Every finding on record at Twilight Acres

Based on clinical record review and staff interviews, the facility failed to notify the Physician and/or resident legal representative when a resident had a significant change of condition for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 27 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 indicating severely impaired cognition. The MDS identified Resident #1 was independent of eating . Resident #1's MDS included diagnoses of non-Alzheimer's dementia, hip fracture, malnutrition, heart failure, and dysphagia (difficulty swallowing). The MDS identified Resident #1 was on a mechanically altered diet. The Care Plan with a target date of 10/15/26 revealed Resident #1 had a nutritional problem related to diagnosis of dementia, depression, dysphagia and the need for a mechanically altered diet due to pocketing of food. The care plan directed staff to weigh Resident #1 per facility protocol and to report any significant changes.The Progress Note titled Weight Record Note dated 5/27/26 revealed Resident #1 had a weight loss of 6.4% in the last 30 days. On 4/15/2026, Resident #1 weighed 180.3 pounds (lbs). On 5/13/2026, Resident #1 weighed 168.7 lbs which was a 11.6 lb weight loss or 6.4% loss in the last 30 days. The Clinical Record lacked documentation Resident #1's legal representative or Physician was notified regarding the significant weight loss on 5/27/26. The Progress Note titled Nutrition/Dietary Note dated 7/2/26 revealed Resident #1 had an 8.8% weight loss in the past 90 days. On 7/1/26, Resident #1 weighed 164.5 lbs. The Clinical Record lacked documentation Resident #1's legal representative was notified regarding the significant weight loss on 7/2/26. On 8/4/26 at 12:45 PM, the Director of Nursing (DON) reported she could not locate any documentation Resident #1's legal representative was notified of the weight loss on 5/27/26 or 7/2/26 and/or the Physician notified on 5/27/26.On 8/4/26 at 1:52 PM, the DON stated her expectation was for the nurses to notify the resident representative and Physician whenever there was a significant change in condition and for each notification to be documented in the electronic medical record. The DON reported she could not find a facility policy regarding notifications. She said it was her expectation that staff strictly adhere to Federal and State regulation regarding notifications.

Based on clinical record review, staff interviews and policy review the facility failed to implement weight loss interventions for 1 of 1 residents reviewed (Resident #1) for significant weight loss. The facility reported a census of 27 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 indicating severely impaired cognition. The MDS identified Resident #1 was independent of eating. Resident #1's MDS included diagnoses of non-Alzheimer's dementia, hip fracture, malnutrition, heart failure, and dysphagia (difficulty swallowing). The MDS identified Resident #1 was on a mechanically altered diet. The Care Plan with a target date of 10/15/26 revealed Resident #1 had a nutritional problem related to diagnosis of dementia, depression, dysphagia and the need for a mechanically altered diet due to pocketing of food.The Weight Summary documented the following weights during the last three months and the scale used to obtain the weights:4/15/26- 180.3 pounds (lbs)- hoyer lift (mechanical lift)4/19/26- 179.4 lbs- hoyer lift4/21/26- 166.1 lbs- hoyer lift5/6/26- 170.7 lbs- stand lift5/13/26- 168.7 lbs- hoyer lift5/20/26- 166.1 lbs- hoyer lift5/27/26- 169.5 lbs- hoyer lift6/3/26- 167.7 lbs- hoyer lift6/10/26- 167.9 lbs- hoyer lift7/1/26- 164.5 lbs- stand liftThe Progress Note titled Nutrition/Dietary Note dated 4/20/26 documented Resident #1's intake was poor on the current diet and recommended to start a 4 ounce (oz) house supplement twice a day (BID) to increase nutrient intake. The Progress Note titled Weight Record Note dated 5/27/26 revealed Resident #1 had a weight loss of 6.4% in the last 30 days. On 4/15/2026, Resident #1 weighed 180.3 pounds (lbs). On 5/13/2026, Resident #1 weighed 168.7 lbs which was a 11.6 lb weight loss or 6.4% loss in the last 30 days. The note documented there was no nutritional supplement in place and recommended to start 4 oz Ensure Clear BID to increase nutrient intake and prevent further weight loss. The Progress Note title Nutrition/Dietary Note dated 6/1/26 revealed Resident #1 had deep tissue injuries to her bilateral heels. The note documented the nutritional supplement recommended on 5/27/26 due to weight loss was not in place yet and continued to be recommended to increase nutrient intake for wound healing and weight loss prevention. The Progress Note titled Nutrition/Dietary Note dated 7/2/26 revealed Resident #1 had an 8.8% weight loss in the past 90 days. On 7/1/26, Resident #1 weighed 164.5 lbs. The note documented there was no nutritional supplement in place. Review of the Clinical Record lacked documentation the nutritional supplement was started or given per the Registered Dietician's (RD) recommendations. On 8/4/26 at 12:45 PM, the Director of Nursing (DON) verified the nutritional supplements were not started per the RD recommendations. The DON reported the supplement would be documented on the Medication Administration Records (MAR). On 8/4/26 at 1:27 PM, the Registered Dietician reported when a dietary recommendation was made she would fill out a recommendation form. She said the form was given to the DON and then the DON would send the form onto the Physician. She said the same process would occur when a weight loss was identified. She said she would fill out the weight change form and give it to the DON. She said sometimes the weight change form would have recommendations and other times not. She said when the form was returned from the Physician, the recommendations were implemented. She said the nutritional supplements should be documented on the MAR. She said 90% of the time there had not been a problem with getting supplements started. She reported the last time she assessed Resident #1, she was doing better and her intakes had improved. She said she thought her admission weight seemed out of range and a little high. She said she was concerned about some swelling and/or fluid. She said she expected a little weight loss due to the fracture and her not eating. She said Resident #1 weight loss had stabilized in the 3 months. She said she was not sure about the lost paperwork. The undated facility policy titled Significant Weight Change Policy documented the purpose of the policy was to recognize and treat residents with significant weight change. The policy directed staff to document acceptance of supplements on the MAR and for nursing and the dietician to collaborate as needed regarding significant weight changes.

Based on clinical record review and staff interviews, the facility failed to start Physical Therapy (PT) and Occupational Therapy (OT) in a timely manner for 1 of 3 resident reviewed (Resident #1) for therapy services. The facility reported a census of 27 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04 indicating severely impaired cognition. The MDS identified Resident #1 was dependent on staff to assist with bed mobility, transfers and ambulation were not attempted due to medical conditions or safety concerns. Resident #1's MDS included diagnoses of non-Alzheimer's dementia, hip fracture, heart failure, depression and chronic lung disease.The Care Plan with a target date of 10/15/26 revealed Resident #1 had an Activity of Daily Living (ADL) self-care performance deficit related to activity intolerance, dementia, impaired balance, and a fracture of the left femur with repair.The Hospital After Visit Summary revealed Resident #1 was in the hospital from [DATE] to 4/13/26 due to left femur fracture with repair and was toe touch weight bearing on the left leg. The Progress Note dated 5/18/26 documented Resident #1 returned from Dr's appointment with new orders for 50% weight bearing to left lower extremity for 2 weeks then weight bearing as tolerated and PT to evaluate and treat. The Progress Note dated 5/29/26 documented Resident #1's insurance denied skilled services and the Power of Attorney (POA) would like to appeal the decision. The Progress Note dated 6/3/26 documented a new physician order was received to start PT and OT under Part B services.Review of the Clinical record revealed Part B therapy orders for PT and OT were not started. The clinical record revealed private pay therapy for PT was started on 6/18/26.On 8/4/26 at 2:00 PM, Staff A, Occupational Therapist (OT) reported the therapy department was waiting on authorization from the insurance before starting therapy. She said the Administrator would be the one to obtain the prior authorizations. Staff A said she asked the Administrator a few times about the prior authorization before starting private pay therapy. She said therapy was dragging their feet a little bit before starting private pay therapy. She said she was also concerned because she did not know how private pay therapy would work with Resident #1's insurance. Staff A said she had heard 2 or 3 times skilled care was denied but she did not hear about Part B therapy. Staff A said on 6/3/26 a group message was sent to the Administrator, DON and Social Services Director informing them a prior authorization for Part B therapy would be needed while waiting for the appeal results for skilled therapy. Staff A said on 6/5/26 she asked again about the preauthorization for the Part B therapy services and did not get a response. She said on 6/11/26 she was told Resident #1's family wanted to pay privately for therapy and pricing was requested. She said on 6/12/26 pricing was obtained and sent to the Administrator. Staff A said on 6/16/26, the Administrator sent an email to therapy asking about pricing and he was told an email had been sent on 6/12/26. Staff A said she thought the Administrator had missed the original email and didn't see it until 6/16/26. Staff A said they heard back from the Administrator on 6/17/26 that the facility received permission to start private pay PT. She said it was decided to start with one discipline because of the cost. She said she never heard back about the prior authorization for the Part B therapy orders so they started private pay therapy.On 8/4/26 at 3:46 PM, the Administrator reported a preauthorization for Part B therapy services for Resident #1 was not completed. On 8/4/26 at 4:14 PM, the Director of Nursing (DON) reported the facility did not have a policy regarding therapy services.

Based on observation, record review, and staff interview, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 29 residents.Findings include:The MDS assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister.Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar.Unstageable Ulcer: inability to see the wound bed.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. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 0 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required partial/moderate assistance with rolling left and right, and depended on staff for transfers. The resident's diagnoses included hip fracture and malnutrition. The MDS documented the resident was at risk for pressure sores but had no pressure sores. The resident had a pressure reduction device for the chair. A Braden Scale for Predicting Pressure Sore Risk dated 9/12/25 scored Resident #2 at 19, indicating low risk.The Care Plan initiated 9/24/25, identified Resident #2 had potential and actual impairment to skin related to fragile skin, and need for assistance with activities of daily living. Interventions included: a. Encouraging good nutrition and hydration in order to promote healthier skin, b. Following facility protocols for treatment of injury, keeping skin clean and dry, c. Identifying/documenting potential causative factors and eliminating/resolving where possible, d. Using lotion on dry skin. e. Monitoring/documenting location, size and treatment of skin injury, f. Reporting abnormalities, failure to heal, signs and symptoms of infection. maceration etc. to provider.A Braden Scale for Predicting Pressure Sore Risk dated 12/11/25 scored Resident #2 at 14, indicating moderate risk. The clinical record lacked documentation the facility identified additional interventions to prevent pressure sores with the increased risk. The Progress Notes dated 1/2/26 at 10:14 a.m. documented a new area to Resident #2's left heel, a 2 by 2 cm pressure area with the outside edges black and the center white.The Progress Notes dated 1/2/26 at 3:28 p.m. documented Resident #2 had an area on her left heel. Received an order for skin prep 2 times a day until healed. A Nursing Home Recert Visit dated 1/12/26 by the Advanced Registered Nurse Practitioner (ARNP) documented the Resident's left heel with an unstageable pressure area.The Progress Notes dated 1/14/26 at 12:12 a.m. documented there was an order stating heel protectors on while in bed and in the chair. Added the order to the Treatment Administration Record (TAR). Would have the day shift update family to ensure they were aware of this also.The Progress Notes dated 1/15/26 at 1:32 p.m. documented receipt of a verbal order to cleanse the area to left heel with normal saline, apply Santyl cream to the dark area, skin prep to the surrounding tissue, cover with a small piece of Adaptic (mesh dressing impregnated with a petroleum emulsion), cover with Mepilex (dressing), and change daily until resolved. The Progress Notes dated 1/20/26 at 1:59 p.m. documented the black eschar (necrotic dead tissue) area to the left heel measured 3 by 3 cm. The treatment continued and heel protector boots on at all times. The Progress Notes dated 1/27/26 at 12:59 p.m. documented Resident #2 had black eschar to her left heel measuring 3.2 by 3 cm. The treatment continued, and heel protector boots on at all times. A Physician's Orders and Progress Notes dated 2/2/26 documented the ARNP was there to evaluate Resident #2's skin condition. Exam of the right buttock revealed a quarter size area without signs or symptoms of infection. Exam of the left heel revealed a pressure ulcer with eschar present, measuring 3 by 1.8 cm at its widest width, with no signs or symptoms of infection.The Clinical Physician's Orders with a start date of 2/23/26 directed the left heel wound treatment including cleansing daily with wound cleanser, applying Santyl collagenase 2 times a day to the area, skin prep to the surrounding area, covering with Adaptic , 4 by 4, and wrapping with Kling On 3/3/26 at 1:45 p.m. Resident #2 sat in her recliner in her room with shoes and socks off, heels floating. The ARNP came in to check on the resident. The left heel had an area of eschar, appeared loosening at the edges. The ARNP explained they were (now) keeping pressure off of it, and it was stable. On 3/4/26 at 8:15 a.m. Staff A Certified Nursing Assistant (CNA) combed Resident #2's hair as she sat in the wheelchair. The resident had boots on bilateral feet/legs.On 3/4/26 10:23 a.m. Resident #2 in sat in her recliner in her room. Staff B Licensed Practical Nurse (LPN) removed the resident's boot, sock, and dressing. Staff B completed the treatment. The resident showed no signs of discomfort during the treatment. On 3/5/26 10:12 a.m. the Director of Nursing (DON) did not know when interventions started to prevent pressure ulcers. She said if the Braden score went down, she thought they would notify the physician. She said they really didn't have a procedure to prevent/treat pressure ulcers until recently they were working on it.The National Pressure Injury Advisory Panel (NPIAP) last updated in 2016 included using a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible. Develop a plan of care based on the areas of risk. Repositioning and mobilization included turning and repositioning all individuals at risk for pressure injury, unless contraindicated due to medical condition, choosing a frequency for turning based on the support surface in use, the tolerance for pressure, and ensuring the heels were free from the bed.

Based on clinical record review and staff interview, the facility failed to ensure a consistent code status between the IowaPhysician's for Scope of Treatment (IPOST), and the Electronic Health Record (EHR) for 3 of 12 resident reviewed for advanceddirectives (Resident #18, #23 and #26). The facility reported a census of 26 residents. Findings include: 1.The Care Plan initiated date of [DATE] failed to indicate Resident #23 desired to be a do not resuscitate (DNR) per his IPOST. The Clinical Physician Orders reviewed on [DATE] included an order dated [DATE] for Resident #23 to be DNR. Review of Resident #23's IPOST dated [DATE] reflected she desired a DNR status. Interview on [DATE] at 4:00 p.m. with Staff A, Licensed Practical Nurse (LPN), stated there is a list in the nurses station with the code status of the residents. Staff A stated when she looked for it she could not find it. Staff A stated the charts are color coded with dots, green dots are for DNR, red are for CPR and yellow is the limited interventions on the IPOST. Staff A looked up Resident #23's electronic health record and acknowledged that it was blank. Staff A stated it must have been missed since all the administration changes have happened. Staff A stated she is not sure who is responsible for putting the code status in the electronic health record. Staff A stated if there was an issue and she had to look for a resident's code status, she would go to look in the electronic health record. Interview on [DATE] at 4:20 p.m. with Staff B, LPN, stated if there is an incident with a resident that she needed to find the code status, Staff B stated that she would look in their electronic health record. Interview on [DATE] at 4:30 pm with Administrator and Director of Nursing (DON) stated that it is the nurse's responsibility to put the code status in the electronic health record. An undated policy named Resuscitation Procedure states the purpose is to ensure that resident wishes regarding cardiopulmonary resuscitation (CPR), life-sustaining measures, and life-prolonging interventions are honored and implemented within the capabilities of the facility. All residents will be asked about their resuscitation preferences upon admission and during quarterly care conferences. These preferences must be documented in the medical record and communicated to the physician. Residents have the option to sign a directive specifying which life-sustaining measures they wish to receive or decline. Staff are responsible for ensuring that these preferences are clearly visible and accessible in both the resident's chart and care plan. 2.Resident #18's IPOST dated [DATE] reflected a DNR code status. Resident #18's Clinical Physician's Orders and base information in the EHR, printed [DATE] at 9:28 a.m. lacked identification of the resident's code status. Resident #18's Care Plan printed [DATE] at 9:32 a.m. did not address the resident's code status. 3.Resident #26's IPOST dated [DATE] reflected a DNR code status. Resident #26's Clinical Care Plans page in the EHR, printed [DATE] at 9:35 a.m. lacked identification of the resident's code status. Resident #26's Clinical Physician's Orders in the EHR, printed [DATE] at 9:42 a.m. added DNR on [DATE]. Resident #26's Care Plan printed [DATE] at 9:38 a.m. did not address the resident's code status. On [DATE] at 12:40 p.m. Staff C Registered Nurse (RN) stated the list of resident's code status was printed from PCC, so the resident's code status was input into their EHR. The outgoing DON showed if you knew where to look, it could be found.

Based on clinical record review, staff interviews and policy review, the facility failed to offer to provide pneumococcal vaccine for 5 of 5 residents reviewed for Resident #2, #3, #10, #11, and #24. The facility reported a census of 26 residents. Findings include: 1)The Minimum Data Set (MDS) dated for 10/23/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score not completed noting severe impaired cognition. Review of the immunization tab in the electronic health record revealed the last Pneumococcal Immunization was the PVC 13 on 5/16/16. 2) The Minimum Data Set (MDS) dated for 9/18/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of the immunization tab in the electronic health record revealed the last Pneumococcal Immunization was the PVC 13 on 7/18/16. 3) The Minimum Data Set (MDS) dated for 9/25/25, Resident #10 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe impaired cognition. Review of the immunization tab in the electronic health record revealed the last Pneumococcal Immunization was the PVC 13 on 4/23/15. 4)The Minimum Data Set (MDS) dated for 9/25/25, Resident #11 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe impaired cognition. Review of the immunization tab in the electronic health record revealed the last Pneumococcal Immunization was the PVC 13 on 3/8/18. 5)The Minimum Data Set (MDS) dated for 12/4/25, Resident #24 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe impaired cognition. Review of the immunization tab in the electronic health record revealed the last Pneumococcal Immunization was the PVC 13 on 6/3/15. A facility policy titled Infection Control and Prevention Plan dated 2025 showed that residents are encouraged to receive routine vaccinations as recommended by public health authorities, including but not limited to: Influenza annually, Pneumococcal vaccines, COVID-19 vaccines and boosters, Tetanus, Diphtheria, Pertussis, Shingles and Hepatitis B. Upon admission, the resident's vaccination history will be reviewed and documented in their medical records. Any missing or overdue vaccinations will be identified and scheduled accordingly. Residents and their families will be informed about the importance of vaccinations and the recommended schedule. Residents with medical contraindications to certain vaccines will be exempt from those vaccinations. Documentation of medical exemptions will be maintained in the resident's medical records. Interview with the Infections Preventionist (IP) on 12/17/25 at 3:45 p.m. stated that the facility did a complete audit of all the charts to see where the residents were currently at with their immunizations. The IP acknowledged they have not done a pneumococcal clinic and that the residents/resident representative have not been offered or given the updated immunizations.

Based on record review, staff interview, and policy review, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days unless the attending physician or prescribing practitioner believed it appropriate for the PRN order to be extended beyond 14 days, and documented their rationale in the resident's medical record and indicated the duration for the PRN order, for 2 of 5 resident's reviewed (Resident #7 and #24). The facility reported a census of 26 residents.Findings include: 1) According to the MDS assessment dated [DATE] Resident #7 scored 2 on the BIMS indicating severe cognitive impairment. The resident's diagnoses included non-Alzheimer's dementia. Resident #7 did not take antianxiety medication. A facsimile (fax) dated 9/30/25 notified the physician Resident #7 had an increase in behaviors and explained some of them. The fax included current meds the resident took and asked for a PRN medication. The physician responded on 10/2/25 with an order for Lorazepam 0.5 mg every 6 hours PRN for agitation. The Medication Administration Record (MAR) for October 2025 added Lorazepam 0.5 mg every 6 hours PRN on 10/3/25, and the 1st dose given 10/3/25 (with the 17th at 14 days). The medication continued PRN through the month of October including receipt on the 25th and 27th without reconsideration by the provider. An Outpatient Psychiatric/Mental Health Progress Note dated 11/4/25 documented treatment recommendations and orders included continuing Resident #7's as needed lorazepam- renewing for 14 days (through the 18th). The provider sent a renewal for 14 days again on 11/11/25 (through 11/25/25). The MAR for November showed no documentation the resident received Lorazepam in the month. The MAR for December showed the resident received the Lorazepam on the 3rd and the 7th without an extension of the order. On 12/18/25 at 8:15 a.m. the DON confirmed they had no additional orders related to the PRN Lorazepam prior to discontinuation this month. The undated facility Policy for the Use of Psychotropics Drugs identified the purpose to ensure the safe and appropriate use of psychoactive drugs. The procedure included the facility would Facility will follow current state and federal regulations regarding psychotropic medications. The use of PRN orders for psychotropic medications were limited to 14 days. Excluding anti-psychotic drugs, if the attending physician or provider believed that was appropriate for the PRN order to be extended beyond 14 days, he or she would document their rationale in the resident's medical record and indicate the duration for the PRN order. 2) According to the MDS assessment dated [DATE] Resident #24 scored 00 on the BIMS indicating severe cognitive impairment. The resident's diagnoses included non-Alzheimer's dementia and anxiety disorder. Resident #24 did take an antianxiety medication during the last 7 days of the look back period. A facsimile (fax) dated 9/19/25 notified the physician Resident #24 had an increased anxiety and exit seeking behaviors, and increased anxiety appears very problematic for resident. Family questions if something as needed would be helpful. The physician responded on 9/19/25 with an order for Alprazolam 0.25 milligrams (mg) by mouth every 8 hours as needed, may repeat dose times 1, one hour after if no improvement in symptoms. A Consultant Pharmacist Communication to Physician facsimile (fax) dated 11/25/25 notified the physician Resident #24 had an order for Alprazolam 0.25mg every 8 hours as needed which is being used for anxiety. This medication needs to be reviewed every 2 weeks for continuation. Could this be renewed at this time. The physician responded on 12/10/25 with a yes, please renew. Review of Resident #24's medical record failed to find end dates for the Alprazolam for the dates of 9/19/25 and 11/25/25.

Based on record review and staff interview the facility failed to asses and provide interventions for residents who displayed respiratory symptoms for 2 of 2 residents reviewed, (Residents #1 and #16). The facility reported a census of 23. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The Care Plan for Resident #1 showed diagnoses of chronic obstructive pulmonary disease (COPD), amnesia (brain damage) and heart failure. The Progress Notes for Resident #1 documented the following: On 12/9/24 at 10:07 PM- Resident has been congested and coughing a lot this evening. COVID test was negative. On 12/10/24 at 12:58 AM- Resident congested and coughing bringing up moderate amounts of clear/white sputum. Albuterol nebulizer provided for wheezing as lung sounds with wheezes throughout bilateral lung fields. Remains afebrile. Tachycardic with pulse rate of 103, oxygen saturations within normal limits at 94% on room air. The resident did take the nebulizer mask off three times during nebulizer treatment to wipe nose and did not reapply the mask but this nurse reapplied the mask promptly. The resident continues to cough after the nebulizer was provided. The Progress Notes for Resident #1 further revealed the facility failed to initiate isolation precautions for symptoms of infection until the next shift on 12/10/24 at 6 AM. In an interview on 12/11/24 at 12:18 PM, Staff A, Licensed Practical Nurse (LPN) reported during shift report on 12/10/24 the night shift nurse informed her that Resident #1 suffered respiratory symptoms. Staff A stated, we set up isolation precautions. When asked if Resident #1 should have been placed in isolation precautions prior to her arrival, Staff A stated, yes. When asked when Resident #1 should have been placed in isolation precautions, Staff A stated, as soon as the nurse realized he had symptoms. 2. The MDS assessment dated [DATE] for Resident #16 documented diagnoses of anemia, hypertension and a history of COVID. The MDS showed a BIMS score of 12 which indicated moderate cognitive impairment. The Progress Notes for Resident #16 documented the following: On 11/28/2024 at 8:15 AM- Resident states he was coughing all night, has a hoarse voice, and that his throat hurts a little, also had a headache the night before and was given Tylenol. Vital signs are within normal limits. Cough medicine given and COVID test negative. The resident states he would like to continue to take cough medicine as needed to see if it helps. On 11/29/2024 at 11:42 AM- The physician responds via fax with a new order for Mucinex 600 milligrams twice a day for 7days. The Progress Notes for Resident #16 further revealed the facility failed to further document the status of respiratory symptoms, failed to complete assessments, and failed to place the resident in isolation precautions due to the presence of repository symptoms. The Temperature, Pulse, Blood Pressure and Oxygen Saturation Summaries for Resident #16 showed the facility failed to obtain vital signs from the onset of respiratory symptoms that occurred on 11/28/24. No vital signs recorded until 12/4/24. The undated Potential of COVID Positive Resident Recognized facility policy identified to provide a safe environment for those residents ill with COVID and separating them from those residents that are not ill in order to prevent the further spread of COVID. To also create a healing atmosphere for the resident to recover. Procedure: 1. A resident may or may not exhibit signs and symptoms of COVID. 2. The Centers for Disease Control and Prevention (CDC) for has identified signs and symptoms of probable disease that nurses will monitor in the residents as per outbreak status and non-outbreak status. 3. If residents exhibit these signs and symptoms without a positive test, they will be placed in Transmission-Based Precaution Isolation in their single room, unless married and refuse to move, for the illness for 3-5 days, testing daily. The resident's physicians will be updated to allow for any medication that may be prescribed for comfort and healing. 4. An isolation cart with signage directing personal protective equipment (PPE), and the need for the door to be closed will be put into place outside the room with Transmission-Based Isolation in place. 5. Communication will be forwarded to all departments identifying the isolation status of the particular resident. 6. During that time in which COVID positive residents are identified, they will be isolated in their private rooms, unless married and refusing to move. Isolation protocols will remain in place as per policy. 7. If and when the positive outbreak is outside the perimeter of more than one resident per hall, it will be evaluated to the need to establish a COVID Hall. In an interview on 12/19/24, the Administrator reported the facility currently had one COVID positive resident and two residents in isolation precautions due to respiratory symptoms. The Administrator reported residents that displayed respiratory symptoms, without explanation, should be placed in isolation precautions immediately and a COVID test should be performed. The Administrator reported residents should remain in isolation precautions for the duration of COVID testing cycle as policy.

Based on record review, staff interview, Resident Assessment Instrument (RAI) manual, and policy review the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days for a resident who started on hospice care for 1 of 3 residents reviewed (Resident #8). Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The MDS included a diagnosis of Non-Alzheimer's Dementia. Review of Resident #8's Clinical Census sheet revealed the resident started hospice level of care on 9/28/23. Resident #8's Hospice Certification and Plan of Care listed a current election date of 9/28/23 with certification period of 9/28/23 - 12/26/23. The review completed on 10/17/23 at 2:15 PM of Resident #8's MDS assessments listed of a Significant Change assessment started on 10/11/23 and remained still in progress. The undated MDS Policy instructed that it is the policy of the facility to follow the Resident Assessment Instrument (RAI) manual for all MDS procedures. On 10/18/23 at 3:26 PM, the Director of Nursing reported that she expected a significant change MDS completed within 14 days after a resident is placed on hospice. The MDS RAI manual dated October 2019 defines a significant change as a major decline or improvement in a resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting b. Impacts more than one area of the resident's health status; and c. Requires interdisciplinary review and/or revision of the Care Plan A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. The MDS completion date must be no later than 14 days from the ARD (ARD plus (+) 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met (hospice election date + 14 days).

Based on record review, staff interview, and policy review, the facility failed to have the necessary required members (Infection Preventionist) attend the quarterly Quality Assurance (QA) meetings. The facility reported a census of 24 residents. Findings include: The QA Sign in Sheets for the months of August 2022, November 2022, February 2023, May 2023, and August 2023 lacked an Infection Preventionist that attended the QA meeting. On 10/18/23 at 8:59 AM the Administrator revealed that the facility did not have an infection Preventionist in August 2022 through March of 2023 to attend the QA meetings. The Administrator further revealed that the Infection Preventionist (IP) did not attend the QA meetings since obtaining his IP certification in April 2023 and that she expected the Infection Preventionist to attend the meetings. The Facility's Quality Assurance and Performance Improvement (QAPI) directed that the QAPI committee would consist of, but not be limited to: the Medical Director, Administrator, the Director of Nursing (DON), A (Assistant) DON/Care Plan Coordinator, Infection Control Nurse, Laundry, Housekeeping, Office, Dietary Supervisor, Social Service, Activity Director, Maintenance Supervisor, and QAPI Coordinator.

Based on observations, clinical record reviews, facility policy review, and staff interviews the facility failed to adequately supervise and implement interventions to prevent falls for 1 of 3 residents (Resident #1) reviewed. On 8/24/22 staff found Resident #1 on the floor in the resident's room with increased complaints of right hip pain. Resident #1 required a transfer to the hospital and surgical repair of a right hip fracture. The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1 dated 8/29/22, identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS identified that the resident had signs and symptoms of [CONDITION(S)] that fluctuated, inattention, and disorganized thinking. The MDS revealed the resident required extensive physical assistance of 1-2 staff for bed mobility, transfers, dressing, and personal hygiene. Resident #1 required total dependence of 2 staff for toilet use. The MDS coded the resident's balance during transitions as not steady and only able to stabilize with staff assistance. The MDS coded frequent incontinence of bowel and bladder with use of a current toileting program. The MDS included diagnoses of hypertension, Alzheimer's disease, non-Alzheimer's dementia, and anxiety. The Care Plan Focus revised 8/25/22, identified that Resident #1 had a risk for injuries related to Alzheimer's disease as her level of cognition and function changed daily. The care plan interventions included: a. Anticipate needs as she may not express or may refuse when asked. Provide tender loving care (TLC) and support daily (12/5/19) b. Body alarm when in recliner, baby monitor at the nurses station, her room due to novel Coronavirus 2019 (COVID) isolation to further monitor, and a laser alarm placed on the floor next to the bed and the recliner (8/16/22) c. Bolster mattress on bed (6/25/20) d. Encourage activities that promote exercises, physical activity for strengthening, and improved mobility (3/17/20) e. Gripper strips on the floor in front of the recliner (10/6/20) f. Sensor alarm in bed and the wheelchair (8/16/22) g. Often spontaneous and not aware of the need for assistance to get up (3/8/20) h. Assist with all transfers (3/17/20) i. Place near common area/nurse's station when resting in wheelchair or anxious (12/12/21) j. Take to the bathroom prior to meals and after lunch, and as needed (2/21/22) k. Provide rest periods after lunch to remain more rested and not fatigued (12/12/21) The Care Plan Focus revised 12/5/19 identified that Resident #1 required assistance with daily care due to Alzheimer's, a history of left clavicle fracture, and unable to care for herself. The Care Plan interventions included: a. Assist x2 to use the commode (5/26/22) b. Transfer with gait belt, walker, and assist of 2 or use of the Hoyer lift with assist of 2 as needed (8/24/22) c. Encourage to use the bell to call for assistance (1/18/22) On 8/31/22 at 3:15 PM, observed Resident #1 lying in bed on her back with her eyes closed, she had a blanket on with her bed in the lowest position. She had an alarm box on the floor at the foot of her bed pointed towards the head of the bed, with no light on. Resident #3 had a personal alarm box at the edge of her bed, attached to her with a green light flashing. On 9/1/22 at 8:55 AM, witnessed Resident #1 up in her wheelchair in her room, after the facility staff finished getting her ready and took her out for breakfast. Noticed the chair pad alarm and a clip alarm in place and a sling underneath her in the wheelchair. On 9/1/22 at 10:45 AM, observed Resident #1 lying in the bed in her room with an alarm box on the floor at the foot of her bed, pointed towards the head of the bed, an alarm box hanging on the side rail, and a body pillow on the outside of her bed. Progress Notes reviewed a. On 8/19/22 at 12:47 PM, the Social/Activity note identified the resident as not alert and oriented. The documentation indicated the resident as confused, required cues, and reminders. b. On 8/24/22 at 4:15 PM, the Incident note (IN) identified that the facility staff who heard the resident on a baby monitor at the nurses station requested help. The staff found the resident on the floor behind the room door. c. On 8/24/22 at 4:15 PM, IN stated staff observed the resident on the floor in her room, behind the door sitting up against the door. The staff noticed Resident #1's right leg bent and tucked under her left leg. The resident complained of right hip pain. At the time of the fall, Resident #1 did not have anyone with her. The resident had a laser alarm that did not activate with Resident #3's independent ambulation from the recliner. At 2:45 PM when the staff took Resident #3's vitals, they noticed the body alarm attached. The staff assessed Resident #1's vital signs. Resident #1 received Tylenol (pain medication) and [MEDICATION(S)] (antianxiety) due to her right hip pain and anticipated anxiety. Resident #1 went to the hospital after notifying the physician and family. d. On 8/24/22 at 5:48 PM, IN revealed that when the facility nurse first entered the resident's room and observed the resident on the floor, the laser alarm activated and worked. e. On 8/31/22 at 1:35 PM, the Admission summary note identified the resident readmitted to room 308 for skilled services with diagnosis of orthopedic aftercare following pinning of the right hip. The resident transferred from the wheelchair with the Hoyer lift (full body mechanical lift) with assistance of four staff. The staff reoriented Resident #1 to use the call light and instructed her to call for help if needed. The facility documents titled Fall Risk assessment dated [DATE], 8/15/22 and 8/23/22, identified Resident #1 at risk for falls due to a history of falls, cognition, continence, mobility, balance, age, health, and medications. The facility document titled Fall Investigation Report dated 8/24/22, identified that Resident #1 fell in her room at 4:15 PM. a. The personal alarm used, not activated by the resident's motion b. The body alarm disconnected c. Call light not turned on d. Identified factors: the resident attempted to self-transfer e. Injury noted at the time of the fall: right hip pain The facility document titled Post Fall Assessment for the Nurse on Duty dated 8/24/22 for Resident #1 revealed: a. What the resident tried to do - self-transferred from the recliner b. Specifics of the fall - while the nurse at the nurse's station, heard the resident call for help and found the resident on the floor in the room next to the door. No alarms sounded when the nurse entered the resident's room. c. What would have prevented the fall - the resident sat by the nurse's station The facility document titled Fall Investigation for the Certified Nurse's Aide (CNA)/staff member on duty dated 8/24/22 for Resident #1 revealed: a. Any alarms sounded: No b. Interventions in place at time of the fall: pull alarm and sensor alarm c. Last visual of the resident at 3:45 PM, the resident asleep in the recliner with her alarms in place. d. What the resident did at the time or attempted to do at the time of the fall: the resident attempted to walk across the room e. The resident observed sitting upright on the floor behind the door f. The floor dry g. Factors that contributed to the fall: the resident ambulated without assistance The emergency room (ER) Evaluation dated 8/24/22 at 6:16 PM, identified that Resident #1 presented to the ER via emergency medical services (EMS) after an apparent fall at the nursing home. The resident complained of severe pain to her right hip. The right leg foreshortened (dramatically shorter) and externally rotated. A minimal amount of range of motion caused a significant amount of pain to Resident #1. The x-ray of the hip showed a hip fracture on the right side. Due to the level of pain, the resident received a hip block from anesthesia for pain control. The resident transferred to another hospital for orthopedic services for orthopedic surgery. The ER Radiology Report for Resident #1 dated 8/24/22, revealed intertrochanteric fracture right proximal femur (type of hip fracture). The facility policy titled Fall Incident Policy dated 11/10/19 identified; in order to protect the residents from injury, conditions surrounding the person reviewing the physical, mental, the environment, and potential causes for injury are evaluated. Potential causes may be related to mental impairment, medications, abuse, vision problems, and conditions of the flooring. Procedures: a. The fall investigation report utilized vitals, health conditions, medications, and general safety factors. Prevention/Interventions placed immediately to prevent further falls for the resident and future incidents that may be related to the situation. b. The fall review would be discussed in Quality Assurance and potential plan to discover the root cause and solutions may be created. A written statement dated 8/25/22 by Staff B, Registered Nurse (RN), recorded that no alarms sounded at the time of Resident #1's fall. The statement indicated that when Staff A, Licensed Practical Nurse (LPN), entered the room, the laser alarm sounded. The laser alarm had been positioned on the floor to the front and the right of the recliner. A written statement dated 8/25/22 by Staff A documented that no alarms sounded when entered Resident #1 room and observed the resident on the floor. Noted the laser alarm sounded as entered further into the room. A written statement dated 8/25/22 by the DON recorded that no alarms sounded as they entered Resident #1 room at the time of the fall, and thought the nurses turned off the alarms in the room. Noted the laser alarm had been in place and the body alarm in place, however, detached from the resident. On 8/31/22 at 3:42 PM, Staff A confirmed working 6a-2p shift on 8/24/22. Staff A stated Resident #1 in room 309 when the fall occurred. Staff A reported being the nurse on duty at the time of the fall, Staff B heard Resident #1 on the baby monitor at the nurses station saying help. Staff A stated entered Resident #1's room with Staff B at the same time and upon entering the room, no alarms sounded. Staff A stated she observed the laser alarm on the floor, not sounding and when she walked closer to the recliner, the laser alarm sounded. Staff A explained that she noticed the personal alarm still in the recliner, not sounding. Staff A stated the personal alarm had to be clipped to the resident. Staff A stated Resident #1 would be active and remove the alarms by herself. Staff A stated the resident had a chair pad alarm in the recliner and when they found the resident, they found it on the floor, not sounding. Staff A stated once the barrier broke on the laser alarm, the alarm would sound until turned off by the facility staff. Staff A stated that it would be the same with the other two alarms, once sounding they do not shut off until the facility staff turn them off. Staff A stated that the baby monitor started about the time the resident tested positive for COVID, however, she already had the other alarms in place. Staff A stated Resident #1 had been in the recliner, in the middle of the room as her roommate was not in the room at the time due to COVID. Staff A explained they found the recliner in the middle of the room with the laser alarm pointing to the right front of the recliner. They discovered Resident #1 behind the door to the right of the recliner. Staff A stated the last time she saw the resident was around 12:30 PM or 12:45 PM. Staff A said they assisted the resident to the toilet before and after meals with assistance of two at the time of her fall. Staff A denied know if Resident #1 had been restless the day she fell or if she attempted to self-transfer. Staff A stated did not recall if Resident #1 was incontinent at the time of the fall. On 8/31/22 at 3:55 PM, the Director of Nursing (DON) stated Resident #1's roommate had not been in the room at the time of the fall due to COVID and that the roommate used the chair pad alarm when in the recliner, not Resident #1. The DON stated the agency nurse did not realize Resident #1 did not need the chair pad alarm, only the clip alarm when in the recliner. The DON stated if Resident #1 had utilized a chair pad alarm at the time of the fall, by the time the chair pad alarm would have sounded, the resident would have already been up. The DON stated they only placed a clip alarm and a laser alarm on the resident when in the recliner. The DON stated the clip alarm and personal alarm were still in the chair when the resident was on the floor, not apart, and not sounding. The DON said she did not know that Resident #1 could remove the personal alarm by herself until the survey interviews. On 8/31/22 at 4:00 PM Staff C, CNA, confirmed that she worked the 2 PM to 10 PM shift on 8/24/22, when Resident #1 fell . Staff C explained that they had a new agency aide working and she provided orientation to that aide at the start of the shift. Staff C said they started down the 300 hall together reviewing the residents and the alarms utilized. Staff C stated she emphasized to the agency aide that Resident #1 was heavily alarmed and a big fall risk. Staff C stated the agency aide acknowledged Resident #1 utilized alarms and her risk for falls. Staff C stated that while she reviewed the residents in the 300 hall with the agency aide, they observed Resident #1 in the recliner in her room with a pull clip alarm attached to her shirt and the box blinking attached to the recliner. Staff C stated that she did not physically go in Resident #1's room as looked in from the doorway. Staff C stated the baby monitor at the nurse's desk had been on. Staff C stated she returned to the 200 hall to assist another resident and received notification that Resident #1 fell . Staff C said that the last time she observed Resident #1 with the agency aide, around 2:15 PM or 2:30 PM, when they first reported to duty. Staff C stated she noticed Resident 1's eyes closed and sleeping. She did not appear anxious but appeared comfortable. Staff C explained that she did not check the laser alarm, she just saw it on the floor. Staff C stated Resident #1 usually got up for supper between 3:30 PM and 3:45 PM, however, the resident stayed in her room due to having COVID. Staff C stated Resident #1 usually used the toilet before the delivery of her supper tray. Staff C stated that the day shift would have helped the resident to the toilet between 1:00 PM and 1:30 PM, due to being one of the last residents to go to the toilet. On 9/1/22 at 10:07 AM, Staff B reported that he heard Resident #1 on the baby monitor and went to her room. When Staff B entered the room, no alarms sounded. Staff B added that he discovered Resident #1 on the floor in the room behind the door, to the right of her recliner. Staff B stated Resident #1 did not have the clip alarm on her shirt and the laser alarm on the floor had not been sounding. Staff B stated that when Staff A entered Resident #1's room and passed the laser alarm, it immediately sounded. Staff B stated that Resident #1 got around the laser alarm and took off the clip alarm attached to her shirt. Staff B stated the recliner had a pad alarm, left from a different situation and he did not believe Resident #1 had a chair alarm. Staff B said he went in Resident #1's room around 2:15 PM to obtain vitals and observed the clip pull alarm attached to Resident #1's left arm while she sat in the recliner. Staff B stated the fall occurred at 4:16 PM. Staff B stated the clip alarm attached or hung off the back side of the recliner with the clip still attached to the resident's shirt. Staff B stated Resident #1 took the clip off her shirt, and got around the alarm on the floor. Staff B stated at 4:15 PM, when the fall occurred, the alarm on the floor had been on, it just did not sound until the second nurse entered the room. Staff B stated he did not recall if Resident #1 had been incontinent at the time of the fall, she could have been as she is known to be incontinent throughout the day and in general. Staff B stated Resident #1 is a regular check and change due to incontinence. Staff B stated Resident #1 ate in the room because of COVID isolation. Staff B stated the alarms are not new for Resident #1. Staff B stated Resident #1 had not set the alarms off from 2 PM - 4 PM, prior to her fall. Staff B stated Resident #1 had been resting in the recliner. Staff B stated the facility staff knew of Resident #1's risk of falls and that was the reason they placed the baby monitor at the nurses' station when the resident tested positive for COVID. Staff B stated that Resident #1 had a history of being restless, she would get up and down frequently setting off her alarms. Staff B said Resident #1 was known to remove the clip alarm in the past and Staff D, CNA, saw Resident #1 remove the alarm before. On 9/1/22 at 11:21 AM, Staff D confirmed that he worked the day shift on 8/24/22. Staff D stated her routine would be to check Resident #1's alarm every 15-30 minutes because when she woke up she would get up on own. Staff D stated that after Resident #1 got changed and up for the day they would place her in the recliner with a pull alarm and laser alarm in place. Staff D stated that when Resident #1 laid in bed they placed a sensor and laser alarm. Staff D explained that Resident #1 had alarms prior to COVID, however, they implemented the baby monitor when she got diagnosed with COVID. Staff D stated Resident #1 utilized the commode and/or check and change and required assisting/cuing for breakfast. Staff D stated they allowed Resident #1 to sit for about 30 minutes after eating, and then they helped her to the toilet again. Staff D explained that they placed Resident #1 in the recliner with all of her alarms in place with the television on. Staff D reported that Resident #1 usually napped mid-morning to lunch time. Staff D stated they helped Resident #1 use the toilet before lunch and again after she finished lunch. Staff D stated that most days Resident #1 would lay down after lunch due to being tired and other days, if she seemed anxious, she would leave her in the recliner and give her other things to do. Staff D stated Resident #1 liked certain cartoons on the television or they provided her with a busy blanket. Staff D stated they did not use the call light. Staff D confirmed that she saw Resident #1 remove the clip alarm, however, she would try to clip it far enough back that she would not touch it as she did not know about the alarm there. Staff D stated on 8/24/22, Resident #1 sat in her recliner and watched television, however, the resident did not seem anxious but actually seemed content. Staff D stated that the resident did not sleep much that day. Staff D stated Resident #1 had a history of being restless, as she got up and down, and other days she would sleep for a couple days and then become restless again. Staff D stated that when Resident #1 did not have COVID, they placed her at the nurse's station with the nurse or with activities. Staff D said she remembered taking Resident #1 to the toilet after lunch on 8/24/22, however, she did not remember the time. Staff D stated Resident #1 returned to the recliner after going to the toilet due to her not sleeping. Staff D added that she did not want to lay Resident #1 down due to her getting irritated if she was not tired and got laid down. On 9/1/22 at 11:37 AM Staff E, CNA, confirmed that she worked the day shift on 8/24/22. Staff E explained that Resident #1 liked to sleep and she allowed her to decide when she got up. Staff E explained they helped Resident #1 use the toilet before and after meals. Staff E stated after lunch Resident #1 would usually lay down or relax in her recliner. Staff E stated when Resident #1 started to fall asleep in the recliner, she would put her in bed. Staff E reported that if Resident #1 did not eat a good lunch, she would lay her down in bed with a bed alarm, sensor pad alarm, and laser alarms in place. Staff E said that Resident #1 utilized a sensor pad alarm and pull tab alarm while in the recliner. Staff E stated Resident #1 never used the call light to ask for assistance. Staff E stated Resident #1 could answer questions, however, she had progressed dementia. Staff E explained that on 8/24/22, the day Resident #1 fell , she helped Resident #1 use the toilet on the commode and then she returned to the recliner with all of her alarms all in place. Staff E added that the sensor pad alarm automatically turned on once pressure applied. Staff E explained that they had to turn on the laser alarm. Staff E could not remember if Resident #1 had been anxious on 8/24/22. Staff E reported that Resident #1 did have anxious days, but she did not recall her being anxious that day. Staff E stated at times the staff had to sit with Resident #1 in COVID isolation because of her increased anxiety but not that day. On 9/6/22 at 10:20 AM, the DON stated prior to Resident #1 having COVID and being in isolation, the facility utilized a sensor pad alarm when she sat in her wheelchair and a laser alarm when in her bed. The DON stated Resident #1 did not spend time in bed prior to COVID, as she did not like to be in bed. She enjoyed being out and about. The DON stated that once Resident #1 tested positive for COVID they utilized a body sensor alarm, laser alarm, and baby monitor when in bed, and substituted the pull tab alarm while in the recliner for the sensor pad alarm in the wheelchair. The DON said Resident #1 moved too fast for the sensor pad alarm to be utilized in the recliner because by the time the sensor pad alarm sounded, she would already be out of the recliner. The DON explained that Resident #1 did not use her recliner prior to being in COVID isolation due to her moving around too much with her increased anxiety. The DON added that they kept Resident #1 by the nurse's station, by the DON's office, or with activity staff all the time, she never stayed in her room alone. The DON explained that Resident #1 always stayed in the common area for supervision before having COVID. The DON reported that at the time of Resident #1's fall, the recliner had a sensor alarm in it, but it did not belong to Resident #1. They did not utilize a sensor alarm for Resident #1. The DON reported that the sensor alarm belonged to Resident #1's roommate, but because of COVID her roommate did not live in the room at the time of her fall. The DON did not how common it was for Resident #1 to remove her clip alarm. She declared that from her input it was not common for Resident #1 to remove her alarm. The DON explained that during the interviews one CNA reported seeing Resident #1 remove her clip alarm one time. The DON reported that the facility had lots of residents who have removed their alarm one time. The DON expressed that as soon as Resident #1's body came off the chair, the pull alarm would sound, sooner than the sensor pad alarm. The DON added that if she knew about Resident #1 removing her alarm, she would have changed her alarms. The DON denied knowing if the nurses knew about Resident #1 removing her alarms either. The DON stated one CNA saw Resident #1 remove the alarm one time. The DON explained that staff had to turn on the laser alarms while the sensor alarm automatically turned with applied pressure. The DON said that the clip alarm did not have to be turned on. The connector needed to be clipped to the resident and would sound when unclipped.

Based on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses for 7 of 29 residents reviewed. In a series of observations on 7/25/22 and 7/26/22 it was discovered that residents that tested positive and negative for novel Coronavirus 2019 (COVID) remained in the same hallway, and many times had their bedroom doors left open. An observation showed staff not wearing full Personal Protective Equipment (PPE) when administering a nasal COVID test to a symptomatic resident, staff wore surgical masks improperly, and a symptomatic resident did not have isolation precautions and later tested positive for COVID. The facility reported a census of 28 residents. Due to these findings, the care of the residents, their health, and safety resulted in an immediate jeopardy (IJ) situation on 7/26/22. The facility removed the IJ situation on 7/27/22 decreasing the scope to an F. The facility reported a census of 29 residents. Findings include: On 7/25/22 at 9:35 AM, the Administrator reported that they had five residents that tested positive for COVID at that time. The Director of Nursing (DON) stated that the COVID positive residents stayed in their rooms on isolation precautions and added that the facility did not have the proper set up to provide a designated unit to separate those who tested positive from the healthy residents. 1. On 7/26/22 at 6:05 AM observed a cloth gown hanging on the outside of the open door to room [ROOM NUMBER]. On 7/26/22 observed the door to room [ROOM NUMBER] wide open at 10:00 AM and 12:06 PM. The Health Status Note dated 7/24/22 at 7:00 AM documented that Resident #23 got tested with a rapid COVID test twice. Each test result indicated Resident #23 as positive with COVID. Resident #23's skin, warm, and dry. The auscultation (listening) of Resident #23's lungs determined them to be clear with an occasional nonproductive cough reported by Resident #23. Resident #23 denied shortness of breath (dyspnea) and not feeling well. Isolation precautions initiated and explained to Resident #23. 2. On 7/26/22 at 8:47 AM, noted room [ROOM NUMBER] with their door wide open. On 7/26/22 at 9:24 AM observed the door to room [ROOM NUMBER] remained wide open and with the resident coughing. On 7/26/22 witnessed the door to room [ROOM NUMBER] open at 7:45 AM and 8:47 AM. The review on 7/28/22 at 1:43 PM of Resident #2's electronic health record determined the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 7/26/22 at 11:15 AM witnessed the door to room [ROOM NUMBER] wide open with a container of PPE outside the door. On 7/26/22 at 12:06 PM saw the door to room [ROOM NUMBER] open. On 7/26/22 at 12:23 PM Staff D, Dietary, put on a cloth gown and went into room [ROOM NUMBER]. She soon came back out of the room wearing the same gown, gathered more items from the food cart in the hallway, and went back into room [ROOM NUMBER]. Staff D then exited out of room [ROOM NUMBER] and stood in the middle of the hallway. Staff D asked several staff members what she should do with her PPE. She explained that she just started and didn't get trained on PPE use. The Health Status Note documented that Resident #24 had no signs or symptoms per the list of CDC guidelines of apparent illness indicating COVID noted that shift for the following notes: 7/24/22 at 10:09 AM, 7/24/22 at 3:10 PM, and 7/25/22 at 4:23 AM. The Condition Note dated 7/25/22 at 1:53 PM documented that Resident #24 tested positive for COVID that morning. Resident #24 continued to cough and have congestion. Resident #24's electronic health record reviewed 8/1/22 at 1:19 PM diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 4. On 7/26/22 at 8:40 AM, observed Staff C, Social Services, enter Resident #16's room, number 116, without wearing a gown. After she entered the room she administered a COVID nasal test. From there Staff C went into Resident #14's room. The Communication Note dated 7/26/22 at 3:37 PM documented by Staff C indicated that they visited with Resident #16's responsible party about moving him temporarily out of his room to remove him from the COVID area of the building as he did not have signs or symptoms. On 7/26/22 at 2:06 PM, the Director of Nursing (DON) said that they used cloth gowns due to the shortage of PPE back in 2020 and Public Health told them it was acceptable to use the cloth gown. She said that she had taught staff to use them only once and that they were not to hang them on the outside of the door. The DON said that the facility wasn't set up to have a separate COVID unit and they didn't feel that it was in the best interest of the residents to move them if/when they tested positive for COVID. She said that they did not talk about plans for a possible outbreak but that they all had the knowledge base to handle an outbreak. The DON acknowledged with the resident isolating in their rooms, the doors should have been closed and that the staff knew to close the doors. The DON explained that she felt they should be closed. The DON began typing up a list of processes to follow for isolation precautions to put at each room and said that she would add it to the list to remind staff to close the doors. She reported that she was making up a list of reminders to put outside of the residents rooms. On 7/26/22 at 2:13 PM the DON said that she instructed the dietary staff to stay out of COVID positive rooms. She also told staff to keep the doors closed to positive rooms and instructed staff not to hang used cloth gowns on the outside of the bedroom doors. 5. Observations of Staff F, Housekeeper, with her mask down below her nose a. On 7/25/22 at 11:31 AM: Staff F entered and exited rooms in the 200 hall with her mask worn below her nose. b. On 7/25/22 at 1:55 PM: Staff F seen in the intersection of the 200 and 300 hall with a mask worn below her nose. c. On 7/26/22 at 8:01 AM: Staff F worked in the 200 hall with her mask worn below her nose as residents passed by. d. On 7/26/22 at 9:50 AM: Staff F observed at the intersection of 200 and 300 hall with a mask worn below her nose as residents passed by. e. On 7/27/22 at 8:01 AM watched Staff F in the 200 hall wearing a mask below her nose as a resident passed by. When asked if she had trouble with the mask staying on her face, Staff F stated that she pulls her mask down sometimes because it gets hard for her to breathe. On 7/26/22 at 3:55 PM, the Administer and DON reported that they expected staff to wear their PPE appropriately. The DON acknowledged that she previously addressed mask expectations with Staff F. The Personal Protective Equipment Guidelines policy updated 6/7/22 directed that all facility personnel should wear source control (a well-fitting mask or a N95) when in resident care areas and/or when it is likely that they could encounter another person. The mask or respirator should cover the individual's nose and mouth at all times. 6. Resident #1's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/25/22 at 1:33 PM, observed Resident #1 with a loose hacky, productive cough. Resident #1 reported that he tested negative for COVID the day before and the day of the interview. Resident #1's cough appeared to be frequent as it occurred approximately every 30-90 seconds. At the time of interview Resident #1 was not in transmission based precautions (TBP) for symptoms of COVID. On 7/25/22 at 4:16 PM noted that Resident #1 could be heard coughing in the hall. TBP not initiated. In an interview on 7/26/22 at 9:05 AM, the Administrator reported that Resident #1 tested positive for COVID. The facility failed to initiate TBP until 9:29 AM by the DON. On 7/26/22 at 2:06 PM, the DON reported that the facility did not initiate TBP unless the resident had a positive test result for COVID. The Personal Protective Equipment Guidelines policy updated 6/7/22 instructed staff about providing care for a COVID positive person or a person in quarantine. Personnel who enter the room of a resident with suspected or confirmed COVID infection should adhere to Standard Precautions and use an N95, equivalent, or a higher-level respirator, gown, gloves and eye protection. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes. Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection, last updated on Feb. 2, 2022 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) indicated that when healthcare professionals cared for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection they should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). The facility abated the IJ on 7/27/22 after initiating the following corrective actions: 1. The facility established a COVID wing behind a set of double doors that would remain closed until the facility is out of outbreak status. 2. The facility replaced the cloth gowns with disposable gowns in the isolation areas. 3. All staff received education on the proper use of PPE. 4. The facility would assign designated staff to the COVID hallway whenever possible.

Based on observations, staff interviews, the facility's menu review, and the facility's meal selection record review, the facility failed to follow the planned menu for cognitively impaired residents and failed to serve the correct food portions during meal service. The facility identified a census of 28 residents. Findings include: 1. Observation on 7/27/22 at 11:27 AM of the residents' lunch selection records revealed incomplete meal selections for cognitively imparied residents. Staff A, Dietary Aide, reported that she picked out the menu items for confused residents. When asked how she decided what menu items to pick, Staff A stated, it depends on what the resident likes or if they are big eaters. If they don't usually eat much, I don't order much. 2. Observations during meal service on 7/27/22 at 12:08 PM revealed a variety of facility staff that assisted kitchen staff in plating meals for residents from two buffets. The staff failed to consistently serve proper amounts of food by not entirely filling the scoop, overfilling scoops, or not completely emptying scoops of food onto the resident's dish. The undated Dining Policy failed to address meal selections for cognitively impaired residents and lacked directions that would ensure the proper amount of food is served. In an interview on 7/27/22 at 12:08 PM, Staff A and Staff B, Cook, acknowledged that they observed some of the staff not scooping food portions correctly when plating food. In an interview on 7/27/22 at 2:33 PM, the Director of Nursing reported that all staff received food service education.She acknowledged that staff should scoop the correct amount of food for residents. In an interview on 8/1/22 at 3:01 PM, the Dietitian stated that she expected the meal to be served per the planned menu and per the portion size required for every meal to meet nutritional needs, to avoid weight loss and to prevent complications related to diabetes.

Based on observations and staff interviews the facility failed to prevent contamination during meal service and failed to keep sanitary conditions in the dishwashing area. The facility identified a census of 28 residents. Findings included: 1. An initial kitchen tour conducted on 7/25/22 at 10:16 AM, revealed a white flaky substance on the dishwasher and the surrounding countertop area. 2. During the meal service on 7/27/22 at 11:27 AM: a. Staff A, Dietary Aide, observed to clean up a resident's spilled drink then failed to perform hand hygiene before touching the food scoop handles. b. A variety of facility staff assisted the kitchen staff with plating meals for the residents from two buffets. While serving the food staff failed to prevent cross contamination by allowing the scoop handles to fall into the pans of food. c. All kitchen staff failed to perform hand hygiene during the lunch service. The undated Dining Policy failed to address hand hygiene during meal service. In an interview on 7/27/22 at 12:08 PM, Staff A and Staff B, Cook, acknowledged that they did not perform hand hygiene and neither did the other kitchen staff while serving lunch. In an interview on 7/27/22 at 2:33 PM, the Director of Nursing (DON), reported that all staff received food service education. When asked if she expected kitchen staff to perform hand hygiene during meal service she stated, yes. The DON also acknowledged issues with the lime build up in the dishwasher area. In an interview on 8/1/22 at 3:01 PM, the Dietitian stated that she expected staff to perform hand hygiene as needed throughout the meal service.

Based on observations, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to complete incident reports regarding skin conditions for two of two residents reviewed (Residents #15 and #22). In addition the facility failed to document signs and symptoms of novel Coronavirus 2019 (COVID) when residents experienced them before testing positive for COVID for two of three residents reviewed (Residents #1 and #17) . The facility reported a census of 29 residents. Findings include: 1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #15 required extensive assistance of one person for bed mobility, transfers and toilet use. The Incident Note dated 2/7/22 at 1:12 PM documented that Resident #15 went to the bathroom with assistance of the stand up lift. On the way to the bathroom he caught his right elbow on the door sill that caused a 1.5 centimeter (cm) long by (x) 0.5 cm wide skin tear. The Care Plan Focus revised 9/17/18 documented Resident #15 at risk for injuries related to his [CONDITION(S)]. The Care Plan included an intervention dated 2/7/22 that indicated that staff received education to watch for arm placement with the stand lift use. The Care Plan Focus dated 11/26/19 recorded that Resident #15 had fragile skin. The included intervention dated 6/16/21 directed staff to monitor extremities when going through doorways as Resident #15 could tolerate. Resident #15's record lacked an incident report or follow-up investigation on the bruise happened and how to prevent future incidences. 2. Resident #22's MDS dated [DATE] identified a BIMS score of 13, indicating intact cognition. Resident #22 required extensive assistance of one person with transfers, dressing and toilet use. The Incident Note dated 2/3/22 at 9:20 PM identified that Resident #22 went to the bathroom while using a standing lift and bumped his left elbow on the grab bar. Resident #22 sustained a 4 cm x 9 cm bruise to his left arm just below his left elbow and 2 cm long skin tear to the same area. The nurse documented the intervention to make sure to tuck Resident #22's extremities in before proceeding into areas with grab bars. The chart lacked an incident report or investigation into possible causes or interventions to prevent further incidences. On 7/27/22 at 9:25 AM when asked about a report of follow up investigations for the incidents related to Resident #15 and Resident #22, the Director of Nursing said that they only did incident reports on falls and did not do investigations related to bruising. The Care Plan Focus revised 2/10/20 indicated that Resident #22 had fragile skin. The Care Plan included the following intervention initiated on 9/22/21 to Monitor placement of Resident #22's arms during any transfers. 3. Resident #17's MDS assessment dated [DATE] documented a BIMS score of 14, indicating intact cognition. Resident #17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17 experienced shortness of breath (dyspnea) while exerting (walking or transferring) himself, when sitting at rest, and when lying flat in the lookback period. Resident #17 used oxygen therapy in the last 14 days of the lookback period. On 7/25/22 at 9:25 AM observed Resident #17 coughing. An unidentified staff person told him said that he should stay in his room because he showed symptoms of COVID. The Nursing notes dated 7/26/22 at 1:19 AM, 1:50 PM, and 3:16 PM all indicated that Resident #17 had no signs of symptoms per the list of Centers for Disease Control (CDC) guidelines of apparent illness indicating COVID noted this shift. A nursing note dated 7/27/22 at 2:50 PM showed that Resident #17 tested positive for COVID. The note documented that Resident #17 also had continued signs and symptoms of head congestion. On 7/27/22 at 9:48 AM the Director of Nursing (DON) said that sometimes the nurses would copy and paste a canned text related to signs and symptoms of COVID. She agreed that the documentation showed an inaccurate picture of Resident #17's condition when he actually had a cough and runny nose. 4. Resident #1's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/25/22 at 1:33 PM, observed Resident #1 with a loose hacky, productive cough. Resident #1 reported that he tested negative for COVID the day before and that day. Resident #1's cough appeared to be frequent as it occurred approximately every 30-90 seconds. In an interview on 7/26/22 at 9:05 AM, the Administrator reported that Resident #1 tested positive for COVID. The Progress Notes reviewed on 7/26/22 at 11:11 AM revealed the nurse's documentation failed to record respiratory signs or symptoms for the days prior to Resident #1 testing positive for COVID. The documentation revealed the exact same notation of no signs or symptoms (s/s) per the list of CDC guidelines of apparent illness indicating COVID noted this shift. Resident #1 received testing for COVID on 7/25, 7/26 and 7/27, however the suspicion of COVID nor the sign and symptoms were not documented. The [Facility Name] Nursing Documentation policy reviewed April 2022 directed the staff that nursing documentation is part of the nursing process, which is a deliberate, problem-solving approach to meet the health care and nursing needs of residents. It involves assessment, nursing diagnosis, planning, implementation and evaluation to fit within the standards of care.

Based on observation and interviews the facility failed to store scheduled IV medications separately from non- scheduled medications. Facility census was 30 residents. Findings Include: During medication cart review in the 300 hall on 8/11/21 at 11:16 a.m., showed the cart to contain 8 cassettes of [MEDICATION(S)] (antianxiety) stored with the non- scheduled medications. During observation of the medication cart located in the 300 hall on 8/11/21 at 11:16 a.m., showed to contain three cassettes containing [MEDICATION(S)] labeled for Resident # 7. The cart also contained a red cassette containing [MEDICATION(S)] and labeled with as needed for Resident #7. During observation of the medication cart located in hall 300 on 8/11/21 at 11:16 a.m., showed to contain 2 cassettes containing [MEDICATION(S)] labeled for Resident # 20 During observation of the medication cart located in hall 300 on 8/11/21 at 11:16 a.m., showed to contain 1 cassette of [MEDICATION(S)] labeled for Resident # 15 and one red cassette of [MEDICATION(S)] labeled for Resident # 15 for as needed use. Review of the federal regulation 483.45(g) under medication access and storage in the State Operation Manual Appendix PP stated, schedule II-V medications must be maintained in separately locked, permanently affixed compartments. The access system (e.g. key, security codes) used to lock Schedule II-V medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications. On 8/11/21 at 11:16 AM the Director of Nursing (DON) the facility pharmacist informed her that [MEDICATION(S)] did not need separate storage from the non-scheduled medications. On 8/11/21 at 1:42 PM the DON stated she removed all the [MEDICATION(S)] from the medication cart nonscheduled medication areas and placed them in the scheduled medication storage area.

Based on observation, clinical record and policy review, and staff interview, the facility failed to follow a diet order that directed the resident to receive finely chopped meat. The facility served a resident the resident a hot dog for 1 out of 15 residents reviewed. (Resident #21). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] assessed Resident #21 with a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. MDS dated [DATE] identified Resident #21 independent with eating. Observation revealed on 08/10/21 at 11:34 AM staff served the resident a hot dog on a bun, cut in half. The diet order dated 12/19/18 revealed the physician ordered a mechanical soft, small serving diet for the resident and directed staff to chop meat up fine and cut all foods into bite size pieces due to coughing with meals/foods. A Progress Note dated 12/5/2018 at 08:43 PM revealed the resident's family member expressed concern over the resident coughing and questioned possible need for x-ray or a swallow study or a swallow evaluation since the resident sometimes coughed and gagged during her meals. The Progress Note dated 12/18/2018 at 07:00 PM revealed the ARNP (advanced registered nurse practitioner) ordered a mechanical soft, chopped meat diet with foot cut in bite size pieces. The Progress Note dated 12/7/2018 at 09:27 PM revealed a new order received for swallow evaluation by speech therapy. The Mechanical Soft Diet policy with no date revealed that all foods allowed on the diet can be made easier to chew and swallow by using machines to blend, puree, grind, or finely chop the food. On 08/11/21 at 08:42 AM, Staff A, dietary aide, reported a resident with a mechanical soft diet and cut meat into fine pieces order should not receive a whole hot dog. On 08/11/21 at 09:12 AM, the Director of Nursing (DON) reported she expected staff to follow the diet ordered by the physician just like any physician's order.

Based on observation, Food Safety Code 2017, and staff interviews, the facility failed to hold cold foods served for a noon meal at 41° Fahrenheit (°F) or lower. The facility reported a census of 30 residents. Findings include: Observation on 08/10/21 at 10:07 AM revealed pre-meal service cold food temperatures taken by the Dietary Manager as follows: [MEDICATION(S)] 40.5 °F, lettuce 41.3°F, and fruited gelatin 43.6°F. Additional pre-meal service cold temperatures on 08/10/21 at 11:24 AM were baked apples 40.5°F, pureed baked apples 37.4°F, blueberries and pears 38.5°F, and coleslaw 37.4°F. Observation on 08/10/21 at 12:35 PM revealed after meal service temperatures taken by Staff B, dietary aide, as follows: milk 47.3°F, pureed baked apples 51.4°F, lettuce 47.6°F, [MEDICATION(S)] 48.7°F, coleslaw 43.9°F, blueberries and pears 42.3°F, and fruited gelatin 54.5°F. During the same observation the temperature of the baked apples not in the cold table and held in a pan of ice at 44.2°F. Continued observation revealed the thermometer in the cold table read 38°F. The Food Safety Code 2017 in the section Time/Temperature Control for Safety Food, Hot and Cold Holding revealed that cold food should be held at 5ºC (41ºF) or less. On 08/10/21 at 12:35 PM, Staff B reported all of the cold foods served at the noon meal that were held at higher than 41°F would be refrigerated and served at a later meal. Staff B also reported the cold table did not hold cold food at 41°F or lower whenever the weather outdoors is hot and humid. On 08/10/21 on 03:28 PM, the Administrator reported the maintenance director adjusted the cold table later in the afternoon and that ice will be used in the cold table until it is determined the table functions correctly to keep cold food temperatures at 41°F or lower. On 08/11/21 at 09:07 AM, the Dietary Manager reported administration knew of the issue with the cold table not holding food at 41°F or lower during hot and humid weather.

Based on observation, record and policy review, and staff interview, the facility failed to change oxygen tubing for 1 out of 1 resident reviewed (Resident #20) and did not implement appropriate infection control practices during care of a resident with urinary catheter for 1 out of 3 residents reviewed (Resident #15). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] assessed Resident #20 with a Brief Interview of Mental Status (BIMS) score of 12 (moderate cognitive impairment). The MDS revealed the resident required extensive assistance of one staff with bed mobility, transfers, and toileting. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/09/21 at 03:10 PM revealed no date on oxygen tubing The oxygen order dated 4/23/2021 2 p.m. directed Oxygen 2-5L/NC to maintain O2 saturation equal or greater than 90%. The Clinical Record lacked documentation pertaining to when staff changed oxygen tubing. The Regular Replacement of Oxygen Tubing Replacement for Oxygen Provided by Canister or Concentrator policy dated 01/04/21 directed staff to replace oxygen tubing, including nasal cannula and /or mask on Sunday nights during the 10-6 shift. The same policy directed documentation of the change in the Treatment Administration Record (TARS) using staff initial to mark off the task. On 08/10/21 at 04:39 PM, the Director of Nursing (DON) reported staff replaced oxygen tubing each week on Sunday overnight shift and the only place they would document the change as the TAR. The DON reviewed the resident's TAR during the interview with no documentation of oxygen tubing changes found. 2. The MDS dated [DATE] assessed Resident #15 with BIMS score of 6 which indicated severely impaired cognition. The MDS revealed the resident required extensive assistance of 2 staff with bed mobility and extensive assistance of 1 staff with transfers and toileting. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/10/21 at 03:56 PM showed Staff C perform perineal care and empty Resident #15's urinary drainage bag. Staff C donned gloves after performing hand hygiene and then performed perineal care using a new wipe for each area cleaned. Staff C then changed gloves without performing hand hygiene. The Director of Nursing assisted Staff C with positioning resident for perineal care to the anal area. Staff C then changed gloves without performing hand hygiene and placed a new brief on the resident with the assistance of the DON. Staff C then changed gloves without performing hand hygiene. During the process of emptying the urinary drainage bag, Staff C changed gloves without performing hand hygiene one time . The Standard Precautions policy dated 11/02/20 revealed hand hygiene is required after removing gloves. On 08/10/21 at 04:11 PM, the Director of Nursing (DON) reported she expected staff to perform hand hygiene between glove changes.

Based on observation, record review, and staff interview, the facility failed to assure they implemented appropriate safety measures during transfer with a mechanical lift for 1 of 3 residents reviewed (Resident #1) resulting in a fall with a major injury. The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 0 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for activities of daily living (ADL's) including bed mobility, transfer, toilet use, personal hygiene and dressing. The resident's [DIAGNOSES REDACTED]. The Care Plan revised 6/5/18 identified the resident as unable to perform her own daily cares due to [MEDICAL CONDITION]. The interventions included: assuring the Hoyer (total mechanical lift) pad not left under the resident when up in her chair. The resident needed help with all transfers using the total mechanical lift with assist of 1-2 staff. The Progress Notes dated 2/2/21 at 4:15 p.m. documented 2 staff at bedside, using the total mechanical lift because the resident wiggled her hips and moved her legs side to side. During the transfer the right strap gave way, causing the resident to slide out. The resident's shoulder slid out and the rest of her body followed. She rested on her back at the bed side. She talked to staff, moved her legs, and gripped with both hands. Her pupils were equal and reactive to light (PEARL). The resident had a hematoma on the back of her head, with a possible laceration. The Director of Nursing (DON) notified the physician and family. At 4:50 p.m. the resident left per ambulance. At 9:20 p.m. the hospital called and reported they would keep the resident for 24 Hours for further evaluation. The Progress Notes dated 2/5/21 at 11:35 a.m. documented the resident readmitted from the hospital following a fall at the facility on 2/2/21. The resident would admit to hospice. Updated [DIAGNOSES REDACTED]. The resident settled in bed and appeared talkative and cheerful with no complaints of pain or discomfort. A hospital Discharge Summary dated 2/5/21 at 8:46 a.m. documented the resident's principal [DIAGNOSES REDACTED]. A hospitalization report dated 2/5/21 documented a brief hospital course. The resident brought to the emergency room after a fall. She had a scalp laceration and brain bleed, and admitted for treatment of [REDACTED]. The family elected for conservative measures and no transfer for aggressive neurosurgery evaluation or possible intervention. The resident remained fairly lethargic for the 1st 24-48 hours and then perked up. She had minimal verbalization, but the report identified her as close to baseline. She did not take much for oral intake. The family elected for comfort measures and she would transition to hospice. The course of her illness would be difficult to predict, but with intracranial bleeding, her life expectancy not predicted to be very long. The discharge exam included her posterior scalp area had a laceration well approximated with staples intact. A Major Injury Determination Form signed by the DON and dated 2/2/21 at 4:15 p.m. documented the circumstances of the incident causing the injury were a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) assisted the resident with the mechanical lift from the bed to the recliner. The resident moved her hips and legs side to side. The right shoulder strap slipped off, and the resident slipped out to the floor. The physician responded the resident's prognosis poor, and after reviewing the circumstances, injury, and prognosis of the patient, he believed the injury sustained was a major injury. A Hospice Physician order [REDACTED]. A Fall Investigation for CNA/Staff Member on Duty to Complete dated 2/2/21 by Staff A CNA documented 2 staff worked with the resident at the time of the incident. At 4:05 p.m. Staff A went to the resident's room and washed her up. At 4:15 p.m. she got the nurse and they began the transfer. The resident moved and twisted her shoulders, hips and legs. They had the resident up in the lift to place her in the recliner. They proceeded to move the lift when the right side of the upper part of the strap came off. The resident's head and right shoulder slid out on the floor. The new intervention suggested to prevent a similar fall in the future: pause to ensure straps were in hooks adequately for a double check. A facility Written Warning dated 2/3/21 documented Staff A on probation starting 2/2/21 for 90 days. The probation took place due to the severity of the incident on 2/2/21 with the resident and failure to ensure safety while using a mechanical lift during the transfer of a resident. Staff A's performance would be evaluated very closely over the 90 days. Failure to adhere to safety protocol in regard to performance would result in the termination of employment. A Post Fall Assessment for Nurse on Duty to Complete dated 2/2/21 by Staff B LPN documented staff performed a passive transfer with the total mechanical lift from the bed to the recliner to eat supper. Staff transferred the resident with assist of 2 because she wiggled and moved so much. They placed the sling, crossing the sling between her legs, suspended her off the bed with straps in place at that time. They began to transfer from the bed to the recliner. The resident wiggled and moved her legs. Instantly her right arm and shoulder slipped out and the rest of her body followed. She laid on her back beside the bed. The resident had a hematoma, possibly golf ball size with blood oozing from the hematoma and/or possibly a laceration. She moved her legs freely, and able to grip hands bilaterally. The resident's pupils equal and reactive to light (PEARL). The resident awake and talking, responding to staff, stating she felt fine. Staff B wrote she felt pausing to ensure they placed the straps appropriately in the hooks for a double check would have prevented the fall. A facility Written Warning dated 2/3/21 documented Staff B on probation starting 2/2/21 for 90 days. The probation took place due to the severity of the incident on 2/2/21 with the resident and failure to ensure safety while using a mechanical lift during the transfer of a resident. The facility would evaluate Staff A's performance very closely over the 90 days. Failure to adhere to safety protocol in regard to performance would result in the termination of employment. A sign in sheet documented the facility conducted a lift in-service by the lift company, territory Sales Manager on 2/3/21. The Care Plan revised 12/10/19 identified the resident at risk for injury related to inability to process how to walk due to her Alzheimer's progressing. The interventions included when staff used the mechanical lift for transfers they would pause for the cause and evaluate/placing sling straps dated 2/2/21. During an observation on 2/8/21 at 2:09 p.m., Staff C CNA and Staff D CNA transferred the resident from the recliner to the bed with the total mechanical lift. They used the short loops at the shoulders, and the middle loops at the legs. After they raised the lift and applied tension to the straps they stopped and checked placement of all 4 loops, then transferred the resident to bed. During an observation on 2/9/21 at 8:52 a.m. Staff E CNA and a hospice aide transferred the resident with the total mechanical lift from the bed to the recliner. Staff paused after raising the lift to check the loops placement in the hooks. The lift hooks had black safety pieces on the hooks, not present the day before. The DON present during the transfer said they must have placed them the day before when staff from the lift company cleaned and inspected all of their lifts. She said the representative who gave the in-service the previous week (2/3/21) stated the safety devices were not necessary if the loops were correctly in the hooks. During an observation on 2/11/21 at 9:18 a.m. the laceration to the resident's posterior scalp had 4 intact staples, well approximated with no redness or drainage noted. During an interview on 2/8/21 at 1:09 p.m. Staff A stated she assisted with the transfer 2/2/21 with Staff B. She washed the resident up and asked Staff B to assist with the transfer. They placed the lift sling and put the loops in the hooks. She raised the resident up with the lift and, when moving the lift, the right shoulder strap/loop came off the U shaped hook. The resident fell right shoulder 1st, and landed on the floor. During subsequent interview on 2/10/21 at 10:03 a.m. Staff A confirmed the loop at the back right came off causing the fall. She said they did not stop to check if the loops were secure in the hooks, because they thought it was going okay. During an interview on 2/9/21 at 1:55 p.m. Staff B stated on 2/2/21 she went to the resident's room to assist with the transfer. Staff A had provided care for the resident. Staff B stood (by the bed) on the resident's right side, and Staff A on the left where the lift sat. They hooked the lift sling to the lift hooks. Staff A ran the lift to raise the resident up. They went to swing her over and she just went down right beside the bed. She said it happened so quickly, she had not gone around to the other side of the bed when the fall occurred. She said she knew something gave away because she fell out the right side, it had to be the right back side. She thought the sling had been hooked up correctly because it lifted her. She did not check the loops when the lift raised up. She did not routinely do that. During an interview on 2/9/21 at 10:18 a.m. the lift company representative stated he did go to the facility and staff described the transfer to him. He checked the lift and the sling and both were in normal working order. It sounded like a loop did not get placed properly. Once they had gravity on the loop and if correctly in the hook, it would not come out of the hook, including when a resident had movement during the transfer. He in-serviced staff on pause for the cause to assure when they had tension on the loops, they were checked them to assure they placed the loops correctly in the hooks. During an interview on 2/9/21 the DON stated pause for the cause meant when they raised the resident and had weight on the lift straps to check and make sure the loops were correctly in the hooks. She said it was not new, they always checked when she observed transfers (she did not observe transfer 2/2/21). They may not have touched each one but they visualized to assure it. The lift manual operating instructions on page 4 (after the lift sling placed for transfer from the bed to chair and ready for transfer) included pushing the up button on the hand control. Once they had tension on the loops, to double check them to make sure they were securely in the hooks. The facility corrected the G level deficiency on 2/3/21, prior to the surveyor's entrance, by retraining and educating all nursing staff and issuing disciplinary action to the involved staff. This resulted in past noncompliance for the facility.

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents for 1 of 5 sampled (Resident #27). Resident #27 required assistance of one staff, a gait belt and a walker. The staff failed to use a gait belt and left Resident #27 unattended and she fell . Resident #27 transferred to the hospital. Resident #27 sustained a left [MEDICAL CONDITION] requiring surgical repair and multiple left rib fractures. The facility reported a census of 37. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 had [DIAGNOSES REDACTED]. Resident #27 required extensive staff assistance for bed mobility, transfers, walking, toilet use, personal hygiene and dressing. Resident #27 had no cognitive impairments The Care Plan dated 7/19/19 identified Resident #27 at risk for injury related to gait/balance problems, right hip/groin pain and a history of falls. The Care Plan directed the staff to provide assistance with daily cares due to weakness and provide assistance of one staff, a gait belt and a walker for transfers. The Admission/Readmission CARE SHEET dated 2/11/19 directed the staff to provide assistance of one staff with a gait belt and walker as needed. The PT - Therapist Progress and Discharge Summary sheet dated 9/22/19 documented Resident #27 ambulated with contact guard assist (contact with resident due to unsteadiness). The Fall Investigation Form sheet dated 9/22/19 at 9:00 p.m., documented Resident #27 had a fall and the care plan not followed. The sheet revealed an immediate action to prevent further falls of staff educated not to step away from Resident #27 even for a short while. The Incident Note dated 9/22/19 at 9:13 p.m., documented Resident #27 observed lying on her left side on the floor. The Nurse Aide reported while ambulating Resident #27 with the front wheeled walker, Resident #27 requested something be done with her hearing aids. The Nurse Aide stepped away from Resident #27 and she fell on her left side. Resident #27 sustained a 3.0 centimeter (cm) by 0.1 cm skin tear to her left elbow and a 0.4 cm by 0.3 cm skin tear on the left side of her head. The staff initiated neurological checks. Resident #27 complained of pain in the rib area and reported it took her breath away. Resident #27 complained of left hip and buttock pain, with no shortening or rotation noted to the lower extremities. During an interview on 10/22/19 at 11:10 a.m., Staff A (Nurse Aide) stated the evening the resident fell was the first night he worked at the facility. Staff A reported his assigned area did not include Resident #27's section and did not know Resident #27's status. Staff A reported the nurse asked him to assist Resident #27 to the bathroom and bed. Staff a reported Resident #27 did not have a gait belt on. Staff A walked with Resident #27 to the bathroom and then to her room. Resident #27 entered the room and asked Staff A to remove her hearing aids. Staff A stepped outside the door when he heard Resident #27 fall. Staff A did not witness the fall. Staff A reported the nurse handed Resident #27 over with no gait belt and that's the way he took her, and assumed she required supervision. During an interview on 10/22/19 at 11:23 a.m., Staff B (Registered Nurse) reported she heard an alarm sound and asked Staff A to assist Resident #27 so she could respond to the alarm. Staff B reported she did not have an alarm on Resident #27. Staff B stated she held on to Resident #27's pants. After assisting the resident with the alarm sounding, Staff B encountered Staff A, distraught about Resident #27 falling. Staff B stated she often assisted Resident #27 holding onto her pants as she felt it stabilized her better. During an interview on 10/21/19 at 9:25 a.m., the Administrator stated an expectation of staff to stay with a resident who required assistance. During an interview on 10/22/19 at 11:35 a.m., the Administrator had no knowledge Staff A and Staff B failed to use a gait belt while walking with Resident #27 prior to the fall. At 12:01 p.m., the Administrator confirmed Staff A worked one shift at the facility. She re-affirmed residents who needed staff assistance should not be left unattended while standing. During interviews on 10/22/19 at 12:10 p.m., Staff J (Registered Nurse) stated she observed other staff always use a gait belt when assisting Resident #27. During an interview on 10/22/19 at 12:20 p.m., Staff [NAME] (Restorative Aide) stated she always used a gait belt when assisting Resident #27. During an interview on 10/22/19 at 12:26 p.m., Staff G (Nurse Aide) stated she always used a gait belt when assisting Resident #27. Staff G reported prior to the fall Resident #27 had declined and was unsteady. During an interview on 10/22/19 at 1:15 p.m., Staff C (Restorative Aide) stated she always used the gait belt, it was very important. During an interview on 10/22/19 at 3:35 p.m., Staff L (Nurse Aide) stated she always used the gait belt because Resident #27 could get wobbly and the gait belt stabilized her. During an interview on 10/22/19 at 10:22 a.m., the Physical Therapist reviewed the therapy discharge and stated at the time of the fall the resident walked 40 feet with contact guard assist which meant hands on. She said generally that meant you should not let go of the resident or step away from them when standing or ambulating. The emergency room Report dated 9/22/19, documented Resident #27 complained of left rib pain, left shoulder pain, and left hip pain after fall. The Physical Examination revealed a small punctate superficial laceration in the left parietal region of the scalp, tenderness to palpation in the left posterior chest wall, and tenderness to the left hip. Resident #27 had a superficial skin tear to the left elbow. Resident #27 received 1000 milligrams (mg) of Tylenol intravenously (IV), 2 mg of [MEDICATION NAME] IV and 4 mg of [MEDICATION NAME] IV to satisfactorily manage her pain. Resident #27 transferred to another hospital. The emergency room Report dated 9/22/19, revealed Resident #27 sustained an impacted fracture through the neck of the left proximal femur, and multiple displaced and angulated left rib fractures laterally involving at least the left ribs 3 through 8. The Computerized [NAME]ography (CT) Scan dated 9/23/19, documented Resident #27 had multiple left lateral rib fractures including ribs 3 through 6, 8 and 9, and some displaced. The CT of the pelvis showed an impacted left subcapital femoral neck fracture. The Operative/Procedure Report dated 9/24/19, documented Resident #27 had an open reduction and internal fixation of the left valgus impacted femoral neck fracture. The Hospital Progress Note dated 9/26/19, documented Resident #27 had pain and at times medications failed to keep her comfortable. The Progress Notes dated 9/27/19 at 5:45 p.m., documented Resident #27 readmitted via ambulance and had orders for bed rest. The Nursing Admission assessment dated [DATE], documented Resident #27 had sharp pain at times. The Progress Notes dated 9/29/19 at 11:37 a.m., documented Resident #27's staples intact and dressing changed. Resident #27 had 2 pain medications and complained of pain when repositioned. The Progress Notes dated 9/29/19 at 8:49 p.m., documented Resident #27 had dressings changed and complained of increased pain when repositioned. The Staff administered [MEDICATION NAME] at 7:00 p.m. and [MEDICATION NAME] at 4:00 p.m. The Progress Notes dated 10/3/19 at 8:00 p.m., documented the staff administered [MEDICATION NAME] 4:00 p.m. due to ribs hurting and general pain. Resident #27 up in the Geri chair for supper. Resident #27 stated she had pain all over. The staff contacted the Hospice nurse. Hospice obtained an order for [REDACTED]. The Progress Notes dated 10/6/19 at 6:30 p.m., documented the resident complained of pain when repositioned. The Progress Notes dated 10/7/19 at 5:30 a.m., documented Resident #27 received [MEDICATION NAME] prior to cares. However, Resident #27 continued to yell out and cry during cares. The Progress Notes dated 10/17/19 at 12:31 a.m., documented Resident #27's vital signs ceased. The Death Certificate filed 10/21/19, documented Resident #27 had a cause of death of pneumonia due to or as a consequence of left femoral neck fracture and multiple rib fractures. The Physician's Assistant note dated 10/24/19, revealed after reviewing the medical records and discussing the case with the physician, they concluded the fall and fracture were secondary to a pathological condition, her [MEDICAL CONDITION]. During an interview on 10/24/19 at 10:53 a.m., the Physician's Assistant stated the physician felt it was more than likely the [MEDICAL CONDITION] was pathological. She stated the rib fractures were a result of the fall. On 10/24/19, Resident #27's Surgeon documented it was undetermined if the fracture was spontaneous or pathological.

Based on record review, staff interview and policy review the facility failed protect Resident #3 from physical/environmental hazards on 11/3/16. The facility failed to investigate bruises of unknown origin to determine cause for the bruises on 11/3/16; in addition the facility failed to place appropriate interventions for known bruises for 1 of 4 residents reviewed. The facility identified a census of 37 current residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 5 which indicated severe cognitive impairment. According to the assessment, Resident #3 required two staff extensive assistance with bed mobility and transfers and one staff assistance for dressing and toilet use. The MDS identified the resident required use of a wheelchair for mobility. Review of the Bruise Documentation record revealed the following documentation on 11/3/16 at 10:06 a.m. : 1). Dark purple bruise to top of left wrist toward front aspect 6.6 by 9.4 centimeter (cm)/length by width. 2). Dark purple bruise to top of left wrist towards outside aspect 2.9 by 1.9 cm. 3). Dark purple bruise to top of wrist towards inner aspect of bruise (#2 above), 2 by 1.9 cm. 4). Dark purple bruise to top of wrist towards hand 1 by 0.4 cm. The interventions included to encourage long sleeves. (The photographs obtained during the investigation of Resident #3 ' s bruises were identified as the prior documentation.) Review of the Progress Notes revealed on 11/3/16 4 bruises noted to the top of the left wrist. Dark purple in color. No pain voiced. Will monitor until resolved. Palliative Care updated. The care plan dated 12/6/16 included the following interventions: a. 11/3/16 Encourage long sleeve garments. The resident's care plan addressed a risk for impaired skin primarily related to urinary incontinence. On 12/7/16 the facility padded the resident ' s wheelchair. On 12/9/16 the facility attempted use protectors with monitoring. During an interview with Staff A, LPN (Licensed Practical Nurse) on 12/29/16 at 2:00 PM she stated she had walked up the hallway and saw the resident's arm with bruises on 11/3/16. She further stated that she had witnessed a few times that the resident sat with his/her arms pressed against the dining room table with his/her weight against it and falls asleep, but is did not occur on 11/3/16. She further stated she always talked to staff about new bruises but cannot remember who she talked to concerning the bruise on 11/3/16. During an interview with Staff B, (LPN) on 12/13/16 at 11:20 a.m. she stated the resident seemed to bruise easily and did have bruises on his/her arms. Staff try to investigate cause and look at their surroundings. She further stated the resident had a history of [REDACTED]. The resident also slept in the wheelchair after eating. Staff complete the bruise sheet and write the bruise on the weekly calendar. They also report bruises to oncoming staff. Record review identified: 1).Review of the Bruise Documentation record revealed on 7/12/16 at 9:02 a.m. - outer right breast from incident on 7/11/16 (related to gait belt transfer.) Review of the Progress Notes revealed on 7/12/16 at 6:57 AM new skin area noted 3 by 1.5 cm bruise on right outer breast from incident on 7/11/16. On 7/13/16, the care plan interventions added stand lift only with assist of 1 or 2 staff. 2). Review of the Bruise Documentation record revealed the following bruises on 5/9/16 at 8:51 p.m., left elbow outer aspect red/purple bruise, 4 by 4 cm circular. The top of left hand 9 by 5 cm dark purple bruise. The interventions included staff educated to monitor arm during transfers and in wheelchair. Staff also educated to monitor hands while in wheelchair, resident does propel self throughout the building. On 5/9/16, the care plan directed staff to monitor the resident's arms during transfers and in wheelchair. 3). Review of the Bruise Documentation record indicated on 4/27/16 at 9:33 PM - left elbow outer aspect red/purple bruise, 4 by 4 cm circular. Interventions included staff educated to monitor arm during transfers and in the wheelchair. Review of the Progress Notes revealed the following entries: on 4/27/16 at 9:36 PM Staff reported new bruise. Upon inspection, outer aspect left elbow bruise measured 4 by 4 cm, circular and red/purple in color. The facility failed to provide interventions to protect with self mobility and prevent bruising prior to on 4/27/26 and 5/9/16. On 4/22/16, the care plan directed staff to use care/caution when placing the resident on the commode. During an interview with Staff C, CNA (certified nursing assistant) on 12/30/16 at 1:00 PM she stated the resident always had bruises on his/her arms. The resident sleeps in the wheelchair with hands on his/her stomach. Staff cannot see his/her arms and may have hit the table when staff push him/her in. The resident also pushes him/herself in the wheelchair and she had seen him/her struggle to get in the doorways. The facility abuse Policy and Procedure titled Resident Abuse Prevention Plan (not dated) directed staff to do the following when an (resident) injury of unknown source including but not limited to bruising and skin tears), is made to any employee of the facility, the staff member or employee shall immediately notify the person in charge of the facility or the person's designated agent. The facility shall conduct a timely investigation which includes, at a minimum, an interview with the alleged victim (if the victim is able to communicate). Additionally, witnesses who have knowledge of the facts related to the complaint shall be interviewed, if identifiable and available. The facility shall document the complaint, the notification of the person in charge of the facility (or their designee), and all follow up investigation in an investigatory file. During an interview with the Administrator on 12/29/16 at 3:30 PM she stated the facility staff are expected to find the root cause of an incident and place an intervention. Examples include a skin tear, any type of increased pain or anything out of the norm. If staff do not know the root cause they complete the form titled unknown injury and direct it to the DON (Director of Nursing). During an interview with the Director of Nursing (DON) on 12/30/16 at 2:00 PM she stated the facility went over their documentation of root cause. They changed the bruise assessment to include documentation of the cause of the bruise on the paperwork. She further stated she had the understanding that staff saw the resident sitting at the table with arms against the table when they found the bruises. She stated the bruises continued to grow and appeared to be 1 larger bruise. Staff monitor bruises daily but only assess the measurements on initial observation.

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision to prevent accidents for 3 of 9 active residents reviewed (Resident #1, #3 & #5). The facility reported a census of 35 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment, with a reference date of 07/14/15, Resident #1 scored 9 on the Brief Interview for Mental Status (BIMS). The score of 9 identified the resident had a cognitive impairment. Resident #1 demonstrated fluctuating disorganized thinking and delusions. Resident #1 required extensive assistance for activities of daily living (ADL's) including bed mobility, dressing, and toilet use, and limited assistance with transfer, and ambulation. Resident #1's [DIAGNOSES REDACTED]. The Physician order [REDACTED].#1 had a sensor pad alarm when in the chair with a start date of 01/09/15. The physician signed the order summary. The Care Plan dated 04/21/15 identified Resident #1 at risk for injury related to memory and balance problems. The interventions included resident could be spontaneous and had alarms in place, a laser alarm at the foot and side of the bed, and sensor alarm in chair. On 06/24/15 Resident #1 independent in room during waking hours, assist with a.m. /p.m. cares and encourage to use the call light as needed. A Physical Therapy Discharge Summary dated 06/23/15 to 07/08/15 documented therapy saw Resident #1 for safety awareness and for alarm reduction. The discharge indicated communication written for alarm reduction. An Alarm Reduction Criteria/Assessment documented in step 1 Resident #1 was a candidate for alarm removal. Step 2 documented on 07/08/16 that Resident #1 had a moderate risk for falls. Step 3 of the process identified alternatives to initiate to take the place of the alarm. The interventions identified were to monitor resident closely, keeping call light in reach, and encouraging activity involvement for distraction. Steps to follow up included documentation of the effectiveness of alternatives to the alarm and continued safety every shift times 3 days, updating the care plan, and if alarm was ordered, review with the physician to discontinue the alarm. The clinical record lacked follow up documentation, new interventions on the care plan, and physician consultation regarding discontinuing the alarm. The Care Plan dated 01/08/15 and revised 07/31/15 identified Resident #1 at risk for injury related to senile dementia. The interventions included Resident #1 could be spontaneous and had alarms in place, laser alarm at bedtime (HS), needed assist of 1, gait belt and walker during the night, independent with walker during waking hours, assist a.m./p.m. cares, encourage call light, and may need reminders to slow down when ambulating. The Care Plan lacked direction for close monitoring of Resident #1. The Progress Notes dated 08/20/15 at 5:00 p.m. documented Resident #1 sat on the floor in his/her room, alert. Resident #1 had active range of motion to all extremities. The resident did offer some discomfort to the right upper leg and buttock. ROM rechecked and did all movements per self. Three staff members raised the resident up to feet slowly with the use of a gait belt. Resident #1 unable to bear weight on the right leg. At 5:40 p.m. Resident #1 was sent to the hospital. A Fall Investigation Form dated 08/20/15 at 5:00 p.m. documented the foot of the recliner up and the walker next to Resident #1. Resident #1 went to the emergency room (ER). The new intervention documented the resident to have sensor alarms at all times. A Physician Transfer Order Report dated 08/21/15 documented Resident #1 had a closed fracture of the right pubis (pelvic bone). A Major Injury Determination Form dated 08/20/15 documented Resident #1 had pain in the right upper leg and buttock and unable to bear weight on the right leg. The foot of the recliner was up and Resident #1 laid next to the recliner. The resident climbed over the foot to get up, with the walker next to him/her. Resident #1 was independent with transfers and ambulation in the facility. The provider documented per nursing home, pelvic fracture with hospital admits. The provider indicated Resident #1 sustained a major injury. An Occupational Therapy (OT) Evaluation & Plan of Treatment dated 08/28/15 page 2 of 5 documented Resident #1 referred to therapy following a fall and subsequent pelvic fracture. Resident #1 declined in self- care, functional mobility, and transfers. Page 3 of 5 documented pain limited Resident #1's functional activities. A Physical Therapy (PT) Evaluation and Plan of Treatment dated 08/25/15 page 2 of 5 documented Resident #1 exhibited new onset of decreased strength, decreased functional mobility, decreased transfers, reduced ability to ambulate, reduced balance, reduced functional activity tolerance, increased need for assistance from others and pain placing resident at risk for falls, further decline in function and increased pain. During an interview on 05/11/16 at 9:50 a.m. Staff C Registered Nurse (RN) who reviews fall reports, stated they had gone through physical therapy to reduce Resident #1's alarms. She did not know about the alarm reduction criteria assessment. At 10:30 a.m. Staff C stated apparently PT did the alarm reduction criteria/assessment and they (the facility) didn't know about it, even though it was in the resident's chart. She said they had a CNA do filing for them. Staff C stated therapy didn't alert nursing and the interventions were not added to the Care Plan. Staff C stated the physician did not sign the alarm reduction and they did not obtain an order to discontinue the alarm. A Fall Investigation Form dated 12/25/16 at 4:50 p.m. documented the factors involved in the fall were hanging a sweater. The alarm sounded. The immediate intervention was to place the alarm on the recliner back. A new intervention dated 12/31/15 directed the sensor alarm box for the recliner to be affixed to the wall with Velcro. The Care Plan dated 01/08/15 and revised on 02/19/16 identified Resident #1 needed assist with ADL's. The interventions included a sensor alarm at all times, and sensor alarm box for the recliner to be affixed to the wall with Velcro. According to the MDS assessment with a reference date of 02/12/16, Resident #1 scored 6 on the BIMS. A score of 6 represented the resident had severe cognitive impairment. Resident #1 demonstrated fluctuating disorganized thinking and delusions. Resident #1 required extensive assistance for ADL's including bed mobility, dressing, and toilet use, and limited assistance with transfer, and ambulation. The Progress Notes dated 04/16/16 at 2:00 p.m. documented staff observed Resident #1 sitting on the floor next to his/her chair. Resident #1 had good ROM (Range of Motion) in legs and left arm, but complained of pain in his/her right upper arm. Staff received new orders to give 1000 mg (milligrams) of Tylenol (analgesic) stat, apply ice to the right upper arm, and take to the ER (emergency room ). A Fall Investigation Form dated 04/16/16 at 2:00 p.m. documented Resident #1 observed sitting on the floor in his/her room. The alarm was not on and functioning. The hospital History and Physical dated 04/16/16 at 3:15 p.m. documented Resident #1 presented with shoulder pain. The resident had a fall and had moderate shoulder pain of 5 out of 10. The pain had been constant since onset, and radiated. Resident #1 had a right humerus (upper arm) fracture. A Major Injury Determination Form dated 04/16/16 documented Resident #1 fell and fractured his/her left arm. Resident #1 attempted to stand/walk by him/herself. He/she was not safe/steady without help due to dementia. Staff previously assisted Resident #1 with all cares, had safety interventions in place, and ambulated with a walker and staff assist of 1 (staff person). The provider determined Resident #1 sustained a major injury. An OT Evaluation and Plan of Treatment dated 04/20/16 page 3 of 5 documented Resident #1 presented to therapy with the inability to use his/her right arm for ADL's due to pain and a fractured humerus. Resident #1 needed minimum to moderate assist for self- feeding with his/her left hand. Resident #1 had impaired balance due to inability to use his/her right arm. Resident #1 had stiffness and slight weakness in his/her right hand due to decreased use. A PT Evaluation and Plan of Treatment dated 04/20/16 documented on page 2 of 5, Resident #1 fell and suffered a right humerus fracture and unable to use a walker with increased difficulty walking. Page 3 of 5 documented Resident #1 had pain with movement at 7 out of 10, intermittent, sharp and distressing. During an observation on 05/09/16 at 9:48 a.m. Resident #1 sat in the wheelchair with an immobilizer on his/her right arm. During an interview on 05/11/16 at 9:10 a.m. Staff E CNA stated (on 04/16/16) she thought Staff F CNA took Resident #1 back to his/her room and toileted him/her (after lunch). Staff E thought Resident #1 had an alarm that did not turn off/on. She said the alarm box hung on the hook behind the recliner. She didn't know how they placed it after lunch that day. During an interview on 05/10/16 at 1:50 p.m. Staff F stated she walked Resident #1 back to his/her room after lunch. Resident #1 did not need to go to the bathroom. She assisted Resident #1 in the recliner. She put the alarm box on the floor behind the recliner. Staff F found Resident #1 on the floor close to the recliner. The alarm box sat on the bed and it did not sound. Resident #1 sat in the recliner about half an hour. She didn't know if anyone checked to see if the alarm box was turned on. During an interview on 05/10/16 at 9:45 a.m. Staff D Registered Nurse (RN) stated after thinking about it Resident #1 had a sensor alarm. It did not sound (04/16/16). She did not know if they had it turned on or not. The alarm box laid on the bed, not on the wall behind the recliner. It did not sound to alert staff Resident #1 got up. Staff D did not check the alarm box after the incident. In a statement dated 04/18/16, the Director of Nursing (DON) wrote after testing the alarm box in place at the time of the fall, she noted when the box was turned on and the wire came out of the box the alarm sounded. This showed the box was never turned on to begin with. During an interview on 05/11/16 at 9:05 a.m. the DON stated she got a couple different stories from Staff F. The DON stated the alarm worked after the incident so she felt it had not been turned on. She said Resident #1 previously had an alarm box with a reset button, but had one with an on/off button at the time of the fall. She said they would have to turn the alarm off when the resident did not sit on it or it would beep continuously, and then they would need to turn it back on. She said the alarm boxes needing turning off/on had a blue dot on them to help staff remember to turn them on. She said they originally put the alarm box on the wall to keep the resident from fidgeting with it, but the cord would not reach and no one told them. She said the cord probably didn't reach because the chair moved, and they could easily have moved the chair to make it work 2. According to the MDS assessment with a reference date of 02/27/16, Resident #3 scored 4 on the BIMS indicating severe cognitive impairment. Resident #3 required extensive assistance with ADL's including transfer. Resident #3's [DIAGNOSES REDACTED]. The Care Plan dated 08/27/14 and revised 03/03/16 identified Resident #3 with an ADL self- care performance deficit related to weakness. The interventions included Resident #3 needed assist of 1, a gait belt, and a walker to transfer. The Care Plan identified Resident #3 at risk for injury with interventions including to transfer with assist of 1 with a gait belt and walker. The Progress Notes dated 05/05/16 at 5:30 p.m. documented staff lowered Resident #3 to the floor beside the bed with a CNA with him/her. The resident could not pivot and no injury was noted. A Fall Investigation Form dated 05/05/16 at 5:30 p.m. documented a CNA lowered Resident #3 to the floor. The investigation indicated the Care Plan was followed. The Progress Notes dated 05/07/16 at 8:16 a.m. documented observation of a 3 by 5 centimeter bruise on Resident #3's right knee with slight swelling. During an observation on 05/10/16 at 6:14 a.m. staff assisted Resident #3 with personal care. Resident #3's right knee appeared bruised. During an interview on 05/12/16 at 8:05 a.m. the Director of Nursing stated she talked to the nurse on duty at the time of the fall and an agency (contracted staff) CNA transferred Resident #3 without a gait belt. The DON stated she expected staff to follow the Care Plan. 3 According to the MDS assessment with a reference date of 01/06/16, Resident #5 scored 3 on the BIMS indicating severe cognitive impairment. Resident #5 wandered daily. Resident #5 required extensive assistance with ADL's including transfer and ambulation. Resident #5 used a walker and a wheelchair. Resident #5's [DIAGNOSES REDACTED]. Resident #5 did not experience pain. Resident #5 had 1 fall with injury (not major) since admission (12/30/16). The Care Plan dated 12/30/16 with a goal target date of 03/29/16 identified Resident #5 at risk of injury. The interventions included: a. Assure nonskid well-fitting footwear on (resident). b. Assure call light in reach. c. Assess decision making ability, muscle strength and balance. d. Clear environment of unnecessary items. e. Assure sensor alarm on and functioning at all times in wheelchair, recliner and bed. f. Turn and reposition resident at least 4 times a shift. g. Resident used wheelchair for primary locomotion, able to propel self. h. Transferred with assist 1 with a gait belt. The Care Plan identified Resident #5 with a self-care deficit. The interventions included. a. Resident forgets his/her limitations in mobility; assure sensor alarm at all times on wheelchair, bed and recliner. Care Plan changes: a. 01/11/16 body alarm in wheelchair and recliner. b. 02/26/16 body alarm discontinued. c. 02/29/16 body alarm reapplied. d. 03/19/16 new clip applied to body alarm. Fall Investigation Forms documented the following: 1. On 01/02/16 at 2:00 p.m. Resident #5 had taken nylons and shoes off. The immediate intervention was a sensor alarm at all times. Resident #5 sustained skin tears and bruises. 2. On 01/11/16 at 1:15 p.m. Resident #5 transferred him/herself in the bathroom and fell to the floor. The alarm was on and functioning. The immediate intervention was application of a body alarm in the wheelchair, recliner, and bed. No injuries were noted. 3. On 02/29/16 at 7:10 p.m. Resident #5 was by his/her roommate's bed. The alarm was on and functioning. The new intervention was reapplication of the body alarm; they had removed it a few days before due to resident's increased irritation. Resident #5 sustained abrasions to the left wrist and elbow. 4. On 03/19/16 at 11:00 a.m. dietary staff intervened and lowered the resident to the floor. The seat alarm was good, but the body alarm slid off the resident's shirt. The new intervention was applying a new clip on the body alarm. 5. On 03/23/16 at 6:30 p.m. Resident #5 took him/herself to the restroom in another hall. Staff were with other residents. The personal alarm sounded. Resident went to the emergency room (ER). The Progress Notes dated 03/23/16 at 6:30 p.m. documented Resident #5 was on the floor in the hallway. He/she had walked out from the bathroom without the wheelchair by him/herself. The personal alarm sounded. Resident #5 cried out in pain to the right shoulder and right hip and knee. Staff called and received an order to transport to the ER. The hospital H&P (history & physical) Encounter Notes dated 03/25/16 at 10:13 a.m. documented Resident #5 presented with a spiral fracture of the right femur (upper leg) and right humerus fracture. The resident presented to theER on [DATE] after a fall at the nursing home that evening. No one witnessed the fall. The x-rays obtained on 03/24/16 identified a closed non-displaced humerus fracture and 2 right rib fractures. The plan included (hip) surgery to take place on 03/25/16. A Major Injury Determination Form dated 03/23/16 documented the hospital confirmed a right spiral femur fracture and possible fracture of the right shoulder. Resident #5 wandered in the facility in a wheelchair, attempted to self- transfer in the 300 hall near the bathroom/shower room and walked into the hall. Resident #5 could not ambulate him/herself; he/she needed assist of staff and a walker. He/she used a wheelchair for locomotion, and propelled him/herself throughout the facility. The provider responded Resident #5 sustained a major injury. A hospital Physician Transfer Order Report dated 03/28/16 documented Resident #5 had a closed fracture of the distal end of the right femur, closed fracture of multiple ribs of the right side, closed fracture of the proximal end of the right humerus, and contusion of the right lung. The Progress Notes dated 04/01/16 at 12:00 p.m. documented Resident #5 was readmitted to the facility. Resident #5 had multiple dark blue discoloration bruises to the right side from the shoulder all the way down to the ankle. He/she had 59 staples counted down the right hip, with 2 post drain areas. The top one red, warm to touch with serous drainage. He/she wore an immobilizer around the abdomen and upper right arm. An OT Evaluation and Plan of Treatment dated 04/01/16 page 2 of 6 documented Resident #5 had closed fracture of the distal end of the right femur, closed fracture of multiple ribs of the right side, closed fracture of the proximal end of the right humerus, contusion of the right lung, and postoperative anemia due to acute blood loss. Page 3 of 6 documented pain limited Resident #5's functional activities. A PT Evaluation and Plan of Treatment dated 04/01/16 page 2 of 5 documented Resident #5 exhibited pain at an 8 out of 10. Pain level determined based on resident behaviors. Resident #5 held area of pain, exhibited defensiveness to touch, restless activity, fidgeting and tension. A Palliative Care Consult Note with an encounter date of 04/07/16 documented a progress note on page 2 of 9 dated 04/08/16 at 9:00 a.m. revealing Resident #5 referred for symptom management. Resident #5 experienced a fall on 03/23/16 with a right femur fracture resulting in surgical repair. The plan on page 6 of 9 documented Resident #5 did appear to be quite uncomfortable, and suspected change in behavior related to pain. They would start him/her on a Fentanyl patch (pain medication) 12 mcg/hour, and continue to use Hydrocodone (pain medication) as needed. They would schedule Lorazepam (antianxiety) 0.5 mg 3 times a day and discontinue the as needed order. A Palliative Care follow up on 04/12/16 with Progress Notes dated 04/13/16 at 8:18 a.m. documented staff reported Resident #5 continued to show signs of pain and discomfort. He/she had taken Hydrocodone 3-4 times a day along with the Fentanyl patch. They would increase the patch to 25 mcg/hour. They would also add as needed Lorazepam for overnight hours. During an interview on 05/10/16 at 1:23 p.m. Staff A Licensed Practical Nurse (LPN) stated she toileted Resident #5 at 4:00 p.m. (on 03/23/16) and he/she went to supper. Stated (when he/she fell ) Resident #5 was clear to the end of the 300 hall. She last saw Resident #5 at the supper table, and gave him/her meds at 5:30 p.m. The personal alarm sounded, but the sensor alarm did not. No staff were on the hall to hear the alarm. Staff B found Resident #5. During an interview on 05/10/16 at 2:50 p.m. Staff B LPN stated she did not see Resident #5 go to the 300 hall. She passed meds on the 200 hall and Resident #5 must have passed through when she went in a room. She said the 2 CNA's working on the 200/300 hall were also on the 200 hall, answering 2 alarms. Staff B heard a resident yelling for help and went to the 300 where she saw Resident #5 on the floor outside the bathroom at the end of the hall. She did not hear the alarm until she got down the hall. Resident #5's wheelchair sat in the bathroom near the toilet and the resident had apparently walked out of the bathroom and fell . During an interview on 05/11/16 at 9:50 a.m. Staff C Registered Nurse (RN) who reviews fall reports, stated after Resident #5's 1st fall they applied the sensor alarm. After the 2nd fall they placed a body alarm because they thought it would alarm sooner and they would catch him/her quicker. She said they discontinued the body alarm due to the distress it caused Resident #5 and he/she fell not long after (3rd fall), so they started the body alarm again. The 4th fall they had to replace the clip to the body alarm. She said they did do other things with Resident #5 (other than just alarms). She said it may not have added it to the Care Plan. Resident #5 moved fast and could get down the hall quickly. She did not know they could not hear the alarm (03/23/16 at the time of the fall) and did not know if both alarms sounded on 03/23/16. She said the newer alarms they purchased were louder, but there were some older alarms. She agreed if they heard the alarm immediately, they may have been able to intervene, because the resident walked from the bathroom out to the hall before falling. She agreed all their post fall interventions had to do with alarms