resident #6 had a skin assessment documented on 11/6/16, which pertained to the coccyx wound, and the next assessment completed on 12/6/16. The Risk Factor/Skin Assessment Policy dated 5/27/09, revealed skin assessments completed daily by the nurse on residents at high risk for skin conditions. The policy included the CNA inspected the skin during cares, and reported any areas of concern to the charge nurse immediately. The nurse completed a full body assessment weekly when the resident bathed. The Skin Documentation policy dated 3/12/12, revealed the nurse documented assessment of Stage 3 and Stage 4 pressure ulcer when the wound dressing changed, otherwise an assessment documented weekly on other wounds. The Skin Care Policy dated 5/31/12, revealed a skin condition report sheet and treatment documented weekly on any resident with open areas. The treatment protocol included care plan interventions implemented immediately. 2.The 10/30/16 quarterly MDS recorded the Resident #11's cognitive skills for daily decision making as severely impaired. The resident was totally depended on staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing and was incontinent. The MDS recorded the resident had two stage 1(intact skin with non-blanchable redness over a bony prominence) pressure ulcers. The 11/9/16 care plan recorded Resident #11 had potential for altered skin integrity related to impaired mobility and needs assistance with all cares. Interventions included floating resident's heels when in bed. The care plan lacked a comprehensive plan of care for the prevention of a pressure injury. The 10/24/16 Wound Assessment Report recorded a new wound to the left heel 1.50 cm x 1.50 cm unstageable due to suspected deep tissue injury and a 1.cm x 1.cm new wound to the right heel, unstageable due to suspected deep tissue injury. The note recorded the resident to have purple discoloration to heels bilaterally and the skin was intact. The 10/24/16 Departmental Notes at 5:27 a.m. recorded pressure ulcer to left heel and the resident noted to have purple discoloration to heels bilaterally. Recorded the heels floated with pillow and faxed sent to request treatment and the skin was intact. The 10/24/16 Departmental Notes at 1:48 p.m. recorded a new order received for skin prep to bilateral heels twice a day until healed. The 11/2/16 Wound Assessment Report recorded a weekly update to the right heel 1.cm x 1.cm to the right heel, unstageable due to suspected deep tissue injury. The 11/4/16 Wound Assessment Report recorded a weekly update to the left heel 5 cm x 4 cm unstageable due to suspected deep tissue injury and a 3cm x 3cm to the right heel, unstageable due to suspected deep tissue injury. The 11/8/16 Wound Assessment Report recorded a weekly update to the left heel 4.5 cm x 4 cm unstageable due to suspected deep tissue injury and a 3cm x 3cm to the right heel, unstageable due to suspected deep tissue injury. The 11/22/16 Wound Assessment Report recorded a weekly update to the left heel 4 cm x 4 cm unstageable due to suspected deep tissue injury and a 3cm x 3cm to the right heel, unstageable due to suspected deep tissue injury. The 11/29/16 Wound Assessment Report recorded a weekly update to the left heel 1.5 cm x .5 cm unstageable due to suspected deep tissue injury and a 1.5 cm x 1.5 cm to the right heel, unstageable due to suspected deep tissue injury. The 12/6/16 Wound Assessment Report recorded a weekly update to the right heel 2.cm x 1. 8 cm to the right heel, unstageable due to suspected deep tissue injury. During an observation on 12/6/16 at 6:50 a.m. revealed the Resident sitting in a broda chair with his/her feet on the hard surface of the foot rest. During an observation on 12/6/16 at 9:05 revealed the resident sitting in a broda chair with his/her feet on the hard surface of the foot rest in the lounge area. During an observation on 12/6/16 at 9:25 a.m. revealed the resident sitting in a broda chair with his/her feet on the hard surface of the foot rest while the CNA's took the resident to his/her room to lay down. During an observation on 12/6/16 at 12:00 p.m. with Staff D Licensed Practical Nurse (LPN) cleansed the areas on the bilateral heels and applied skin prep to the areas. Staff D continued and measured the heels, the left heel measured 2 cm x 1.8 cm and 0.2 cm deep. The right heel measured 0.8 cm x 1 cm. The 12/7/16 Wound Assessment Report recorded a weekly update to the left heel 1.4 cm x .5 cm stage 1 pressure ulcer and a 0.8 cm x 0.5 cm to the right heel, stage 1 pressure ulcer. During an observation on 12/8/16 at 8:05 a.m. revealed the sheets on the resident's bed with multiple areas of dried serosanguinous drainage. During an observation on 12/8/16 at 9:00 a.m. Staff D LPN took the resident back to his/her room to look at the heels after observing the serosanguinous drainage on the bed. The resident had his/her left heel resting on top of the right foot on the hard surface of the foot rest. The sock on the left heel had serosanguinous drainage though the sock that transferred to the top of the right foot sook. The left heel had a large area red that covered from the back of the heel to under the foot non- blanchable with the center of the area open with serosanguinous drainage. An Interview with Staff D LPN on 12/8/16 at 9:00 a.m. acknowledged the serosanguinous drainage had not been reported to her and she would expected that staff report that to her. Staff D revealed she was going to call the physician to obtain a different order other than skin prep for the bilateral heel areas. The 5/31/12 Skin Care Policy under section B) Skin Inspection a CNA ' s on a daily basis inspect skin with cares and report to charge nurse or designee the findings. ii) All skin concerns will be reported immediately to the charge nurse.

The following deficiency relates to facility self report incident -I, -I, -I and -I. Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and assistive devices to mitigate the risk for elopement, falls and resident to resident altercations. (Resident #2, #3, #4, #6, #13 and #17) The facility reported a census of 116 residents and the sample consisted of 17 residents. Findings include: Resident #2/elopement: According to the Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #2 had short and long term memory problems and severely impaired cognitive skills for daily decision making. Resident #2 required extensive assistance to total dependence on staff with dressing, toilet use and personal hygiene needs. Resident #2 was independently mobile and wanders daily. Resident #2's [DIAGNOSES REDACTED]. The MDS indicated the resident had behaviors of rejecting care ,[DATE] days of the assessment period and wandering each day. An Elopement Assessment form dated [DATE] indicated Resident #2 at risk for elopement. The Care Plan dated [DATE] noted Resident #2 at risk for elopement due to dementia, history of wandering and exit seeking behavior. The approaches included and directed the staff to redirect Resident #2 away from doors, offering diversion activities and a WanderGuard bracelet to be worn. The [DATE] Treatment Administration Record (TAR) indicated the Wanderguard bracelet to be worn at all times, check function and placement every shift. The TAR indicated Resident #2's WanderGuard in place and functioning properly throughout the entire month of [DATE]. The Departmental Notes dated [DATE] at 2:34 p.m. identified the facility sent Resident #2 to the emergency room following a fall and the resident returned to the facility at 7:00 p.m. The Departmental Notes dated [DATE] at 4:06 p.m. (noted as late entry for ,[DATE] shift) indicated mid-morning a resident's spouse informed nursing staff that on Sunday [DATE], spouse saw Resident #2 walking in the front parking lot and he brought Resident #2 back in to the facility. The spouse did not inform anyone at the time. In an interview on [DATE] at 12:05 p.m. the Director of Nursing (DON) , stated on [DATE] it was discovered Resident #2 had exited the facility without staff's knowledge. The DON stated Resident #2 would shadow people and walk off the unit behind a guest on [DATE]. The guest noticed Resident #2 in the parking lot and returned Resident #2 to the unit without notifying staff. The guest reported the incident on [DATE]. The DON stated Resident #2 had a Care Plan to wear a WanderGuard bracelet and it is to be checked for placement and functioning status every shift daily (3x). The documentation reflected the checks were conducted, yet there was no WanderGuard alarm sounding when Resident #2 exited the unit and facility on [DATE]. The DON stated when checked ([DATE]); Resident #2's WanderGuard was not present. Further investigation found that the WanderGuard was removed during a hospital visit on [DATE] and staff failed to ensure the bracelet then replaced upon return from the hospital. The DON stated she disciplined five staff involved in falsely documenting the WanderGuard bracelet was present and functioning from [DATE] through [DATE]. Note: At the time of the complaint investigation, the complaint was coded at a K immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the immediate jeopardy and the grid placement was lowered to a G as a result of incidents with Residents #3, #6, #13. The facility informed the visitor to tell them if a resident follows them out the door. On [DATE], the facility did a WanderGuard audit of all residents needing WanderGuards and ensured the devices were present and active. The facility placed a WanderGuard bracelet on Resident #2. An in-service was provided to nursing staff regarding proper documention of WanderGuard devices on residents. Resident #4, #3 resident to resident altercation According to the Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #4 had short and long term memory deficits and moderately impaired cognitive abilities for daily decision making. The MDS identified the resident as independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #4 resided in a CCDI (chronic confusion or a dementing illness) unit and had [DIAGNOSES REDACTED]. The Care Plan dated [DATE] noted Resident #4 with potential for impaired social interactions. The approach included and on [DATE], directed the staff to keep Resident #4 occupied after the evening meal until Resident #3 goes to his/her room. The Resident Information Sheet (RIS) indicated to Separate from Resident #3 if possible and after evening meal direct Resident #4 into common area bathroom and keep Resident #4 entertained in the common area until Resident #3 walks by an goes to his/her room if possible. According to the Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3. A score of 3 identified the resident had severely impaired cognitive status. The MDS identified the resident as independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #3 resided in the CCDI unit. The MDS identified the resident had [DIAGNOSES REDACTED]. In an interview on [DATE] at 10:15 a.m. Staff F, Licensed Practical Nurse, stated on the evening of [DATE] at around 5:30 p.m. Resident #3 was walking up the hall and Resident #4 was walking down the hall. As the residents passed one another and without any observed provocation, Resident #4 struck Resident #3 in the chest three times. Staff immediately responded and separated the two residents. Resident #3 was assessed and found without injury. Resident #4 was provided 1:1 supervision the remainder of the shift. Staff F stated Resident #4 was not overtly agitated at the time of the incident. Staff F noted Resident #4 can get agitated and when observed staff will redirect him/her and separate him/her from other residents. Staff F stated she was unaware of Resident #3 ever being aggressive towards another resident. Staff F stated she was not aware of any interventions which address keeping Resident #4 away from Resident #3. In an interview on [DATE] at 5:30 p.m. Staff R, certified nurse aide, stated he was in the hallway on [DATE] when Resident #4 struck Resident #3 in the chest two to three times. Staff R stated it happened without notice. Staff R stated he helped separate the two residents. Staff R stated since the incident, they try to keep Resident #4 and Resident #3 separated and know their whereabouts at all times. Staff R stated he has never known Resident #4 to be aggressive towards other residents. In an interview on [DATE] at 5:20 p.m. Staff S, certified nurse aide, stated she has worked at the facility a couple of months. Staff S knew of no interventions related to Resident #4's potential for aggression. Staff S stated they try to redirect Resident #4 when he/she approaches other residents or exit seeks. Staff S was not aware of any interventions regarding keeping Resident #4 separated from Resident #3. In an interview on [DATE] at 10:27 a.m. Staff T, certified nurse aide, stated Resident #4 can become agitated with staff when assisting with toileting, but she has never know Resident #4 to direct his/her agitation towards other residents. When Resident #4 becomes agitated, staff will provided 1:1 supervision or redirect in an attempt to get him/her to calm. Staff T knew of no interventions to maintain separation of Resident #4 from Resident #3. In an interview on [DATE] at 8:20 a.m. Staff D, Director of Nursing, stated Care Plans are developed by the management team. Staff D stated regarding the altercation between Resident #4 and Resident #3 on [DATE], the management team discussed moving one of the residents to another unit, but didn't believe this would be in the best interest of either. Resident #3 has a pretty set routine in which he/she only leaves his/her room during meals and promptly returns after meals. Resident #3 has been known to raise his/her voice towards staff. Resident #4 is more known as the protector and seems to want to defend staff from Resident #3. Staff D stated she thought the Care Plan directed staff to keep Resident #4 separated from Resident #3 at meal times. Record review noted one similar incident in which Resident #4 struck Resident #3 in the chest on [DATE]. Resident #13/fall with fracture According to the Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #13 had a Brief Interview for Mental Status (BIMS) score of 9. A score of 9 indicated a moderate cognitive impairment. Resident #13 required limited assistance with transfers, dressing, toilet use and personal hygiene needs. The MDS identified the resident as independently mobile, but needed supervision. The MDS indicated the resident ' s [DIAGNOSES REDACTED]. The Care Plan dated [DATE] noted Resident #13 had a potential for falls. The approaches included directed the staff the resident needed stand by assistance as needed when ambulating independently as needed, ensure the reminder is located on the wheel walker to remind the resident to use it, lip mattress on bed and perform frequent visual checks in early morning hours. In an interview on [DATE] at 9:48 a.m. Staff F, Licensed Practical Nurse, stated on the evening of Friday, [DATE], she and other aides had noticed Resident #13 was getting weaker and attempting to self-transfer more often. Staff F feared Resident #13 was becoming a high risk for fall and injury. Staff F suggested to the unit nurse, Staff Q, that they place an alarm on Resident #13. Staff Q stated Resident #13 would likely refuse an alarm. Staff F then contacted Staff C, house coordinator, and asked if they could get an alarm for Resident #13. Staff C instructed Staff F to change Resident #13's status to assist of one with transfers and a personal alarm. Staff F stated she informed Staff Q of the change. Staff Q stated there was no available alarms and Staff F suggested he get an alarm off a dining room chair and Staff Q agreed. On Monday [DATE], after supper, Staff F was on A-hall when someone hollered for Staff Q, noting Resident #13 had fallen in his/her room. Staff F assisted with an assessment and assisted with getting Resident #13 in a chair. Staff F discovered later that Resident #13 had fractured his/her hip. In an interview on [DATE] at 10:35 a.m. Staff C, household coordinator, stated on the evening of [DATE], she received a call from Staff F. Staff F stated Resident #13 was attempting to get up unassisted was weak and Staff F feared he/she might fall. Staff C instructed Staff F to use a pressure alarm and make him/her an assist of one with transfers and ambulation. Staff C stated she did not realize until later that Staff F was working on a different hall and Staff Q was actually responsible for Resident #13. In an interview on [DATE] at 8:33 a.m. Staff Q, Registered Nurse, stated on the evening of [DATE], Staff F instructed him to place an alarm on Resident #13. Staff Q stated he did, but once Resident #13 was in bed he removed the alarm and returned it to the dining room. Staff Q stated Resident #13 was capable of using his/her call light and summoning assistance when needed. Staff Q stated he did not formally make the changes to add an alarm on Resident #13's plan of care, resident information sheets or 24 hour sheets. Nor did he pass on the changes in shift report. In an interview on [DATE] at 1:30 p.m. Staff D, Director of Nursing, stated on the evening of [DATE] Staff F contacted the on call supervisor, Staff C, and noted Resident #13 was getting weaker and getting up unassisted. Staff C instructed Staff F to make Resident #13 an assist of one staff with transfers and to use a pressure alarm pad in his/her chair. Staff F informed the primary care nurse, Staff Q. The pressure alarm was never initiated and on the evening of [DATE], Resident #13 fell in his/her room while attempting to go to the bathroom unassisted. Staff D stated she spoke with Staff Q who admitted Staff F had instructed him to implement a pressure alarm and that those instructions came from a supervisor, Staff C. Nevertheless Staff Q didn't believe Resident #13 needed an alarm and therefore did not implement it. Resident #13 returned to the facility and placed on hospice care. Resident #13 expired on [DATE]. Radiology report dated [DATE] identified Resident #13 had an acute fracture at the base of the left femoral neck with foreshortening. Resident #17, #6 resident to resident altercation According to the Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 3 indicating a severely impaired cognitive status. The MDS identified Resident #17 was independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #17 resides on the CCDI unit. The MDS identified [DIAGNOSES REDACTED]. The Care Plan dated [DATE] noted Resident #17 with potential for confusion and agitation with an approach which included when agitated/aggressive remove residents nearby. Resident Information Sheet (RIS) indicated to separate resident from other residents when he/she is agitated or when other residents are agitated. According to the Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #6 had short and long term memory deficits and impaired cognitive abilities for daily decision making. Resident #6 was independently mobile, but required total dependence with dressing, toilet use and personal hygiene needs. Resident #6 resides on a chronically confused demented individual (CCDI) unit and [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:10 p.m. the Director of Nursing, stated on the evening of [DATE] the 2 overnight staff went into the room of a resident, while the 2 evening shift aides remained in the commons area. Before the overnight staff returned to the commons area, the 2 evening shift aides left, leaving the residents in the common area unsupervised. Upon returning the 2 overnight aides observed Resident #17 grasping the forearms of Resident #6 as Resident #6 was attempting to free him/herself. The residents were separated without injury. The Director of Nursing stated since the event, the facility has provided 1:1 supervision of Resident #17. The Director of Nursing stated she reviewed the facility video which confirmed the evening aides left the facility leaving the area unsupervised for about 3 minutes. The Director of Nursing stated it was an expectation that when any resident(s) are in the commons area that a staff member be present.

The following deficiency relates to facility self report -I: Based on record review, staff interviews and review of facility policy/procedures, the facility failed to administer medications as ordered by the physician and facility policy/procedures which resulted in a significant medication error (Resident #1). The facility reported a census of 116 residents and the sample consisted of 17 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 8/14/16. The MDS indicated Resident #1 had long and short term memory deficits and severely impaired cognitive status for daily decision making. Resident #1 required total dependence on staff for bed mobility, dressing, toilet use and personal hygiene. The MDS identified the resident ' s [DIAGNOSES REDACTED]. The physician orders [REDACTED]. On 9/6/16 at 3:48 p.m. Staff K, Licensed Practical Nurse, was interviewed and stated on 8/25/16 she received an order which included increasing Resident #1's [MEDICATION NAME] from 100 milligrams twice daily to 150 milligrams twice daily. Staff K initiated the medication order process, placing the new order on the Medication Administration Record, [REDACTED]. Staff K stated she left the old dosage bubble pack of [MEDICATION NAME] in Resident #1's supply and assumed when the new dosage bubble pack arrived from pharmacy, they would pull the old bubble pack and return it to the pharmacy per protocol. Staff K stated she informed the on-coming nurse at 2:00 p.m. that the process was not complete. The next morning (8/26/16) Staff K was passing Resident #1 his/her [MEDICATION NAME] and noticed two bubble packs. Staff K stated she thought one bubble pack was 100 milligrams twice daily (old dosage) and the other one said 50 milligrams twice daily (new dosage 150 milligrams). Staff K stated she knew Resident #1 was to get 150 milligrams of [MEDICATION NAME] and thought she administered the correct dose. Staff K stated she was unaware of the error until informed on 8/28/16. In an interview on 9/7/16 at 9:57 a.m. Staff J, Licensed Practical Nurse, stated she worked the day shift on 8/27/16 and administered Resident #1's medications. Staff J stated she did not recall whether there was 1 or 2 bubble packs of [MEDICATION NAME] in Resident #1's supply. Staff J stated she checked the bubble pack label with the Medication Administration Record [REDACTED]. Staff K did not recall whether she checked the labels with the MAR indicated [REDACTED] On 9/6/16 at 11:47 a.m. Staff L, Licensed Practical Nurse, was interviewed and stated on the morning of 8/28/16 (Sunday) he was setting up Resident #1's medications and noticed Resident #1's [MEDICATION NAME] had been increased from 100 milligrams twice daily to 150 milligrams twice daily on 8/25/16 and both the 100 milligram bubble pack and 150 milligram bubble pack remained in her supply. Staff L noticed the morning 100 milligram doses for 8/26/16 and 8/27/16 had been punched out. Not certain whether the 100 milligram doses had been given, Staff L removed the bubble pack and placed a note on it to bring it to the attention of his supervisor on Monday. Staff L stated he checked Resident #1 and found him/her to be quieter than normal, but not significant. Staff L gave Resident #1 the morning dose of [MEDICATION NAME]. At the end of his shift, Staff L reported the medication error to the on-coming nurse, Staff M. On 9/6/16 at 4:30 p.m. Staff M, Registered Nurse, was interviewed and stated she worked the evening shift (2:00 p.m. to 10:00 p.m.) on 8/27/16 and 8/28/16. Staff M did not recall Resident #1 having any issues on 8/27/16. On 8/28/16 shift change report, Staff L reported a medication error in which Resident #1 had received an extra 100 milligrams of [MEDICATION NAME] on both 8/26/16 and 8/27/16. Staff L stated he left a note for his supervisor who was scheduled to come in the next day (Monday). Staff M stated she assumed Staff L had taken care of everything like notifying the physician, family and supervisor. Staff M stated her responsibility was to monitor Resident #1. Staff M stated she checked Resident #1's vital signs around 2:00 p.m. and noticed no changes. Staff M administered the scheduled 4:00 p.m. dose of [MEDICATION NAME] to Resident #1. At 6:00 p.m. Staff M noticed Resident #1 coughing during supper and being lethargic. Staff M checked Resident #1's vital signs and noted a significant drop in blood pressure and an oxygen saturation level of 68%. Staff M administered oxygen and contacted the evening supervisor, who directed her to contact the physician and family. Resident #1 went to the emergency room for an evaluation. The Departmental Notes dated 8/28/16 at 8:49 p.m. and signed by Staff M noted Staff M aware of a medication error involving Resident #1 at shift change report (2:00 p.m.). Resident #1 was monitored and at around 6:00 p.m. a change in condition was noted. Vital signs included a blood pressure 84/49, pulse rate 92 and irregular, respirations 16 and shallow. Oxygen saturation level ranging from 68% to 75%. Resident #1 also observed change in sensorium as resident generally loud and restless and now lethargic and quiet. Lips also noted as cyanotic. Administered oxygen at 5 liters per minute. Physician notified and orders to send Resident #1 to the emergency room for an evaluation. The Discharge Summary dated 8/31/16 indicated Resident #1 had an admitted to the hospital on [DATE] with unresponsiveness and acute hypoxic [MEDICAL CONDITION]. Resident #1 was currently on [MEDICATION NAME] 150 milligrams twice a day and believed he/she might have received a higher dose for her agitation. Resident #1 was found unresponsive, struggling to breath and hypoxic. The nurse placed Resident #1 on oxygen and transferred to the emergency room . There he/she was noted as hypotensive (low blood pressure) in sinus [MEDICAL CONDITION](heart rate above 100) and elected to proceed with comfort care. The hospital course noted Resident #1 as admitted for palliative care. On 9/6/16 at 12:45 p.m. Staff N, Licensed Practical Nurse, was interviewed and stated she came into the facility on the evening of 8/28/16 to piece together what had happened to Resident #1. Upon reviewing the records and visiting with Staff M, Staff N discovered Staff K had not removed the old dosage bubble pack of [MEDICATION NAME] from Resident #1's supply and consequently both Staff K and Staff J had administered an extra 100 milligrams of [MEDICATION NAME] to Resident #1 on 8/26/16 and 8/27/16. On the morning of 8/28/16 Staff L caught the error and removed the bubble pack from the supply. Staff L failed to fill out a medication error report or notify a physician. Staff L reported the error to Staff M at shift change report. Staff M also failed to report the error or notify a physician. Staff N stated she spoke with Staff K who admitted she likely gave both the 100 milligram dose and 150 milligram dose of [MEDICATION NAME] on the morning of 8/26/16. In an interview on 9/7/16 at 2:43 p.m. Resident #1's nurse practitioner stated Resident #1's death was most likely due to generalized decline related to [MEDICAL CONDITION] and a failure to thrive. The nurse practitioner stated she had not yet had an opportunity to thoroughly review Resident #1's entire record; therefore, her opinion was not conclusive. The nurse practitioner stated the extra doses of [MEDICATION NAME] on 8/26/16 and 8/27/16 likely contributed to his/her demise, but noted Resident #1's life expectancy was probably less than a month regardless. In an interview on 9/1/16 at 10:30 a.m. the Director of Nursing, stated the process of noting new medication orders include removing the discontinued bubble packs from the resident's supply and sending it back to pharmacy. The Director of Nursing stated nurses are also expected to follow professional standards when passing medications which include checking the packaging label with the Medication Administration Record [REDACTED]. The Director of Nursing stated nurses are also expected to immediately report any suspected medication error to their supervisors and follow medication error protocols. The facility policy and procedures titled Telephone Orders (dated 9/1/16) directed the staff of the following: When a nurse receives a telephone order to change a pre-existing medication order they need to remove the existing medication card from the med cart and return it to the pharmacy bin. The facility policy and procedures titled Administering Medications (date revised 12/2012) included and directed the following: The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time, right method (route) of administration before giving the medication. The facility policy and procedure titled Medication Errors (not dated) included and directed if staff members noting a discrepancy will complete a medication error report, assess the resident and notify the physician and family Note: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. On 8/28/16, the facility identified the error and had implemented measures that adequately addressed the jeopardy. By 9/2/16, the nurses and medication aides received medication administration training by LTC Resources LLC. An in-service was held with nursing staff and the following policies and procedures were reviewed: verbal physician orders, telephone orders, medication and treatment orders.

The following deficiency relates to facility self report incident -I and -I. Based on record review and staff interviews, the facility failed to ensure Residents #3, #6 are kept free from abuse and failed to ensure the residents are treated with dignity and respect by Residents #12 and #4. The facility reported a census of 116 residents. The sample consisted of 17 residents. Findings include: RESIDENT #3 Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 7/24/16. Resident #4 had short and long term memory deficits and impaired cognitive abilities for daily decision making. Resident #4 was independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #4 resided in the CCDI (Chronic Confusion or a dementing illness) unit and [DIAGNOSES REDACTED]. The Care Plan dated 8/3/16 noted Resident #4 with potential for impaired social interactions with an approach which included on 8/22/16 to keep Resident #4 occupied after the evening meal until Resident #3 goes to his/her room. The Resident Information Sheet (RIS) used by the aides, indicated to separate from Resident #3 if possible and after evening meal direct Resident #4 into common area bathroom and keep Resident #4 entertained in the common area until Resident #3 walks by an goes to his/her room if possible. According to the MDS assessment with a reference date of 7/3/16, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3 indicating a severely impaired cognitive status. Resident #3 was independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #3 resides on a chronically confused demented individual (CCDI) unit and [DIAGNOSES REDACTED]. In an interview on 9/14/16 at 10:15 a.m. Staff F, Licensed Practical Nurse, stated on the evening of 8/21/16 at around 5:30 p.m. Resident #3 was walking up the hall and Resident #4 was walking down the hall. As the resident's passed one another and without any observed provocation Resident #4 struck Resident #3 in the chest three times. Staff immediately responded and separated the two residents. Resident #3 was assessed and found without injury. Resident #4 was provided 1:1 supervision the remainder of the shift. Staff F stated Resident #4 was not overtly agitated at the time of the incident. Staff F noted Resident #4 can get agitated and when observed staff will redirect him/her and separate him/her from other residents. Staff F stated she was unaware of Resident #3 ever being aggressive towards another resident. Staff F stated she was not aware of any interventions which address keeping Resident #4 away from Resident #3. In an interview on 9/14/16 at 5:30 p.m. Staff R, certified nurse aide, stated he was in the hallway on 8/21/16 when Resident #4 struck Resident #3 in the chest two to three times. Staff R stated it happened without notice. Staff R stated he helped separate the two residents. Staff R stated since the incident they try to keep Resident #4 and Resident #3 separated and know their whereabouts at all times. Staff R stated he has never known Resident #4 to be aggressive towards other residents. In an interview on 9/14/16 at 5:20 p.m. Staff S, certified nurse aide, stated she has worked at the facility a couple of months. Staff S knew of no interventions related to Resident #4's potential for aggression. Staff S stated they try to redirect Resident #4 when he/she approaches other residents or exit seeks. Staff S stated not aware of any interventions regarding keeping Resident #4 separated from Resident #3. On 9/14/16 at 10:27 a.m. Staff T, certified nurse aide, was interviewed and stated Resident #4 can become agitated with staff when assisting with toileting, but she has never know Resident #4 to direct his/her agitation towards other residents. When Resident #4 becomes agitated, staff would provide 1:1 supervision or redirect in an attempt to get him/her to calm. Staff T knew of no interventions to maintain separation of Resident #4 from Resident #3. On 9/15/16 at 8:20 a.m. the Director of Nursing, was interviewed and stated the Care Plans are developed by the management team. The Director of Nursing stated regarding the altercation between Resident #4 and Resident #3 on 8/21/16, the management team discussed moving one of the residents to another unit, but didn't believe this would be in the best interest of either. The Director of Nursing stated Resident #3 has a pretty set routine in which he only leaves his/her room during meals and promptly returns after meals. Resident #3 has been known to raise his/her voice towards staff. Resident #4 is more known as the protector and seems to want to defend staff from Resident #3. The Director of Nursing stated she thought the Care Plan was to keep Resident #4 separated from Resident #3 at meal times. Record review noted one similar incident in which Resident #4 struck Resident #3 in the chest on 5/25/16. Review of Resident #4's Care Plan found no indication Resident #4 had two previous acts of aggression towards another resident or of his/her potential to re-offend. The Care Plan was void of interventions which would ensure Resident #4 and Resident #3 are kept separated at all times. RESIDENT #6 According to the Minimum Data Set (MDS) assessment with a reference date of 6/26/16, Resident #6 had short and long term memory deficits and impaired cognitive abilities for daily decision making. The MDS determined Resident #6 as independently mobile, but required total dependence with dressing, toilet use and personal hygiene needs. Resident #6 resides on a chronically confused demented individual (CCDI) unit and [DIAGNOSES REDACTED]. According to the MDS assessment with a reference date of 8/14/16, Resident #12 had short and long term memory deficits and impaired cognitive abilities for daily decision making. The MDS identified Resident #12 as independently mobile and required limited assistance with dressing, toilet use and personal hygiene needs. Resident #12 resides on a CCDI unit and [DIAGNOSES REDACTED]. In an interview on 9/13/16 at 10:15 p.m. Staff W, certified nurse aide, stated during the early hours on 9/6/16, she and another aide were sitting in the unit hallway to monitor resident activity, when Staff W heard a moaning sound. Staff W responded immediately and discovered Resident #12 standing over the bed of Resident #6 with a pillow pressed across Resident #6's face. Staff W immediately separated the residents and contacted the charge nurse. Resident #12 was shaking and not coherent. Resident #12 was moved to a private room and Staff W was positioned in the hallway to monitor Resident #12.

Based on record review, staff interviews and review of facility abuse policy and procedures, the facility failed to report, separate and investigate allegations of abuse within 24 hours (Resident #1, #2). The facility had a census of 20 residents in the identified memory care unit. Two residents were investigated for alleged abuse and the remaining 18 residents were at risk for abuse due to the lack of reporting, investigating and separating in a timely manner. Findings include: 1. Resident #2 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 5/01/16. The MDS identified the resident had both short and long term memory loss. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had verbal and physical behaviors on 1 to 3 times during the 7 day assessment period of review. The MDS identified the resident rejected an evaluation or care 1 to 3 times in the assessment period. The MDS indicated the resident had wandering behaviors each day. The MDS documented the resident had no impairment to the lower or upper extremities. The Care Plan identified on 2/24/16 and 5/11/16, the resident at risk for adverse mood and behaviors due to [DIAGNOSES REDACTED]. The Care Plan approach directed staff if the resident becomes physically abusive with staff, then reproach. An approach dated 5/10/16 directed staff if the resident is noted to be around Resident #3 and his/her wife, then separate when possible and ask the nursing assistant or nurse for assistance. A Care Plan approach, with the date 5/11/6, directed the staff to perform 15 minutes checks on the resident until discontinued by the administrative staff. The Care Plan identified the resident had potential for impaired social interaction related to the [DIAGNOSES REDACTED]. The Care Plan approach directed staff to keep the resident separated from Resident#8 as much as possible. The Resident Incident Report for Resident #2 dated 5/10/16 at 1:45 p.m., indicated Staff A, Certified Nurse ' s Aide (C.N.A) came to the Director of Nursing (DON) office. The CNA stated about 2-3 weeks ago, either before or after lunch, she witnessed Resident #3's spouse slap Resident #2 in the face. Staff A reported she went over to Resident #3's spouse and asked the spouse why he/she slapped Resident #2. The spouse reported because Resident #2 spit in his/her face. Staff A reported she told Staff B, Licensed Practical Nurse (LPN) about the incident, and Staff B looked over Resident #2. Staff B then asked the spouse if he/she hit Resident#2, and the spouse reported he/she did not hit Resident #2. During an interview on 7/26/16 at 2:27 p. m. the DON reported she was not sure when the incident happened between Resident #2, and Resident #3's spouse. Staff A reported to her the event happened 2-3 weeks prior to 5/10/16. During an interview on 7/27/16 at 10:15 a.m. Staff A, C.N.A reported about 3 weeks after she saw Resident #3's spouse hit Resident #2 she told the DON about the incident. Staff A stated the DON did not know about the incident. On 7/27/16 at 11:40 a.m. Staff B, LPN, was interviewed and stated that Staff A, C.N.A reported to her that the spouse of Resident #3 hit Resident #2. Staff B stated she did not see any injury to either the spouse or Resident#2. Staff B stated she told Staff A to report the incident to Staff C, Registered Nurse/ Household Coordinator of the Memory Care Units. Staff B stated she did not think she should have to report this since she did not witness the incident. On 7/27/16 at 11:27 a.m. Staff C Registered Nurse/Household Coordinator of Memory Care Units was interviewed and stated Staff A, C.N.A reported the spouse of Resident#3 hit Resident#2 2-3 weeks prior to 5/10/16. Staff C stated Staff A reported the incident to her and the DON on 5/10/16, and that was when she became aware of the incident. Staff C stated that Staff A reported that she told Staff B, LPN about the incident. Staff C stated that Staff B did not report the incident to either her or the DON. Staff C stated anybody should report any incident to the supervisor and an abuse incident should be reported with 24 hours. On 7/27/16 at 10:42 a.m. Staff E, C.N.A was interviewed and stated abuse should be reported within 24 hours. During an interview on 7/27/16 at 1:36 p.m. Staff D, C.N.A reported that you need to report abuse as soon as possible. During an interview on 8/1/16 at 12:56 p.m. Staff F, LPN reported that you need to report abuse within 24 hours. During an interview on 8/1/16 at 3:03 p.m. Staff G, C.N.A stated an abuse event needs to be reported as soon as possible. The following was added to the facility ' s Dependent Adult Abuse Policy on May 2016: We are required to report to the Department of Inspections and Appeals ANY resident to resident contact even if no injury occurred. If ANY staff member observes the following behaviors between residents, it must IMMEDIATELY be reported to the charge nurse and the charge nurse IMMEDIATELY be reported to the Director of Nursing, Administrator, or designated representative AND the nurse needs to complete an Incident Report on both residents. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Staff will report any of the above to the nurse on the floor. That nurse will then need to report it immediately (day or night) to the Assistant Director of Nursing (ADON). If the ADON is not available then contact the Director of Nursing (DON). If the DON is not available, contact the Administrator. Management will then start further investigation 2. Resident #1 had a quarterly MDS with an assessment date of 6/26/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had physical and verbal behavior symptoms towards others on a daily bases. The MDS documented the resident required a scheduled pain medication. The Physician order [REDACTED]. During an interview on 7/26/16 at 2:59 p.m. the Director of Nursing (DON) stated the staff members were doing narcotic count on 7/8/16 and discovered a missing [MEDICATION NAME] (pain medication). The facility began witness statements. The DON stated she started the investigation on the following Monday. The DON did not report the missing medication to the Iowa Department of Inspections and Appeals until ten days later because she was not sure that she had too. The facility policy/procedure titled Abuse Prevention, Identification, Investigation, and Reporting Policy dated July, 2015 documented a policy statement that included, the policy of this facility is to implement written procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The policy defined misappropriation of resident property as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Resident's belongings or money without the Resident's consent (theft). Note: At the time of the complaint investigation, the complaint was coded at a L, wide spread (memory unit) immediate and serious jeopardy. The investigation determined the facility had self corrected the immediate jeopardy on 5/11/2016 by doing the following: · Revised the facility abuse policy/procedures. · All staff completed abuse in-service training per the facility new policy/procedures.

Based on record review, staff and family interviews and review of facility policy/procedures, the facility failed to ensure residents are free from abuse. A visitor had an altercation with Resident #2. The facility listed Resident #2 with physical and verbal behaviors which escalated an altercation with the spouse of Resident #3, who visited daily. The sample consisted of 8 residents and the facility reported a total census of 118 residents. Twenty residents resided in the identified memory unit. Findings include: Resident #2 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 5/01/16. The MDS identified the resident had both short and long term memory loss. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had verbal and physical behaviors on 1 to 3 times during the 7 day assessment period of review. The MDS identified the resident rejected an evaluation or care 1 to 3 times in the assessment period. The MDS indicated the resident had wandering behaviors each day. The MDS indicated the resident required extensive assistance of one staff member for toilet use, and personal hygiene (the resident would frequently be incontinent of urine and occasionally incontinent of bowel). The MDS indicated the resident required limited assistance of one staff member for walking in the resident ' s room and walking in the hallway. The MDS documented the resident had no impairment to the lower or upper extremities. The Care Plan identified on 2/24/16 and 5/11/16, the resident at risk for adverse mood and behaviors due to [DIAGNOSES REDACTED]. The Care Plan approach directed staff if the resident becomes physically abusive with staff, then reproach. An approach dated 5/10/16 directed staff if the resident is noted to be around Resident #3 and his/her wife, then separate when possible and ask the nursing assistant or nurse for assistance. A Care Plan approach, with the date 5/11/6, directed the staff to perform 15 minutes checks on the resident until discontinued by the administrative staff. The Care Plan identified the resident had potential for impaired social interaction related to the [DIAGNOSES REDACTED]. The Care Plan approach directed staff to keep the resident separated from Resident#8 as much as possible. The Resident Incident Report for Resident #2 dated 5/10/16 at 1:45 p.m., indicated Staff A, Certified Nurse ' s Aide (C.N.A) came to the Director of Nursing (DON) office. The CNA stated about 2-3 weeks ago, either before or after lunch, she witnessed Resident #3's spouse slap Resident #2 in the face. Staff A reported she went over to Resident #3's spouse and asked the spouse why he/she slapped Resident #2. The spouse reported because Resident #2 spit in his/her face. Staff A reported she told Staff B, Licensed Practical Nurse (LPN) about the incident, and Staff B looked over Resident #2. Staff B then asked the spouse if he/she hit Resident#2, and the spouse reported he/she did not hit Resident #2. During an interview on 7/26/16 at 2:27 p.m. the DON reported she was not sure when the incident happened between Resident #2, and Resident #3's spouse. Staff A, C.N.A reported to her that the event happened 2-3 weeks prior to 5/10/16. The DON reported it was a habit for the spouse of Resident #3's to visit daily. During an interview on 7/27/16 at 10:15 a.m. Staff A, C.N.A reported about 3 weeks after she saw Resident #3's spouse hit Resident #2, she told the DON about the incident. Staff A reported the DON did not know about the incident. Staff A reported Resident #3's spouse visited daily. On 8/1/16 at 12:56 p.m. Staff F, Licensed Practical Nurse (LPN) reported the spouse of Resident#3 had visited daily since Resident #3 began living at the facility. On 7/27/16 at 10:42 a.m. Staff E, C.N.A reported Resident#3's spouse always visited daily. Staff E reported the spouse of Resident #3 maybe jealous of Resident #2 trying to make friends with Resident #3. Staff E reported the spouse of Resident #3 may hurt a resident. Staff E reported Resident #3's spouse can be impatient with staff. During an interview on 7/27/16 at 1:36 p.m. Staff D, C.N.A reported the spouse of Resident#3 as not tolerant of people who are confused. Staff D reported the spouse of Resident #3, as a daily visitor since Resident#3 became a resident at the facility. During an interview on 7/27/16 at 10:56 a.m. the spouse of Resident #3 reported visiting daily when able. The spouse of Resident#3 reported the spouse of Resident#7 had been visiting when Resident#2 spit at him/her in the face. During an interview on 7/28/16 at 10:22 a.m. the spouse of Resident#7 reported Resident #2 stood beside Resident #3 and Resident #3's spouse. Resident #7's spouse turned away and then Resident #7 ' s spouse heard a slap, but could not be sure who slapped who. Resident #7's spouse reported the incident happened sometime in April (2016). Resident#7's spouse reported Resident #3's spouse visited daily even before the incident. Resident#7's spouse reported he/she visited every day. The facility policy and procedures titled Abuse Prevention, Identification, Investigation, and Reporting Policy; dated 7/2015 directed the staff that all residents have the right of freedom from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The Policy Statement documented that it shall be the policy of this facility to implement written procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility abuse policy documented under the protection during an investigation section as follows; that during an investigation, the facility staff shall separate the affected resident from the person accused of abuse and maintain separation until the abuse investigation is completed. When the investigation results in a reporting of the incident to the Department, the separation must be maintained until the conclusion of the Department investigation. Note: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. The investigation determined the facility had self corrected the immediate jeopardy on 5/11/2016 by doing the following: · Revised the facility abuse policy/procedures. · All staff completed abuse in-service training per the facility new policy/procedures.

Based on record review, facility documents and interviews, the facility failed to provide adequate supervision for two of three residents (Resident #2 and Resident #3). On [DATE], Resident #2 attempted to walk without his/her walker and fell sustaining facial fractures which resulted in his/her death on [DATE]. Staff interviews, record review, and facility documents revealed no alarm sound when the resident got up and staff were on break at the time of the incident. Staff interviews identify Resident #2 frequently forgot to use his/her walker and or turned off his/her alarm which was not always shared with the nursing staff. The facility reported a census of 118 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident # 24 dated [DATE], documented [DIAGNOSES REDACTED]. The MDS documented the resident scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated severely impaired cognitive ability. The MDS documented the resident independent with bed mobility and supervision with setup only for transfers, walking in room and in corridor, locomotion on unit and off unit. The admission care plan dated [DATE], indicated the resident walks with a walker independently and self transfers with assistance out of chairs as needed (PRN). Record review of fall risk assessments dated [DATE], [DATE], [DATE], revealed the resident at high risk for falls (the resident scored 10 or greater on these assessments). A document titled Trinity Center at Luther Park Fall assessment dated [DATE], documented a grand total score of 15 which a score of 10 or more indicates high risk for falls. Review of Resident Incident Reports dated [DATE], [DATE], [DATE] and [DATE], documented falls with no injuries. New intervention were put into place and documented on the care plan. The quarterly MDS assessment dated [DATE], documented [DIAGNOSES REDACTED]. The MDS documented the resident scored a 4 on the BIMS which indicated severely impaired cognitive ability. The MDS documented the resident required limited assistance of one for bed mobility and extensive assistance of one for transfers. The resident required supervision with setup help only for walking in room and in corridor and locomotion on unit and off unit. The care plan for fall prevention onset dated [DATE], included a potential for fall related injuries due to impaired vision, takes antidepressant medications, [DIAGNOSES REDACTED]. The problem included the following interventions: a. observe resident using walker and remind prn b. ,[DATE] side rails times one c. PT evaluation and treat as needed d. assess orthostasis blood pressure changes with falls e. observe for adverse side effects from antidepressant medications and notify doctor prn f. assist prn with transfers from chair and/or bed g. bed in regular position not low h. staff to assist resident to bathroom ASAP in morning i. bed alarm while in bed. A document titled resident Incident Report dated [DATE] at 8:40 p.m., documented the resident had an unwitnessed fall in the common area. The resident was walking from his/her room without a walker and carrying some books. The resident fell forward landing behind the first set of recliners. The resident's forehead had a cut on it and his/her nose was bleeding. Staff attended to the resident to stop the bleeding and got orders to send the resident to the hospital for evaluation. The bed alarm was on but did not sound when the resident got up. The Emergency Department notes dated [DATE] at 4:45 a.m., documented the nursing home staff found the resident on the floor with his/her face swollen and covered in blood. The resident ambulates with a walker but there was no walker found near the resident. The fall occurred while walking and he/she landed on a hard floor. A significant amount of swelling present on the entire face including the forehead. The nose is massively swollen, bruised and very tender to palpation. Three lacerations noted on the face. The largerest one is on the right forehead. Persistent bleeding was present from the laceration, measuring 4 centi-meters (cm) in length and it is full-thickness in depth. The second laceration is on the bridge of the nose about 1 cm in length and partial thickness deep. The third and last laceration is present on the right anterior naris. It is full-thickness deep and about 1 cm long with persistent bleeding noted. The computed tomography (CT) of the maxillofacial dated [DATE] reported extensive facial fractures, pterygoid processes fractures or zygomatic arch fracture. The hospital Discharge Summary dated [DATE] documented the resident fell at nursing home and at the this time he/she is not able to protect his/her airway and was gurgling fluids in the back of his/her throat. The resident had been admitted for further evaluation. A document titled State of Iowa Certificate of Death dated [DATE] at 6:15 a.m., revealed immediate cause of death: Complications of Facial Fractures. Interviews: An interview on [DATE] at 2:14 p.m., the Attending Physician reported seeing the resident on the morning of [DATE] and the resident was non-verbal at the time. The physician stated the resident had a bad fall and was just moaning. There was extensive contusions and abrasions to the face and the resident was unable to handle oral secretions with a lot of blood in the oral cavity. The physician stated radiology reports showed extensive facial fractures and the resident had to have fallen hard. The resident was unable to protect his/her airway and possibly aspirated. The family wanted to keep the resident comfortable and ultimately died from complications related to facial fractures. An interview on [DATE] at 2:30 p.m., Staff F, LPN reported the resident was sleepy throughout the evening shift on [DATE] but was a routine for this resident to be awake during the night. The resident was put to bed at approximately 8:,[DATE]:30 p.m. Staff G, CNA went on a ten minute break and left the unit. Staff F, LPN reported visiting with Staff H, CNA around 8:,[DATE]:45 p.m. over by the television and then heard a thud. Staff F, LPN and Staff H, CNA ran over to the noise and found Resident # 24 lying face down more on his/her right side. The resident had a cut over the eye brow and blood coming from his/her nose. Staff F, LPN stated the resident was carrying books and did not have a walker. Staff F, LPN sat the resident up and Staff H, CNA obtained the vital machine and wash clothes. Staff G, CNA returned from break and assisted with stopping the bleeding. The resident was then sent out to the hospital. Staff F, LPN stated the resident had a bed alarm but had not alarmed. Staff F, LPN reported checking the bed alarm after the resident was sent to the hospital and the alarm was still plugged into the alarm box and when tested it sounded. Staff F, LPN stated the resident had previous attempts of getting out of bed. Staff F, LPN reported the resident was independent with a walker in the facility but often forgetful to use the walker. Stated staff would approach the resident when seen without the walker and reminded to use it when ambulating. On [DATE] at 5:35 p.m., Staff F, LPN reported knowing that the resident knew how to unplug the alarm and stated staff knew to place it out of reach from the resident. Staff F, LPN stated the resident fiddled with the alarm more within the last month. Staff F, LPN stated that the charge nurse check alarms every four hours. A document titled disciplinary notice dated [DATE] documented Staff F, Licensed Practical Nurse (LPN) on written warning due to severity of an incident that occurred on [DATE]. The facility documented upon their investigation they found that Staff F's work to be defective that Staff F was taking a break on the unit while another staff member had left the unit for a break. An untiled document with Staff F's name revealed prior to the fall, one CNA had left the unit for break and Staff F had been sitting in the TV area on the unit during that time; and as the charge nurse it's your responsibility to ensure the remaining staff provided oversight to the residents (as possible). An interview on [DATE] at 5:08 p.m., Staff G, CNA reported the resident was independent with a walker in the facility and would often forget to use the walker. The resident was reminded by staff to use the walker. Staff G reported toileting the resident and put the resident to bed around 7:,[DATE]:45 p.m. Staff G reported the resident had a bed alarm under the sheet and the alarm sounded when the resident laid down in bed. Staff G reported leaving the unit and went to break around 8:00- 8:15 p.m. and when he/she arrived back from break Resident #24 was sitting with his/her back against a recliner in the common area with Staff F, LPN and Staff H, CNA. Staff G stated no alarms were sounding when arriving back to the unit. On [DATE] at 4:53 p.m., Staff G, CNA reported he/she was unaware of the resident unplugging or fiddling with the alarms. An interview on [DATE] at 2:10 p.m., Staff H, CNA reported Staff G, CNA left the floor to go to break and Staff F, LPN was over by the television talking with another nurse from a different unit. Staff H, CNA walked over to see what Staff F, LPN was doing and then heard a smack. Both Staff H, CNA and Staff F, LPN went to find Resident #24 lying on his/her side with a bloody nose and a cut above the eye. Staff H reported Staff F, LPN assessed the resident and then got paperwork ready to send the resident to the hospital. Staff H, CNA reported the resident had a bed alarm but did not hear an alarm sounding. On [DATE] at 4:31 p.m., Staff H, CNA reported the last couple months the resident did not utilize his/her walker and needed reminded often to use it. Staff H unaware of the resident fiddling with the alarm box. A document titled employee training dated [DATE] documented Staff H, Certified nurses assistant (CNA) educated on supervision of residents. The document revealed it is the responsibility of staff on the unit to provide adequate supervision of the residents and adjustments need to be made when one staff left the unit for break. An untiled document with Staff H's name revealed prior to the fall, one CNA had left the unit for break and Staff H had been sitting in the TV area on the unit during that time; and it's the responsibility of the remaining staff on the unit to provide adequate supervision to residents. An interview on [DATE] at 9:34 a.m., the Assistant Director of Nursing (ADON) stated some staff reported that the bed alarm may have been put on the wrong way but the CNA that put the resident to bed stated it was on correctly. The ADON stated education was provided to Staff H, CNA and Staff F, LPN regarding staff need to be by the hall and able to see everything and not by the television. The ADON reported that Staff F, LPN was taking a break on the unit while Staff G, CNA was on break off the unit. The ADON stated the expectation is to have two staff on the floor at a minimum. The alarms are checked every four hours for function and placement then documented on the treatment administration record (TAR) by the nurses. The ADON stated the expectation is for staff to physically check the alarms then initial it off on the TAR. The ADON reported that Staff F, LPN was placed on written warning for lack of supervision. On [DATE] at 11:57 a.m., the ADON stated Staff F, LPN reported that the resident fiddled with the alarms at times and informed the ADON at the time of the investigation. The ADON was unaware of the resident fiddling or unplugging the alarm in the past and the expectation is for staff to inform her of such situations so an update to the care plan and other interventions can be put into place. During an interview on [DATE] at 3:13 p.m., Staff K, CNA stated the resident's alarm would typically go off in the mornings and then staff would get the resident ready for the day. Staff K stated the resident was independent with a walker in the facility but forgetful at times to use the walker. Staff K reported that bed alarms are checked every time a resident is laid down. An interview on [DATE] at 1:40 p.m., Staff I, CNA reported the resident was independent with a walker but was more forgetful that week and had to be reminded to use the walker. An interview on [DATE] at 1:58 p.m., Staff J, CNA/CMA stated the resident was independent in the facility with a walker and often forgot to use the walker. A statement provided from Staff J to the facility dated [DATE] documented I personally have witnessed the resident shut off and pull out plug from his/her bed alarm. During an interview on [DATE] at 4:15 p.m., Staff E, CNA stated the resident was known to walk away without his/her walker and staff would remind the resident to use the walker. The resident was known to fiddle with the alarm box and knows of two times the resident had unplugged the alarm cord from the alarm box. At 5:30 p.m., Staff E reported that he/she reported it to the charge nurse that the resident knew how to unplug the alarm. A statement provided from Staff E to the facility dated [DATE] documented the following: I have known that resident to unhook his/her alarm on two different times. I have put him/her to bed an hooked his/her alarm up, I'll go back to check on the alarm and the alarm was unhooked an the resident was getting up. Multiple staff interviews revealed the resident did not use his/her walker however the resident ' s record only included the following entries: a). An entry in the Departmental Notes dated [DATE] at 8:55 p.m., documented the resident ambulates with a walker throughout unit but at times the resident did forget to take the walker, but easily redirected to use the walker. b.) An entry in the Departmental Notes on [DATE] at 5:25 a.m., documented the resident ambulating in hallway without a walker. c). An entry in the Departmental Notes on [DATE] at 9:31 p.m., documented the resident able to ambulate with steady gait using his/her walker although at times will forget to grab the walker. d). An entry in the Departmental Notes on [DATE] at 4:41 p.m., documented the resident refuses to use walker and redirected throughout shift however not effective. e). An entry in the Departmental Notes on [DATE] at 4:53 p.m., documented the resident ambulates independently with front wheeled walker however often leaves it or refuses to use it and gait is not very steady. f). An entry in the Departmental Notes on [DATE] at 4:48 p.m., documented the resident not using his/her walker. Staff reported attempts to redirect resident to usage of walker ineffective increasingly, especially after supper. g). An entry in the Departmental Notes on [DATE] at 4:39 a.m., documented the resident is noncompliant with walker. 2. The Minimum Data Set (MDS) assessment for Resident # 3 dated [DATE], documented [DIAGNOSES REDACTED]. The MDS documented the resident's cognitive ability was severely impaired. The MDS documented the resident required extensive assistance of one for bed mobility and total dependence of two staff for transfers. The MDS documented the resident used a trunk restraint daily while in a chair or out of bed. The care plan problem dated [DATE] documented potential for fall related injuries due to [DIAGNOSES REDACTED]. a. Floor mat alarm b. Fall mat c. Bed in lowest position d. Mobility alarm on at all times e. Assure mobility alarm is attached to clothing other than sweater f. Mobility alarm on bed near wall g. Prime clip on mobility alarm h. Wheelchair with seat belt for safety due to self-transfer attempts and history of falls i. Move the seat belt to the side j. Assist of one with transfers using gait belt-two prn The quarterly fall risk assessment dated [DATE] totaled a score of 19 which a score of 10 or more indicates high risk for falls. A facility document titled Resident Incident Report dated [DATE] at 3:03 p.m., documented the resident seen going down from wheelchair and was on left side with head supported by chair. The resident was located between the wheelchair and chair in the common area. The seat belt was off and the resident's mobility alarm was not on. An interview on [DATE] at 9:55 a.m., Staff L, Licensed Practical Nurse (LPN) stated the certified nurse aide failed to fasten the seat belt and attach the mobility alarm to the resident. Staff L, LPN stated the expectation is staff need to be following the interventions on each residents care plan. Staff L, LPN stated staff educated on the importance of making sure all resident's safety equipment are on. A facility document titled Resident Incident Report dated [DATE] at 8:00 a.m., documented the CNA transferred the resident to the wheelchair and the resident had to be lowered to the floor. The resident received a 6.0 centimeter (cm) bruise to the left calf. The resident was assisted up to the wheelchair with assist from another CNA. An interview on [DATE] at 10:34 a.m., Staff L, LPN stated the expectation is for staff to follow the care plan.